Committee Of Supply – Head O (Ministry of Health)

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

Healthy Together - Beyond Healthcare 2020

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

I know of a man, now in his 70s, who had been smoking since his teens. No amount of persuasion, threats, nicotine patches or counseling could make him quit. And then, he was hospitalised for a minor heart attack a few years ago, and he has not smoked since. That man is my father.

I know of a woman, also in her 70s, who cares about so many people around her, but despite her advancing years somehow never got around to going for health screening, despite the urging of her family, and although she herself would urge her family to go for regular health checks. And then, one day her group of friends decided to go for a health check at the nearby polyclinic, and because it was their regular meet-up for lunch, she decided to just tag along, had the very first mammogram of her life, which detected very early stage breast cancer, which was then quickly and safely removed. That woman is my mother.

Much has been written on how one’s attitudes to health and health seeking behavior can be changed. It can be due to some catastrophic event, such as the onset of disease but in the absence of such event, what else can be done to nudge someone towards better health practices?

You would think that any reasonable person would take the appropriate steps to stay healthy, but we smoke, we drink more than we should, we eat too much, exercise not too much, and so on. We emphasise health education, we try to "game-ify" healthy practices such as the 10,000 step challenge. We penalise poor choices with sin taxes. Against tobacco, we have cornered the industry at every turn short of an outright ban. But still, ill health in our society remains frustratingly, maddeningly sticky. Some years ago I was proud to mention that Singapore was the Healthiest Country in the World. Disappointingly this year we have dropped to eighth position from fourth position a year before.

In terms of healthcare, the system in Singapore remains affordable and accessible, and of very high quality. But rightly, over the past few years Singapore has shifted more and more resources towards health promotion and maintenance, rather than to costly medical services. Part of the three key shifts espoused by MOH.

I believe that choosing and maintaining healthy lifestyle choices can only be achieved if there is a community and whole-of-society approach – a support structure that positively reinforces such behavior. Just like recidivism among ex-offenders can only be drastically reduced by strong family and community support, many studies show that if we encourage each other at every opportunity then we will find it easy to live healthily. Hence, we have to be healthy together, as it is difficult to stay the course alone. We often go for health screenings on the encouragement of friends and loved ones, maintain our diets with the support of friends and family, and quit smoking when we want to do it for the betterment of both ourselves and our families.

It is vitally important that the Government supports this whole-of-society effort. I was very happy to learn of the new multi-agency task force that has been set up to drive health promotion. I understand that “it will coordinate and synergise efforts across multiple public agencies, to nudge Singaporeans towards adopting a healthy lifestyle”. Can the Ministry provide an update on the progress of this task force?

With regard to diabetes, we are now in the third year of a long and bruising campaign against diabetes. What milestones in our war on diabetes have been achieved? Sugar is indeed the enemy. From December last year till January this year, MOH sought views on four proposals: (a) a total ban on pre-packed high-sugar drinks; (b) single or tiered taxes on high-sugar drinks; (c) mandatory front-of-pack labelling on sugar/nutrition content; and finally perhaps even (d) a ban on advertisements for high-sugar drinks on all platforms.

Has a decision been reached following the public consultation on possible measures for pre-packaged sugar-sweetened beverages? Is the Ministry still considering a tax on sugar?

Singapore also hosted the inaugural Ministerial Conference on Diabetes in November of last year. The Conference brought together more than 300 international and local delegates, including health ministers, senior government officials, academics and thought leaders from 18 countries. What are the takeaways from the inaugural Ministerial Conference on Diabetes in November last year?

Moving on to alcohol, concerning alcohol intake, I would like to follow up on a recent Parliamentary Question (PQ) I filed concerning recommendations about alcohol consumption. MOH’s current recommended limit for regular alcohol consumption is two standard drinks a day for men and one standard drink a day for women. I think we should review this recommendation in view of the latest findings that there is in fact no safe level of alcohol consumption.

A systematic analysis of scientific evidence that was published about alcohol in the Lancet in September last year, concluded that: "Alcohol use is a leading risk factor for disease burden worldwide, accounting for nearly 10% of global deaths among populations aged 15 to 49 years", very young, "and poses dire ramifications for future population health in the absence of policy action today. The widely held view of the health benefits of alcohol needs revising, particularly as improved methods and analyses continue to show how much alcohol use contributes to global death and disability. Our results show that the safest level of drinking is none. This level is in conflict with most health guidelines, which espouse health benefits associated with consuming up to two drinks a day".

Regarding dementia, I note that there have been cuts filed on mental health, but I would like to ask about our national strategy to deal with dementia. With longer lifespans and an ageing population, comes an increase in the number of patients with dementia. I would like to ask how can we prevent or delay its onset, increase diagnosis rates and provide the necessary support and long-term care for patients with dementia? What is the progress on the expansion of dementia-friendly communities?

Let me now move on to obesity. How are we tackling obesity? In Singapore, the percentages of overweight men and women are expected to increase to 36.5% and 21.7% respectively by 2025, according to the World Obesity Federation. In 2017, MOH figures showed that 36.2% of Singaporeans aged 18 to 69 years and 13% of children in mainstream schools are overweight.

In addition to measures to curb sugar intake that are alluded to earlier, are there also efforts to reduce fat intake in our diet? What about efforts to increase participation in regular exercise and sports?

Finally, let me touch on Health Screenings and Immunisations. The Screen for Life (SFL) programme I believe is a landmark initiative as early disease detection typically supersedes any medical treatment for established disease. I would like to ask how can we encourage more Singaporeans to take up the SFL programme for health screenings and post-screening follow-ups?

Although heavily subsidised, many older Singaporeans, and many of them live in my constituency of Queenstown, still maintain the attitude that it is better not to know about their health conditions, or are concerned that screening examinations are too inconvenient or too difficult or too onerous for them.

Since November 2017, adult Singaporeans can now use their MediSave to pay for vaccinations which MOH is recommending depending on their age and health status. It is the latest step in the push to encourage preventive care. The new National Adult Immunisation Schedule (NAIS), which lists who should be vaccinated and when, includes immunisation for diseases such as the flu and hepatitis B.

How has the response been? What is the proportion of adults who have had vaccinations since? Are we still seeing 100% coverage for children under the National Childhood Immunisation Programme? I know that there has been cases of parents who have refused due to misconceptions about potential side effects of vaccinations for the children. How can MOH reach out to them and convince them of the benefits? And finally, I would like to ask, are there more diseases of public health importance that can be addressed by a nationwide programme of immunisation? Thank you and I beg to move.

Question proposed.

Future-ready Healthcare System

Prof Fatimah Lateef (Marine Parade): Sir, we have a strong healthcare system, with strong, sound fundamentals. One of the most important characteristics that keep us at the forefront is the ability to robustly adapt and be dynamic. And this is unique in terms of healthcare because it is an area that is rapidly changing and developing. But this journey never ends. It is going to have to continue into the future. I have five areas that we have to focus on moving ahead.

Firstly, the balance of quality and affordability. We have been doing this a lot. We have been reviewing our policies, we have been liberalising, we have been doing all kinds of things and tweaking according to the needs of our population as we move into the future. We must continue to do this. We must review at regular intervals and we must make sure that we tweak accordingly and appropriately as well.

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The second area is really to embark on new models of care. This must be more in terms of ambulatory, more community based, more home-based care, more step down care and more intermediate care needs as we move forward with an ageing population. There will also be a need to review more preventive services and to have these made more widely available and accessible.

Thirdly, manpower. We need an adequate projection of numbers into the future of the pipeline for provision of care of the types of different healthcare personnel that we will need. The demand will be high in an industry which is really labour intensive. Our graduates from our traditional schools and institutions will continue to churn out numbers but the numbers will need tweaking as well and this will have to meet our demands. Perhaps also tapping on the retired personnel, who are still healthy will be an option to consider moving into the future.

In terms of innovation and productivity, healthcare, as I said, is a labour intensive patient-centric so we need to review that appropriately as well.

Fifth, it is data-driven healthcare which is really a must moving into the future. This will help us formulate guidelines and policies. KPIs must be reviewed regularly as well.

With all that in mind, I would like to ask Minister: first, on our healthcare productivity – how are we doing and how are our targets set and how are we moving ahead with this? Secondly, what will be MOH regulating framework for adopting new models of care for Singapore moving ahead with ageing on top of our minds. And, thirdly, can we also have an update on the progress of the regulatory sandbox licensing experimentation and adoption programme ( LEAP).

MediShield Life for Community Hospitals

Mr Murali Pillai (Bukit Batok): Sir, in 2017, I suggested that MediShield Life coverage be extended to patients who are directly admitted to Community Hospitals. The Ministry indicated that it would study my suggestion.

In Bukit Batok SMC, where I serve, residents have benefited from a range of in-patient services provided by St Luke’s Hospital, a community hospital dedicated to the elderly sick, over two decades.

The services extended by the Hospital have increased significantly and now includes, in addition to medical care, palliative care, rehabilitation care and dementia care. A change in MediShield Life coverage will help residents in paying for these "cares".

The hon Minister responded in 2017 by stating that MediShield Life was designed to provide coverage for large acute hospital bills and there is a need to guard against costs escalation. I would respectfully point out that there are benefits in right-siting the care of the patients at an appropriate healthcare institutions so that precious resources in acute hospitals are not stretched. I would be grateful for an update on this matter.

Private Ambulance Services

Ms Sylvia Lim (Aljunied): Mr Chairman, while SCDF ambulances attend to about 90% of emergency cases, consumers will call for private ambulances in emergency cases if they wish to send a patient to a preferred or private hospital and in non-emergency cases. For the consumer, however, the current lack of regulation has meant that there is patchy information on available services and vastly different consumer experiences. On the one hand, I have personally had good experiences with private ambulances. On the other hand, I hear less happy accounts from residents. Such feedback include high charges and a lack of advance disclosure or transparency about the costs of various services and equipment. others include asking the family to decide if certain equipment should be used en route which laypersons have little knowledge on.

Another concern is that private ambulances attending cases at HDB flats may not have the stretchers that can be manoeuvred into an incline position to fit the size of HDB lifts. The quality of the vehicles is also disparate with some ambulances apparently retrofitted from cargo vans. Some businesses insist on taking cash payments only which can be stressful if the charges come up to about $1,000 to be paid by the family in the middle of the night.

It was recently reported that regulation is coming in the form of the proposed Healthcare Services Bill. While this is welcomed by consumers as well as industry players, there are some concerns. One concern is the proposed distinction in licensing requirements between those operating emergency ambulance services and those operating medical transport services. The current proposal is that those licensed to provide emergency ambulance services would have more stringent requirements. For example, they will need to appoint a clinical director to maintain standards of comprehensive emergency care, to conduct audits, do training and protocol development.

In contrast, businesses who provide medical transport services in non-emergency cases do not need to meet the same standard but will have operational restrictions. For example, they will not be allowed to have blinkers and sirens. Operators have pointed out that patients who are initially stable cases can deteriorate suddenly en route to the hospital which will turn a non-emergency situation to an emergency one. When this happens, time is of the essence and blinkers and sirens may make all the difference. What is the status of MOH's review of the regulation regime?

Finally, to better facilitate consumer choice, could the Government arrange for a one-stop portal for consumers where they can evaluate the offerings and consumer feedback of private ambulance services? As for the reasonableness of the charges, will the Government consider publishing fee benchmarks so as to keep this essential service affordable.

Primary Care and CHAS

Dr Chia Shi-Lu (Tanjong Pagar): Mr Chairman, the CHAS programme, I am happy to note, has progressed significantly since its inception. Today, the majority of General Practitioners (GPs) clinics support it. A new CHAS card for chronic disease management was announced by the Prime Minister last year and I would like to ask for more details about this new card.

As the new card will cover all Singaporeans for chronic conditions, regardless of income, we can expect greater demand for the services of participating GPs. Does the Ministry expect more GP clinics to join the network and can we look forward to a 100% participation rate? What are the obstacles that still prevent clinics from joining? What plans does MOH have to help them?

Given the rise in median household incomes over the years, I would also like to ask if the qualifying income criteria for the Blue and Orange CHAS cards will be revised and also, if the benefits can be revised upwards, in addition to the new benefits announced, that is, the increased subsidies for complex chronic conditions and the extension of subsidies for common illnesses to Orange cardholders.

MOH has also stated that it aims to strengthen the private primary healthcare sector. MOH started the Primary Care Networks (PCN) scheme in January 2018, where GPs come together to provide holistic team-based care for their patients. Would MOH please provide an update on this scheme? It was announced during the Budget Statement, that the Ministry “will be looking at how to help CHAS clinics better track their patients’ progress and outcomes”. Can this tracking process also be enabled at the PCN level?

Personalised Medicine

Mr Low Thia Khiang (Aljunied): Mr Chairman, Sir, personalised medicine involves the customisation of medical treatments to specific patient groups based on genetic profiles.

At last year’s MOH COS, I asked the Minister whether MOH was on track with drafting the code of practice for clinical genetic testing. Minister replied that the Ministry was developing an integrated national strategy for precision medicine research and implementation; and would provide a thorough update at an appropriate time. It has been a year since, hence, I would like to ask for an update.

There have been reports that hundreds of patients have benefited from personalised medicine treatments at our public hospitals. I would like to know how many Singaporeans have benefited to date?

I have three concerns. First, precision medicine is a fast-developing field of clinical research and application. I am concerned that the longer we take in enforcing the code of practice and implementing the national strategy, developments in the field would have outpaced the code and strategy.

Second, if a substantial number of Singaporeans have already obtained personalised medical treatments, then the delay in enforcing the code of practice may expose these Singaporeans to the misuse of their personal and DNA data, medical risks associated with DNA-editing and other bio-ethical risks.

Third, last November a Chinese scientist used gene-editing technology in an experiment that led to the birth of the world’s first genetically modified baby. There was an international uproar and the Chinese Government is putting in a regulatory regime now in response. I am concerned that the longer we take, in regulating precision medicine and genetic testing, we may run the risk of such an incident happening here that will damage our reputation as a biomedical R&D hub.

Data Security for National Electronic Health Record (NEHR)

Assoc Prof Daniel Goh Pei Siong (Non-Constituency Member): Mr Chairman, the SingHealth's cyber attack and HIV Registry leak have shaken confidence in the security of our personal and patient information and health records. Learning from these events, how will the personal and patient data be kept in NEHR be better secured and protected against hacks and also leaks by administrators, doctors, finance staff and researchers.

In 2018, a joint survey on public sentiments towards the NEHR showed that over 11% of respondents said they would prefer to opt out of the NEHR and 56% said they would like to have their records maintained in NEHR but do not want any healthcare provider to access it without their explicit consent except during emergencies. This negative sentiment preceded the SingHealth's cyber attack and HIV Registry leak. Thus, the Government will need to get better buy-ins for the NEHR from the public now. Should the NEHR be minimally covered by the PDPA and the data protection regime that provides for additional safeguards and is patient-centric? Such a move can improve public confidence as many are now familiar with the PDPA framework. Small private clinics will need extra help to secure the data.

Patient Electronic Records

Ms Sylvia Lim: Mr Chairman, Singapore has been centralising patients’ health records through the National Electronic Health Record System (NEHR). The benefits of convenience are evident. Patients can go to any healthcare facility and receive treatment that takes account of their medical history. However, the recent MOH data leaks and the cyberattack on SingHealth, have shaken the public confidence in such centralised electronic health records. These incidents targeting patients’ personal records are reminders of the risks to privacy and security that accompany convenience, risks which we had not understood or taken seriously enough.

MOH has announced that primary care providers such as private GPs will be required to enter case notes into the NEHR. This has been held in abeyance while MOH does a thorough of cyber security. However, even before the recent breaches, some GPs in private practice told me they had grave reservations about the impending requirement for them to key in confidential data about their patients into the NEHR. They cited that they had a duty of doctor-patient confidentiality and were not comfortable keying in the medical conditions and drugs prescribed to patients, for review by unknown persons down the line. In view of the potential for unauthorised access or leaks, they would also be reluctant to put in sensitive information, however relevant to treatment.

Sir, we must acknowledge that even with the best fortifications, cyber defence is an endeavour that pits us against potentially the most technically advanced and resourced hackers in the world. There is also the risk of disgruntled or rogue employees who can exploit legitimate access for improper purposes. As it is impossible to completely prevent hacks and data breaches, one key concern would be to limit damage in the event of breaches.

To mitigate the risks and fallout from data breaches, common and effective measures include improvements in ways to store and access information, such as data compartmentalisation and restrictions on authority. For instance, it would be odd for persons responsible for macro-level policy to access personally identifiable information. It would also be unnecessary for staff not attending to a particular patient to access the patient’s records. There may be particular sensitivities if certain information gets into the wrong hands. In view of all this, I would like to ask what the Ministry of Health has done, or is doing, to compartmentalise data and limit who can gain access to data stored at MOH and at the healthcare providers it regulates.

Cybersecurity – Protecting Medical Information

Mr Christopher de Souza (Holland-Bukit Timah): Mr Chairman, patient data is often – and sometimes very – sensitive. It is personal as it may contain information relating to medical conditions and diseases that the patient may want to keep private. The release of this information could cause turmoil to the patient and his or her family – leading to serious stress in relationships. To ensure IT and cyber security specialists operating within the specialised sphere of medical information are trained well and that standards are kept high across health clusters and the many hospitals, would the MOH consider setting up a Medical Cybersecurity Academy to train a core group of medical cybersecurity specialists, share best practices between them and then steadily raise the industry standard such as to protect medical records and the related information contained in them?

Affordability for an Average Singaporean

Ms Tin Pei Ling (MacPherson): MediSave, MediShield Life and Medifund are the three pillars of our public healthcare financing system supporting the healthcare needs of all Singaporeans. These are on top of the universal Government subsidies available. On top of these, the Government introduced different schemes to help Singaporeans, especially the elderly, better cope in their old age.

Objectively, we know that public healthcare expenditure has more than doubled within a short span of five to six years. Singaporeans’ average out-of-pocket expenditure as a percentage of bill size has also trended downwards.

Still, worries about healthcare affordability persist. Some Singaporeans genuinely cannot afford it, some struggle to pay it off, and some do not even seek treatment because they do not know if they can afford it.

For the low-income, they can apply for Medifund or public financial assistance if they pass the means test. This will cover their medical expenses in public healthcare settings. In the course of my community work in MacPherson, I have met many low-income residents, especially vulnerable elderly, receiving full medical coverage under such schemes. This is assuring to observe. However, for the average Singaporean, the ability to afford or continue to afford is less certain.

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Hence, I would like to ask the Ministry how ready is an average Singaporean in coping with his/her healthcare cost, especially in old age? Could the Ministry share the calculations and projections? Could the Ministry compare how an average retiree today and an average retiree in, say, 2030 or beyond, cope with their expected healthcare costs? Is our current public healthcare financing method sustainable?

Value-based Healthcare

Mr Leon Perera (Non-Constituency Member): Sir, Singaporeans are still concerned about the cost of healthcare. A recent REACH survey concluded incidents like the recent furore of MediShield Life not covering much of a certain bill, do not help. Some Singaporeans go to Johor Baru (JB) to purchase medication.

Other than other pocket expenses, there is concern that premiums for MediShield Life and IPs may rise in future. Thanks to healthcare inflation.

Going forward, can we find cheaper ways to deliver the same healthcare outcomes? Value-based healthcare (VBH) which was conceptualised in the University of Utah in the US is a healthcare delivery model in which providers, including hospitals and doctors, are paid based on patient's health outcomes. Value-based care differs from paying providers based on the amount of healthcare services they deliver. While it is hard to summarise how this works in practice in under two minutes, it involves practices like sharing of data across physicians, to prevent redundant testing and adjusting payments to hospitals based on good care practices.

While there have been trials by organisations, no national healthcare system has implemented VBH on a national level yet. But I understand that many companies are developing solutions for VBH in anticipation of an eventual VBH revolution in healthcare. Amazon, Berkshire Hathaway and JP Morgan Chase have a joint venture to champion elements of VBH as a disruptive healthcare solution.

I understand that NUHS has adopted a value-driven outcome initiative (VDO). NUHS states that the true ideas from VBH concept from University of Utah and has shared the concept with public healthcare clusters in Singapore.

I would like to ask the Government whether it would study the VBH approach, conduct pilots and move towards a comprehensive adoption of VBH or its equivalent across the entire healthcare system if results are positive. If so, when is the target date for a more broad-based adoption of VBH and would a roadmap be published?

MediSave Limits for Long-term Care

Assoc Prof Daniel Goh Pei Siong: Chairman, from 2020, severely disabled Singaporeans will be allowed to draw up to $200 a month from MediSave for long-term care needs. However, this is very limiting for those with more than $20,000 in their MediSave Accounts. This is especially if the long-term care is the only medical cost that they have to deal with, and that which the care is effective and preventive, it will minimise additional medical expenses.

The current limit of $200 is prime for 100 months. However, the median duration of stay in a nursing home is 59 months. Why not peg the limit to the median duration instead? The Government should consider increasing the maximum quantum to $600, scale up according to the amount in the member's MediSave savings.

If the Member has $20,000 in his/her MediSave Account, he/she can draw up to $300 a month as $20,000 will cover 60 months of stay in a nursing home. If the member has $40,000, he/she can withdraw up to $600 a month. This may be a more efficient and effective way for severely disabled Singaporeans to make use of their MediSave savings to meet their long-term medical needs.

MediSave Withdrawal Limit

Mr Muhamad Faisal Bin Abdul Manap (Aljunied): Sir, as Members of this House, I believe many of us may have been asked by residents, relatives, friends and acquaintances who are unhappy with the use of CPF, on why should there be a limit set for the use of all MediSave money and why is the allowable amount to be utilised annually so minimal.

Sir, for the first question on the limits set for the use of MediSave, I will share with them MOH's explanation, that is, the setting of the withdrawal limit is with the intention to ensure that Singaporeans have sufficient in their MediSave Account for their basic healthcare needs in old age.

For the second question, my reply would be, "Sorry. I do not have the answer."

Therefore, Sir, I would like to ask the Ministry the following questions pertaining to MediSave withdrawal limits.

One, how is the withdrawal limit amount as well as the incremental amount being tabulated and arrived at? Is there any specific formula applied and if yes, can the Ministry share this formula?

Two, how regular is the review on the withdrawal limit conducted? Is there any specific cycle or is it on situational basis, for example, review will be conducted when there is an inflation in the healthcare cost?

Third, who are involved in this reviewing process?

Sir, the answers to the above questions may not be able to address or lessen the unhappiness. However, it will provide some clarity and transparency on the matter.

The Chairman: Mr Pritam Singh, you can take your two cuts together.

Greater MediSave Flexibility

Mr Pritam Singh (Aljunied): Sir, this cut seeks to explore whether the Ministry can grant Singaporeans greater flexibility to use more of their own MediSave to pay their hospital bills. This is particularly for bills which are not covered by MediShield Life or because the amount owing is within the deductible limit and hence, must be settled solely by the patient in cash or MediSave.

In such cases, MediShield Life does not kick in because it is meant for larger hospital bills. While MediSave can be used, it is subject to limits and, in many cases, a few hundred dollars will still have to coughed up in cash. I believe there is scope for the Government to exercise some flexibility and give Singaporeans the choice of allowing the entire remaining amount after subsidies to be paid by a patient's Medisave instead of cash, bearing in mind the matter involves a hospitalisation.

For citizens with sufficient MediSave balances, and who are in their senior years from the age of 60, in particular, some additional flexibility in terms of choice, would bring significant peace of mind, leaving cash in their pocket.

I hope the Government can look into this to reduce the out-of-pocket expenses for this category of Singaporeans. For example, can the Government consider a tiered-withdrawal quantum for those above 60, not too dissimilar from the MediSave withdrawals for Long-Term Care announced in July last year to achieve a sustainable balance between the use of member's MediSave savings for the immediate term and the future respectively?

Compulsory Insurance – Adequacy Ratios

Chairman, Sir, CareShield Life and MediShield Life are both compulsory schemes with the former soon to become a central pillar of our healthcare system. The public cannot opt-out of either scheme and this fact alone brings into sharp focus the premiums of compulsory risk pooling schemes. It would follow that the adequacy ratios of such schemes and the Government's reasons and assumptions behind premium pricing should be made more transparent so that the public can understand the factors behind premiums calculation.

One of the pain points that was manifested through public discussions prior to the debate in this House on the CareShield Life White Paper last year surrounded the fact that from 2002 to 2016, ElderShield collected $2.6 billion in premiums, and only slightly in excess of $100 million was paid out. The importance of pre-funding for such schemes aside, a general lack of understanding contributed to the public dissonance on the issue, as the numbers suggest over-collection of premiums. I appreciate that the actuarial models that determine how premiums are priced are complex and multi-faceted. Some factors include disability mortality, recovery rate, claims continuance rate, improvements to mortality as well as the risk profiles of various cohorts amongst others.

However, complexity should not be a reason to avoid publishing these considerations and the weightage of the calculations behind them. With the upcoming legislation of CareShield Life, I hope these assumptions and considerations can be meaningfully communicated to all Singaporeans.

On a similar note, I would like to enquire about the frequency with which MediShield Life's adequacy ratio is reviewed by the MediShield Life Council and considered by the Ministry, so as to ensure that the greater transparency on reserve requirements called for in the MediShield Life Review Committee report are meaningfully operationalised. I understand the FAQ section on MediShield Life on the MOH website provides a helpful table, setting out the incurred loss ratio of the scheme each year.

Can the Minister share, in light of MediShield Life transitional subsidies ending this year and the incurred loss ratios over the years exceeding 90% so far, does the Council foresees an increase in premiums in the near future?

Sir, I believe transparency can help control healthcare costs by widening debate and scrutiny. It also helps create the peace of mind that all is done to ensure the affordability of these compulsory insurance schemes. In the absence of such knowledge regarding spending, insurance may be inaccurately perceived by some as a pure tax, rather than a risk-pooling scheme that is closely tied to each participating cohorts' expected benefits.

Helping Expectant Mothers

Mr Christopher de Souza: Mr Chairman, arising from feedback I received from Singaporeans who went through difficulties during and after giving birth to their baby, I had asked in October last year whether MOH could consider extending additional financial support for expectant mothers who find it difficult to obtain maternity insurance from private insurance companies due to previously-experienced pregnancy complications. MOH said then that a review was being conducted for serious pregnancy and delivery complications. Could MOH provide an update on the review, please?

Integrated Shield Plan

Mr Mohamed Irshad (Nominated Member): Mr Chairman, from 1 April 2019, Singaporeans who purchase new Integrated Shield Plan riders will no longer be able to purchase "full-rider" policies and must be prepared for co-payment of at least 5% of the medical bill.

The Health Ministry explained that this change is aimed at "full rider policies which encourage a "buffer syndrome" which leads to over-consumption, over-servicing and over-charging of healthcare services, which could, in turn, lead to higher fees and premiums over time. I support this but it looks like most of the abuse comes from patients in private hospitals.

The Straits Times reported that the average total in-patient bill in the private sector has increased by 9% each year over the last 10 years, from 2007 to 2017. This is almost double the 4.9% increase for bills in the public sector's Class A wards.

From the numbers, it looks like there is lower risk of over-spending in the public hospitals. The less financially savvy patients rely heavily on the hospital and their doctors to determine the course and cost of treatment. This risk is further mitigated by the implementation of cost benchmarks in public hospitals.

In that light, will the Ministry consider having co-payment on Integrated Shield Plan riders only for private hospitals and have zero or lower co-payment for claims relating to public hospitals?

Affordability

Ms Joan Pereira (Tanjong Pagar): Sir, I would like to ask the Minister what measures the Ministry has in place to ensure that healthcare remains accessible to all, its costs affordable, and whether more subsidies for a wider range of generic drugs can be included.

First, one of the most effective ways to keep costs down is to provide transparency, thereby encouraging healthy competition among providers. Patients should have access to more information which include not only fees but also standard or quality of delivery.

Presently, fee benchmarks and bill amount information for common surgical procedures for both public and private hospitals are available on MOH's website. I hope it is also possible for MOH to provide more qualitative information.

Second, besides providing more subsidies for more generic drugs, additional assistance for needy patients for drugs should also be well-understood by all public hospital staff so that they can advise patients accordingly. This issue was highlighted in the newspapers recently by members of the public. It appeared that the affected patients and family members were not informed of the Medication Assistance Fund (MAF and MAF Plus), which is different from Medifund. MAF subsidises non-standard drugs prescribed for Pioneer Generation or Community Health Assist Scheme (CHAS) cardholders.

Finally, may I request for the Ministry to look into increasing our Seniors' Mobility and Enabling Fund (SMF) subsidies.

Mr Charles Chong (Punggol East): Mr Chairman, a number of speakers before me have already raised most of the points which I have so I will not repeat them and I will be very brief.

As Singapore's population ages, one of the issues which will be of increasing concern of our citizens is the affordability and the accessibility of healthcare. Given the importance and the relevance of this issue for most Singaporeans, I am sure the Minister will provide some updates on what is being done or can be done to ensure that healthcare remains affordable for Singaporeans. In particular, are there plans to use technology and medical advances to increase efficiencies, reduce doctor time and empower other professionals within the healthcare ecosystem such that costs can be contained?

Could the Minister also clarify the extent to which generic drugs are used as another means of reducing costs? I believe Ms Joan Pereira has already raised this. Could MOH also provide comfort to patients that generic drugs are just as efficacious as brand named drugs?

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Merdeka Generation Outreach

Dr Chia Shi-Lu: Chairman, the Merdeka Generation Package (MGP) is a wide-ranging and comprehensive package of measures that addresses concerns that the Merdeka Generation would have regarding healthcare affordability.

What are MOH's plans to reach out to the MG seniors to let them know about the MGP and support their aspirations for active ageing?

In particular, I note that the package includes a participation incentive of $1,500 to join CareShield Life on top of the previously announced $2,500. The total incentive of $4,000, together with the higher lifelong payouts, should be highlighted to the seniors during outreach activities, as they may be concerned about the higher monthly premiums.

With longer lifespans, the risk of more seniors facing severe disability in their latter years is higher. We can see for ourselves today, within our communities, many of the old-old, as we move from an aged society to a super aged society, and with the old-old defined as those age 85 years and above, needing help with at least three out of six Activities of Daily Living (ADLs) – washing, dressing, feeding, transferring, toileting and walking. This proportion is growing higher day by day. Affected seniors covered under CareShield Life will qualify for lifelong payouts, compared to only six years for the previous ElderShield400 system, and this will be very useful for paying for care assistance or necessary consumables.

Singapore Medical Council (SMC) Complaints Procedures

Mr Leon Perera: Sir, on 2 March, Senior Minister of State Mr Edwin Tong announced that MOH will be doing a very comprehensive review of the entire medical regulatory landscape as overseen by the SMC, including reviews of disciplinary processes.

I have several questions and suggestions on how these disciplinary processes currently operate and what would be the parameters governing the pending review.

Firstly, the current process allows complainants to appeal to the Minister should they be dissatisfied with the ruling of the Complaints Committee (CC). I understand that MOH has signalled its intent to do away with this avenue of appeal in future. But that reform may take time to implement. For now, I would like to ask, how does this appeals review process operate within MOH? It would seem to be opaque to many in the profession. What expertise and skill sets and processes are brought to bear in considering such appeals within MOH and what sorts of personnel are involved?

Next, once a complaint is escalated to an SMC Disciplinary Tribunal (DT), it is my understanding that lawyers begin to play a key role in the process. What measures are being taken to minimise the legal fees incurred by the SMC for DTs which are paid by insurers, since this has the potential to elevate medical indemnity insurance premiums borne by doctors?

Next, will the review process yield changes to reduce the long time period often associated with the CC and DT processes? And can the Government consider if disciplinary action for more minor complaints can be addressed by a different form of committee than a DT, to reduce the considerable time and cost associated with the DT process.

Lastly, the Government currently appoints the majority of members of the SMC. What is the Government doing or will do to correct any perception now or in the future that the SMC is insufficiently independent of the Government? If any such perception took root, it may erode confidence among doctors of getting a fair hearing, which in turn could lead to things like defensive medicine, which can escalate costs and worsen efficiency.

Allied Healthcare – Career and Training

Mr Christopher de Souza: Mr Chairman, allied healthcare workers such as nurses, physiotherapists and speech therapists play a key role in supporting the overall medical care of the patient. I had previously asked how we could formalise their continuing professional development, career progression, and the sharing of best practices within the allied health profession. Would MOH be able to provide an update on the steps taken so far to help achieve this outcome?

More Singaporeans in Nursing

Mr Dennis Tan Lip Fong (Non-Constituency Member): Chairmain, demographics have only increased the demand for healthcare. In the Government's Healthcare Manpower Plan 2020, released in October 2016, the healthcare services estimated an addition of 30,000 healthcare workers by 2020. With more hospitals and polyclinics coming online in the communities to establish the key infrastructure for delivering healthcare needs to our people, it is time to look at the manpower available to operate and manage both new and existing infrastructure.

A strong local core is important as healthcare needs are better served with cultural understanding. I would like to seek clarification from the Ministry on the plans to build a "strong local workforce" in accordance to the Healthcare Manpower Plan 2020; how is the Ministry monitoring and ensuring that enrolment figures and local graduate figures translate to reinforcements to the nursing manpower, and then retaining the local graduates to meet the long-term plan of building a strong local workforce?

I ask as the number of local nursing graduates have been gradually decreasing since a peak of 1,744 graduates in 2012, to 1,479 graduates in 2015. During the COS debate in 2017, Dr Amy Khor stated that the foreign workforce for nursing is 33%. Even as we have learnt that the reduction in services DRC will not impact healthcare operations, how has this percentage shifted with the introduction of conversion programmes available at the tertiary institutions, such as SIT, and the push to increase intakes to the healthcare courses?

The retention rate of new healthcare workers will also be a key measure of sustainability of our healthcare operations. What is the attrition rate and average tenure of nurses and other healthcare workers? Is the suite of measures to retain the local graduate healthcare workers in the industry sufficient? And what are common reasons for healthcare workers leaving the workforce?

Allied Health Professionals

Dr Chia Shi-Lu: Chairman, besides doctors and nurses, Allied Health Professionals and TCM practitioners make significant contributions to our healthcare eco-system. In a rapidly ageing country like ours, there will be greater demand for their services, particularly for therapists, psychologists, audiologists, dietitians and medical social workers, just to name a few. They are an integral part of a healthcare system which delivers comprehensive and seamless care.

Sir, I have four questions. One, how is MOH ensuring that we will have a steady pipeline of Allied Health Professionals, given the need for holistic care; two, will there be measures to upskill and better empower of nurses to take on a greater role in our healthcare system, given our tight labour market and the heavy work burdens of our nurses; three, in addition to the training and development of these professionals through the traditional career progression pathways, would the Ministry elaborate on measures to attract those interested in making a mid-career change to these professions; and lastly, how would the Ministry ensure that the remunerations of those in the public sector remain competitive?

Engaging VWOs in Intermediate and Long-term Care (ILTC)

Mr Leon Perera: Sir, I declare my interest as the CEO of a research consultancy that undertakes work in the silver industry, among other sectors. Voluntary Welfare Organizations (VWOs) figure prominently in the Intermediate and Long-Term Care (ILTC) sector. It is in our interest to ensure that these VWOs flourish in the long-term and become sources of good quality care.

I have a few questions and suggestions for improving the intersection between the Government and VWOs in ILTC, though some of these points may apply to private sector developers and/or operators of ILTC facilities as well.

Firstly, the tendering process takes into consideration a range of factors, but by virtue of convention, public tendering tends to create pressure on bidders to bid higher or lower, if it is a tender for operating services and not land. And this is not a bad thing, value-for-money is an important consideration.

Nevertheless, the ILTC sector is a space where innovation and experimentation is still relevant. There should be space for facilities in our ILTC sector which are unorthodox, and which may come with a higher price tag, as it were. What is the consideration given to striking the right balance between quality and innovation on the one hand and cost on the other?

Secondly, what steps are being taken by the Government to further empower and help VWOs in the ILTC sector in terms of funding, manpower and organisational development? Capacity-building is one area where VWOs may face challenges.

Lastly, in growing the ILTC sector, the VWO sector may need to be augmented by the private sector, which has potentially a substantial capacity to invest financially, as well as, in some cases, to deploy relevant, cutting edge technology. What is the Government doing to engage and support good companies to invest in this sector and possibly to partner with our VWOs?

Advanced Care Planning

Prof Fatimah Lateef: Sir, advanced care planning is a sensitive area, and more so in our multi-religious and multi-ethnic society. Many lack the genuine understanding of what it is, and it also stems from the fact that it is a taboo subject many choose not want to talk about and they feel discomfort in discussing it. It cuts across all ages because talking about death and the end of our lives is really not the easiest thing.

As a result many lack the understanding and may be unaware of the important decisions and options they have or have to make, whilst they still can. In my work as an Emergency Medicine Specialist, people come in with critical and serious illnesses and presentations, many even stemming from many years of harbouring a chronic illness or diagnosis, and yet, not having an ACP done at all. We then have to discuss with them or the next of kin, at this critical juncture, in order to have a decision to be made pertaining to the level and depth of care and resuscitation they wish. Many grapple at this stage as they may not know what their loved ones wish for. They may never have broached the topic and have a sense of guilt can prevail.

Choosing to know, learn and decide on advanced care planning is really something we may need to do. How is the Ministry send out more educational messaging and campaigns, perhaps to be executed in a sensitive way and also perhaps working across Ministries – MOH, MSF and other partnering organisations, VWOs and NGOs; perhaps also getting our IROs and IRCC to talk as well in our society.

The Chairman: Minister Gan Kim Yong.

The Minister for Health (Mr Gan Kim Yong): Mr Chairman, I would like to thank the Members for their thoughtful comments. With your permission, may I share a slide at the end of my speech?

The Chairman: Yes, please.

Mr Gan Kim Yong: Dr Chia asked for an update on our overall healthcare system. Let me begin by reviewing our overall state of health. Singapore's overall health outcomes are generally good. The Global Burden of Disease 2017 Study (GBD) published in The Lancet ranked Singapore favourably as the country with the highest Life Expectancy. Our Life Expectancy at birth has risen from 83.2 years in 2010 to 84.8 years in 2017. Health Adjusted Life Expectancy (HALE) at birth also increased from 72.9 years to 74.2 years over the same period. But these figures also show that we are living about 10 years of our lives in ill health. For every 10 years we live, we spend more than a year in illness.

These findings are not surprising. The mortality rates due to cancer, stroke and heart diseases, have reduced significantly by 16%, from 2010 to 2017. This was made possible in part due to the early prevention, better treatment and disease management, which have contributed to our increase in life expectancy.

However, it is not time for us to celebrate yet. The recent Bloomberg report also reminds us that we need to keep up on our efforts. Data also shows that many of us are living with chronic illness. From 2010 to 2017, the prevalence rates of diabetes, hypertension and hyperlipidaemia among Singapore residents aged 18 to 69 years have increased by 4%, 14% and 33% respectively. This is partly due to an older population, but we cannot blame everything on an ageing population because it is also partly due to unhealthy lifestyles and habits. If these chronic conditions are not managed well, more serious conditions may result further down the road.

On capacity and accessibility, we have stepped up our building programmes. We have completed seven hospitals since 2010 which will add up to about 3,800 number of beds when fully opened. In 2018 itself, we opened the new CGH Medical Centre, Sengkang General and Community Hospitals, and earlier this year, the new National University Centre for Oral Health Singapore commenced operations.

We also injected a significant supply of aged care services, especially in home and community care to encourage ageing in place.

We have been training and recruiting healthcare professionals to meet our manpower demand. The number of registered doctors rose significantly, by 52% over the period from 2010 to 2018. Local medicine intake increased by some 60%, from about 300 to about 500 today. Together with Dentistry and Pharmacy, the total intake now exceeds 700 a year and contribute to a strong local pipeline, reducing our need for foreign-trained professionals.

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Registered nurses have also increased significantly by 44%. While we had a record local nursing intake of over 2,100 students last year, we will still need more, especially in the critical community care sector. Senior Minister of State Khor and Senior Parliamentary Secretary Amrin will share more about opportunities for nursing and allied health professions later.

Our expenditure on healthcare has increased, too. Since 2010, Singapore’s national healthcare expenditure has almost doubled, from $11 billion to reach $21 billion in 2016. Government Health Expenditure (GHE) increased even faster, by 2.4 times, from $3.9 billion to $9.3 billion. We have more than doubled the amount of direct Government subsidies given to Singaporeans from about $2.6 billion to $5.6 billion over the same period. And this has helped to keep healthcare affordable, especially for needy Singaporeans.

However, it is unsustainable for us to continue increasing our national healthcare expenditure at this current rate. And I agree with Prof Fatimah Lateef that our healthcare system has to transform the way it delivers care and we must continue to refine our way of funding healthcare services. As individuals, each of us must also take responsibility for our own health.

Our healthcare institutions are doing their part to transform their healthcare models. Polyclinics, for example, have been experimenting with new ways to enhance chronic disease management. The National Healthcare Group Polyclinics (NHGP) have piloted a teamlet care model since 2015. By assigning patients with chronic diseases to the same team comprising family physicians, nurse care managers as well as care coordinators, there is better continuity of care. As a result, patient outcomes have improved, with more regular preventive health screenings done, and visits to the doctors and emergency departments reduced. SingHealth Polyclinics (SHP) and National University Polyclinics (NUP) are also rolling out team-based care models.

Private GPs are our key partners in primary care, too. The Primary Care Network (PCN) started as a ground-up initiative by GPs from the Frontier Healthcare Group to share resources and improve chronic disease management. Senior Minister of State Lam will share more about the progress of the PCN scheme.

Similarly, we are working towards transforming care at the community level to better integrate social and healthcare services. Community care providers are also doing their part. Some of them are piloting innovative ways to enhance patient care and safety. For example, several of our community care providers, such as All Saints Home, have introduced new sensor mats to monitor residents’ movements so as to prevent falls and to provide better care.

To catalyse efforts on care transformation, we set up the MOH Office for Healthcare Transformation (MOHT) in 2018. MOHT has been working with partners to design innovative healthcare pilots, such as the new Integrated General Hospital (IGH) model piloted at Alexandra Hospital (AH). This model particularly benefits patients with multiple active conditions, who would typically be attended to by a few specialists during each admission. Under this new IGH model, one care team will look after each patient for better integrated care.

Let me give Members an example of Mr Kang Swee Hiang. Mr Kang is an 81-year-old senior who lives alone and was recently admitted to AH for uncontrolled hypertension. He has a number of active medical conditions but he was looked after by one care team, without transfers across wards and doctors. The care team found that Mr Kang's cataracts made it very difficult for him to take his medications and may increase future fall risks. The team then reduced the pills he had to take, and counselled him on how to take them properly. He also underwent cataract surgery and received physiotherapy, too. They also engaged community partners to schedule befriending and home care services, and connected Mr Kang to the Social Service Office for post-discharge assistance and support. AH is now working to consolidate his outpatient care under one principal doctor.

About 4,000 patients have benefited from Phase 1 of the IGH model, which focuses primarily on inpatient care. While efforts under Phase 1 will continue, MOHT and NUHS have commenced Phase 2, which aims to better integrate hospital care with community services required by patients living around Queentown. Dr Chia will be very happy to know that this pilot will be in Queenstown. It is still early days, and these efforts will need to be fully developed and evaluated before scaling up.

MOH will continue our care transformation efforts, in line with our strategy to move Beyond Hospital to Community, Beyond Quality to Value, and Beyond Healthcare to Health. However, there are a few key challenges ahead of us.

First, we have to strengthen the robustness of our healthcare IT systems, including data privacy and security. As highlighted by Mr de Souza, IT and data play an important role in our care transformation journey as they help to better inform policy, ensure continuity of care, and allow innovative care models to evolve. The NEHR system, for example, is an important, large-scale national system designed to better support patient care. Prof Goh and Ms Lim asked about the safeguards in place for NEHR to ensure patient confidentiality. Broadly, there are three levels of safeguards.

The first is the protection against cyber-attacks and unauthorised access. There are several lines of defences before the NEHR database, with intrusion detection at each line. Regular security audits are conducted, with the most recent penetration test done in October last year. In addition, there are ongoing robustness tests conducted by CSA, GovTech and an independent third party PwC. At the user level, the NEHR should only be used for direct patient care. There are strict controls to protect against unauthorised access. The NEHR system also does not allow users to download records onto workstations.

As highlighted by Mr de Souza, having well-trained IT and cybersecurity specialists familiar with healthcare is key. MOH, with CSA’s support, is working to ensure that technical training for our cybersecurity specialists meet industry’s best practices and standards. Good cyber-hygiene practices are regularly shared with all public healthcare staff.

But we must assume that persistent attackers will not give up and they will eventually get through, despite the strongest protection. Therefore, the second level of safeguards is having proper detection and enforcement measures to pick up any breaches quickly and escalate to the appropriate level for prompt investigation and containment. All NEHR accesses are logged and subjected to monthly audits, using analytics to detect unusual usage patterns. IHiS plans to roll out a feature that will allow patients to view accesses made to their NEHR records so that they, too, can report any suspicious access.

The third level is deterrence. We must take stern action against anyone who is responsible for data breaches, including our staff who have failed their duties. This way, we can ensure a strong data protection system.

Sir, our next challenge, as highlighted by many Members, is to keep healthcare affordable. As Mr Charles Chong pointed out, all stakeholders must work together to ensure that our healthcare system will be sustainable not just for our current needs but also for the needs of our future generations.

As our Minister for Finance has announced in his Budget speech, we will be launching the Merdeka Generation Package (MGP) this year. The MGP is our way of honouring this Merdeka Generation for their unique contributions in shaping the nation during our formative years. The Package is designed to support MG seniors in leading a healthy and active life as they age, and to provide assurance that they will be able to afford their care expenses. Senior Minister of State Khor will share more details on MGP later.

Senior Minister of State Tong will update on our proposed enhancements to the Community Health Assist Scheme (CHAS) so that all Singaporeans will have access to affordable quality primary care, especially for their chronic conditions.

Healthcare providers and professionals, too, play an important role in keeping healthcare costs in check, through ensuring efficient operations and abiding by appropriate pricing and clinical practices. We had introduced fee benchmarks last year to provide all stakeholders with a useful reference on appropriate fee levels. We have also studied best practices and approaches on value-based healthcare in the US and elsewhere – which Mr Perera asked about – and adapted it to our local context. It is also difficult for me to explain value-based healthcare in two minutes. So, I will try to be brief.

Since 2017, MOH has appointed a National Value-based Healthcare (NVH) Workgroup to look into this. By comparing standardised clinical quality indicators and cost data across our public healthcare institutions, it will help our healthcare providers to identify best practices among them as well as identify opportunities to improve clinical outcomes in a cost-effective way. More work will need to be done and we are continuing to explore this.

Insurance allows risks and resources to be shared across all members in the pool, helping patients to cope with large and unexpected healthcare costs. This is why we have MediShield Life and, soon, CareShield Life. We will continue to explore how we can further strengthen the role of insurance as we move forward.

Lastly, individuals have the responsibility of saving for our own healthcare needs during our working years, including through MediSave, to meet our future needs when we grow old. We also have the responsibility to make well-informed decisions to choose appropriate healthcare services.

But the most effective way to keep healthcare affordable is to stay healthy. The next challenge is, therefore, to take more decisive steps to encourage healthy living. Three years ago, I declared war on diabetes in this House. This is probably the only war that the Parliament has ever declared. We have made some progress but we do need to push harder. We held a Ministerial Conference on Diabetes last year and one of the key takeaways is that to tackle diabetes effectively, we need a coordinated effort by all stakeholders, not just MOH.

In the year ahead, we will step up our efforts on several fronts, reducing diabetes-related amputations, empowering patients and healthcare professionals to better manage diabetes and minimise complications. In particular, we are also recommending the use of non-fasting screening test for diabetes to increase screening rates, and will make early screening more convenient for women with a history of gestational diabetes. My colleagues will elaborate more on these efforts later.

Smoking is another area that we need to move more swiftly and strategically on. Tobacco use is the second-highest contributor to Singapore’s disease burden. More than 2,000 Singaporeans die prematurely from smoking-related diseases each year, and the social cost of smoking in Singapore has been estimated to be at least $600 million annually. We will continue to work on reducing smoking rates.

However, despite our best efforts to stay healthy, we may still fall ill and become frail as we age. Care-givers will need greater support as they will play a key role in caring for the sick and frail among us. With an ageing population and longer life expectancy, care-giving needs will rise, with family and informal care-givers playing an increasingly important role. Many will have to balance their work and family responsibilities. There is, therefore, greater urgency for the society to come together and collectively support our care-givers, and ensure that adequate “hardware” and “heartware” are in place.

Sir, allow me to share the story of Mr Tang in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] Mr Tang, who is 42 years old, heads the business development department of his company. In the past year or so, Mr Tang has been caring for his 81-year-old father with dementia, together with his mother, wife and siblings. While his mother is the main caregiver, the other family members also take turns to help care for his father. Although Mr Tang and his family faced challenges adapting to his father’s behavioural changes, it was fortunate that his wife works in the healthcare sector, and the family was able to identify various avenues of support and help.

Nonetheless, not all caregivers are equipped with such knowledge, or have other family members to share the caregiving burden. With our ageing population, caregiving needs will grow and we need to strengthen the support for our caregivers. We need to increase awareness of the resources that are available to caregivers, and more systematically match these caregivers to the help they require.

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(In English): I have spoken about our progress, transformative initiatives that can change our care models, and MOH’s focus areas for the next three to five years. But at the heart of our healthcare strategies, is people – people like you and I. MOH and our healthcare providers can only do so much. For every “top-down” programme, we need many “ground-up” support and initiatives. Each of us must actively take charge of our health, and come together as a community, or just as a group of friends, to support one another.

This is why I find the example of “Team Strong Silvers” so inspiring. Team Strong Silvers is small, but mighty. It is a group of friends with a common interest in health and fitness who decided to form a senior citizens’ interest group in 2013. Just like its name suggests, the members build up their strength through calisthenic exercises. The team hopes to encourage more seniors to age actively, and to inspire younger generations to invest in their health from an earlier age. I am glad to see the team actively spreading the healthy lifestyle message via social media and even carrying out on-site fitness training sessions for other seniors. With more seniors like them, I am hopeful that we will add more years of healthy life to our growing life expectancy. And when we replace “I” with “We” and do it together, “Illness” can become “Wellness”.

The Chairman: Every Wednesday, we will have Parliament running in the evenings. So, join us as well. Dr Lily Neo.

Support for Seniors

Dr Lily Neo (Jalan Besar): MOH estimates that one in two healthy Singaporeans aged 65 could become severely disabled in their lifetime, and may need long-term care. About 7% of the population or about 83,000 individuals in 2030 will have deficit in one or more ADLs. This is about two-and-a-half times today.

May I ask MOH whether there is any postulation on the healthcare services required to meet the needs of an ageing population especially the disabled seniors requiring long-term care?

Are we building enough infrastructure such as acute hospitals, community hospitals, nursing homes, dementia-care, palliative-care and respite homes and so on? Can we also provide more day care centres, dementia, rehabilitation, and respite day care centres, and senior activity centres? Are we training enough medical personnel to cushion the impending explosion on the need of healthcare providers?

Last year, the social aged care functions, under the Senior Cluster Network, was transferred from MSF to MOH. What are MOH’s plans to better support an ageing population with its expanded functions?

One important form of preventive healthcare is allowing seniors to remain active and independent within the community, and living in their own homes. This is because being active and independent in the community will facilitate physical, mental and social well-being of seniors. As what Finance Minister said, “The best way of protecting ourselves is to lead a healthy lifestyle”.

What is MOH doing to support seniors who wish to remain independent in the community?

Many seniors have expressed that they prefer to live for as long as possible in their own homes, in the familiar environment and in the community with families and friends. We should have policies to enable this. We should also encourage the community to come together to make this work.

Every few HDB blocks should have at least one senior activity centre to promote physical, mental and social wellness of the mobile seniors and to facilitate them to remain active and healthy in the community.

For frail seniors, the Ageing Gracefully @ Home (AGH) programme carried out by full-time shared care-givers that include nurses should be expanded, especially at HDB rental blocks. Under AGH, home visits are provided for these frail seniors with the following services: daily supervision on meals, blood pressure checks, medicine intake, home cleaning services, bathing, identifying people who are sick, medical assistance, hospital transportation and so on. VWOs can be roped in to provide the assistance to the seniors to fill the gaps.

We need to expand homecare expeditiously to allow seniors with medical conditions to remain in their own homes and in the community. This is especially useful after discharge from hospitals. Homecare in Singapore is at its infancy. Under homecare, MOH can facilitate services such as medical care-giving, nursing, medication, nutrition, occupational and rehabilitation therapy. Physiotherapy at home is especially crucial to allow earlier regaining of mobility from reversible medical conditions, such as mild strokes and surgeries. At discharge from hospitals, patients can be dispensed with mobility aids to facilitate independent living at home. Homecare aides can be recruited and trained to provide specific job scopes.

Transitional Care Programme by acute hospitals to help care-givers look after their loved ones at home enhances homecare and should be expanded.

Seniors with ADL deficiency need care-givers for their daily living. Care-givers can assist seniors live with dignity. Many care-givers are family members who also hold employments. Could our Government facilitate flexible work arrangements for care-givers? Would our Government also consider paid "Care Leave" for care-givers? It can be two weeks per year, for a start, similar to "Parental Leave" for fathers.

Care-givers can suffer "burnt-out syndrome" from emotional and physical fatigue. Could we have more respite care centres that are accessible and affordable? Could there be a one-stop centre for information and respite care referrals for care-givers. Many care-givers also get domestic helpers to assist them with their care-giving roles. However, many foreign domestic helpers are ill equipped to take up this role. Could we improve the know-how and enforce this area of domestic employment requirement?

The number of seniors who will live alone will double to about to 92,000 by 2030. Could we provide more housing adaptability to accommodate seniors’ mobility to facilitate independent living, as well as having seniors’ friendly environment in the vicinity, such as food centres, health facility, and wellness centres? Examples of housing adaptability are, doors for motorised mobility aids, appropriate-height kitchen table tops, hoisting aids to get out of beds, emergency call points and so on. Technology adaptability such as smart home aids for seniors, fall sensors, emergency medical detection sensors can enhance quality of life.

Ms Joan Pereira: Sir, as MOH had taken over the responsibility for Senior Activity Centres (SACs) from MSF, would the Minister share the update on plans for our SACs? I would also like to take this opportunity to share some suggestions which I hope can be considered for SACs’ future development.

Firstly, I hope that MOH will scale up and expand the number of SACs in all our estates to meet the demands of our rapidly ageing population. As a communal space for social and recreational activities, the number and capacity of the programmes must be able to cope with the higher demand which will come with more seniors taking up active ageing.

Second, I hope all SACs will have sufficient attached day care, respite care and assisted living facilities to provide a seamless experience for the elderly. Imagine a healthy, active senior who has taken part in SAC’s activities, transiting into its respite and day care services, and subsequently assisted living facilities, as he grows older and more frail. The proximity of all these to his home, the familiarity of the environment, staff, neighbours, fellow participants and volunteers will provide him or her with a lot of comfort and peace of mind.

Regulation of Private Homecare Services

Ms Anthea Ong (Nominated Member): Mr Chairman, the additional funding from the Long-Term Care Support Fund and Home Care-giving Grant is likely to boost the use of formal home and centre-based services. There is a need therefore to improve the regulatory framework for homecare and day-care services. Lien Foundation reported that, as of 2018, only two out of 60 such private providers were receiving subsidies which came with mandatory minimum requirements by MOH.

Perhaps it is time to consolidate existing healthcare legislation into a holistic framework that covers the whole care spectrum. A strong regulatory framework should have at least three components: legislation, care quality auditing, and feedback and disputes. Independent bodies and a rating system could be set up for these purposes.

What plans does MOH have to regulate private homecare and centre-based services? Given the absence of mandatory minimum service standards, what is being done to ensure the quality and effectiveness of these services.

Ageing Meaningfully

Ms Tin Pei Ling: As we enhance our healthcare, we can expect longer and more healthy years. Future work will also rely more of intellect and wisdom. Our population will become better educated and more savvy with the digital space and, therefore, less fear and deeper entrenchment of technology in our lives.

There is, therefore, much that we can do to help seniors age meaningfully. More importantly, we need to ensure that our seniors do not slip into isolation. We need to ensure that they are constantly connected to our larger social network.

I had spoken many times in this House about how to enable active aging and what seniors can do. I would like to ask the Ministry to give an update on what it is doing to encourage senior volunteerism, senior employment and socialising?

I would also like to highlight one point today and that is lifelong learning. Learning keeps our mind stimulated. It is exciting to explore new things and exhilarating to achieve what we did not know or have before. We should re-ignite that sense of curiosity in our seniors and offer many opportunities for them to learn new things.

SkillsFuture is an excellent scheme to promote lifelong learning. The National Silver Academy also offers a variety of courses tailored for seniors. Some of the seniors in MacPherson have actively utilised the credits and attend courses. Some have even depleted the credits. That is why we launched the Lifelong Learning Fund in MacPherson, so that they can continue to take on courses and acquire new knowledge and skills, especially in the digital space.

As such, for the earnest senior learners, will the Government consider a special top up to the SkillsFuture Credits for seniors? What plan does the Ministry have to encourage more seniors to embrace lifelong learning?

Successful Ageing Targets for Singapore

Mr Murali Pillai: Sir, year after year, we have seen an increase in our health budget, as mentioned by the hon Minister for Health, to cater for health and healthcare needs of Singaporeans. It may be timely to review our “investment” in health over the years and determine how we have fared thus far and what targets we should aim for the future.

My attention was recently drawn to a study published earlier this year in the Singapore Medical Journal by a group of 10 doctors and researchers entitled “Successful ageing in Singapore”. The study focused on successful ageing amongst Singaporeans aged 60 and older. Successful ageing is defined as having no major diseases, no disability, high cognitive functions as well as physical functions and active life engagement. The study revealed that 25.4% of our seniors have aged successfully.

What is the Minister’s view of the finding in light of the “investments” made in promoting good health over the years and against the backdrop of increase in lifestyle diseases, as hon Minister just mentioned? What are our targets for the future?

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

Independent Living for Seniors

Ms Tin Pei Ling: Singaporeans aspire to age in place. This requires putting in place home and community care support, programmes to engage and promote active ageing, infrastructural investments, retrofitting and hardware maintenance to create an elderly-friendly environment where seniors can live independently.

We should apply elder-friendly designs into our hardware and heartware solutions. Make such designs mainstream. Share best practices and set standards and audit public and private projects across all sectors.

We should proliferate digital eldercare to supplement the shortage of manpower. Leverage technology and artificial intelligence to enable quality and personalised care for seniors. Continue to research, develop and invest in digital eldercare solutions so that more innovations can reach market faster.

We could do more to recruit and organise volunteers into a powerful network of resources in the community. Exploit physical and digital platforms to optimise the matching of regular and ad hoc volunteers to help seniors who may have differing needs at different times of the day.

In essence, we can still do more to enable independent living for seniors. I would therefore like to ask what is the Ministry and whole-of-Government doing to help seniors live independently. What is being done in terms of physical hardware and programmes? How is the Government actively utilising digital solutions to achieve our goals?

2.30 pm

Support for Care-givers

Care-givers play a very important role in our ageing landscape. They offer the human touch that Government policies or programmes cannot provide, no matter how brilliantly designed they can be.

For a long time, the Government was focused on addressing the direct needs of our seniors. But I am heartened that in the parliamentary debate on care-givers just last month, the Ministry responded very encouragingly with the introduction of the Care-giver Support Action Plan, comprising assistance such as the Home Care-giving Grant and night respite service.

I have no doubt that these assistance will alleviate the burden and stress care-givers face at present.

However, as we know from our ground experiences, the financial burden on a care-giver who has given up her job can be significant, higher than what the care-giving grant can offer on a monthly basis.

Not all care-givers who are still working can successfully negotiate for flexible work arrangement, or at least, not as easily, depending on the employer's attitude and nature of the job.

Even as the night respite care pilot is underway, there is still an army of care-givers embedded in different parts of our community, providing non-stop care to their loved ones and quietly enduring the inevitable fatigue.

As such, I would like to ask the Ministry if it will continue to engage care-givers to ensure that their needs are understood and that the support put in place will address them adequately. Would the Ministry also work towards accelerating the implementation of the action plan so that more care-givers can benefit sooner than later?

Care-giving

Mr Charles Chong: Thank you, Mr Chairman. One result of us having an ageing population is that more support will need to be given to elderly Singaporeans.

Apart from those who care for the elderly, there are also those who care for people with disabilities, for those with chronic or terminal illnesses. Very often, these care-givers are family members – children, parents or siblings.

The demands placed on care-givers must not be underestimated. Apart from the stresses involved with looking after persons under their care, they also have their own lives to lead. And while I believe that most care-givers embrace the caring responsibilities, they often face their own challenges and these could be professional, financial or psychological.

Care-givers play a vital role in ensuring the well-being of our older citizens and citizens with disabilities or chronic illnesses. And I think it is only right if we do what we can to support them.

I would like to ask the Minister if more could be done to support care-givers in their role. For example, what kinds of training can they attend to carry out procedures which they may need to execute and what resources are available to them to provide emotional and psychological support? Could the Minister also consider, if beyond the existing schemes, the financial needs of care-givers, something that we can look into supporting, as being part of the broader package of support for the person who is receiving the care?

Mental Health Patients and Their Families

Mr Murali Pillai: Sir, families whose members are diagnosed with mental health conditions often have difficulty managing these patients.

It is not unusual for such patients not to adhere to instructions to take their medication or even attend medical appointments. This would lead to relapses on the part of the patients. Often, their care-givers undergo quite a bit of stress as a result.

There are also families where the care-givers are older than the patients giving rise to uncertainty and worry on the part of care-givers as to how the patients, usually their children, would be taken care of once they pass on.

During the recent debate on the Care-givers for Seniors' motion introduced in this House by hon Member of Parliament, Dr Chia Shi-Lu, the Government announced a slew of measures to help care-givers of seniors- such as provision of the Home Care-giver Grant of $200 per month and care-giver support network.

The hon Senior Minister of State, Mr Edwin Tong, pertinently recognised in his speech at the debate that there is a "broad range of care-givers who operate in a variety of different circumstances and a very broad landscape". It is time to consider providing similar support for care-givers of mental health patients as announced for the care-givers of seniors.

Separately, there are a good number of cases of mental health patients who live alone or do not get any support from family members and are in sore need of medical intervention. From time to time, we hear of such patients engaged in behaviour such as hoarding materials in common corridors of HDB flats, quarrelling with neighbours based on perceived threats, throwing bags of urine and faeces, and so on. A good number of them cannot help themselves because they suffer from anti-social personality disorders whose prognosis is guarded.

Often, in the absence of supervision from families, there are practical difficulties in ensuring that these patients receive and adhere to their treatment. Even if the Police gets called in, and the patients are eventually referred to IMH, there is no guarantee that they would present themselves at scheduled appointments. Once they are off their medicine, the tendency is for them to go back to their anti-social behaviour and the entire cycle repeats itself. This raises a conundrum in the communities where they live. Not only that, these patients may harm themselves, especially if they plunge into depression.

I would like to ask the hon Minister what are his plans to provide more help to mental health patients and their care-givers, including those who are older patients? Also, how can the community and other partners help in this regard?

Mental Health

Mr Melvin Yong Yik Chye (Tanjong Pagar): Mr Chairman, there is an increasing need to ensure that we make mental health services more accessible to support those with mental health conditions. A distinction is often made between mental and physical health. But the mind and body are inextricably linked. The two are inseparable and we need to pay attention to both to achieve wellness and not fall into illness.

Our workplace can be a very stressful environment. A 2017 study by Willis Towers Watson found that 44% of local employers identified stress as their number one health issue, while 60% of the employees admitted to having above average or high levels of stress. Prolonged exposure to such stress can potentially lead to mental health conditions.

But there remains a societal stigma when it comes to dealing with mental health issues. Many are unwilling to openly talk about such issues. And a 2018 survey conducted by the National Council of Social Service revealed that over half of those surveyed were unwilling to live or work with a person with a mental health condition.

Mental health issues affect Singaporeans of all ages, in particular, our youths and millennials. Some have started calling them the "burnout generation". Yet, addressing such issues remain a stigma in Singapore.

I would like to ask how is MOH making mental health services more accessible to support persons with mental health conditions, especially among our youths.

Community Mental Health and Wellness

Mr Christopher de Souza: Mr Chairman, staying engaged, being active and socialising are key to good mental health. If one has physical health but is not connected to a social network, then mental health can decline.It is one of the reasons why we have situated a childcare centre next to an active ageing centre in the constituency I serve – Ulu Pandan. The elderly and young can interact and bring joy to each other, across generations.

As an extra step, would MOH consider setting up Community Mental Wellness Conservatories in heartland areas to bring together care-givers of elderly Singaporeans who may have dementia or mental illnesses to share care-giving best practices on how to re-connect the elderly to a social network, with the mind to lift their spirits and re-energise them into joyful and active ageing?

Protecting the Unborn

Mr Alex Yam (Marsiling-Yew Tee): Mr Chairman, I first asked in 2014 if the Ministry will consider adjusting the threshold of gestational age for abortion from 24 weeks to 22 weeks based on the increasing viability of even extreme preterm babies. I have made the same request consistently since then.

As early as in 1991, the viability limit defined in the Motherhood Protection Act in Japan was amended from 24 weeks to 22 weeks based on medical advances. I am certain that if we look at the numbers in our own hospitals , there will be similar medical justifications.

In Mandarin, Japanese and Korean, the written word for the womb translates to " the palace of the child". In Hebrew, the word Rakh’am is used to refer to the womb and translates to compassion and protection from harm. And I do hope that unborn children of Singapore will truly find it a palace for them to develop well and a place of mercy for them who do not have a voice.

I therefore repeat my request for the Ministry's careful consideration, based on medical evidence, if a review of the gestational limit is due and an adjustment to the term limit be adopted.

Women's Health

Ms Tin Pei Ling: Women are living longer and have longer life expectancy than men. Women are also typically the main care-giver at home, caring for our young and old. Their health therefore not only concern herself but will impact the entire family's well-being. Moreover, women is a formidable source of manpower for Singapore, driving our continued growth.

It is therefore important that we ensure Singaporean women are healthy and vibrant. I would thus like to ask what is the Ministry doing to help women and mothers. What is in place to drive preventive health effort for women?

The Chairman: Dr Amy Khor.

The Senior Minister of State for Health (Dr Amy Khor Lean Suan): This House recently saw a lively debate on ageing. I was encouraged by the support for the Action Plan for Successful Ageing launched in 2015, when I shared about its progress.

As Minister Gan shared, our Life Expectancy and Healthy Life Expectancy are good. Nonetheless, through the Action Plan, we want to further help Singaporeans add more life to years, not just years to life. As we provide for seniors today, we will do more for seniors of tomorrow, who will live longer, be better educated and have different aspirations. MOH will conduct a public consultation later this year with stakeholders, including seniors, community and business partners to develop an updated Action Plan.

A study by the Duke-NUS Centre for Ageing Research and Education (CARE) showed that seniors who are supported by social networks and befriending can better manage their chronic diseases. Strengthening integration between social and healthcare is key to successful ageing. Let me elaborate on our efforts, which I call the "3 Ps" – People, Places and Programmes.

First, we want to further enable people in the social and health sectors to integrate care for our seniors. Since the beginning of 2018, about 3,000 Silver Generation Ambassadors (SGAs) have engaged around 280,000 seniors, identifying seniors with needs and working with stakeholders to link them to active ageing, befriending and care services. Seniors can have their social and healthcare needs managed jointly by the Silver Generation Office (SGO) and Social Service Offices (SSOs). More of these offices will be co-located where possible. SGO is recruiting more SGAs, to reach out to seniors, including the Merdeka Generation (MG). I encourage Singaporeans to come forward and join this endeavour.

MOH works closely with our community care providers and healthcare professionals to deliver quality care, ensuring good governance over our services, while allowing room for the sector to evolve. To Ms Anthea Ong's query, in 2015, MOH developed developmental guidelines for home and day care providers to work towards quality care. Healthcare professionals providing these services, such as doctors, nurses and therapists, must also be licensed by their professional bodies.

Looking ahead, MOH will review the need for more formal regulation, including licensing under the proposed Healthcare Services Act (HCSA), as Mr Louis Ng has also asked in a Parliamentary Question (PQ). We will adopt a risk-based approach, and subject services with higher patient risks to higher levels of regulation. Hence, we will start with licensing home medical services, and review the need to licence other services as the sector evolves.

Second, we will strengthen integration by providing places and programmes to address the social and health care needs of our seniors. Following the transfer of functions from MSF, as of end 2018, MOH oversees 127 Senior Activity Centres (SACs) providing wellness programmes to seniors living in studio apartments and rental flats; 118 Senior Care Centres (SCCs) providing day care and community rehabilitation services, and five Active Ageing Hubs (AAHs) serving seniors across a spectrum of needs.

Chairman, may I display some slides?

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

Dr Amy Khor Lean Suan: In response to Ms Joan Pereira and Dr Lily Neo, we aspire towards more age-friendly neighbourhoods, with accessible care and amenities. We are expanding aged care services capacity but must do so sustainably. MOH will partner our operators to enhance the scope and reach of services in our Senior Centres. For example, those currently providing day care services may offer additional wellness programmes. Services will be made available to all seniors, not just those living in studio apartments and rental flats.

We will work with operators, enhancing their capacity and capabilities, to implement this common vision of SACs, SCCs and AAHs as places where seniors can access a range of services from fiscal year 2020.

2.45 pm

In relation to Mr Leon Perera’s question, since 2012, we introduced the Build-Own-Lease (BOL) framework to support efforts to increase capacity, encourage improvements in care quality while keeping fees affordable. Our tender process covers quality (including innovative care models) and affordable fees. AIC supports providers in capability development, including leadership development, manpower recruitment and quality improvement programmes.

To support preventive health, we grew the number of Community Health Posts (CHPs) to around 150. We will now expand the number of areas covered by Community Nursing teams, from 18 to 29 areas around Singapore. We will also partner more Senior Centres to make community nursing services accessible to more seniors by 2020.

Members, such as Ms Rahayu Mahzam, have called for Assisted Living options.

MOH and MND plan to launch a pilot where seniors buy a home bundled with a package of programmes and services that can be customised to suit their needs and preferences. For instance, healthy seniors could buy into basic services, such as light housekeeping. Additional services, like care coordination, can be layered on as their needs change. We have identified a possible location, and MND will share more on this.

The development could comprise flats with senior-friendly features, complemented by communal spaces like recreation-cum-dining rooms with light programming to encourage interaction. MOH and MND will start Focus Group Discussions over the next few months to better understand Singaporeans’ aspirations and fine-tune this new option for ageing-in-place before going to market.

As Ms Tin Pei Ling suggested, we are tapping on technology to benefit seniors, starting with MG seniors who are more IT literate. MOH is partnering SNDGO and PSD to include a new module under the existing Moments of Life app to support active ageing. I have seen a prototype and found it useful. The app will include an Active Ageing Programme finder that can show seniors programmes near their homes. Seniors can also use the app to check their eligibility for Government benefits like the Merdeka Generation Package and GST Voucher scheme. In a later phase, we will explore features, such as allowing bookings for active ageing programmes. The app will be piloted later this year, and I look forward to using and sharing it.

An ageing population raises demand for community mental health services. Someone once jokingly said to me, “The nice thing about ageing and losing your memory is that you make new friends every day!” Joke aside, in reality, dementia can be debilitating not just to patients but also care-givers. I agree with Mr Christopher de Souza and Mr Melvin Yong as well as Ms Ong that we must support persons with mental health conditions and their care-givers. In 2017, arising from the recommendations of the Inter-agency Committee on Community Mental Health, MOH launched the enhanced Community Mental Health Masterplan to further strengthen mental health care. We have made good progress since, in increasing outreach, early detection and providing care and support in the community.

Through a multi-pronged approach strategy, we bring the community together, to raise awareness and support for seniors with or are at-risk of dementia and depression. Thirty-nine community outreach teams have been set up and have reached out to over 210,000 people. We are on-track to meet our 2021 target of 50 teams. We established eight Dementia-Friendly Communities, building networks of support around those with dementia and their care-givers. Our Dementia Friends Mobile App has encouraged more than 4,100 people to sign up as Dementia Friends and assisted over 50 persons since its launch in October 2018.

Our Community Network for Seniors (CNS) has been expanded nationwide to anchor a strong community care system for seniors, including those with mental health conditions. Under the CNS, SG Ambassadors proactively reach out to seniors, referring those with possible mental health conditions to support services. Community befrienders visit lonely seniors regularly, providing them with emotional support to keep social isolation and depression at bay.

Furthermore, AIC has trained over 14,000 front-line staff from Government agencies and community partners to identify and respond to persons with mental health conditions. Over 2,700 individuals have been supported with medical care or social support according to their needs. We will continue to work with agencies like MHA and HDB, grassroots leaders and voluntary welfare organisations to identify and provide social and medical support for those in need, including persons who exhibit behavioural challenges in the community.

Addressing the stigma associated with mental health conditions is also a collective effort. NCSS and IMH launched the “Beyond the Label” campaign in September 2018. We hope this will catalyse more conversations about mental health and encourage those facing such challenges to seek help.

To strengthen care and support in the community, we increased access to mental health and dementia services in 12 polyclinics, up from eight in 2018 and also at our GP clinics. As of December 2018, over 190 GPs have been trained to diagnose and support persons with mental health conditions. Twenty allied health-led community intervention teams were established to support GPs and community organisations in managing persons with mental health conditions.

Beyond building on existing efforts and scaling up programmes, we are developing new initiatives to better address emerging areas. Following the NurtureSG Taskforce’s recommendation to better support youths, MOE and HPB have been establishing peer support structures in mainstream schools and Institutes of Higher Learning (IHL) to equip students to look out for signs of mental stress among peers and support and encourage them to seek help when needed. Since 2007, about 2,400 Allied Educators have received training to identify and support students who require referrals to mental health services. We will train more moving forward. The Community Health Assessment Team (CHAT) operates a mental health wellness centre for youths, which has reached out and provided mental health assessment to more than 3,100 at-risk youths as of December last year.

As social and mental health issues are interlinked, we will take a more holistic approach for at-risk youths. MOH will develop a new integrated youth service, together with community youth partners, IMH, AIC, NCSS and HPB. We will expand on the success of the CHAT model, to increase outreach and educate youths on resilience and mental well-being. Those who need help will be referred to social and health services for assistance and intervention in an integrated manner. MOH will update the enhanced Community Mental Health Masterplan and rally a whole-of-society effort to build communities of care around mental health patients and their care-givers.

The Merdeka Generation Package (MGP) is a major fiscal undertaking and is our show of appreciation and support for the Merdeka Generation (MG) in their silver years. After Prime Minister announced the MGP at the National Day Rally (NDR) last year, many of my MG cohort friends excitedly asked me “What, what, what are the benefits?” Following Minister Heng’s Budget speech, the constant refrain became "When, when, when, when will I get these benefits?”

We want our MG seniors to benefit from the package as soon as possible. Implementing the MGP is a major effort involving multiple Government agencies and partners, and we are working closely to roll out the benefits quickly. The bulk of the MGP benefits will be available in two tranches – July and November 2019.

From July 2019, MG seniors will receive three benefits. One, their MediSave accounts will be automatically credited with their first $200 top-up, which they will continue to get once every year until 2023. Two, additional MediShield Life premium subsidies for MG seniors will take effect. MG seniors will receive subsidies starting from 5% of their MediShield Life annual premiums, and increasing to 10% after reaching 75 years old. Although system changes to automatically apply the additional subsidies will be ready only towards the end of this year, we will backdate the subsidies to 1 July, to allow more MG seniors to enjoy them. MG seniors with policy renewals between 1 July and 31 October this year will pay the full premium first, and receive the additional subsidies as a refund automatically by end December 2019. Three, the one-time $100 top-up to their PAssion Silver cards, we will share more details on how to redeem the top-up when ready. As you will have till 31 December next year to do so, and the credits do not expire, we would like to assure all our MG seniors that there is no need to rush.

Come 1 November 2019, MG seniors will receive additional subsidies for outpatient care, for life. Implementing the outpatient subsidies involves many healthcare partners, who need to train front-line staff and make necessary system changes. We need time to do this properly and correctly, so implementation can be as smooth as possible. When MG seniors visit polyclinics and public specialist outpatient clinics from 1 November 2019 onwards, they will automatically receive an additional 25% off their subsidised bills.

MG seniors can also bring their MG cards when they visit CHAS GP and dental clinics, to enjoy special subsidies of up to $23.50 per visit for common illnesses, $520 in annual chronic subsidies and $261.50 per procedure for dental procedures. Also, eligible MG seniors will pay only $2 for screenings recommended under the Screen for Life programme, compared to up to $5 today.

Finally, in 2021, when CareShield Life becomes available for existing cohorts, we will give an additional participation incentive of $1,500 to each MG senior who joins the scheme, on top of the $2,500 previously announced. MG seniors who join CareShield Life will hence receive participation incentives totalling $4,000 each, which will offset annual premiums for 10 years.

Eligible seniors will receive a notification letter for the MGP by April 2019. From the same month, SGO will start to proactively reach out to 500,000 MG seniors to share details of the MGP.

To Dr Chia Shi-Lu’s query, beyond home visits, SGO will employ new approaches, such as group engagements at workplaces, which may be preferred by MG seniors, among whom one in two are working. SGO will also conduct engagements at community locations frequented by MG seniors, like hawker centres. It will connect MG seniors to volunteering and learning opportunities, such as the Retire with a Purpose (RWAP) programme under the RSVP and National Silver Academy courses.

As mentioned by Minister Gan, Senior Minister of State Sim Ann and I will co-chair a Merdeka Generation Communications and Engagement Taskforce to ensure effective communications and outreach to our MGs and their family members. The taskforce comprises 23 members from the public, private and people sectors, which had its first meeting two weeks ago.

Ms Tin noted that women are living longer and we must address their healthcare needs. The Women’s Health Committee will continue to champion good health among Singaporean women at all stages of their life.

One focus area is cervical cancer. From 2011 to 2015, about 200 new cases were diagnosed annually and around 70 die of the disease every year. This cancer, which is caused by infection with the Human Papilloma Virus (HPV), can be prevented with vaccination and screening. To bring about more comprehensive coverage of HPV vaccination for cervical cancer prevention, MOH will offer fully subsidised HPV vaccination from April 2019 as part of our national school-based health programme, similar to countries, such as the United Kingdom and Brunei. Current and future cohorts of Secondary 1 female students will be offered the HPV vaccination, and a one-time catch-up programme will be progressively provided for current cohorts of Secondary school female students. All other female Singapore citizens and permanent residents from the same age-equivalent cohorts, including those studying in private education institutions, will also be eligible. The vaccination will be fully subsidised, as part of an opt-in scheme.

For women aged 30 years and above, we are introducing a more accurate HPV screening test for cervical cancer, which only needs to be done every five years, compared to the current recommended protocol involving Pap smear test which needs to be done once every three years. The better test will cost more, but the Government will provide more subsidies, so the cost to women will be the same in the long run.

We will also make early screening more convenient for women with history of gestational diabetes, who are at higher risk of diabetes later in life and need to start regular screening soon after pregnancy. They will be automatically eligible for subsidised cardiovascular risk screening under the Screen for Life programme, and will no longer need to take the online diabetes risk assessment tool to qualify.

For women intending to enrol in IVF, Mr Ng will be pleased to know that we will lift the requirement for purchase of Assisted Reproduction Programme (ARP) insurance from 1 April 2019.

This is because MediShield Life and MediSave now provide basic healthcare coverage for all Singaporeans from birth.

Mr de Souza and Mr Dennis Tan asked about attracting more Singaporeans to nursing, and supporting continuing development and career progression of healthcare professionals.

3.00 pm

Over the last five years, we increased nursing intakes by around 30%. In 2018, we admitted more than 2,100 students, our highest intake to date, up from 1,600 in 2013. But it will be challenging to continually increase student intakes in view of falling cohort sizes, so we need to look at mid-careerists, too, beyond supplementing our local workforce with foreigners. For those looking for a second career in healthcare, our Professional Conversion Programmes (PCPs) provide sponsorship for course fees and an allowance. In 2018, about 130 mid-career individuals embarked on our nursing PCPs, our highest intake in 10 years. MOH will continue to work with healthcare employers to improve retention, provide meaningful job opportunities, and enhance careers through multiple progression pathways and entry points to ensure we maintain a strong local core of the nursing workforce.

In line with the SkillsFuture movement, we worked with Nanyang and Ngee Ann Polytechnics to create a new, faster progression pathway for Enrolled Nurses who did well during their ITE training, to upskill to a Registered Nurse. We now have a 2+2 Diploma in Nursing which will allow ITE Upgraders to complete the Diploma in Nursing course in two years instead of the current 2.5 years.

We will strengthen and better recognise workplace-based learning, to achieve the twin objectives of better care for our patients and professional growth for our healthcare staff. Assuring our staff of continued opportunities for professional development is key to retaining them in the healthcare workforce.

I am pleased to announce that we will set up the National Nursing Academy (NNA) to coordinate and support lifelong learning across healthcare institutions, schools and training providers. The NNA will oversee Continuing Education and Training (CET) efforts to develop future-ready nurses with the requisite skills and competencies to meet evolving healthcare needs. In line with the push towards digitalisation, the NNA platform will allow nurses and healthcare leaders to access a comprehensive suite of high-quality courses and learning opportunities online.

Today, many healthcare providers have in-house training programmes which are often not recognised and transferable across different institutions. The NNA will accredit and strengthen the quality of workplace-based training and develop a system to recognise the skills and competencies attained by a nurse at the workplace. This will make the skills portable and stackable to advance nurses’ careers and professional practice across healthcare institutions and settings.

To facilitate this, the NNA will articulate the skills and competencies needed for nurses' evolving roles as part of the larger Skills Framework for Healthcare. We will deepen this framework, starting with the Community Nursing Competency Framework, which will be completed by May this year. This will be followed by frameworks for palliative and gerontology care in 2020.

The NNA’s efforts will benefit all nurses and healthcare providers in the public, private and community sectors.

Mr Chairman, in conclusion, as MOH continues to empower all Singaporeans to take charge of our health, I invite everyone to work with us to add more life to years.

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

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

Mr Speaker: Order. I suspend the Sitting and will take the Chair at 3.25 pm.

Sitting accordingly suspended

at 3.02 pm until 3.25 pm.

Sitting resumed at 3.25 pm.

[Mr Speaker in the Chair]

Debate in Committee of Supply resumed.

[Mr Speaker in the Chair]

Head O (cont) –

Preventive Healthcare

Dr Lily Neo (Jalan Besar): Sir, I have been an advocate on preventive healthcare all these years and I have spoken many times before in this House on this topic. Thus, I agree with the Minister for Finance wholeheartedly when he said, “The best way of protecting ourselves is to lead a healthy lifestyle, and take preventive actions”. This is the best approach as it will result in quality of life and a happier populace.

Preventive healthcare means adopting healthy lifestyles to stay healthy and to prevent diseases, especially chronic diseases. It also means detecting and treating chronic diseases early and consistently. The purpose is to prevent severe ill health and disability as a result of chronic diseases like diabetes, hypertension and hyperlipidaemia. Untreated, chronic diseases can lead to heart diseases, stroke, renal failure, foot amputation, blindness and so on.

We cannot carry on with just the traditional approach of healthcare systems on diagnosing and treating diseases alone, because this will lead to increasing demand on healthcare services, which can be daunting in an ageing population.

Preventive healthcare has to be expanded quickly and urgently, as the success of which will allow people to live healthily and happily, and will cushion the demand for increasing healthcare services.

I am glad that the Minister for Finance has announced that CHAS is now expanded to subsidise all Singaporeans in seeking treatment for chronic diseases at private clinics. This will encourage more people to seek treatment early for chronic diseases. Subsidising the treatment for chronic diseases is a good way to prevent the complications of such diseases, will reduce ill health and lessen the demand for acute care.

May I ask MOH on the detail of subsidy for the expanded CHAS scheme for chronic diseases for all CHAS holders? May I also ask MOH how it plans to ensure that the intent of preventive healthcare with regard to chronic diseases can be achieved with the expanded CHAS?

It will be a pity if we have such a good CHAS scheme but people do not make full use of it. This may be due to either insufficient information about the scheme or the patients are not bothered to go for early and continuous treatment of chronic diseases, due to a lack of knowledge of chronic diseases and their side effects. I urge MOH to raise awareness and campaign on the importance of early diagnosis and treatment of chronic diseases.

Could MOH provide an update on the war on diabetes, Healthy SG task force and Health Promotion Board (HPB)’s progress on healthy lifestyle promotion? Promotion of mental well-being is an integral part of preventive healthcare. Presently, MOH’s psychiatric and mental healthcare is insufficient, especially in the community setting. Could MOH expand and provide more resources in this area?

There is a saying “We are what we eat”. Singaporeans’ sugar intake increased from 59 gm a day in 2010 to 60 gm last year. The World Health Organization (WHO) recommends a daily sugar intake of 25 gm ideally. However, Singaporeans are already taking more than twice that. Sugar provides calories with no added nutrients. Excessive sugar intake may result in excessive weight, diabetes, heart diseases, fatty liver and so on.

Could MOH strategise more effectively to nudge Singaporeans to reduce their sugar intake? MOH will need to adopt a range of measures, including better information and a national campaign to facilitate better-informed choices. Labelling of the sugar and calorie contents should be made widely available in the food on sale here, even at our hawker centers. Such information will not only remind people to keep healthy but also give consumers an informed choice, to better plan their sugar and calorie intake for the day.

3.30 pm

I favour to go for “half of your sugar intake or no sugar intake” campaign. Other measures should include sugar taxation and to reduce the sugar content in beverages. In our schools, we can go further in helping our children by reducing their palate for sweetness, by not selling beverages and other sugar-added food in school canteens. We should facilitate our young to achieve reduced palate for sweetness when they are in schools, so as to achieve better health when they grow up.

Outreach to Malay and Indian Communities

Mr Mohamed Irshad (Nominated Member): Mr Chairman, during the 2017 National Day Rally, Prime Minister Lee cited Diabetes as a health crisis for Malays and Indians. He pointed out that the main common causes of death like stroke, heart attack and kidney failure can be traced back to diabetes. Can the Minister share what efforts are undertaken to customise health promotional messages to Malay and Indian communities? Could the Minister also provide an update on the war on diabetes?

War on Diabetes

Mr Melvin Yong Yik Chye: Mr Chairman, it has been quite a few years since MOH declared war on diabetes. I would like to ask the Ministry to provide an update on the progress of our fight against diabetes, and what were some of the most effective initiatives that have been rolled out thus far.

Singaporeans spend a lot of time at the workplace. Therefore, promoting workplace health is a key battleground in our fight against diabetes. We are what we eat, meals with reduced salt and oil, and drinks with reduced sugar are some simple steps that workers can take towards forming healthy eating habits.

Employers too can play a vital role in encourage healthier eating habits. The National Transport Workers Union (NTWU) and SBS Transit (SBST) have collaborated to do just that. Today, 43 NTWU canteens today offer healthier brown rice meal options. As employer, SBST has contributed $150,000 to support this initiative. More than 10,000 SBST staff can get a stamp with each brown rice meal they buy. Every five stamps can be exchanged for a $2.50 meal voucher. Since we started this initiative, our transport workers have taken more than 50,000 brown rice meals at our NTWU canteens.

I hope the MOH can continue to encourage and support more such collaborations at our workplaces.

Tobacco Control

Dr Chia Shi-Lu: Chairman, MOH has introduced a series of tobacco measures to make it harder for smokers and to deter new ones. These include excise taxes, restrictions on smoking areas, a ban on point-of-sale display and a gradual increase in the minimum legal age. Very soon, cigarette packaging will also have to be plain and standardized, with bigger graphic health warnings.

Can the Ministry take one step further and reconsider a ban on flavored and particularly, menthol cigarettes, such as what Canada has recently done and which the USA is considering once again. Such products are particularly appealing to new smokers, especially youths.

The World Health Organisation (WHO) has also recently introduced the concept of a “best buy” policy. How aligned is Singapore with WHO’s recommended, cost-effective policy action for smoking? For example, should we increase the minimum legal age beyond 21 and is our tobacco tax sufficiently prohibitive? Can more be done to help smokers, particularly young ones?

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

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

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

Dr Lam Pin Min: Mr Chairman, with our high life expectancy, we are facing an increasing burden of chronic diseases, coupled with rising healthcare costs and emerging diseases. We need to be ready to meet these challenges. I will share more on the work we have done to keep Singaporeans healthy and safe, while keeping healthcare affordable for all.

Primary care plays a crucial role as the foundation of our healthcare system. It enables good quality, comprehensive and continued care for Singaporeans near their homes. We will continue to invest in our primary care to enhance facilities, and provide more resources for our General Practitioner (GP) partners.

MOH had previously announced plans to enlarge our polyclinic network from 20 currently to about 30 to 32 polyclinics by 2030. Currently, these are slated for Bukit Panjang, Eunos, Kallang, Sembawang, Khatib and Tampines North. I am pleased to inform Members that in addition to these, two more polyclinics will be developed in Serangoon and Tengah, which are expected to be operational by 2025.

Minister Gan earlier shared about our primary care transformation efforts, including the Primary Care Network (PCN) scheme, of which Dr Chia Shi-Lu has asked for an update. Please allow me to share more in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] In 2018, MOH launched the Primary Care Network (PCN) scheme. This is part of our strategy to transform primary care. This scheme aims to support private GPs to come together to form networks with the sharing of clinical and administrative resources, and provide more holistic care for patients with chronic diseases.

Last year, more than 300 GP clinics participated in this scheme to form 10 PCNs, and collectively are serving more than 70,000 patients with chronic disease. Through this scheme, patients with diabetes have enhanced accessibility to various ancillary services, such as eye and foot checks. To date, more than 5,000 patients with diabetes have benefitted from this.

This year, there are more than 450 GP clinics participating in the PCN scheme. This number is more than 40% of CHAS GP clinics. In order to benefit more patients with chronic disease, MOH targets to have half of all CHAS GP clinics participating in the PCN scheme by 2020.

(In English): Mr Chairman, let me now share a success story from United PCN. Like many Singaporeans, Mr Adrian Chia, who is 38 years old, loves food. He used to drink a 1.5-litre bottle of sweetened beverage daily, and ate fried and oily food. He was diagnosed with diabetes by his general practitioner, Dr Kelvin Goh, who practices in a clinic under United PCN.

Mr Chia took his diagnosis as a wake-up call. Working together with Dr Goh, the PCN nurse and care coordinator supported Mr Chia with managing his condition. He also received nurse counselling for his diabetes, as well as foot and eye screening checks through the PCN. Mr Chia began to take small steps, and started to exercise daily. Through much perseverance and self-motivation, he has progressed to participating in Iron Man races. He also changed his eating habits to include healthier food choices such as oatmeal and fruits.

Today, Mr Chia’s condition is now under control, and may not even require diabetes medicine if he maintains his new regime.

Dr Chia has also asked about our efforts to support PCN clinics in tracking and monitoring patients' progress. A key feature of the PCN scheme is the provision of resources to maintain a chronic disease registry that tracks the care processes and patient outcomes. By aggregating resources through PCN networks, GPs in the PCN scheme also stand to benefit from greater economies of scale.

For example, NUHS PCN in the Western region has worked with major laboratory providers to provide common laboratory tests for chronic disease management at reduced prices, and facilitate the electronic collation of laboratory results for the chronic disease registry, reducing the need for GPs to manually compile these. Such systematic data collection allows PCN GPs to reflect on their professional practice and work with the PCN HQ to implement quality improvement programmes and improve patient outcomes.

Learning from the experience of the PCNs, MOH will study how to help CHAS clinics better track their patients’ progress and outcomes.

MOH will also continue to encourage more GPs to join CHAS, though there are always some who chose not to, such as those who prefer not to take on additional load.

At the same time, we have continued our efforts in the War on Diabetes. Mr Melvin Yong and Mr Mohamed Irshad have asked for an update on this. We should recognise that our fellow Singaporeans with diabetes do not have to journey alone; we all play a part in supporting them to better manage their condition, and avoid long term complications from diabetes.

Patient empowerment has emerged as a new paradigm that can help improve medical outcomes while lowering costs of treatment. This concept seems particularly promising in the management of chronic diseases, including diabetes. As such, the Diabetes Prevention and Care Taskforce has developed a new Patient Empowerment for Self-Care Framework which aims to empower patients to co-own their care journeys for better care outcomes. It helps patients initiate and sustain lifestyle changes for better disease management, prioritising what is of greatest importance to them. This is done with the support of their families, healthcare professionals, community-based providers, as well as other forms of social support.

We have developed the national diabetes reference materials for patients, care-givers and the public. The first tranche of materials is largely pictorial and easy to understand. A beta version of the introductory section, which is mainly targeted at newly diagnosed patients, has been available on HealthHub since December 2018. The full set of materials will be published on HealthHub in four languages in the second half of 2019. We will also be seeking public views from mid-2019 on specific diabetes-related topics for more in-depth materials to be developed, and published online for reference.

Besides empowering our patients, our healthcare workers can look forward to more training and resources to improve their delivery of care. MOH will be developing a care team training framework to equip healthcare professionals, and lay volunteers in the community, with essential skills to empower their patients and care-givers more effectively. This will be developed in consultation with various stakeholders, and rolled out progressively from end-2019.

Last year, I shared about our high rate of diabetes-related amputations of the leg and foot. MOH formed the National Diabetic Foot Workgroup in April last year to develop a strategy to reduce such amputations. A key recommendation of the Workgroup is a risk-stratified diabetic foot screening, management and escalation framework, which aims to streamline diabetic foot care services across primary and tertiary care, and provide healthcare professionals with clinical guidelines for timely and appropriate care.

This framework will be progressively launched in our polyclinics and public hospitals from the second quarter of 2019. MOH will continue to closely track the rate of amputations among patients with diabetes.

Aside from equipping our healthcare professionals, MOH also seeks to uphold the standards of practice and public confidence in the medical profession. The medical disciplinary process is specified in the Medical Registration Act (MRA) and aims to protect both the public, and ensures fairness to the doctors. Mr Leon Perera has given some feedback, and asked about the review of the medical disciplinary process. MOH is currently looking into making amendments to the MRA, which was last amended in 2010. This will include looking at the issues raised by Mr Perera.

In addition, as announced over the weekend, my Ministry will form a Workgroup to undertake a comprehensive review of the taking of informed consent by doctors. The Workgroup will also review the medical disciplinary process with a review to enhance the regulatory framework. This ranges from the filing of complaints, to the structure, composition and processes of the Complaints Committees and the Disciplinary Tribunals, and the use of expert evidence.

The Workgroup will consult widely in evaluating the issues raised, and make appropriate recommendations to the Ministry. MOH will take into consideration these recommendations from the Workgroup.

To ensure consistency and fairness in the sentencing of disciplinary cases, a separate committee, which is the Sentencing Guidelines Committee, was also appointed by the Singapore Medical Council in January 2019 to develop guidelines on the appropriate sanctions to be meted out. My Ministry will continue to engage the medical community and carefully consider what steps are necessary to improve the medical disciplinary process.

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Minister Gan highlighted the need for all of us to work together to keep our healthcare system sustainable for future generations. While MOH continues to provide subsidies, this will be unsustainable if we do not manage increases in healthcare costs. A significant part of managing such increases is to aid patients and providers to choose care which is appropriate to the patient’s medical conditions and needs.

Ms Joan Pereira has asked if we can explore having more subsidies for a wider range of generic drugs. Back in 2017, to encourage the use of generic drugs, we introduced a basket of clinically and cost-effective generic drugs which can replace the more expensive branded equivalents.

MOH reviews the generic drugs basket annually with the National Pharmacy and Therapeutics Committee. We will also actively monitor new generic drugs from overseas, and work with the Health Sciences Authority to introduce them locally.

By volume, the usage of the generic drugs in the basket has increased from 87% in 2013 to 99% in 2017.

Currently, clinically and cost-effective drugs are eligible for subsidies. When generic alternatives of these subsidised drugs become available, prescribing of generic alternatives is encouraged to provide more savings for patients.

Ms Pereira also asked about the Medication Assistance Fund (MAF), which was introduced to help needy patients pay for non-standard drugs which have been assessed to be clinically necessary.

Since October 2018, MOH has streamlined the MAF application process such that eligible patients, with the assistance of hospital staff, can receive the MAF assistance upfront, without a separate financial assessment by the medical social worker. The public hospitals will be enhancing their systems to support this simplified process.

To ensure costs are kept affordable, patients should also be informed of the estimated charges before making a decision. Mr Charles Chong has asked about the measures to empower patients to make informed decisions about private hospital fees. Since 2003, MOH has been publishing historical transacted hospital bill sizes. More conditions were covered over the years and in 2014, we further published total operation fees for common procedures to ensure transparency of healthcare charges. As shared by Minister Gan earlier, we have since introduced fee benchmarks in November last year for professional fees for common surgical procedures.

These fee benchmarks provide a useful reference to guide private healthcare providers in charging appropriately, and enables patients and payers to make more informed decisions. Both the bill size publication and fee benchmarks are available on MOH's website. Doctors should take reference from the benchmarks in setting their fees and advising their patients. They should also be prepared to explain to patients where their charges exceed the range, such as when addressing a highly complex case, or in exceptional circumstances. Patients are encouraged to use the benchmarks to have a conversation with their doctor on their treatment, the complexity of their condition and the fees charged.

We will monitor the bills and charging practice following the release of the fee benchmarks, and consider the approach for periodic updating of the fee benchmarks to ensure they remain relevant and updated.

Mr Mohamed Irshad has asked about having reduced co-payment for patients with Integrated Shield Plan riders who are treated at public hospitals. Co-payment is a tenet of our healthcare financing framework that encourages prudent and appropriate use of healthcare services, both in the private as well as the public sectors. This helps to ensure that healthcare costs and health insurance premiums remain affordable and sustainable for Singaporeans in the long term.

All new Integrated Shield Plan riders are required to have a co-payment of 5% or more. The co-payment amounts can be paid using MediSave, up to the applicable limits. Medifund is also available for those who require assistance with their healthcare bills.

Mr Low Thia Khiang has asked for an update on precision medicine research and implementation.

Work is on-going. However, I am glad to inform Mr Low that MOH's Health Regulation Group, together with the Genetic Testing Advisory Committee, introduced a Code of Practice for the Standards for the provision of clinical and laboratory genetic/genomic testing services in July 2018. The Code addresses key issues such as competency and training of personnel delivering the services, and the appropriateness in the ordering of genetic tests. An IT architecture is also being conceptualised to pull together, store, and analyse the information from healthcare institutions in a robust and secure manner.

Precision medicine has been deployed in our public healthcare institutions. For example, approximately 240 Singaporean and PR children with Acute Lymphoblastic Leukaemia have benefited from personalised treatment in the past 15 years.

Currently, gene editing involving human subjects is regulated under the Human Biomedical Research Act. Research of a nature similar to that of the cited case in China is strictly controlled, and cannot be conducted without the explicit approval from MOH.

As precision medicine is an emerging field, we will need to carefully consider many factors, such as ethical, legal and social implications, and weigh the investments required against the potential benefits, before systematically implementing the strategy to maximise the benefit to the population.

We will continue our efforts to keep our healthcare system sustainable for the long term and ensure that all Singaporeans can receive appropriate and affordable care.

Beyond keeping healthcare affordable, we need to keep Singapore and Singaporeans safe from infectious diseases. MOH regularly reviews existing legislation, policies and capacity to safeguard public health and prevent the spread of infectious diseases.

The Infectious Diseases (Amendment) Bill was passed in January 2019 and will come into effect in the subsequent months. Key amendments include strengthening processes for infectious diseases notifications and surveillance, powers to disseminate health advisories more expediently, and enhancing powers for national public health research.

In addition to enhancing legislation, we have also increased public health education and protection by providing guidance on recommended vaccinations through the National Childhood Immunisation Schedule and the National Adult Immunisation Schedule.

Dr Chia Shi-Lu asked about the vaccination take-up rates. Childhood vaccination rates remain high. Measles and diphtheria vaccination rates, at age 2 years, have been around 95% or higher in the last decade. The take-up of recommended vaccinations for adults has been encouraging, with more using MediSave for them. For example, MediSave used for influenza vaccinations has increased by about 60%, from about 32,000 between November 2016 and October 2017, to about 52,000 in the same period a year later. However, there is still room for improvement as the numbers represent a small proportion of the at-risk population for which vaccination is recommended. MOH will continue to educate the public on the importance and benefits of vaccination to encourage up-take but ultimately, we should all take responsibility for our own health by going for the recommended vaccinations.

Minister Gan mentioned that MOH has developed the National Centre for Infectious Diseases (NCID), a 330-bed national facility designed for containment of dangerous infectious diseases. It is expected to be fully operational by May 2019. During an outbreak, NCID will centrally manage the screening, isolation and treatment of infected patients. NCID also houses public health capabilities, such as the National Public Health Laboratory, to support the detection of infectious diseases. NCID will also conduct training and research to strengthen national preparedness against outbreaks.

In conclusion, my Ministry will continue to grow Singapore's healthcare capabilities while keeping costs affordable for all. We must work together as one to tackle the challenges, and ensure that Singaporeans can enjoy many more years of health to come.

The Chairman: Senior Minister of State Mr Edwin Tong.

The Senior Minister of State for Health (Mr Edwin Tong Chun Fai): Mr Chairman, Minister for Health has emphasised in his speech earlier our collective responsibility in ensuring better health for all Singaporeans. With a united front, I believe we can do much more, moving forward to ensure that healthcare remains sustainable, accessible and also affordable for all Singaporeans.

Let me elaborate on how MOH can help to strengthen our support for individuals, providers and the community in enabling us to achieve this together.

Ms Tin Pei Ling asked how can we keep our healthcare affordable and sustainable. Mr Pritam Singh also wanted to understand how we can pay for our hospitalisation bills that fall below the MediShield Life deductible.

As a starting premise, our healthcare financing system is designed to ensure that no Singaporean is denied access to appropriate healthcare because they cannot pay. We provide support through multiple, and often overlapping layers, each one playing an important but different role.

First, the Government provides means-tested subsidies of up to 80% for Singaporeans across all public healthcare settings.

In addition, all Singaporeans are covered by MediShield Life, for life. MediShield Life focuses on large bills and selected costly outpatient treatments to keep the premiums affordable.

Next, we then have MediSave to help Singaporeans set aside part of their income to pay for future healthcare needs. Singaporeans can also tap on MediSave to pay for MediShield Life deductible and co-insurance.

Finally, Medifund provides a safety net for Singaporeans who face financial difficulties with their remaining healthcare bills.

Overall, our system has worked well. In 2017, the majority of Singaporeans already pay little or no cash after subsidies, MediShield Life and MediSave for their subsidised hospitalisation bills. Seven in 10 subsidised hospitalisations by Singaporeans did not require any cash payment, and eight in 10 paid less than $100 in cash after subsidies, MediShield Life and MediSave.

Nonetheless, we must continue to constantly innovate, raise productivity, manage cost and also be responsive to changes in order to ensure the long-term sustainability of our healthcare financing model.

Ms Tin has also asked a broad question on how ready an average Singaporean might be, in terms of coping with his or her healthcare cost, especially in old age.

Projections on expenses give us some assurance but we have to remember that healthcare costs can vary and can vary quite easily with a myriad of factors such as personal health management, disease progression trends, medical technological advances and, of course, the effectiveness of our care model transformation. These are in turn shaped by the actions of individuals, providers and payers. We therefore take a calibrated approach to regularly review and take stock, see where we are, and ensure that our financing schemes continue to be relevant and adequate. We will continue to do so, to keep care affordable and accessible at each setting.

At the primary care setting, we have targeted subsidies at Singaporeans who need them more. CHAS enables Singaporeans from lower to middle income households to receive subsidies at participating GPs. In 2018, about 630,000 patients have benefited from reduced out-of-pocket medical expenses due to CHAS and are therefore better able to cope with their bills, especially for chronic conditions such as diabetes.

With an ageing population, we expect more Singaporeans will require assistance to help manage their chronic conditions.

Primary care, being the foundational bedrock of our healthcare system, plays a critical role in shifting healthcare beyond hospitals and into the community. We want Singaporeans to be able to obtain chronic are in the community, and to work with GPs in enabling that. We have therefore reviewed our financing structure, to better achieve this, with the whole primary care sector and our partner GPs.

As mentioned by Prime Minister at the National Day Rally last year, we will extend CHAS to cover all Singaporeans with chronic conditions. This is a major philosophical shift, as Singapore has never had universal subsidies for GP care, but we believe this will help Singaporeans as they grow old and also allow for a greater anchoring of chronic care in the community. And as Dr Lily Neo puts it, to facilitate the seeking of early treatment as far as possible.

This new tier – CHAS Green – will soon be available to all Singaporeans who previously did not qualify for CHAS Blue or CHAS Orange. This would consist of households with per capita household income (PCHI) greater than $1,800. It will provide up to $160 of annual subsidies for chronic conditions. In addition to keeping primary care affordable, CHAS will be another step towards transforming our primary care system to serve Singaporeans.

To better support existing CHAS cardholders as well in managing their chronic conditions, we will also be increasing the annual subsidies for complex chronic conditions for CHAS Blue and Orange cardholders. They will see an increase of up to $20 in their annual subsidies. This means that existing CHAS cardholders can now enjoy up to $500 in annual chronic subsidies.

We will also be introducing additional subsidies for CHAS Orange cardholders. They will be able to receive up to $10 in subsidy per visit for common illnesses, such as cough and cold, at CHAS GP clinics.

Collectively, we expect to pay out more than $200 million a year on CHAS subsidies.

These changes will take place from 1 November 2019 onwards. We will provide more details closer to that date.

To encourage more Singaporeans to tap on the scheme, my Ministry is also looking into ways to simplify the application process for CHAS. We are developing an online application, which we expect to be ready by September 2019. It will be more convenient for Singaporeans thereafter to apply and we hope that more Singaporeans can benefit from CHAS.

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At the same time, as CHAS helps more Singaporeans manage their chronic conditions at CHAS GPs near their home, we will put in the measures to monitor that CHAS clinics are in fact delivering good outcomes.

MOH is also reviewing clinical guidelines for care provided at CHAS dental clinics, to ensure that the care delivered is appropriate, relevant and meets the needs of the patients.

Finally, as I have mentioned in this House last month, Dr Chia Shi-Lu will be pleased to know that we will continue to review the per-capita household income (PCHI) criteria for CHAS and other healthcare subsidy schemes, so that the appropriate target group of Singaporeans can continue to benefit from these subsidies.

Aside from Government subsidies, we also review our MediSave limits regularly to keep subsidised healthcare affordable for all Singaporeans.

Mr Muhamad Faisal Abdul Manap asked what are the considerations in determining the MediSave withdrawal limits.

MediSave withdrawal limits are set to be sufficient for the vast majority of expenses in each healthcare setting, after Government subsidies and MediShield Life pay-outs, where applicable, are taken into account. For example, for inpatient stays which MediSave is primarily designed for, we set different withdrawal limits to take into account the varying charges and also the different complexity of surgical procedures. MOH also considers the use of MediSave beyond withdrawal limits on a case-by-case basis, taking into account factors such as the need for more complex treatments, sometimes unforeseen circumstances or complications, and also financial difficulties which may make it hard for the family to pay the outstanding bill. Ultimately, we need to strike a right balance between present use of MediSave and its role as savings to cater for healthcare needs in old age.

Dr Lily Neo asked about the affordability of long-term care, and more specifically, Assoc Prof Daniel Goh proposed increasing the MediSave withdrawal limits for such care.

Let me first set the context. Today, around two-thirds of households qualify for means-tested subsidies of up to 80% for intermediate and long-term care services. We will be introducing CareShield Life, which provides a pay-out of at least $600 per month for persons who are severely disabled. In addition, we also enabled a cash withdrawal of up to $200 a month from MediSave to complement these schemes. Severely disabled individuals with $20,000 balance in their MediSave, can expect to withdraw MediSave up to about 70 months, after setting aside a minimum of $5,000, taking into account other MediSave users such as paying for medical expenses. And that is not too different from the median 59 months which is proposed by Mr Goh. Mr Goh's 60 months was premised on taking it out exactly, but we have to cater for individuals who might require the services beyond the immediate.

The amount of MediSave withdrawal has been carefully considered to strike the right balance between the long-term care and other medical needs of an individual, such as insurance premiums and also hospitalisation expenses. Those who require further assistance beyond what I have mentioned can seek help from Medifund, ComCare, and the upcoming Elderfund.

The long-term care needs of Singaporeans are therefore not solely reliant on a single measure like MediSave withdrawals. They are supported in fact by a robust long-term care financing framework that mirrors the current financing framework for acute care, which has worked well for us.

Let me now turn to MediShield Life, another key pillar of our healthcare financing system. To alleviate the concerns over healthcare expenses related to marriage and parenthood aspirations, we mentioned last year that MOH would review how to extend MediShield Life to cover serious pregnancy and delivery-related complications. These complications could give rise to large bills and become a worry for expectant parents. Mr Christopher de Souza, who raised the point last year, asked for an update on the review.

I am happy to say that we have completed the review after consultations with senior clinicians and have decided to extend the coverage of MediShield Life. From 1 April this year, MediShield Life will cover inpatient treatments for serious pregnancy and delivery-related complications such as eclampsia, cervical incompetency and postpartum haemorrhage, under the existing inpatient claim limits. There are a few more of such complications which will also be covered, and the full list will be found on the MOH website. This enhancement can potentially benefit up to 4,000 patients each year.

Besides providing greater assurance against large hospitalisation bills, we also regularly review how MediShield Life can stay relevant as the model of care evolves. Let me share two examples.

First, on direct admissions into community hospitals which Mr Murali Pillai asked about and raised a suggestion earlier in the House to allow patients who were directly admitted into community hospitals to tap on to MediShield Life and MediSave, similar to those who were transferred from the acute hospitals for continuation of care. I am happy to say that since 15 July 2018, MediShield Life coverage has been extended to patients directly admitted from the emergency departments of public hospitals into community hospitals.

Patients identified for such direct admissions have to be reviewed to be in a stable condition with a clear diagnosis, and require a period of medical, nursing or rehabilitation care. Reason for that is because they are stepping down to a community hospital. This is to ensure that patients are appropriately right-sited and care is safe for patients.

All patients in community hospitals can already tap on their MediSave, regardless of where they were admitted from. We will continue to review MediShield Life coverage for other direct admissions in to community hospitals, based on assessment that such admission is appropriate and safe for patients.

Second, on bone marrow transplants, patients undergoing an autologous bone marrow transplant for multiple myeloma used to be admitted for the entire transplant treatment. Presently, however, part of the transplant treatment including conditioning, stem cell infusion and post-transplant monitoring can be done in an outpatient setting for suitable patients. This potentially shortens the inpatient stays by up to three weeks.

To better support these patients in continuing their bone marrow transplant treatments in the outpatient setting, MediShield Life will be extended to cover these costs up to a claim limit of $6,000 per treatment at approved hospitals. This will apply to treatments performed on or after 1 April 2019. This enhancement can potentially benefit over 20 patients a year. Treatment received in the inpatient setting will continue to be claimable under the existing inpatient claim limits.

In addition to MediShield Life, we will soon introduce our second national insurance scheme, CareShield Life, next year. Mr Pritam Singh asked for more transparency on the adequacy ratios and the assumptions behind premium pricing for these schemes.

As a start it must be remembered that MediShield Life and CareShield Life are not-for-profit, long-term schemes. Collected premiums and the investment returns are solely used for the administration of the scheme and the benefit of policyholders – there is no other use of these funds. Premiums are priced by external professional actuaries based on established actuarial principles, taking into account scheme benefits, claims experience, and future changes in demographics, utilisation rates, and of course, the costs of medical treatment, amongst other factors.

For MediShield Life, the actual claims experience has been close to the projections used in the pricing of premiums. In 2017, for example, our actual claims amounted to 99% of expected claims.

But we have to bear in mind that these are current-year claims. As MediShield Life, however, is a long-term scheme, and part of the premiums collected are set aside as reserves to support long-term commitments and to buffer against adverse scenarios such as a worse than expected claims experience. Further, to help with the affordability of premiums in advanced years, policyholders also pay ahead during their working ages, so that their premiums rise by less in their older ages, when at that stage, they become less economically active.

Quite apart from that, we also regularly monitor the Capital Adequacy Ratio and the Incurred Loss Ratio of the Fund to ensure that the Fund remains healthy.

The Capital Adequacy Ratio reflects the Scheme's ability to meet its liabilities under adverse scenarios. MediShield Life's capital adequacy ratio for 2017 falls within the range of private healthcare insurers'.

As part of our on-going review of the MediShield Life claims limit, we will also be reviewing the Scheme's capital adequacy ratio in tandem with its impact on premiums.

The Incurred Loss Ratio of the MediShield Life Fund over the last five years was approximately 97% – sufficient to ensure the sustainability of the scheme but not excessive. This ratio compares the total premiums collected to the total monies required to ensure that the Fund is able to meet both current-year claims and also its liabilities into the future.

Total monies required for the Fund include immediate claims pay-out each year, and the change in required reserves for future pay-outs.

A less appropriate approach sometimes cited to assess the adequacy of the Fund's premiums collection is to compare total premiums collected to total claims paid in the same year. This approach, however, is not a holistic representation as it omits a large part of what MediShield Life's premiums are meant to support, namely future long-term claims and premium affordability in advanced ages.

For MediShield Life, the benefits are outlined in the information booklet issued to all members. Further information about the Fund size, the reserves and the Incurred Loss Ratio is published on the MOH website, and the MediShield Life financial accounts are audited each year by an external auditor and then submitted to the Parliament every year.

In addition, the independent MediShield Life Council also reviews premiums collection and claims experience amongst others, and thereafter provides recommendations to the Government to ensure that MediShield Life provides effective protection in an affordable and sustainable manner.

The CareShield Life scheme design was also discussed in this House in 2018. CareShield Life supports the long-term care needs of Singaporeans in old age. Premiums are paid during the working ages, for lifetime coverage should the policyholder become disabled.

Similar to MediShield Life, an independent CareShield Life Council will be set up to advise the Government on the sustainability of the CareShield Life scheme.

I turn now to address the questions and the cuts on care-giver support.

Even as we address Singaporeans' concern over healthcare expenses, we also recognise the need to consider accessibility to healthcare, which is critical for the timely management of the condition. This is especially so for elderly who needs long-term care, and we must also care for the care-giver. With this in mind, MOH announced a Care-giver Support Action Plan earlier last month to strengthen support for senior care-giving.

Ms Tin Pei Ling and Mr Charles Chong have asked what we intend to do to continue to support care-givers. We intend to do more in at least three areas – financial support, flexible work arrangements and options for respite care for care-givers.

Firstly, in terms of financial support, we have put in place several financial support measures to help defray the costs of care-giving, such as means-tested subsidies for aged care services, the Seniors’ Mobility and Enabling Fund which subsidises the costs of assistive devices and home healthcare items, and the Care-givers Training Grant which subsidises training.

In addition, we will be introducing a new Home Care-giving Grant (HCG) by end 2019, as further financial support to care recipients living in the community with permanent disability and require some assistance in at least three Activities of Daily Living (ADLs). The HCG replaces the existing Foreign Domestic Worker (FDW) Grant with an enhanced quantum of $200 per month. While the FDW Grant helps to offset the costs of hiring an FDW, the HCG provides greater flexibility to help offset more care-giving expenses, such as the costs of home and community-based services, and transportation to medical appointments. In some cases, some might prefer to hire an FDW to help; others might not; it does not matter. The HCD can be used in either scenario.

Secondly, MOM has shared their plans to increase the budget for the Work-Life Grant to allow more companies to benefit from the grant and implement flexible work arrangements for their employees. This will help working care-givers to manage their work and care-giving commitments, and is a key step to building a sustainable approach that balances the needs of both employers and employees.

Third, we will be expanding the existing respite care services. We currently have respite services at our centres and nursing homes to allow care-givers to take a break from their care-giving duties. Centre-based respite services cater to the needs of care-givers who need a few hours off, while nursing home respite services allow overnight stays from several days to a few weeks. To date, over 2,400 clients have benefited from these respite services. We will be piloting a new night respite service with selected nursing home providers in the second half of 2019 to support care-givers of seniors with dementia who experience behavioural and sleep difficulties at night. We will continue to explore new models of care to meet the needs of care-givers.

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The Care-giver Support Action Plan complements the already existing suite of services and schemes currently available to seniors and their care-givers. MOH will be implementing the Action Plan over the next two years to better support care-givers, and will provide more details on other specific measures in the coming months.

Further to strengthening the financial and care-giving support, we also believe that having a reliable healthcare network is fundamental to every successful healthcare system. And this could be achieved through proper regulations.

Prof Fatimah Lateef has asked for an update on our regulatory approach and progress with regulatory sandbox. As a regulator, our priority is with ensuring patient safety and proper continuity of care, as new and innovative care models evolve to meet the healthcare needs of Singaporeans.

To do so effectively and safely, there is a need to review and replace the current Private Hospitals and Medical Clinics Act (PHMCA). The proposed Healthcare Services Act (HCSA), which will come before Parliament shortly, aims to enhance the regulatory clarity as to the types of healthcare services regulated, strengthen the governance of the licensees providing the healthcare services, provide the necessary safeguards to patient safety and welfare, and to ensure continuity of care and accountability.

To complement the change in our approach to regulation, we have also launched a regulatory sandbox in April last year to support the safe growth of new modalities of care and innovations within current care services – the Licensing Experimentation and Adaptation Programme or LEAP.

Doctor-led Telemedicine and house-calls were the first services to come under LEAP, and within the last year, we have 11 providers on LEAP. As providers and models mature, we are also encouraging a shift in the services provided, from managing simple acute conditions, such as cough and cold, to more complex chronic diseases such as diabetes, supporting MOH's "Beyond Hospital to Community" strategy.

Prof Fatimah Lateef will be pleased to note, and I think Mr Leon Perera also raised the point about encouraging innovation in the intermediate and long-term care sector, that we are constantly looking at how technology can help us create a sustainable healthcare future. We are also supporting our healthcare institutions to find solutions to increase productivity through the Healthcare Productivity Fund. We are seeing some early results. On the average, our productivity efforts have saved about 300,000 man-hours across public healthcare and community care institutions per year.

However, even with innovations in modalities of care and changes in the way patients can access healthcare services with technology, we are mindful that there are certain aspects of care that we should not or perhaps ought not to replace – for example, the human touch. One of our key strategies in supporting productivity is to continually explore how innovations can free up manpower from routine work so that they can go back to the business of caring for patients directly.

To conclude, Chairman, the Government will continue to support productivity and innovation for greater healthcare sustainability, affordability and accessibility. We hope that new policies, such as the enhanced CHAS scheme, will encourage all Singaporeans to seek help early and in the community. We will also be helping care-givers to continue to care for their loved ones in the community. Let us all work together and move away from healthcare to health. Help us, help you – with each and every one of us taking good care of our health, we can all be hopefully happy and active in our golden years.

The Chairman: Senior Parliamentary Secretary Mr Amrin Amin.

The Senior Parliamentary Secretary to the Minister for Health (Mr Amrin Amin): Mr Chairman, I will focus on three areas: removing trans-fat from our food supply; reducing smoking rates; and third, strengthening our health eco-system.

On the first area, artificial trans-fat is harmful to health. According to the World Health Organization (WHO), artificial trans-fat increases risk of heart disease and has no known health benefits. WHO has called for countries to remove artificial trans-fat from the food supply.

Currently, our law requires food manufacturers to declare and limit the amount of trans-fat in cooking oil and fats. Local trans-fat halved from about two grammes per day in 2010 to one gramme per day in 2018.

It is timely to build on this. We will be introducing a ban on partially-hydrogenated oil (PHO) in our food. Current trans-fat regulations only apply to fats and oil. This ban will also extend to pre-packaged food products such as snacks, baked foods, prepared meals and fat spread PHO is a major source of artificial trans-fat in these food.

Banning PHO will not have an adverse effect on Singaporeans' food options and cost. MOH has consulted the local food industry who are generally supportive. United States, Canada, and Thailand have also banned PHO.

The industry will be given time to make adjustments. Details will be shared subsequently.

Mr Chairman, turning to second area: reducing smoking rates. Dr Chia asked about efforts to help smokers quit. Smoking remains a concern in Singapore. I had announced in May 2018 that we are working towards a smoking prevalence of less than 10% by 2020. There are about 400,000 daily smokers today. One in six smokers tell us that they are thinking about quitting, but only three in 100 smokers actually take action. We target to get more smokers to go beyond thinking about quitting to actually taking active steps to quit smoking.

Successful cessation rates range from 10% for telephone-based interventions to 20% for programmes that combine intensive counselling and pharmacotherapy. This is comparable intentionally. It is difficult to quit smoking. That is why it is called an addiction, but it is not impossible.

One story inspired me. Mr Iskandar shared with me about how he successfully quit smoking, and he also helped his father to quit a 30-year smoking habit.

Mr Iskandar started smoking when he was 14. After smoking for about eight years, he started his quit journey last year. He wanted to save money for travel and improve himself. He quit cold turkey. He went to the gymnasium and jogged.

Mr Iskandar shared his quit journey with his father, Mr Muhamed Ibrahim, a smoker of 30 years. The son motivated the father and his father had also quit smoking. Mr Iskandar is now working on his brother, Mr Noor Muhamed, to cut back on smoking.

There are learning points from Mr Iskandar's story. First, personal motivation is important. Studies show that self-motivation and important milestones, such as the arrival of a new baby, or discovering a serious disease, are critical turning points. Second, supportive family and friends are critical. And third, it is never too late to quit smoking. Mr Iskandar's father is one example.

We will be speaking with more smokers this year to see how we can help. Details will be shared in HealthySG Task Force's recommendations.

There are some who have suggested e-cigarettes as smoking cessation aids. Members are aware that we disallowed the importation, sale, distribution, purchase, possession and use of e-cigarettes since February 2018.

Cessation products and programmes must first be effective and evidence-based. The current evidence for e-cigarettes as a smoking cessation aid is mixed, and we are monitoring studies that have been conducted. One concern we have is a "substitution effect". Some smokers substitute cigarettes with e-cigarettes instead of quitting or, worse, they use both. So it is hardly smoking cessation. It is more like swapping one nicotine/tobacco addiction in one's guise for another.

The other concern is the "gateway effect". Various studies have shown that e-cigarette users are more likely to become cigarette smokers compared to non-users. The experience with e-cigarettes in United States and Hong Kong are instructive. US' Sergeant-General has called alarming increase in new cigarette use an epidemic. Hong Kong reported a rise in Primary 2 to 4 students trying e-cigarettes in the last two years. And Hong Kong has recently banned e-cigarettes.

We are open to allowing a specific product to be registered and regulated under the Health Products Act as a therapeutic product for smoking cessation, but there must be good evidence and it must be effective.

Dr Chia Shi-Lu asked about help for younger smokers. Smoking rate among Secondary school, ITE and Polytechnic students dropped from 8% in 2011 to 2019, to about to 4% in 2014-2016. But this means that there are still 12,000 under-aged smokers. We are focused not only on preventing initiation, but also helping younger smokers quit, and this is our strategy.

The Health Sciences Authority (HSA) has stepped up ground surveillance and enforcement activities among tobacco retailers to reduce youth access to tobacco. In 2018, HSA suspended the tobacco retail licences of 23 first-time offender retailers and revoked four repeat offenders.

Youth smokers are referred to counsellors, Quitline, or Student Health Advisors (SHAs) at 50 Secondary schools or ITE Colleges and Polytechnics for cessation counselling. In 2017, 3,000 youths were counselled and 43% managed to reduce smoking, and about 10% quit.

In June 2018, we launched "Better Things to Do", a campaign for youths. We hope to encourage youths to tap on their network to promote a tobacco-free lifestyle.

And in January this year, we focused on harmful, emerging products – e-cigarettes in particular, which contain nicotine and benzene. And we will intensify our tobacco-free efforts.

Mr Chairman, turning to the third area of my speech, strengthening our health eco-system, I have three points to make.

First, growing our healthcare professionals, and traditional Chinese medicine practitioners. Second, making screening and follow-up more convenient. And third, the progress on war on diabetes and HealthSG Task Force.

On the first point, Dr Chia Shi-Lu asked about ensuring sufficient numbers of allied health professionals. MOH had worked with MOE and the Singapore Institute of Technology (SIT) to increase the intake of four Allied Health degree programmes in Physiotherapy, Occupational Therapy, Diagnostic Radiography and Radiation Therapy from 230 in 2016 to about 300 students in 2018.

There are also Graduate Entry Masters programmes in Speech Therapy, Clinical Psychology and Audiology at the National University of Singapore.

MOH regularly reviews our training pipelines, for example, to the growing need of dietitians in Singapore, SIT launched the first local four-year Dietetics and Nutrition degree programme. The first cohort will begin the programme in September 2019.

Earlier this year, we introduced an accelerated Professional Conversion Programme for Physiotherapists as an additional pathway for those keen to join the healthcare sector as Physiotherapists. This programme allows mid-career locals with a degree in science-related fields to complete physiotherapy training in less than three years, compared to four.

Mr Christopher de Souza asked about continuing development and career progression for allied health professionals. We are launching the "Skills Framework for Healthcare" for six professions – Nurses, Pharmacy Technicians, Physiotherapists, Occupational Therapists, Speech Therapists and Patient Service Associates.

The Skills Framework for Healthcare (SFH) is a common reference for skills and competencies for different stakeholders. MOH will work closely with the respective professions to identify training needs and build a future ready healthcare workforce.

Turning to Traditional Chinese Medicine (TCM) Practitioners, to raise professional standards of TCM practitioners, Continuing Professional Education (CPE) is compulsory when renewing practicing certificates. To defray CPE costs, TCM practitioners can apply for the TCM Development Grant, launched in 2018, at a cap of $200 per year. As of end 2018, we had given more than $70,000 to over 400 TCM practitioners. TCM practitioners can use their SkillsFuture Credit to attend eligible TCM-related courses. And we will continue to work closely with the TCM Associations to support TCM practitioners.

We will make health screening and follow-up more convenient. From May 2019, you can have subsidised checks for blood sugar and cholesterol levels at CHAS clinics without having to fast overnight or for 12 hours.

We will update our guidelines to recommend the use of glycated haemoglobin (HbA1c), and the non-fasting lipid tests, as alternative screening tests for diabetes and high blood cholesterol respectively. This has been endorsed by international and local medical professional bodies. A local clinic working group found that the HbA1c, if used correctly, was just as capable as the current test in detecting diabetes. The group also recommended the use of non-fasting lipid profiles for screening high cholesterol based on international guidelines and studies.

The non-fasting tests give Singaporeans a wider range of screening options to choose from. This will be helpful for seniors who are more prone to episodes of low blood sugar. We hope to increase screening uptake with this added convenience.

Singaporeans with eye conditions can now receive care closer to their homes. We piloted community eye clinics with Singapore National Eye Centre (SNEC), Tan Tock Seng Hospital (TTSH) and National University Hospital (NUH). At CECs, patients can have their eyes checked and managed. There are four CECs at Punggol Polyclinic, Keat Hong Family Medicine Clinic, Hougang Polyclinic and the Health Promotion Board at Outram. Later this year, there will be two more community eye clinics at Pioneer and Geylang Polyclinics.

Dr Lily Neo asked about promoting healthy lifestyles to prevent chronic diseases, and supporting Singaporeans to reduce sugar intake. Mr Melvin Yong asked for updates on the War on Diabetes and Dr Chia asked for updates on the HealthySG Taskforce.

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Healthier eating is now more accessible. As of December 2018, more than 1,200 food and beverage (F&B) operators, hawker centres, and coffee shops, with 8,900 touchpoints island-wide, have joined the Healthy Dining Programme (HDP). Singaporeans consumed 131 million healthier meals in 2018, double that in 2017.

Lower sugar beverages are now within reach. We have more drink partners with about 200 outlets, as well as drink stalls in hawker centres and coffee shops with the "H", with the healthy dining programme.

HPB’s Eat Drink Shop Healthy Campaign nudges Singaporeans to earn points when choosing healthier options during grocery shopping.

We extended the Healthier Ingredient Development Scheme (HIDS) to include sugar-sweetened beverages, desserts and sauces. We partnered five dessert suppliers, three beverage suppliers, and one sauce supplier, and there are now healthier options available.

Exercise is another area. The National Steps Challenge Season Three helped 8 in ten participants who were previously inactive clock more than 150 minutes of physical activity a week. We are taking another step forward. We are encouraging higher-intensity physical activity, hence better fitness. 740,000 participants in Season Four of the National Steps Challenge were provided with a new step-tracker that can measure heart rate.

There were also many exercise programmes in the community, but there is more to do. The HealthySG Taskforce, which I chair, seeks to integrate, coordinate, scale up health promotion efforts across our social and infrastructure agencies and communities, and especially the under-reached and disadvantaged groups, such as the lower income. Public consultations will start in end March to early May, and we are targeting to release recommendations in early second half of the year.

Mr Mohamed Irshad asked about how health promotion efforts have reached our Malay and Indian communities. Let me give an update. Mr Chairman, with your permission, in Malay, please.

(In Malay): [Please refer to Vernacular Speech.] Our effort to develop a healthy Malay community focuses on three aspects.

First, by watching what we eat and drink. Second, be physically active. Third, undergo health screenings and seek early treatment.

Many initiatives introduced this year have refreshed the three thrusts mentioned earlier.

Let us talk about food. In 2017, there were only two halal Healthier Choice dishes at the hawker centres: Thosai and Mee Soto.

Now there are more choices with six halal dishes that are healthier. Halal Healthier Choice dishes now include chicken porridge, Penang asam laksa and mee bakso. Crowd favourites like briyani, nasi padang, chicken rice, rendang and many other kinds of dishes can also be modified into healthier versions.

Well-known Malay restaurants also began to serve a wider choice of delicious and healthy food. Rumah Minang, Hajah Maimunah, Sabar Menanti, and many more. These are some of the 1,100 food establishments that serve healthier halal dishes using brown rice, healthier cooking oil, vegetables and less coconut milk.

It is not just when eating out. If you attend religious feasts or weddings, healthier choices are also available. There are now 107 caterers providing halal healthy food, including 24 Malay wedding caterers like Jamil Catering and Istana Wedding Services. The feedback has been positive. The dishes taste the same and the flavour is not compromised. In January this year, we offered get-fit courses to those getting married at the Wedding Fair. One hundred and forty couples who are tying the knot participated in this pilot programme so that on their big day, they will be lighter, slimmer and more importantly, healthier.

Our “Kita dah cukup manis!” (We are sweet enough!) and “Korang OK?” (Are You OK?) campaigns, especially during the fasting and Hari Raya period, advise us to consume less sugar.

In November 2018, I launched the “Korang OK?” exercise video for pre-school children. To bend a bamboo, do it when it is still a bamboo shoot (Malay proverb meaning to cultivate good values while they are still young). From young, develop healthy habits, exercise, as these can be done easily and enjoyably.

Six dialogue sessions sharing nuggets of wisdom on health were organised with Berita Harian. It is always best to get medical advice from the professionals. Therefore, during these dialogue sessions, the public were able to obtain health tips from the experts like doctors from the Muslim Healthcare Professionals Association.

The dialogues did not end there, and in fact, it continued online. The “Korang OK?” social media site set up in June 2018 has more than 23,000 followers and the site is actively sharing healthy recipes and health tips.

Exercise is important. I was concerned when I saw many of our seniors experiencing leg pains when I performed my Umrah (minor pilgrimage) in 2017. Together with HPB and Umrah travel agents, we launched the “Get Fit For Haj/Umrah” in November 2017. The six-week exercise programme organised in mosques and stadiums attracted 900 participants. I was informed that, through this programme, our pilgrims were able to move quicker when performing their tawaf (haj ritual that involves walking).

After the Umrah season, there are also exercise programmes like the “Gerak Gelak” walking event organised by the MAEC from the community clubs. Four “Gerak Gelak” sessions were organised since 2018 by the Tampines, Marine Parade and Sembawang GRCs, as well as in Jurong last week, with a total of 2,200 participants.

Taking care of health is also encouraged in Islam. The “Jaga Kesihatan, Jaga Ummah” (Taking Care of Health, Taking Care of Community) programme launched two years ago began with five mosques. It has expanded to include 23 mosques, with various exercise programmes, health workshops and health screening sessions held at JKJU mosques, and it has benefited more than 4,500 congregants this year.

Good health is a precious gift. Let us take care of our health and our families together.

(In English): Let me now turn to the Indian community. I attended a dialogue with 20 Indian voluntary oganisations to talk about community health matters and programmes. We are partnering with various Indian groups such as Sree Narayana Mission, the Central Sikh Temple, and Narpani Pearavai, the Indian Activity Executive Council Committees.

We partnered with Suria, Vasantham and various Mediacorp artistes to run the Family Funival earlier this January. Over 5,000 people bonded over zumba and various workouts. We will do more this year.

In conclusion, Mr Chairman, Singaporeans are living longer, and my colleagues and I are working hard to ensure all of us can lead healthy, fulfilling lives. Let us grow healthier together! Let us build a healthy Singapore together.

The Chairman: I do not know about you but I feel very hungry after his speech. Clarifications? Mr Alex Yam.

Mr Alex Yam: Thank you, Chairman. My clarification is for the Senior Minister of State Dr Amy Khor. I hope she can address my cut on reviewing the medical evidence on pre-term viability.

The Senior Minister of State for Health (Dr Amy Khor Lean Suan): I thank the Member for reminding me about his cut. My apologies.

In response to the cut, the current cut-off of 24 gestational weeks for abortion was based on scientific evidence of foetal viability outside the womb. According to local experts as well as based on our hospitals' experience, foetal viability below 24 weeks remain low. Furthermore, morbidities such as neuro-developmental disabilities are very high among the premature babies who survived.

International studies and professional bodies also largely support the low foetal viability below 24 gestational weeks. In addition, in 2018, it is worthwhile to note that about 1% of all abortions performed were performed between 22 and 24 gestational weeks, of which more than half of these abortions were performed due to foetal anomalies and other medical reasons.

So, essentially, the number of abortions below 24 but between 22 to 24 is already very low, and quite a large percentage is really due to medical reasons. So, what we have done, really, is also to work together with MSF to strengthen pre-abortion counselling and to raise awareness among these women with unplanned pregnancies of the options available to them including adoptions. MOH will continue to monitor and review this issue as new evidence emerges.

The Chairman: Dr Chia Shi-Lu.

Dr Chia Shi-Lu: Thank you. Just two clarifications. One is concerning the Agency for Care Effectiveness (ACE). I have been very supportive of it because it gives guidelines on what is the best practices. So, perhaps, I was hoping that MOH could share with the House the achievements of ACE thus far.

The second clarification is regarding MediShield Life. Earlier this year, there were some concerns about inadequate payouts for certain patients. I understand from previous replies that the MediShield Life Review Committee is looking at claims limits. But, in the meanwhile, to give better assurances to Singaporeans, is there any mechanism by which we can appeal for higher payouts from MediShield Life in certain of these bills?

Dr Lam Pin Min: Mr Chairman, I would like to thank Dr Chia Shi-Lu for the supplementary questions with regard to ACE. Just to give a brief background. ACE, which is the Agency for Care Effectiveness, was actually set up within MOH in August 2015 as a national health technology assessment agency, against this backdrop of rising healthcare costs and the need to drive clinically effective and cost-effective healthcare.

Over the years, there has been a lot of good work done by ACE. Just to name some of the achievements that ACE has done, which includes producing technology guidances on drugs and medical technologies. In fact, they have published almost 33 drug guidances, three medical technology guidances, as of 2 January 2019.

In addition to that, ACE also produces Appropriate Care Guides (ACGs) which are targeted and concise as recommended care practices and pathways that promote appropriate prescribing behaviours. As of 2 January this year, they have already produced nine ACGs.

ACE also conducts value-based pricing, or what we call VBP, in parallel with drug and medical technology evaluation. This is to ensure that the price of patented drugs or medical technologies recommended for subsidy commensurates with the drugs or medical technologies' value in Singapore's context.

So, suffice to say, ACE has done a lot of good work and it has also achieved its objective of driving healthcare costs down.

Mr Edwin Tong Chun Fai: Chairman, I will address Dr Chia's second question. At this point in time, we do not look at appeals for MediShield Life payouts. The reason for that, obviously, is the more you get the payout on an individual, that compromises the fund because you draw out from other persons who have put premiums inside.

But on Dr Chia's point, we can consider appeals for higher MediSave withdrawals or, if not, then the use of Medifund, in the meantime. But the MediShield claims limit is being reviewed.

The Chairman: Ms Joan Pereira.

Ms Joan Pereira: Thank you, Chairman. I have two questions for MOH. First, in my earlier cut, I mentioned that patients now have access to information on bills and fee information in the MOH website. But there is no information on the website on the standard or quality of delivery; basically qualitative information. So, would the Minister consider providing such information on the website, which I feel will be helpful? First question.

My second question: last year, MOH announced the formation of the Agency for Logistics and Procurement Services (ALPS) to pool together the supply chain functions and resources of the three health clusters. May I know what is the progress of ALPS and how has that benefited our patients?

Mr Gan Kim Yong: Sir, on the quality information of our healthcare institutions, I will take on the suggestion and will take a look and see what kind of quality information we can put up to help patients make informed decisions. It is a useful suggestion. I want to thank the Member for that suggestion.

Secondly, on ALPS, ALPS stands for Agency for Logistics and Procurement Services. It is quite a mouthful but it is an important initiative that we have introduced. The idea is to bring together the supply chain functions of all our clusters, so that we can achieve economies of scale, aggregate demand, and so on.

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The first step is to better understand the procurement practices of the different clusters and see whether we can harmonise them – first, to achieve economies of scale by aggregating the purchases of the various clusters; then we have a higher leverage with our suppliers so that we can negotiate for better pricing.

Secondly, we are also looking at whether we can take the next step of standardising some of the products, instead of each one having their own prescribed specific products for the cluster, and whether we can find common products that we can further aggregate the demand so that we can optimise the supplies.

Beyond that, the agency is also looking into how we can reorganise our distribution network, our logistics arrangement, our entire supply chain management so that we are able to optimise resources. For example, if you can imagine that you store your pharmaceuticals in one warehouse and deliver them to another hospital, and you have another warehouse deliver to the other hospital, actually we can just have one warehouse to deliver to both hospitals. So, there is opportunity for us to optimise.

Lastly, having done some of these optimisation, we also want the agency to think out of the box to see whether they can have new innovative ways of managing the supply chain. For example, if you allow your imagination to run wild a little bit, you can think about whether we can deliver medication to the patients rather than having to collect it from the pharmacy. So, if you do a national kind of distribution network, that may be possible. Today, many of us purchase through e-commerce and they deliver to your house quite regularly. But, of course, delivering medication is quite different from delivering your food items and sundries and so on. It is more stringent. We will have to study it very carefully. But aggregating the supply chain and logistics function will allow us to think out of the box and develop new models of distribution which will in the long term benefit our patients.

Ms Sylvia Lim: Thank you, Chairman. I do not recall hearing a response to my cut on the private ambulance service industry. So, may I have a response to that and, in particular, what the Ministry is doing to improve outcomes for consumers?

Mr Edwin Tong Chun Fai: The Healthcare Services Bill (HCSA) that I talked about will regulate private ambulances and I think Ms Lim, in particular, spoke about the publication of rates for more transparency. That legislation will mandate the publication of common fees charged as well as give more transparency to the bill components to be paid by the consumers so they will know upfront what those costs would be. Further details would be set out in the HCSA Bill as we will put it up shortly.

Ms Irene Quay Siew Ching (Nominated Member): Mr Chairman, can I ask the Minister for his comments regarding the proposal in my Budget debate speech to acknowledge allied health professionals' and pharmacists' expertise in a national subsidy framework for cost containment as well as to keep patients in the community, such as the extension of drug subsidy schemes to community pharmacies as well as extension of CHAS scheme to allied health services in the community because we need a holistic approach to keep patients in the community?

Mr Amrin Amin: I thank Ms Irene Quay for the good suggestions. MOH is actually currently studying the models of care that will help patients access allied health services earlier, say, for example, the direct referral to community physiotherapists for agreed musculoskeletal presentations.

On the point about remuneration for public sector allied health professionals, a point that was raised by Ms Quay, beyond salaries, MOH works with clusters to enhance the value proposition of an AHP career in the public sector and these are things that I mentioned by providing learning and development opportunities. I mentioned in my speech also about the skills framework for healthcare that was launched in 2019 that will cover various training opportunities and career plans that they can have.

As for pay, it is something that we will review. We always want to make sure that it is competitive so that we can retain good AHPs in the public sector.

Mr Pritam Singh: Thank you, Chairman. My question is directed at Senior Minister of State Edwin Tong. This is with respect to my cut on Greater MediSave Flexibility for senior citizens, particularly those above 60. The Senior Minister of State mentioned in his reply that eight out of 10 patients pay less than $100 in cash as a result of their hospitalisation. Can I just get a sense of the average amount that patients pay for the remaining 20% of that category? In addition to that, what are the absolute numbers of hospitalisations we are talking about in that particular category – those who pay above $100?

Mr Edwin Tong Chun Fai: I do not have those numbers to hand out, but if the Member could file a PQ, I would have those numbers to hand.

Dr Lily Neo: Thank you, Mr Chairman. Two clarifications, please. May I ask whether there is sufficient aged care capacity to support our ageing population? Secondly, what is HPB doing to make healthier food options more affordable?

Dr Amy Khor Lean Suan: Since 2015, we have been significantly increasing aged care capacity in terms of nursing homes as well as community care, home and centre-based care facilities. In fact, we have added 2,700 day care places since 2015 so that seniors can access day care services near their homes. We have also added another 2,300 home care places over the same period.

In fact, the supply of home and day care places has actually stabilised. We see sufficient capacity at the national level. So, in fact, at the national level, there are more vacancies than wait-listed seniors, except that there could be an imbalance in demand and supply within certain local areas because of patient or family preferences and so on. So, in those areas where there is an imbalance, we are actually ramping up capacity in terms of new centres, as well as building new centres. Our focus now is on the quality and variety of aged care services available. Earlier on in my speech I said that we are actually looking at better integration of social and health services and, therefore, because the Senior Activity Centres have now come under MOH, together with the Senior Care Centres, we are now looking at a range of services that all these Senior Centres can offer within the community and, therefore, increasing access and availability of services for the seniors.

Mr Amrin Amin: Sir, to answer Dr Lily Neo's question on making healthier food more affordable, this is something that we are studying in greater depth under the Healthy SG Taskforce, but there have been some efforts going on. HPB collaborates, for instance, with the local retailers to offer price discounts for Healthier Choice symbol housebrand products and we have been working closely with retailers, such as NTUC, Cold Storage and Sheng Siong.

We will see what else we can do on this front. But it is also worth pointing out that on healthier food, it does not cost so much to eat healthy. You can actually prepare chicken in healthier ways.

Mr Leon Perera: Thank you, Sir. Just a quick clarification. I thank the Minister for addressing my cut on Value-based Healthcare. Is there a targeted timeframe for moving in a more broad-based way towards a value-based healthcare model in Singapore and will a roadmap be published towards that end?

Mr Gan Kim Yong: Sir, the value-driven care initiative started in 2017, as I explained in my speech. We appointed a national value-based healthcare workgroup. This workgroup already comprised representatives from the various public healthcare institutions, so it is already quite broad-based. To date, we have initiated a total of 17 conditions under value-driven care and we want to expand this over time. But we need to do it very carefully because, as the Member pointed out, we need a buy-in from both service providers as well as patients so that they are on this journey of value-driven care.

We will continue to press on with this effort. But it is already broad-based, involving most of our public healthcare institutions and they have a plan to gradually expand these conditions to more conditions. But we would prefer to focus on these 17 for the time being to make sure that they are done well so that the same methodology, the same model, can then be replicated. If we rush into it, I think it may create more problems and difficulties. So, we would prefer to focus on these 17, do it well and develop a dashboard so that we can get everybody on board and try to improve and optimise the care outcome and cost effectiveness. Later on, we can replicate to other conditions.

The Chairman: Dr Chia, would you like to withdraw your amendment?

Dr Chia Shi-Lu: Mr Chairman, as always, I would like to thank all Members for their active participation and for the very healthy debate and, of course, to Minister Gan, Senior Ministers of State Amy Khor, Lam Pin Min and Edwin Tong and Senior Parliamentary Secretary Amrin Amin and all staff of the Ministry of Health for the care they have given; you get explanations and the surgical precision of their responses. May we all live long and prosper. With that, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $10,023,750,700 for Head O ordered to stand part of the Main Estimates.

The sum of $1,698,806,800 for Head O ordered to stand part of the Development Estimates.