Committee of Supply − Head O (Ministry of Health)

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

11.43 am

Future-proofing Healthcare in Singapore

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

I would like to begin with a quote from George Burns − he may probably not be the best person to begin this debate with because he is well-known for being always seen with a cigar hanging out of his mouth − but he once quipped that, "I look to the future because that's where I'm going to spend the rest of my life".

In other words, we reap what we sow, and the lifestyle decisions we make have a significant impact on our health in later life. We cannot choose our parents and so our genetic make-up is predetermined, but we can certainly choose how we live our lives. Likewise, as a nation, decisions we now make regarding our healthcare framework will have deep and far-reaching consequences on the healthcare landscape of the future.

In Singapore we should take some credit for always keeping a constant eye on the future. We have all heard about SkillsFuture and other forward-looking policies, and healthcare is no exception. Since my earliest speeches about health and healthcare in this House during the Budget Debates, the Ministry of Health (MOH) has progressed its Healthcare Masterplan, first to 2020, then beyond 2020, and now onto 2030.

It is great that we are planning for the future, but in order to future-proof the health of our citizens, we need to pay close attention to the present.

Shaping lifestyle decisions, ensuring a clean living environment and further improving socioeconomic conditions through inclusive growth remain arguably the most powerful means of influencing the health of our country.

That is why many studies have shown an inconstant correlation between healthcare spending and the overall health status of a country, since healthcare spending primarily captures the magnitude of expenditure on medical care, rather than the sum of efforts directed towards health maintenance.

I hope that MOH will be able to provide an update to this House as to what progress has been made in encouraging Singaporeans to keep active and live healthily.

We still pride ourselves on being able to support a world-class medical care system and achieve world-class health standards, but it is increasingly becoming a stretch to declare that we can do so at a modest price. True, healthcare expenditure remains a small percentage of our gross domestic product (GDP) compared to what many other developed countries spend. But I note that, this year, the healthcare budget is close to S$10.7 billion, which is about an eighth of our operating Budget for 2017, and this is almost a 10% increase from last year's Budget.

Just a few years ago, then Finance Minister Deputy Prime Minister Tharman announced that we can expect healthcare spending to jump to $12 billion by 2020, and it certainly seems that we may be reaching this target earlier rather than later.

11.45 am

One of the big issues that has dominated this year's Budget is concerning the rise in the price of water. Healthcare, like water, is a necessity and it is a public good. But it, too, has resource limitations. One of the measures that has been suggested to impress on the public the importance and true cost of water is to reintroduce rationing exercises. I certainly am not suggesting that we consider rationing healthcare to encourage more judicious use of medical care, although I do note with consternation that there are countries, both developed and developing, which are actually seriously exploring various ways of rationing healthcare to their population as costs have ballooned out of control.

But we have to act now to rein in healthcare spending and channel resources to policies which have a proven impact on the health status of Singaporeans. My point is that we should rationalise, but not ration.

I was encouraged that MOH had earlier announced three key shifts in healthcare (a) moving beyond the hospital to the community; (b) beyond quality to value; and (c) beyond healthcare to health. These are critical to the sustainability and future-proofing of our healthcare system, and I would like to ask what the Ministry has done to begin these shifts.

Over the past few years, we have made great progress in providing quality, affordable and accessible medical care, but the challenges to the health of Singaporeans remain formidable. Smoking prevalence continues to be stubbornly sticky, many of us still feel helpless when trying to eat healthily and exercise often, and trying to maintain an optimal work-life balance remains a struggle for many.

I applaud the recent announcement of the NurtureSG programme, which encapsulates many suggestions that healthcare professionals have been advocating. I would like to ask the Ministry if it can update this House on how it intends to see this programme through and what resources will be made available to ensure that this programme succeeds.

The emphasis on healthy eating is particularly laudable, since studies have shown that children who learn to eat healthily tend to continue to do so in their adult lives and are likely to pass on such habits to their children. This would surely be a significant pre-emptive strike in our continuing battle against diabetes and other chronic diseases.

I believe that the Ministry could go even further by perhaps looking at legislation and enshrining such good practices in the requisite laws, such as what the United States (US) has done with the Healthy Hunger-Free Kids Act, which also addresses another issue, which is, to ensure that no child should start the school day without having a healthy breakfast. I would like to ask if MOH or perhaps the Ministry of Education (MOE) has any data on the percentage of our school children who do not regularly have breakfast before the school day begins.

I also commend the announced focus on safeguarding sleep for our children. How does the Ministry intend to help parents and caregivers achieve the sleep goals for their children?

Next, I would like to recognise the steady investment the Ministry has made over the years in intermediate and long-term care (ILTC) and end-of-life care, both in terms of manpower and infrastructure. Nonetheless, there remain concerns about how such care will be financed as the current MediSave, MediShield Life and MediFund (3M) framework does not adequately address this area of care. I am happy that the Government has recognised the urgency for a thorough review and enhancement of the ElderShield programme. In our 2013 Paper on Healthcare Affordability, we opined that "with the integration of social care and healthcare under one Ministry, the Government Parliamentary Committee (GPC) for Health recommends that the current ElderShield payout be revised. Meant for severely disabled elderly Singaporeans, the current ElderShield payout is insufficient for Singaporeans to even cover nursing home fees. Its coverage should, therefore, be strengthened to make it more relevant."

The GPC for Health has been concerned about this issue for some time now, and we will be presenting our comments and suggestions to the ElderShield Review Committee in due course. I would like to ask MOH if the timeline for the review remains on track.

Finally, we are privileged to live in an era which has seen rapid and breathtaking advances in medical and healthcare technology. The disruptive effects of these advances will lead to new paradigms of healthcare delivery, and Singapore should be ready to embrace these shifts as they could lead to significant improvements in our well-being and can also be an impetus for economic development.

In this generation, it is quite probable that medical care will become highly personalised, such that the care patients receive becomes more targeted, more efficient, safer and, ultimately, more affordable.

Personalised healthcare, also known as precision medicine, holds great promise for the future of healthcare. Precision medicine refers to the ability to "tailor therapies to a patient's individual needs by examining their individual characteristics". Many countries are actively developing their capabilities here. The US has its Precision Medicine Initiative, Europe has its European Alliance for Personalised Medicine, and China announced a massive investment in Personalised Medicine as part of its 13th Five-year Plan.

However, this brave new world of medical therapy will have to be carefully navigated, and regulators will need to keep up. Traditional systems of healthcare delivery will change, such as what defines a hospital, and can treatment only come from the more traditional medical institutions? How do we make sense of the barrage of new technology and treatments and curate them properly for the benefit of our citizens?

I have previously asked for a more robust framework for evaluating healthcare therapies, as there are many cautionary tales if one just looks around. The sad stories of dubious therapies like alkaline water treatment, spectacular failures like that of the flawed or perhaps even fraudulent blood testing technology of Theranos are but some examples.

I would like to request an update on the health technology assessment framework. I think it bears repeating that we should rationalise and not ration healthcare. It has also announced that MOH is reviewing the Private Hospitals and Medical Clinics Act (PHMCA). What is the progress of this review and how will updating this Act better safeguard the welfare of our patients?

In conclusion, Madam, the real answer to future-proofing healthcare in Singapore is simply to be future-ready. This means that we have to invest prudently and sustainably in the present and have a pragmatic roadmap for the future.

Question proposed.

The Chairman: Ms Tin Pei Ling.

Beyond Healthcare 2020

Ms Tin Pei Ling (MacPherson): One of the aims of Healthcare 2020 was to offer seamless, hassle-free and holistic care for patients across different stages of their healthcare journey. With an ageing population, the need for primary and geriatric care will rise, relative to acute care. Given the profile and needs of the aged and the already heavy load on our healthcare system, community-based healthcare is important and the pace of implementation has to pick up.

Given this, could the Ministry share what it has done and will continue to do to shift the centre of care to the community? And in this digital age and in this Budget where we talk about digitalisation, could the Ministry also share how it has embraced technology to improve efficiency of healthcare delivery and to improve patients' access to healthcare within the community?

Over the years, we have put in place, streamlined and updated our healthcare systems and structures so as to keep pace with developments and needs. Healthcare in Singapore has made many improvements and won international recognition. Looking ahead, we must look beyond ensuring access, cost containment and convenience − all of which are still important − but also consider how we can deliver value-based healthcare, where health outcomes are maximised per dollar spent.

As such, could MOH share what are its vision and plan beyond Healthcare 2020 and what it has done to achieve value-based healthcare? Could MOH share the desired outcomes that it wishes to attain for Singapore's healthcare system and population, as well as the key indicators that are being tracked?

Meeting the Needs of an Ageing Population

Mr Low Thia Khiang (Aljunied): Madam, the percentage of our population aged 65 and above increased from 11.2% in 2014 to 12.4% in 2016 and will only rise further. It is crucial that we plan ahead, in tandem with the expected ageing population, to ensure that we have the necessary infrastructure and manpower to meet the present and future healthcare needs of Singaporeans.

In recent years, the construction of hospitals and medical centres has been ramped up, resulting in significant increases in the development expenditure of MOH.

Yet, according to a report published by the Lien Foundation and the Khoo Chwee Neo Foundation, the Government's efforts to ramp up capacity lags behind the rate at which the population is ageing. The report found that "Singapore had around 26.1 nursing home beds per 1,000 people aged 65 and above in 2015 − the lowest proportion in 15 years − down from around 28 beds in 2000 and well below the Organisation for Economic Co-operation and Development average of 45.2 beds."

The Straits Times article goes on to add that based on the percentage of the elderly population living in residential aged care facilities in developed countries, such as the US, Australia and Finland, there will be 50,000 seniors in Singapore who will require such facilities by 2030. The Government's current plan is to bring the total number of nursing home beds to slightly over 17,000 by 2020. Is this sufficient to cope with projected demand? I would like to find out from the Minister what is the progress of the plans to increase the physical capacity of our healthcare system, and is the current expansion of existing infrastructure sufficient to meet the healthcare needs of the population?

On manpower, the Government's Healthcare Manpower Plan 2020 seeks to add 30,000 healthcare workers by 2020. In early 2016, in a reply to a Parliamentary Question filed by my colleague, our doctor and nurse to population ratios still lag behind other developed countries, such as Australia, Japan, the United Kingdom (UK) and the US.

I have a few questions for the Minister. Given that the number of nurses and allied health professional graduates has fallen since 2012, while the number of medical graduates has also fallen since 2013, all these despite great efforts by the Government to make these jobs more attractive, how confident is MOH in meeting the targets in the Manpower Plan 2020?

It was reported that there were 2,100 foreign doctors in public hospitals and polyclinics at the end of 2014. What is this number today? Also, what is the ratio of foreign nurses to local nurses currently in public hospitals and polyclinics, and what is the ratio that the Ministry hopes to achieve by 2020?

Healthcare Cluster Reorganisation

Dr Chia Shi-Lu: Madam, MOH announced a reorganisation of the healthcare system from six regional groups into three clusters in January this year. The intention is to better optimise resources and provide more comprehensive and patient-centred care services. Each cluster will provide the full range of acute hospital care, primary care and community care and also include a medical school.

However, a number of my patients and residents have expressed concern that if their preferred polyclinic and Government hospital are not within the same clusters, they will encounter problems after the regrouping is completed in 2018. I had reassured them that under the National Electronic Health Record (NEHR) system, our hospitals, specialist outpatient clinics and polyclinics have access to their medical records. In fact, they can also access them through the HealthHub system. So, it is quite seamless and they will not be adversely affected.

However, this explanation was not fully satisfactory for them as some of them could not understand the necessity of the regrouping in the first place. Would the Ministry share in greater detail about the new healthcare system regrouping and, ultimately, how Singaporeans will benefit from this reorganisation? In what ways will the new system be more suitable for our future healthcare needs?

Care Coordination and Strengthening

Assoc Prof Fatimah Lateef (Marine Parade): Chairman, Mdm A is 70 years old. She has complicated diabetes and has to follow up with her diabetologist for sugar control; her podiatrist for her long-term foot ulcer; an ophthalmologist for her diabetes which has affected her eyes; and her worsening kidney function requires her to see a renal physician. Some of her appointments are six-monthly and others are two- to three-monthly. Each visit will require her to collect medications from the pharmacist as well. To get to the specialist outpatient clinic or polyclinic, her daughter and son need to take turns off work, or her domestic helper will assist when they are overseas. She will take a taxi usually but, a few times, she has had to have a non-emergency ambulance to send her to the facility which, of course, costs her more.

Care coordination is the deliberate organisation of patient care activities to facilitate appropriate delivery of services. It will help our patients negotiate the system efficiently and effectively and, of course, it will also save them time. There is a need to address the potential gaps in meeting patients' interrelated medical, social, educational, as well as support services needs. Too many transitions that exist today can, indeed, be confusing and time-consuming, especially for our seniors, and we are going to see more of them in the coming years.

Care coordination has been identified as the key strategy by the US Institute of Medicine to increase effectiveness and safety. How can we streamline and coordinate, as well as integrate these various types of services so that someone like as Mdm A can be in one place and all the disciplines can see her there, more along the lines of perhaps a medical mall, but not at private sector costing.

12.00 pm

Cost of Medicine and Vaccines

Mr Low Thia Khiang: Madam, the Government has been talking about keeping long-term healthcare costs affordable for Singaporeans. Based on feedback from residents, some Singaporeans still find the cost of medicine high. I believe this is partly due to doctors prescribing drugs for a long duration or prescribing non-standard drugs. I would like to ask MOH what measures have been taken to reduce the cost of medicine for patients and how effectively have these measures lowered the cost of medicine for patients, especially those with chronic diseases.

The Minister said in 2012 that the profit margins for drugs sold in public hospitals typically range from 5% to 30%. I would like to ask if the profit margins today are still the same and what are the profit margins for drugs sold in polyclinics.

Two years ago, the Workers' Party (WP) suggested that the Government look into publishing drug prices for public hospitals. The Minister rejected this saying that, "drugs constitute only one aspect of the overall treatment." I would like to repeat the call to publish drug prices at public hospitals for better transparency.

Next, under the National Childhood Immunisation Programme, all recommended vaccinations are fully subsidised and provided free of charge at all polyclinics for children who are Singapore Citizens, except pneumococcal vaccinations.

Pneumococcal disease manifests in illnesses, such as pneumonia and meningitis, and is the leading infectious cause of death in children and adults worldwide. According to MOH's figures, pneumonia is the second most common cause of death in Singapore and one of the top five conditions of hospitalisation. I understand that pneumococcal meningitis is a disease that is difficult to detect in the early stages but progresses rapidly and could result in death or cause long-term health complications, such as paralysis or brain damage. Children below five years old and adults above 50 are at greater risk of being affected by such a disease.

In 2013 and, again in 2015, when WP called for fully subsidised pneumococcal vaccinations, the Minister said that this was not necessary since "the potential for a public health epidemic or outbreak is relatively low." Madam, a complete series of the vaccine doses costs around $500, which is costly for parents. I ask MOH to consider providing a subsidy to encourage parents to use it.

I believe that the Government stands to benefit from providing subsidised pneumococcal vaccinations in the long run through the reduced burden on MediSave and MediShield Life. It could also save on expensive treatments, hospitalisations and medications down the line.

Means Testing

Mr Dennis Tan Lip Fong (Non-Constituency Member): Madam, the Government provides means-tested subsidies for MOH-funded ILTC facilities as well as treatments at public hospitals. I am appealing to MOH to implement a grace period for the withdrawal or reduction of subsidies instead of effecting the changes immediately when the per capita household income rises.

Let me give an example of a household with a per capita monthly income of $650. Under the current framework, a Singapore Citizen will qualify for 75% subsidies. Subsequently, if the per capita monthly household income rises to the next tier, that is, between $701 to $1,100, due to salary increment, bonus or commission, the subsidies will drop to 60%. This is a 15% decrease, which is considerable, especially since we are talking about Singaporeans with lower household per capita monthly income. This would apply even if their income only rose by about 10% to $710.

For Singaporeans who are at the receiving end, this can be very discouraging and could feel like two steps forward, one step back. A grace period should be given before the subsidy is withdrawn or reduced. This will give people some breathing room to consolidate their finances or even pay off some lingering debts, instead of hitting them with an immediate cost increase for medical expenses. I would like to call for the Ministry to review this to see how best we can help fellow Singaporeans who are in such situations.

MediSave

Dr Lim Wee Kiak (Sembawang): Madam, on Monday, I had a resident who brought two bills to me. One was a medical bill and the other was a Central Provident Fund (CPF) statement of her 91-year-old parent. On the medical bill, it was stated $120 outstanding for payment in cash, after deducting MediSave claim. Then, she showed me the CPF statement of her 91-year-old parent. There was more than $10,000 in her CPF. She was asking me, "My parent is 91 years old. Why can the Government not allow her to deduct a bit more from her MediSave? We do have our MediSave, we can help her out, too, but why do you need us to still use cash to make payment?"

I know that the Government has already introduced Flexi-MediSave for the elderly. Under this scheme, all patients aged 65 and above can deduct up to $200 per year per patient for outpatient medical treatment at Specialist Outpatient Clinics at the public hospitals or the national specialty centres, polyclinics and Participating Community Health Assist Scheme (CHAS) general practitioner (GP) clinics. It can also be used together with other outpatient MediSave limits, such as the MediSave400 limit. But this is a very small amount.

I would like to appeal to the Government and MOH to review the MediSave claiming for the elderly, especially to increase the claim limit for the elderly, especially those with healthy MediSave balances so as to reduce their cash outlay for medical expenses. Can the Government further enhance this Flexi-MediSave for the elderly to allow for a further increase, perhaps a 20% increase, in claim limit for MediSave for hospitalisation, surgery and treatment?

MediShield Life for Community Hospitals

Mr Murali Pillai (Bukit Batok): Madam, community hospitals play an ever-increasingly important role in our healthcare system, given our ageing population. For our elderly patients, the systemic rehabilitation programmes offered by community hospitals help to improve their functional abilities and quality of life.

We should do what we can to increase accessibility to such services at community hospitals. Deputy Prime Minister Teo referred to this as "right-siting" in his speech last week in this House. Paradoxically, our healthcare financing scheme may stand in the way of such a development.

Based on the current MediShield Life system, MediShield Life benefits for inpatient treatment at community hospitals are only claimable upon referral from a public hospital for further medical treatment after an inpatient admission.

I propose that direct admission patients in community hospitals be allowed to utilise MediShield Life for their inpatient treatments. There is no need for acute hospitals to act as a filter.

ElderShield

Dr Lily Neo (Jalan Besar): I am glad that ElderShield will be enhanced soon. May I ask Minister when will this be happening?

I first spoke on ElderShield in May 2002, several months before its implementation. In fact, this is the 11th time I am speaking on this topic in this House. Before its implementation in 2002, I already raised concerns about its inadequacy with payouts of $300 over a tenure of five years. Fifteen years later, the same payout makes its inadequacy even more severe. These patients with three Activities of Daily Living (ADLs) are totally dependent on others for their daily living. A payout pegged to the amount required for engaging a full-time domestic helper will be more appropriate. I am not suggesting that such full-time assistance be a norm.

These patients with three ADLs, especially those as a result of old age, are unlikely to get back to normal if they have reached the stage of inability to perform the daily activities. But even for other sick patients with severe disability due to sicknesses, such as stroke or cancer, to reach the stage of not being able to perform three daily activities will usually mean that their illnesses are too severe for them to revert to normal activities again.

Thus, the insurance coverage of five to six years will leave them in a lurch at the end when their needs usually increase rather than decrease and they need even more dependent care at higher costs.

ElderShield has to be made permanent as long as the disability persists, if this scheme is to serve as a safety net and a remaining piece towards strengthening our society, as the Prime Minister referred to. It is necessary because of our society's fast-ageing population and smaller families. The present opt-out scheme of ElderShield should be converted into a universal scheme to cover everyone and ensure that no one is left out. Through bigger economies of scale, a universal scheme will help make this insurance viable in the long run. Everyone should be included, regardless of age and prevailing medical conditions, just like in MediShield Life. The MediShield premium is affordable because there are subvention and subsidy, especially for those with lower income. I hope ElderShield premiums will be made affordable, too.

In the 15 years since it started, there have been about 13,000 claimants. Considering that the disability prevalence rate presently is about 5% for those 65 years and above, it means there are already some 15,000 people requiring aged care facility per year. Thus, 13,000 claimants for ElderShield over 15 years is actually a small number. This may be due to ElderShield's onerous eligibility of three out of five ADLs for claims. I would like to see the ADL criteria − washing, dressing, feeding, toilet, mobility and transferring criteria − reduced to one for seniors or a maximum two for younger claimants instead of three.

Enhanced ElderShield is important to reduce the dependence on institutional care unnecessarily as well as providing right-siting. Presently, some families take the option of sending their dependent members to community hospitals or overstaying in acute hospitals to save on dependent care cost, as there is subvention for hospital and institutional care.

The present ElderShield excludes those 70-year-olds in 2002 and those with existing illnesses. These are the people who are more likely to get severe disability and be badly in need of the ElderShield but are excluded for this insurance.

For those aged 60 to 64, the annual premium payable to join ElderShield is from $1,000 to $3,000 respectively. Many seniors are not in the scheme because they cannot afford these premium amounts. I hope the Enhanced ElderShield will include this group with affordable premiums.

MediShield has been revamped to the superior MediShield Life. Perhaps MOH will now consider revamping ElderShield to ElderShield Life, similar to MediShield Life. The many new features of MediShield Life had been well thought out and they are very good. It will be good if MOH could consider adopting them similarly to ElderShield Life with inclusion of its lifelong coverage, its universal feature and its permanent subsidy in premiums for seniors, low-income Singaporeans and so on.

I hope MOH will consider my suggestions above in reviewing ElderShield and to make ElderShield the true safety net that it is intended to be.

Extending ElderShield Payouts

Mr Louis Ng Kok Kwang (Nee Soon): ElderShield is meant to be a Severe Disability Insurance scheme. However, payouts are only for 72 months, and I understand that a quarter of claimants outlive this and still need care.

Would the Ministry consider making payouts for life? In addition, premiums are also higher for women than it is for men. Insurance is supposed to pool risks across different life expectancies. As such, will the Ministry make the premiums equal for men and women?

In-vitro Fertilisation Subsidies

Mr Desmond Choo (Tampines): Mdm Chairman, for the general subsidies for Assisted Reproduction Technology (ART) treatment, only women below 40 years of age can benefit from it. And even then, the subsidies only apply for the procedures and public hospitals. Some research state that clinically relevant facility decline is in for women aged 41 to 42.

Would the Ministry consider extending the qualifying age for subsidies to 42? Would the subsidies also be extended to treatments at private hospitals so as to reduce waiting time?

Co-funding for ART at Private Hospitals

Mr Louis Ng Kok Kwang: We have a strong focus on urging Singaporeans to start a family and trying to assist those who are not ready to start a family yet. This is important but we should also provide more help for those who want to start a family but are facing difficulties conceiving.

It has been four years since the Government enhanced the co-funding of ART treatments, and it should be time for us to review this. We currently only provide the co-funding for treatments done at public hospitals. The success rate at private hospitals or clinics may be higher. As such, I hope we can extend the co-funding for the last fresh cycle to be done at private hospitals and clinics. This will help couples who have tried repeatedly at public hospitals and have not been able to have a successful pregnancy. This will also help alleviate the large demand for ART treatments at our public hospitals.

Innovative Anti-diabetes Strategies

Mr Leon Perera (Non-Constituency Member): Mdm Chairman, at the last COS, I spoke about how Social Impact Bonds (SIBs) could help drive outcomes-based social policies in Singapore, such as reducing recidivism among ex-offenders. Pay for Success contracting (PFS) and Social Impact Bonds (SIBs) have been growing worldwide since 2010. One estimate has identified over 40 SIB and PFS projects worldwide in 2015, spanning subject areas like early childhood education, healthcare and recidivism.

In Israel, an SIB is underway to help prevent pre-diabetics from contracting diabetes. The National University of Singapore (NUS) School of Public Health estimates that diabetes could cause Singapore $2.5 billion a year by 2050, not to mention the cost of human suffering.

In Singapore, MOH could explore launching an SIB to raise funds for reliable non-government organisation (NGO) partners who can then work with pre-diabetics and diabetics to improve health indicators like blood sugar levels and emergency hospitalisation events. Philanthropic donors, foundations and so on could buy the bond. Such NGOs could then use the bond proceeds to fund programmes to help at-risk individuals manage their diets, for example. The state would redeem the bond and pay the donors only if outcomes are achieved, which makes for better use of state monies.

12.15 pm

NGOs may be better placed than state entities to dream up and execute creative ideas that can nudge behavioural change in the face of entrenched habits, thus solving tricky social problems.

I hope that MOH will look into the possibility of launching an SIB or PFS initiative to work with NGOs over the social challenge of diabetes.

War on Diabetes

Mr Chen Show Mao (Aljunied): Madam, last year, the Minister declared War on Diabetes to great fanfare, as befitting the importance of the campaign. Our children and young people are increasingly overweight. One in three Singaporeans has a lifetime risk of developing diabetes, with serious and costly consequences. Could the Minister give us a report of the progress from the front?

On sugary processed food, would the Government consider requiring warnings on containers of sugary processed food, such as cans and packets of candies, soft drinks and so on? This could be similar to requiring warnings on tobacco packaging in order to discourage smoking, which is another risk factor for diabetes. Smokers are 30%-40% more likely to develop diabetes.

Similarly, would the Government consider requiring retailers to display signs that encourage shoppers to choose low-sugar options, or school canteens and hawker centres to display signs warning about the dangers of diabetes and encouraging low-sugar options?

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

Update on Our Battle against Diabetes

Mr Christopher de Souza (Holland-Bukit Timah): Madam, diabetes is a major problem in Singapore. It is projected that in less than 20 years, the number of diabetics in Singapore could rise to 670,000 and more than a million Singaporeans could get diabetes by 2050.

According to the US Renal Data System Report last year, Singapore leads the world in the percentage of kidney failures caused by diabetes. In numbers, every two days, nine people lose their kidneys because of diabetes. Besides kidney failure, diabetes is also associated with heart attack and stroke. Furthermore, every day, four amputations are carried out because of complications from diabetes. Because of the high social and financial costs that diabetes has on the individual Singaporean, his family and society, war was declared on diabetes in April last year.

Would the Minister provide an update on the programmes that it has recently introduced to combat diabetes, especially in terms of healthy diet initiatives and proposed regular exercise regimes? Ultimately, the war on diabetes is something we have to fight together and the best cure for it is prevention.

Smart Ageing and Future Enabling (SAFE) Care

Dr Lily Neo: Madam, at the Budget Debate, I spoke about Smart Ageing and Future Enabling care (SAFEcare), which aims to keep disability away for as long as possible and improve the lives of our seniors with graceful living through smart technology and preventive medicine. This is a suggestion, going forward, to improve the care of our seniors with a sustainable solution.

MOH has been adopting the adage "prevention is better than cure" over the years to manage many chronic health diseases like diabetes. May I now beseech MOH to adopt the same concept for elderly disability? Thus, let us aim for seniors to age gracefully with independent living in their own homes despite their frailty or medical conditions by preventing disabilities and to better manage any disabilities.

Many older adults express the desire to "age-in-place" for as long as possible and prefer to live at home rather than being admitted to nursing homes or community hospitals. Will MOH consider a concept of "smart cluster housing" where many seniors live in the same block of flats on their own, in their 1- or 2-room flats, which can be converted from the Housing and Development Board (HDB) rental flats, some studio apartments or even newly-built HDB homes?

Such cluster homes enable daily service delivery convenience. These cluster homes will have elderly-smart home concepts that embrace accessible designs and environmental modifications to foster independent living and to improve the occupant's functional ability-related outcomes. Could the various Ministries work hand in hand towards this end? Thus, it would be good if there is collaboration between MOH and the Ministry of National Development (MND) in co-planning "smart cluster homes" for seniors.

The seniors in such cluster homes can be provided with daily needs with assistance from helpers and even medical personnel when necessary. The ground floors of such homes should be used for community services. Hence, "Seniors Activity Centres" to enable those well seniors to come down daily for physical, social and mental wellness programmes would be ideal. Such venues will also serve as coordinating centres that enable concept partners like the grassroots organisations, VWOs and various corporations to volunteer their services. Could MOH collaborate with the Ministry of Social and Family Development (MSF) to provide seamless assistance to those seniors who require financial and social needs in these cluster homes?

Senior Care Centres (SCCs) for residents and coordinating centres for volunteers at the void decks of cluster homes can be managed by MSF. MOH can provide training, like ability to pick up tell-tale signs of suicidal thoughts, for the befriender volunteers that MSF manages. Again, collaboration among Ministries is important for better identification of needy residents and the delivery of assistance and outreach. Such collaboration will also prevent duplication of services or over-servicing to some residents.

Does MOH have any charting of roadmaps for the care of seniors? There is a need for this to better plan for the delivery of services. For instance, it helps to know where the places with the highest concentration of seniors are, what the age group of seniors who require most assistance and the types of assistance they require. There is also a need to know the number of cases with medical conditions, such as chronic diseases, physical disabilities, dementia and other mental illnesses. This will enable better planning, especially in the area of medical personnel, towards catering for these conditions.

Do we have enough geriatricians, physiotherapists, community doctors and hospice-care doctors? We do need more community medical personnel that can visit patients in their homes in order to provide good homecare. We should train more medical workers using shorter course modules as in wound dressings, change of catheters or nasogastric tubes and so on. In England, medical workers are trained in just months to accomplish these tasks. Does MOH have enough dieticians to help in the fight against diabetes? Dieticians are also needed to advise all centres, especially the Seniors Activity Centres, that provide food for groups of people to ensure healthy diets.

The use of medical technology to improve quality of living is the way forward. Does MOH have a designated team or department to look into the availability, applications and effectiveness of medical technological devices that can enable better healthcare monitoring, especially for elderly care, and test them on their effectiveness? Does MOH have collaborative partnerships with Institutes of Higher Learning (IHLs) to develop new technology, while researching and developing cost-effective systems that promote an age-friendly living environment in homes?

According to the Global Burden of Disease 2015 published in the Lancet last year, women spend the last nine years of their lives in ill-health. In 2015, life expectancy for women here was 84.9 years and, for men, 80.4 years, making people here among the longest living in the world. But women spend 10.7% of their lives in ill-health, and men 9.4%. In fact, men here top the world in terms of the number of healthy years they live, according to the Lancet report.

Could MOH step up the healthcare awareness and promotion for prevention of chronic diseases, osteoporosis, heart diseases and mental illnesses among women? May I ask for the work progress of the Women's Health Committee that was set up in 2012? Is there a target for achievement and what else can be done to get a better outcome to reduce problems faced by women in combating ill-health? Can there be a more ground-up approach that involves corporations and community groups to get better outreach to the wider audience?

Caregivers of Mentally Disabled Persons

Mr Murali Pillai: Mdm Chairman, in July last year, I spoke in this House during my Adjournment Motion speech on the need to address challenges faced by caregivers of children with mental disabilities.

Since then, the Enabling Masterplan 3 was issued in December last year, with various recommendations and proposed strategies to create a more inclusive society for people with disabilities as well as to provide better support to caregivers in their roles in caring for persons with disabilities.

As highlighted in the Masterplan, we, as a community, must recognise that caregivers are individuals with their own aspirations and ambitions. While family is the first and most important line of support, family caregivers can only carry out their roles effectively if they are emotionally and physically well. In this regard, I am concerned to note that the National Council of Social Service (NCSS) study in 2014 found that a good number of our caregivers experienced poor mental health. This was a point carried in the Enabling Masterplan 3 Report.

This problem may be more acute for caregivers of persons with mental disabilities. While there are options of Drop-in Disability Programmes and Day Activity Centres, as acknowledged in this House by Minister Tan Chuan-Jin, there are limited spaces in such programmes and applicants are often waitlisted. Hence, we see the current focus to build capacity for home-based and community-based care services. However, this cannot happen overnight.

Where caregivers of persons with mental disabilities do not have access to such services, the care responsibility falls solely and squarely on them. They, therefore, suffer tremendous stress and may even feel overwhelmed by the circumstances. This issue is even more acute where the caregiver is the primary breadwinner and has to juggle employment and worry about finances.

One area identified in Enabling Masterplan 3 to enhance caregivers' well-being and their caregiving capabilities, albeit with respect to persons having physical disabilities, is the possibility of expanding the existing criteria for Foreign Domestic Worker Levy Concession and Grant. This is an eminently sensible recommendation.

I also recommend that the Foreign Domestic Worker Levy Concession and Grant be extended to families with persons having mental disabilities, too. Caregivers for such persons face the same, if not more, pressure as compared to caregivers of persons with physical disabilities. There should be no distinction between these groups. I made the same point during my Adjournment Motion last year. I understand that the relevant agencies are still studying this issue. I would be grateful, therefore, if the Ministry could share some of its plans for greater home-based support and to give caregivers of persons with mental disabilities more opportunities for respite.

Senior Caregivers Support

Assoc Prof Daniel Goh Pei Siong (Non-Constituency Member): Madam, caregivers of seniors need a lot of support. The stress of caregiving goes up exponentially when the elderly develop chronic illnesses, dementia or disabilities. This issue will deepen with the rapidly ageing population. I note that the Government will be setting up a Disability Caregiver Support Centre. I propose that the Government set up similar caregiver support centres for senior caregivers.

As senior caregiving is of a scale larger than disability caregiving, I believe that there is a need to set up multiple support centres to provide the same level of support to senior caregivers. These centres are a natural extension to the existing SCCs. Since SCCs are specially situated in places with higher demand for eldercare services, Senior Caregiver Support Centres can be co-located with SCCs. Like the Disability Caregiver Support Centre, Senior Caregiver Support Centres can provide information, planned respite, training, peer support and offer various VWO programmes to help caregivers.

There is one more important function the support centres can perform. Senior caregivers face greater risk of health and financial vulnerabilities as they get older due to lower lifetime earnings. Many are women who leave the workforce to be full-time caregivers and who find it difficult to re-enter the labour market. These support centres can also act as the main touchpoints for caregivers to receive important health and financial assistance and even advice on finding part-time work to support themselves.

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Nursing Homes

Mr Dennis Tan Lip Fong: Madam, the Government announced in 2014 that seven new nursing homes will be built to accommodate up to 17,150 residents by 2020 to meet the growing demand arising from the rapidly ageing population.

Even as we are ramping up new nursing homes, sadly, the care model in our nursing homes remains the so-called "medicalised model" similar to hospitals. This is not the most suitable model to enhance the quality of life for our seniors who are residing in these homes. Do each of us want to live in such an environment in the winter of our lives?

Countries like the US, Japan and Australia have moved away from the "medicalised" model. We should move away from the "medicalised" model now and aim for the rehabilitative model, making the living environment more like homes and less like hospitals. We should move away from the dormitory-like environment, go beyond basic physical care to a home-like environment with care specialists attending to the social well-being as well as nursing needs of elderly residents so that they can live and age with dignity.

MOH set up the Enhanced Nursing Home Standard in 2014 providing basic standards for medical and nursing care, facilities maintenance and hygiene. We should go beyond these basic standards. MOH should consult as many stakeholders as possible, as well as the specific medical interest groups most associated with the care of patients afflicted with specific illnesses, such as the Alzheimer's Disease Association, Kidney Dialysis Foundation and so on, in order to better understand how the clinical and social needs of different and specific types of patients can be best met. This would allow for a range, rather than a bare minimum standard, of care in each nursing home.

The standards of nursing homes in Singapore do vary considerably. Recently, a Fengshan resident shared with me her concern to transfer her mother from one nursing home to another, and one of the reasons cited was poor and indifferent care by staff.

I understand that, right now, the Ministry conducts regular audits on nursing homes. However, the audit reports are not disclosed to the public. I would like to suggest that these audit reports should be made available to the public so that families of nursing home residents are aware of the compliance standards of the homes. I believe that such measures may enhance standards and weed out operators who are not able to provide suitable services.

Ms Tin Pei Ling: Madam, may I take both cuts together?

The Chairman: No, please proceed with your first cut.

Digital Eldercare

Ms Tin Pei Ling: Okay. I had spoken about digital eldercare in last year and this year's Budget. Digital eldercare offers many possibilities and has many applications. Today, I would just like to focus on how it can enable independent living and better match demand to the supply of eldercare services and how we can facilitate this.

First, on enabled independent living. With land scarcity and manpower constraints and our vision towards ageing in place, the eldercare model needs to shift away from institutions. Let us reserve institutional care for those who need very highly intensive care.

We should leverage more on technology, such as sensors, assistive devices and telemedicine, to enable independent living at home, even for those who have moderate disabilities and little or no family support. There are already pilots being done with the deployment of the Elderly Monitoring System (EMS), for example. Could the Ministry update the House on the results and key learning points from these pilots?

Some solutions are still being developed. Could the lab-to-market process be accelerated? Could the Government take a point position and lead a nationwide implementation of smart homes for seniors? Could the Ministry facilitate the integration of these solutions so that the elderly can enjoy the services at home in an easy and seamless manner? We need to enable them to age in a very holistic conceptual manner if we were to have smart homes for seniors.

Next, digital platforms are now available to link freelance healthcare professionals and caregivers to facilitate on-demand provision of home care or other related eldercare services.

But some of these platforms are privately run and the elderly who wish to utilise them may be deterred for fear that the subsidies they may be eligible for cannot be applied via these platforms. Could the Ministry look into enabling this?

The Chairman: Minister Gan Kim Yong.

The Minister for Health (Mr Gan Kim Yong): Madam, with your permission, may I display some slides during my speech?

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

Mr Gan Kim Yong: Madam, we announced the Healthcare 2020 Master Plan in 2012 which outlined our plans to add capacity, improve affordability, as well as enhance care quality. Last year, we declared war here in this Chamber, War on Diabetes. I also highlighted three key shifts we need to make to prepare ourselves for the future beyond 2020. Today, I will give an update on the progress of Healthcare 2020, as requested by Dr Chia Shi-Lu. I will also give Members an update on the state of the War on Diabetes and outline our broad strategies to achieve the three key shifts beyond 2020. My colleagues will then elaborate on the specific efforts and the measures we intend to include.

Madam, a report published in the Lancet medical journal last year placed Singapore in the top ranks for global health, alongside Iceland and Sweden. We have also made progress in managing and treating diseases which are leading causes of premature death for Singaporeans, such as ischaemic heart disease and stroke. Between 2000 and 2015, we have reduced the premature mortality rates for both diseases by half.

However, there are some worrying trends. Our obesity prevalence rate has risen to 1.7 times, a 70% increase, from 1992 to 2013. Not 1.7%, but 1.7 times. What is even more worrying is that the obesity rate amongst younger Singaporeans aged 18 to 39 has grown at an even faster rate, doubling from 4.2% to 8.4% over the same period. This is worrying as obesity is a key driver contributing to the diabetes burden in Singapore. Based on our projections, one in three Singaporeans will develop diabetes in their lifetime. Obesity and diabetes are risk factors for heart disease and stroke. If we do not address these risk factors early, the progress on these two diseases will be eroded.

We, therefore, have a strong impetus to keep our Singaporeans healthy. Allow me to give an update on Healthcare 2020.

Since 2012, we have opened Ng Teng Fong General Hospital (NTFGH), Changi General Hospital Integrated Building (CGH IB), Jurong Community Hospital (JCH) and Yishun Community Hospital (YCH). Together with the expansion of existing facilities, we have added a total of 2,500 hospital beds.

Next year, Changi General Hospital will open its new Medical Centre, which will allow it to expand its specialist outpatient services. We also expect to open the Sengkang General and Community Hospitals by end-2018. The new National Centre for Infectious Diseases is also due to open progressively from end-2018. The construction of Outram Community Hospital is underway and it is scheduled to open by 2020. This is part of our overall plan to redevelop the Outram Campus, including the Singapore General Hospital, in a multi-phase process that will take us up to 20 years or more. Woodlands General Hospital and its co-located community hospital will break ground next month and they will be opened progressively from 2022.

The National University Health System (NUHS) will take over the operations of Alexandra Hospital after the Sengkang team, which is currently in Alexandra Hospital, moves to the new Sengkang hospital in 2018. The 79-year-old Alexandra Campus is a unique site. The campus offers a unique opportunity as it has tremendous potential for redevelopment. I have, therefore, tasked NUHS to re-imagine healthcare for the future, taking the opportunity to design new and innovative care models that can better promote health and integrate care, and test them out at the Alexandra Campus.

In addition to hospital developments, we have added seven new Family Medicine Clinics (FMCs) and seven Community Health Centres (CHCs) to support the primary care GPs in the community. We have also added 3,400 nursing home beds and 5,600 centre-based care and home care places since 2012. We will add another 4,200 beds and 4,700 places by 2020.

But adding capacity alone is not a sustainable solution in the long term if we do nothing else. Our capacity growth must be coupled with efforts to transform our care model to leverage on strong primary and community care and keep our people healthy with better disease prevention and healthier lifestyle choices.

To deliver quality services to our people, we need to grow and develop our healthcare manpower. The healthcare workforce has expanded by some 23,000 or 33% over the past five years. We need 9,000 more healthcare workers over the next three years, and there are many good career opportunities for Singaporean professionals, managers, executives and technicians (PMETs) in the healthcare sector.

Given Singapore's limited labour pool, however, we cannot just grow the number but ensure that our healthcare workers are meaningfully and effectively deployed. Senior Minister of State Amy Khor will share more about MOH's efforts to build a strong, future-ready healthcare workforce.

Several Members have asked about the affordability of healthcare. We have a multi-layer system of support to ensure that Singaporeans can afford the appropriate care that they need.

Treatment and drugs that are clinically effective and cost-effective are subsidised. Means-tested Government subsidies at hospitals, Specialist Outpatient Clinics, CHAS clinics and nursing homes serve as the baseline support.

Larger bills, such as inpatient hospital bills and selected costly outpatient bills like chemotherapy and kidney dialysis, are covered by MediShield Life. Since its launch in late 2015, MediShield Life has provided Singaporeans and, especially the seniors, with better support and assurance. Over 500,000 claims were approved under MediShield Life in 2016, an increase of 47% compared to 2015. Claims by older Singaporeans aged above 65 increased even more, at 73% from 124,000 to 215,000 claims. This resulted in a 90% jump in the total amount of claims for seniors from $181 million to $343 million.

Mr Murali Pillai asked about MediShield Life coverage for direct admissions to community hospitals. MediShield Life was designed primarily to provide coverage for large, acute hospital bills. As an extension of this coverage, MediShield Life covers community hospital stays for patients transferred from acute hospitals to community hospitals.

Nonetheless, we note there could be some groups of patients who are suitable for direct admission to community hospitals without going through acute hospitals and might benefit from MediShield Life coverage. We will study this proposal carefully because it has impact on premiums as well.

After subsidies and MediShield Life, the patient can use his MediSave savings to cover his share of the healthcare bills. Dr Lim Wee Kiak asked if the Flexi-MediSave limits could be raised. The Flexi-MediSave scheme was recently introduced in 2015 to allow older Singaporeans to use up to $200 a year to pay for outpatient medical treatment. So far, the majority of eligible patients have not fully utilised their Flexi-MediSave withdrawal limits. It is still early days, but it suggests that the claim limits are generally sufficient. We will review from time to time.

Finally, for needy Singaporeans who still have difficulties with healthcare costs after Government subsidies, MediShield Life coverage and MediSave, we have MediFund to help.

Mr Low Thia Khiang asked about profit margins for our drugs in our hospitals and public healthcare institutions. I should take this opportunity to clarify that our public healthcare institutions are not-for-profit organisations. While the drug prices include a margin, this is to offset overheads and operation costs. Therefore, they are not profit margins; they are just margins to cover part of operation costs. In fact, last year, we provided a total of $4.3 billion of funding to our public healthcare institutions to support their operations to keep our healthcare costs low.

To help patients with their medication costs, our public healthcare institutions like our Specialist Outpatient Clinics (SOCs) and our polyclinics provide subsidies of up to 75% for standard drugs, with Pioneers receiving a further 50% subsidy. In addition, the Medications Assistance Fund (MAF) is also available to help patients with selected high-cost non-standard drugs, if it is deemed necessary. Patients who still face difficulties despite all these subsidies can also apply for MediFund.

With Government subsidies and the 3Ms, MediShield Life, MediFund and MediSave, Singaporeans have multiple layers of support for their healthcare needs. The system is constantly evolving and we will regularly review the adequacy of drug subsidies and the different schemes to ensure that medication remains affordable.

12.45 pm

While we have made steady progress on Healthcare 2020, we need to plan for the long term. Last year, I outlined our plans to go beyond Healthcare 2020, encapsulated in the "3 Beyonds". We need to move beyond hospital to the community; move beyond quality to value; and move beyond healthcare to health. These three moves are critical in preparing us to meet our long-term healthcare needs in a sustainable manner.

The first step is to better organise ourselves so that we can implement these three shifts more decisively and effectively. In January, we announced that we will be reorganising our healthcare system into three integrated clusters.

With the reorganisation, the three integrated clusters will each have a broader range of healthcare services and facilities that will provide our patients with more seamless care. They can also tap on a larger pool of resources, including manpower and talent, both professional and managerial talent. The integrated clusters can also offer healthcare workers greater development and training opportunities, thereby raising the competency of our workers that will translate into better quality of care and, eventually, benefit our patients.

Primary care will play an increasingly important role in our care transformation. This is why we are strengthening the primary care capabilities of each cluster. The National University Polyclinics (NUP) will be created under NUHS. With this move, each cluster will now have its own polyclinic group. This will enable the clusters to work in close collaboration with the GPs to augment our primary care sector and partner a wider range of community-based service providers, including VWOs, to anchor care firmly in the community, as pointed out by Ms Tin Pei Ling.

Minister of State Lam Pin Min will share more about our plans in the primary care sector, including partnerships with the private GPs, through the Primary Care Networks scheme. Senior Minister of State Amy Khor will speak on our plans to strengthen our community mental health capabilities. Minister of State Chee Hong Tat will share about our collaboration with our community partners.

Another area of emphasis for us is to go beyond quality and offer patients value in healthcare provision. Advancements in medicine and healthcare technology offer new opportunities and potential for health and healthcare in Singapore. We want to keep abreast of such developments so that we can introduce new solutions that are clinically effective and cost-efficient and improve healthcare outcomes and quality of life.

As pointed out by Dr Chia Shi-Lu, we must be mindful that newer does not always mean better. Some new drugs or treatments may not offer significant clinical advantage and, yet, come at a significantly higher cost. Generic drugs often offer similar outcomes as branded drugs, but at fraction of the cost. A good example would be the generic drugs for statins, used to manage high blood cholesterol, which usually cost less than half the price of the branded versions. Opting for generic drugs will help to reduce medication cost and we are working with our doctors to promote the use of generic drugs.

The Agency for Care Effectiveness (ACE) was set up to evaluate the clinical and cost-effectiveness of new treatments. Through the work of ACE, we aim to identify treatments with good outcomes at affordable costs to guide our doctors and patients. ACE will be publishing their first set of Guidance in May this year. Minister of State Lam will also share how ACE's work on Appropriate Care Guides will play an important role in our war on diabetes.

Moving beyond hospital to community, and beyond quality to value, are about how we change and improve the way we deliver healthcare to our patients who are already ill. But what is perhaps even more important and critical is to nurture a healthy nation and a healthy people. This is why our third thrust is on moving beyond healthcare to health, focusing on early interventions and healthy lifestyle choices which will keep people in good health. This is easy to say but hard to do. We have several initiatives on this, which my colleagues will elaborate later.

Mr Christopher de Souza and Mr Chen Show Mao have asked about the progress of our War on Diabetes. The National Diabetes Prevention and Care Taskforce was set up to drive the efforts on this war with three strategic focus areas, namely, healthy living and prevention; screening and follow-up; and disease management. These are underpinned by public education, data analytics and research as well as the mobilisation of stakeholders. The taskforce has engaged widely over the last six months and made useful recommendations even as their work continues. My colleagues will elaborate on these recommendations later on. I will focus on how we can win this war, by working together with communities, businesses, employers, workers and individuals, you and me.

First, we need to mobilise the community. And we are doing so through initiatives, such as the Community Networks for Seniors (CNS) which we launched last year. We set up Community Health Posts under CNS to make services, such as health screening and monitoring, more accessible to residents living in our heartlands. We have already established some 30 active ageing nodes in the three pilot CNS sites and engaged over 5,000 seniors, including those with diabetes or at risk of diabetes, in preventive health activities, such as health screening and monitoring, health talks and exercise sessions. We plan to expand CNS to the remaining precincts in the three participating Group Representation Constituencies (GRCs) of Tampines, Marine Parade and Chua Chu Kang by the end of 2017. Our aim is to bring CNS to more mature communities progressively so that we can make every community a place where our seniors can be cared for and supported by the community to age well in place.

Advisors and Members of Parliament (MPs), too, can play an active part in helping to spread the message and keep their residents healthy. Minister Lim Swee Say, for example, has set up a diabetes taskforce in Bedok to raise awareness on diabetes. I visited one of his many Chit Chat sessions last week, where he personally shared about the War on Diabetes with about 50 residents. It is a lot of hard work, but there is no short cut. All of us have to play our part, in our own way, to reach out to our residents, to help them stay healthy.

Not just in the community, at the workplaces, too. Seagate Technology International's Woodlands office is one such example. They regularly organise activities for their staff and participated in the National Steps ChallengeTM Season 2 Corporate Challenge. The office even organised an "intra-organisation challenge" to motivate their employees to clock more steps. Their efforts have paid off as I was told that all their participants have an average daily step count of more than 10,000 steps. Seagate Woodlands is also one of the top scorers for the Corporate Challenge! I look forward to more employers coming on board this War on Diabetes. After all, a healthy workforce is a prerequisite for a productive workforce.

To fight this war, and to fight any war, we need soldiers. So, who are the soldiers? We are the soldiers. As individuals, we can play a part by being responsible for the choices that we make every day. Apart from staying active, it is also important that we watch our diet. A healthy diet is half a battle won, as we say. Many of us eat out regularly, and that is why MOH and the Health Promotion Board (HPB) have also been actively engaging our hawker centres, coffee shops and restaurants to offer healthier meals with lower calories and beverages with lower sugar. Like Minister Lim, I, too, share with my residents tips to combat diabetes. I encourage them to follow the three "R's" − Refrain, Reduce and Replace. When we decide what to eat, Refrain from unhealthy food, if you can. But I know it is difficult. If you cannot but have to eat, try to Reduce the amount of unhealthy food that you have to eat. If you cannot Refrain and cannot Reduce the amount, then please Replace with healthier alternatives. So, Refrain, Reduce and Replace. These are secrets to healthy living. Mdm Chairman, let me say a few words in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] For those who are at risk of developing diabetes, or who already have the disease, we need to help them manage their condition and prevent complications. Last year, we introduced diabetes roadshows, talks and screenings in the community, and reached more than 120,000 people. In addition, we also have HPB's Diabetes Prevention Programme which helps those with slightly elevated blood sugar levels reverse their risk for diabetes. One of the beneficiaries is Mdm Goh Soo Eng who was at risk of diabetes due to her elevated blood sugar level. Mdm Goh used to lead a sedentary lifestyle and had a sugar-heavy diet. This left her feeling sluggish and lethargic. Under the recommendation of her doctor, Mdm Goh joined HPB's Diabetes Prevention Programme and learnt to adopt healthy eating and exercise habits. Through these efforts, Mdm Goh has managed to keep her blood sugar level under control without the need for medication and is now an advocate for healthy living and diabetes prevention. She frequently encourages her friends to go for beverages with less or no sugar, and to choose healthier meal options. She also participates in the physical activities at Agape Village. Mdm Goh is a model soldier of the War on Diabetes.

(In English): Madam, in my Mandarin speech, I shared the story of Mdm Goh who benefited from HPB's Diabetes Prevention Programme, which helped her manage her blood sugar level and prevent diabetes. Programmes like these are useful in helping pre-diabetics better manage their conditions through healthy eating and exercise habits. We hope to see many more take a step towards proactive disease management and prevent diabetes. Therefore, HPB will launch the "HealthHub Track" in April this year. This is a personal health management app in HealthHub which will provide users with digital tools to monitor and manage their health conditions more conveniently.

The War on Diabetes will not be a quick battle and we must be prepared to keep up the momentum and go the distance. We need to fight the war on the ground one day at a time, one battle at a time, and even one person at a time. Winning the war is not about building more hospitals and clinics to take care of those who are already ill. We need to do so, but not only building them, but motivating Singaporeans to take charge of their health, to live their lives free of diabetes and, for those who already have diabetes, to provide them with support to help them to manage their conditions well.

The three key shifts − beyond hospital to community, beyond quality to value and beyond healthcare to health − will define the future direction of health and healthcare in Singapore. They will lead us towards good, affordable and sustainable healthcare in the long term. All Singaporeans − you and me − want to have good health for themselves and for their family members. Therefore, let us work together as one healthcare system to bring better care, better health and better life to all Singaporeans.

The Chairman: Ms Tin Pei Ling.

Community Mental Health

Ms Tin Pei Ling: Madam, there is a stronger focus on community mental healthcare in Singapore, through which there is quicker identification, faster access to assistance and better social integration for those who suffer from mental health issues. Of course, it also helps to foster stronger mental resilience within the community.

In MacPherson, we are thankful to have the support of VWOs and agencies, such as the Agency for Integrated Care (AIC) and South East Community Development Council (CDC), to implement a range of programmes, including the MacPherson Mental Health Programme and Dementia Friendly Community. Grassroots leaders, hawkers, community partners and residents who are interested were all engaged and trained to equip them with useful information and skills so that they can offer timely assistance to residents with mental health issues.

However, the current set up is only effective if the elderly or their families approach us. Currently, we only know of the elderly who are identified through our local screening exercise. There are others who are already diagnosed but may not be known to us. As a community, we can do more.

For instance, instead of waiting to help a lost elderly, we can have befrienders and micro-community networks to reach out to and support elderly with dementia and their families. This will help these elderly continue to be part of our community and lead lives as normal as possible. Hence, would the Ministry consider creating a database of elderly diagnosed with dementia so that the community can support these elderly better?

1.00 pm

Finally, the stigma of mental health, including dementia. This continues to be a barrier to people wanting to seek help and also cause prejudice to deepen within the community. So, could the Ministry share what it is doing to combat the stigma, increase awareness and ensure that those who need help will get the help needed?

Ms Joan Pereira (Tanjong Pagar): Madam, patients with mental health conditions and their families need all the support and understanding our community can give them. With our ageing population, the number of patients with mental health issues, such as dementia, is expected to rise. I hope public education efforts will be stepped up to help raise our community's general knowledge of such conditions, so that we can better support the efforts of our health professionals.

The Community Mental Health (CMH) Masterplan is making good progress, especially in reaching out to patients to ensure they get more community support. I am particularly glad for the setting up of dementia-friendly communities and the Community Resource, Engagement and Support Teams (CREST). When will dementia-friendly communities reach island-wide coverage?

I would also like to ask for a clearer framework to support residents dealing with instances of neighbours with mental health issues creating disturbances in the estate. Callers should be able to receive speedy responses after contacting dedicated 24-hour hotlines for help. And in the event that the Police are contacted, officers should also be aware of the need to refer such cases to AIC for help and assessment from its professional counsellors.

I understand that, to date, we have over 120 GPs trained in the diagnosis and support of patients with mild to moderate mental health conditions. I would like to ask what is the target number of such trained GPs and whether these GPs are evenly distributed throughout our HDB estates. How does the Ministry ensure we have sufficient numbers of trained GPs in ageing estates?

Fighting Dementia

Mr Dennis Tan Lip Fong: Madam, in 2012, about 28,000 people in Singapore aged 60 and older had dementia. The Minister estimated that this figure is expected to rise to 80,000 by 2030. Based on projections from the Alzheimer's Disease Association, by 2050, we will be faced with 187,000 people aged 65 and above who have dementia.

We are also starting to see growing numbers of younger dementia patients. In an article last year, Assoc Prof Nagaendran Kandiah at the National Neuroscience Institute (NNI) estimated that of the 40,000 people with dementia in Singapore, 10% are below the age of 65. The rapid increase in the number of people with dementia is a cause for concern, especially if we do not have enough resources to support them.

As such, I would like to ask the Minister for an update on the progress in preparing for the rise in dementia cases. Is enough being done to educate Singaporeans on the risk factors for dementia? There has been an initiative to build dementia-friendly communities in Singapore, piloted at Yishun, Hong Kah and MacPherson. These communities feature "community touchpoints" that act as go-to points for those who have lost their way, and training is provided to persons and businesses within the area so that they may render assistance to persons with dementia. What are the findings of this initiative so far, and how does it compare with plans to address dementia in other countries? Are there plans to roll out this initiative island-wide; and, if so, what is the schedule for this?

I would also like to raise the issue of dementia assessments. Currently, dementia assessments are usually carried out at hospitals and the Institute of Mental Health (IMH). Will the Ministry set a target to eventually have trained staff at all polyclinics to perform the assessment?

The Singapore Mental Health Framework

Assoc Prof Fatimah Lateef: Mdm Chairman, health encompasses physical, psychological and social wellness. There are a variety of reasons why mental wellness and mental health issues are becoming more prominent in society and these are due to greater awareness, public education and, of course, our ageing population, among others. We are making positive moves in managing mental health issues. Greater strengthening and coordination will help consolidate the many good initiatives which are already existing.

My proposal: what we really need is a national recovery and stabilisation-oriented mental health practice framework. This will really help to reinforce what we already have. It is with the aim of enhancing service delivery, standardisation of care with a shared mental model, appropriate skills mix in providers potentiated through relevant training, thus forming a multidisciplinary community of practice, as well as the inclusion of caregiver support and empowerment, and not forgetting also the preventive and educational part as well as the rehabilitative services for such patients.

With this, everyone involved in mental health care is aligned. And to value-add to the suggested model, a focus on advocacy and partnership with a variety of groups, such as NGOs and voluntary welfare organisations (VWOs), is also beneficial.

This suggested framework can align with probably part of the $160 million set aside for mental health for the next five years. It is also a model that stresses on the multidimensional aspects of quality care required in mental health issues. This model framework can also guide recovery-oriented services. Also, can I ask MOH for an update as to when the next mental health blueprint will be up?

Transforming Healthcare Workforce

Ms K Thanaletchimi (Nominated Member): Madam, as Singapore faces challenges of an ageing population and as we move beyond the hospital to the community, how can we transform our healthcare workforce to realise this shift? There are several issues which I wish to highlight with some suggestions.

First, the manpower issues in primary care and step-down care. At the last Budget, I suggested for VWOs or private organisations to run an alliance of step-down care institutions. By forming an association with ILTC organisations coordinated by AIC, the alliance can help bring these institutions up to speed with technology, improve their processes to become more manpower-lean, as well as develop career opportunities and advancement for their staff.

With the growing need to address the intermediate and long-term needs of Singaporeans and to further strengthen our primary care sector via primary care network or community care services, the jobs of the future may well be from the ILTC sectors. With approximately 30,000 jobs to fill, how pervasive are the initiatives rolled out by the Ministry of Manpower (MOM), such as Professional Conversion Programme (PCP), Career Support Programme and how can we link step-down care institutions with jobseekers under the Attach and Train programme which is newly announced?

The healthcare sector faces challenges filling the many job vacancies. I encourage MOH to work with the Labour Movement which has set up a Future Jobs, Skills and Training (FJST) department to identify emerging opportunities in the job market across various sectors. Together with employers, FJST will determine the necessary expertise and training workers will need to join the healthcare industry. The Ministry and FJST will then work in close collaboration to tailor relevant training courses which are supported by the National Trades Union Congress (NTUC) Education and Training Fund. To that, how can MOH facilitate the gathering and sharing of such data to best utilise funds for targeted training?

With a greater demand for manpower in the ILTC sector, how can we enhance the attractiveness of jobs in the industry through better wages and career progression? Bearing in mind the ageing population's need for continued spending in acute care hospitals and the gradual cut in the Ministry's budget in the next two years, how can we manage the allocation of budget effectively?

As the ILTC sector grows its manpower, how do we ensure a strong Singaporean Core? How can the SkillsFuture programmes allow more to be equipped with the necessary skills to enter the industry? There are many women in their 50s seeking employment and this can be a possible source of manpower to fill job vacancies in the ILTC sector. I believe that with the new Attach and Train programme as well as SkillsFuture funding support, we can better tap into this resource to address the manpower shortage issue.

Nurses play a major role in our healthcare system. Besides the recommendations of the National Nursing Taskforce in 2014, does the Ministry have plans to develop the nursing workforce further? How can we further improve the Singaporean Core in the nursing profession?

It is, indeed, encouraging to note that the Government supports modular and e-learning training. This is a step in the right direction. How would MOH regulate certification required of healthcare staff with the move towards modular and e-learning? How ready are MOH and the respective healthcare regulatory bodies in recognising modular learning and qualification? How do we ensure that this does not erode the quality of care to patients?

The SkillsFuture Leadership Development Initiative which aims to help aspiring Singaporeans acquire leadership competencies and critical experiences can attract more young Singaporeans to join the healthcare sector. As we welcome the initiative, how can it be extended to the healthcare sector as part of leadership development for healthcare workers? While offering more overseas training opportunities for nurses or allied healthcare professionals, how can we ensure that they return to Singapore to help build a stronger Singaporean Core with deeper capabilities?

With abundant training opportunities and great growth potential for the professionals, managers and executives (PMEs) in the healthcare sector, I suggest for MOH to develop an academy for the healthcare sector to help in structuring training for workers. This will be a well-coordinated effort which standardises training beyond the basics and provides a one-stop centre for courses and skills advancement. With the support from MOM, the Employment and Employability Institute (e2i), NTUC Learning Hub and various IHL partnerships, the tripartite alliance academy for healthcare can help to meet the demand for a skilled workforce in the healthcare sector.

One would also understand that the lack of manpower and the reliance on foreign workers are inevitable unless the healthcare sector transforms itself to improve productivity and innovation. Through this, many improvements were made over the last five years as we embark on automation and improve processes. It is important to align and standardise best practices for systems and processes to keep our healthcare system safe and affordable.

The reorganisation is a step in the right direction. I would also urge that MOH consider having health volunteers, health ambassadors to penetrate the community to address the need of an ageing population better and tapping into the pool of caregivers or domestic helpers.

Manpower Cost and Sustainability

Ms Tin Pei Ling: Healthcare expenditure and the demand for manpower are rising with our ageing population. The Government healthcare spending per capita has also been rising from an average of $488 in 2003 to $1,962 in 2016. The old-age support ratio, however, is steadily falling from nine is to one in 2000 to an expected two is to one in 2030. Therefore, healthcare manpower and fiscal sustainability are critical for us to solve.

Could MOH share what it is doing to ensure manpower and fiscal sustainability? What innovations and productivity measures have been implemented and how have the gains from these measures helped improve sustainability? Can the community and volunteers play a bigger role to address unfulfilled needs?

The Chairman: Ms Tin, can you please conclude. Dr Chia Shi-Lu.

Healthcare Manpower

Dr Chia Shi-Lu: Madam, with a rapidly ageing population, the demands on our healthcare system will increase correspondingly. MOH has projected that 30,000 additional healthcare workers will be needed by 2020, many of whom will be providing direct caregiving services. So far, it has been an uphill task attracting more Singaporeans to such caregiving jobs and also the attrition rate, particularly in the public sector, has been higher than desired.

Has the Ministry identified the main reasons for these problems and what measures does it have to overcome these challenges? In addition, for foreigners recruited to help fill the manpower shortage, what measures does MOH have to ensure that they are sufficiently trained in our local system and our local culture so that they can deliver the desired quality of care?

I would also like to know if we are on track to train and recruit enough doctors and nurses for geriatric medicine and gerontology and how we can build a strong Singaporean Core for this group of specialists.

The confluence of information technology (IT), artificial intelligence (AI) and robotics will have a significant impact on healthcare. Today, we are already deploying autonomous transporters, such as automated guided vehicles (AGV) and clean fix robots, in our healthcare institutions. These and robotic-assisted beds and many other smart applications and machines will play an increasingly vital role in our hospitals and clinics. I have no doubt that they will lead to higher quality services and gains in productivity. However, this would mean that we need a strong team of competent technical professionals to service, maintain and upgrade these sophisticated networks and machinery. Would the Ministry share how we can train and recruit these talents and keep them in this competitive global market?

Manpower Development

Mr Patrick Tay Teck Guan (West Coast): With more than 30,000 jobs in the healthcare sector, the sector is poised to absorb many more workers, especially mid-career PMEs and workers who may be displaced or looking for an alternative career. This includes women who are keen to return to work after having left the workforce to look after their children or care for the elderly.

PMEs who visit our NTUC U PME Centre lament to me that most of the PCP places for the healthcare sector have been taken up. I, therefore, urge MOH to work with e2i and Workforce Singapore (WSG) to come up with new PCPs in more areas than the current offering and even more PCP places in view of the strong manpower demand.

On another note, I am excited to hear of the various expansion plans and new public healthcare institutions coming up. However, I am very concerned about how we can find the necessary manpower needed to staff these institutions, with the many productivity and technological interventions already in place.

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Allied Health Employment Opportunities

Mr Christopher de Souza: Allied health professionals, such as physiotherapists, dieticians and speech therapists, are important vocations which ease the load off doctors and nurses.

Why not then formalise their training and continuing professional development through the vehicle of a new MOH-sponsored academy? A well-trained and professional allied workforce benefits the patients immensely, eases the doctor's workload and, importantly, provides meaningful career opportunities for young Singaporeans. Why not introduce diploma and degree courses in our polytechnics and universities to build up a locally trained body of allied health professionals to meet the growing need for healthcare? After these Singaporeans graduate, they can become members of an allied health academy, so as to keep abreast of latest developments and advancements in medicine, continue their professional development and share best practices.

Outcome of Public Consultation

Mr Louis Ng Kok Kwang: MOH has just completed a public consultation on a suite of potential tobacco control measures. Can the Minister provide details of the outcome of these public consultations, in particular, increasing the minimum legal age for the purchase, possession and use of tobacco in Singapore from 18 to 21 years old?

In addition, are there further plans to increase our support for those who want to quit smoking? As a former smoker, I know how difficult it is to quit and how quitting made me a Grouchy Smurf for quite a while. The decision to quit is easy; the ability to follow through is very difficult. And if we can provide more support, I am sure we will see a higher success rate. Will the Ministry, for example, expand and enhance the very successful "I Quit" campaign? I am proud to say that since 12 October 2013, I have remained smoke-free and I am a very happy Papa Smurf now.

Tobacco and Smoking Controls

Ms Joan Pereira: Madam, I commend the Ministry for its efforts to reduce the smoking prevalence through its multi-pronged approach, which includes the banning of tobacco product sales to minors and the "I Quit" 28-day Countdown.

Unfortunately, smoking continues to be a significant contributor to the disease burden in Singapore. We are familiar with the diseases suffered by smokers and those exposed to second-hand smoke. Recent research has highlighted the dangers of third-hand smoke.

Third-hand smoke clings to the hair, clothes and any surface in the vicinity long after smoking has stopped. The residual nicotine and chemicals build up on surfaces over time and resist normal cleaning, posing a potential health hazard to anyone exposed to them, especially children. Would MOH implement more stringent measures to combat the hazards of third-hand smoke?

The Chairman: Senior Minister of State Amy Khor.

The Senior Minister of State for Health (Dr Amy Khor Lean Suan): Madam, may I please show some slides to accompany my speech?

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

Dr Amy Khor Lean Suan: Thank you. Madam, we need to grow our healthcare workforce to support the increasing healthcare demand due to an ageing population and growing chronic disease burden. We also need to transform our healthcare workforce in order to support care transformation that Minister Gan spoke about, so that we can sustainably achieve better health and better care for all.

The positive news is that growth in the healthcare sector will bring many good jobs, clinical and non-clinical, and at different levels, for Singaporeans. In the next three years, we estimate that about 9,000 additional staff will be needed for new facilities and services in the public healthcare and aged care settings. Approximately 50% of these jobs are PMET-level roles. These include nurses, therapists, administrative executives and operations managers.

Dr Chia Shi-Lu and Mr Patrick Tay asked what the Ministry is doing to help Singaporeans access these jobs. We will support young school leavers to join healthcare. Over the past five years, the number of graduates for medical and allied health has generally increased, while the number of graduates for nursing has decreased. However, we have made consistent efforts in the past few years to enhance nursing in terms of career progression, professional development and recognition. The positive news is that intakes have increased. MOH has attracted more students to join nursing programmes in the Institute of Technical Education (ITE), polytechnics and NUS, from 1,500 in 2012 to over 1,800 in 2016. Overall, our intake for nursing has increased by 20%. We will continue to sustain efforts to enhance the attractiveness of nursing.

Mr Christopher de Souza suggested that we develop our local allied health professional workforce. In 2016, MOH worked with the Singapore Institute of Technology (SIT) to introduce four degree-level allied health programmes (AHPs) in physiotherapy, occupational therapy, diagnostic radiography and radiation therapy. Two hundred and thirty students were admitted in the first cohort. This year, SIT will be increasing the number of places for these AHP courses by 30% to 300 students for fresh school leavers and mid-career professionals.

I agree with Mr Patrick Tay that we would like to attract more mid-career Singaporeans into healthcare. MOH will invest an additional $24 million over the next three years to enhance our healthcare conversion and training programmes to enable more mid-career Singaporeans to take up new careers in the sector.

MOH and WSG have established PCPs for mid-career Singaporeans to be trained as registered nurses (RNs) and enrolled nurses (ENs), physiotherapists, occupational therapists and diagnostic radiographers. The latest PCP for dental surgery assistants (DSAs) was launched in November 2016. Since 2003, over 1,000 locals have participated in the Healthcare PCPs.

This year, MOH will further increase funding for nursing PCP training so that employers co-fund only 10% of the training cost, down from the current 20% to 50%. We will also provide new on-the-job training support of $12,000 per mid-career EN and $16,000 per mid-career RN to employers. The funding will encourage employers to admit more PCP-trained nurses and enable them to better support these nurses in their transition to a new career. We will also tap on MOM's new Attach and Train scheme to enable more mid-career Singaporeans to take up PCP nursing training.

Besides enhancing the local PCPs, MOH will introduce a new overseas nursing scholarship under the Healthcare Graduate Studies Award (HGSA) for non-nursing degree graduates, including fresh graduates and those with prior work experience. Awardees can pursue an overseas Graduate Entry Masters (GEM) nursing programme and will join the nursing profession as RNs after their studies. They will be fully sponsored for their nursing course, including tuition fees and maintenance allowances. We target to give out 20 such nursing scholarships annually.

There are also non-clinical roles for PMETs in the healthcare sector. Our public healthcare clusters will offer administrative and executive positions under WSG's PCP for professional executives, in areas like human resource and hospital operations. The Regional Health Systems (RHSes) will be training more mid-career Singaporeans as Care Coordinator Associates, to coordinate the care services required by patients post-discharge and empower patients to manage their conditions well at home. Several public hospitals have created Basic Care Assistant positions to help nurses provide personal care to patients, such as feeding and transferring. This will free up nurses' time to concentrate on their clinical duties. MOH will be providing employers with on-the-job training support of $10,000 for each Basic Care Assistant hired. The public hospitals aim to recruit about 200 Singaporeans for these part-time positions over the next three years.

There are even more job opportunities in the aged care sector. In the past five years, MOH has increased aged care capacity substantially and is on track to increase our nursing home capacity to 17,000 beds by 2020, an increase of 33% from 2016. We have also improved the designs of nursing homes to provide more greenery and a cosier living environment.

Since 2014, we have also put in place the Enhanced Nursing Home Standards (ENHS) which was developed in consultation with the sector to not only guide consistent, safe and quality care in homes, but also to ensure that the psycho-social needs of residents are met. MOH conducts licensing checks to ensure that nursing homes uphold these standards. We impose measures, such as a shorter licensing period, on nursing homes with severe or repeated non-compliances. The licensing period of each nursing home is available online for the public's reference. We will continue to support the sector in improving their quality of care, including sharing good practices beyond the enhanced standards amongst providers.

But the needs for aged care are not and should not be met by nursing homes alone. In fact, most Singaporeans prefer to age at home. So, we should work towards making nursing home care an option of last resort. To achieve this, MOH is strengthening home and community care options to help seniors avoid institutionalisation and age comfortably at home and in the community. Between 2016 and 2020, MOH aims to increase day and home care services by 40%. Today, many seniors are also cared for at home by foreign domestic workers (FDWs) and the Government provides FDW grants to some 6,900 households caring for seniors. With home care, centre-based care, trained domestic workers and nursing home places, we can adequately support the needs of seniors in 2020 and beyond.

The growth in the aged care sector means we have new job positions for care staff across the island, offering Singaporeans a chance to work closer to home. In 2016, AIC helped 400 locals find jobs in the aged care sector through four job fairs, with about 25 participating aged care providers.

This year, AIC will enhance the Community Care Traineeship Programme (CCTP), which is a Place and Train programme, by including more structured bite-sized training under the programme to help Singaporeans take up healthcare and therapy assistant roles. In addition, MOH will provide on-the-job training support of $10,000 to employers for each new care worker, to better facilitate mentoring, supervision and development of the new hires.

Besides care staff, the aged care sector will need PMETs to join its workforce to lead the new institutions. Mid-career Singaporeans with managerial experience can tap on the Senior Management Associate Scheme (SMAS) to switch careers to the aged care sector.

In addition, MOH will enhance our "Return to Nursing" programme to encourage non-practising local nurses to rejoin the healthcare sector and, in particular, to take up new positions in the aged care sector. Non-practising nurses employed by aged care providers will receive support for their refresher training course fees and draw full salaries now, instead of training allowances during their three-month training. They will also be able to enjoy a bonus of between $3,000 and $5,000 for transiting into the aged care sector.

Mdm Chairman, we need to nurture a future-ready healthcare workforce that can support our efforts to transform our healthcare delivery.

Ms K Thanaletchimi asked about the Ministry's efforts to further develop the nursing profession. MOH set up the National Nursing Taskforce in 2012 to strengthen the development of the nursing profession. We have since enhanced professional development, career advancement and recognition for nurses.

Going forward, we will have to meet higher healthcare needs with a more constrained workforce. This challenge would be felt more acutely for the nursing profession as the over 34,000 practising nurses currently form the largest professional group of the healthcare workforce. Also, nurses are needed to anchor primary and aged care to lead care transformation.

Therefore, MOH set up the Future Nursing Career Review Committee in April last year, comprising nursing leaders from across the different care settings. The Committee has identified three strategic areas of focus, namely, Care, Community and Competency, to develop a future-ready nursing workforce.

The first area of focus is job and process redesign to enable nurses to focus more on patient care. We encourage public healthcare institutions to undertake a comprehensive review of nurses' roles so that they can spend more time on direct patient care and take on deeper nursing care roles. For example, the Singapore General Hospital (SGH) has introduced a digital nursing handover notes system to minimise the time spent handing over patients' case notes between shifts. Experienced ENs can be trained to take on more complex procedures, such as wound care, administering oral medications and giving subcutaneous and intramuscular injections

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The second area of focus is to develop community nursing. If we want to go beyond healthcare to health, we need nurses to deliver preventive health in the community. If we want to go beyond hospitals to the community and home, we need nurses to support patients with good day and home-based care. The RHSes will expand the existing pilot manpower partnership scheme under which they hire and deploy nurses across their community care partners. RHSes will also pilot a community nursing team network, comprising nurses and support care staff, to provide seamless care to patients from hospital to home and help seniors age in place. The RHSes have started a network of community nursing teams providing preventive and transitional care in the northern and eastern regions, which have served over 3,000 clients to date.

These RHS-level community services and partnerships with community care providers will give nurses greater exposure to different aspects of community nursing for a more diverse career. MOH will work with the nursing profession to develop Community Nursing as a distinctive career track in its own right, with a comprehensive competency framework that covers the skills needed for different roles in the community. This will underpin a more holistic system of training and deployment of community nurses.

We will start building a pipeline for nurses to enter the community care sector. MOH plans to introduce a Community Nursing Scholarship later this year to attract GCE "O" and "A" level students into nursing with specialisation in community nursing. The Community Nursing Scholarship will support students who choose to undergo the nursing diploma or degree courses and offer them clinical attachments with community institutions and work in the community care setting after graduation. They will be further supported to undergo the Advanced Diploma in Community Nursing to gain deeper skills in community nursing. The scholarship will also support in-service nurses who are keen to join community nursing to deepen their skills via local and overseas programmes. We are targeting 20 community nursing scholars annually. This exposure to community nursing will also become part of the leadership development of nursing leaders so that they will gain competencies across both acute and community care.

The third area of focus is on developing competencies to prepare nurses for the future. A more fundamental review of our nursing training system is needed so that we can better support nurses in developing deeper, future-ready skills in their nursing career. For instance, we will need to enhance the recognition of the skills and competencies that ENs have acquired at work to facilitate experienced ENs to undertake an accelerated diploma upgrading course to become RNs. For RNs, the Advanced Diploma courses will be reviewed to support more flexible, modularised ways of learning so that more can upgrade themselves. MOH has convened a Nursing Education Executive Committee (NEEC) comprising nursing leaders and will complete its review by 2018.

Over the next few months, MOH will work with the Healthcare Services Employees' Union and healthcare institutions to engage nurses through focus group discussions to hear more ideas to implement the Committee's recommendations.

With these three shifts, nurses can look forward to more meaningful and dynamic careers across the acute and community care sectors. With more time dedicated to direct patient care, nurses can better focus on what they are trained for and what they are passionate about. Patients can look forward to more integrated care and care within the community.

Beyond nursing, we are working to build a future-ready healthcare workforce across all healthcare professions. MOH is collaborating with SkillsFuture Singapore (SSG) to develop a Skills Framework for the healthcare sector to support healthcare workers in their professional and career development. For a start, we will focus on developing the Skills Framework for nurses, physiotherapists, occupational therapists, speech therapists, pharmacy technicians and support care staff, and this is targeted for launch in end-2018. MOH is working closely with MSF to ensure that the Skills Framework is applicable to their counterparts in the social service sector.

We will further develop the capabilities of our pharmacy workforce. Last year, we implemented the National Pharmacy Residency Programme to train specialist pharmacists, with a total of 15 residents enrolled to date. In addition, we are developing advanced pharmacy practitioners through the Advanced Practice Competency Framework for Pharmacists. This framework serves as a developmental tool for pharmacists to gear towards advanced level competencies. To upskill our pharmacy technicians, we developed the SkillsFuture Earn and Learn Programme leading to an Advanced Diploma in Pharmaceutical Sciences in collaboration with Nanyang Polytechnic. This 18-month structured work-learn programme aims to enhance core competencies of pharmacy technicians so that they can take on bigger roles. Training for the first batch is slated to start in April this year.

Even as we grow and develop our healthcare workforce to meet current and future needs, we recognise that with a shrinking local labour force, we will need to supplement our core local healthcare workforce with foreign manpower. Currently, foreign doctors and nurses make up 16% and 33% of our total medical and nursing workforce respectively. The proportion of foreign doctors has decreased from 18% in end 2012. We will work to help our foreign workforce assimilate to the local environment to meet our healthcare needs.

As Dr Chia Shi-Lu mentioned, it is also important to ensure that good staff are retained. Through various efforts, we have reduced our public healthcare staff attrition rate from 10.1% to 8.4% between 2012 and 2016. Attrition for nurses has decreased from 8.4% in 2012 to 6.5% in 2016.

But the formal workforce is only one part of our care system. Caregivers play just as, if not a more important role, in our healthcare ecosystem. Assoc Prof Daniel Goh asked about our plans to support caregivers of seniors. We have expanded home and centre-based care services, as well as respite care services, including weekend respite at our SCCs, where caregivers can place their loved ones to be cared for, while they run errands or take a short break. AIC also started a three-year pilot since September 2015 to embed more comprehensive caregiver support services within five SCCs. These include supporting caregivers' emotional and psycho-social needs and assisting them with information and referral services. For caregivers requiring further assistance, the SCCs will also link them to a central pool of social work support. AIC has also rolled out AICareLinks at five hospitals and at its office at Maxwell Road. These are one-stop counters where caregivers can receive advice on services and schemes. Caregivers can also call AIC's Singapore Silver Line to receive assistance over the phone.

The Government has also supported households which need to hire FDWs to care for seniors and disabled persons with a reduced FDW levy of $60 per month and an FDW Grant of $120 per month. We also provide an annual training grant of $200 for caregivers of seniors and persons with disabilities.

MOH is also leveraging technology to care for seniors. We have started several pilots on senior monitoring using technology in Yuhua, Bedok and Marine Parade. Under the Community Network for Seniors pilot in Tampines, Eastern Health Alliance is piloting a call centre service called "Careline" to support seniors living alone. Seniors enrolled in the service can call the Careline should they need help. Careline will also make regular calls to seniors and provide them with useful health information. In line with Dr Lily Neo's suggestion, we are also working with MND and HDB to study new forms of housing and care options for seniors to age-in-place.

Assoc Prof Fatimah Lateef and Ms Tin Pei Ling, as well as Mr Dennis Tan and Ms Joan Pereira, asked about support for mental health. MOH will further strengthen care in the community over the next five years in five ways.

First, to improve the early identification of mental health symptoms, frontline staff of selected Government agencies, such as HDB, the Singapore Police Force (SPF), the National Environment Agency (NEA), community partners and social service agencies, will receive basic training on mental health conditions. They will be trained to identify and respond to persons with mental health issues in the community, such as referring these persons to AIC for help. We will also continue to create more Dementia-Friendly Communities (DFCs), where residents, businesses and other partners are trained to identify and assist seniors with dementia.

Second, we will strengthen our response to mental health needs in the community. AIC will act as a "first responder" to mental health needs identified in the community and coordinate care across the health and social sectors. Community partners and caregivers looking after persons with mental health needs may call the Singapore Silver Line (SSL) or email for assistance and support. By 2021, we target to respond and support about 1,000 cases a year, up from the current 500.

Third, we will expand mental health and dementia services in polyclinics to make care more accessible. Our target is for one in two polyclinics to implement mental health clinics by 2021.

Fourth, MOH and MSF will work together to strengthen integrated health and social care services in the community. AIC will partner and support social service agencies so that they can support clients with stable mental health conditions. We will also expand our network of community outreach teams from the current 18 to 50 by 2021, to educate the public on mental health and reach out to vulnerable and at-risk individuals. MOH will increase the number of allied health community intervention teams from 14 to 18 by financial year (FY) 2021, to support GPs, community and grassroots organisations in caring for persons with mental health conditions.

Finally, we will strengthen IMH's post-discharge "after-care" support. MOH will resource IMH to widen their case management support so that more IMH patients will be supported in the post-discharge period and transit well back home. IMH expects to be able to support an additional 3,000 patients over the next five years, on top of the current 8,000 patients.

As we move beyond healthcare to health, we need to do more to tackle factors that contribute to ill-health and diseases. Tobacco use is one such major contributor in Singapore. HPB has a programme called "I Quit" that supports smokers to quit. It will extend the programme's outreach through roadshows at various community and workplace settings this year.

We want to protect our young from the harms of tobacco and lay the foundations for good health. In Singapore, nearly half or 45% of smokers become regular smokers between the ages of 18 and 21. According to a report by the World Health Organisation (WHO), persons who do not start smoking before the age of 21 "are unlikely to ever begin". Findings from Needham, Massachusetts, the first US town to increase its minimum legal age (MLA) for sale of tobacco from 18 to 21, are promising. Youth smoking rates have fallen more rapidly here, compared to neighbouring areas. At least 215 localities in the US, including New York City and the states of Hawaii and California, have since increased their MLA to 21. Between December 2015 and March 2016, HPB conducted public consultation on further tobacco control measures. The feedback showed considerable support for raising the MLA in Singapore.

MOH will take further steps to reduce, if not eliminate, the opportunities for our young to be tempted and to take up smoking before 21. We will propose legislative changes to Parliament within a year to raise the MLA for sale of tobacco products to minors, from 18 to 21. The change will be phased in over a few years.

We are taking steps towards standardising tobacco packaging. Australia, France and the UK have all implemented standardised packaging. We have closely studied the experience of these countries and seen significant value in moving in this direction so as to reduce the appeal of tobacco products, particularly to youths, and raise the visibility and effectiveness of health warnings. We will conduct a further public consultation on standardised packaging this year to seek additional and more detailed views on possible standardised packaging measures. We will carefully review relevant considerations, including public health, intellectual property and international law perspectives, and ensure that any measures taken are consistent with our domestic law and international obligations. We will continue to monitor international best practices in tobacco control and will adopt appropriate measures to control tobacco use.

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In conclusion, as healthcare needs continue to increase, we need to make bold changes in our healthcare delivery and workforce so that we can achieve our vision of better health and better care for all Singaporeans now and in the future.

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

Polyclinic Expansion

Dr Tan Wu Meng (Jurong): Madam, my residents tell me that the Clementi Polyclinic is very, very crowded.

While the CHAS scheme helps bring some of the patients to nearby GPs, many Clementi residents are concerned whether the polyclinic will get more crowded in the years ahead, especially with new HDB developments, an ageing population, more chronic diseases and senior residents with mobility needs needing more space in the waiting room of the polyclinic as they move around.

Can MOH consider expanding the Clementi Polyclinic and other polyclinics nationwide in a similar situation? This will help MOH stay ahead of future demand and provide better care to keep our residents in better health.

Primary Care Networks

Next, more broadly, primary care has to be the bedrock of a healthcare system, especially with an ageing population. Can MOH tell us how it plans to strengthen primary care nationwide so that more patients can be managed in the community more effectively? Will these networks link up with nursing homes, VWOs and other agencies like MSF's Social Service Offices, to provide more holistic care across the patient's journey in the community?

Palliative Care for Sick Children

Next, on palliative care. As a doctor and as the son of a cancer patient, I have seen first-hand how important palliative care can be for adult patients. That need is even more crucial when the patient on palliative care is a child, a child with life-limiting illness. The child may not understand what is going on and the parents will need that extra support.

For the parents, the journey is heartbreaking when the child has a life-limiting illness. No parent wants to outlive their child. No parent wants to see their child suffering or in pain. This is why it is all the more important that MOH ensures that every child with a life-limiting illness, every such child and their parents, have adequate access to subsidised care in the community so that on this most heartbreaking of journeys, parent and child can be supported as best as possible.

Palliative Care

Ms Joan Pereira: Madam, palliative or end-of-life care is still a sensitive topic in Singapore. Nonetheless, we need to persist with our efforts as a community, together with our health professionals, to raise palliative care awareness. We should encourage more dialogues to destigmatise end-of-life issues so that the early conversations can better inform care planning. Will the Ministry share an update about the public education initiatives to increase awareness about Advanced Care Planning (ACP), palliative care and end-of-life issues? How will MOH work with VWOs to improve public awareness of the accessibility and types of palliative care available?

For many families, increasingly, spouses and adult children are working full-time and need palliative care support for their loved ones. Will we be able to meet the demands for hospices and home palliative services? Will MOH be able to train enough qualified personnel to cope with the rising demand due to our ageing population?

In addition, how do we ensure that good quality palliative care will be accessible at affordable fees? Will the Minister share how funding and MediSave uses will be augmented to meet this need?

Finally, I would like to request MOH to work closely with AIC to ensure that attention is also paid to our caregivers' emotional state. AIC can support and help caregivers find closure when the loved ones pass on, so that they, usually family members, will not go into a depressive state.

Would the Ministry elaborate on the available support for the bereaved, especially those from our vulnerable groups, such as caregivers with low incomes or little family support?

Productivity and Ergonomics

Dr Tan Wu Meng: Madam, a Swiss study quoted on Channel NewsAsia looked at how doctors spent their time at work. In this overseas study by Wenger and colleagues, no relation to the football manager, Swiss doctors spent less than one-third of their time on direct patient care. The rest was used up by paperwork and administrative duties.

Madam, I think we can do much better than the Swiss. What measures is MOH taking to reduce paperwork and administration for doctors, nurses and healthcare workers? Furthermore, in the design of hospital wards and clinics, is MOH looking at economy of movement, making sure that staff do not have to move around more than necessary, making sure computer systems simplify rather than complicate? This can help our healthcare workers spend more time, and more quality time, with patients in better communication, better engagement, better care.

Innovation and Productivity in Healthcare

Assoc Prof Fatimah Lateef: Madam, the healthcare industry is very labour-intensive. It is also a people- and patient-centric one, utilising the encounter-based delivery model. However, just doing our best and working very hard may not be good enough. As healthcare organisations face unprecedented challenges to enhance quality, productivity, reduce harm, improve access and efficiency, eliminate waste and lower cost, innovation and technology have to become a focus.

It may require some shift in mindsets to implement new organisational models, service delivery and customer relations. The Harvard Business Review states that 65% of healthcare interactions will be mobile by 2018. Investments in consumer-facing mobile apps, wearable technology, remote monitoring devices, virtual care and big data analytics will become common practices.

Data-driven healthcare creates a tremendous potential to make every care environment a data-driven learning environment. How are we doing in Singapore? How is MOH utilising data-driven healthcare to help formulate guidelines and policies and set new relevant key performance indicators (KPIs)? I strongly feel that across the continuum from primary to tertiary care, there is, indeed, room for a concerted effort to revamp, relook, review, reconnect and reinvent. At the end of the day, it is really about the smart balance of technology, both the digital and the human touch.

The Chairman: Minister of State Lam Pin Min.

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

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

Dr Lam Pin Min: Minister Gan Kim Yong has highlighted key shifts in our healthcare system to help build a sustainable healthcare system for Singaporeans in the future.

I will focus on how we are working to implement the "3 Beyonds" − beyond hospital to community, beyond quality to value, and beyond healthcare to health – in laying the foundation for a healthier future.

Mdm Chairman, let me begin by illustrating with a story of two villages that are situated along a river. This river is the source of life as it provides food and water to the people living along it. However, the inhabitants up-river are dumping waste into the river polluting the water downstream. Villagers staying down-river are falling ill as a result of bathing in and drinking the polluted water.

The affected village has several options. It can invest substantial resources researching the health effects of polluted water or put lots of money into expensive technological solutions to treat and purify the water. It can also look for alternative sources of drinking water. All these options would translate into long-term commitment of time and resources in managing the consequences of a real problem. However, the underlying root cause has not gone away.

Alternatively, the affected village can work with the inhabitants upstream to identify and remove the source of pollution into the river. This would definitely help address the real problem, without having to resort to expensive and complex solutions. Yes, this upstream approach is one of the fundamental shifts that Minister Gan has alluded to in his speech − beyond healthcare to health.

Besides advocating health promotion in the general population, our focus now has shifted even more upstream to target Singaporeans as young as possible, from the preschool ages. The foundation of a healthier future is in our children and youth. There is strong evidence that good habits start from young, and these continue to reap benefits in healthier lifestyles and choices into adulthood.

Minister of State Dr Janil Puthucheary and I co-led an interagency NurtureSG Taskforce last year to jointly guide the development of a plan to enhance the health outcomes among our young. Mdm Chairman, before I elaborate further, I would like to request to deliver a summary of the NurtureSG plan in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] Good health will lay a good foundation for the holistic development of our children and youths. However, we are now seeing several new trends, such as more frequent use of electronic gadgets, easy access to high-calorie food and drinks, and increasingly sedentary behaviour. Therefore, we need to look into nurturing healthier children and youths in a sustainable way.

Last year, Minister of State for Education Dr Janil Puthucheary and I co-chaired a taskforce to jointly develop a NurtureSG plan to enhance the health outcomes of young Singaporeans. NurtureSG focuses on the health of our children and youths in three health considerations, including physical activity and nutrition, mental well-being and sleep health. We will equip young Singaporeans, their parents, caregivers and teachers to help our children and youths lead a healthier lifestyle.

NurtureSG will focus on the greater engagement of parents by equipping them with relevant knowledge and parenting skills so that they can play an active role in providing a health-promoting home environment for their children. In addition, the physical and social environments are key determinants of health, particularly for children who are in the early stages of development. Hence, NurtureSG will also focus on fostering active and healthy living in the school and the community so as to integrate health promotion into the daily activities of our young.

In order to deepen and strengthen health education in educational institutions, we will provide more opportunities for children and youths to be more active in physical activities and have access to healthier meal options. We will help them understand the importance of quality sleep and enhance their socio-emotional skills so that they stay healthy, both physically and mentally.

As long as we all work together, I believe we can raise awareness of the importance of good health amongst young Singaporeans and create a healthier future for them.

(In English): We announced the plans for NurtureSG two weeks ago. I thank Dr Chia Shi-Lu for his strong support for the NurtureSG Taskforce's recommendations. NurtureSG seeks to foster healthier habits in our young in three key areas, namely, physical activity and nutrition, mental well-being and sleep health. And we will do so through two enablers: through parents, who are role models in shaping the attitudes and behaviours of our children, and through the school and community.

Dr Janil had elaborated during the MOE COS the various initiatives that mainstream schools will be embarking on to address these three focus areas. I will now share with Members what we will do in going further upstream to target children of preschool ages.

With regard to the nutrition of our preschoolers, let me share an example of how the HPB's Healthy Meals in Childcare Centres Programme (HMCCP) contributes to our vision of "Healthy Meals for Every Child".

This is Raenelle. Since 2015, she has been attending Agape Little Uni @ Sengkang, which participates in HMCCP. Raenelle has grown to love healthier food and is a health ambassador in her home. As a result, her mother, Regina, has adopted healthier cooking methods, such as steaming and stir-frying at home, and also taking right meal portions. And when they shop for groceries, they look for healthier food options contributing to a balanced diet. Although certain healthy food options can be slightly more expensive, there is also a wide variety of affordable alternatives labelled with the Healthier Choice Symbol (HCS). By making the right choices, Raenelle and Regina are on track towards a healthier future.

To complement the efforts of improving nutrition in the meals served in preschools, the Early Childhood Development Agency (ECDA) will double the minimum daily time for physical activities for full-day preschool programmes to an hour a day, of which, 30 minutes will be conducted outdoors to cultivate young children's interests in physical activities.

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We also have plans to teach our young to manage themselves well, by equipping preschool educators with the knowledge and understanding of socio-emotional development in young children.

Last but not least, we want to raise awareness on the importance and benefits of adequate and quality sleep. A lack of sleep is associated with impaired cognition, obesity and an increased risk of mental health issues. HPB will be launching a campaign in mid-2017 to share tips about good sleep habits. For example, parents who establish regular sleep patterns for children and reduce the amount of screen time for computers, television or mobile phones before sleep, will go a long way towards ensuring quality sleep and better physical and mental health for their children.

To Dr Chia Shi-Lu's queries on Nurture SG, the initiative will benefit our children and young from preschool to IHLs. The respective agencies will be supporting the respective recommendations. However, as this is a multi-year ongoing effort and builds on top of existing efforts on child health, it is more meaningful to focus on the programmes and on an overall budget.

As reported in HPB's student health survey in 2015, one in six of our Secondary 1 to Secondary 5, junior colleges and centralised institute students do not eat breakfast at all. This is of concern and we hope that Nurture SG's plans will better guide our youths to live a healthier life.

Minister Gan has spoken about the War on Diabetes. I will now focus on the clinical management of diabetes and the development and implementation of evidence-based clinical and lifestyle management of the disease. This work is led by a Disease Management Workgroup under the National Diabetes Prevention and Care Taskforce set up in July last year.

Good clinical management of diabetes is important, as poorly controlled blood sugars can lead to multiple complications in the long term, such as diabetic retinopathy, limb amputations and chronic kidney disease. In 2014, two in three new kidney failure cases were due to diabetes. Early detection and treatment can prevent or slow down the progression of diabetes-related kidney disease.

In 2011, the National University Hospital (NUH) and the National Healthcare Group Polyclinics developed the Nephrology Evaluation, Management and Optimisation programme (NEMO). The pilot programme initiates and optimises kidney protective medication for suitable patients showing early signs of kidney disease. As of September 2016, about one-third enrolled on the programme demonstrated improvements, while over 60% maintained stable kidney function. These positive outcomes give us confidence to scale this initiative nationwide.

From April this year, we plan to extend an enhanced version of the NEMO programme. We will call it "HALT-CKD", which stands for Holistic Approach in Lowering and Tracking Chronic Kidney Disease. The new national programme will benefit more patients nationwide and will be implemented progressively at all polyclinics.

Minister Gan also spoke about the setting up of the Agency for Care Effectiveness (or ACE). This will help clinicians and patients alike achieve value, beyond quality, in the area of drugs and healthcare technology, which will support our War on Diabetes. To better equip our primary care doctors to care for diabetic patients, we will roll out two Appropriate Care Guides (ACGs) in July this year. The first care guide will provide recommendations on medications for type 2 diabetes and, the second, a systematic way to manage pre-diabetes.

ACE also recently evaluated two classes of patented diabetic drugs. One of them was found to be significantly more cost-effective. Arising from this, MOH will be listing the drug from the more cost-effective group under the Medication Assistance Fund (MAF), and eligible patients can apply for financial support for this drug.

Patients themselves also have a vital role to play to achieve optimal control of diabetes. The key to managing diabetes starts with taking active steps to lead a healthier lifestyle and to comply with treatment. To better support patients, we are developing a framework to empower them to initiate and sustain lifestyle changes and enhance treatment adherence. Diabetic patients are also best managed when anchored in meaningful doctor-patient relationships in the community.

This brings me to primary care. Primary care is the bedrock of our healthcare system and the key to enabling the shift to bring healthcare beyond hospitals into the community. It is an integral component in our transformative efforts to bring patient-focused care closer to home.

Currently, only 20% of our primary care attendances are in polyclinics, the remainder are with private GPs. This is also reflective of where our primary care doctors practise today. Eighty percent of our primary care doctors are private GPs and a small number of them provide medical care in nursing homes and home medical services. Within primary care, we are also seeing an increase in attendances with chronic medical conditions, like diabetes, hypertension and hypercholesterolaemia, rising from 18% in 2010 to about 27% today.

Our GPs are, therefore, very much a part of our healthcare ecosystem in delivering care in our communities and providing better chronic disease management for our patients. We have introduced the CHAS scheme in 2012 to provide means-tested patient subsidies at participating CHAS GPs. We have also piloted the Primary Care Networks (PCNs) in 2012 which have shown promising results, in terms of the outcome of chronic diseases management. This year, we will be scaling up our PCNs to better support GPs.

PCNs are made up of GPs who are organised into virtual networks and deliver care through a multidisciplinary team of doctors and nurses to manage patients' needs more holistically and effectively. Patients will benefit from nurse counsellors who will provide individualised advice to better manage their conditions. In addition, diabetic patients will be able to access diabetic foot and eye screening services more conveniently at the PCN GP clinics, allowing for early detection and treatment.

Through PCNs, GPs also have greater scale to link up with community providers. Dr Tan Wu Meng and Assoc Prof Fatimah Lateef suggested strengthening primary care to manage patients in the community and better streamlining of care coordination across care settings. I agree with both of them. The RHSes and public healthcare institutions have care coordination programmes and care coordinators for patients with multiple needs and frequent hospitalisations. PCN care coordinators would also be able to spend more time evaluating care needs holistically and refer these patients to the appropriate channels of social assistance, including VWOs and MSF's Social Service Offices. The team-based arrangement will also facilitate like-minded GPs in cross-sharing and peer learning of best practices across PCNs.

MOH will provide GPs participating in PCNs with funding and administrative support to implement team-based care to better track the care outcomes and monitor patients more closely. MOH will be launching the PCN application call on 1 April this year for a period of two months and interested GPs are encouraged to participate in this application. Funding support will also be available to enable GPs to better care for patients with complex chronic conditions, such as diabetes.

I would like to share a story about Mr Mohd Bin Sahat who has been seeing his regular family physician, Dr Chong Chin Kwang, for about eight years to manage his chronic medical conditions. Since 2012, he has been utilising the PCN services at Dr Chong's clinic, which gives him access to ancillary services, such as diabetic foot and eye screenings. I would like to quote Mr Mohd and he said, "I have received timely reminders on my appointments and follow-ups from the (PCN) staff…the (PCN) nurses also gave advice and recommended tips on diet and exercise. I really appreciate them."

I am happy to note that Mr Mohd's efforts in leading a healthy lifestyle, coupled with holistic chronic disease management by the PCN team, have helped him to manage his chronic conditions optimally.

Beyond PCNs, MOH will also continue to renew our primary care infrastructure. As announced last year, two new FMCs in Keat Hong and Tampines will be operational early this year. In particular, Tampines FMC will be located at the integrated complex, Our Tampines Hub, together with a Community Health Centre (CHC) and an SCC, providing our patients with a range of comprehensive community care options.

Residents in Jurong West and Punggol can also look forward to the opening of Pioneer and Punggol polyclinics this year. We are on track to operationalise new polyclinics in Bukit Panjang, Eunos and Sembawang by 2020. I am also pleased to announce that we will build a new polyclinic in the Kallang/Balestier area which is expected to be operational by 2020.

We are also working with the polyclinic groups to refresh the existing polyclinics, to evolve the polyclinics according to changing care needs. Polyclinics have progressively been renovated and expanded over the years.

Dr Tan Wu Meng had asked if Clementi Polyclinic can be expanded. I have good news for Dr Tan. Expansion plans are already being planned for Clementi Polytechnic and are expected to be completed by next year. My Ministry is also looking into partner arrangements to better care for patients. Since June 2014, Clementi Polyclinic has worked with NUHS-Frontier FMC to transfer over 6,700 patients from Clementi Polyclinic to Frontier FMC for primary care needs.

Finally, to future-ready our healthcare system, we will also be revising the PHMCA which was enacted in the 1980s. Dr Chia Shi-Lu asked for the progress of the review of PHMCA. While PHMCA has served us well in ensuring the delivery of safe and quality care, more IT-enabled interventions and mobile services have emerged in recent years. We need to ensure adequate standards for these services. It is important that our healthcare laws stay current and flexible to allow for these shifts in models of care.

I announced the revision of PHMCA in October 2016. Since then, we have actively engaged stakeholders, including hospitals and clinics, in focus group discussions. We have also engaged patient groups and members of the public to see how we can better ensure patient safety, welfare and continuity of care through the new Healthcare Services Act.

To date, we have held 11 Advisory Panel Discussion sessions and 34 Focus Group Discussion sessions. The feedback has been constructive and helpful. Both providers and the public have welcomed changes to license healthcare providers by services rather than by premises. They have also been supportive of changes aimed at making healthcare costs more transparent through the display of fees, more targeted financial counselling and bill itemisation.

Requirements to increase the accountability of healthcare providers and clinical oversight over more complex services have been generally positive. Various providers and members of the public gave useful suggestions on how we can enhance continuity of care for patients through an integrated NEHR.

One of our Focus Group Discussion participants, Dr Theresa Yap, commended NEHR as she felt that it not only enabled her to make better treatment decisions but also provided patients with greater continuity of care when they visited multiple healthcare checkpoints. Members of the public who were consulted were also supportive of NEHR as they felt that it would make healthcare less costly by preventing duplication of diagnostic tests and chances of erroneous prescription or drug interactions.

However, we are also aware of the concerns raised with regard to ensuring security of patient records, confidentiality of patient information and costs to providers. There are currently security measures in place and my Ministry will continue to strengthen the measures to address these concerns.

The draft Bill will be put up for public consultation this year. We welcome all healthcare service providers and members of the public to review the Bill and provide us with more feedback and suggestions.

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Mdm Chair, our country's journey for better care and better health starts from a commitment and understanding of how to stay healthy in every individual. Healthy lifestyle habits keep chronic diseases at bay. Staying connected to a regular doctor with improved access to healthcare services within the community will allow for better care management. MOH will continue to review our system and ensure that it evolves to ensure a safe delivery of appropriate care to patients. I urge all Singaporeans and healthcare providers to partner us in our initiatives to build a healthier future for Singapore.

The Chairman: Minister of State Chee Hong Tat.

The Minister of State for Health (Mr Chee Hong Tat): Mdm Chairman, I will focus on how MOH is partnering communities, healthcare institutions, unions and companies to implement the three shifts that Minister Gan spoke about so that we can develop a sustainable healthcare system for all Singaporeans.

I agree with Dr Tan Wu Meng and Assoc Prof Fatimah Lateef that we need to raise healthcare productivity through innovation and process improvements to deliver quality care and better value for our patients.

Since April 2012, we have supported more than 200 ground-up projects under the Healthcare Productivity Roadmap. Let me give some examples of how we have improved productivity in the healthcare sector.

Our public healthcare institutions did a successful pilot where selected patients with conditions like back pain can be directly referred by their polyclinic doctors for subsidised physiotherapy services, without having to go through a specialist. This improves patients' access to physiotherapy services and reduces unnecessary delays and referrals. It also allows the specialists to focus on other patients who require their services. MOH will work with our healthcare institutions to look at other areas where we can apply this approach to encourage right-siting and effective use of healthcare resources.

Dr Tan Wu Meng is right that we need to reduce administrative work for healthcare professionals so that they can focus on patient care. With this in mind, NUH reviewed its processes for documenting patient information and replaced hardcopy forms with electronic ones. Patient information is now collected just once, then stored and pre-populated, enabling our nurses to spend 10% less time on documentation.

We will look at further measures to cut down the administrative load for our healthcare workers across the healthcare system, including doing away with unnecessary surveys and form-filling.

Dr Tan also asked about the design of hospital wards and clinics. Tan Tock Seng Hospital has reduced walking distance for healthcare staff by nearly half through a remodeling of their wards. There is scope to further improve productivity through clever use of design and technology. This includes doing time-motion studies to monitor operational workflows and finding ways to optimise the processes and reduce inefficiencies.

Technology is a key enabler in our efforts to improve productivity. Our strategy for technology is three-pronged: digitise, connect, analyse.

First, our institutions need to digitise their information and processes to provide healthcare professionals the information they need for decision-making.

Next, we are strengthening connections across IT systems to facilitate the exchange of information, especially across different clusters and institutions. This includes linkages with VWOs and private sector providers.

Third, we are analysing the healthcare data collected to better predict care needs and utilisation patterns. For example, using data to identify and reach out to seniors who visit hospitals regularly to see how their healthcare needs can be better met through community and home care.

Madam, while technology is an enabler, the most critical factor for improving productivity lies with our people. Our healthcare professionals are well-trained and dedicated, often going the extra mile to look after their patients. I would like to thank our healthcare workers for their service, sacrifices and care to go beyond.

I also want to acknowledge the strong support from Ms Thanaletchimi and our brothers and sisters from the Healthcare Services Employees’ Union (HSEU) and thank them for their valuable feedback and active participation in improving our healthcare system. MOH greatly appreciates our partnership with the union. By working together as trusted partners, we increase our chances of success and shorten the time we need to reach our goals.

Madam, we need to look beyond the public healthcare sector, to work with private sector providers in both healthcare and non-healthcare-related industries like design, engineering and infocomm technologies.

Earlier this year, I launched the Philips Health Continuum Space in Toa Payoh. The company is now focusing on health-related products as a core business, bringing together expertise from different fields, including design and engineering. The innovation facility is a living lab for healthcare professionals to collaborate, co-create and test out healthcare solutions. I am glad that Philips is interested to work with local small and medium enterprises (SMEs) and startups to use this facility and also to test-bed their solutions in the community.

Our startups are also providing innovative solutions to tackle healthcare-related challenges in Singapore. Ms Tin Pei Ling spoke about using digital technology to enhance eldercare. Home-grown company Jaga-Me offers "home care on demand" to give patients and their families access to professional home nursing and caregiving services. I met the founders. They are a group of young Singaporeans who are keen to make a difference in improving lives.

Another technology solution is T-Rehab, where patients carry out physiotherapy exercises at home using wearable sensors, with their progress monitored remotely by physiotherapists.

I encourage our healthcare institutions to work with startups like Jaga-Me and T-Rehab to support their innovations and use these new ideas to help transform our healthcare system. Not all the ideas will succeed. We must expect some to fail. The key is to have an environment where we can try new ideas and fail safely so that we can learn from these failures and continue to innovate by pushing the boundaries.

Madam, a priority for MOH is to promote healthy living. This is also a key focus for the War on Diabetes. Mr Christopher de Souza has asked for an update. Let me start with what we have done to encourage physical activity.

Minister Gan spoke about the National Steps Challenge. So far, nearly 500,000 Singaporeans of all ages have participated. For Season Two of the National Steps Challenge, participants have hit key milestones more quickly than Season One. One hundred and fifty thousand people clocked 10,000 steps or more on at least five days per week. Well done!

To step up the momentum, HPB has been working with SportSG to scale up popular programmes like Sundays @ The Park, Sunrise in the City and Fitness@Work to increase the variety of activities.

Next, on healthy eating. When it comes to preventing and managing diabetes, diet is a critical factor. While the decision and responsibility to eat healthily rest with the individual, MOH will continue to work with our partners to foster a supportive environment for Singaporeans to make healthy food choices.

We have increased availability of healthier meals in restaurants, food courts and hawker centres. HPB works closely with industry players through the Healthier Dining Programme and HCS programme. With MOE's support, schools can only sell packaged drinks with lower sugar content of less than 6%. It is important to help our children adopt healthy habits from young.

I applaud the People's Association for their initiative to cater healthier foods at grassroots events since December 2016. I have also done this for my constituency events and received positive feedback from my residents who appreciate our efforts to provide them with healthier meals and healthier snacks.

Madam, I am pleased to announce that from 1 April 2017, the public sector will likewise adopt healthier catering guidelines for all events and training courses. We want to provide tasty healthier choices for our public officers and guests so that they can enjoy the food while staying healthy and active.

I thank Mr Chen Show Mao for his suggestions on how we can promote healthy eating. HPB has been working on this important area over the last few years. To further encourage the use of healthier ingredients by the food industry, we will introduce the Healthier Ingredient Development Scheme (HIDS) from 1 July this year.

HIDS will provide funding support for food manufacturers to innovate and develop tasty products with healthier ingredients, such as incorporating more whole grains and using healthier cooking oils. The aim is to go upstream in the food manufacturing process, to increase the proportion of whole grains and healthier oils served in restaurants, food courts and hawker centres. Through this scheme, consumers can benefit from a wider variety of healthier meals, to help prevent and manage diabetes.

Food manufacturing is one of Singapore's strengths, and our manufacturers are recognised worldwide for the quality and taste of their products. By working closely with the industry, I am confident we can further enhance the sector's value-add by developing healthier products which taste just as delicious and riding on the trusted Singapore brand to expand our markets overseas.

I am encouraged to see more Singaporeans switching to healthier choices. The market share of HCS products has increased from 15% in 2012 to 18% in 2016. I believe this can grow further. Companies have also reformulated their products to reduce the amount of salt, oil and sugar so that they can qualify for HCS certification.

For example, the median sugar level of pre-packaged beverages has decreased from 9.5% to 6.5% over the past decade. Today, there are over 2,500 HCS products available across 70 food categories, compared to just 300 products when HCS started in 2001. The sale of HCS products has been growing at 9% annually, compared to 2% to 3% for other food products.

While Singaporeans are eating more healthily, we are still consuming too much sugar. This increases our risks of getting diabetes. On average, Singaporeans consume 12 teaspoons of sugar daily, more than the five teaspoons limit recommended by WHO. We also see a worrying trend of children and youths consuming more sugar-sweetened beverages (SSB) than before.

Compared to food, SSBs are easy to over-consume as they do not provide a sense of fullness. Many are also low in nutrients and are essentially "empty calories". In Singapore, SSBs contribute 60% of our total sugar intake, higher than many other countries. Two-thirds of this sugar come from pre-packaged SSBs, such as soft drinks and packet drinks. Other countries have implemented a range of measures targeted at lowering SSB consumption to reduce obesity and chronic diseases like diabetes.

The Diabetes Taskforce has obtained views from industry players and individuals on how to reduce sugar consumption in Singapore, including from pre-packaged SSBs. We studied the practices in other countries, which include regulatory measures like soda tax, warning labels for high-sugar drinks and advertising restrictions. Mr Chen Show Mao has also highlighted some of these examples.

Madam, it is important to do further consultation with businesses and consumers before we decide on what to implement in Singapore. We will also continue to monitor the situation in other countries to assess the effectiveness of the measures that they have implemented in changing dietary preferences and consumer behaviours.

Madam, I thank Mr Leon Perera for his suggestion on using SIBs to fund efforts by NGOs to tackle diabetes. NGOs and VWOs are important partners for MOH.

In our War on Diabetes, we work with the Diabetic Society of Singapore (DSS) and Touch Community Services in areas, such as diabetes education, patient and caregiver support and disease management.

We work with and support the work of NGOs in different ways, such as funding them to provide services, extending seed funding for them to experiment with new ideas and collaborating with them through our RHSes.

For SIBs, some observers have noted the benefits, including those which Mr Perera highlighted. Others saw downsides, such as the complex negotiations among multiple parties, resulting in delays and high transaction costs and possible diversion of attention and resources away from important causes which are less measurable and harder to achieve outcomes.

In some countries, SIBs are used out of financial necessity due to insufficient public budget to support certain social programmes. Singapore is fortunate to be in a stronger fiscal position, thanks to our stable political system and the Government which has been planning long term and spending prudently within our means. We will continue to study different ways of funding and working with NGOs. Ultimately, regardless of the funding arrangement, what we need are collective action and strong partnerships among the Government, NGOs, industry players, communities and individuals to win the war on diabetes.

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Another important area is to encourage early and regular health screening. For diabetes, the current arrangement is for Singaporeans aged 40 and above to go for screening every three years. Madam, age is only one factor. There are also other factors, such as family history, body mass index and so on.

Learning from the experiences of other countries, such as the US, UK, Australia and Finland, MOH will roll out the Diabetes Risk Assessment (DRA) tool from September 1 this year. DRA is an evidence-based, self-administered questionnaire to assess an individual's diabetes risk. It will supplement our current screening efforts.

From 1 September this year, we will also enhance Government subsidies for the Screen for Life programme to encourage more Singaporeans to go for screening and post-screening consultation at CHAS clinics. The fee for screening and the first post-screening consultation will be fixed at $5 for eligible Singaporeans and $2 for CHAS cardholders, both Blue and Orange. Pioneers will not have to pay. We will offer these services to them for free as a special benefit for our Pioneer Generation (PG).

The fixed fee of $2 and $5 will cover both the initial screening and the first post-screening consultation, if the test results show that a consultation is required. We want to reduce the drop-off rate of someone who is tested positive but does not follow-up to see a doctor for post-screening consultation.

Through these enhancements, we hope that more Singaporeans will go for screening, including those who face higher risks of getting diabetes. Early detection and intervention are important in preventing diabetes and managing the disease.

Madam, Mr Low Thia Khiang asked about pneumococcal vaccination. This has also been raised by other Members in the past, most recently by Ms Cheng Li Hui in October 2016.

Our vaccination subsidy policies are guided by recommendations from the Expert Committee on Immunisation (ECI). This is a committee which comprises specialists from public and private healthcare institutions in infectious diseases, microbiology, paediatrics and public health.

ECI will assess a vaccine based on factors, such as the burden of the disease in Singapore, safety and efficacy, and cost-effectiveness of the vaccine. Vaccinations, such as measles and diphtheria, are subsidised to achieve sufficient population immunity to prevent community outbreaks.

For pneumococcal disease, the risk of an outbreak is currently assessed to be low. Our incidence of serious invasive pneumococcal disease in Singapore is also lower than other countries, such as the US and Australia. Hence, the Committee has recommended a targeted approach for specific high-risk groups, such as children below five, seniors above 65 and individuals with chronic medical conditions, such as diabetes, asthma and heart diseases. They can use MediSave for pneumococcal vaccination.

Madam, currently, all Singapore Citizen babies receive a $4,000 Government grant in their MediSave account and parents can draw from this grant to defray the cost of recommended vaccinations, including pneumococcal. There are also generous Government grants via the Baby Bonus cash gift and the Child Development Account which can be used for pneumococcal vaccination.

Madam, I will now touch on palliative care. MOH has been increasing our support for this sector over the past years.

Ms Joan Pereira asked how MOH is working with VWOs to improve public awareness, quality and accessibility of palliative care. This remains a priority for us. We will work with community providers to reach out to the public through different channels, including using art as one of the ways to reach out to Singaporeans. Alongside such efforts, MOH will work with the Singapore Hospice Council on a structured three-year initiative to promote public understanding of palliative care, including how we can better support caregivers during grief and bereavement.

An important initiative is to help Singaporeans plan ahead for their care preferences through ACP, together with their loved ones and their care team. ACP is about respecting patient choice. We aim to reach out to 25,000 Singaporeans over the next four years. MOH will work with our community partners, RHSes and AIC to expand ACP in different care settings, such as specialist outpatient clinics and primary care.

Another area is to increase the capacity, accessibility and quality of palliative care services. I recently visited Assisi Hospice again and they have a new building with 85 palliative beds, including five beds for paediatric palliative care. They are also increasing their home palliative care services to about 1,000 patients each year. At the national level, we currently have 232 palliative care beds and about 5,500 home palliative care places per year and we are on track to meet the target of 360 palliative care beds and 6,000 home palliative care places per year by 2020. The palliative care workforce has also increased by 50% from 2011 to 2016.

With the added capacity, more Singaporeans with terminal illnesses can benefit from palliative care services. We are working with the Singapore Hospice Council to launch a quality improvement programme for palliative care providers, to maintain high quality standards as we increase our capacity in this sector.

Madam, based on a 2014 survey by Lien Foundation, 77% of Singaporeans preferred to pass on at home. To further enhance home palliative care services, our RHSes will work with community providers and VWOs to pilot integrated home palliative care programmes. Under these programmes, patients can receive medical and nursing care at home, as well as assistance in their daily activities. Patients requiring short inpatient stays will be cared for in community hospitals, before they return home.

I agree with Dr Tan Wu Meng on the need to support children with life-limiting illnesses. It is a difficult time for families which are facing this situation. From 1 August 2017, MOH will extend subsidies to paediatrics home palliative care to provide the families of these children with more financial support. This follows earlier measures by MOH, such as removal of the MediSave withdrawal limit in 2015 for patients on home palliative care for cancer and end-stage organ failure. We also introduced subsidies and MediSave coverage for day hospice care in 2016.

Madam, I thank Dr Chia Shi-Lu, Dr Lily Neo and Mr Louis Ng for their comments on ElderShield. We have formed the ElderShield Review Committee chaired by Mr Chaly Mah in October last year. The Committee has engaged different groups of stakeholders, such as caregivers, service providers, insurers and members of the public, through focus group discussions. The consultation process is still ongoing.

In doing its review, the Committee is looking at ways to enhance the benefits and payout period, while balancing the need to keep premiums affordable for all Singaporeans. It will continue to consult widely to gather further views and feedback.

Madam, ElderShield is an important risk-pooling scheme to prepare ourselves for an ageing society, as some of us will require extra help if we become seriously disabled when we grow old.

To sum up, MOH will focus on three key shifts for the next few years: beyond healthcare to health, beyond hospital to community, and beyond quality to value.

We will continue to grow a future-ready healthcare workforce and strengthen primary and community care. We will achieve these outcomes by working in partnership with communities, healthcare institutions, companies and unions. Our goal, Madam, is to help all Singaporeans achieve better health, better care and a better life. [Applause.]

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

Dr Chia Shi-Lu: Madam, just some quick clarifications. First, the Minister mentioned that the reorganisation of the clusters is to enable us to pursue care transformation and, I quote, "more effectively and decisively". We note that the RHSes have also been in existence for a few years. So, could I just ask: what are some of the achievements of the RHSes when they were around?

The second clarification is for Senior Minister of State Amy Khor. Yesterday was International Women's Day. I just wanted a quick question about whether the Senior Minister of State could say something about initiatives to improve the health of women and what more is being planned in terms of women healthcare.

For Minister of State Chee, on productivity, we have been talking a lot about aged care. I was just wondering if there has been maybe equal at least, even additional emphasis, on productivity in the aged care sector and how the Ministry is encouraging manpower effectiveness in this sector, given that we can expect a lot more demand for manpower in the future.

And for Minister of State Lam, yes, last year, he mentioned about the one-doctor-one-patient initiative in the context of primary care. I was wondering what has the progress been on that particular front?

The Chairman: Minister Gan.

Mr Gan Kim Yong: Madam, let me give a quick answer. When we first set up the RHSes, they had a very clear mission, that is, to integrate care in the respective regions. The RHSes have since worked very hard to establish collaborations and partnerships with the regional service providers so that we can integrate care at the regional level and reach out to the population within the region. Over the last few years, they have done exactly that. This has also provided the impetus for the RHSes to be innovative, test out new models of care and provide the diversity needed for the healthcare system to evolve and to develop. Today, we are moving towards the three key shifts and this is why we are bringing the RHSes together so that they can leverage one another's strengths.

One example is the Eastern Health Alliance. Over the last few years, they have spent a lot of effort and invested heavily in community engagement. They have worked very well with the nursing homes in the area. With the GPs, they have the GPFirst programme. They will bring this experience in engaging the community players to SingHealth when they eventually come together and merge with SingHeatlh. We are leveraging the experience and knowledge that they have developed to help the integrated clusters move forward in a decisive and effective manner.

The Chairman: Senior Minister of State Amy Khor.

Dr Amy Khor Lean Suan: First, I want to thank Dr Chia Shi-Lu for speaking in the interest of women and I must acknowledge that actually Dr Lily Neo also asked about women's health in her cut earlier.

First, let me say that women's health is an important priority for Singapore simply because they face significant health losses due to the various disease groups that affect them, as well as the fact that, of course, they have a longer life expectancy. As Dr Lily Neo says, they now still spend the longer life years in disability.

The Women's Health Advisory Committee, now known as the Women's Health Committee, was established in 2012. One key focus is on promoting screening, such as cancer screening and breast cancer screening, and we have worked with the Breast Cancer Foundation since 2012, particularly for low-income women. Since 2012, we have been offering mammograms for women from low-income families at no cost, together with Breast Cancer Foundation, and we have reached out to about 25,000 women.

In addition, we have promoted healthy lifestyle and habits to women at the workplace through our women's workplace health grant to about 108 companies. This programme has morphed into a workplace grant for companies with particular programmes that they can pick up.

The others will be outreach into the community through health talks, for instance, through HPB, as well as we have a women's health calendar that we have been publishing for many years, and in the vernacular also, to reach out to women.

Currently, we are promoting women's health in three aspects: firstly, is continuation of promoting breast cancer screening as well as follow-up through new outreach programmes and campaigns. The other one is on bone health, so we are targeting campaigns working towards World Osteoporosis Day, with targeted campaigns to raise awareness among women about the importance of bone health from young, not just for women in the older age groups. The third one, I am pleased to announce, is in support of diabetes. We are also working with the public hospitals to promote greater awareness about gestational diabetes. In fact, now, gestational diabetes screening is available in all public hospitals for pregnant women.

And that is important because studies have shown that, if you pick them early, then it will help to reduce complications during pregnancy as well as reduce the risk of having type-2 diabetes for the mother and child later on through preventive programmes.

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HPB will also be designing and developing a mobile pregnancy app on HealthHub for pregnant women so that they can monitor their blood pressure level, blood sugar level as well as the body mass index (BMI). In addition to that, we will also be reaching out through the community to raise awareness about Gestational Diabetes Mellitus (GDM) and to get people who had GDM to take preventive measures to reduce their risk of type-2 diabetes developing later on.

The Chairman: Minister of State Chee Hong Tat.

Mr Chee Hong Tat: Madam, I would like to address Dr Chia Shi-Lu's question on productivity for the aged care sector.

Madam, what I spoke about earlier in terms of productivity being a very important priority for MOH is not only for acute healthcare services. We also want to do this for primary care, step-down care and ILTC as well as for community care. This is something which we want to do throughout the entire healthcare system.

For aged care, for example, there are a few things we have worked together with the providers. In areas, such as cleaning, how do we have equipment and technology that can allow them to do cleaning in a more efficient and more productive manner, one that will require less manpower? The manpower challenges they face are actually similar to the manpower challenges that are faced by our acute healthcare institutions.

The second area is that we also want to see what we can do to multiply the impact that our healthcare workers can make. For example, in the area of physiotherapy, instead of one therapist attached to one patient, what they do now is that they have the equipment that can be programmed. You can choose the setting and it will record the performance of the user and that gets captured in the system and the therapist can then analyse to see whether the patient is keeping up with the programme, whether there is a need to make any adjustments. And one therapist can then look after several patients who are doing their exercises all at the same time. I think these are useful ways to try and see how we can multiply the impact of our healthcare workers.

One other example I would like to share, Madam, is because we have an ageing healthcare workforce, in tandem with our ageing population. One other priority for us is how can we help our older healthcare workers to continue working so that they can continue to contribute and serve the patients? Technology can come in as a very useful enabler. Lifting up patients, for example, from the bed to the wheelchair to go to the bathroom is a physically very demanding task. And as our healthcare workers get older, some of them will require some assistance. We can use hoists, machines and equipment that allow them to do the task competently, safely but also for them to be able to do this for longer periods so that they can continue to serve our patients for longer.

The Chairman: Minister of State Lam Pin Min.

Dr Lam Pin Min: Madam, let me address Dr Chia Shi-Lu's last clarification on primary care. As I have mentioned in my speech earlier, primary care is the bedrock of our healthcare system and we envisage that our primary care landscape will transform into one integrated primary care system, linking vertically with the hospitals as well as horizontally with our community partners. And more importantly, we believe in the central role of the family doctor. Thus, our vision of one Singaporean, one family doctor.

I just want to reassure Dr Chia that MOH is working very closely with our polyclinics, GPs and community partners to drive this transformation so that we can better anchor patients in the community.

The Chairman: Members, we do not have much time. One clarification and the responses alone have taken 10 minutes. So, please keep them short. Mr Low Thia Khiang.

Mr Low Thia Khiang: I have two clarifications. First, is there a new polyclinic planned for Hougang area? It is time for MOH to look at Hougang Polyclinic with the view of building a new generation of polyclinics to serve residents.

Secondly, I would like to know whether MOH has a target on foreign-local ratio for nurses and doctors.

The Chairman: Minister of State Lam Pin Min.

Dr Lam Pin Min: I would like to thank Mr Low for the clarifications. At this moment, we do not have any plans for a new polyclinic in Hougang but I would like to reassure the Member that MOH does look at the utilisation of polyclinics all around Singapore. If needed, we will look into expanding or even building new polyclinics.

We also want to encourage patients to utilise the CHAS GPs because we believe that there is spare capacity in the CHAS GP clinics that residents can utilise using their CHAS card. Also, as I mentioned in my speech, MOH is also looking at Primary Care Networks (PCNs) and, hopefully, with this pilot programme, we are able to reach out to even more patients in the Hougang area.

The Chairman: Senior Minister of State Amy Khor.

Dr Amy Khor Lean Suan: In reply to Mr Low's question about the foreign-local ratio for doctors and nurses, first, let me affirm that our priority is to build a strong local core of healthcare workforce, whether it is medical, nursing, AHPs or even healthcare support staff. So, the top priority is to build a strong local workforce. And, as I have said earlier, first of all, our medical intake has been increasing over the years and, with the addition of the new medical school, our intake will increase to 500 eventually. The AHPs, again, because we are working with SIT to convert some of the programmes into a degree programme, in fact, the first intake was over-subscribed by many times. So, we should be able to increase this further. Our target this year is to increase it by another 30%.

For nurses, that has been a challenge. It decreased for a while but with intensive efforts to reach out to students as well as even mid-career professionals through our PCP programmes, the intake for fresh students has turned around and it is increasing. So, currently, as I have noted earlier also, the foreign workforce for doctors is about 16% and for nursing it is 33%. For doctors, actually, it is has been going down. It was 18% for a couple of years, or between 18% and 19%. It has now gone down to 16%.

What we hope to do is to build up a strong local workforce. We have even implemented a pre-employment grant for overseas Singaporean medical students. We have managed to attract quite a number. Let me say, through the pre-employment grants, we have attracted some 700 Singaporean medical and dental students studying overseas between 2012 and 2016. That is in addition to our local intakes which have also been increasing. We have also awarded 1,200 scholarships for training in healthcare disciplines locally and overseas. I do not think we have a target but what we want to do is to make sure that we build up a strong local workforce.

The Chairman: Dr Lily Neo.

Dr Lily Neo: Madam, may I seek clarifications from Minister Gan on my suggestion earlier on SAFEcare based on smart technology and preventive medicine? Does he not agree that this concept fits into two out of three of MOH's shift plans? Does he not think this concept, in fact, will reduce our total dependence on nursing homes? Therefore, will he not endorse, especially to enable our seniors to age gracefully in their homes?

The Chairman: Senior Minister of State Amy Khor.

Dr Amy Khor Lean Suan: This is in regard to Dr Neo's idea of providing services to homes, cluster kind of concept on assisted living. Let me say that, indeed, it is a very good idea. In line with her idea, we are already working with MND and HDB to look at new housing forms as well as care services. In some ways, we are already doing this. For instance, in the Kampung Admiralty Integrated Hub, there will be an active ageing hub that will provide senior care as well as active ageing programmes and homecare and home monitoring from the Active Ageing Hub for residents living in the studio apartments in that integrated hub.

The Chairman: Mr Dennis Tan.

Mr Dennis Tan Lip Fong: Can I have a quick clarification for Senior Minister of State Amy Khor? Is it possible in the interest of promoting better standards in nursing homes as well as for the benefit of the nursing home residents and their families that the audit reports be made available to the public, or at least an extract of the audit points?

Dr Amy Khor Lean Suan: As I have explained earlier, we will do pre-licensing checks and then compliance checks after we have licensed them and, if necessary, also audits by independent auditors.

There is also a home nursing visitors programme where these volunteers will go in and they will get feedback from the residents as well as the families and access the home environment. What we do is put up the licence period of all the nursing homes on our website, including the kind of services they provide. From the licensing term that has been given, you would know if they had complied fully with our enhanced nursing home standards.

The Chairman: Dr Tan Wu Meng.

Dr Tan Wu Meng: Madam, I just have three short clarifications for Minister of State Dr Lam Pin Min. Firstly, would the Minister of State join me in saluting the efforts of the nurses, doctors, healthcare workers of diverse backgrounds throughout Singapore who work so hard and with so much heart to serve our patients in primary care and our hospitals?

Secondly, when a polyclinic expands, not in reference to any specific location, but generally, what kind of additional services may be provided? And does the Ministry take into account the demographics of the area?

Thirdly, when we expand our polyclinics, will the layout be flexible so that there is adaptability to address future changes in demography and clinical needs?

Dr Lam Pin Min: I thank Dr Tan for the clarifications. First of all, just let me say that for any expansion plans, we do take into consideration the demographic profile as well as the type of diseases, especially chronic diseases, that are being seen at those polyclinics. For example, in the case of Clementi Polyclinic, definitely, we will have child-related services, such as immunisation as well as child development assessment, because I understand that there are young family members there, and also chronic care management services which cover things like diabetic food screening as well as retinopathy.

We hear the Member's suggestions about the future needs of his residents and we will take those suggestions into consideration in our expansion plans, not just only in Clementi Polyclinic, but in other polyclinics as well

Last but not least, I do agree that we really need to thank all the healthcare workers, not just in Clementi Polyclinic, but in the whole of Singapore, that they have been doing a good job, the hard work to our patients.

The Chairman: Dr Lam, you can take that as a given. We thank everybody. They have all been working very, very hard. Ms Thanaletchimi.

Ms K Thanaletchimi: Just a quick one. I would just like to ask the Senior Minister of State Dr Amy Khor how prepared are our healthcare institutions in managing a diverse workforce? Do they have policies on diversity management in ensuring equal opportunities when the healthcare workforce comprised people of different nationalities or Singaporeans, as well as getting people of disabilities to work in the healthcare along with ex-convicts? They can be a potential alternate source of workers.

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Dr Amy Khor Lean Suan: Indeed, the healthcare institutions do practise policies to ensure that there is diversity in their workforce. In the case of the disabled, for instance, they work with the various institutions representing the disabled community to employ the disabled where there is a job fit. In our hospitals now, there are already people from the disabled community who are employed. In terms of integration or assimilating people of different nationalities, especially the foreign workforce, there are orientation programmes to help the foreign workforce to integrate and assimilate into the workplace.

The Chairman: Ms Chia Yong Yong.

Ms Chia Yong Yong (Nominated Member): A question for the Senior Minister of State on the charting of a future-ready nursing workforce. Does the Ministry believe that to do better, we need a mindset change and, therefore, not limit the roles of nurses to nursing care?

Are we prepared to take reference from countries like the US, for example, which have nurse practitioners in specialist areas who can provide consultation, manage simpler cases and, even in some cases, issuing prescriptions? In order to broaden the supply or value, beyond quality nursing services, will MOH consider creating a track for nurse practitioners to complement doctors in the anticipated, more complex healthcare management requirement?

The final question, will the nurse practitioner then be considered an integral part of our future-ready healthcare landscape, given that it can, in turn, encourage the return of Singaporean specialist nurse practitioners and, by reason of the greater empowerment and progression opportunity, thereby occasion and encourage an increased take-up of the nursing and basic care professions?

Dr Amy Khor Lean Suan: Indeed, we are forming a committee to look into the curricular of our nurses in terms of training as well as curricular on the roles they play. That is part of our Future Nursing Career Review Committee's work. We will be engaging the nurses themselves as well as the various stakeholders to look into the training requirements as well as the curricular.

Indeed, as we talk about nurses doing what they are passionate about, what they are interested in, which is in clinical care, we are looking at, first of all, productivity initiatives, cutting processes which are not necessary, redesigning jobs and so on.

In addition, where there are jobs which could be done by others, say, healthcare support assistants and so on, that would also be taken into account. For the nurses, as I have said in the speech, for ENs, we will look at allowing them to do higher order jobs, higher value-added jobs, take on deeper roles. For RNs, there is this group of nurses, for instance, whom we call, "Advanced Practice Nurses". Many of the Advanced Practice Nurses are holding sessions in the community, for instance, educating patients as well as doing some medication work, which they are allowed to do. We will look at their scope of work and review them.

The Chairman: Ms Tin Pei Ling, last clarification.

Ms Tin Pei Ling: Thank you, Madam. I would like to ask, in relation to NurtureSG, what is the current obesity rate of children in schools, what is being done to manage the children with overweight issues and, therefore, raise awareness about how being overweight will increase the risk of diabetes in future.

The Chairman: Minister of State Lam Pin Min.

Dr Lam Pin Min: I would like to thank Ms Tin Pei Ling for the clarification. I recall Ms Tin asked about the "Trim and Fit" (TAF) programme last year and I appreciate her passion on this issue.

While the obesity rate amongst our children is not alarming compared to the western countries, the proportion of overweight and severely overweight students in our mainstream schools has crept up from 10% to 12% in 2016. Under NurtureSG, a new programme for students will be implemented to provide more support to them.

Unlike the old TAF programme which actually focused very much on losing weight and, as a result, caused some forms of stigmatisation among the students, this new programme will focus on lifestyle as well as behavioural changes to cultivate healthy eating habits and regular exercise among the children. More importantly, we have to focus on the active involvement of parents as well to make it successful.

The Chairman: Dr Chia Shi-Lu, do you wish to withdraw your amendment?

Dr Chia Shi-Lu: Madam, I would like to thank all colleagues who have participated in today's COS debate and, certainly, a healthy dose of appreciation to Minister Gan Kim Yong, Senior Minister Amy Khor, Minister of State Dr Lam Pin Min and Minister of State Chee Hong Tat, as well as the entire staff of MOH for illuminating the debate with their replies.

We may not know what the future brings but, certainly, on this basis, the future of healthcare in Singapore seems secure. Madam, I beg to leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $9,200,108,100 for Head O ordered to stand part of the Main Estimates.

The sum of $1,534,789,500 for Head O ordered to stand part of the Development Estimates.