Update on ICU and Hospital Capacity

12.34 pm

The Senior Minister of State for Health (Dr Janil Puthucheary) (for the Minister for Health): Mr Speaker, may I have your permission to deliver this Statement on behalf of the Minister for Health.

Mr Speaker: Please proceed.

Dr Janil Puthucheary: Thank you, Sir. Sir, from today's Order Paper, I will address Oral Questions Nos 1 to 10 and Written Question No 40, as well as questions filed by Ms He Ting Ru, Assoc Prof Jamus Lim, Mr Liang Eng Hwa¹, Mr Leong Mun Wai, Ms Mariam Jaafar² as well as Mr Murali Pillai for future Sittings. Members may wish to withdraw the questions filed for future Sittings if they have had their questions addressed.

Sir, it has been five weeks since we entered the Stabilisation Phase. We had tightened restrictions to slow the growth in the number of cases and to further expand and stabilise our healthcare system. I would like to explain to the House the current situation in the Intensive Care Units (ICUs) and hospitals and address questions about deaths and severe cases from COVID-19. I have been meeting the clinical teams that run the ICUs, visiting them on site to go through operational details and speaking to their staff to understand the challenges that they face. These discussions and the insights shared are vital in helping us plan ahead should infection rates climb and severe cases increase.

As of yesterday, we have 1,672 COVID-19 patients admitted into our acute hospitals and they take up about 18% of hospital beds in our acute public hospitals. The occupancy rate of all our general ward beds is currently at about 90%. For isolation beds, it is now at 85%.

Of the COVID-19 patients who are hospitalised, the more serious cases will need oxygen supplementation. This number of cases continues to increase, with 284 cases currently needing oxygen support in the general wards.

The most serious cases need ICU care. The proportion of COVID-19 cases requiring ICU care is at about 0.3% today. Even though this is a small proportion, it translates into a large absolute number of ICU patients when case numbers are high and will place a serious strain on our ICU capacity.

There are currently 130 patients who are critically ill in the ICU. Some are intubated and require a mechanical ventilator. All of these patients require the continuous care of the ICU team. They occupy around 60% of the 219 ICU beds currently reserved for COVID-19 patients. These patients stay for an average of 11 to 15 days in the ICU and some stay for up to a month in the ICU.

Besides COVID-19 cases, there are also non-COVID-19 patients with life-threatening medical conditions who require ICU care, adding to the sustained load that our hospitals have to bear. Our public hospitals currently operate about 163 adult ICU beds for these patients, with an average occupancy of close to 80%.

In comparison, in 2019, before COVID-19 struck, we had 298 adult ICU beds, and the average occupancy rate was 63%. So, we have been reducing the non-COVID-19 ICU beds, in order to cope with more COVID-19 patients. This is one of the key trade-offs when we increase the number of COVID-19 ICU beds.

We have had to increase the total number of ICU beds to 382 for both COVID-19 and non-COVID-19 patients over the past two months. And the need to increase the capacity of our healthcare system is a heavy burden carried by the staff, our healthcare workers.

Already, our hospitals are feeling the manpower crunch. Signs of fatigue can be seen amongst our healthcare workers. It has been over 20 months of continuous daily battle against the pandemic. A large proportion of our healthcare workers have not had the opportunity to take leave since 2020 and over 90% of them will not be able to clear their accumulated leave for 2021. This is clearly a much higher proportion compared to the past two years. Our healthcare workers have gone and continue to go way beyond the call of duty to care for their patients. The hospitals are trying to minimise having staff work overtime. For the month of September, our nurses worked for an average of 160 to 175 hours per month.

I received a WhatsApp message from a senior member of the clinical teams. It says, "We are getting increasingly stretched, overworked and fatigued... We are uncertain how long we can keep this up. Morale is slipping." Another colleague sent me a WhatsApp message and it goes: "It feels like what started as a 2.4km run became a marathon and just as we are reaching the finishing line, we have to run a second marathon. Our people are exhausted physically, mentally, emotionally – whether they will admit it or not." I know this person as a professional colleague. I know both of them. Their roles to look after ICU patients also extend to looking after their staff, managing their teams, making sure that people are in a position and have the ability to perform at their best. So, when people like them say words like these, "exhausted physically, mentally, emotionally – whether they will admit it or not", I take it very, very seriously.

It is therefore not surprising to find resignation rates going up this year. About 1,500 healthcare workers have resigned in the first half of 2021 compared to about 2,000 annually pre-pandemic. Foreign healthcare workers have also resigned in bigger numbers, especially when they are unable to travel to see their families back home. Close to 500 foreign doctors and nurses, healthcare workers, have resigned in the first half of 2021, as compared to around 500 in the whole of 2020 and around 600 in 2019, about double the usual rate. These resignations were mostly tendered for personal reasons, for migration, or moving back to their home countries.

But it is also in such trying circumstances that we find stories of inspiration, stories of commitment to public service. On a recent visit to a COVID-19 ICU, I met a nurse who had been redeployed from her usual job in the Orthopaedic Department into the COVID-19 ICU. In the Orthopaedic Department, they look after bones, joints, muscles and she was now redeployed into a COVID-19 ICU. She had had a short training and orientation course, and then subsequently on-the-job training from her ICU colleagues. She is senior, she is a Nurse Clinician and an Advanced Practice Nurse, with many, many decades in public service. And although it is a challenge to work in a new environment and with a new set of equipment, drugs and protocols, because of her excellent fundamentals and her experience and resolve, she demonstrated confidence and competence in delivering care that the ICU patients need.

On the day I visited, she was looking after her first ever obstetric patient. After many years, this is her first ever obstetric patient, a young lady who had to have her baby delivered prematurely because of COVID-19 and was now needing treatment in the COVID-19 ICU, not in a post-natal ward. An orthopaedic nurse, deployed to a COVID-19 ICU, now looking after an obstetric patient. And there are many others like her, doctors, nurses, therapists, social workers – re-deployed to do what is urgently needed. And despite having to do difficult work in unfamiliar environments they have kept the clinical outcomes excellent, through hard work, professionalism, dedication and resilience.

But this is taking a toll. They are getting tired. They are carrying a burden of care that is sometimes unimaginable. Having to hold a phone for a patient so that the family can say their last goodbyes. Holding their patient's hand, to keep them company, on behalf of the relatives. They need all the support we can give them.

At MOH, we are redeploying manpower, to serve as healthcare or patient care assistants at our institutions. We are reaching out to more volunteers to join the SG Healthcare Corps and support this important work. We are collaborating with private hospitals to ease some of the load on our healthcare workers in our public hospitals. We are stepping up the recruitment of healthcare workers from overseas.

Our public healthcare institutions have also stepped up their outreach to staff to support them through measures that will safeguard their well-being, including counselling services, staff helplines and peer support programmes.

To Dr Tan Wu Meng's question about hospital departments factoring in sick leave as one of the indicators of work performance, there have previously been isolated incidents, but this practice has ceased. Healthcare workers who are concerned about the way sick leave affects their performance appraisals can approach their union, MOM or MOH for assistance.

Besides addressing the issues of manpower, we have also been working with public, community and private hospitals to set aside more beds for COVID-19 patients. We have also stood up COVID-19 Treatment Facilities (CTFs), which have close to 2,000 beds with an occupancy of 50% or less. We are continuing to add further capacity to our CTFs, with a view to reach around 4,000 beds in November.

We will expand our ICU capacity further, in preparation for a potential rise in severe cases. We are currently working with our hospitals to ramp up from 219 to 280 ICU beds for COVID-19 patients. These can be ready this week. If needed, our next expansion will be to 350 beds. We have been repurposing existing hospital wards, such as single rooms and isolation rooms, into additional ICU beds. We have been augmenting ICU manpower by deploying previously trained ICU staff to help with patient care. Non-ICU staff have also been brought in, as I described earlier, and they work under the supervision of ICU-trained staff. The shift pattern of nurses may have to be adjusted in order to cater to these needs and this has already started to happen in some hospitals. At the same time, we are also asking the private hospitals to set aside ICU beds to assist in managing both COVID-19 patients and non-COVID-19 patients who are critically ill.

Increasing ICU beds takes time and it affects regular hospital operations. Converting non-COVID-19 ICU beds for use by COVID-19 patients who need intensive care has a limit, as it diverts resources from non-COVID-19 patients who also need care.

The most important limit is the manpower required to staff ICU beds. Patients in ICU need trained staff, who must be able to provide individualised care, including round-the-clock monitoring and continuous care. So, any increase in ICU bed capacity must be supported by an increase in manpower, which has to be diverted away from non-COVID-19 ICU duties. Any redeployed staff or new hires would also have to undergo training to operate the specialised equipment and medical devices in the ICU to care for their COVID-19 patients.

Logistically, we can keep stepping up our ICU beds. We have ventilators, we have equipment, consumables, all the things that are needed, but not enough people. As a result, if we keep increasing our beds, we stretch and stretch our healthcare workers. We will come to the point that they will no longer be able to provide that continuous excellent care. Our nurse-to-patient ratio will also be lower, which means each nurse will have to take care of more patients than they do today. In a normal ICU – peacetime, pre-COVID-19 – one nurse would look after one or two patients. If she has to look after four, she will not have enough hands or time to provide the same level of care.

There will come a point where even as the healthcare professionals are doing their very best, they are trying their hardest, more patients will die.

And this will affect both COVID-19 and non-COVID-19 patients. As more healthcare resources are diverted to support COVID-19 services, our hospitals' ability to sustain regular non-COVID-19 services will be reduced.

So, while we may have plans to step up to a certain number of ICU beds, the real situation on the ground, the operational considerations, are not straightforward. We do not want to go anywhere near to this theoretical limit. If we do, the situation can easily get out of hand. It will affect the unvaccinated disproportionately, but it will also affect all the rest of us.

MOH has strategies to restrict the number of cases, not only to try to shield our healthcare workers and hospitals from the large surges, but also to protect all of us. We will continue to need care for heart disease, diabetes and cancer. We will have accidents and broken bones, and all of the patients, all of us, will need care, comfort and healing.

Our ICU staff have been stretched to their limit in the last two weeks. At its peak, we had 171 COVID-19 cases in ICU. But the situation has eased a little. Today, this has come down to 130. The booster doses have helped in reducing severe illnesses among vaccinated seniors, but the unvaccinated continues to be at risk. That is why we continue to monitor the situation very closely, especially the number of unvaccinated seniors who get infected. Every day, there are about 60 of them and six are likely to end up in the ICU. We need to keep this group as small as possible to ensure everyone who needs care can receive it.

Thankfully, because of our high vaccination coverage, almost all cases, about 99%, have had no or mild symptoms. We have also managed to keep our fatalities very low. But sadly, we have seen 407 deaths so far. Each death is a tragedy and a loss felt by the family, the patient's loved ones and the care team. Of these, 395 of them passed away in a hospital, eight at home and four in a care facility. The number of deaths has increased in the past two months as the overall number of cases increased.

Seniors who are unvaccinated and have underlying medical conditions are at much greater risk of severe illness and death. Close to 95% of those who died in the last six months were seniors aged 60 and above, and 72% of all deceased cases had not been fully vaccinated. Almost all of the remaining 28% who were fully vaccinated, suffered from underlying medical conditions such as high blood pressure, diabetes, cancer and heart, lung, or kidney diseases. Underlying conditions add risks, even if the conditions are well controlled before the patient encounters COVID-19, especially if the patient is elderly.

There is not yet conclusive information about the long-term health consequences of COVID-19. An NCID study found that one in 10 COVID-19 patients who recovered after the initial infection continued to display symptoms such as coughing or breathlessness six months after recovering from the acute illness. A study in the UK found that those who are vaccinated are half as likely to continue having symptoms about a month after COVID-19 infection as compared to those who are unvaccinated.

While most of our cases recover fully from COVID-19, we do see instances of re-infection. Up to mid-August, we had detected 32 re-infected cases and all of them were unvaccinated.

The risks of being unvaccinated are high. Compared to the vaccinated, someone who is 60 years old and above and unvaccinated, is six times more likely to need oxygen, eight times more likely to become critically ill and need the ICU and 17 times more likely to die.

So far, we have had one of the lowest fatality rates in the world. At the beginning, it was because we had such tight restrictions, rapid contact tracing and low total number of cases in the community. But with cases rising fast, the case fatality rate remains low now because we have reached such a high vaccination rate and because all those who have become sick have been able to receive the care that they need. Our healthcare system is stressed, but it has not been overwhelmed, unlike many countries last year, where patients had to be turned away and doctors had to choose amongst many patients whom to save.

These other countries experienced what is known as excess mortality, as the pandemic spread rapidly through the population and hospitals were overwhelmed. Excess mortality is when a lot more people die in a year than you expect.

We are trying very hard to avoid that, by keeping restrictions tight last year when our population was vulnerable to the disease and then cautiously opening up after we vaccinated the vast majority of our population. Even then, we have to accept there will be some deaths. Our goal is to make sure that there are no significant excess deaths, as a result of an inability to provide adequate medical care. And so far, that is something that we have been able to do and that we want to keep doing.

Up until recently we kept the absolute number of deaths small by ensuring that few people caught COVID-19 and also that those who were infected got good treatment and care. Now that we have to live with COVID-19, we will continue to protect people from getting infected through vaccination and safe management measures, but this protection is not complete. And that is why much larger numbers will get infected. But we will continue to make sure that those who are infected get good treatment and care, and so keep the death rate from COVID-19 as low as possible. Hence, we are doing everything we can to expand our ICU capacity and protect our healthcare system.

These efforts have succeeded. Our death rate is 0.2%, compared to 3% or more in countries that experienced a surge in cases before vaccination. This rate of 0.2% is comparable to catching pneumonia – pre-COVID-19. But it does mean that over time, the absolute number of deaths from COVID-19 will rise despite the best possible medical care. We could have, perhaps, 2,000 deaths per year from COVID-19. Most of these will be the elderly and those who are already unwell.

In comparison, every year, in peacetime, pre-COVID-19, about 4,000 patients pass on as a result of influenza, viral pneumonias and other respiratory diseases. These are also mostly the elderly and the unwell. That is why we keep emphasising the importance of vaccination and boosters. We must make sure that everyone who is infected with COVID-19 will receive proper medical care by our healthcare workers and hospital system and be given the best possible chance to fight the disease.

We have got to this point in our fight against COVID-19 without excess mortality. We have managed to continue to provide excellent healthcare for all COVID-19 and non-COVID-19 patients. I am extremely proud of my colleagues, co-workers and friends who man the wards, clinics, and many other sites where they perform their duties and we should place a high value on maintaining the standard.

What we are trying to do has not yet been done by any other country. We are trying to get to the point where the combination of high vaccination rates, booster jabs and even more boosting from mild infections means that COVID-19 will no longer spread as an epidemic in Singapore. And we are trying to get there without excess mortality. But no other country has done that before. In other words, though we will have fatalities as a result of COVID-19, we will not see more overall deaths than we would in a normal non-COVID-19 year. Nearly every other country that has arrived at that destination has paid a high price in lives.

I hope my explanation has helped Members understand why although we say we are living with COVID-19, we cannot just open up and risk having the number of cases shoot up, because more and more cases will translate into more and more ICU beds used. Beyond a certain point, that will force us to accept a lower standard of care, and hence, have more deaths that could have been prevented.

Despite our best efforts, events may overtake us and we may have no choice in the matter. If, despite our caution, ICU cases rise sharply, we will still do our very best to look after every patient. But at what level of care? I would strongly prefer if we can avoid that dreadful scenario. We need to continue to manage the overall number of cases in our population, even as we continue to increase our hospital capacity.

In all of this, there is hope. The main reason why we got to this point in the fight with COVID-19 with such low mortality rates is our people. I have spoken at length about the staff that I met at the ICUs and this applies to all our healthcare workers in the emergency departments, the clinics, the PHPCs, our swabbers, our contact tracers. Across every sector, everyone has given their all, together with an ongoing commitment to excellence in service.

MOH and the healthcare teams will continue to train staff, increase beds and expand ICU capacity. My MOH colleagues and I will keep working directly with the ICU directors and clinical leads to help them. They know better than me how to manage the patients, to provide clinical care, but they need support, resources and policies that allow them to optimise their outcomes. We will help to look after them and their staff.

All of us can continue to play our part. Vaccination remains critical, every single extra person who gets vaccinated makes a difference, to themselves and for all of us. Getting your booster shot as soon as you are eligible makes a difference. Following the safe management measures makes a difference. Regular testing makes a difference. Using the right healthcare resources appropriately makes a difference.

The current situation will not last forever. We will eventually come out of this. Eventually, enough of us will be vaccinated or will have been infected, that we will see the case numbers come down and the situation stabilise. But in getting there we should try to keep the number of deaths as low as possible.

That we got to this point, where after nearly two years of fighting a pandemic, I can explain our hope to maintain one of the lowest case fatality rates in the world, is a small miracle. It did not happen by chance. It happened because Singaporeans stood together, looked out for each other, did their duty and put the interests of others ahead of their own. And the healthcare workers of Singapore have done all this and much, much, more, caring for us all.

I received another message from a colleague: "we are one of the few countries in the world where ICU teams don't have to worry about resources and equipment – very grateful for that. Healthcare workers have given everything in the last two years, we have held ourselves up to the highest standards; we have the lowest mortality in the world; our people are still pushing on". Our people are still pushing on!

The healthcare workers we are worried about are also the same healthcare workers who are committed to doing what is needed to look after all their patients. They will do their duty, do their best and try their hardest. Words will never be enough, but I express our gratitude on behalf of this House. [Applause.]

Mr Speaker: Mr Yip Hon Weng.

1.02 pm

Mr Yip Hon Weng (Yio Chu Kang): I thank the Senior Minister of State for the clarity about the COVID-19 situation in Singapore in the Ministerial Statement.

Given that seniors, especially those who are not vaccinated, are most susceptible to severe illnesses due to COVID-19, can there be initiatives to identify, isolate and protect these seniors? And thus, if we can implement such measures to protect seniors in an effective way, is the Ministry prepared to consider loosening safe management measures for the rest of the population?

Dr Janil Puthucheary: Sir, I thank the Member for the question. In a way, that is what we are trying to do with our vaccination-differentiated measures: expose some people to a lower level of risk while allowing other parts of our population to do the things that make life a bit more bearable.

But there is only so far that we can go. If you are a senior and you are unwell and, for some reason, unvaccinated, you cannot be isolated completely. You need fresh air, food, contact with other people.

So, I understand what the Member is asking. The question is, how far can we go and we do not think we can go much further than where we are today, with vaccination-differentiated measures.

But there is another dimension to this question. Because it supposes that the seniors and the vulnerable are a different segment of the population from the rest of us, who are younger, healthier and vaccinated. The truth is, we interact and we meet and we pass infections on to them.

I think the experience of the last two years, in a way, has demonstrated just how much intermingling and interconnectedness there is between all kinds of networks and communities here in Singapore. It is part of our human response. Our grandparents want to see their grandkids. We want to go and look after our parents. Each of those interactions poses a very small but measurable risk to them as well.

So, I think we have to assume that whatever it is that we are doing, we must treat the whole population as one. We will try with the vaccination-differentiated measures but there is only so far that we can go.

Mr Speaker: Dr Lim Wee Kiak.

Dr Lim Wee Kiak (Sembawang): Thank you, Mr Speaker. I would like to raise two supplementary questions. Let me thank the Senior Minister of State for the Statement just now.

The first supplementary question is about whether we can make vaccination mandatory since the vaccine now has been fully approved by the Food and Drug Administration (FDA). I filed a Parliamentary Question asking when will HSA make the vaccine not used under emergency use, which means it can be fully licensed to use for normal times. That is the first supplementary question.

The second supplementary question is regarding the Senior Minister of State's observation about the immense stress and pressure on our healthcare workers and what they are shouldering, especially over the last past few months. I would like to ask whether MOH will be planning for more support and recognition awards to healthcare workers, given the amount of stress and the work they have shouldered through the pandemic.

Dr Janil Puthucheary: Sir, making COVID-19 vaccination compulsory is a significant move. It should be carefully considered. We would have to consider a number of factors: vaccination coverage, international practice and the availability or performance of fully registered COVID-19 vaccines.

The introduction of the vaccination-differentiated measures, in a way, is to try and get around some of that problem, to expose the different segments of the population to different risks. But in terms of making vaccination compulsory, it is also quite difficult in terms of the execution.

You can imagine that for something like childhood vaccines, you may say that without it, you cannot have access to play groups or school. There is a specific thing that you want to do and for that, you are getting the vaccine. But here, we are talking about all the normal activities of life and so policing it, executing it, implementing it is not without challenges. And the question is, how much benefit will there be?

So, I think it is something to consider but there are a whole lot of complications associated with that. Sir, the Minister for Health has indicated that he will answer the second question.

1.07 pm

The Minister for Health (Mr Ong Ye Kung): Thank you, Mr Speaker. I thank Dr Lim Wee Kiak for asking the question on recognition for healthcare workers.

Many people contributed to this fight against COVID-19. We have the people who do all the swabs, supervise our self-swabs, the people who run our vaccination centres, people who make sure the vaccines arrive on Singapore shores, the people who do conveyancing every day – hundreds, thousands of trips to and fro, hospitals to treatment facilities – all our officers on the ground, safe distancing ambassadors, our vendors who disinfect places that we have been to, teachers who kept schools going for past 20 months, preschool teachers included, social workers, our community volunteers who help out those who are in need. We all owe a debt of gratitude to all of them for collectively putting up this fight.

But as Senior Minister of State Janil Puthucheary has very vividly and, in a very heartfelt way, described, I think the role of healthcare workers is especially important. They are not like the other frontliners, they are also our last line of defence.

So, while the rest of Singapore try to get back to a normal life, we try to get back to work, to travel for work or study, they bear that disproportionate responsibility. If something goes wrong, they are the ones who carry the burden and are literally the last line of defence, while the rest of us can continue our work and life.

So, I know that monetary award is not everything but I think it is probably appropriate and the least we can do to recognise their commitment, their dedication and all the physical, mental, emotional stress that they are going through. So, thank you for that suggestion. It is something that we are seriously looking into.

Mr Speaker: Leader of the Opposition.

Mr Pritam Singh (Aljunied): Thank you, Mr Speaker, and thank you to the Senior Minister of State for the Statement on ICU capacity.

I would like to refer to a report which is found on the SingHealth website. It is carrying a Straits Times article on ICU capacity. This is dated 13 August and I think this number has been quoted by individuals online as well as when the Minister for Health said that up to 1,000 ICU beds can be made available for critically ill COVID-19 patients, if needed.

I think what the numbers suggest, and what the numbers we have now insofar as ICU capacity is concerned, is that there is yet sufficient potential for upscaling the number of ICU beds. Of course, the assumption being that this remark that was made on 13 August refers both to the bed itself, the ancillary equipment needed and the manpower needed to manage 1,000 beds.

Sir, I would just like to ask a question pertaining to this number of 1,000. Is this still the operating parameter or have things changed quite significantly?

The second point is somewhat connected but it is with regard to the measures introduced vis-a-vis the Stabilisation Phase.

I think there has been some pushback in terms of retaining the number of two individuals in a dining capacity. There is significant public feedback that this should be increased to five, especially for vaccinated individuals, particularly since the Government is also opening up more Vaccinated Travel Lanes (VTLs) and lifting travel bans. At least, for the South Asian group of countries, this was lifted very recently.

So, there is a view that cannot quite connect why dining capacity cannot be opened up in view of the number of vaccinated individuals who actually are not imposing on the ICU capacity as much as non-vaccinated individuals. So, I hope there could be some clarity provided insofar as what is holding the Government back on this number, on opening up at least for dining for up to five individuals.

My third question really – and this is the last one, Mr Speaker – follows up on the numbers the Senior Minister of State shared with regard to the resignations in the healthcare system. One thousand five hundred for the first half of 2021 and I believe an additional 500 were foreign healthcare professionals.

Can I just confirm what have been the recruitment numbers over the same period? The Senior Minister of State said in his Statement that the recruitment of healthcare workers from overseas is continuing. So, it will be helpful to have the numbers that are coming on board as well and not just the numbers that are leaving.

Mr Ong Ye Kung: I will take the first two questions and maybe Senior Minister of State Janil Puthucheary can also comment on the first question and answer the third.

I remember quite vividly that we talked about the possibility of ramping up to 1,000 beds. I spoke about it at a press conference illustrating how if cases doubled every week, in five weeks, the beds will actually be exhausted. It is the illustration that even with that kind of capacity, if infections run away from us, it will be of no use. We would just get overwhelmed in a matter of weeks.

I also remember vividly – do not even get near that – not even near the 1,000 limit.

Senior Minister of State Janil Puthucheary is a lot more experienced in this and he knows it inside out. I think he had explained that we have all the logistics and all the consumables to set it up but I think manpower will be a serious constraint. Can they handle 1,000 ICUs? I think not without a major degradation of care.

So, I think it is not a black-and-white kind of situation. With every step up in the number of beds, there is degradation of care and there is a trade-off.

The second question on whether we can increase dining to five for vaccinated diners. We wish to get there too. We were there before. We were even at eight at one point. It is important to the F&B industry, it is important to Singaporeans, it is important for families to get together.

But I think the time is not here yet. I think we will get there. Because when you meet with five, as explained by Senior Minister of State Janil Puthucheary, you do increase the risk of transmission. If it is transmission within vaccinated individuals, it may not be that serious. But we also live with older people, with seniors who may be unvaccinated. And we can inadvertently bring the virus to them.

I have a neighbour, an unvaccinated senior and she has streams of visitors coming to visit her, persuading her to get vaccinated. So, I was persuading their visitors maybe stop coming to persuade her, just give her a call. But this is life in Singapore. So, we do have to pay attention to that.

There is always a comparison with why is it that we can open for travel but not for dine-in. The difference is this, that in the initial stage, Singapore has very low infections and the world around us has very high infection rates. So, when you open up borders at that time, you are opening up the floodgates. Today, the situation is entirely different. Our infection rates and the rates outside are similar. In fact, they may have lower infections than us because they went through huge waves and we are still going through ours. Furthermore, we limit travel or SHN-free travel to only vaccinated individuals and at the border, you are subject to tests.

So, theoretically, if you can have an event, like a wedding, a bigger wedding, everybody is subject to a test, you can sit in fives. So, it is actually a similar concept. This also present possibilities for the MTF to think about in future, whether through testing, through vaccination, we can allow gathering that is a bit less restrictive. These are all possibilities that we will continue to think about.

Dr Janil Puthucheary: Sir, I do not have the specific numbers of recruitment figures for the different clusters and organisations. We can get them.

But I think one of the challenges we have to appreciate is that even if we recruit from overseas, anybody coming into that environment is new, they are inexperienced. By definition, they are inexperienced with the environment, our healthcare protocols, but they may actually be literally new in terms of their training as well. So, their role is going to be quite different. It is going to be augmenting manpower where, perhaps, that level of acuity and that level of complexity does not exist.

So, while we are recruiting – and we have been actively and I will get the numbers – operationally, I cannot see that that is going to make a huge difference in the ICUs. It will make a difference in other parts of our ecosystem. We hope that can displace a little bit of the manpower into some of the higher acuity areas and then release a few people to go and help in the ICU. But I think this is a bit more of a medium-term strategy rather than something that we can rely on as an urgent fix to our current problem.

If I may make a comment on the first part that Minister for Health talked about, some of the uncertainties are about how long we have to carry a certain load or a certain number of patients within the ICU. If you have a terrible disaster, mass casualty, a very bad accident, you may have many times the number of patients that we currently have in the ICU. But as a one-off incident, the patients will not stay as long.

What we have today is the equivalent of a low-intensity conflict and having to be on readiness and high alert for weeks and weeks, and months and months. Your surge capacity at the start of a low-intensity conflict is very, very different after two years or after one month. Even this current surge when it started, there was really no way to know or model how long it was going to last and what the peak of peaks would be.

So, what the Minister talked about is the logistical planning parameter. If you do not have 1,000 bed spaces, you know that you cannot get there. But if you do, that is physically where you can locate people. If you need the equipment and, thankfully, as a system over the last two years – but it started long before the last two years, through emergency planning and resilience preparedness – we actually have the stocks of equipment that we need: the consumables, the little parts to drive the machines as well as the drugs, in order to cater for many, many more patients than we have today. So, as the colleague of mine said, we are not resource-constrained at the moment.

The manpower issue is not something that we can do a simple calculation for. As I said, it depends on how long this goes on for, how long the peak goes on for. Crucially, today, coming to the end of 2021, the amount that we can reduce business-as-usual is really quite different from where we were, let us say, six months ago; in fact, where we were, even three months ago. That is an additional factor that we have to take into account. So, the number is something that we have to think about in a fairly dynamic way.

Mr Speaker: Mr Lim Biow Chuan.

Mr Lim Biow Chuan (Mountbatten): Sir, I just want to thank the Senior Minister of State for his reply. Sir, I am just concerned that over the past week, the number of deaths had been in the double digits. We had 13 yesterday, 14 the day before; 16, 15, 10, as compared to the end of September, where the deaths were two, three, four.

Can the Senior Minister of State explain why has the number of deaths increased by such a large number? Is it due to the relaxation of rules? Is there anything else we can do to cut down on the number of deaths because every life lost is a tragedy.

Dr Janil Puthucheary: Sir, I thank the Member for his questions. Why are deaths rising? The proportion of deaths has not changed. Of people who get COVID-19, the risk of dying, the proportion of them who go on to need the ICU and then, subsequently succumbed actually has not changed.

There are two major reasons why we are starting to see the absolute total numbers rise now. The first is that the base number of our population that is being infected with COVID-19 has risen very, very significantly compared to the time period that he was talking about.

The second is that although some patients with COVID-19 who pass on, will pass on very soon after getting the infection, most will take a long time to get seriously ill and may take some time before they succumb, which is a testament to the care that we have put in place and their attempts to fight the infection.

So, there is a lag. The deaths that we are seeing now are not necessarily the same people who are being infected this week. There are people who are infected, perhaps, two weeks ago, maybe even a month ago. After you get the infection, it takes time before you develop the need to go on oxygen support. And then, once you are on oxygen, not everybody will go on to the ICU or succumb, but it takes time for conditions to worsen to the point where then you need further care.

So, there are two main reasons why the deaths are rising in total number: baseline has increased and it is that effect of the lag. But I stress, the proportion of patients who then succumb has not changed.

How to prevent the deaths? Well, vaccinations, as I have explained; booster jabs, as I have explained. But even if you have had those, you may have other underlying illnesses and the underlying illnesses need to be well-controlled. So, if you have diabetes, control your diabetes well. If you are requiring medication, take your medication regularly, comply with all the usual prescriptions around maintaining good health.

For those of us that are fortunate not to have health problems, all the usual rules apply: eat better, sleep better, get more exercise and reach out to your loved ones. And if you are a smoker, stop smoking. If you get a lung infection with COVID-19 and you have knocked out some of your lung function through smoking, you are not off to a good start. These are the ways in which we can prevent mortality and morbidity in COVID-19.

Mr Speaker: Assoc Prof Jamus Lim.

Assoc Prof Jamus Jerome Lim (Sengkang): Thank you, Speaker, and I thank the Senior Minister of State Janil for a comprehensive explanation. Like him, I am very much grateful for the efforts that our healthcare workers and frontline workers have put in.

I have two questions to follow up on pre-empting infrastructure. One has to do with ICU beds. I would note that just before this discussion about increasing COVID-19 coverage to 1,000 ICU beds, our ICU beds per 100,000 population was about six. This is half that of the OECD average. And only Japan, among those that have lower ICU beds per 100,000 of the population has a significantly larger elderly share of the population. So, the question here is: if we know, as we did in the earlier half of this year, that we were going into an endemic surge, why is it that during this lull period, there was not a more concerted effort in increasing our capacity and this, of course, includes bringing in relevant manpower, as Senior Minister of State Janil mentioned was the big challenge?

My second question builds on this issue of manpower. Given the global nurse shortage, WHO actually estimates that by 2030, there will be nine million needed worldwide and 370,000 just for the US. My question is whether looking forward, Singapore would be competitive in attracting these foreign nurses, and if not, what steps are being made to expand our local nursing and doctor workforce to ensure that we are able to meet our future needs?

Dr Janil Puthucheary: Sir, I thank Assoc Prof Lim for the question. Sir, as I have explained, pre-COVID-19, peacetime, we had about 300 ICU beds for the country; 298 to be precise. And the average occupancy was about 63%. So, it is not that we did not have spare capacity pre-COVID-19. But as I have already also explained, if you wanted to open up more of this capacity and keep it empty, it would have an impact on resources that could have been applied elsewhere.

So, I do not know if that addresses his first question about why we did not do more before we knew about COVID-19. I think comparing with other countries is fraught in this situation because the number does not reflect, for example, clinical practices, the demographics in terms of the health patterns that they have. So, I do not think one can take the view that there is a certain number of ICU beds that you must have per population. I think what we are most interested in is what the ICU system and the healthcare system is able to deliver in terms of clinical outcomes. I think if the Member dove into those details, he would find that our clinical outcomes and our ICU outcomes are much more than comparable to any of those countries that he has listed, with perhaps less total beds per population.

Some of these also rest on what counts as an ICU admission. It is quite different from country to country because of the way in which the nurses are licensed, the way in which drugs are licensed, the way in which doctors practise.

He then asked about a more concerted effort to increase capacity. Well, it is not that we stood still and waited to see what happened. We were indeed doing the cross-training. As I had explained, the cross-training and the cross deployment of nurses, that was a concerted effort. The reduction in elective work to free up resources, that was a concerted effort during the lull.

But the thing about ICU manpower, you cannot stand it up and have it lying around waiting. If a year ago, we said we needed to increase our manpower by three times or by four times, what would those nurses have been doing in the ensuing 12 months or six months? They certainly would not have been getting experience at ICU care because you need to look after ICU patients in order to become an ICU-trained staff.

So, you can see that what we have been doing is opening up capacity ahead of the curve, but not so far ahead of the curve that we are having people sit around idle, while other services are undermanned or unmanned. But ahead of the curve, so that we can do some of that training and redeployment training and redeployment.

Intensive care, critical care, whether you talk about the doctors, the nurses, the respiratory therapists, the social workers, the pharmacists that are deployed in there, it is a clinical practice. It is not something that you can learn and be ready for by reading textbooks and doing online courses. You have to be mentored and precepted into looking after patients with your hands, eyes and senses. So, it is not something that you could have gone five X, four X, in vacuo in peacetime and held everything ready in abeyance. It would have been a waste of resources but it also would not have been effective in terms of changing the outcomes currently.

I stress again that while the healthcare system is under stress and our healthcare workers are tired, they are delivering excellent outcomes. And I say this not as matter of hyperbole but that lowest mortality rate in the world is matched by any number of other patient care and clinical quality indicators which I think we and our healthcare workers should be justifiably proud of.

Mr Speaker: Ms Mariam Jaafar.

Ms Mariam Jaafar (Sembawang): I thank the Senior Minister of State for his explanations. I have a supplementary question related to ICU bed capacity. Sir, the Senior Minister of State gave the data on ICU bed capacity and utilisation for both COVID-19 and non-COVID-19 beds and clarifying the limiting factor, that is, manpower.

I have a question because based on the data provided, we have currently, I think, 382 total ICU beds and he also said that 163 non-COVID-19 ICU beds are running at 80% utilisation today, an increase from 63% pre-COVID-19. So, I think, my supplementary question really is, despite this increase, how do I benchmark 80%? Is it something that we are still being too conservative about and part of the increase to 350 ICU beds will still be able to come from this pool? Or is it really something we should be really quite concerned about, because if my Math serves me right, 63% occupancy of 298 beds in 2019 means a 188 non-COVID-19 ICU beds being occupied versus 130 today that you are saying 80% of 163? Are we just putting less people in ICU today? And is there really no impact or no deterioration on patient outcomes?

Dr Janil Puthucheary: Sir, I thank the Member for her question. Maybe I can start with the last part first, which is, is there no impact and no deterioration? Actually, I would say, firstly there is an impact. And I think the statements and quotes from my professional colleagues, what I have described as the conditions under which they are working and their concerns for themselves, that is the impact.

But there has not been a deterioration, that is the outcomes.

So, it is through their heroic efforts, their resolve, their resilience and, frankly, the excellence of the people that we have in our healthcare system, that in these conditions, as a result of this impact on our manpower deployment, they have been able to deliver excellent clinical outcomes. I think the uncertainty is how long do we expect them to do this for? Do they know and do we know? And there is some uncertainty with this.

I think in this issue of being too conservative or do we have the right number of beds, maybe I can try to phrase it the other way around.

First, let me assume that she agrees with me that actually we cannot over-divert resources from non-COVID-19 patients to stand by for COVID-19 patients that have not arrived yet. People will have heart attacks, people will have accidents and they will need care; and if you have nurses, doctors, beds ready only to accept COVID-19 patients and not to accept all these other conditions, we will see an increased death rate, we will see excess mortality not from COVID-19, but from all these other conditions.

So, we must increase slowly step by step trying to be just ahead of the curve. Ultimately, as I say, we may end up having to accept a lower standard of care, but we will want the lower standard of care, as it were, to be evenly spread across so that no part of the system breaks, that everybody is under some degree of strain and going through this together.

But in terms of maybe understanding where we are, the 63% of certain number of beds, 280 beds, it is a bit hard to grasp in terms of the proportions because we keep changing the denominator. We keep increasing the number of ICU beds. So, when you had 100 ICU beds, you may have 60% occupancy; now, we have got 280 ICU beds, you are still at 60% occupancy.

So, it sounds as if it is not too much of an issue, but if we try to think of it in terms of workload; so, currently, we have about 160 ICU beds set aside for non-COVID-19 patients. Not all of them are occupied. We will come to that in a minute. But they are there. There is an administrative and logistical load keeping those beds on standby.

We also have, by the end of this week, 280 beds set aside for COVID-19 patients in the ICU. That is a total of about 440. So, 440 beds, currently set aside in ICU. What does that compare to in 2019? It is exactly 298, but let us say 300; so, essentially, the hospital system is carrying a logistical and administrative load of about 140%, 145% compared to peacetime, just on standby.

But if you look at the actual number of patients that we have in the ICU, the actual number of patients that our care teams are working on, it is about between 130 and 140 non-COVID-19 ICU patients, what we would call the business-as-usual patients; and today, it is about 130, a few days ago is 139 for COVID-19. So, let us say about 135 each, about half-half, that is 270 ICU patients across the hospital ecosystem that our teams have to manage. Pre-COVID-19, 2019, we had about on average in the hospital system 180 ICU patients across the across the landscape.

So, that is a workload increase to 150%. You can sustain that for a short period of time. Can you sustain that for a prolonged period of time?

So, I hope that answers the Member's questions in terms of are we being conservative or are we planning ahead. What we are hoping to do is chart a middle path, ramp up capacity just ahead of demand, with enough time to give the staff some degree of orientation, training and be ready for when the surge comes in, but not so much that we end up sacrificing the rest of our healthcare system. That would be the inappropriate thing to do. We are trying to tread a middle ground.

Mr Speaker: Mr Gerald Giam.

Mr Gerald Giam Yean Song (Aljunied): Thank you, Sir. I join the Minister and Senior Minister of State in expressing my deepest gratitude to our healthcare workers for fighting this battle on the frontlines and holding the fort in very trying conditions.

I have two clarifications.

First, based on the situation that Senior Minister of State outlined, it appears the number of healthcare workers is the limiting factor for further reopening. Since healthcare human resource capacity cannot be easily ramped up and our vaccination coverage is almost maximised, what prospect then is there for a further reopening anytime soon?

Secondly, while the Sinovac vaccine has been added to the national vaccination programme, I understand it is still not available to those who can take mRNA vaccines. Others can register their interest but are not guaranteed the booking. So, in the interest of maximising vaccine coverage and minimising hospitalisations, can MOH make Sinovac generally available to all those who have not been vaccinated but simply prefer to get that vaccine, whatever the merits of that preference are?

Dr Janil Puthucheary: Sir, I thank the Member for his questions. I think he has misunderstood. The availability of healthcare workers is not what will decide whether we reopen or do not reopen. It is how many with severe illnesses and how many deaths we are prepared to tolerate in that controlled process of getting to the point whereas a combination of vaccination, boosters and mild or asymptomatic infections, our overall population is much, much more resistant to COVID-19. Getting there is not a function of how many healthcare workers we have. How many deaths we have on the road to that destination is a function of how many healthcare workers we have and how many cases we can manage at a time.

So, as I have said and as many other people have said, this will pass, this will get better. We do not know exactly when but we are building up our entire society's immunity and resilience against COVID-19. And as we do so, every day that passes, every extra time that we can hold the situation, we are more likely to be able to open up safely. When we do lighten restrictions, you can expect there will be more cases and there will be more waves.

But if our immunity and our resilience is built up, each wave will be less threatening, there will be less cases than the last. And hence, our restrictions do not have to be anywhere near as tight. So, I do not know that I have answered his question directly, but I disagree with the way he has framed it. And I hope he understands the explanation that I have given.

For Sinovac, I think we have to remember that the proportion of people who prefer Sinovac and who need Sinovac is very, very small. It is 1% or 2% of our total base. But also that its effectiveness with the Delta variant has not been demonstrated to the same degree as all the other vaccines. And what we are concerned about is what happens if you get the infection despite having had the vaccination.

With our national vaccination programme, if you get the infection even though you have had the vaccination, having had the vaccination converts it to a mild illness, a mild illness you may not even be aware of, an asymptomatic infection and, potentially, rest at home as a result. We do not have such data for Sinovac and so, given that is the case, we feel it is our clinical responsibility to recommend that if it is possible, our population take the mRNA vaccine. Sinovac is available as an option when that is not possible. And so, it is better than nothing, but it is not what we would see as the most appropriate, given that it is the Delta variant that is spreading through our population and given that we are trying to avoid serious illnesses and convert this infection into a mild infection.

Mr Speaker: Mr Ang Wei Neng.

Mr Ang Wei Neng (West Coast): Thank you, Mr Speaker. I also want to join the rest of the Members here to salute the efforts put in by the healthcare workers for doing such a wonderful job so far.

Meanwhile, I would like to raise the issue of ICU beds from the other perspective. We note that one of the most important indicators as the Senior Minister of State and Minister have said that MOH is watching, is the utilisation rate of the ICU beds. So, I would like to clarify the following: if the utilisation of the ICU beds is acceptable, that is, not overly stretched and even the daily cases are about two, three thousand a day, does it mean that we are prepared to live with this high number for the next one, two months? If so, are we prepared to remove some of the restrictions or lessen some the restrictions of COVID-19?

Dr Janil Puthucheary: Sir, I thank the Member for his question. Mr Ang Wei Neng is correct that the high total number, because 99% are asymptomatic, does not in itself mean whether we can lift or not lift restrictions. What we have to look at is the number of cases that require assistance and help from our healthcare system and make sure that we are able to provide for that.

But it is not the case that only looking at the ICU utilisation rate will we then make the decision. The reason is we have a much larger group of people who require oxygen. Not all of them require ICU care but you cannot entirely predict which of them will end up requiring ICU care. So, if we have a very large base of people requiring oxygen, you have to be ready that some of them will deteriorate and so there is a forward projection for ICU care that we have to take into account in terms of our decisions to open up or loosen or lighten. Because as the total number of patients increases, the total number of patients requiring oxygen will also increase in proportion.

So, he is right but there is a little bit more nuance to the consideration. And so, this is why in the previous MTF press conference, they talked about the doubling rate or the expansion rate of the ICU care. It is not the number. It is whether we think it is going up and how fast we think it is going up or coming back down here. So, these are some of the factors we have to take into account, Sir.

Mr Speaker: Mr Leong Mun Wai.

Mr Leong Mun Wai (Non-Constituency Member): Thank you, Speaker. I would like to ask the Senior Minister of State what exactly caused the infections in our country to suddenly surge to the thousand cases level, around about the end of September? What are the various routes of infection, especially for the seniors? Because that is the base where the subsequent fatality comes about, which the Senior Minister of State has shared just now.

For example, there are some rumours, unconfirmed information in the public arena, that a lot of these seniors, those who are living alone, come from the nursing homes and those who are infected in their own homes, together with their children — how many of them are actually having another COVID-19 patient inside the home, under the Home Recovery Programme? So, these various routes of infection would be something that, I think, we hope to get more information from the Senior Minister of State.

Second is that, while we are saying that the fatality had gone up, are there changes in our treatment protocols for the seniors in the hospital? And then, is there a possibility that we have some preventive treatments for seniors and also for other citizens or other residents in our country, to lower the risk of COVID-19? So, in other words, are there potential treatments that we can introduce? So far, there has not been a lot of information on that from the Government.

And thirdly, of course, the most sensitive topic right now in our society is that: is there a justification to impose vaccination differentiation on the whole group of unvaccinated people? Because the unvaccinated group consists of: one, the 70,000 seniors who are still unvaccinated and probably, like just now, one of the Members had raised the issue, maybe we should isolate them a bit more, or rather pay attention specially to them so that we cut down on their infection rate. But these 70,000 had come down from 200,000 in August. So, maybe there is very little leeway that we can actually convince them to get vaccinated. So, we have to isolate them and special care has to be given to them and more volunteers may be assigned to look after them and all that.

But there is also another group of unvaccinated people in our country, 240,000 of them, between 13 years old and 59 years old, relatively healthy, but they chosed not to be vaccinated for various reasons. They are healthy and so, is it appropriate to also impose the vaccination differentiation policy on them, especially the latest MOM advisory which actually may affect their livelihood? Is it fair to impose something that destroys a livelihood of a person who chooses not to be vaccinated? Thank you. Sorry for the long explanation.

Dr Janil Puthucheary: I thank Mr Leong for his questions. I would point out that his questions have some contradictions. He asked if there was a change or some treatment which could prevent COVID-19 for seniors who either get sick or get unwell. I presume that by asking that question, he then requires us to use a preventive treatment. If I propose to him that there is a preventive treatment which is 10 times effective, it would reduce your risk by 10 times, he may even then ask me to mandate it and require it. We have one; it is called vaccination. If you are above the age of 60, you are 17 times more likely to pass, if you are unvaccinated than if you are vaccinated. So, a vaccination answers Mr Leong's second question.

Hence, when he then asks, "How do we justify our vaccine-differentiated measures and how do we justify imposing something on people who chose not to get vaccinated?" Our justification is that we are trying to save their lives, we are trying for their loved ones and their family not to lose a family member. We are trying to prevent them from becoming sick and overwhelming our healthcare system so that them and the rest of us, then do not lose the ability to have good care for heart disease, diabetes and cancer, and all the other things we need healthcare for.

So, his second and third questions seem to me to contradict each other and I think he needs to decide does he believe that we should be fairly liberal about this and choose to allow people to take on for themselves a really unacceptable degree of risk and impose the consequences of that risk on all of us? Or does he want us to go and tell people exactly what to do and constrain their lives in a way that protects all of us? He seems to, in his two questions, choose extremes at one end of the other. We are trying to tread a middle path and trying to get the best of both.

He asks then what caused the infections in our country and what are the routes of infection for seniors who are living alone, in their own homes. The route of infection is largely from human-to-human contact. That is how people get this infection. If you were truly isolated and you were entirely living alone, with no human contact, you could maybe get away without this. But I think, people find that sort of life is also fairly unbearable. So, whether you are living alone as a senior or in a nursing home or in your own home, usually there is some form of human contact. And that is precisely why we cannot think of our population as the seniors and the rest of us, the unvaccinated and the rest of us. We intermingle and we meet each other and we pass on the infection to each other.

Our vaccine-differentiated measures are trying to make the risk lower for one than the other, but it is not about separating us out into completely separate populations and that would not be possible.

Mr Speaker: Dr Shahira Abdullah.

Dr Shahira Abdullah (Nominated Member): I thank the Senior Minister of State for his clarification on the situation. I know that you have said that patients with underlying conditions, even if well-controlled, will still be at a higher risk of death; and that not being vaccinated will put Singaporeans at an even higher risk.

Could I ask if currently MOH has any data on the percentage of vaccinated patients who have died from COVID-19 who have underlying conditions that are actually well-controlled; and if not, would MOH consider tracking this?

Dr Janil Puthucheary: Sir, I thank the Member for her question. It is not straightforward to answer. Because the definition of well-controlled will vary and the way in which you see the impact of good control of the disease when you get COVID-19 will also be quite different. Let me give some examples.

Let us just use diabetes for example. If you have had diabetes for many years, diagnosed young, struggling with it, living with it, but you have had it kind of controlled. Do you have a lower risk than someone who perhaps had it diagnosed only one or two years ago, but really has not had it well-controlled yet? I am not entirely sure what the answer to that question is. And when you then encounter COVID-19, even if you had it well-controlled, because your body is fighting another illness, now COVID-19, your diabetes control goes out. So, do you then look at well-controlled at the point that you got infected, or the point that you got into ICU?

The data that we have does not help to inform us to the point where we can make a recommendation and we can say, "Well, if you have diabetes and your blood sugar is like this, you are okay; if your blood sugar is like that, it is not okay". We are still at the point where we say, "If you have diabetes, control it as best you can. Whether you have COVID-19 or not, that is a risk. Now that COVID-19 is present, you need to really make sure you take care of yourself." And this then applies to a wide variety of conditions.

So, it is quite clear that poorly controlled diseases do increase the risk very significantly. But there are some patients even with well-controlled diseases, it appears that having that disease means that they handle COVID-19 poorly even if the disease was well-controlled when they get COVID-19. I hope that adds some clarity to the Member's question.

Mr Speaker: Mr Melvin Yong.

Mr Melvin Yong Yik Chye (Radin Mas): Thank you, Mr Speaker. I thank the Senior Minister of State for his comprehensive Statement. I would like to shift the focus to the welfare of our healthcare professionals. According to the Director of Medical Services, the COVID-19 pandemic has caused a significant backlog of follow-up visits and elective operations, and it will take the hospitals many months to catch up and clear this backlog. The Senior Minister of State also earlier mentioned that 90% of our healthcare workers were not able to clear their annual leave.

I would like to ask which hospitals have the greatest backlog and how will this affect the amount of leave that its staff will be allowed to take, given the immense pressure faced to clear the backlog. As there are clear challenges mentioned by the Senior Minister of State to quickly increase staffing to alleviate the manpower situation, what are the hospitals planning to do to allow our healthcare professionals to at least take a break during this period?

Dr Janil Puthucheary: Sir, I do not have the data in terms of specific hospitals or clinical sites which have backlogs and which do not. Part of that is because we do operate as one system and where there is a little bit of capacity here or there, there is some load balancing and different sites work together. So, that is going to be dynamic, they are working to try to clear this as best they can.

We are also uncertain how long this will go on for, so it is a bit hard to predict where we will be in terms of this – the rest of the healthcare system's duties and responsibilities once COVID-19 starts to wane – because we do not quite know when that will happen. So, there is a stress on the healthcare system, it will persist for some time after COVID-19 starts to come down, precisely for the reasons the Member has identified.

Will this affect leave? Possibly. But the hospitals and the staff, the leadership are going to try to find ways to give their teams some rest and I do not think this is something that we can settle on a policy basis, it is very granular, it depends on the size of your team and the various other duties, when is your lull time, when is your up time. And I suspect what will happen is that the different teams, the different departments, the different divisions will allow rotating leave in different patterns to suit their acuity levels. And probably, you may have some people who are on leave but have a relatively short notice to be present, or they may be on local leave and another proportion which are allowed overseas leave and so forth.

I think these are operational parameters and you have to let the clinical teams make these decisions on their own. We need to try to support them at a more systemic level.

Mr Speaker: Minister Ong Ye Kung.

Mr Ong Ye Kung: Thank you, Mr Speaker. I want to make a comment but also to go back to two questions that were raised earlier. One is by the Member, Mr Gerald Giam, who asked about Sinovac. As the Senior Minister of State mentioned, it is now available as an option under our National Vaccination Programme. So, it is generally available in some clinics and also at the Raffles City Vaccination Centre just nearby. So, if you are 60 and above, cannot take or just do not want to take mRNA, you can walk in to take your Sinovac. Yesterday, I think a few hundreds did so, covered by Zaobao. If you are below 60, you have to make an appointment, but it is generally available.

The second point I want to mention is what Mr Leong Mun Wai raised, where he talked about some rumours. I am not sure you can repeat rumours in this House; I will leave it to the Leader. But he mentioned something about "nursing home", something about "home transmission".

Nursing home infections are a small percentage of the total senior infection. The last I calculated, it is not the most updated but it is about 6.4%. So, it is a small percentage. The large majority is actually transmission within the community. [Please refer to "Clarification by Minister for Health", Official Report, 1 November 2021, Vol 95, Issue No 41, Correction by Written Statement section.]

He asked about transmission in households. We have been tracking this. Within a household, if somebody is positive, approximately 10% of household members will subsequently get infected. So, about one in 10. But out of that 10%, 8% get it very early on. That means at the point of entry into quarantine or into Health Risk Warning (HRW), you are tested and you are positive; suggesting that actually, they got it at the same time as the index case. Then, during the subsequent days, another 2% then got transmitted.

Therefore, I think from the evidence that we have been tracking so far, the incidence of transmitting at home, so long as you take the precautions, is actually not high. The high transmissions still happen within the community, through person-to-person interaction.

I want to just maybe make some general comments after hearing all the questions.

Dealing with COVID-19 is quite different from business or organisation planning, where you know that this season or this month, if it is coming to Christmas, business is going to go up, so, let us plan for it, make sure we have manpower and capacity.

But we are looking at a crisis of a generation, a global pandemic crisis, not something that we plan year-to-year based on seasons or a five-year plan. It hits you and it overwhelms the healthcare system all over the world.

You look at the papers today on the G20 meeting and in France and Italy, life seems to be normal, but we forget what they went through last year. Go back, dig up the papers last year on how the whole healthcare system was overwhelmed.

Regardless of what you say about their ICU provisions and all that, or their healthcare workers' provisions, when COVID-19 hit those societies, they were totally overwhelmed. Doctors had to choose who got the hospital bed, who did not, who they had to save and who does not get saved. Those were the painful human tragedies that happened and the big human price that they paid to get to where they are today. Do not forget that.

Mr Lim Biow Chuan asked, how do we prevent and minimise death? We prevent and minimise death by making sure we do not go through that, of what other countries have gone through. You name it. Whether it is the US, the UK, France, Germany, Italy. They all went through that. Near home – Indonesia, Malaysia. They all went through that.

We avoid excess death by avoiding that, by preventing that totally. How do we do that? By not being dogmatic.

There are two camps in the world. One says zero-COVID-19 strategy is the right way to go. One says, no, you have to have living-with-COVID-19 strategies and maybe even Freedom Day. We say, we do both.

Last year, before we had vaccinations, when we were vulnerable to the disease, we took a zero-COVID-19 strategy. Everything was tight. Borders were closed as a result. Quarantined everybody. We kept incidences very low. We kept deaths very low. That was last year.

Then, we went on to a national vaccination programme, got ourselves to about 70% to 75% by National Day. Then, we said, zero-COVID-19 is over, we need to start opening up. But yet, we do not take another dogmatic approach to say we must go for Freedom Day and open up all at once. But we take the middle path: not total lockdown, neither is it Freedom Day, but we open up gradually.

And what is the limiting factor? It is our healthcare system. Making sure that it can cope, given the infection rate and how that translates into ICU cases and to people who fall severely ill.

That is how we have been proceeding. As Senior Minister of State Janil Puthucheary said, with each passing day, with more vaccinations and some people recovered well and built up natural immunity, we accumulated antibodies and resilience within our society.

I know Members of this House, including myself, all wish that life goes back to normal, that we can have dining in five or more, we can have our proper wedding dinners and events, go back to our grassroots functions and community functions. We all wish we can all do that. We do not have to sit up there in the Gallery anymore. Everybody can sit in the Chamber, engaging each other.

We all wish to do that and I think we will get there. We get there by continuing this path, building up our antibodies day by day. I do not know how long it would take. The Prime Minister said maybe three months, maybe six. We wish it is shorter rather than longer. But many countries have gone through the process and reached there, and we shall reach there too.

Mr Speaker: End of Ministerial Statement. We have a Personal Explanation from Ms Raeesah Khan.