Chia Shi-Lu
Singapore
“Chairman, I wish to thank all Members who have taken part in this debate and, of course, Minister Gan, Senior Ministers of State Amy Khor and Dr Lam Pin Min and Mr Edwin Tong and also Senior Parliamentary Secretary Amrin Amin, together with all the staff at MOH for their replies and the work they have put in for the healthcare system for…”
“Nonetheless, I believe that a united society will be a key piece to this puzzle, and I look forward to the Ministry of Health's stewardship in this regard. May we all live long, live well and grow old together as one people. Thank you, and I beg to move. [(proc text) Question proposed.”
“Mr Chairman, high usage of air-conditioning and refrigerators contributes to global warming, and none more so than in Singapore where we love our climate control and air-conditioning. But as a responsible member of the global community, we should do our best to reduce our carbon footprint.”
“Management of E-waste Last cut. With the introduction of the Resource Sustainability Act last year, the EPR scheme will commence and a PRS operator I alluded to earlier will be appointed to collect and ensure proper disposal of electrical and electronic consumer products.”
“I thank the Minister for the update. I just have two clarifications about the Disease Outbreak Response System Condition (DORSCON) level – the acronym of the year, so far! First, some clarification about how this DORSCON is arrived at. Is it by independent committee that makes this decision and recommends to the Minister?”
“I just want to echo and express my thanks to Minister Gan Kim Yong for his statement of thanks and support for healthcare workers. Two short but slightly technical questions, I apologise. The first, the Minister touched about it earlier.”
The complete record
Every one of 326 lines we hold for Chia Shi-Lu, in date order, each linked to its source. Free to read, in full, without an account. Page 3 of 7.
“Mr Speaker, I rise in strong support of the Bill, as I have done in the past in support of legislative measures that will reduce smoking rates in Singapore. Over the past few years, we have made important strides in curbing the pernicious influence of smoking, through point-of-sale display bans, raising the minimum age for smoking, and restricting public areas where smoking is permitted. I believe that plain or standard packaging will prove to be another nail in the coffin for smoking, a habit which has brought grief and misery through ill-health to generations of smokers and their loved ones. The evidence that plain packaging reduces the allure of cigarettes and so reduces smoking initiation and may even improve smoking cessation rates is substantial and convincing. The post-implementation data from Australia, which was the first country to introduce standard packaging for tobacco products in 2012, and also from France, reinforces the efficacy of such a measure. Tobacco companies and the lobby groups associated with them have decried that plain packaging would have little effect on smoking rates except to make life more vexatious for retailers and their customers, but their robust efforts to fight against standard packaging, for example, by launching lawsuits against Australia, proves that this is otherwise. The tobacco industry is running scared, thus underlining the potential impact of standard packaging legislation on smoking rates. With the passing of this amendment, Singapore will join several countries besides Australia which have already enacted this legislation, and many other countries are expected to follow.”
“I do support this more calibrated approach in principle and welcome the increased focus on rehabilitation for drug offenders, but would seek the Minister's assurance that these amendments still signal a firm approach towards drug abuse. Finally, I would like to ask the Minister if he could elaborate on the appeal processes for those charged with drug offences. I support the Bill.”
“Currently, drug abusers arrested for the first and second time undergo rehabilitation at the DRC. Under the new proposed framework, first-time abusers assessed to be of low risk will, instead, be placed on the Enhanced Direct Supervision Order (EDSO), a non-custodial supervision order, get assigned a case manager and undergo counselling. Only first-time abusers with moderate or high risk of further abuse, as well as those arrested for the second time and above will go through programmes of varying degrees of intensity and durations at the DRC. The plan is, of course, to better help all drug abusers break this vicious cycle of addiction and reintegrate into society sooner. While I fully support the decision to focus more on rehabilitation and move away from penalties for first-time offenders, I am concerned that this approach may be perceived to be soft – a slap on the wrist – and may send the wrong signal to those tempted to experiment with drugs. I am particularly worried by the results of the 2015 survey commissioned by the Government's Task Force on Youth and Drugs. It found that even some of the young with good academic results from middle and upper middle-class families are abusing drugs. In the past, most drug addicts were dropouts from school or from troubled or lower-income families. We also have anecdotal feedback from CNB and lawyers who observe more youths of both genders, across wider income and education spectrums, testing positive for drugs after returning from overseas trips or studies. If they perceive that they would be treated more leniently because they are first-time offenders, would not they perhaps be more open to trying out drugs? Would harsher penalties, such as detention, be more effective deterrents so they do not get started on drugs at all?”
“Deputy Speaker, Sir, Singapore has been described by many as having the toughest laws against the misuse of drugs in the world. And we continue to be unrelenting in our fight against drugs in a global environment which seems to be going in the opposite direction, becoming more liberal towards drugs, with more countries considering or already implementing drug decriminalisation. Singaporeans are travel addicts and have access to information and news from all over the world. It is inevitable that we compare our nation with other regimes, particularly the west. In fact, for many of us who fly into Singapore, we are often given the announcement, in no certain terms, that Singapore has very harsh penalties against drug offences. So, in this respect, some of us may ask, are our drug laws too antiquated, too draconian? As a doctor, I cannot emphasise enough the damage illicit drugs can wreak upon one's body, much of which is irreversible. But you do not need a doctor to tell you this. It is the Government's duty to protect its people from harm and, hence, its firm stance on drugs should be supported and applauded. Our traditional position had been to set firm and harsh penalties for those involved in drugs, to serve as a deterrent. So far, our measures had been quite effective for an open economy which welcomes visitors and the free flow of goods and services. Our statistics and results speak for themselves. The Ministry is now attempting a more calibrated approach to segment drug abusers who only take drugs from those with other concurrent criminal offences. I would like to take this opportunity to express my concerns about the new rules for detention, or rather, the lack thereof.”
“I also want to echo my thanks to both Ministers and also to the COI for their work. Three questions to the Minister for Health. First, while we are trying to strengthen the systems, if we take a leaf from how we manage infectious diseases while we are trying to think of better treatments and so on, I think a key focus would be surveillance, that means detection and containment. So, there was some talk about the advanced threat protection and other systems to detect the systems and, as I know it, our healthcare system has hundreds of computer systems, not just in SingHealth but also the private sector. Could I just ask what is the extent to which these detection systems have been deployed through the national healthcare system, just to get an idea? Because there are other healthcare systems out there that could still be vulnerable and may not have these systems. I just want to have an idea about that. Second, there was a point in the COI which merits study, which is the impact on patient care. Can I also find out what has been the work of MOH in looking at the impact that this cyberattack has had on patient care efficacy and efficiency? Third, I am also concerned about the impact on the rollout of NEHR. It is something that is very useful. I think it is something that we should all have. It is for the future of Singapore's healthcare. So, in terms of the study on NEHR, could I get a sense of what sort of goals we are looking at in terms of the assessment of whether or not NEHR will be safe in terms of cybersecurity threats and so on, so that maybe we have an idea how long this may be delayed?”
“I would like to ask the Ministry to clarify what is the precise mechanism through which a decision is made to allow such public health research in normal times, whereby, for example, clinical samples may need to be sent to third party collaborators or laboratories, or when research on individually-identifiable specimens can be conducted. What is the process of review and who are the entities that conduct such a review? I look forward to the Minister's clarifications on these points and support the amendments to the Bill.”
“I agree with the Ministry that this can be impractical, particularly if the numbers of visitors arriving are large, and many countries already reserve the right to turn away unvaccinated travellers. I would like to ask the Minister to clarify whether these new powers also apply to emerging infectious diseases of a serious nature, for which perhaps there may be no known preventive or therapeutic measure. If one recalls the Ebola outbreaks in the not too distant past, we debated the measures that were available to safeguard Singapore by controlling the entry of travellers from the affected countries. This had to be achieved via a rather circuitous route whereby travellers from countries with active and significant Ebola transmission had to obtain a temporary entry visa before travelling into Singapore. The new sections 45A and 45B refer to monitoring activities. But what if there is no accurate or practical means of screening travellers from hot zones? Second, the amended section 21 now allows for risk stratification of disease cases and carriers, so that they may perform limited vocational duties, or make limited travel outside their homes. For cases and carriers, I would like to ask what is the mechanism by which they can appeal for or against that particular risk classification. Finally, I also welcome the amendments which facilitate infectious disease, public health research even when there is no imminent danger of an infectious disease crisis.”
“Mr Deputy Speaker, Sir, I was born in the 1970s, when advances in antimicrobial therapy and vaccination were so blindingly impressive that they led many experts to foretell the end of infectious diseases and epidemics as health threats. How wrong they were. Although here in Singapore we remain rightly focused on the control of chronic diseases, such as diabetes, as they pose the greatest burden on our ageing population, we must never let our guard down on the threat that infectious diseases pose to a small, densely-populated country like ours. The spectre of SARS, barely 15 years ago, remains fresh in many of our minds, and since then, many serious epidemics have occurred in many parts of the world, often spreading with frightening speed, both within the affected country and beyond its borders. WHO has published guidelines on how disease epidemics should be managed, but certainly, a key focus for any society would be, first, to prevent the spread of disease into the country, and, of course, later, following a disease outbreak, on how to contain its spread both within the country and beyond its borders. The amendments to this Bill are, therefore, timely as they seek to strengthen powers directed towards both epidemic prevention and containment. As the Senior Minister of State has just pointed out, presently, non-citizen visitors to Singapore travelling from a location with active transmission of a serious communicable disease, such as Yellow Fever, and who are unvaccinated and thus potential carriers of the disease, cannot be refused entry without first offering them monitoring, disease prophylaxis or isolation.”
“Mr Deputy Speaker, in Mandarin, please. (In Mandarin): [Please refer to Vernacular Speech.] I appeal to the Government to implement and enforce more stringent measures to protect our workers in the cleaning sector. They face many risky situations and hazardous materials in the course of their work, including chemicals they have to work with, physical hazards, and micro-organisms, such as viruses, bacteria and moulds. Employers and contractors must be held accountable for measures to protect our cleaners' health and safety. We should also monitor their workloads and schedules to prevent exploitation. By improving the treatment and work conditions of our cleaners, companies will benefit from retaining and attracting experienced and better qualified staff, who will contribute to higher productivity and quality services for clients. I would like to conclude with my support for the Bill.”
“However, just as we need to continue to educate and remind our residents that nothing except human waste and toilet paper should be flushed down the toilet, we have to teach residents what should and should not be thrown into refuse hoppers. Last year, for instance, we read about how a monster "fatberg", which was 250 metres long and weighing 130 tonnes, blocked a sewer in London, and required about three weeks to dismantle, using pneumatic equipment. For those who may not be aware, "fatbergs" are formed by things which should not be thrown into toilets like plasters, sanitary towels, nappies, condoms, all of these things that we have always been told not to do; it can lead to things like this. This public education exercise has to be held in conjunction with recycling initiatives and also the provision of conveniently located disposal areas for bulky items. And here we need all residents’ civic cooperation to prevent blockages and keep the PWCS functioning smoothly. I am also happy to support the payment of mandatory PWM Bonuses to all our cleaners, whether they are hired directly by organisations or work at contracting companies. I hope that the adoption of progressive wage practices in the cleaning industry will lead to more stability in employment, and also continuous skills upgrading and greater productivity. In tandem with technological advances and innovation in the cleaning industry, cleaning will evolve as a profession. Specific skills will be needed to operate more complex machinery and systems and the remuneration will adjust up accordingly. For example, in future, autonomous vehicles will be used to clean buildings and streets. Our cleaners’ jobs will then be running these fleets of cleaning bots, which require very different skillsets.”
“Mr Deputy Speaker, Sir, the two main proposals introduced in this Bill are both timely and necessary for the transformation of our cleaning industry. With the implementation of DPWCS and, more importantly, compulsory annual bonuses to our Singaporean and PR cleaners, we can look forward to a more productive and supportive work environment for our cleaners. The cleaning sector is an important and indispensable part of our economy, not only in its contribution to our environmental hygiene and disease prevention, but also in maintaining our infrastructure and facilities. ES enables other sectors and industries to function smoothly and efficiently. It is a particularly labour-intensive sector, which is worrying for us as we face manpower shortages amidst an ageing population. In addition, as more and more of our younger generation receive higher education and the variety of jobs open to them increases, there might be fewer who are willing to take on traditional cleaning sector jobs. Fortunately, technology will play an increasingly bigger role in ES. Automation will help to boost productivity and take over an increasing number of the less pleasant chores. PWCS is a case in point. It does away with manual refuse haulage altogether – an essential but laborious, repetitive and unpleasant task – and substantially reduce the disamenities, such as foul odours and pests. The PWCS is thus a game changer for refuse collection, in much the same way the onsite sewerage system that we all took for granted was for waste collection just over 30 years ago.”
“I want to thank the Senior Minister of State for his response. I have three supplementary questions. First, since HSA already has guidelines, would the Ministry of Health consider making sure that we do some legislation to back it up? With regard to the issue about the test results, I understand that what HSA does now is that they actually test these supplements for toxic substances. I am not sure what the testing or monitoring regime is. Perhaps the Senior Minister of State could enlighten the House on what some of these monitoring regimes are. But as I understand it, they do not also test whether these supplements actually contain what they profess to contain. So, for example, if a product says "I contain X grammes of this active ingredient", do we actually know that this product actually contains X grammes of this ingredient? Because there have been many cases over the years all over the world when independent testers actually test these products, they do not actually contain the health ingredients that they say that they do. Finally, the last question is: if consumers do actually get side effects or adverse effects from consuming these supplements, what are their recourse for mediation or where can they turn to? Is it just caveat emptor or do they have some avenues they can turn to for redress?”
“I thank the Senior Minister of State for his replies. Just two supplementary questions. One, would the Ministry consider collecting data on plastic surgery done on minors, 18 years and below or 21 and below, in the private sector as well? I think the Senior Minister of State would understand that the impetus for this Parliamentary Question came from a recent newspaper report where some private plastic surgeons actually did mention that there were significant increases in the number of minors seeking plastic surgery and then even with their parents' support. My second supplementary question is whether the Ministry, in addition to the ethics codes and various guidelines for cosmetic procedures, would consider coming up with guidelines specifically for plastic surgery in minors. Because if we look at the literature, the reasons for plastic surgery in minors versus adults can be quite different. For example, in minors, it is more to fit in; in adults, more to stand out. That is just one example. Also, because minors are still growing, the risks are also different. It may affect their development. So, it is a special group of patients, and I just would like MOH to consider looking at this.”
“I thank both Ministers for their comprehensive Statements. We have been talking about cyberattack but, practically, this has been more a case of cyber snooping or cyber theft rather than an attack, which brings me to my main question: how sure are we that no malicious malware still remains in the systems? I think we have been lucky in the sense that the systems have not been disrupted in terms of patients' safety or care. But as I understand it – correct me if I am wrong – with this APT type of attacks, a lot of these initial attacks are meant to demonstrate that they can actually invade the systems, but the ultimate goal may be to be able to plant some malware that can disrupt our systems when the time comes. That was my main question: how sure are we that no malicious software remains in the systems, given that the databases is a very large and complex system.”
“Just a quick question. I think with all these moves in the ITLC financing sector, are there any considerations whether this might impact the MediSave contribution rate or the basic healthcare sum?”
“I believe there have been cases in the past where ElderShield policyholders who are able to actually make claims when they became disabled, have not done so because they were simply not aware that they could do so, or even that they were on the scheme. Finally, I hope that the Ministry will leave no stone unturned to encourage those who are currently not included but eligible for CareShield Life to join the scheme, by not only providing incentives but also making the process as smooth as possible. For those who are already disabled but cannot be covered by CareShield Life, I am sure the Government will continue to provide the necessary assistance and support to them. I support the Motion.”
“For instance, when will we know that $600 a month is no longer adequate, and how much should the minimum payout be revised to? Two, in our report, we recognised the actuarial basis for the higher premiums that women pay but would like to repeat our call that this gender differentiation be removed, in line, for example, with other insurance programmes, such as medical and hospitalisation insurance, such as MediShield. I note also that Singaporean women tend to have lower average MediSave balances than men, so I hope that consideration be given to provide additional premium support for women as well. Three, I hope that the Government will remain focused on investing or continuing to invest in Intermediate and Long-Term Care (ILTC) infrastructure and manpower and focus on keeping such services affordable. CareShield Life is a means of financing ILTC for the severely and permanently disabled, but such services are also necessary for those who are less severely disabled, or thankfully only temporarily disabled. If we do not keep ILTC costs in check, then payouts will be unable to keep up, and CareShield Life will become ineffective. I hope the Ministry will also share with this House how it intends to keep ILTC costs affordable for all, and also the support care within the community. The prospect of becoming significantly disabled in our lifetime is very real and, by some estimates, may be as high as one in two, but this risk is often underestimated or discounted, and quite understandably, particularly by the young. I hope that, as with the rollout of MediShield Life and the PG Package, the Government will have a comprehensive communications plan to help Singaporeans understand the scheme better.”
“In January this year, the Government Parliamentary Committee (GPC) for Health submitted its recommendations on enhancing ElderShield to the Ministry of Health (MOH), and we note that our recommendations are broadly in line with those made by the ElderShield Review Committee. I would like to begin by quoting from our paper, by stating the principal considerations for our recommendations. One, Prime Minister Lee Hsien Loong described ElderShield as the “one remaining piece” that is needed to consolidate the progressive enhancements to our social safety net. Hence, the GPC believes that in order for it to fulfil its function as a cornerstone of our social security apparatus, ElderShield coverage for our population should be universal. Two, as for any social welfare programme, a careful balance has to be struck between increasing and expanding benefits so that the programme remains relevant and useful, and yet keeping the scheme both affordable and sustainable for the long term. Three, if ElderShield is to be universal with mandatory enrolment, then the GPC believes that the Government will have to provide targeted financial assistance to ensure that all Singaporeans will be able to participate in this social security programme, which is designed to increase peace of mind in the event of severe disability. I have three comments and clarifications. One, the GPC concurs that payouts be adjusted to keep pace with general and medical inflation and, in order for this to be financially sustainable, CareShield Life premiums will also need to be adjusted. Could the Minister elaborate on the mechanism through which payouts and premiums are determined and adjusted to ensure that the system remains fiscally relevant yet affordable for all Singaporeans?”
“Mr Speaker, many of us may take our health for granted. But I would submit that many of us may take our mobility and individual independence for granted even more so. This morning, many of us would have gotten out of bed, had our breakfast, dressed ourselves, maybe even gone in to have shower, did some toileting, but we do not often give these actions a second thought. But we can lose all of these and become disabled and dependent, sometimes suddenly, catastrophically, such as after a stroke. My late grandmother was 70 years old and she was one of the most active individuals I have ever met. She was still working and she would always walk instead of taking the bus. One afternoon, after an afternoon nap, she found that she could no longer do any of these things. She could not walk by herself, she could not take a bus, she could not feed herself or even go to the toilet by herself. And this was all in a matter of a few seconds. Or it could happen after a terrible accident, such as with a spinal cord injury. Sometimes, the disability may come slowly, insidiously, such as with chronic nerve or muscle diseases and sometimes through mental problems, such as dementia. But all of these could lead us to greater dependence on other people for our everyday activities. So, Mr Speaker, I feel that the enhancement of ElderShield to CareShield Life is timely and significant, as it constitutes an important piece of our social safety net, which until now, I would submit, has been deficient, in terms of the adequacy of our national long-term disability insurance system.”
“We have come a long way; we have passed 50 years successfully as an Independent nation, and we are now moving on to 200 years after the founding of Singapore. We now have a new generation of Singaporeans and Singaporean leaders that will steer us towards SG100. It is my hope that our healthcare system remains future-ready, and also friction-free where it counts. I support the Motion. 1.56 pm”
“What constitutes a provider of primary healthcare services can be defined and licensed, and this is also an issue that can perhaps be addressed when we debate the Healthcare Services Act later this year. I appreciate that there will be issues with the implementation of such a scheme, but I certainly believe that it merits consideration. Lastly, a little bit about insurance coverage. The introduction of MediShield Life, which provides universal health insurance or coverage for Singaporeans, marked a proud day for Singapore’s healthcare system, exemplifying the caring and inclusive society that President Mdm Halimah Yacob spoke of. Although a hallmark of MediShield Life is that no one is excluded, including those with pre-existing conditions, like virtually all medical insurance systems, there remain some gaps. For instance, I would like to draw your attention to two areas. First, with regard to pregnancy-related complications; and, second, about conditions related to mental health. These are still not covered under MediShield Life when hospitalisation is required. I believe that we should consider expanding coverage to these conditions as well. We have been strongly encouraging parenthood and it would serve as greater assurance to would-be parents that the mother’s medical care can be covered in the uncommon instances of complications related to the pregnancy. We have also been slowly but significantly expanding our support for mental health, even as the disease burden inches up within our community. I hope that when MediShield Life is reviewed, consideration can be given to expand coverage to some, if not all, mental health-related hospitalisations.”
“We are also trying, of course, to shift our model of care beyond the hospital and back to the community by strengthening our primary healthcare networks. While the majority of hospital care is now provided for by public hospitals, the majority of Singaporeans still choose to visit their family doctors or general practitioners (GPs), rather than polyclinics, for their primary care needs. The CHAS and PG schemes have helped to deliver Government subsidies to our family doctors and have strengthened general practice through the reduction of market distortions due to larger subsidies received by polyclinic patients. I believe we can do even more in this field, or in this regard, and I would like to consider or for us to think about potentially exempting primary healthcare services from the Goods and Services Tax (GST). This would be a major deviation from our GST framework, which favours a flat system with later reliefs or Government transfers. Philosophically, I realise this is a slippery slope, but in practical terms it would be very much in keeping with the intent of current policy that already absorbs GST from subsidised healthcare services. Removing this consumption tax from all primary healthcare services could nudge more patients back to family doctors or GPs for care, and encourage compliance with treatment and follow-up, by reducing costs. I wish to emphasise that this suggestion refers only to primary care services and not for hospital or other types of medical care. I also appreciate that, at present, most solo practices, for instance, are not GST-registered. But with the emergence of more group practices and with the increasing cost of healthcare, the number of healthcare providers that need to pay GST may increase in the future.”
“Or three, he or she could just simply choose to forego treatment or to forgo some of the treatment in excess of what he is willing to pay for in cash. Allowing for greater MediSave withdrawal in these cases can help a patient avoid trying the welfare route, which ultimately adds to public expenditures, and also encourage compliance with treatment. If the patient follows on with treatment, then the future consequences of his condition, if left improperly managed or sub-optimally managed, would be less and the eventual costs to both the patient and society would ultimately be lower. I am of the opinion that further loosening of the MediSave purse strings would not lead to over-servicing or over-consumption. I would like to remark that we are talking about patients here who are adhering to treatment protocols that a public service doctor has deemed to be necessary and who has to certify that it is necessary without a cheaper alternative. There also remains an element of co-payment. Our treatment management schemes have been strengthened over the past few years. For example, agencies such as the Agency for Care Effectiveness (ACE) are now putting in place guidelines about what constitutes effective treatment and what is not. The introduction of the PG package, for instance, a few years ago, with very generous benefits, has also not led to worrying levels of over-consumption or over-servicing within the public healthcare system thus far. Second, I think it is just and right that the Government has been absorbing the GST charged to subsidised medical services in public healthcare institutions for many years now, at considerable cost to the Ministry.”
“If you look at the statistics over the past few years, the mean MediSave account balances among Singaporeans have been increasing steadily, and a significant number do pass on with remaining balances of fairly appreciable amount in their accounts. For some Singaporeans with multiple chronic diseases or whose illnesses cannot be adequately controlled by medicines on the Standard Medication list, the out-of-pocket cash outlay for medical treatment, even at polyclinics and with Pioneer Generation (PG) benefits, can still remain quite high due to the current utilisation limits on MediSave. I would like to propose that Singaporeans who are above the retirement age be allowed to pay for a greater amount of their subsidised outpatient treatment costs at Government clinics using their MediSave. Perhaps, as a start, up to 80% of the expenses, and this can be adjusted as needs arise. This should be subject to a doctor's certification. Such a move would not change matters for the majority of elderly patients, for whom the current chronic disease withdrawal limit of $400 and the Flexi MediSave limit of $200 would already more than adequately covered 80% of their annual outpatient treatment costs. But it could make a meaningful difference to the elderly with multiple or less common conditions requiring more specialised and expensive medications, or who require more medical investigations to better manage their conditions. Presently, for a patient who has exceeded his MediSave claims limits and who finds it challenging to pay the remainder in cash, he or she has a few options. One, he can appeal to the Ministry to withdraw more from his MediSave. Two, he can apply to the Medication Assistance Fund and other welfare schemes.”
“Mr Speaker, I join other hon Members in expressing my support for the Motion of Thanks to the President for her Address. To heed the President's call for us to forge a cohesive, caring and inclusive society, particularly for our seniors, I would like to take this opportunity to raise three ideas about how we can smoothen some of the bumps and ripples in our healthcare landscape and to remove some of the friction where it is not needed, so as to promote more equal access to medical services. As my following comments do concern some adjustments of a fiscal nature, I would like to declare my interest currently as a medical practitioner in a public healthcare institution. First, let me talk about MediSave. I would like to propose that we think once again and hard about further liberalising the use of MediSave in a bolder and more decisive manner. Over the years, I and many others within this House have called for the liberalisation of MediSave use, in particular for outpatient treatments. The Ministry of Health (MOH) has certainly done very much in this regard, by introducing and expanding many schemes such as the Chronic Disease Management Programme (CDMP) and, more recently, the Flexi-MediSave Programme. They have also allowed greater use of MediSave for medical scans, and so on. These measures are effective but can be complex and, at times, may be too restrictive. The concern, of course, and it is something we all appreciate, is that too loose a policy on MediSave withdrawals could lead to an earlier depletion of our accounts, leaving nothing for us to rely on in later years when medical needs and expenses could be greater. However, I am not sure that this worry is always necessarily well founded.”
“Thank you, Chairman. First of all, I would like to thank all Members for their healthy participation in this debate and, of course, as usual, to thank Minister Gan Kim Yong, Senior Minister of State Chee Hong Tat, Senior Minister of State Amy Khor, Senior Minister of State Lam Pin Min and Parliamentary Secretary Amrin Amin and, of course, all the staff of MOH for their detailed clarifications. I wish them every success in their efforts to transform healthcare for Singaporeans, for now and for the future. Thus, I beg leave to withdraw my amendment. [(proc text) Amendment, by leave, withdrawn. (proc text)] [(proc text) The sum of $8,951,942,100 for Head O ordered to stand part of the Main Estimates. (proc text)] [(proc text) The sum of $1,279,876,000 for Head O ordered to stand part of the Development Estimates. (proc text)]”
“Thank you, Chairman. Just one quick clarification for the Parliamentary Secretary. I talked about the 10% increase in excise duty for tobacco. It seems that it has been an ongoing thing. We raise these taxes every few years. Could we have an idea of how useful these taxes are, in terms of reducing smoking prevalence? Secondly, would the Parliamentary Secretary know whether there are any plans to further increase these taxes? Some people say that 10% is too little. So, perhaps I could have the Parliamentary Secretary's comment on that. 7.15 pm”
“Chairman, just two clarifications on manpower. Firstly, I am glad to hear that locally trained doctors would reach the target of 500 per year from local institutions. As I understand it, Singaporeans who are training abroad to be doctors, the numbers of them could reach the same number every year. I am just wondering how the Ministry is looking into these numbers and factoring them into our manpower planning plans. Also, are we still quite dependent on foreign medical manpower to meet our medical needs for the near future? The second question is about nursing manpower. I am glad to hear about the remuneration framework. But as we have just heard from MSF, social service professionals are looking at up to a 12% rise in their remuneration package. So, I am just asking whether our nurses can also look forward to such salary increases, to attract more local nurses into the workforce.”
“Sir, sadly, the proportion of smokers in Singapore has stayed around 13% for the last few years. The recently announced 10% increase in excise duty on all tobacco products may help to reduce the demand for cigarettes but we must also continue with other measures, such as public education, to highlight the negative effects of smoking and perhaps also increasing the number of smoke-free zones. The Government will also need to step up its surveillance in this regard. Smugglers are increasingly creative due to the attractive profits. Beyond raising the minimum legal age for smoking and purchase of tobacco to 21 years by the year 2021, what other measures is MOH taking or considering to reduce tobacco use in our population? In addition, what measures does the Ministry have to reduce the impact of second- and third-hand smoke?”
“Sir, MOH has previously stated its support for the principle of "One patient, One doctor", and I am heartened by its commitment towards strengthening our primary care services through many programmes, such as the Primary Care Network, for example. Our family doctors, I am sure everyone will agree, are at the frontlines of healthcare in our community. Often, they are the first point of contact for medical intervention by patients and their families, and patients and their families have also built a relationship with them. Family doctors are thus usually in the best position to provide patient-centric care as they have a comprehensive overview of their patients' physical and mental health conditions and, to varying degrees, the context as well. They play an important role in complex care needs, such as case management and preventive care. These will help lower our escalating healthcare expenditure due to our ageing population. Can MOH provide an update on the progress of and future plans for primary care transformation in Singapore? Healthcare Delivery System”
“Sir, due to our ageing population, the demands upon our healthcare providers are expected to escalate. As this is a labour-intensive sector, our manpower shortage has to be overcome through enhancing productivity and innovation. How is MOH encouraging innovation and spurring productivity in the healthcare sector? Would the Minister elaborate on process improvements which have contributed to better patient care and experience and boost productivity gains in different segments of our medical sector? Tremendous gains are being made every day in the fields of robotics, artificial intelligence (AI), big data analytics and the Internet of Things (IoT). These have the potential to vastly improve healthcare delivery and outcomes. How are we leveraging such positive disruptions in healthcare services for Singaporeans? Would the Minister share an update on the investments the Government is making to boost automation and tap upon new and innovative technologies to provide quality, affordable healthcare? 4.30 pm Increasingly, the healthcare sector will have to work closely with diverse fields, such as information technology (IT), engineering and biotech, to come up with innovative healthcare solutions but, at the same time, without losing the human touch. What are some of our local success stories in innovative research and cross-sector collaboration? Silver Towns”
“MediSave for Outpatient Treatment Over the years, MOH has liberalised the use of MediSave for outpatient medical costs, and I would like to ask if MOH would consider further enhancements to the Chronic Disease Management Programme (CDMP) and also the Flexi-MediSave Scheme, which allows the elderly to utilise more of their MediSave for outpatient medical expenses. Will the Ministry consider raising the Flexi-MediSave sum? Would MOH consider liberalising the use of MediSave for the cost of other allied services, such as physiotherapy, or perhaps the use of consumables for chronic conditions like heart disease and diabetes? As I often call for during the COS debate, I would like to ask the Ministry to include more chronic conditions under CDMP. I have always felt that this is an excellent programme and feel that it should be expanded wherever possible. Including more conditions beyond the 19 already included will reduce the cash outlay required and encourage patients to be more compliant with treatment. I would also like to renew my call for the CDMP withdrawal limit to be calibrated to the number of chronic conditions that a patient has. Thus, a patient suffering from three chronic illnesses should perhaps be allowed to withdraw a little bit more than a patient who only has one chronic illness. MediSave Flexibility for Special Needs”
“Sir, the objective of the Health Insurance Task Force (HITF) is to study ways of improving private health insurance in Singapore in order to achieve more efficient and sustainable outcomes for our healthcare system. This is important as close to two-thirds of Singaporeans currently have an integrated health insurance plan. In its report that was released in 2016, HITF had recommended a few things, the first being the publication of medical fee benchmarks to help raise price transparency so that patients can make more informed choices. The fee guidelines are expected to be published sometime this year. The intention is to rein in escalating healthcare costs and ensure that medical services and goods remain affordable and accessible to all Singaporeans. The second recommendation was that HITF noted in its report that there were private insurance features and riders that "provide policyholders with 100% coverage without any co-payment", and they expressed their concern that the absence of co-payment may encourage both over consumption and over servicing in regard to medical care. And I note from the report in today's papers that the six Integrated Shield Plans (IP) insurance have appealed to MOH to make co-payments compulsory. Finally, HITF also made other recommendations to manage IP claims costs, such as the use of a panel of preferred providers and pre-approval of claims. What is the status of MOH's review on the HITF's report and recommendations?”
“In conclusion, the health check for our healthcare system is good for now, but just as our economy needs to transform itself to position itself for the future, so, too, does our healthcare system, which needs to see through its transformation to continue serving our country well beyond 2020, and, in fact, beyond 2030. Thank you and I beg to move. [(proc text) Question proposed. (proc text)]”
“Of course, value is important because, if we are counting our pennies, we have to ensure that healthcare remains affordable by ensuring that we get the best outcomes for the lowest financial outlay. Budget 2018 is frank and upfront about the financial pressures that our nation is likely to face over the next decade, and healthcare spending is one of the areas that will see the greatest increase in public spending. Value-driven healthcare policies could be a significant avenue of ensuring the sustainability of our system. Our healthcare institutions were recently reorganised from six clusters to three. This was announced last year. Can I ask if this has led to any desired gains in efficiency and value of care delivery? I have also previously asked for a body to be set up to evaluate not only the efficacy, but also the value of various medical and health-related interventions, whether diagnostic or therapeutic. I am glad that we now have the Agency for Care Effectiveness (ACE), and I call for ACE to play a bigger role in our quest for value and clarity in our healthcare spending. Some interventions may seem very promising but with uncertain benefits, and they are controversial. For example, for things like hypertension, hyperlipidaemia, at which point do we actually choose to treat otherwise healthy individuals with medications, new technologies, remote consultations? Some studies have shown that although it is easier, but it tended to increase the utilisation of services with no discernable improvements in health outcomes.”
“It was a very good study but, I think, one repeated observation that I got was that residents who had higher educational levels were less likely to smoke and they were more likely to go for health screening, such as colonoscopy for colon cancer, mammography for breast cancer and pap smears for cervical cancer. The researchers actually found that this difference was not due to any knowledge gaps. If you ask people from all educational levels whether they knew what mammography was and why it was important, I think the knowledge was the same. Whether you came from a low or high educational background, you understood the importance of it. It was just that those from higher educational levels actually made that extra effort to go ahead with the screening. Thus, it is clear that an important determinant of health inequity is also social inequality, and as we strive to be a healthier country, we should never lose focus on enhancing social mobility and reducing social inequities. In the meantime, I hope that this new compact between our social and health services will allow us to dive deep into the social circumstances of our lower-income fellow Singaporeans to give them the support that they need to achieve a long and healthy life. I hope that the Ministry would be able to share more about the proposed integration of health and social services, as I feel that this would go a long way towards flattening the social gradients in the health of our population. Finally, from quality to value. It is a tricky subject, because what is value in healthcare? Just as the quality of health services is sometimes difficult to quantify, what represents good value in medical care?”
“So, what the researchers found was that while parents from all backgrounds understood which foods were healthy and which were not, eat more vegetables, less fried foods and so on and sweets, parents who were less educated and with lower incomes often did not persist in offering healthier foods to their kids. This could be because of the steep upfront cost in introducing these foods to children. Let us take vegetables, for instance. If a parent who is already working within a tight budget and time is short and a child refuses broccoli, for instance, then they will be less likely to persist with it because the child will probably refuse and it will end up on the floor. They would soon give up and say, "Okay, maybe we will just give them the chicken nuggets that they are clamouring for". A family which is wealthier may perhaps have the luxury to be able to continue offering this food, even though the broccoli ends up on the floor 10 or 15 times, until the child learns to appreciate it. In line with this, let me call on the Ministry to continue working with MOE and our schools to ensure that only healthy foods be served to our children. I understand the constraints that some families will face in regard to food choices at home, but I hope that our schools can play a bigger role towards inculcating healthy eating habits in our young. I feel that this should actually start at the preschool level, rather than just at the primary school level. Another example closer to home. Some years ago, a team from the Saw Swee Hock School of Public Health worked with myself and my grassroots volunteers to conduct a health survey in one area of Queenstown. This survey reached out to almost 3,000 residents and was conducted over a period of about a year.”
“One commentator went so far as to suggest that "being rich is the best healthcare plan that America has to offer". Closer to home, as Member Dr Tan Wu Meng had alluded to in an earlier speech, a study in Singapore also noted that if you use public rental housing as a measure of socioeconomic status, then this, in itself, is independently associated with increased hospital re-admission risk, and being a frequent hospital admitter and also an Emergency Department user. There could be many reasons why people with lower incomes have poorer health scores. The most obvious would be access to healthcare, but this is probably less true in Singapore than in other countries because our comprehensive healthcare system with universal coverage and very targeted subsidies has tended to flatten inequities in medical coverage. What then about other factors? Poorer health has also been associated with educational level which, itself, correlates with lower income. People with lower educational status, however, are not necessarily less knowledgeable about health, compared to those with higher education. Allow me to elaborate with two examples. We all appreciate that one of the most important paths to good health is to exercise good food choices. One study looked at why children coming from wealthier, better-educated parents grew up preferring healthier foods and were ultimately healthier. It is important before we go in to understand that where children are concerned, research has shown that kids might actually need to try a new type of food, about eight or up to 15 times, before they can accept it and perhaps grow to like it.”
“For instance, where I work, all of the kopitiams and coffee-shops no longer put sugar in their beverages of coffee and tea. If you want to, you actually have to add it yourself. It is initiatives and small little measures like these that will help our fight forward. I look forward to more initiatives from MOH and the Health Promotion Board (HPB) to promote healthy living in Singaporeans. As in every battle, it would be a mistake to step back when the tide is in our favour. I would like to request an update from MOH regarding its strategies for promoting healthy lifestyle choices amongst Singaporeans. Second, moving from hospital to community. I have voiced my strong support for the right citing of medical care to the community wherever possible and, for this to be possible, we have to continue strengthening both our primary care and intermediate and long-term care (ILTC) sectors. I will speak on primary care transformation later. But at this juncture, I would just like to ask: are our efforts to increase ILTC manpower and infrastructure on track, as detailed in the 2020 Masterplan? This call to shift from hospital to community also heralds another key theme that was announced in this year's Budget Statement. Many Members have already spoken on this, but I was heartened, like the rest, by the announcements that health and social services will be more closely integrated. This is because there is clear evidence from around the world that the health of an individual is closely related to one's socioeconomic status. The wealthier also tend to be healthier. A recent study from the United States (US), using data from the Centres for Disease Control, confirmed that people with higher incomes lived longer and had better health scores in virtually every parameter.”
“Chairman, I beg to move, "That the total sum to be allocated for Head O of the Estimates be reduced by $100". We are now just two years away from the year 2020, and I would like to begin by asking the Ministry of Health (MOH) to give an update on the progress of the Healthcare 2020 Masterplan. The Budget Statement which was delivered last week, gave us a stark reminder that although Singapore may be one of the healthiest nations in the world with a healthcare system that is admired by many, and Singaporeans may be amongst the longest living, but with our ageing population and a growing chronic disease burden, healthcare expenditure is rising, and it is rising very quickly. The MOH's operating Budget has risen from $5.87 billion in financial year (FY) 2014 to almost $9 billion for FY2018. In an effort to maintain the relevance and sustainability of our healthcare system, MOH earlier outlined its chief strategies to transform our healthcare system to meet the challenges of the future with three key shifts. The first was moving beyond healthcare to health; the second, moving beyond the hospital to the community; and third, moving beyond quality to value. I would like to comment on these proposed shifts. First, moving beyond healthcare to health. Over the past few years, the focus on health promotion and maintenance has been unrelenting and I applaud all Singaporeans for rising to this challenge. The call to arms to fight diabetes has reverberated through our society. We are all exercising more, eating more brown rice, for instance, saying "no" to sugar and "no" to over-eating. I appreciate the many initiatives and the nudges that we are making to make Singaporeans choose a healthier lifestyle.”
“Just a quick one for the Senior Minister of State. Could I just ask or clarify whether it is possible for someone who has been caught for littering, if he is unable to pay the fine, could he choose to take a CWO instead of paying a fine?”
“Some residents have told me that much as they would like to recycle, after their neighbourhood karung guni man retired, they sometimes do not quite know what to do. Tackling E-waste”
“Sir, I have previously asked about our effort to address e-waste. The Ministry mentioned last year that it is looking into a national e-waste management system. Can the Ministry provide an update on the plans to recycle the 60,000 tonnes of e-waste that we produce annually? Only 6% of our household e-waste, which accounts about half of the total, is sent for recycling. How about the recycling rate for non-household e-waste? We would need a comprehensive legislative framework and national collection infrastructure. It is important to get the manufacturers, producers and importers of electrical and electronic goods involved in this process, so that we can work together to meet recycling targets. Our market may be very small but we can still contribute to the movement for zero-waste manufacturing through a system of incentives and taxes. My constituency of Queenstown still has quite a large population of the karung guni men, and this informal sector, the rag-and-bone men of karang guni men could also be consulted and tapped upon in this new framework. I read recently about the rise of the new generation of karang guni men. These workers have had decades of experience and involvement in community recycling, going from door to door collecting from residents all over Singapore. They provide, and continue to provide, an important service and could continue to play a part in our recycling drive, especially as our population ages. The Ministry may wish to consider a combination of incentives and fines to increase the level of cooperation from households. I hope that under the new framework, the set-up of collection points could be expedited. The locations should be highly visible, accessible and convenient. Are there plans to facilitate the recycling of larger items?”
“I also appreciate the Ministry's efforts to provide the public with timely alerts about flash floods through a wide range of communication channels, which include radio broadcasts, short message service (SMS) alerts and mobile apps, and LTA's Expressway Monitoring Advisory System (EMAS). For the National Environment Agency's (NEA's) SMS alerts, I would like to request for subscribers to be allowed to select more than one chosen location for alerts on the water level in monitored drains and canals. This would be useful for people who need to monitor multiple locations due to their travel patterns. Zero-waste Nation”
“Sir, with climate change, Singapore is experiencing more unpredictable and sometimes intense and torrential rainfall. My constituency of Queenstown, which traditionally has been relatively safe from flooding, has in the past two to three years also experienced flash flooding more frequently. What are PUB's plans to mitigate flash floods in the face of this challenge? 1.30 pm Would the Minister share an update on the progress of the works on the Bukit Timah First Diversion Canal, which has been delayed by the difficult terrain, as well as the Stamford Diversion Canal and Stamford Detention Tank, which will protect our Orchard road shopping belt from flooding? Last month, the Minister also mentioned that there were 73 locations undergoing drainage improvement works, with 22 more planned this year. In addition, he said that there were about 500 submissions for plans to do retention tanks for developments above 0.2 hectares, out of which only 158 have been completed. What are the main challenges faced in these improvement works and the building of retention tanks? Is it expertise, is it manpower or component shortages? Would the Ministry consider increasing the intake of foreign specialists and workers to expedite the completion of these tanks? The new generation of pervious or permeable concrete has improved properties. They are more porous and durable and facilitate drainage. Does the Ministry intend to work with the other Boards or organisations, like the Land Transport Authority (LTA) or the National Parks Board (NParks), to use more of these materials in our roads and pavements?”
“I am not sure whether there is data on this. But of those cases that the Parliamentary Secretary cited, does he have any data on how many are non-accidental in nature? That means is it related to abuse or suspected abuse?”
“I would like to thank the Senior Minister of State for his very comprehensive response and I agree that Singapore's healthcare spending is probably the more critical part of this puzzle. Just one clarification with regard to medical inflation. There are many figures that are bandied around and, sometimes, this does cause unnecessary concern to the public. It depends on where the source of the so-called medical inflation figures come from. But just in terms of clarification, what figures does MOH use when they are looking at medical inflation? Because a large part of expenditure is on private services, auxiliary or allied services, for example, even things like traditional Chinese medicine, which many members of our population actually make use of. For allied health, for example, for an ageing population, what are people spending on daycare, for instance, or other services of this sort? So, what methodology does MOH look at in order to follow medical inflation in Singapore?”
“And I would like to check with the Ministry what its strategy is to control this source of ENDS. And for my final point of clarification, the Bill proposes to align the penalties for the possession of tobacco products and imitation tobacco products for the purposes of sale to that for import, distribution, sale or offer for sale. For a first offence, a fine of up to $10,000, or jail of up to six months or both; and for the second and subsequent offences, a fine of up to $20,000 or jail of up to 12 months or both. May I suggest that we set minimum sums for the fines but remove the ceilings in order to introduce fines based on the quantity and value of the products seized? In addition, we should consider imposing fines on the logistics companies used by the importers to motivate them to inspect their cargo more carefully. An additional layer of checks would be useful. Thank you and I support the Bill. 2.43 pm”
“However, I am of the opinion that such stepped implementation is unnecessary and perhaps too gradual. If someone who has just turned 18 has also just started smoking, this gradual implementation will continue to allow him/her to buy and use cigarettes until he/she is well and truly hooked. If we stop this smoker at the early stage of the addiction, it may be easier for him to quit. Therefore, I would like to urge the Ministry to increase the MLA for smoking to 21 as soon as possible. We should supplement our efforts with a stronger public campaign to highlight all the negative impact on smokers' health − from the more obvious damage to the lungs to less widely known disease-causing DNA damage which can last more than 30 years after a person has stopped smoking. We have to engage our youths through every platform available as their future can be greatly affected by this life-changing addiction. In addition, the adverse impact of smoking on our National Service personnel, and the financial and resource burden upon our national health system should also not be under-estimated. Second, we also have to consider the impact on tobacco retailers' employees, some of whom are aged between 18 and 20. With this increase in the MLA, staff aged below 21 will not be able to sell tobacco. I think this is a move in the right direction, as constant exposure to tobacco products in the course of their work could tempt these young persons to try smoking themselves. Nonetheless, I would like to ask if measures can be taken to diminish the economic impact on these young employees over this period of implementation. Third, while I laud the ban on Electronic Nicotine Delivery Systems (ENDS), I am concerned that there are many online vendors.”
“Mr Speaker, I rise in strong support of the Bill. I am particularly worried that smoking prevalence remains sticky amongst the young. As Parliamentary Secretary Mr Amrin Amin has just noted earlier in his speech, 95% of Singapore's smokers first smoked before the age of 21 and 45%, became regular smokers between the ages of 18 and 20. If we were to look at the age of inception, that means, at the age at which smokers took their first puff, the statistics also bear grim reading. In 2001, our youth smokers started when they were 17. That was the age when they took their first cigarette. In 2013, we found out that they were actually taking their first puff at 16 years of age. And all these occurred despite current legislation which makes it illegal to smoke under the age of 18. As noted, adolescent brains are more sensitive to the rewarding effects of nicotine. Hence, young persons who start smoking early are more likely to continue smoking into adulthood and become addicted. The intensity and persistence of smoking also correlate with how early smoking started. We should take note of the 2008 World Health Organization report which states that people who do not start smoking before the age of 21 "are unlikely to ever begin". Bearing this in mind, this leads to the first of my four clarifications. First, this Bill proposes to increase the minimum legal age (MLA) over three years to 21 years. Twelve months from the day the law is passed, the MLA will be raised to 19. Then, we have to wait another 12 months for it to go up to 20, and another year before it is raised to the age of 21. As a result, smokers aged between 18 and 21 at the time the Act is amended will be exempted. The rationale is to give youth smokers who may be already addicted some time to adjust.”