Khaw Boon Wan
Singapore
“Motor vehicle dealerships and showrooms have been closed since the start of the circuit breaker. As COE bidding is done mostly by the motor vehicle dealers on behalf of prospective owners, the Land Transport Authority (LTA) suspended COE bidding for the months of April and May.”
“Though stressed by the financial pain, they press on with the immediate priority of fighting the virus and supporting essential services. Post-pandemic, we will see how public transport evolves. Will demand for public transport services simply return to the pre-pandemic level?”
“Under our rail financing framework, the Government fully pays for the cost of building new rail lines. In other words, we do not recover the cost of building the Cross Island Line (CRL) from commuters through fares. The CRL project is being implemented and the final costs will depend on tender bids.”
“There are around 5,000 private bus operators with a combined fleet of 13,500 private buses. As we do not track the number of private bus trips and passengers, we do not have data on their carbon emissions.”
“There are nursing rooms at 50% of our bus interchanges. We will provide nursing rooms at all new bus interchanges and integrated transport hubs. For the MRT network, we will provide nursing rooms at all new interchange stations. We will also explore providing such facilities when MRT stations undergo upgrading.”
“Over the last three years, Singapore carriers have reported a total of 20 incidents of food allergies on board their flights. None required the use of epinephrine or emergency flight diversions.”
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“The deductible is a problem that can be easily overcome, and I have spoken to GPs and our own polyclinics. And one way they do it – which is quite legitimate and in fact advisable – is they package it up. So, yes, each visit may be only about $30 or $40, as noted by Ms Sylvia Lim. But these are chronic disease management programme, we expect the patients to come forward three or four times a year depending on the risk profile. And, in fact, we want the patients to come forward. We would be very worried if they only come once and disappear. Then compliance would be a problem and their diabetes or high blood pressure will not be managed well. So, many clinics have now offered what is called package deal. They charge per year or even per two years and the whole sum, let us say, $250, will attract the same deductible of $30. The rest can be deducted from their Medisave. So, this is one way to overcome this deductible issue but, more importantly, it secures compliance by the patients. Recently there was some public discussion on the use of Medisave for health screening. I think Dr Lam Pin Min and Dr Fatimah Lateef have suggested that we consider expanding Medisave for health screening, subject to certain limits and guidelines. I am sympathetic to the call as I believe in prevention. Regular screening and early detection followed by medical intervention and lifestyle changes can avoid future complications and costly medical treatment down the road. There is a case for allowing some Medisave withdrawals for health screening. The question is what kind of health screening? There is a wide range of health screening tests; not all are fully justified or necessary. More screening is not necessarily better. Some accrue benefits more to the provider than the consumer.”
“She made a couple of observations: one, that the utilisation rate of this scheme seems below expectation, less than 15% of chronically ill have made use of this scheme. It is not a surprise to me because when we estimate the total number of chronically ill, it is based on the disease incidence. Like in all population, probably half of those with chronic illness do not even know they have the disease. And that is why we must step up mass screening. And even among those half who knew they have a chronic disease, not all come forward. Many studies have shown, and again also observed in Singapore, that only half of those who knew they have chronic disease will come forward to see a doctor. And among those who come forward to see a doctor, not all comply; they may decide that changing lifestyle is too troublesome; taking medication is too troublesome, or for whatever reasons. So, when 15% of potential users of this scheme come forward, I thought it was not bad. At first, I thought we cannot even cross 10%. But, yes, we should now aim higher and try to get more people to make use of this scheme. I have spoken to some who are on regular chronic disease management but not using the Medisave. I asked them, they said "why should I", and they gave a couple of reasons. One, some of them are paid for by their employers, so there is no need for them to use their own Medisave. Secondly, some are quite smart, they said that Medisave pays interest rate – I do not know what it is now – 4%-5%. They have enough cash, and they say they will pay cash, which in the bank you cannot even collect 0.5% interest rate today. So, there are all sorts of reasons why we ended up with only 15% utilisation. I do not think we should be discouraged by this figure.”
“Even then, it is usually just nominally. They would get into problems if they or their dependants fall sick. And it would be worse if they also do not subscribe to MediShield and ElderShield. We must all help to get them into Medisave, MediShield and ElderShield, so that they can enjoy the same protection as the salaried employees. Mdm Halimah asked about the adequacy of the Medisave Minimum Sum. She asked if it is adequate to meet the needs of an ageing population. The current Medisave Minimum Sum is at $32,000 and is not bad for those opting for Class B2 or Class C wards and have MediShield and ElderShield coverage. We will continue to adjust it annually to take into account medical inflation, so as to preserve the purchasing power of the account holders. My concern is that currently, most are not able to achieve the Medisave Minimum Sum by the time they reach 55. The top 40% of income earners are all right, but not those in the lower-income group. That is why we have to be careful in not over-liberalising the use of Medisave for other purposes, which it was not originally designed for. I have the unpleasant task of being the gatekeeper to Medisave. I heard Ms Sylvia Lim. Yes, Medisave is your own money, but if it runs out prematurely, the member will be in trouble. And I am trying to prevent such an outcome. That is why we have stringent Medisave withdrawal rules and limits. This will help to balance current consumption against future needs and ensure that Singaporeans have enough Medisave to look after their medical needs during retirement. Ms Sylvia Lim spoke about the Chronic Disease Management Programme (CDMP) and the deductible of $30 that we put in.”
“But 90% of all Singaporeans have MediShield coverage, which would reduce the patient's share of the bill substantially. For these Singaporeans, their Medisave balances can cover even more hospital admissions. This is a remarkable achievement. Medisave is one main reason why sophisticated but costly healthcare services are within the reach of all Singaporeans, including the lower-income group. In the current health reforms debate in Washington, serious economists are all advocating what they call "HSA" (health savings account) as a necessary solution for the American healthcare system. Medisave is a HSA – a health savings account; we pioneered it long before economists developed this insight and coined this term. The idea came from Minister Mentor Lee. Dr Goh Keng Swee sketched out a rough outline. Senior Minister Goh fleshed out the details, persuaded Singaporeans to accept this idea and got it successfully implemented. We have all three to thank for this innovation, which has now become an integral part of Singaporean life. Mdm Halimah asked about the existing Medisave contribution rates. This is tied in with the overall CPF contribution rate and is a factor in employment cost and overall competitiveness. I have no grave concern on the adequacy of the existing Medisave contribution rate. But I must add one caveat on the self-employed who form 12% of CPF members. Many are careful and contribute regularly to their Medisave. They too have an average Medisave balance close to the salaried employees of similar income band. My worry is the 140,000 self-employed members who have an average Medisave balance below $10,000, some just a mere few thousand dollars. Out of this group, only 40% had made some contribution to their Medisave last year.”
“Mdm Halimah spoke about knee replacement surgery, which she raised last year. We have fixed the problem by revising the claim limits. On average, the cost of treating such a patient in Class C now is about $16,000. My Ministry subsidises about $11,500 with the patient co-paying the remaining $4,500. With Medisave and MediShield, many do not have to pay anything out of pocket, unless they insist on some costly fanciful implants. This is our approach to subsidising care. As medical advances and hospital operating costs go up, we increase our subvention to the hospitals so that patients remain subsidised in accordance with the prescribed subsidy policy. We actually miss the target sometimes. For example, Class B2 subsidy is 65%, with patients co-paying 35% of cost. But, in reality, B2 patients today co-pay 30%, which is five percentage points below target. We will have to close the gap eventually, but let me assure Members that it will be gradual and will not inflict unnecessary hardship on our patients. After Government subsidies, Medisave forms the second layer of protection. As Mdm Halimah put it, it is a key pillar of our healthcare system. Medisave turns 26 this year. Collectively, we now have more than $45 billion in Medisave. At the individual account level, all salaried employees have healthy Medisave balances for themselves and their dependents. There are many statistics to prove this point, but let me just highlight one. By age 50, the average Medisave balance of all salaried employees would have exceeded $27,000. This is good for 18 hospital admissions if he chooses Class C. And even if he chooses Class A, it can cover six hospital admissions. This assumes he has no insurance coverage.”
“This afternoon, I will discuss how our financing model can be improved further. 1.15 pm In the new financial year, our budget to subsidise patients will increase by 10% to $2.2 billion. I am grateful to the Finance Minister for his support. In fact, the increase is more as the Finance Ministry has also topped up Medisave accounts, Medifund and Eldercare Fund by $710 million. These top-ups are, in fact, subsidies as they help Singaporeans pay for their future healthcare needs. Such Government subsidy for healthcare is the first layer of protection for Singaporeans, which ensures universal access to basic healthcare by all. Because the 3Ms label does not include this item, Government subsidy is often taken for granted. I have been trying to see how we can slip in the "S" (for subsidy) into the 3Ms. But in the end, I still end up with just 3Ms. I suppose the small "s" in the 3Ms could be "subsidy", but in real life our subsidy actually is a big "S" and not a small "s" at all. It is our huge Government subsidy which differentiates our healthcare funding model from that in the US, Japan and many European countries, where hospitals and clinics would charge all their patients at full cost without subsidy. In Singapore, 80% of the patients in our hospitals choose Class B2 or C wards. In these wards, the bulk of the cost is picked up by the Government. For example, a Class C patient going for a hip replacement surgery, which is a major surgery, would cost the hospital, on average, $17,500. Eighty per cent of the cost, or $14,000, is paid by my Ministry through our annual subvention to the hospital. The patient co-pays the remaining 20% or $3,500, which are largely covered by MediShield and his Medisave savings.”
“Earlier, Dr Lam referred to a recent positive commentary on our healthcare system by the Washington Post. It described Singapore as "the only rich nation that boasts universal coverage with health outcomes better than ours [meaning the United States] while spending one-fifth as much per person on health care". Our system is not perfect. Indeed, we still have many problems to iron out, including the current shortage of hospital beds on certain days. But it is among the most cost-effective in the world, delivering a high clinical standard without inflicting too much financial hardship on patients or taxpayers. Over the years, many have come to study us. My most recent visitor was a delegation from Armenia, formerly in the communist bloc. Armenia, as Members may know, is a small landlocked country but with talented people. We used to have an Armenian community here in Singapore. They told me that there are still about 100 of them living here. There is an Armenian Church and, of course, our world famous Raffles Hotel was set up by three Armenian brothers a century ago. The delegates who came to study us were serious and bright. They asked critical questions. But for most of the last century, they were bogged down by the communist system of central planning. Twenty years after the fall of the Berlin Wall, they are at a cross-road. They know that their current system of free healthcare and centralised delivery is not sustainable. They read about us and its Health Minister led a team here to probe. I shared with them abundantly, and my parting comment was that health reforms would take decades. And even then, it would always be work-in-progress. Earlier, we discussed our healthcare delivery system.”
“He was born with a brittle bone disease and told me that even a severe cough could fracture his ribs. He is wheelchair bound but has never allowed the disability to hold him back. As he put it to Zaobao over the weekend, "We cannot determine what life will bring us, but we can determine our life journey". He added, "I cannot walk like other kids, but I can still do many things that other kids can". He told Straits Times this: "I focus on the things that I have, rather than the things that I don't." Life is really a series of successive moments. We cannot change the past moments and we do not know what the next moment will bring. But we can all seize the current moment and live it to the fullest helping others and touching their lives. How? Lao-tzu's prescription is 2,500 years old but I think it remains relevant today: “上善若水, 水善利万物而不争”. This, I need to translate because it is in classical Chinese and Lao-tzu is not the easiest to fathom. He said: "Water nourishes all life, but itself does not gain anything." What he is trying to tell us is we should all live a life like water. We are here to help others, be kind to everyone else, not to help ourselves. This is a high ideal, but I think we all can strive to be as close as possible to that ideal. Medisave for health screening”
“But the job is not mine alone. My Ministry can only provide a supportive environment. Successful living and successful ageing are personal choices. Dr Chee Pui Hang provided an example, but there are many others. Prof. Chan Heng Leong, a former Head of Medicine in NUS, is another, a brilliant doctor, a dedicated academic and a good family man. He could have earned more in private sector but chose a public career to teach and to treat the poor. In retirement, he continued to contribute in the university and at the hospital. When his time was up, he refused further medical interventions and passed away peacefully at home surrounded by his loved ones. 1.00 pm The last few days of these wise people are not mournful partings but quiet celebrations of having lived a fulfilling life. Friends and family members drop by to talk about the past and the good times together. Some, I suppose, even karaoke and probably sing Jin Daban - zuihou yi ye: hong deng jiang mie, jiu ye xing, ci ke gai kai xiang ta gao bie ( 金大班 - 最后一夜: “红灯将灭,酒也醒, 此刻该向它告别”). I do not think I need to translate because I am told that this is a very popular karaoke song amongst Members of Parliament. Indeed, Mr Chairman, everyone, rich or poor, will say goodbye one day. And we all want to end well. But to end well, we need to stay well and live a healthy and fulfilling life. We have different starting points but all can live well. Over the weekend, I was so happy to read about Jeremy Lim's achievements at his GCE 'A' level examinations. He was an NKF Ambassador when I first met him several years ago.”
“That is why we have been quietly restructuring our healthcare delivery system and gearing it up for our future with many more elderly patients. It is a quiet revolution, no fanfare, no sensational headline news. But if we do it well, our efforts will show positive results in 10 years' time. This I promise. I do not know if I will stay so long in the Ministry of Health, though. We have a lot to do. We need to work harder at keeping patients well in the community, avoiding unnecessary hospitalisation, achieving greater integration between hospitals and the community partners and helping patients achieve successful ageing at home. We are not alone. Every country is trying to figure out the best solutions. The efforts are not just happening in the public sector nor are they restricted to the healthcare sector. The industries are seeing an important role for themselves in tackling the ageing problem. In Japan, Toto – the largest toilet producer – makes a toilet that has arms supports to help the old get off the toilet more easily. They were the first to come up with the toilet seat with an integrated bidet. When I first saw it in Japan many years ago, I thought it was because of infection control reasons. They said no. They explained that using water to cleanse rather than paper reduces efforts for the seniors. Zojirushi, an appliance maker, has a kettle that sends a wireless message if granny does not use it by a certain time each morning. It is a clever, non-intrusive way for families to check that things are all right with their elderly. There are many such pockets of excellence and innovations all over the world. In healthcare, I regularly remind my colleagues that we must challenge ourselves to match the best performer in each class.”
“Along the way, many would perish as they got eaten up by crocodiles as they crossed rivers or hunted down by lions and cheetahs in the savannah plain. One late afternoon, we were positioned near the edge of Mara River as a group of wildebeests, numbering tens of thousands attempted a river crossing. There was much hesitation as they could see crocodiles waiting in the river. Almost ritualistically, a leader would eventually emerge, go into the river alone, test the water, and suddenly make a dash across the river. The rest would then rapidly follow in a mass stampede. I prayed for their safety but, inevitably, the weakest could not make it. Most made it and continued their journey northwards. Some, visibly old and frail, dared not even cross and were left behind on the south side of the river. Just as we gathered our cameras and videos to return to camp, we suddenly saw a small group of wildebeests, numbering about 30, which had already made a successful crossing, yet, surprisingly, backtracked. They had already crossed the river but backtracked to presumably rejoin their family members which had failed to make the crossing. Instead of moving on with the rest of the pack, they risked their lives in order to be with their loved ones. It was very moving and very touching. It was an instinctive expression of family bonds, love and sacrifice. I prayed for them even more deeply because the night will bring even more dangers as they were now in a smaller group. These were wild beasts but their behaviour that afternoon was not beastly at all. Mr Chairman, our population is ageing and living longer. We have a good health care system but past solutions will not work as well for the future.”
“In her gentle, soft-spoken way, she leads a team of nurses, carers and volunteers, caring the patients with selfless dedication and love. I asked her, "do you have difficult patients or family members?" She said, "yes". She went on to relate one incident where the son of a patient demanded that the nurses should brush his mother's teeth within 15 minutes after every meal. He said that he loved his mother, and such a service level would be in line with the patient-centric mission of the Home and also a demonstration of love and compassion. Sister Geraldine gently but firmly reminded the man that a place in a nursing home is a gift, it is not a right. If every patient imposed such a demand, they will not be able to cope. She went on to add that the nursing staff – whether it is an employee or a volunteer or a Catholic nun and no matter how kind and compassionate – is not the son of the patient. The man got the message. The love of family members cannot be delegated away. That was why it was so sad to hear Ms Indranee Rajah speaking about a case of abandonment of parents by one resident. Our hospital nurses have also begun to come across cases of children refusing to take back their parents after discharge. They demand that the parents be sent to a nursing home instead. The numbers are still small but we must not allow this to become a trend. I have told our hospitals to be firm with such irresponsible children. Three years ago, I spent several days in Kenya's Masai Mara Game Reserve watching wild animals in their natural habitat. It was the season for their annual long march as some two million wildebeests – a kind of antelope – migrate northwards from Serengeti National Park in Tanzania, in search of water and food.”
“Second, there is no free healthcare. Every healthcare service is eventually paid for by the patient, either through taxes or reduced wages. Ultimately, patients and their families pay for the bills. Our job is to make sure that the cost of delivery is as low as possible, and this means cutting out abuses and other moral hazards. Third, specialisation and sub-specialisation have brought about much medical advances and benefiting many acute patients. But as noted by Dr Fatimah Lateef, there is also such a thing as over sub-specialisation. For the elderly with several chronic illnesses, treatment by multiple sub-specialists is often not the best approach. Fourth, despite medical advances, we are still mortals and we will die one day. Three weeks before Dr Chee Pui Hang passed away, I visited him in his house. We had a good chat for the last time. He had been frail but rejected all attempts by his attending doctors to get him hospitalised. He had the money and the medical network to get the most up-to-date sophisticated medical interventions, but he knew that they would be futile. The interventions might extend his biological life by a few days, or a few weeks, but he knew that the hospitalisation would, in fact, reduce his social interactions and quality time with his loved ones. He wanted every hour of his remaining life to be with his family and friends in the comfort of his home. This is a wise man. Fifth, when cure is no longer available, care becomes the the most valued by patients, and the highest form of care is underpinned by love and compassion. Last month, I visited the St Joseph's Home in Jurong and watched the saintly Sister Geraldine in action. And she has many wonderful stories to tell, all were inspiring.”
“It will help identify and provide support for patients who default follow-up appointments or treatments, thereby reducing the number who relapse because they do not take their medication. But for this strategy to work we need the support of the community, accommodation and job opportunities so that they can lead normal lives again. Hence, I fully agree with Dr Lam Pin Min, Dr Fatimah Lateef, Mdm Halimah Yacob and Mdm Cynthia Phua that working with employers, community partners and the grassroots is a must. IMH's "job club" has successfully placed more than 380 patients over the last two years with the help of enlightened employers. And I share Mdm Halimah's hope that more such enlightened employers would come forward to offer such job opportunities. IMH will certainly work with VWOs and the community to tap on their resources to help expand IMH's outreach to the discharged patients. Dr Fatimah asked about the use of Medisave for schizophrenia and severe depression. Five months after implementation, it has benefited 500 patients who withdrew a total of $160,000 for their outpatient treatment. Mr Chairman, healthcare is a complicated subject. It is also highly emotional and that is why it gets politicised very quickly. Just see what is happening now in Washington. The debate on the Obama health reforms – it is largely politicking. Health systems are, therefore, distorted in all countries, becoming dysfunctional when distortions become extreme. To reduce distortions, we have consciously tried to stick to the basics. And what are they? First, as stressed by Dr Lam, health outcome is largely a personal matter. Doctors and nurses can only point the way forward, the patient must play his part. This is especially so in the case of chronic illnesses.”
“The lack of public empathy for the mentally ill arises from misinformation and ignorance. With treatment and support, most mentally-ill patients can recover and can function in the community. 12.45 pm Mdm Halimah Yacob, Mr Ong Ah Heng, Ms Indranee Rajah and Dr Amy Khor have asked about the follow-up care for discharged IMH patients and crisis support. I heard with concern Dr Amy Khor's account of a resident who committed suicide last month after discharge from IMH. I do not know the details of this case and whether there are systemic gaps which could have prevented this tragedy. We should try to minimise the suicide rate but, unfortunately, not all suicides are preventable. IMH carefully selects the patients to be discharged. They must have responded positively to treatment, have adequate family or social support and pose minimum danger to themselves or to others. IMH would then teach such patients and their families on the need to comply with medication and regular follow-up to avoid future relapse. Those with higher risk of relapse are followed up closely by their community mental health teams. IMH now runs a 24-hour hotline and provides advice and support to families and patients during periods of crisis. Our follow-up care is getting better but we know there are still gaps. MPs' comments earlier confirm this. I am, therefore, adding a further $57 million for mental health initiatives on top of the $123 million already committed. This is a significant $180 million commitment to enhancing our mental health programme. Part of the new budget will be used to increase psychiatric nursing manpower, another will go towards setting up a long-term monitoring and risk assessment system.”
“It can be a think tank of practical people to help conceptualise and facilitate successful ageing, working closely with Government agencies, NGOs and the community leaders. We are also upgrading our nurses so that more can take on greater responsibilities and deliver more complex care as Advanced Practice Nurse (APNs). We are targeting 200 new APNs over the next five years. Another important group of healthcare professionals are the Allied Health Professionals (AHPs). We have started regulating optometrists and opticians. Later this year, I will come back to Parliament with a Bill to regulate the other professions. For this year, we will target the registration of the physiotherapists, occupational therapists and speech therapists. Some 1,300 therapists will be involved. Fifth, we are enhancing our mental health programme, a topic raised by several Members. We made this commitment in 2007 when we rolled out a National Mental Health Blueprint and we backed it up with $123 million budget. The strategy includes offering a range of treatment options from acute care at IMH to follow-up care in the community. We are making some headway. We now have many more Community Mental Health Teams to facilitate the early detection and treatment of mental health cases within the community. We have developed programmes for at-risk groups such as caregivers and out-of-school youths. We also have an employers-led alliance that promotes the importance of mental well-being at the workplace. However, as noted by Dr Lam and Mdm Halimah, the biggest obstacle to an enhanced mental health programme is stigma and unfounded prejudice. Mental illness makes people fearful. High profile crisis incidents lead people to think that the mentally ill are all dangerous and should all be locked away.”
“I remember blogging about it after hearing this and I made a point that I will figure out a way to "get our kids back" to Singapore. And I will. The restructured hospitals are studying an idea of offering a pre-employment grant to these medical students, to help them with their costs overseas, in return for a bond to serve them when they graduate. It was an idea that Dr Lily Neo planted in my head some years ago and I think it is doable. We have also been embracing the value proposition of a career in the public sector. We are investing in biomedical research and supporting those with research interest. For the young doctors, we are ramping up training opportunities. This will allow every young doctor to reach his maximum potential in his chosen specialty, including as a family physician. We are setting aside $120 million to strengthen our specialist training programmes over the next five years. We are also building up geriatric care capabilities. We will encourage GPs to undertake further post-graduate training in geriatric care so that they can better manage their patients in the community. In addition, we will also need more specialist geriatricians. We have 48 now. Over the next three years, we expect to increase it by 30% to 40%. We have incorporated geriatric medicine as a core module of our medical student undergraduate training, and have introduced incentive allowances for geriatric trainees over the more popular specialities. Next to the new KTPH, we are right now planning a community hospital. My project brief to the team is, let us raise the level, ie, create the next generation of community hospital. They are actively thinking about it. Among the fresh ideas being considered is to base an institute of geriatrics and gerontology there.”
“Fourth, we will back up the physical expansion with the necessary manpower. In the public sector, we have been adding more doctors, nurses and other healthcare professionals, to improve the staff-to-patient ratio. We launched this in 2007, when we set aside $1.5 billion to recruit 7,700 more healthcare professionals. We are now halfway through this five-year plan. And I am pleased to report to Dr Lily Neo and Assoc. Prof. Straughan that we are on track to achieving the target. Our headcounts have increased by 44%. Our doctor staffing level has gone up from six doctors to eight doctors per 10 beds. Our nurse staffing level has gone up from 20 nurses to 26 nurses per 10 beds. Recently, I met a group of hospital Medical Social Workers where we have been adding numbers. They were "complaining" to me that many of their new recruits do not even have offices and the hospital is rapidly adding workstations to hold them. Equally important is staff retention as Dr Fatimah Lateef emphasised. Although our staff attrition rates have come down from 8% to 6% for doctors and from 10% to 7% for nurses, it is an ongoing challenge. With two new private hospitals coming on-stream, we must expect significant attrition. The only practical way forward is to ramp up training and foreign recruitment. Last month, in my Sembawang branch, I bade farewell to a young Party activist who left us to start her medical education in a medical school in New South Wales. I asked her about the student intake numbers. She said that she was not sure but more than 300 per year for her batch. But she knew that in her batch, there would be 60 international students. But out of the 60, 40 are Singaporeans. And this is just in one medical school in Australia.”
“Recently, it launched a new service, what they call "hospital-on-wheels", to "bus" its team of doctors and nurses around Singapore. We are open to all practical ideas. Third, a minority of elderly patients will unfortunately require long-term care in a nursing home. In Europe, up to 7% of the elderly live in nursing homes. We now have 62 nursing homes, serving 2% of our elderly population. This is not excessive, neither is it grossly inadequate as we are a young society and family bonding is still strong. There is, however, variance in the performance standards of our nursing homes. While some well-run nursing homes are full with a long waiting list, a few others have significant vacancies. We will push the weaker nursing homes to upgrade so that resources are put to optimal use. Still, there is scope for some expansion. That is why we are currently planning three new nursing homes and rebuilding three old ones in larger facilities in better locations within HDB towns. But we must not make it too easy for irresponsible children to abandon their parents. Abandonment is not a major issue here but we do encounter some from time to time. Last week, Ms Indranee Rajah quoted one case involving her resident. When it happens, it is a very sad situation. I will talk more about this later. Assoc. Prof. Straughan asked about the impact of the increased foreign worker levy on nursing homes. We have assessed – the direct cost impact actually is small. But, separately, we have just increased our subvention to them by about 7% to help them cope with the higher cost of treating patients with more severe disabilities, what we call category III and category IV patients. The increase will be quite substantial.”
“Indeed, it will take us a decade to complete this assignment. Second, with more elderly patients requiring care in the community, including those with dementia, we are expanding our long term care sector. This is a point emphasised by several Members – Ms Indranee Rajah, Mdm Cynthia Phua. Many chronic patients can be cared for at home by their family members and their maids. But as Dr Lily Neo and Mdm Cynthia Phua observed, distress among caregivers might arise. I agree that carers need training and support, and we will help them. All elderly patients want to age at home and many children want to take care of their elderly parents at home. We will build up the home nursing capabilities and we are working with several partners to do so. We must avoid seniors becoming permanent residents in nursing homes. We are working with the Home Nursing Foundation (HNF) to scale up their operations. They will also extend their services beyond the low-income group to also help the higher-income group access appropriate home nursing care. Many patients do not need subsidies but may not have the knowledge and the contact of how to meet their needs. HNF is working with the TTSH team to ensure a smooth handover for patients newly discharged from the hospital. Once a patient is home, HNF will coordinate with other providers to meet the patient's care needs in the community. We will launch this new initiative within the next couple of months, targeting patients in the Central region. Mr Terry Lee suggested the use of mobile medical services. Some VWOs do run mobile clinics to bring medical care and treatment to the patients at home. SATA is one example. St Andrew's Community Hospital is another.”
“The Prime Minister spoke about this during his National Day Rally last year. Young patients recover quickly. They return to status quo soon after discharge. Elderly patients take longer to recover and sometimes full recovery may not even be achievable. They merely change their status from an acute patient to a chronic patient. Many need some transitional care in a community hospital or a nursing home and occasional re-admissions to the acute hospital. That is why it is so important for close collaboration and effective coordination between the acute hospitals and their clinical partners in the community. Done right, this will free up acute beds for patients with more serious conditions and reduce cost for those requiring less intensive care in the community. Dr Lam referred to this as "seamless, integrated care". I code-name it as "hassle-free healthcare system". And one key enabler is the National Electronic Healthcare Records (NEHR), to allow all providers common access to an individual's critical medical information, so that they can develop and coordinate shared care plans. This will reduce unnecessary repeat tests and medication errors, and bring us one step closer to the vision of "One Patient – One Medical Record". I gave the team planning the new Jurong General Hospital (JGH) the project brief to build a hassle-free healthcare system to serve the residents in the West. They accepted the challenge. Being ambitious, they self-imposed an additional target: to make JGH a paperless hospital when it opens. Meanwhile, the hospital team in KTPH, CGH and TTSH are also trying to do the same for their respective regions. They will compete to deliver the best ideas. And I told my Ministry of Health colleagues that this is our priority in the next decade.”
“30 pm As we discuss this year's Budget and reflect upon our achievements, I agree with Dr Fatimah Lateef that we focus on how we can shape the future to meet our aspirations. I have heard Members' many thoughtful comments. Let me just pick up their key points. First, the past decade has seen our resident population grow from four million to five million. In the next decade, will we add another million? The Economic Strategies Committee has noted our physical constraints and Singaporeans have also been voicing their concerns. So, I doubt it will be a "6-million people decade". But even a "5.5-million people decade" will mean a substantial increase in demand on healthcare services, as Singaporeans are getting older. In 2000, life expectancy at age 65 was 82 years. Now, it is 84, an increase of two years. With medical advances, this should increase further to 86, I think, in the next decade. This is success. It means that many more Singaporeans can live to their 80s and 90s. With better nutrition and lifestyle, many remain well. But, yes, some will get sick. So we are gearing up for this demographic change. We are adding more beds, more clinics, more staff, more nursing homes, more day care centres. I have shared my expansion plan before but given time constraints, I will not repeat it. Let me just highlight the next big event: the opening of Khoo Teck Puat Hospital (KTPH) in Yishun. Over the next few months, we will open it in stages. Indeed, it will start treating outpatients and conduct day surgeries in three weeks' time. The ambition of the hospital team is to make KTPH a hassle-free hospital, and I look forward to that. The change in patient profile from younger to older patients will have significant impact on healthcare delivery.”
“The Chinese have a saying, jiu bing wu xiao zi: "When you have a prolonged illness, very hard to find filial children". Outsourcing the care of patients is not the solution. The scene in "Money, No Enough 2 " of children dumping their mother outside the gate of a nursing home touched a chord, because that is exactly what we all fear. I know death is a morbid subject and we have just celebrated Chinese New Year. But let me assure Members that this speech is not about gloom and sadness; it is about living well and celebrating life. Yes, we are ageing, but there is much cause for optimism. Today’s seniors are very different from the seniors of the past. I am 58 and my residents often tell me that "You look younger". So, to Ms Indranee who talked about ageing earlier on, ageing can be fun, ageing may not be so bad. When our children become seniors, they will, in turn, be even better than the seniors of today. Where is the evidence? More Singaporeans are exercising, jogging, swimming, brisk walking and engaging in all sorts of sports. Here, I must thank Minister Mah Bow Tan, the HDB, the NParks and the PUB for creating an increasingly health promoting environment. In Sembawang, for example, we see our residents regularly jogging away, using the bicycle tracks, the park connectors and the various parks. My GRC MPs, including Dr Lim Wee Kiak, are now working with the NParks to refresh the Sembawang Park so that it keeps up with the needs of modern Singaporeans. But we will ensure that it retains its natural, old world charms. Ms Irene Ng’s observation yesterday that some parks have become too "artificial, plastic", was timely. We would not make that kind of mistake. 12.”
“To PPK means to live a long and healthy life without illness and when the time to go, just go swiftly: "Pin pin korori ". And there are pokkuri temples all over the place in Japan, promising the worshippers PPK. Although Japan has been in recession for two decades, pokkuri temples are doing quite well. I studied the Japanese approach carefully because they have the most experience dealing with ageing. Just how advanced is ageing in the Japanese society? Let me share some observations. In 1963, Japan started giving silver cups to Japanese who turned 100. That year, they gave away 153 cups. There are now 40,000 centenarians and they have just reduced the cup size by 15% to save on silver. Their ageing problem is magnified by their very low birth rate. There are now more adult diapers being sold than children’s diapers. There are 23 million children but 44 million pets! Pet care is big business in Japan. Yesterday, if Members read the Straits Times, they would see a picture of a Japanese man: how he pampered his poodle by carrying it piggy-back on his back, just as he would piggy-back his kid, which he probably does not have. Even pets are ageing, so in the supermarkets they have pet food calibrated by age bands. As noted by Dr Lam Pin Min and Dr Lily Neo, we have a good healthcare system. As the current and the former Head of GPC for Health, they know what they are talking about. Our system has brought us much success – low mortality, increased longevity, high clinical standards and among the most cost-effective in the world. But ageing of the population will bring new problems. We hope for PPK, but what if we do not simply "roll over and die"?”
“Mr Chairman, Sir, on the first day of Chinese New Year, I received news that Dr Chee Pui Hung had passed away that morning peacefully at home. He was 87. As I wrote in my blog, "I lost a friend, a supporter and a critic" whom I respect. Dr Chee was a legend and was larger than life. Within the medical community, he was widely and affectionately referred to as the "A-gong" of the Medical Alumni, who held together the large community of doctors, dentists and pharmacists. He lived life to the fullest, had a successful medical career, brought up three children well and even dabbled in politics in his early days. I am told that he had even chided a couple of Ministers in public when he disagreed with some of their policies. In his unique way, he contributed to Singapore. Many years ago, my father, too, passed away during the Chinese New Year period. He lived a full life, without any bad habit, kept slim, remained active and socially engaged in retirement. Several days after all the children who lived overseas had returned to their respective homes following several days of New Year reunion with him, he had internal bleeding in his brain one night while watching – and I suppose fallen asleep – in front of the TV. My mother rushed him to the hospital in an ambulance. I took the first flight out to Penang but missed him by an hour. The suddenness was traumatic for the family, but after the emotions had settled, we knew it was a good death and we all quietly wished that when it is our time to go, we could do so just as swiftly. The Japanese call this “pin pin korori”. "Pin pin" means to be healthy, bouncy and dynamic; "korori" means just roll over and die. The expression is so common among Japanese, they even abbreviate it to just PPK.”
“Mr Deputy Speaker, Sir, I beg to report that the Committee of Supply has made further progress on the Estimates of Expenditure for the financial year 2010/2011, and ask leave to sit again tomorrow.”
“In particular, it will be the platform which will make possible proper, right-sited chronic disease management to the benefit of patients. The NEHR would bring about cost savings for patients, from eliminating duplicate or unnecessary tests, as well as reducing medication errors and adverse drug events that could result in unnecessary healthcare expenses. APPENDICES Section Name: SPEAKER Title: COMMITTEE OF SUPPLY Filename : Guillotine Times MP Name: Mr Speaker”
“We are proceeding in phases so that each subsequent phase will take into account the experience of the earlier phase and be able to exploit emerging technologies. We may not need to extend the NEHR to every healthcare provider. Each phase of new incremental investment will have to be justified on cost-benefit grounds. We have a long term goal but we are not committing to the details of each subsequent phase. Put it another way, we have set the direction that we are going, but we are not committing to the pace of reaching each subsequent milestone. We will settle such details incrementally and progressively. This is a prudent way going forward, as IT will continue to evolve. For the current phase of implementation, we will be spending $176 million and by the time of project completion in April 2011, key medical information including patient demographics, allergies, clinical diagnoses, medication history, X-rays, laboratory investigations and discharge summaries will be fully exchangeable. They will also be in a form which lends them for more thorough analysis. A number of primary and step-down care providers, including GPs, polyclinics and a community hospital will also be linked up in this current phase. This will enable us to better prepare for the subsequent extension of NEHR to all the other healthcare providers, if we so decide. My Ministry has committed attention to IT governance and management of the NEHR project. Overall, we are progressing well along this journey towards "one Singaporean, one health record", which is essentially what the NEHR seeks to achieve. This will allow Singaporeans to move seamlessly across the healthcare system to get the most appropriate care in the most appropriate setting as we work towards integrated healthcare in Singapore.”
“In particular, as healthcare systems seek to integrate service delivery beyond acute hospitals to include the providers in the community in order to right-site services, raise the level of chronic disease management and empower patients to look after their health proactively, the need for a National Electronic Health Record system has been recognised here and in many developed countries. This is a necessary step forward to create a health record that is truly personalised and available everywhere. Unlike some other countries, we are not starting from scratch. We are building on the strong foundations of the past investments in healthcare IT that our public hospitals already have in place today. The NEHR is not to replace EMRs. Indeed, we will need to continue to invest in the EMRs at the clusters level to further exploit IT within the institutions. The level of details required in a local EMR is much more than in a NEHR. The NEHR will ride on the EMRs, drawing key information from the various EMRs in the public healthcare institutions, in order to construct a patient-centric view for both healthcare workers and patients to make better care decisions. Thus, the NEHR sets out the system-level architecture for how the different existing and new systems must fit together. To make this possible, we have to settle the standards for the data and establish the ways to properly exchange and synchronise information over a longitudinal basis. Moreover, in order to support integration of care and chronic disease management, NEHR has to cover the entire healthcare ecosystem, and not just the public sector. This is therefore a complex and difficult undertaking. Full implementation will take many years.”
“As an interim solution, we implemented an Electronic Medical Records Exchange (EMRX) to allow secure cross-cluster exchange of patient information so that regardless of where the patient seeks treatment, key information could be pulled to enable safer decision making. Subsequently, we extended EMRX to some healthcare partners. Today, the EMRX is a pivotal capability that allows easy movement of records across the public healthcare clusters, community hospitals and MINDEF, facilitating care delivery. All these efforts have shown the early benefits in safety and convenience for our patients as information is much more easily accessed at various points of care. However, the current EMRX has a major drawback: it is essentially a document-level exchange, with no standardised or structured data. While it has been useful, it limits further exploitation of the data. Seamless sharing of data beyond documents is very difficult, if not impossible. For example, diagnostic images, including X-rays, cannot be exchanged over the EMRX, because various institutions use different vendors and their current viewers use different versions of image protocols. Images from one institution are therefore not easily readable in another institution without degradation of quality and significant translation effort. The lack of structured data also means that anything beyond information exchange, such as making the system "smarter" to aid clinical decisions, research and disease surveillance is technically impossible. Recent progress in IT and further standardisation of medical data internationally has enabled us now to move into the next step of IT exploitation.”
“Mr Khaw Boon Wan: Although the question is on the National Electronic Health Record (NEHR) currently being implemented, I will briefly provide the backdrop to this development so that NEHR is seen in its proper context. Information Technology (IT) is an important capability and a critical infrastructure in any modern healthcare sector. In fact, the weaknesses observed in the healthcare sector in many countries can be better addressed through greater and skilful investment in IT by the sector. In the current healthcare reforms debate in the US, for example, there are many calls for NEHR investments. Traditionally, healthcare has been a laggard in the use and exploitation of IT, as compared to other economic sectors, such as finance, manufacturing. Singapore is no exception, though we probably fare better than many other countries as we have been investing in healthcare IT for years. As a result, the use of IT is now quite pervasive and widespread in our healthcare institutions. Some institutions have become "paper-less", like the National Skin Centre and the Bukit Batok Polyclinic. Many hospitals have gone "film-less", as diagnostic images are digitised. Some hospitals have adopted pharmacy systems with electronic ordering. SingHealth Cluster and NHG Cluster have each an integrated core of financial, administrative, health service management and electronic medical record (EMR) systems which have become an integral part of their hospital operations. Dr Lam, who works in our hospital, will know that his clinical work, whether in the specialist outpatient clinic or in the ward, will be severely hampered, if the IT system breaks down. The clusters had developed their EMRs independently. This created a problem when a patient moved across the cluster.”
“(b) Second, we will increase the availability and access to dementia care so that caregivers and persons with dementia can seek medical attention early. We have piloted community mental health teams for the elderly (Community Psycho-Geriatric Programme) that partner eldercare agencies to pick up seniors with dementia early. We are also looking at new models of dementia care such as partnerships between specialist memory clinics and General Practitioners. (c) Third, we will strengthen community and caregiver respite services. We are working with MCYS to build up early dementia day-care programmes to keep patients mentally, physically, and socially engaged. We have also piloted a home and community respite service with the Alzheimer's Disease Association. (d) Fourth, we will work with partner agencies to ensure that the supply of services and facilities keeps up with the increase in demand. MOH is expanding the number of nursing home beds. Many of the new nursing homes will be able to serve people with dementia. (e) Finally, we will expand our pool of trained healthcare professionals, including psychiatrists, geriatricians, neurologists, family physicians, nurses, psychologists, occupational therapists, and medical social workers. We will also improve their training on geriatric medicine, and create more subspecialisation opportunities in this area. NATIONAL ELECTRONIC HEALTH RECORDS SYSTEM (Update) 11. Dr Lam Pin Min asked the Minister for Health if he will provide an update on the National Electronic Health Records System, its implementation strategy and the cost implication for Singaporeans once it is implemented.”
“About 20,000 Singaporeans suffer from dementia. This is a prevalence rate of 5.7% among those aged 65 years and above. In comparison, Australia, North America, and Japan reported higher rates of 6.5%, 6.9%, and 8.5% respectively. This is because we have a relatively younger population of those over 65, ie, fewer people in their 90s and over. As more people turn elderly, we will encounter more dementia cases. At the current prevalence rate, we will see the number more than double to about 45,000 by 2020. However, dementia is not part of the normal ageing process. The main causes are vascular dementia and Alzheimer's disease. The risk factors of vascular dementia are the same as for stroke and heart disease. The preventive strategies are therefore similar, namely not smoking, eating in moderation, exercising regularly, and treating high blood pressure and diabetes. As for Alzheimer's disease, doctors still know little about the modifiable risk factors. But people who keep mentally and socially active are less likely to develop Alzheimer's disease. Hence, we need to tackle this growing problem of dementia on multiple fronts: (a) First, we must emphasise prevention. Efforts by the Health Promotion Board to promote a healthy lifestyle from young will also contribute towards preventing dementia. This year, HPB started its public education campaign to increase awareness about dementia, its warning signs, and risk factors. It will continue to educate the public on how best to reduce the risks of the disease. There are also programmes by the PA and Council for Third Age that help older Singaporeans keep active mentally and socially.”
“For Suria, whilst the repeat rate is higher, it is comparable to Channel 5 and CNA. Ultimately, the true test is whether the viewership for Suria and Vasantham has improved. On this count, both Suria and Vasantham have done well, increasing their viewership over the past few years. In 2007, Suria's viewership averaged about 40,000 Malay viewers during prime time; this has increased by more than 65% to about 67,000 viewers last year. Over the same period, Vasantham's prime time viewership, which averaged about 24,000 Indian viewers before its launch as a standalone channel, has increased by about 50% to 36,000 viewers currently. Mr Speaker, Sir, I would like to assure the House that MDA will continue to review its funding support for PSB programmes on Suria and Vasantham, as well as the rest of MediaCorp's channels, so that Singaporeans have every opportunity to enjoy a wide variety of high quality local programmes.”
“The Acting Minister for Information, Communications and the Arts (RAdm [NS] Lui Tuck Yew): Sir, Suria and Vasantham are important channels that reflect our multi-cultural heritage and multi-racial society. They offer relevant Malay and Tamil programmes for these two communities. To support these two channels, the Media Development Authority (MDA) provides public service broadcast (PSB) funding for the production and acquisition of quality programmes, such as news, current affairs, drama and children's programmes. Together with MediaCorp, MDA carries out annual reviews of the funding for PSB programmes across all MediaCorp's TV channels. These annual reviews ensure that the programmes continue to be of high standards and of relevance to Singaporeans. MDA also conducts periodic studies to assess the state of MediaCorp's TV channels. The launch of Vasantham as a standalone channel in 2008 was a recommendation of such a study. As a result, Vasantham's local programme hours have more than doubled from 30 hours to 65 hours a week, and the channel also offers a wider variety of Tamil programmes. To provide greater support for quality local Malay and Tamil programmes, MDA has increased 2010 PSB funding for Suria and Vasantham by about 12% and 27% respectively compared to two years ago, ie, FY2008. Besides supporting MediaCorp's launch of Vasantham as a full-fledged channel, the increase in funding had improved the quality and diversity of programmes for both channels, and reduced the repeat rates. On repeat rates during prime time and off prime time, these vary across MediaCorp's channels depending on the strategy adopted for each channel. For repeat rates during prime time, Vasantham's is now at a level comparable to that for Channel 8.”
“In fact, in many countries electives take months. But we have been spoilt to be able to respond to electives within a few weeks. When my visitors come in from Europe or US, they express surprise. They said, "why do you do that?". For them, to wait a few months for elective surgery is no big deal. But because we have now reached this standard, it is very hard to reduce it. So I plead for some patience, if we have to delay the electives a little in order to cope with this immediate shortage of beds for the next few months, until we fully open Khoo Teck Puat Hospital. Do foreigners crowd out locals? The statistics do not show that because we know that foreigners, including PRs, make up maybe one-third or 35% of the total resident population here. But in subsidised wards, they only make up about 15% of the total in-patient load. 85% are Singaporeans. Why foreigners make up 35% of the population but 15% of in-patient load can be explained because the foreigners, the people working here, are generally young, as compared to locals staying here. Older people do get hospitalised more often. FUNDING OF MALAY AND TAMIL TV PROGRAMMES (Period of review) 3. Mr Zaqy Mohamad asked the Acting Minister for Information, Communications and the Arts (a) how often the Media Development Authority (MDA) reviews the funding for public broadcasting of Malay and Tamil programmes; (b) when was the last time the funding was reviewed for both types of programmes and what was the increase in funding to improve the quality of programmes by MediaCorp; and (c) compared to the English and Mandarin channels, what is the proportion of re-run programmes on the Malay and Tamil channels during prime time and off-peak periods.”
“In hospitals, we handle both, what we call electives – non-emergencies and of course emergencies. Public hospitals typically handle a huge share of emergency workload because we are the only ones with true emergency departments. Private hospitals generally handle elective cases. Elective cases have the advantage of predictability; you plan for it. So if you need something, it can be done this week or next week or next month – it does not really matter. Your health is not affected by it, and you can choose the date. Of course, hospitals and doctors prefer electives because life is simpler, whereas emergencies are so unpredictable. In public hospitals, all emergency workloads are heavy. But some hospitals have heavy electives, too. SGH, for example. Of all the admissions into SGH, I would say about 40% to 45% are electives and 55% are emergencies. Whereas other hospitals like Tan Tock Seng or Changi, the emergency workload is about 90%, so electives make up less than 10%. As electives are scheduled events, doctors generally make the request for the hospitals to schedule elective admissions on Sunday so that the surgery can be done on Monday or Tuesday. The emergency work is still there, but on Mondays and Tuesdays, we superimpose the electives on the emergency workload. That is why Mondays and Tuesdays become extra heavy days. And because patients stay a few days, it all accumulates. So for subsequent days of the week, we will cut down the elective numbers in order to accommodate the number of patients in our available beds. That explains this peak pattern on Mondays and Tuesdays. Over the years, we try to manage but the bottomline is, yes, we are at the moment a bit short of beds. And the correct solution is to delay electives.”
“This has, in turn, spread the problem to them, especially to CGH which had a bed occupancy rate of 91% last week. So we are all eagerly awaiting the opening of the Khoo Teck Puat Hospital later this year. That will add 555 beds to our capacity. The shortage of beds on certain days of the week has a significant impact on customer service. Patients, naturally, would like to be admitted to and be able to get settled down in their preferred ward immediately. Our failure to do so for some patients who have to wait a few hours for this to happen is unsatisfactory. I am sorry for this lapse in service level. However, the clinical care for such patients is never compromised. When patients are waiting to be admitted, they continue to receive the appropriate care. Their doctors would assess the patients, order the necessary tests and initiate the appropriate treatment immediately.”
“Sir, our Emergency Departments attend to all life-threatening cases immediately. There is no waiting for such patients. For non-emergency cases which require admission, their waiting time for a bed will depend on the hospital they visit. Overall, we have sufficient beds but there are mismatches on certain days, like Mondays and Tuesdays, resulting in some patients having to wait for a bed longer than we desire. I can explain why if you ask me a supplementary question later on. To address the problem, we have added new hospital beds over the years, while building the new Khoo Teck Puat Hospital and planning the new Jurong General Hospital. This has provided some relief. This January, for example, the average bed occupancy rate was 82%, ranging from 74% at Alexandra Hospital, 81% at Singapore General Hospital to 89% at Tan Tock Seng Hospital (TTSH). The average bed occupancy rate went down to 77% in February as patients avoided hospitalisation during the Lunar New Year. With the end of the festivity, elective admissions have returned. So last week we were heavily stressed. Among the hospitals, TTSH has the highest number of admissions from its Emergency Department. This is because it serves a large population catchment, both from the north and the central part of Singapore. Nonetheless, most patients do not have to wait long. At TTSH, half of the emergency department admissions in January were admitted to their assigned wards within two hours. Another 35% of patients waited two to four hours. But 5% of patients had to wait more than eight hours. In order to relieve the overcrowding in TTSH, the other hospitals have chipped in, to handle the overflows of ambulance cases and admissions.”
“With computers, we are able to churn out the data and present to family members the estimated bill size for a stay in Class B1, B2, C wards. And they make the choice. I think that is a good approach which we have been able to refine as we go along. WAITING TIME FOR BEDS IN PUBLIC HOSPITALS 2. Mdm Halimah Yacob asked the Minister for Health (a) what is the average waiting time for beds in the public hospitals for both emergency and non-emergency cases; (b) what measures are being taken to address the problem of bed shortage; and (c) whether the bed crunch in public hospitals has affected the quality of care for patients.”
“Bed occupancy for the different classes of wards does differ. I do not have the figures off hand. In subsidised wards, it is higher. The shift is noticeable in one aspect – when patients know that their illnesses are complex, they would generally ask to be downgraded to Class C or B2 as they know they may end up in ICU and Class A charges in ICU can be very expensive. We would do some means testing and where they are obviously in financial difficulty, we will allow the downgrading. That is why the length of stay in Class C is the longest compared to Class A. Those who have minor ailments – likely three or four days in hospital and generally with MediShield and Medisave, they can afford it – they will opt for a private ward. I think this is rational behaviour. The question is whether there was a shift with means testing. If there was, it was not noticeable. We expected that with means testing, only about 10% of the higher-income group would be in Class C or B2, and that has been our experience so far. By and large, Singaporeans are choosing their wards according to their means, which is good. Those who can afford it and do not require as much subsidy, go to the higher classes of wards, and those who cannot afford it, go to the Class C wards. This is the principle behind means testing. The short answer is, "so far, so good". As to advising patients on choice of ward, we do that systematically. At admission, every patient would be given financial counselling. By that time, we would know the preliminary diagnosis and from experience, we could estimate the likely length of stay for a patient with such an aliment, and the cost of the stay.”
“But as I promised when we launched that programme three years ago, the bulk of the cost increases will be borne by the Government because our subsidy policy remains unchanged.”
“Indeed, affordability has to do with ability to pay. In our case, quite unique in the world, we have a compulsory savings scheme through Medisave. Without Medisave, healthcare costs would be quite difficult to afford. I think this is one advantage that we have built up over more than 24 years now. And it is an advantage that will continue to be beneficial to Singaporeans. As I said earlier, with Medisave and MediShield, 80% need not have to come out with a single dollar. The other 20% of patients have to come out with some money but it has not been a major issue. That has been our experience in the hospitals. One evidence is the extent of bad debt. In many countries, hospital bad debt is a problem. That is an expression of unaffordability, where they are not able to pay and therefore ending up with an inability to pay their bills. But in our public hospitals, bad debt has not been a problem. The last I saw, bad debt was about 2% of total revenue, which is quite reasonable. I gave a range of increases in bills – from 3% in Class B1 to 10% in Class B2. The other classes are in between. Class A is 7% and Class C is 8%. The reasons for cost increases have been discussed several times in this House. Wage increase is one because this is a very labour-intensive industry. Some of the cost increases are deliberate because as I explained to this House in 2007, we wanted to improve the staff-to-patient ratio. We launched a five-year programme in 2007 to increase doctors, nurses and allied professionals substantially. Next week, when we discuss our Ministry's budget, I will give an update on the progress of this significant increase in staffing level. That was a deliberate move and would push up costs.”
“I do not have the complete 2009 data yet. Based on the claims submitted during the first nine months of 2009, the average acute hospital bills incurred in Class A, B1, B2 and C wards were respectively: $4,751; $3,873; $1,660; and $1,506. The distribution of patients was 8% in Class A, 12% in B1, 39% in B2 and 41% in C. Patients would tap on various kinds of payment modes, from Medisave, insurance, employers’ medical benefits to outright cash. I do not have the breakdown of these payment modes. However, we know that 80% of all subsidised patients would not need to fork out any cash, after Medisave and MediShield deductions. Between 2008 and 2009, the increase in the average bill sizes ranged from 3% in Class B1 to 10% in Class B2.”
“MOH's estimate is that about 15% of the patients being treated have used their Medisave to help pay their outpatient treatment. About 70% of the claims were within the $300 annual withdrawal limit. For those whose bills exceed $300 per year, they can tap on the Medisave accounts of their family members. Very few did. DISABILITY AMONG YOUNGER SINGAPOREANS 6. Ms Sylvia Lim asked the Minister for Community Development, Youth and Sports whether he will provide an estimate as to how many Singapore residents below 60 years old are disabled.”
“Based on the data in FY 2008, the average bill sizes in the polyclinics were $16 for an acute condition, requiring four types of medication, and $48 for a chronic condition requiring three months of medication. The corresponding median bill sizes were $14 and $36 respectively, based on the data supplied by the NHG Cluster. USAGE OF MEDISAVE FOR OUTPATIENT TREATMENT 5. Ms Sylvia Lim asked the Minister for Health with regard to the utilisation of Medisave from 2006 to 2009 for outpatient treatment of chronic diseases (a) what proportion of outpatients who suffered from the health conditions for which Medisave payment was permitted had paid their outpatient bills using Medisave; and (b) out of the numbers who had done so, how many had exhausted the annual withdrawal limit of $300.”
“The ComCare Social Support Projects Fund (CSPF) and the ComCare Enterprise Fund (CEF) also provide seed funding for pilot programmes and sustainable new social enterprises respectively that meet the needs of the low-income and needy. Over $830,000 were disbursed between April and December 2009. Besides ComCare, there are other help schemes provided by voluntary welfare organisations, self-help groups, grassroots organisations, charities, religious groups and foundations. All these efforts complement the Government’s assistance schemes under the Many Helping Hands approach to form a strong social safety net for needy Singaporeans. I would like to thank the CDC Mayors, Advisers to grassroots organisations and partner organisations in the social sector for their efforts and support. If Members come across anyone who needs assistance, please call ComCare Call at 1800-222 0000 or refer them to the CDCs, grassroots organisations or Family Service Centres.”
“ComCare Transitions, on the other hand, aims to help those who are temporarily unable to work. As at end December 2009, 2,300 individuals were being assisted under the ComCare Transitions scheme. Most of these clients are single. The majority of ComCare Transitions and Work Support beneficiaries have educational qualifications of "O" levels and below (82%), live in 1-room to 3-room HDB flats (59%), and have household income of less than $600 per month (67%). Between April and December 2009, up to $19 million has been disbursed for these two schemes. This figure amounts to 37% of overall ComCare spending. As at end December 2009, there are about 2,900 beneficiaries under the Public Assistance (PA) Scheme. Recipients on PA are generally the elderly, with a majority aged above 60 years old, with little or no means of support. A total of $10.9 million was spent on PA between April and December 2009. This is equivalent to 21% of all ComCare spending in the first three quarters of FY2009. The CDCs continue to be the first line of support for needy residents. From January to December 2009, the CDCs received 62,300 applications for assistance, a 32% increase over 2008. Apart from specific programmes, the ComCare Fund also provides funds to empower the community to help the needy. The CCC ComCare Fund helps needy Singaporeans with urgent and transient needs. Between April and December 2009, the CCCs have disbursed $2.4 million through grassroots leaders to more than 12,600 needy people. This is 42% more than the number of people helped in the same period in 2008.”
“This increase in spending went towards assistance to help more needy families during the economic downturn. From January to December 2009, almost 33,000 cases were approved for assistance under the three ComCare pillars: ComCare GROW, ComCare Self-Reliance and ComCare EnAble. This is a 47% increase from a year ago. As ComCare is targeted at the most needy, close to 48% of ComCare beneficiaries have household income less than $750 per month, and most have educational qualifications of "O" levels and below. About 60% are married with families. The beneficiaries helped under the different ComCare programmes have different profiles. Let me share with you a little more on this. ComCare GROW programmes help young children from low-income families gain access to developmental opportunities and enable them to break out of the poverty cycle. Thirty-five per cent of ComCare expenditure for the first three quarters of FY2009 went to ComCare GROW programmes, with $18.1 million disbursed for the Kindergarten Financial Assistance Scheme (KiFAS), the Centre-based Financial Assistance Scheme for Childcare (CFAC), Student Care Fee Assistance (SCFA) and the Healthy Start Programme (HSP). The beneficiaries are families with children with a monthly household income of $1,800 and below. Close to 18,000 children from low-income families are being assisted on these programmes as at end December 2009. Under the ComCare Self-Reliance pillar, we have the Work Support Programme and ComCare Transitions scheme. Work Support aims to help those who need temporary financial and employment assistance. Three thousand and seven hundred households were being assisted under Work Support as at end December 2009. The majority of our Work Support beneficiaries are families (62%).”
“Mdm Halimah Yacob asked the Minister for Community Development, Youth and Sports (a) what is the total amount disbursed in 2009 under the various financial assistance programmes including the Comcare Fund; and (b) how many families have benefited from these schemes and what is the profile of these families. The Minister of State for Community Development, Youth and Sports (Mrs Yu-Foo Yee Shoon) (for the Minister for Community Development, Youth and Sports): Mr Speaker, Sir, 2009 has been an exceptional year in terms of Government assistance to needy Singaporeans. In light of the economic downturn, the Government had rolled out the Jobs Credit Scheme, Workfare Income Supplement (Special Payment), Skills Programme for Upgrading and Resilience (SPUR) and other programmes to help Singaporeans ride through the recession. MCYS had also increased its budget to help needy Singaporeans. As a whole, we expect to spend $240 million in FY2009 for financial assistance, funding of social services and the building of social infrastructure. This is an increase of 31% over the spending in FY2008. The Community Care Endowment Fund, or ComCare for short, was set up in 2005 to provide financial assistance to the lowest 20% of Singaporeans. The various help schemes are mainly administered by the Community Development Councils (CDCs) and Citizens’ Consultative Committees (CCCs). In FY2009, MCYS expects to spend about $72.2 million on ComCare programmes. This is a 41% increase from the $51.1 million the Ministry spent on similar programmes in FY2008. For the first three quarters of FY2009 (April to December 2009), MCYS disbursed a total of $51.3 million on the various ComCare schemes. This is a 38% increase over the amount disbursed for the same period in FY2008.”