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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“Currently, there are four inpatient hospices, with a total of 127 beds. Their average bed occupancy rate is about 70%. As we promote palliative care, increased awareness and an ageing population should lead to an increase in demand for palliative care. We are gearing up for this development. First, we are expanding capacity. Several hospice providers intend to increase their bed capacity and we are working with them. As a short term target, our plan is to increase the current capacity by about 70 beds. We are also working with home hospice providers to expand this sector so that more patients can receive palliative care at home. Second, we are recruiting and training more palliative specialists. Currently, we have 17 palliative medicine physicians, with a good pipeline of trainees. By 2012, the pool should grow to 25. We are also exposing more doctors to palliative care and palliative care is now part of the training curriculum for all family physicians. As a result, there is a growing interest among doctors, especially family physicians, to take up palliative training as a subspecialty. Thirdly, we are also expanding the pool of nurses trained in palliative care. Currently, we have 141 nurses trained in palliative care. We are sending more nurses on courses on palliative care through our Health Manpower Development Programme. In addition, we have started an Advanced Diploma in Nursing (Palliative Care) programme in Nanyang Polytechnic. From next year, we should see about 20 nurses graduate annually from the programme. Meanwhile, many institutions are providing shorter courses to equip our nurses with the basic skills of palliative management. Column No : 1779 FUNDING FOR SPORTING ACTIVITIES FOR DISABLED 30.”
“While we will continue to invest in healthcare and spend more than now, we must also press on with efficiency and productivity drive on the supply side, and on the demand side, to get Singaporeans to embrace a healthy lifestyle from young. PRIMARY ONE REGISTRATION EXERCISE (Number of PR applicants) 4. Mr Baey Yam Keng asked the Minister for Education (a) what is the percentage and number of permanent residents who gained entry at each phase of the Primary One Registration Exercise in the last three years; and (b) whether there is a need to revise the criteria so that Singapore citizens will be given higher priority at each registration phase for the schools of choice.”
“The recent announcement pertains to the use of Medisave for home palliative care from next year. Medisave can already be used for inpatient hospice care. Last year, about 5,100 patients received hospice and palliative care services, of which about 4,000 were cared for at home. The services are funded largely through Government subsidy and Medisave withdrawals. For the low income patients, my Ministry subsidises up to 75% of the cost. Last year, Government subsidy exceeded $5 million while Medisave withdrawals were about $1.5 million. With greater awareness of palliative care and its promotion by my Ministry, we can expect these figures to rise in tandem with the rise in demand as the population ages further. More than 90% of our current palliative care patients are cancer patients. Among the cancer patients, about 70% receive palliative care. This utilisation rate is comparable to that in the UK and Australia. However, our utilisation of palliative care among the patients with non-cancer terminal illnesses, such as end-stage organ failure, remains low. There is scope to develop this sector further. Currently, health spending amounted to about 4% of our GDP. All over the world, health spending has been growing faster than GDP. Singapore is no exception. One contributing factor is the ageing of the population. There are various projections on the future rate of growth, based on different assumptions. However, simply putting in more money will not solve the healthcare challenges. More money does not automatically translate into a better health outcome.”
“Mdm Halimah Yacob asked the Minister for Manpower (a) what is the breakdown of workers trained in 2008 by age group, gender, educational profile and race; (b) whether he will provide an assessment of employers' support for the training of older workers; and (c) whether there was any research done to assess the effectiveness of training in helping older workers to improve their employability, career prospects and earning power.”
“We do many things to try to increase the take-up rate. We share a common objective that as many Singaporeans as possible ought to be "Shielded", and the coverage rates are not bad. I have in an earlier reply during a past Sitting mentioned that among working adults, more than 90% are insured with at least MediShield. Among all Singaporean residents, about 85% have medical insurance. If you look at the remaining uninsured, 15% or so, two large groups are prominent – first, young kids, those below 20 years old, form a big number, about 300,000. They are not insured for various reasons, ignorance or inertia. Another big group, maybe about a quarter million, or 300,000, comprises housewives whose husbands have forgotten to insure for them. On both fronts, we are working very hard to get them in. For the kids, it is easier because at the stage of registering birth for all newborns, we can remind the parents to sign up their kids. We have more than a year of experience with this system now. 98% of all parents said, yes. Only 2% opted out for whatever reasons. Among the housewives, I am working very hard with Mdm Halimah and NTUC to get them in, and we will get there, I am quite sure of that. It is a matter of time. These are for basic MediShield. And among them, about 60% have private insurance as top-up. If you look at it as a total population, about half of Singaporeans have private insurance. And if you remember that private insurance is really meant for the upper and middle class who prefer and can afford private hospitals, then 50% of medical insurance coverage for private shields is quite a good coverage rate. TRAINING OF OLDER WORKERS 15.”
“In the same website, we provide a comparison of the key features of the Integrated Shield Plans marketed in Singapore. This will help the public to choose the plan that best meets their needs and budget. However, the Ministry of Health does not regulate the decision of private insurers on whether to accept an applicant into their plan. These decisions will have to be made by the insurers based on their claims experience, risk appetite and actuarial analysis. We therefore do not have data on the proportion of applicants who are not accepted for private health insurance coverage, nor the reasons for the rejection. But we do require the insurers to guarantee renewals so that policyholders are not dropped should they fall sick and incur higher claims later. Assoc. Prof. Paulin Tay Straughan: I would like to ask the Minister a supplementary question. Can the Minister comment on the take-up rates for private insurance? I just want to have a good sense of what the gap is out there and the efforts taken by the Ministry to improve the take-up rates.”
“Sir, private health insurers are regulated by both the Monetary Authority of Singapore (MAS) and my Ministry. MAS regulates and supervises all insurance companies in Singapore, so it includes those that offer health insurance. MAS regulates them with a view to promoting the safety and soundness of the industry. Insurance companies are required to have sound risk management systems and maintain adequate financial resources in order to meet their obligations to policyholders. My Ministry regulates Medisave-approved Integrated Shield Plans to ensure that they make proper use of Medisave monies for the welfare of policyholders. We require the Integrated Shield Plans to focus on catastrophic coverage where risk-pooling is most effective. They must retain the core co-payment principle through features such as deductibles and co-insurance. This is to discourage over-consumption and help to keep premiums affordable. Before a plan can be marketed, it is scrutinised by my Ministry to ensure that it complies with these basic requirements. The insurers compete to provide their policyholders with the most cost-effective insurance protection over their lifetime in the most sustainable manner. We encourage them to innovate with new product features but we discourage comprehensive first dollar coverage which has led to many moral hazard problems elsewhere. We encourage insurers to be transparent and upfront with their customers by keeping their terms and conditions simple and clear. Where necessary, we may require an insurer to amend its contract if any of the terms and conditions is ambiguous. We assess the performance of the insurers on an ongoing basis. For example, the time taken for them to process claims is published on my Ministry's website and updated quarterly.”
“Paulin Tay Straughan asked the Minister for Health (a) whether there is a regulatory body that oversees private health insurers in Singapore; (b) whether there is data on the proportion of rejected applications for private health insurance; and (c) what are the reasons for rejecting these applicants.”
“Sir, pneumococcal disease is a major public health problem all over the world. The World Health Organization has estimated that up to one million children die of pneumococcal disease every year, mostly in the developing countries. The disease is caused by bacteria called Streptococcus pneumoniae. Transmission is via direct contact with respiratory secretions from infected persons who may or may not show clinical symptoms. Pneumococcal infections may be invasive, causing, for example, pneumonia and meningitis. The infections may also be non-invasive causing conditions such as middle-ear infections and sinusitis. In Singapore, there were about 70 hospitalisations among children under five years of age for pneumococcal disease every year. Since 2000, we have recorded seven deaths among young children from invasive pneumococcal disease. Fortunately, a vaccine is available to protect children against this disease. Extensive studies have shown the vaccine to be safe and effective. Several countries, including Australia, New Zealand, UK and the US have included pneumococcal vaccination in their national childhood immunisation programmes. Our Expert Committee on Immunisation has reviewed this and they have recommended that we follow suit. My Ministry has considered and accepted the Expert Committee's recommendation to include pneumococcal vaccination into our National Childhood Immunisation Programme. We are following up on the implementation details. PRIVATE HEALTH INSURERS 14. Assoc. Prof.”
“Table 1 – Profile of IMH outpatients (2008) Gender Female 15,089 (44%) Male 18,607(55%) Race Chinese 26,826 (80%) Malay 3,102 ( 9%) Indian 2,409 ( 7%) Others 1,360 ( 4%) Age Group Adult 23,949 (71%) Child and Adolescents 5,683 (17%) Geriatric 4,065 (12%) Column No : 1427 PUBLIC SECTOR TENDERS (Awarding contracts) 4. Mdm Halimah Yacob asked the Minister for Finance (a) whether the public sector is required to award contracts to the lowest tender when outsourcing its activities; and (b) how does it ensure that contractors who tender cheaply do not exploit their workers.”
“There is a wide range of mental illnesses, many kinds of which are mild. As they are not notifiable diseases, we do not have precise numbers. Instead, countries conduct periodic health surveys to ascertain the prevalence of mental illness in their populations. The most recent global survey was made by the World Health Organization (WHO) in 2004. WHO classified mental illnesses under two broad groupings: (a) anxiety disorders, such as generalised anxiety, phobias, obsessive-compulsive disorder and panic disorder; and (b) mood disorders, such as bipolar disorder and depression. Based on this WHO study, the prevalence in Singapore is generally lower or comparable to other developed countries. For example, the rates for anxiety were 18.2% in the United States, 12% in France, 5.3% in Japan and 3.4% in Singapore. As for depression, the prevalence rates were 9.6% in the US, 8.5% in France, 5.6% in Singapore and 3.1% in Japan. Some mental illnesses are more serious, such as schizophrenia, but they are less common. Information is also less readily available. The life-time prevalence of schizophrenia is generally thought to be below 1% in most countries. This is consistent with our local estimate of 0.7%. While schizophrenia is a serious illness, the majority of them are non-aggressive. With proper treatment and support, they can live meaningful and productive lives in the community. We do not have nationwide statistics. As an indication, Table 1 provides the breakdown of the profile of the outpatients treated in the Institute of Mental Health (IMH), bearing in mind that IMH sees patients at the more serious end of the spectrum.”
“Mr Yeo Guat Kwang asked the Minister for Manpower (a) what is the progress of implementation of the Portable Medical Benefits Scheme (PMBS) in the private sector; (b) whether the Ministry is satisfied with the implementation status; and (c) whether the Ministry has any plans to encourage employers to adopt the PMBS in place of existing company-based group hospitalisation and surgical plans which are not portable for employees.”
“This is to ensure that the donor has sufficient time to carefully consider his decision before taking this significant step. Live organ donation is a serious decision. For the donor to make a fully informed choice, the transplant team must make sure that every donor is told about the risks involved. In addition to receiving a rigorous medical fitness evaluation, every donor will be counselled about the medical, psychological, social and financial aspects of the donation. The TEC must be satisfied that the donor demonstrates a good understanding of the organ donation process and its implications. The National Organ Transplant Unit will provide independent donor advocacy. All potential donors will have access to relevant information so that they know what to ask their doctors, what are their rights and the provisions for their welfare. In addition, there will be a donor hotline to be manned by the Organ Transplant Unit for any queries by donors or their families. Although donation surgery is safe, no surgery is 100% risk-free and there can be complications, which will require further treatment. Therefore, we will advise all donors to have medical insurance protection if they have not already done so. Finally, Mr de Souza asked if the regulations will state the formula by which the quantum of reimbursement is calculated or include a cap on the maximum amount. We had a full debate on this particular point in this House. I do not intend to go through the arguments again. Let us get the amendments implemented and as we gain more experience, we will see if we need to further revise our regulations. Column No : 1407 PORTABLE MEDICAL BENEFITS 31.”
“For each transplant application, they will have to review the mode, categories and the nature and quantum of any payment amount to satisfy themselves that there has been no inducement of or coercion on the donor. The declaration forms are legal documents submitted by the donor and recipient stating that no inducement or coercion is involved. They include the declaration of any arrangement by the recipient for reimbursing the donor’s expenses. It is an offence to submit any false or misleading declaration. After consulting the National Medical Ethics Committee, the Ministry of Health (MOH) has revised the current set of guidelines for living organ donation. All TECs shall abide by the guidelines. Meanwhile, we are reconstituting the TECs to include new members and more perspectives. At our invitation, many prominent citizens have agreed to join the panels, including a couple of our parliamentary colleagues. We will be providing the TEC members appropriate training to help them conduct their assessments. The National University of Singapore ( NUS) Centre for Biomedical Ethics will be organising these sessions on a regular basis. The Centre will also provide a platform for the TEC members to meet regularly and share their experiences, compare notes and learn best practices. We have further refined the TEC approval process. If a case is approved by a TEC, the approval shall be valid only for 60 days, as circumstances can change and the justification on which the TEC made its decision may no longer be valid. If a case is rejected by the TEC, the rejection will be binding on other TECs. The case can only be reviewed after approval by MOH to do so. We have also imposed a mandatory cooling-off period of one week between TEC approval and the transplant surgery.”
“There are four major amendments to the Human Organ Transplant Act (HOTA) and we are at different stages of implementing them. The first amendment is to lift the age limit on cadaveric donation. We have launched a large scale mass-media campaign, to inform Singaporeans about this amendment. This included newspaper and TV advertisements, brochures and posters in many public venues. We have mailed to all households the new HOTA booklet containing the information about the HOTA changes, in four languages. We have amended the HOTA forms for opting-out and withdrawal of objection; they came into effect on 1st July. We have also gazetted the regulations setting the implementation date at 1st November 2009. In reciprocity to this amendment, we have lifted the age limit for patients on the waiting list for organs. We no longer remove patients from the waiting list when they reach 60. The second amendment is to allow paired-match transplant. If suitable cases come along, we will allow it. So far, we have not received any such request yet. We do not expect many cases, but to ensure the best chance of realising this, we have established a standard protocol and a national database to facilitate the paired matching. The third amendment is to raise the penalty on organ trading syndicates. We are working closely with hospital transplant ethics committees (TECs) and will continue to maintain vigilance over this. We will not hesitate to bring culprits to court. The fourth amendment is to enable organ recipients to reimburse the expenses incurred by their donors, if they wish to do so. The hospital TECs play an important role in ensuring ethical transplants.”
“Certainly with the return of the Northern winter, there are worries and fears that if the virus mutates and becomes more deadly, the next wave could be very troublesome. That is why scientists all over the world, including ourselves, continue to survey and study the strain very carefully. So far, so good. Viruses always mutate but the mutation of the deadly kind has yet to emerge and hopefully may not emerge in the short or even medium term. But we have been watching the H1N1-2009 incidence in the Northern Hemisphere, particularly in North America. From the peak of H1N1-2009 making up some 40% or 50% of all patients with flu-like symptoms, it has come down drastically to single-digit percentage, eg, in Canada or in the teens in North America. So the easing of the epidemic in the Northern Hemisphere is taking place, but we have to continue to watch what the winter brings with it. One very positive development is that vaccines have now been created and factories are trying to produce as many as they can and we will get our supply soon. We are finalising our purchase order. I will make some announcement this week. Column No : 1299 ROAD CLOSURES FOR F1 RACE 7. Mr Calvin Cheng asked the Minister for Trade and Industry in view of the Monaco Formula One (F1) race where roads are only closed a few hours before and after the race and practice sessions, whether road closures for the Singapore F1 can be further shortened to reduce the impact on businesses along the F1 race circuit.”
“On the Member's second point, was he referring to pneumococcal vaccine? As another Member has filed a PQ on this, allow me to reply to it fully later on. On the various surveillance and border temperature-screening procedures, we review it all the time. Now that the character and the clinical implications of the new strain are much better understood, we have been progressively reducing the measures. But as I just said five minutes ago, we remain at code yellow. Once the vaccine becomes available as an additional measure to address this pandemic, we would of course review the colour code again. But even with the same colour code, there is scope for calibration of the measures, allowing us to progressively reduce them. At the borders, we no longer do temperature screening. In the hospitals, we maintain some screening. But we are actively looking at possibilities of further reducing temperature screening in the hospitals to perhaps just the high-risk areas such as the emergency departments.”
“And this is the reason why we remain in alert code yellow and not green. To reduce mortality, the most important measure is vaccination. When a safe and effective vaccine becomes available, we will make it widely available to the people. We will recommend it especially to the frontline staff and to those at high risk of developing serious complications from influenza.”
“Sir, seasonal influenza as a direct cause for death is very hard to establish. Firstly, we do not routinely test patients for seasonal influenza. Secondly, patients with complications often have other underlying medical conditions. Their deaths may therefore be due to such underlying medical conditions with seasonal influenza as a contributing factor. Deaths due to seasonal influenza are therefore commonly estimated using mathematical modelling techniques. Using such methods, a local study has estimated that there are about 600 influenza-related deaths in Singapore each year. As Influenza H1N1-2009 is a new strain and as the world is still in the midst of a pandemic caused by it, we carried out many more laboratory investigations on some of the infected patients especially those who present with clinical complications. Based on such observations, we have recorded 18 deaths due to this strain of influenza so far. As the methodology of computing these death rates are different, we should not try to directly compare the death rates. The underlying cause of death in influenza infection whether by seasonal influenza or the new strain is commonly pneumonia. Influenza may also cause death by exacerbating pre-existing chronic heart disease resulting in a heart attack or chronic lung disease resulting in respiratory failure. In the case of the new strain, there have also been complications and even deaths among some patients without any underlying medical conditions. This continues to baffle the doctors and scientists and we do not have good answers as yet. While we are comforted by the fact that the new strain remains largely mild among the vast majority of the infected patients, we cannot treat it lightly.”
“Dr Lam Pin Min asked the Minister for Health (a) what are the mortality rates from seasonal influenza for the past three years as compared to the Influenza A (H1N1-2009); (b) what are the underlying cause(s) of death for both conditions; and (c) whether the mortality rates can be further reduced through appropriate medical prophylaxis.”
“For us in public hospitals, our mission is very clear. Our primary objective is to look after Singaporeans' health, particularly those in the bottom half of the population who have no choice. If you are in the upper half, you can consider going to private hospitals or even foreign hospitals. But for the bottom half, we are the only provider for them. That is why our priority or mission is crystal clear; we would always go that way. There are mechanisms in place as our departments are all peer- reviewed. CEOs and departmental heads regularly review work performance and if some professionals neglect their subsidised patients, that will show up in their performance appraisal. Let me assure Members that we will never neglect local patients and simply chase the foreign patient load; we do not. I have repeatedly clarified that medical tourism is never an objective. As far as MOH is concerned, it is an outcome. If we continue to raise our medical standards and keep prices affordable for all Singaporeans, our reputation will spread and foreign patients will naturally come to our shores. And I see no reasons why we should reject them just because they are foreigners. We will treat them within our capabilities and capacity. When we do long-term planning – whether it is manpower or capabilities – we will have to factor in foreign patient load. In practice, the percentage of foreign patient load in public hospitals is not huge. Column No : 1296 H1N1-2009 (Mortality rates) 6.”
“We should allow it as consumers would benefit through such increased competition across the border. Assoc. Prof. Paulin Tay Straughan (Nominated Member): Thank you, Mr Speaker. May I follow up on that last point, Minister? Can you comment on the implications of medical tourism on healthcare cost for Singaporeans? What I am worried about in particular is in the allocation of scarce resources. Where are the checks and balances? What mechanisms are in place to ensure that our medical professionals are looking after the healthcare needs of Singaporeans as their primary concern?”
“I have addressed that point some time ago. Our original target of one million patients by 2012 – we have acknowledged, when we declared it, is a stretched target. It helps mark the goalpost that we want to work towards. When I addressed this point a few months ago, I said that 2012 is probably unrealistic a target. Nevertheless, we will do our best to try to reach this goalpost. Part of the reason is that our domestic demand has also grown a lot. There was actually a shortage, up till last year, of capacity. Our demand is bigger than what we can cope with. We were turning away patients because when supply is below demand, prices adjust themselves, and we probably priced ourselves out at the margin. That is why we got the URA land sales activated and we have now two new projects coming on-stream. But yes, I think 2012 target of one million foreign patients is probably not realistic. How many hospitals are JCI accredited? I believe all public hospitals are JCI accredited. Some private hospitals are. I do not intend to make it mandatory. Private hospitals will respond to market signals. If the patients demand JCI standards and JCI accreditation will help in their marketing, I am sure they will pursue it. I think the private sector CEOs are all pursuing in this direction. On the number of Singaporeans who are medical tourists, I do not have such data. Anecdotally, our counterparts in, for example, Bangkok or Malaysia/Melaka, mentioned that many Singaporeans go there for elective surgeries at substantially lower rates. This is part and parcel of globalisation. Many foreign patients will come here and some of our own patients will go across to Johor Baru, for example, for cheaper-priced treatments.”
“The world is hungry for practical solutions to help people stay healthy, manage their chronic illness and reduce their medical bills. Attracting the sick to come here for treatment is one component of SingaporeMedicine. Contributing to the research and innovation that can yield useful solutions to the global healthcare problems is another major component. That is why we invest in clinical and translational research, support clinician-scientists and offer our hospitals and healthcare providers as test sites for such innovative ideas. This is part of the joint MOH and EDB "Health and Wellness" initiative, where we are positioning Singapore as a future-oriented Living Lab, for the industry to work with the public sector in co-creating, conceptualising, test-bedding and adopting innovative solutions, which could subsequently be exported. While we are still at the early phase of this development, there are opportunities for Singapore to be a leader in addressing global healthcare challenges. The prospects are promising and exciting.”
“Sir, the number of medical tourist arrivals is estimated through annual surveys by the Singapore Tourism Board. The 2009 figures are not yet available. Given the global economic slowdown, we should expect a drop in the number of medical tourists this year. The H1N1 outbreak has further dampened medical travel demand, especially during the initial months of the outbreak. Nonetheless, our major private hospitals experienced only marginal changes in revenue for the second quarter of this year, as compared to the second quarter of last year. This suggests that the impact of the downturn and H1N1 so far is not as bad as originally projected. As the region recovers from the recession, our healthcare system should be able to capture the upturn in medical tourism. We have a competent healthcare system, with world-class facilities and a well-deserved reputation for high medical and ethical standards. We continue with our efforts to expand the capacity and to raise the capabilities of our healthcare services, in both the public and the private sectors. Two new private hospitals are slated to open in 2012 and will give us additional capacity to cater to both locals and foreigners. Professional manpower will continue to be expanded, through increased local training and foreign recruitment. Let me add that SingaporeMedicine should not be narrowly defined and measured by the number of foreign patients coming here. That is only one part of the larger biomedical science sectoral development which we have embarked upon. Beside traditional pharmaceutical investments, a growing area is in medical technology investments, healthcare informatics, healthcare innovations and effective preventive healthcare programmes.”
“We strongly advise all Singaporeans to subscribe to MediShield. We do so through an opt-out scheme. We have not made it mandatory as we foresee problems of enforcing subscription. Under the opt-out approach, 87% of women above the age of 20 have achieved MediShield coverage, which is not bad. But we are working with Mdm Halimah Yacob and the NTUC to raise the coverage rate further. Column No : 1253 WORKING FROM HOME 26. Mdm Ho Geok Choo asked the Minister for Manpower how many employers in Singapore allow their employees to work from home.”
“Column No : 1253 MEDISHIELD FOR HOMEMAKERS 25. Mdm Halimah Yacob asked the Minister for Health if he will consider making it compulsory for husbands to cover their homemaker wives under MediShield.”
“Foreigners coming to work in Singapore are required to have a medical examination to assess their health and fitness status. As part of this medical examination, they are screened for four infectious diseases, namely, tuberculosis (TB), malaria, human immunodeficiency virus (HIV) and syphilis. Those who are found to have malaria and syphilis will be given the appropriate treatment. However, those who have HIV infection or active TB are generally not allowed to work in Singapore. We continually review the screening parameters and put in additional measures as necessary. For example, last year, we included an additional requirement for foreign domestic workers with scarring on their chest X-ray to undergo further evaluation for active TB disease. Scarring indicates past infection with TB, and those with scarring are at a higher risk of developing active TB disease. We have put in this additional precaution for foreign domestic workers as they work in families which may have young children or elderly people, who are more vulnerable. Screening for malaria is currently carried out using the peripheral blood film test. This test is most useful when the patient has fever, and is less effective for screening purposes in asymptomatic individuals. We are currently reviewing this screening programme as well as increasing awareness and enhancing early detection of cases. The disease with the highest number of imported cases last year was Chikungunya. However, the majority of the cases were imported by Singapore residents. Foreign workers accounted for only 15% of the imported cases. Chikungunya fever is a viral disease transmitted by the bite of infected Aedes mosquitoes. As with malaria, the key to controlling Chikungunya is targeted control of the mosquito vector.”
“We will help them upgrade their skills in palliative care approaches to enable their terminally ill patients to receive good care towards the end of life. Some training in palliative care is already part of their basic training. But we hope some of them will subsequently take up more advanced training in this field. And we must not neglect the nurses. My Ministry’s Healthcare Manpower Development Programme has been extended to provide training in palliative care nursing. For example, we are supporting Dover Park Hospice to train up to 100 nurses in basic palliative care nursing within the next 12 months. We will also encourage more nurses to take up the Advanced Diploma in Nursing (Palliative Care) programme at the Nanyang Polytechnic. Column No : 1245 WORKFARE INCOME SUPPLEMENT (Update) 20. Mr Christopher de Souza asked the Minister for Manpower (a) how many Singaporeans have benefited from the Workfare Income Supplement (WIS) since its introduction in 2007; (b) what is the amount of WIS which has been paid so far; (c) of those not paying CPF previously, how many have contributed to their CPF in order to benefit from WIS; and (d) what is the estimated number of workers who have not yet benefited from WIS due to non-contribution to CPF. 21. Mr Christopher de Souza asked the Minister for Manpower if he will reconsider allowing workers whose basic pay is less than $1,500 but whose total pay exceeds $1,500 (due to overtime) to be eligible for Workfare Income Supplement (WIS).”
“Palliative care in Singapore has grown since its early days in the 1980s. There are now seven providers of inpatient hospice and home palliative care. Together, they serve more than 5,000 patients a year. Palliative care has also entered mainstream medical care and palliative medicine, a recognised sub-specialty since 2007. Patients can now use Medisave for inpatient hospice care and soon, home palliative care. There are now palliative care units in practically all the public hospitals with significant oncology or palliative patient loads. The private sector has also taken an interest in palliative care. We are happy with the development but there is scope to go further. First, there are many more patients and their families who can benefit from palliative care. We have to continue to raise awareness through continuing public education. My Ministry is planning a major push this year. Second, there is now better coordination of care between hospitals and hospice providers. The hospice service providers can receive direct referrals from the hospitals. We would like to extend this to nursing homes where some patients may benefit from palliative care. Tan Tock Seng Hospital has started a pilot programme to provide end-of-life planning and palliative care to some nursing homes. Third, we need to further strengthen community palliative care so that they can cope with rising demand for their service. My Ministry is working with hospice service providers on this. An important area is availability of professional staff with interest in palliative medicine. We are still short of palliative care doctors, nurses and social workers. We will recruit and train more. We must also leverage on the large number of family physicians out there.”
“Column No : 1243 PALLIATIVE CARE (Integration) 19. Mdm Halimah Yacob asked the Minister for Health (a) if he will provide an update on the state of palliative care in Singapore and whether it is now better integrated across our healthcare system; and (b) whether there are enough trained healthcare professionals to provide effective palliative care.”
“Third, we want to make home care more affordable through gradually extending the 3Ms framework to long-term care and home care. As a first step, we have decided to extend Medisave to cover home palliative care. As we gain more experience with this pilot, we will consider how the scheme can be further extended to other home care services. Fourth, we will work with the home care providers to improve the coordination of the various home care services, as well as the integration of home care with primary care and hospital care. We will link up home care providers with the GPs, polyclinics and the hospitals, so that there will be less hassle as patients move from one care setting to another. Without coordination and integration, the patients and their families are often at a loss as to how to access the relevant services. The objective is to care and support the elderly with more complex care needs, so that they can stay at home for as long as possible. We have begun discussion with the Home Nursing Foundation on this idea as we think that it can play an important role in the transformation of the home healthcare sector. Finally, we need to ensure that caregivers are well trained to cope with the physical and socio-emotional needs of the elderly. We provide a Caregiver Training Grant to help caregivers participate in such training programmes. In addition, we are currently studying the need to provide structured skills training for foreign domestic workers as they often are critical members of the caregiver team. Home care is a focus area of MOH. There is much that we need to do to beef it up. Our population is still young, but we will have to start to put the various pieces in place to prepare for a more elderly population in the future.”
“As a policy, we support the idea that all seniors should age at home, and not have to rely on long-term institutional care. The vast majority of the elderly are generally healthy and are able to age at home. A small minority will however require long-term medical or nursing care. Where it is not practical to provide such professional care at home, admission to a nursing home becomes inevitable. But we should try to avoid such an outcome as far as practicable. Where it is cost-effective to bring medical or nursing care to the patients at home, we should try to facilitate it. This is also the preferred option by the seniors as they can then remain in a familiar environment, and be in the company of their family members. Currently, home healthcare is not a big part of our healthcare sector. But as our population ages further, we can expect the demand for it to grow. Thus, an important part of our strategy for home care is to ensure there is sufficient capacity in the sector to meet the growing demand. This means an adequate supply of healthcare workers, including doctors, nurses, therapists and other allied health professionals. We are ramping up their numbers through increased training and foreign recruitment. We will also need to expand the number of daycare centres, in tandem with rising demand. Second, we will enhance the capabilities of our home care services. We will need to raise their professional skills and standards so that they are confident to care for the seniors in the community. My Ministry has now extended its support to the training and professional development of healthcare workers from the home care sector through the Health Manpower Development Programme. As the sector grows, we will increase funding for training in home care.”
“The risk pool of MediShield has now been restored, and we have been able to preserve the financial solvency of MediShield. Offhand, I do not have the data, but it is healthy. But like all things, because of escalation in costs and inflation, it requires constant nursing and adjustments – not every year, but every few years or so. Column No : 1109 CELL-SHARING ARRANGEMENTS FOR PRISON INMATES 3. Dr Lam Pin Min asked the Deputy Prime Minister and Minister for Home Affairs (a) what is the incidence of prison abuse by cellmates and law enforcement personnel over the last five years; and (b) what measures have been put in place to minimise such occurrences in the prison. 4. Mr Christopher de Souza asked the Deputy Prime Minister and Minister for Home Affairs (a) if there are any plans to improve supervision at our prisons to reduce the incidents of violence and abuse by inmates against fellow inmates; and (b) whether the Ministry will consider inviting experienced external parties such as District Judges to provide advice on how to make the disciplinary process against prisoners more transparent and effective in lowering incidences of inmate abuse. 5. Ms Sylvia Lim asked the Deputy Prime Minister and Minister for Home Affairs (a) what criteria are used to decide cell-sharing arrangements for prison inmates; (b) how the three Changi Prison inmates convicted in July 2009 were able to inflict serious injury on their cellmate for over a week before it was discovered; and (c) whether the prison authorities are addressing any gaps in prisoner management arising from this incident.”
“Generally, public hospitals do not have a major default problem of arrears whereby patients cannot pay, whether for big bills or small bills. A lot actually depends on the family financial situation. We do have some bad debts which we have to write off periodically, but offhand, I cannot recall the rate. These are manageable. We need to understand why we are in such a situation. It is due to Medisave which we put in place 20 years ago. Can you imagine Singapore without Medisave? I think affordability of hospital bills would then have been a major problem. It is precisely because we have enforced savings and rational withdrawal rules, that we are able to afford increasingly high standards of healthcare which inevitably come with high costs. And the general population, including the lower income group, can afford it. I would say that for acute hospitals, we are in a reasonably satisfactory situation. My job in the last two to three years has been focused on long-term care, care outside of acute hospitals. I am not saying that acute hospitals are perfect. There are still gaps here and there, and we are trying to fix them as we go along. But the bigger gap now is in care outside of acute hospitals, or what the Prime Minister described as step-down care. This is an area that we will be focusing on, and that includes community hospitals, home nursing, as well as in the community – GPs and so on. As to what is the financial position of MediShield, it was heading towards insolvency prior to 2005, and the reason was what we discussed yesterday, ie, cherry picking, which Prof. Straughan mentioned as a possible phenomenon. We have fixed that. We have now won back all the "cherries".”
“Sir, we adjusted the MediShield payouts in December last year – nine months ago. I am not quite ready yet to discuss the full impact of the changes. However, the preliminary data are positive. For example, the MediShield payouts for large hospital bills have gone up from an average of $9,000 per bill to $10,600. What this means is that such patients would have saved hundreds of dollars per hospitalisation episode. As for the MediShield lapsed rate, I spoke about it just awhile ago. Less than 1% of MediShield members have seen their coverage lapse due to insufficient Medisave money. Among them, how many dropped out because of increased premiums? As the premium increases are less than a dollar a month, I think the number is likely to be very small, but I do not have such a number.”
“I am sympathetic towards insurance, not just MediShield, covering mental illnesses. Today, the private MediShield schemes – some of them – do make that provision. Of course, you would have to pay higher premiums. I am holding back purely because we would need more money in order to cover this new benefit which requires more payout. And this is not the time to talk about increasing premiums. Column No : 1107 MEDISHIELD (Coverage of big hospital bills) 2. Mdm Halimah Yacob asked the Minister for Health (a) whether he can give an update on the progress made in the coverage of big hospital bills up to 80% after the last MediShield review; and (b) whether any persons had dropped out of the scheme because they could not afford the higher premiums.”
“As part of the review on community hospital care, we are looking at how to fund this and ensure right-siting so that we do not have an incentive system that is warped, that ends up with patients going to a more expensive place because of the funding structure. We would certainly review how we subvent community hospitals, what is the withdrawal limit out of Medisave and also what is the insurance coverage. We will take a look at whether $150 daily limit is adequate. We had set a differential claim limit because the cost of care is indeed lower, and so the claim limit is lower (than for acute hospital). If we set it too high, it may encourage providers to over price, knowing that the bill will be paid out of Medisave. I am not saying that our community hospitals do that. Many of them are run by religious charities and they do not do such things. But then again, things may happen in an unpredictable way and we need to guard against that.”
“In other words, if you already had something which was there for many years before you subscribed to your insurance policy, the insurers would then exclude that. Those are exceptions rather than the norm. For most people, so long as you subscribe early to MediShield, the insurance will have to cover the illnesses that crop up, eg, cancer, that you get because of ageing. The insurance will have to cover these, whether it is MediShield run by CPF Board or Integrated Shields run by private insurers. I explained yesterday the reason why insurers have to exclude pre-existing illnesses. If everybody waited until they fell ill to subscribe to insurance policies, it would be unfair to those of us who have been subscribing for years.”
“Sir, we have designed MediShield to look after acute hospitalisation, treatments that are generally provided in acute hospitals. The MediShield coverage, premiums and payouts accommodate all the age groups. It is quite robust. It does not mean that if you are elderly, your MediShield may run out or prove inadequate, that is not the case. You have heard in the Prime Minister's National Day Rally speech over the weekend about step-down healthcare, outside of acute hospitals. This is a new and growing area as our population ages. We think that their needs can be adequately taken care of outside of acute hospitals – in fact it would be cheaper for the patients and their families as well. This refers to healthcare in nursing homes, and also community hospitals which the Prime Minister spoke about at great length. Currently, MediShield covers community hospitals. We are now studying how we can also fund long-term care outside of acute and community hospitals, and that includes home nursing as well. So this is a new topic that my Ministry is placing great emphasis on and something that we can continue to discuss over the next few months. I am sure it will be an area of attention in next year's Budget Debate for the Ministry for Health. The Member also asked about middle-aged patients who, after screening, discover something that private insurance may not pay for. It does not work that way because if it does, it would completely discourage medical screening. Who will then go for medical screening, in order to have ailments picked up and then be excluded from insurance coverage? But what insurance does – logically and globally – is to exclude pre-existing illnesses.”
“Sir, in formulating our insurance policy – and MediShield included – we have tried to avoid inter-generational cross subsidy. It does not work in the long term, meaning the young subsidises the old, because we know the population pyramid will change with age. When the pyramid is fat at the bottom, it is easy because there are many young people to support the old. But at some stage, the pyramid becomes more like a diamond which is what countries in the West are facing today. They introduced such policies 50 years ago – which then sounded very gentle and rational – but they are now finding great difficulty in continuing. What we have done instead is to encourage early subscription and then, allow discounts for loyalty, ie, under a loyalty programme. So the longer you stay, you get greater discounts below what your age group premium ought to be actuarially. I think that is the correct way, going forward. Assoc. Prof. Paulin Tay Straughan (Nominated Member): Thank you, Mr Speaker. I have two supplementary questions for Minister. The first concerns older Singaporeans. I am wondering if MediShield is sufficient for chronic ailments. This is the group that is caught in the gap because they are very likely not to be covered by private insurance. What plans does Minister have to augment their healthcare bills? My second supplementary question addresses the middle-aged group, people whom we are now encouraging to go for early health screening so that we can detect ailments at an earlier stage. And yet, contradictory to that, once you have a pre-existing illness, private insurers fail to cover you. So it seems we are sending a lot of people into the lion's den and then they will be without coverage for a long period of time.”
“Last year, less than 1% of MediShield policies lapsed due to insufficient Medisave savings. As it will not be in the interest of the policyholders to allow their MediShield to lapse, MOH and CPF Board go to some length to help the policyholders avoid such an outcome and to restore their MediShield coverage, if possible. First, CPF members will receive prior alerts and get up to three notification letters at various intervals. Second, we give members a two-month grace period to top up their Medisave to enjoy uninterrupted MediShield coverage. Third, we include a reminder in the members’ annual CPF statements. Fourth, we exercise some flexibility to allow members whose MediShield policies have lapsed to be covered under MediShield again, provided their health status has not changed and they start making regular contributions to Medisave. And many have indeed rejoined MediShield under such an arrangement. Sir, as I stressed yesterday, Singaporeans should stay within MediShield and must not allow their coverage to lapse or they will regret it in future. For those who have exhausted their Medisave, their working family members should help them pay their MediShield premiums. Their Medisave can be used for this purpose.”
“Mr Christopher de Souza asked the Minister for Education (a) how many teaching support staff have been recruited so far; (b) what is the Ministry's target for the recruitment of teaching staff for 2009; and (c) how near is the Ministry in achieving this target.”
“Dr Fatimah Lateef asked the Minister for the Environment and Water Resources (a) what is the number of new applications for cooked food stalls annually for the last two years; (b) how many of such cases were rejected because they were found to be carriers of infectious diseases following the pre-approval health screening; and (c) what proportion of existing stall holders who apply for renewal annually are rejected due to conversion of their carrier status to positive. Assoc. Prof. Dr Yaacob Ibrahim: Operators of food outlets must obtain a licence from NEA and register their food handlers with NEA. Licensees must also register themselves as food handlers if they are involved in food preparation. Health requirements are imposed not on food outlet licensees but on food handlers since they are the individuals directly involved in food preparation. NEA requires all food handlers to be vaccinated against typhoid once every three years. Those above 45 years of age must also undergo screening for tuberculosis once every three years. Over the last two years (from January 2007 to December 2008), NEA received about 21,000 applications for registration as food handlers. NEA does not require applicants or existing food handlers to be screened against any food-borne infection. However, they are required to produce valid certificates for typhoid vaccination and tuberculosis screening (if applicable) before they can work as food handlers. NEA is reviewing the health requirements for food handlers to ensure they remain effective in preventing disease transmission. TEACHING SUPPORT STAFF (Recruitment) 2.”
“The Medisave Chronic Disease Management Programme started in October 2006. It now covers six chronic diseases: Diabetes, Hypertension, Lipid Disorders, Stroke, Asthma and Chronic Obstructive Pulmonary Disease (COPD). Last month, MOH published on its website an analysis of the programme, based on two completed years of data. One hundred thousand Singaporean patients are regularly followed up by their doctors under this programme. Most of them have multiple chronic conditions and 90% of them are above 50 years old. The programme has two benefits. First, it helps reduce the out-of-pocket expenses of the patients. They withdrew a total of $18 million from the Medisave Accounts to help pay the outpatient treatment of these chronic conditions last year. Second, it ensures a more systematic treatment of these chronic conditions, in accordance with international best practices. If patients fully comply with their doctors’ advice, they can expect to see improvement in their health outcomes. The data are promising. Almost half (46%) of diabetics who had poor blood sugar (HbA1c) control initially achieved optimal control by the end of the second year. For patients with high blood pressure, at least two in three showed significant lowering of their blood pressure after two years. We are encouraged by the results of the programme. We are working to extending it to cover two common mental conditions, schizophrenia and major depression, by October this year. WRITTEN ANSWERS TO QUESTIONS COOKED FOOD STALLS (New applications) 1.”
“Thus, the decision to cater to an intake of about 1,000 students a year is a realistic one, given the size of our birth cohorts and the existing capacity in the other three autonomous Universities. USE OF PUBLIC TRANSPORT (Encouraging courtesy) 44. Er Lee Bee Wah asked the Minister for Transport with the rise in the number of people using public transport (a) if the Ministry has any plans to encourage the public to exercise courtesy when travelling on trains and buses; and (b) whether public transport operators will deploy inspectors to check on passengers who do not give up priority seats to the elderly and pregnant women.”
“We are open to other suggestions, including the idea as proposed by Mr Sin Boon Ann, provided they are more cost effective and there is a market demand for such options. FOURTH UNIVERSITY AND SINGAPORE INSTITUTE OF APPLIED TECHNOLOGY 41. Mrs Josephine Teo asked the Minister for Education (a) given the significant resources required to start a new institute of higher learning, what were the compelling reasons for having both the fourth university and the Singapore Institute of Applied Technology instead of an integrated facility; and (b) whether more Singaporeans will benefit from the education partnership with the Massachusetts Institute of Technology by having a higher enrolment than 4,000. Dr Ng Eng Hen: The establishment of two more tertiary institutions – the New University and the Singapore Institute of Applied Technology (SIAT) cater to students with different aptitudes and will provide more choices to both A-Level and polytechnic students to obtain their degrees. The New University will have longer, mainly four-year Science and Engineering-based programmes with research components which will suit those who are more inclined towards academic pursuits. The SIAT will tie-up with reputable foreign universities to offer applied degree programmes obtainable within two years and would cater to mainly polytechnic graduates with some working experience. The Member has asked if more Singaporeans would benefit from the education partnership with the Massachusetts Institute of Technology by having a higher enrolment. MIT will develop an academically rigorous curriculum in partnership with the New University. Students will benefit from such an environment but must have sufficient academic grounding to be able to perform to expectations.”
“As we expand nursing homes and home healthcare, we will need to train more staff, whether locals or foreigners. This is part and parcel of preparing Singapore for the further ageing of its population. There are a number of training centres in Singapore that train workers to provide care services for the elderly. This includes the Institute of Technical Education that offers "ITE Skills Certificate in Health Care" which aims to train both locals and foreigners to provide care for the elderly in a nursing home and in a home environment. About 30 nursing homes and home care institutions are accredited as Approved Training Centres for this ITE course. This is currently the main platform where foreign workers are trained as care staff in the long-term care sector. Feedback suggests that this system is satisfactory as the workers are trained by qualified and experienced nurses as well as the more senior nursing aides and healthcare attendants. There is some financial incentive for the long-term care providers to make use of this training programme as they can subsequently enjoy a reduction in their foreign worker’s levy. For employers who need their foreign domestic maids to take care of the seniors at home, there are other training centres run by VWOs which provide subsidised training for these maids. This includes the Hua Mei Training Academy and the AWWA (Asian Women’s Welfare Association) Centre for Caregivers. In addition, my Ministry is working with the Workforce Development Agency to upgrade the skills of staff working in the long-term care sector under the Singapore Workforce Skills Qualifications Framework. This is to ensure that the skills of the staff remain relevant and in pace with medical advancement.”
“We also provide funding support to enable the nursing homes to purchase consultancy services from hospitals to raise their professional standard. MOH also organises manpower development programmes to promote advanced skills training among healthcare professionals, care staff and healthcare administrators. These programmes will equip the staff with necessary skills in infection control, performance monitoring and performance management. Raising the standard of nursing home care is a continuous endeavour. We have nursing homes that are competently run but there is scope for further improvement. And we will try to help our nursing homes up the skill sets so that they can help our seniors recover as quickly and as fully as possible. NURSING CARE TRAINING FOR QUALIFIED FOREIGNERS 40. Mr Sin Boon Ann asked the Minister for Health whether the Government will consider encouraging and incentivising manpower agencies to set up training centres to train suitably qualified foreigners in the provision of nursing care at home for the aged sick.”
“In Singapore, there are 63 nursing homes, run either by private companies or voluntary welfare organisations (VWOs). We regulate them through a licensing regime. MOH’s evaluation of licensing eligibility focuses on two key aspects: The nursing home will need to have written policies and procedures that meet various statutory requirements, including for infection control, fire safety and medicine storage. The facility will need to be in a good state of repair. MOH also considers the adequacy of the facility in ensuring patient comfort and in supporting proper treatment. Beds will need to be sufficiently spaced apart. Sanitary facilities will need to be easily accessible and slip-resistant. There are various other infrastructure requirements, including resident-to-nurse communication system, isolation beds and bed screening facilities. MOH also considers the track record of the applicant. The licensing process ensures that applicants have adequate staff capacity and capabilities to provide long-term nursing care. As part of the licensing requirements for quality assurance, nursing home operators are required to monitor and maintain the quality and appropriateness of their services and care. After the licence has been granted, MOH conducts regular audits and require licence renewals every two years. Besides regulation, MOH works closely with the operators to further strengthen their capacity and capabilities. We regard them as our partners, as we share a common objective to ensure a robust long term care sector that can meet the needs and expectation of our seniors. Hence, we organise regular forums and programmes to promote the sharing of knowledge and experience among the service providers.”