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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“I await the BAC's recommendations and, in due course, if we need to change the laws, we will do so. So I have not taken a position yet. Mr de Souza's view is one, but I think he knows too that there are many others who feel quite differently on this topic.”
“I visit hospitals quite regularly, impromptu, and find that hospital staff requires me to do various hand rubs. I think the procedures are, by and large, in place. But I acknowledge that, globally, hospital-acquired infection is one of the complications, even in the best hospitals, partly because we are talking about human behaviour here. It is not only our staff. It is the patients and also the patients' visitors, and the weakest link will be in the weakest link, and whoever is less than careful, infections just spread. What is important is for us to constantly remind ourselves and try to bring down the rate to as low as we can. To eliminate it to zero, I think no other hospital has done it and I doubt we can ever reach that stage. I have time for Mr de Souza's clarification. I thank him for sharing his views on therapeutic cloning and cybrid research. I heard his view that he is against cybrid research. I agree with Mr de Souza that the science on stem cell research is evolving and, of course, our law must try to keep pace. We do monitor developments globally and we are further advised by an excellent Bioethics Advisory Committee (BAC), comprising some of the top names in the world. They scan global developments and then they do very extensive public consultation before they firm up their views on what would be their recommendations and, typically, we will then review their recommendations and, where appropriate, change the law to do so. One issue for which they have been conducting public consultation is precisely on this aspect of cybrid research, or research on human-animal combinations. I remember they did a public consultation last year. I took part in one of those discussions, and I assume Mr de Souza must have also shared his views with them.”
“Mr Low Thia Khiang asked if there has been an unusual increase in the number of patients who died of pneumonia in Tan Tock Seng Hospital. I checked. We did not observe any unusual trend. Tan Tock Seng Hospital recorded about 600 pneumonia deaths every year. Nationwide, as Mr Low noted, pneumonia is our third killer. It is a major cause of death, just like in many other countries, probably all countries. Our national data show that pneumonia death has hovered at around 2,300 every year; it fluctuates a little bit, plus or minus. But by and large about 2,300 every year and it has been so for many years. The reason it is a major killer is because pneumonia is an outcome with many different causes. I mean there could be many other underlying causes and typically patients with stroke, with cancer, with COPD, or who are bedridden for a long time due to other illnesses, they somehow die of pneumonia as the terminal event. Some pneumonia deaths are caused by viral infection and I think SARS outbreak was a dramatic example of that. SARS taught us many lessons and one of which is to remind us to be constantly vigilant. So hospitals have to put in surveillance systems to monitor patients with atypical pneumonia, patients with unexplained fever for more than 72 hours and relevant travel history, and sudden unexplained death cases with acute respiratory symptoms. 12.45 pm All hospitals adopt strict infection control protocols; so staff are required to clean their hands regularly and correctly, infectious patients are isolated with regular environmental disinfection. And the hospital infection-control teams carry out regular audits to make sure that the SOPs are being followed.”
“Adequate washing facilities in hospitals and a second sitting for Coroner’s cases are now available to reduce any possible delays. And we have prepared our hospital staff quite thoroughly for the HOTA extension to the Muslims. There are always some Malay speakers around and staff are briefed by MUIS on the religious and cultural sensitivity of the Muslims. So from my point of view, the last five months of implementation has been quite smooth. While there were a little kinks here and there, I am sure over time we will improve further. I am particularly grateful to the support rendered by Muslim religious leaders. Last night when I met Haji Mohd Alami Musa, MUIS President, I told him so. They were wonderful. We have a list of their handphone numbers because this thing can happen anytime. We will call them if the family members require religious clarifications and they will come to the hospitals even in the middle of the night to help support the family through the grieving process and also to clarify any religious doubts. Their work, excellent work, complements the work of our medical staff and social workers. We will continue to monitor and make improvements where we can. But as noted by the Senior Parliamentary Secretary just now, the number of Malay patients struck with kidney failure continues to rise so the key is still, as Dr Lily Neo always reminds us, prevention, prevention and prevention. It is quite preventable. Certainly the complications are quite preventable. So HOTA cannot be the key, it cannot be the full answer. Prevention is, and that means changing lifestyles for those who are on the wrong side of the healthcare divide. They have to disrupt their lifestyle as Ms Jessica Tan reminded us yesterday.”
“Currently there are more than 100 Muslim patients on the waiting queue for kidneys. And as noted by Members, we achieved a major milestone when the Muslim community joined HOTA last August. I was very happy for the Muslim community because I have wanted to be able to do this for sometime. We knew as a fact that it will save lives but there were various difficulties that prevented the Muslim community from joining. But better late than never and it is truly life-saving – the numbers speak for themselves. Just to give an example, say 2007, this is before HOTA extension, the number of Muslim patients receiving a transplant was only 19, less than 20. Last year, and bear in mind last year was incomplete, with only five months of HOTA for Muslims, the number has already doubled to 38. From 19 for a full year to 38 for less than half a year: quite an achievement. I expect a record number this year. Similarly, if you look at it in terms of percentage of all patients receiving transplants, the Muslim recipients have increased their proportion from 11% in the past, before HOTA, to last year 19%, comparable to the percentage of Muslims in the total population. Whilst some Muslims have opted out of HOTA, and we respect their decision, the vast majority of Muslims, just like non-Muslim Singaporeans have stayed within HOTA and they support organ donation. So far, over five months, four Muslim cadaveric donors have saved the lives of 15 organ recipients. Our hospitals are very sensitive to the need for relatives to take the bodies of their loved ones as soon as possible for religious rites. Our organ donation teams work through the night to ensure that the donation process is completed within hours, certainly well within 24 hours.”
“Sir, I do not know whether I have time to complete the reply but in case I do not, perhaps I will ask Mr Christopher de Souza to seek a clarification during clarification time so that we can complete the reply. Yesterday, Mr Chiam spoke on dental care. He is not here but I have better reply to his cut first. He quoted a few examples, from his point of view, very expensive dental care treatment in Singapore. The figures sounded very high and I told him so, when Parliament was adjourned. For example, he mentioned "capping" which I presume he meant "crowning", costing $2,000 and he mentioned root canal treatment costing $3,500. So I told him he must have been to a very expensive dentist. Either that or he was mistaken. But he said maybe he was mistaken or the patient had very severe complications and actually received many more treatments and not just, for example, root canal treatment. Last night, I checked and say, in our National Dental Centre, root canal treatment typically ranges from $300 to $800 versus the $3,500 mentioned by Mr Chiam; crowning about $600 to $800 versus the $2,000 that he quoted. In any case, Chiam’s proposal was that we should subsidise dental care. And in fact we do. You can get subsidised basic dental services at dental polyclinics. Dr Chiam mentioned filling, and a filling at polyclinics typically ranges from a few dollars to $25, depending on the condition of the cavity. For the elderly, it is further subsidised. As for specialist care, we provide subsidised services in the National Dental Centre, where typically patients will get at least 50% subsidy. So that is how we go about handling dental care for Singaporeans. Mdm Halimah and Mayor Zainudin asked about HOTA (Human Organ and Transplant Act).”
“Madam, may I seek your consent to move that progress be reported now and leave be asked to sit again tomorrow?”
“I suppose because they think that it win them votes. But you have the Prime Minister and the President on opposite sides of the debate while the poor lady remains in coma. Madam, the silver tsunami is definitely coming and we must gear up so that we do not end up overwhelmed by it. We have some time to fix the gaps in the current system. There will be fundamental changes and disruptive changes which we will take care to implement progressively. Change is necessary for the long-term sustainability of our healthcare system and we should not shy away from these changes, even as we cope with the short-term challenges of the current economic tsunami. School Health Services”
“This used to be quite a taboo subject but I am quite glad that after many months of public discussion on this morbid subject, Singaporeans are now able to discuss this with less emotion and more logic. I thank all Singaporeans who have offered their views and insight on this difficult subject. Some of the discussions focused on euthanasia, which was not the Ministry of Health's intention. What we wanted to do was to get Singaporeans think about the necessity to prepare for a good death. One concrete way of doing so is to introduce broader, what we call, the Advanced Care Planning (ACP) amongst healthcare professionals. We are really trying to find a middle ground between a scenario where families insist on treatment at all cost, contrary to clinical opinion and a situation where families opt for non-action due to ignorance on the option palliative care. There was a recent article in the New England Journal of Medicine by three American ICU doctors on their experience with the terminally ill. It was a moving article on how the dying suffered unnecessary pain, akin to torture as their children insisted on fighting on and refusing to let go. The authors ended the articles with this rhetoric: "Those of us on the frontline can't but wonder for whom do we fight on and why do we do it?" An important part of end-of-life care is the Advanced Medical Directive (AMD). The Directive provides an avenue for people to think about and make a choice about their end-of-life care in advance while they can. You just look at this poor lady in coma in a hospital in Rome, who has been so for 17 years. And during this long period, while in a completely vegetative stage, the family has to fight lawsuit after lawsuit with the courts to just let her die. And now, the politicians jump in.”
“But that is not enough. In parallel, the Ministry of Health has begun reaching out to the general practitioners (GPs) so that we can exchange electronic medical records with the community hospitals and the GPs. These building blocks have provided basic capabilities and health information exchange among public hospitals, polyclinics, GPs and step-down facilities. As the Finance Minister mentioned in his Budget speech, Singapore is in a unique position to be among the first in the world to implement electronic health records nationwide across the primary, acute and step-down care setting. This is made possible through the strong foundations built in our public hospitals. The Ministry of Health will see this initiative through, to benefit our patients. We are spending nearly $180 million over the next two years to complete this project. Healthcare providers would then no longer need to shuttle individual paper records to and fro, can reduce unnecessary repeat tests and ensure improved safety and continuity of care for the patients. We will not disappoint the Finance Minister. Singapore will be among the first in the world with a nationwide system of electronic health records, bringing real benefits to our patients. On Ms Jessica Tan's point on chronic diseases, I totally agree with her. A big priority for me during the last few years is to enhance chronic disease management to make sure that it is better, improves healthcare and lowers cost. A number of initiatives have been done and I am sure there will be new initiatives coming along. Madam, confronting the silver tsunami cannot avoid a discussion on death and end of life issues.”
“The Agency for Integrated Care (AIC) was set up last year to strengthen discharge planning and facilitate the movement of patients from hospitals to the various long-term care services. I have received good feedback on the good work done by AIC where discharge planning is a lot better now. Of course, there is always scope for further improvement and we will. Affordable drugs are another important means to integration as this lowers our financial barrier to right siting. In reply to Dr Fatimah, our restructured hospitals and polyclinics have established drugs supply partnerships with some VWOs running community hospitals and nursing homes. We support these partnerships and we will expand such partnerships to more VWOs. 6.30 pm Finally, we need to tap technology much more smartly to help us fight the silver tsunami. Information technology is an important infrastructure. President Obama's Stimulus Package includes a programme to computerise the medical records nationwide, although over the weekend, I read that this item has been cut. Even if it proceeds, we are already ahead of the United States because for many years, we have had our hospitals –public hospitals, at least, and private hospitals follow suit – computerise their records. But our problem was, and which was our priority in the last few years, that they remain "silos". So if you are in the same hospital, if you go back to them, you are fine. But once you cross hospitals, there is trouble. So in the last few years, we focused on getting the computers to talk to each other so that we can transfer records electronically even if you start off from different hospitals. And we have done it. It is now possible for public hospitals. It is quite a major achievement. That is something to celebrate.”
“We will expand our programme to help improve the mental well-being of elderly and we will scale up targeted public education on signs and symptoms of dementia. This is an area which is bound to increase with greater numbers as we go along. We certainly need to train many more geriatricians. But I would like to emphasise that it is neither sufficient nor sustainable to solely rely on geriatricians to take care of the sick elderly. There needs to be general levelling up of capabilities of our healthcare professionals in caring for the elderly. I agree with Mr Ang Mong Seng that we must be elderly-friendly in our institutions. I do not think we need to set up special counters for elderly. Elderly patients are visible to us, so proper use of language that they are comfortable with, and so on, that ought to be common sense. Fourth, we need to achieve greater integration amongst the various healthcare providers. Our objective is to enable our patients to move seamlessly across different institutions. Integration of care is critical so that we can care for patients in the most appropriate setting and at the lowest cost. To facilitate smooth patient transitions, we need to strengthen collaborative partnerships between primary care hospitals and the long-term care sector. For the frail elderly in particular, a multi-disciplinary approach, with close collaboration between doctors, nurses and allied health professionals, is essential, given their multi-faceted needs. Last month, Tan Tock Seng Hospital signed a clinical governance agreement with the new Ren Ci Community Hospital. We will encourage more such win-win collaborations. We are also building up various support services and mechanism to integrate care.”
“My own view is that for basic ElderShield, maybe we should push it up to $800 for basic, and those in the middle-income group, they should buy a supplement, so that they can afford private nursing homes. We discussed earlier about lower cost possibilities in the neighbouring region, especially Johor Bahru. Let me talk about my day trip during the Chinese New Year to Johor Bahru. I visited one site where a Singaporean investor is going to put up 200-bed nursing home. I asked him, "How much would you be spending on your capex (capital expenditure)?" It is mind-boggling, the construction cost and land cost are so low, that my cost of just putting up a polyclinic is probably more than his cost of putting up a 200-bed nursing home. So the cost of keeping a resident in a private nursing home in Singapore can easily pay 2.5 months of nursing home care in Johor Baru. If the connection is easy and if there is any urgent problem, you can always ambulance in the elderly to Singapore. The family members can get to visit the elderly on weekends. As this nursing home's CEO told me, even in Singapore, when they put the elderly in the nursing home, they also only visit them once a week over the weekends. Of course, many visit daily but quite a significant percentage just visit on the weekends. So, what is the difference with putting them in Johor Baru? But we need to recognise that there are limitations of homecare, brought about by smaller family sizes and frailty with increased life expectancy. We have to be realistic and recognise that homecare may not be for everyone, given that homecare can be relatively expensive and skills intensive. Mdm Cynthia Phua highlighted the major challenge posed by dementia. We need to do more on prevention, early detection and treatment.”
“But for somebody, day in, day out, 24 hours, living and staying with a loved one who does not even recognise you, and constantly forgets that you have just fed him. To call this stressful is an understatement. So we will certainly do as much as we can to support. Much of the time, it is about training, awareness, how to cope and tips on what to do. I am not so sure about caregiver allowance. This is not a topic under the Ministry of Health and is traditionally under the Ministry of Community Development and Sports (MCYS). My own view is, let us do as much as we can to try to support and put the 3Es in place. At the end of the day, it is money. We have carefully constructed ElderShield. Practically, in all other countries, including Japan, their insurance scheme for long-term care is – if it is confirmed that you require long- term care, then go to the long-term care facility approved by the insurance policy and as charged, you can stay there for as long as you can and, therefore, tremendous abuses, over consumption and over servicing. And the patients lose their freedom of choice. Many of them we know would prefer to age at home. What we do for our ElderShield is quite unique; once you are confirmed an ElderShield beneficiary, we just give you the money. With the money, it is up to you on whatever you want to do – to keep the patient at home with additional home help or admit to a nursing home or whatever. Our ElderShield structure, I believe, we have got it right. So do not deviate from that. But what is a weakness today is the amount is too small. So from $300, I raised it to $400 per month. From five years, I raised it to six years – a significant increase. But I think we need to raise it further.”
“For example, we need to raise nursing standards in the nursing homes to deal with increasingly complex needs of the elderly, including care for elderly with dementia. For community hospitals, they need to develop stronger medical capabilities to manage more complex sub-acute cases so that we can discharge the patients over there, saving patients' money and also freeing up the expensive beds in acute hospitals. Similarly, the public will expect a greater degree of accountability from the healthcare VWOs as they receive more Government subsidies and public donations. Beyond delivering good long-term care to patients, sound corporate governance and financial accountability, must be established in the VWOs. We have extended the Health Manpower Development Programme which is a Government-funded training programme to the long-term care sector. Many healthcare professionals from the sector have benefited from both local and overseas training. We have further revamped the programme to provide higher level of support. I agree with Mdm Halimah, Dr Lam and Mdm Cynthia Phua that we should also enhance the homecare sector. My Ministry currently supports several homecare services but as a next step, we are working with the stakeholders to develop viable models to deliver more coordinated and more integrated healthcare services to the home. We certainly recognise and acknowledge that the caregiver is the key and the pressure on them, which Dr Lam talked about – the caregiver syndrome – is real. We have friends and relatives who experienced that, so we can see with our own eyes. It is easy for us, visiting a patient with dementia once in three months.”
“Our immediate plan, and this is confirmed, is to build two new community hospitals with 200 beds each, one next to Khoo Teck Puat Hospital by 2013 and another next to the being planned Jurong General Hospital by 2016. Our target is to raise the current ratio of one community hospital bed per eight acute beds, to one community hospital bed per five acute hospital beds by 2020. That should be sufficient but we have time to review and update the data. Similarly, we are expanding the nursing homes' capacity by half, or 50%, over the next decade, from 9,200 to ,000 beds. This will be in both the private and VWO sectors. We are working with several existing nursing homes to increase their bed capacity and help those with expiring land leases relocate to larger venues. Over the next two years, we will help the private and VWO sectors to set up five new nursing homes. We will also work with URA to reserve more sites for nursing home development to meet longer-term demand. Where appropriate, we are blurring the line between VWO and private nursing homes by allowing means tested patients access to private nursing homes through the Portable Subsidy Scheme. This is one way to help raise professional standards across the industry. Last year, 750 beds in private nursing homes came under this Scheme. So, it is quite significant. I am ready to do more if there is demand. In addition, from this year, the Ministry of Health will extend Medifund Silver to needy subsidised patients in private nursing homes on the Portable Subsidy Scheme. Separately, I agree with Mdm Cynthia Phua that we need to increase the number of community rehabilitation and dementia daycare centres and we will do so. Third, we need to upgrade the capabilities of the long-term care sector.”
“With the increased budget that we are pumping into both acute and long-term care, I will expect that money to flow down to the patients to help them during this difficult period. Do not forget that many of these long-term care services are run by charities which also raise their own funds. They would be able to also top-up with whatever that the Ministry of Health routinely supports. But I know that this may be a difficult period to raise money through charities and that is why the Finance Minister has kindly set aside a special budget for both MCYS and the Ministry of Health. With that fund, we will help those charities, who, for various reasons this year, are not able to raise enough donation funds to cover their needs. But let me assure Ms Sylvia Lim that we will continue to refine the means testing framework and the assessment process so that it remains fair and relevant for Singaporeans. Second, we need to build up capacity, including new community hospitals, nursing homes and train more skilled manpower. Community hospitals play an important role in helping some patients transit from their acute hospital stay to their return home. Timely and appropriate community hospital care results in lower re-admission rates and improves quality of life for patients especially our elderly. With an ageing population, demand for community hospital services is bound to increase further. We now have six community hospitals with more than 800 beds in total. This includes the new Ren Ci Community Hospital which I visited last month. It is still empty but I expect it to be filled up eventually. Over the next 10 years, we will add more community hospital beds. We estimated the need to add an additional 60%.”
“It cannot be just the Government and the hospitals alone. Prof. Mehta asked if current community-based long-term care services are affordable. For the vast majority of Singaporeans, they are. The lower income patients are assisted by MOH subvention, Eldercare fund and donations raised by VWOs, and Medifund Silver provides a safety net. Subsidised services include home medical, home nursing, home rehabilitation, dementia day-care services and also renal dialysis. But as the population further ages, we expect to do more and we will. For the vast majority of the middle and higher income population, if you regularly save, as you do in Medisave for your acute hospitalisation, you do not have to worry about long-term care when you eventually reach retirement. Voluntarily, some people are doing that but it is not sufficient. That is why it is so important for this 3Es framework to be eventually in place to help Singaporeans develop the discipline to save, and ensure that they can afford their long-term care services. 6.15 pm Ms Sylvia Lim asked about the means testing framework for long-term care. The current formula assumes that we subsidise the lower 50% of the population. It therefore includes part of the middle-income group. Whether we use gross income or net income, it does not really matter because if you use gross income, then the threshold criteria must be based on the gross income percentile; if you use net income, then the income threshold will also be based on the net income percentile. So it does not really matter. But the important thing is to be consistent, ie, we cannot use gross income data and then, the threshold is set at net income percentile.”
“So women would have greater need for long-term care, incurring higher medical expenditures, and that is why it is so important that all working females should stay within 3Ms and eventually 3Es, contribute regularly to Medisave and subscribe to both MediShield and ElderShield. For housewives, husbands should do their duty by contributing to their wives' Medisave accounts. I discussed this at some length earlier, so I will not repeat the point. I noted Dr Lily Neo's point about prevention, and that applies to both female and male patients, adult or young. I agree totally with her that prevention is truly the best option. Many things are within our control but if you are not willing to do your part – do the exercise, eat less (eat 70% rather than 100%), and wait until the parts are falling apart and you start looking to us for solution, it is a bit tough. Really, the key to healthcare reform is, besides disruptive innovations, "disruption" to your lifestyle; and make sure for those with unhealthy lifestyle, "disrupt your lifestyle". It is easy. I go to the gym every lunch time. Before coming here, I am busy preparing the last minute speeches, but I still set aside one hour to go to the gym, did my treadmill – a few kilometres of it – and as a result, I eat less too. So, my BMI, I think, is all right. But many are not, and we just have to persuade more people to do so. And regular screening is another. There are many types of screening, but we know that effective screenings are really inexpensive, such as simple blood test after fasting. And these only cost a few dollars; in any case, we heavily subsidise them. So Singaporeans need to play their part. The silver tsunami requires you to take part in this battle.”
“It has not priced in the additional needs for long-term care. So, we need to compute how much Medisave should be enhanced to finance this expenditure going forward. As for ElderShield, I have restructured the industry to incorporate ElderShield supplements in their product offerings, but we need to do more. Half of Singaporeans above age 40 are now enrolled in basic ElderShield. Not bad – I suppose like half-empty or half-full glass. Now we must persuade the other half to join in and we must persuade everyone to also top up with ElderShield supplements as basic ElderShield only pays $400 per month for six years to the successful claimants. This will fall short of the monthly cost of about $1,800 in a private nursing home and will require a sizeable out-of-pocket monthly payment by the elderly or the family. Singaporeans' understanding of this insurance product remains poor. And we have to work harder to raise awareness of ElderShield supplements and their benefits. As for Medifund Silver, we will continue to top it up whenever the Budget position allows it. This year, despite the pressure on the Government Budget, I am grateful to the Finance Minister for topping up Medifund with $100 million, of which a significant portion will be allocated to Medifund Silver. And we would definitely put it to good use. Dr Lily Neo and Mdm Halimah highlighted the larger portion of female among the elderly population. The reasons are straightforward because they live longer and they do have higher incidence of some chronic diseases such as arthritis and osteoporosis.”
“Mr Lim Boon Heng's Elderfund is what we called Medifund Silver, and was introduced in 2007. I am now able to build on these two elements. We need Singaporeans to regularly save for their anticipated long-term care while they are young and working. We can either create an Eldersave or we save more in Medisave so that it can also be used to fund long-term care. The question is how much will be needed for long-term care. We are studying the experience in more mature societies such as the US, UK, Europe and Japan. And preliminary analysis suggests that they spend less than 2% of their GDP on long-term care. There is an outlier – Sweden. Sweden spends higher than 2% but still less than 3% of their GDP. And this gives me a lot of comfort. I was initially very worried that this sector will be a bottomless pit. And potentially it can be a bottomless pit and I was worried that it may suck in a lot of resources which society may not be able to afford. But the figures from these OECD countries give me some comfort – that the funding problem may not be insurmountable. But there must be a conscious effort to ensure that Singaporeans save regularly for their long-term needs, just as they do for their hospitalisation needs. Of course, this is not the time to talk about raising CPF contribution rate, and we have no plans to do so. But when the economy eventually fully recovers, we should re-visit this issue of saving for our long-term care. But meanwhile, we have allowed Medisave to be used for some aspects of long-term care – the community hospitals, chronic sick hospitals and hospices, and also to pay for ElderShield premiums. But we must remember that the current Medisave contribution rate is based on the projected needs of hospitalisation.”
“I think many will expect and will be able to afford, if we help them save up while they are young, a higher standard of care run by professionals and better trained staff – this is the future which we must prepare for. To help Singaporeans prepare for this future, we can take a leaf from how we prepare Singaporeans for their anticipated hospital care in old age. Over 25 years, we have carefully constructed a comprehensive 3Ms framework to ensure its adequate funding. Singaporeans save regularly in Medisave; MediShield ensures efficient risk pooling; and Medifund provides the ultimate safety net. As wisely noted in this House by the Prime Minister's Office Minister Lim Boon Heng last week, we need to construct the equivalent of the 3Ms for the long-term care sector. He called it the 3Es – Eldersave, ElderShield and Elderfund. I support his call. I was part of the Ministry of Health team, led by Senior Minister Goh Chok Tong when he was Health Minister, which 30 years ago carefully thought through and constructed the 3Ms framework for acute hospital care. 3Ms did not come about overnight. It was a carefully thought through plan which we knew politically we have to take our time to slowly explain and implement it phase by phase. So, after 25 years, we now have a fairly robust 3Ms framework – not perfect and there is still room for improvement but, I think, largely it has ensured Singaporeans being able to afford a very high standard of acute hospital care even if you belong to a low-income group. And I think this is what we should do for the long-term care as well. We need to do the same for the long-term care sector. The work has actually already begun. Former Health Minister Lim Hng Kiang drove in a key piling – ElderShield – in 2002.”
“This means that a large part of the burden will fall on the primary, intermediate and long-term care sector. GPs and polyclinics will play important roles in the care of the elderly sick. We have to grow the long-term care sector, both quantitatively and qualitatively, to meet this new and expanding demand. Obviously, we need many more doctors, nurses and allied health professionals. Failure to strengthen the long-term care sector will end up in the elderly patients seeking treatment in more costly hospital care and often with worse health outcomes, less satisfactory service level and larger bills, ending up receiving more expensive but, in many ways, inferior service level. I believe one reason for the US spending 16% of the GDP on healthcare is that many of their elderly patients get treated in the wrong place, in a more expensive, costly acute sector, when lower cost and, in fact, better care should be rendered in the long-term care sector. And we must avoid this. We have 10 to 15 years to put the policy, system and infrastructure in place so that we can face the silver tsunami with confidence. I highlighted this issue last year. After a year of analysis, I now have a better sense of what we need to do. There are gaps in several important areas and we need to fix them. First, we need to have enough funds to support the long-term care sector, of a quality which Singaporeans will demand. Unlike our parents and grandparents, the elderly baby-boomers of 2020 will demand and they will expect a much higher level of care. Many will not be satisfied with the current level of care rendered in some of the nursing homes.”
“Madam, last year, the American Geriatrics Society coined the term "silver tsunami" to sound the alarm of the enormous healthcare challenges facing the United States as their post-war baby-boomer generation enters retirement. The ageing of the baby-boomers combined with a rise in life expectancy and the drop in birth rate will place tremendous strain on the US healthcare system which is already under a lot of pressure. They concluded that the US is ill-prepared to meet the silver tsunami. As noted by Mdm Halimah, Singapore will face a silver tsunami of our own as the elderly are more likely to be hospitalised and consume more healthcare resources. And I noted Dr Lily Neo's point about many of these elderly patients, who will be females. It left a deep impression in me when I visited Okinawa where there were quite a few who were more than 100 years old; over 90% were females, less than 10% were men. And the only man who is above 100 years old is in the nursing home with dementia, and cannot communicate with me. In fact, our hospitals are already facing the first wave of the tsunami – a relatively smaller wave as our baby-boomers turn 60. In 10 or 15 years' time when the baby-boomers turn 70 or 75, we will feel the real pressure of the second and the larger wave of the silver tsunami. We have been served notice. We must protect Singapore against the silver tsunami and we have started the preparation. We are expanding our healthcare capacity and adding beds, training more staff. But preparing for the silver tsunami goes beyond simply expanding the hospital sector. Most of the elderly would have health conditions that require long-term chronic care – a point highlighted by Ms Jessica Tan just now – rather than short-term acute hospital care.”
“But it also highlights the many obstacles and the ingrained self interests of the stakeholders to preserve the status quo. They will fight to avoid or delay the transformation. Maybe President Obama can do some miracle and lead the world in healthcare transformation. We will see, even as we attempt our own disruptive innovations here. 5.30 pm Madam, the economic tsunami is with us and we cannot wish it away. But there are opportunities to transform our healthcare system, even as we implement measures to battle the recession. If we apply our mind, we can help Singaporeans tide over the recession and also make our healthcare system even better when the economy recovers. My Ministry will play its role diligently, Singaporeans and our healthcare providers have equally important roles to play. I thank Members for their advice and support of our economic tsunami battle plan. This will enable Singaporeans to continue to enjoy healthcare that is amongst the best in the world. Healthcare for An Ageing Population”
“As a major third-party payer for subsidised patients, my Ministry has a strong incentive to economise. We will want to create the right regulatory framework and conditions for providers to compete and innovate, like in the case of lasik operators. For surgeries with well-defined conditions and measurable outcomes, like delivery of babies (you cannot fake it), cataract surgeries (I do not know whether it is possible to fake cataract surgeries), knee joint replacement or hip replacement, I am going to tweak our Government subvention to reward the lower-cost providers and pressure the high-cost providers. We will try this out for several common surgical procedures, and see if it is effective in getting our hospitals to work harder to save money for their patients. This recession is a good time to apply this pressure, and will position our hospitals well in terms of offering cost-effective treatments when the economy recovers. Prof. Clayton Christensen, Harvard Business School’s guru on disruptive innovation, has devoted his latest book "The Innovator’s Prescription" to a thorough discussion on applying disruptive solutions in the healthcare sector. This is now one of my bedside reading materials. He is emphatic that the solution to the US, and indeed the global healthcare challenges, is a complete reform of the traditional healthcare system and a disruption of the business model centred on the general hospital. His book makes for both optimistic and pessimistic readings. It points a way forward that will improve quality, accessibility and affordability by changing the way hospitals and doctors work. In other words, healthcare can be better and also cheaper. Who will not want that?”
“If you look at the newspaper advertisements, the volume has come down but lasik advertisements remain prominent. The competition has brought great benefits to consumers. But this "lasik effect" does not seem to extend to other surgeries. There are still many surgical procedures where prices vary widely. For example, the median bill size for cataract surgery varies from $2,900 to $4,200 at the high end – a range of more than $1,000. Why? Some people get it for $2,900 and some, for $4,200. Even for the subsidised patients, the variation is from $875 to $1,000 – a few hundred dollars difference – the same thing for hip replacement. The median bill size for Class B2 varies from $4,100 to $5,100 – a range of $1,000. These bill sizes are easily accessible by patients and we update it every month with actual data but, regrettably, we do not experience the same "lasik effect". Why do patients continue to go to higher-cost doctors and clinics when competent lower-cost providers are available? If patients are indifferent, then why should hospitals try hard to save money for them because there is no reward. I think this is partly because the "lasik effect" has been blunted by third-party payment. For lasik, most consumers pay out from their own pockets – insurers and employers will not cover. But for cataract, knee replacement – employers chip in, insurers chip in, Government chips in with heavy subsidy. Yes, patients do some co-payment but to many, they can afford a couple of hundred dollars. So they just stick with whoever they are comfortable with. There is no incentive to shop around. But, surely, the third-party payers, like employers and insurers, will have an incentive to require the patients they sponsor to shop around?”
“Singaporean healthcare providers have largely been productive and cost efficient. But there is still scope for greater efficiency and higher productivity. Let us look at the computer industry. For years, they focus on adding more features, more capabilities to their products, tempting consumers to buy higher priced products, never mind if they may not need the frills, the bells and the whistles. This strategy of paying more for added capabilities is now under severe stress in the current downturn. And that is why the electronic sector is hardest hit. Consumers are now demanding that manufacturers go back to basics and offer lower priced products, without the frills. They are demanding new technologies that do the same for less money, rather than more for the same price. They prefer computers to get cheaper, rather than more powerful. Small, low-cost laptops, called netbooks, are now "good enough" for many consumers. The same "good enough" approach is also being demanded in the software and many other industries. The Indian manufacturers are particularly innovative on this front: they are shooting for radical breakthroughs like a US$20 laptop and a 1 lakh (US$2,500) car. And not just in manufacturing. Indian ophthalmologists have pioneered the provision of cataract surgeries at less than US$100 per eye when practically everywhere, including Singapore, it is above US$1,000 per eye. We need more of such disruptive innovations in the healthcare sector. Four years ago, I published hospital bill sizes to show the wide variation in cost among our hospitals, with a view to push our hospitals on this effort to "do more with less". And indeed there were some successes as lasik prices dropped by more than $1,000 per eye and the price wars continue.”
“We will continue to study this problem but, honestly, I do not see a quick resolution as this is clearly not the time to revise premiums. Until then, we will continue to rely on Medifund to help the lower-income patients with congenital conditions. So it is not as if they are left vulnerable. Mrs Josephine Teo has wisely advised all Singaporeans to continue to contribute to Medisave and maintain MediShield coverage even during current bad times, and I echo her call. 3Ms is important and is effective, but provided you are within 3Ms. So, please, stay within 3Ms – do not walk out of the 3Ms' giant umbrella. You will be exposed, you will be vulnerable. Basic MediShield premiums are very affordable. Given that Singaporeans have substantial Medisave balances, most would have no problems with maintaining basic MediShield coverage. In cases where the individual has insufficient Medisave balance, that is when the immediate family members must chip in to take over the premium payment to ensure continued coverage. Family members should take care of one another, especially in times of hardship. I took a look at the latest MediShield subscription data, it continues to rise. So it is not as if people have been cancelling their policies because they are unable to do so. Of course, the main reason is because we have Medisave. So Medisave enables the payment to continue even though your salary may be cut or you may have even lost your job. The second group pertains to the healthcare providers. They play an important role in helping patients save money. Saving patients' money is an important responsibility of all healthcare providers both during good and bad times, but it is especially critical during bad times. They have to help deliver better health outcomes at lower cost.”
“Again, when I started this, there were large numbers of housewives who were uninsured and we have worked very hard. So I am personally quite happy with this figure – 90%, not bad. But it can be better because the men are slightly higher, at 93%. Let us raise both rates to 95%, as the immediate target. We are working with NTUC to make workers sign up for their non-working spouses. Mdm Halimah is helping me on this, and I thank her for this. Dr Lam suggested that we have some automatic opt-out for housewives so that unless you opt out, you are in. Actually we do. We have such a scheme. We catch them at the time of marriage, when there is an automatic opt-in. Unless you opt out, the husband has to pay through his Medisave for the MediShield of his wife. Therefore, most women and housewives got covered under this approach. The trouble is that after a few years, some men forgot, which is what they said. So we have to remind them. Mr Yeo Guat Kwang asked about MediShield’s coverage of large hospital bills. After our reform last year, MediShield now pays up to 80% of large Class B2/C bills, a significant improvement from 60% previously. So by a few dollars increase in premiums, we have now greater coverage and I am quite happy with that. Claim limits for cancer treatment were also raised in the 2008 MediShield reform. However, as noted by Mr Yeo and Dr Lam, coverage for congenital conditions remains a gap in our current medical insurance scheme. MediShield and the private insurers do not cover congenital conditions. The reason is financial cost. Including congenital conditions will result in a large increase in the MediShield premiums which the rest of the population may not be willing to shoulder.”
“I am glad that those who could not get the full subsidy, ie, they get means tested out, form less than 10% of the admissions. So more than 90% – nothing has changed with the means testing – are unaffected by means testing. It shows that, by and large, Singaporeans do choose their wards appropriate to their income levels. But we will continue to monitor the situation. As for medical insurance, I thank Dr Lam Pin Min and Mr Yeo Guat Kwang for highlighting the importance. MediShield is essential for all Singaporeans to take care of major illnesses which may lead to large hospital bills. Now MediShield coverage has reached 84%. When I first started, I remember it was something like 75%. So we managed to push it up 10 percentage points, to almost 85% of the total population. I now set a higher target of 90%, and once we reach there, we will push it up further. I agree with Mr Yeo Guat Kwang that Singaporeans should get insured as early as possible, preferably soon after birth. We introduced opt-out MediShield coverage for children in December 2007, and 98% of parents did not opt their newborns out of the scheme. I thank them for their support. We are now working through the schools to catch up with those who were born before 2008. It will take some years but eventually we will catch up with all. As it is, currently, nearly 70% of Singaporeans below 21 years old are covered by MediShield. So, in fact, our 84% MediShield coverage for total population is brought down by the young Singaporeans' lower rate of 70%. As we catch up with the primary school kids and the secondary school kids, we will improve the overall figure. For the adults, 90% of women aged 20 and above have MediShield coverage, which is actually not bad.”
“I think they have a major role to play. I heard Mr Yeo Guat Kwang say in Hokkien just now – "lao liao mai chi lo kun " (let us not end up falling sick and feeding the doctors in old age). I remember there is a Teochew expression which the Japanese also have it, and that is "jia chi hoon " which means one should only eat up to 70% of what you need, as the other 30% you eat for the doctors, meaning that if you overeat, you fall sick as you get obese. Therefore, one major role of everyone is to remain healthy and keep a healthy lifestyle. But besides that, patients can do three things: contribute to Medisave and use it carefully, buy the right type of medical insurance, and choose the right class of ward for admission. These are the public education messages that we periodically advocate in the newspapers. As noted by Mr Zainudin, Singaporeans can stretch their healthcare dollar by being prudent, for example, by choosing the right class of ward. Our restructured hospitals provide financial counselling to ensure that their patients have the proper information to do so. Last week, I was quite glad to read in the Straits Times where it reported one Ms Wee who decided to switch from a private hospital to deliver her second baby in a subsidised ward in Kandang Kerbau Hospital. The move, she was reported as saying, would save her about $1,800 in cash, and this is her way of coping with the current recession, and I said, "Well done, here is a smart lady!" Our subsidised ward does not provide a personal choice of doctor, meaning that you cannot choose your own doctor, but the clinical care is of a high standard. Means testing is now available in public hospitals. This enables the Government to be more targeted in our subsidies to lower income Singaporeans.”
“I therefore agree with NTUC and several Members that we should help our patients stretch their savings and reduce their cost if they opt for elective treatment in the neighbouring countries but my concern is how to ensure safety and adequate standards, while guarding against fraudulent claims. It is easier for me to audit our hospitals here but once across the border, our influence does not go that far. So we have to think through carefully the implications of this proposal. In fact, I made a day trip to Johor during the Chinese New Year last week to chit-chat with some of the hospitals and nursing homes there, to do my homework on how to design a stricter scheme which can achieve the purpose without being abused in any way, and I will share our analysis with Singaporeans in due course. Finally, we will further strengthen Medifund, to make it a robust safety net for the lower income Singaporeans. Last year, we raised the amount of Medifund assistance to $74 million. This year, we will raise it further to $80 million. Medifund assistance is now double the amount of assistance provided just three years ago. I heard the call by Mdm Halimah and Mrs Josephine Teo for our hospitals and Medifund Committees to be compassionate and flexible during this downturn, and I am sure they will be. I have been reminding them. But even without the reminder, we selected compassionate people to be in the Committees. For the step-down care sector, our subventions for the elderly will also grow, by at least $25 million this year. All in, my Ministry will do its best to help Singaporean patients cope with the recession. But we cannot battle the economic tsunami alone. The others have their parts to play too, namely, our patients and the healthcare providers. First are the patients.”
“So for those who have several children, in fact, the withdrawal limit is quite high and we also impose requirements for deductible and co-payment. These are very important conditions and they will also apply to the mentally-ill. But unlike diabetes and stroke, mental illness, as noted by Dr Fatimah, comprises a wide range of conditions, some of which are not easy to diagnose and confirm, nor with clear consensus yet among the psychiatrists on what is the most optimal treatment regime. So if you are not careful, the money may just get depleted and a few doctors "get fat" but the Medisave Account gone and the conditions may not improve. I therefore accept Dr Fatimah's prescription and we will start cautiously with the major conditions of depression and schizophrenia, which affect the bulk of the mentally-ill. The Ministry of Health will also put in place a quality assurance framework with the Institute of Mental Health and the relevant tertiary institutions. This way, I think we can better ensure that Medisave is put to proper use, with clear benefits for the patients' recovery. We will begin detailed discussions with the GPs and the psychiatrists on how best to implement this new initiative, but I promise to get it done before October this year. Mayor Zainudin, Mdm Halimah, Dr Fatimah and Mrs Josephine Teo asked about the proposal to allow Medisave to be used for elective hospitalisation treatment overseas. The unionists asked for this extension when I last met them at a public dialogue. Good competent care for routine treatment is now available in our neighbouring countries, at far cheaper cost, given their lower cost structure.”
“As another example, patients who need a knee joint replacement - an example that Mdm Halimah mentioned - which is a complex operation (Table 6B). They can now save nearly $1,950, when we raise the withdrawal limit for this operation from $3,200 to $5,150. I will try to get this done as soon as possible, but the computer guys need some time to reprogramme the computer. We will get this done latest by June. Dr Fatimah Lateef and Mrs Josephine Teo asked about our Medisave Chronic Disease Management Programme (CDMP). This programme has helped many patients with any of the six major chronic diseases, including diabetes and stroke. I am pleased with the working of the programme. We are now confident enough to further extend it and to benefit the mentally-ill patients. Mdm Halimah, Dr Fatimah and several other Members have asked for this extension, I know, for quite some time. Just like the other chronically ill, the mentally-ill patients also need continuous and often long-term outpatient treatment and the cumulative costs can be high. So I am sure they will find this liberalisation useful but, again, a word of caution. Please remember the original purpose of Medisave, which is to help Singaporeans cope with costly hospitalisations likely to be at old age. Otherwise we end up "feeding the doctors", as mentioned by Mr Yeo Guat Kwang earlier. It was never meant for outpatient care and we must not allow Medisave to be prematurely depleted through inappropriate outpatient services and that is why I cannot support Dr Lam's proposal to extend it to all diseases. We may eventually get there but I think let us take it step by step. To safeguard against premature depletion, we have set a Medisave withdrawal limit of $300 per account per year, rather than per patient.”
“Our burns unit in the SGH is a major asset that we all can be proud of, and is an example of the excellent healthcare that Singaporeans have access to. Fifth, I agree with Mdm Halimah, and we will liberalise Medisave use to help Singaporeans further reduce their out-of-pocket expenses. In 2007, we raised the Medisave per diem withdrawal limit to $450. This has helped many patients, particularly the middle income Singaporeans who asked to be admitted to Class A/B1 wards or the private hospitals and those who do not need any surgery. This year, I will focus on helping those who need surgery. Surgeries, as Members may know, are classified into 21 tables, from Table 1A, 2A, 3A all the way to Table 7A, 7B, 7C, in ascending order of complexity and, then, we set Medisave withdrawal limits associated with each type of surgical table. For example, for the lowest table (1A), we set a limit of $150 because it is the least complex, charges are the lowest and $150 was enough. For Table 7C, which is the highest, we set it at $5,000. We will raise these limits substantially by up to $7,550 for Table 7C. This would reduce the out-of-pocket expenses of all surgical patients, particularly those who stay in Class A/B1 and private hospitals. Subsidised patients in B2/C do not face a problem because the current limits are already enough to cover their highly subsidised bills. Let me give some examples. An eye cataract operation is a Table 4A operation. Patients today can withdraw up to $1,400 for this surgery but, after the liberalisation, they can withdraw up to $2,150. So that will save them $750 out-of-the pocket. I think, during a time like this, it is useful.”
“I pass the worksite almost every day and I can see it shaping up. For a long time, it was submerged, for the basement work, but now it is above ground. The last time I saw, it was about Level 4 now. So we are on track. We will open next year. The opening will directly benefit the patients living in the north, many from my constituency, but it will also relieve the pressure in Tan Tock Seng Hospital and Changi General Hospital where patient load has overflowed there. The proposed Jurong General Hospital is being planned for 700 beds. I think this is in Ms Grace Fu's constituency but I am sure it will also benefit the whole Jurong GRC. Elsewhere, the Duke-NUS Medical School is now almost ready, while the National Heart Centre and the SGH Pathology Building are being built at the Outram Campus. The Kent Ridge Campus is just as busy with the development of the National University Heart Centre and National University Cancer Institute. There will also be developments at the Novena Campus, including the new Communicable Diseases Centre. But it is not just the big ticket items like hospital and Pathology Department. We continue to invest, a point made by Mr Banerjee and reinvest in existing facilities and to upgrade them where appropriate. I give you one example. Last year, SGH debated for quite some time but finally decided to invest $3.5 million in a new hyperbaric oxygen treatment facility to further enhance its capability in treating burns patients. As it turned out, our parliamentary colleague, Mr Seng Han Thong, became a beneficiary of this investment. Daily oxygen treatment, at a concentrated level, at the facility has speeded up considerably his recovery process. For those who have visited him more than once, we can see with our own eyes the speed of the recovery.”
“For example, we need the extra resources to re-engineer our processes, change the ways hospitals and doctors do their work, support better treatment of chronic diseases. And a very important area raised by several Members – Mdm Halimah, Dr Lily Neo – for several years, is to forge greater integration of services, ie, between hospitals, specialists, nursing homes, GPs, and others. In particular, we need to reshape the traditional healthcare sector built around acute hospitals and acute care and to cope better with chronic illnesses. And in chronic care, we need multi-disciplinary teams based on many more nurses, therapists and other allied health professionals. Third, we will help some of the retrenched Singaporeans take up a career in healthcare. We are creating at least 250 mid-career conversion opportunities for those who are retrenched. With the right attitude, they can be trained to become nurses, therapists, radiographers, pharmacy technicians or healthcare assistants. We subsidise the training costs and we pay the trainees quite a reasonable monthly allowance and guarantee them a job at the end of the training. We are prepared to do much more if there is stronger demand, and I hope there will be. We will also increase the number of scholarships and bursaries for students in the various allied health disciplines. This year, we will increase it by 250 but, as I said, budget really should not be the constraint. I hope there will be more demand and we will just grow the number. Fourth, we are bringing forward some capital development projects, to capitalise on softening construction cost. Khoo Teck Puat Hospital in Yishun is on track to open next year. Because my constituency is in the North.”
“I will find another occasion to talk about the results of our recruitment efforts in the last three years. It has been wonderful. We have been very successful in recruiting and continue to be successful. In focus group discussions with the doctors who decided to come back and many of them are Singaporeans – our own children, children of our friends and many others as well – who could not enter NUS Medical School, ended up in, Cambridge, Oxford or elsewhere, and many now come back, and the reason they gave is because of our last few years' focus on life sciences research. We see them coming back, not just to treat patients but also to have opportunities to take part in research. So that is a very important point in improving the value proposition of a career in the public health sector. The number of doctors in the public sector, as a result of all these efforts, has grown by 1,000, from 2,800 in 2004 to 3,900 in 2008. Just over a span of four years, we have increased our medical staff by 1,000. Attrition rate is manageable at 6% last year. I would like to believe that the current recession will help too and attrition will further improve. Similar efforts apply to nurses, pharmacists and the key allied health professionals. Their headcount numbers have also grown by 4,000 from about 11,000 in 2004 to 15,000 last year. But let me quickly add a word of caution here. These efforts, as I said just now, will increase healthcare cost significantly, if we merely use the extra manpower to reduce the workload for each staff. While this is one objective, it cannot be the sole objective. We must also use the extra resources to help us transform the delivery of our healthcare system, and not merely to do the same things with less staff.”
“In reply to Dr Fatimah Lateef’s query, half of these jobs, 50% will be for nurses, one quarter for doctors and allied health professionals, and the remaining one quarter for administrative and ancillary staff. This, as Members can see, is a significant expansion with, of course, long term implication, as it will raise the annual manpower cost of the hospitals permanently by more than $500 million per year. This is a major investment on our part and is in response to patients’ demand for better services and longer consultation times. It will have to be jointly funded by the Government, the patients and their families, their insurers and their employers, but the Government will foot the bulk of the increased cost as we will continue to subsidise 80% of Class C treatment and 65% of Class B2 bills. I thank Mr Banerjee for his kind comments on our healthcare system. He is well-travelled and he has seen healthcare systems elsewhere, both in the third world as well as the first world. So when he commended our healthcare system, I thank him deeply. He asked if the public sector has been competitive in recruiting and retaining our doctors and other human capital. The restructured hospitals have expended a lot of effort and resources to ensure that they have their fair share of talent. Besides regular wage adjustments to narrow the gap with the market, we also focus on training and research opportunities for our professionals, so as to enhance the value proposition of a career in the public health sector. The point about research opportunities is particularly important because, as he noted and advised, we should, besides training locally, also look out to the rest of the world for recruiting well-trained doctors elsewhere, and we have been quite successful.”
“Instead, let me focus on the new initiatives which we will undertake during the new financial year. They will benefit the healthcare sector directly and some will also have a positive impact on the rest of the economy as well. First, as noted by Mdm Halimah, we have increased the health budget substantially, by nearly $1 billion, to $3.7 billion. I am truly grateful to Finance Minister and the colleagues in the Ministry of Finance for their understanding and support. The increase comprises additional operating budget of $700 million and an additional capital budget of $300 million. These are very substantial increases. Government subvention to our restructured hospitals and institutions will therefore grow from $2.0 to $2.7 billion. Of this, $2.2 billion will directly subsidise the patients’ medical bills. The remaining $0.5 billion will help the hospitals recruit and train more doctors, nurses and allied healthcare professionals. The additional capital budget will help us expand our healthcare capacity in the form of more beds, new general hospitals, new community hospitals, nursing homes and enhanced IT capabilities. The total new capital commitment is about $4 billion, which we have planned to take probably five years to complete. But because of the recession, I am bringing forward some of the projects to take advantage of the softening construction cost. Second, we will use the expanded health budget to hire and train more professionals to enhance patient care. This is something we have wanted to do incrementally over the medium term. But given the current recession, we decided to bring forward part of the plan. Over the next two years, we shall add 4,500 more jobs.”
“Madam, I thank Members for their comments. Many have noted the extraordinary circumstances which we are now in. The global recession is raging and we are really battling an economic tsunami. My job is to ensure that healthcare remains affordable to Singaporeans, even if they should lose their jobs or face wage cuts. We are in a much stronger financial position for healthcare as compared to all other countries. This is because we have prepared for rainy days like these over the last 25 years. There are more than $46 billion in our "healthcare reserves" in Medisave, Medifund and ElderCare Fund, most of it in Singaporeans' individual accounts. I think $42 billion of the $46 billion are in their Medisave accounts and the other $4 billion are in endowment funds which belong to everybody, which we hold in trust on behalf of Singaporeans. With our healthcare reserves, Singaporeans do not have to forego essential healthcare treatment during the recession. We have carefully constructed this year’s Health Budget. There will be special schemes to help patients tide over the recession. But our eyes are also on the future when the economy recovers. We are paying particular attention to opportunities which are emerging as a result of the recession and we will seize these opportunities to further strengthen our healthcare system. For this afternoon, let me first elaborate on the strategies which we will implement to cope with the immediate healthcare issues that the recession has brought. Later today, we will discuss the longer term strategies. To battle the recession, my Ministry has already implemented a number of initiatives during the past few months and I will not repeat them.”
“Over the past five years, no household has had to surrender their flat to HDB because the sole breadwinner passed away without HPS coverage. Most households in mortgage arrears tend to be in financial difficulty due to reasons such as business failure or job loss. HDB provides ample time and assistance for such households to seek a long-term solution to their financial difficulties. For example, HDB may consider providing an additional HDB loan to help the household downgrade to a smaller, more affordable flat.”
“The answer is "no". We do not because it is pretty hard to track outgoing traffic and for what purpose. I suppose if we want to do it, we can. That means, at the border, we have to get our Singaporeans to start filling in forms. But then again, they may not fully disclose. But we do see some of these patients, when they turn up in our hospitals, sometimes, because of complications. HOME PROTECTION SCHEME (Compulsory for HDB home owners) 12. Mdm Cynthia Phua asked the Minister for National Development whether he will (i) make the Home Protection Scheme (HPS) compulsory for Housing Board home owners who are not paying their mortgage through their Central Provident Fund; (ii) provide an update on the number of HDB home owners not covered by HPS who have had to surrender their homes when their sole bread-winners passed away over the past five years; and (iii) provide the reason for not making HPS compulsory for all buyers of HDB flats. The Parliamentary Secretary to the Minister for National Development (Dr Mohamad Maliki Bin Osman) (for the Minister for National Development) : The Home Protection Scheme (HPS) protects households against the loss of their flats, should the breadwinner pass away or become incapacitated before the home loan is fully paid. All flat owners using CPF to service their home loans are required to take up HPS or a similar insurance product. In the first half of 2008, 90% of households who purchased a flat with a HDB loan, fall in this category. For those not using CPF to service their home loans, HDB actively encourages them to take up the HPS on an optional basis. Such households generally have to set aside cash to pay for their HPS premiums. Given that their financial circumstances may vary, HPS is not made compulsory for them.”
“Sir, as I explained, the foreign patients numbers were estimated through surveys by STB. We do have some breakdown by country of origin. But I doubt, we have further breakdown into which hospitals they go to or whether it is private or public. But I do have good data of foreign patients who are served in public hospitals. They are not big – they make up, I think, 1% ( I am relying on memory here) of our total patient load. There is no reason for us to reject patients, just because they are foreigners in public hospitals. But our mission remains focused on Singaporean patients, particularly, the bottom 50% of the population. I can give Members the assurance that, that remains our priority. It will always be our priority. And I do not think patient care will be affected by our doctors or hospitals chasing foreign patients. We do not. They come to us and we have to serve them.”
“Meanwhile, we must press on with our efforts to enhance our capabilities in accordance with the needs and demands of Singaporean patients. Such efforts will also help us compete better against the other regional medical centres, based on skills and clinical outcomes, and not merely on costs. Hence, the earlier plan to expand hospital capacity and specialist manpower will remain on track, although some of the private investors may adjust their timing in accordance with their shareholders' priorities.”
“Sir, the figures on medical tourists are estimated by the Singapore Tourism Board (STB) based on exit surveys of international travellers at our airport. The numbers for 2008 are not available yet. The 2007 estimate was 348,000, a 15% drop from 2006's estimate of 410,000. The 2007 figure is even lower than the 2005 figure. So the drop came as a surprise both to STB and to myself, because all hospitals have registered higher patient admissions and patient-days in 2007, as compared to the previous year. STB is re-examining the survey methodology. On the other hand, the same survey estimated that the spending by these foreign patients increased by 30% to $1.7 billion during the same period. In any case, given the severe global economic downturn, it will be a challenge to meet the earlier target of one million foreign patients by 2012. Our hospitals will have to work harder to attract these patients and we may take a longer time to realize this numerical target. But the aim of making Singapore a regional medical hub and the strategy of achieving it through offering a high standard of care which is affordable, remain unchanged. As I have explained before, becoming a regional medical hub is a natural outcome of our efforts to enable all Singaporeans to have access to a high standard of healthcare services which are also affordable. This is our primary mission and our success in this mission is bound to attract foreign patients who can afford to come to our shores. As we do not subsidise foreigners, the volume of foreign patients will naturally be impacted by the state of the regional economy. This is seen not only in medical tourism but in the entire tourism sector in general.”
“All such reviews are notified to my Ministry and we monitor the follow-up actions to ensure that the corrective measures are put in place and useful lessons are shared with the larger health care community. CYBER BULLYING CASES 36. Ms Ellen Lee asked the Deputy Prime Minister and Minister for Home Affairs (a) the total number of cyber bullying cases reported in 2008 and the number of cases involving students; (b) the number of arrests made and if no arrests were made, why not; (c) whether the bullies will be prosecuted; and (d) given that the victims are invariably young and unable to afford civil action against the perpetrators, if specific legislation will be introduced to exempt such prosecutions from the usual criminal procedure and trial process so as to curtail the distress and psychological harm to the victims.”
“Heavy demand on public hospitals should not be an excuse for any act of medical negligence. A healthcare professional may be found negligent by the court if he fails to exercise reasonable diligence and care when providing treatment and causes injury to his patient as a result. In the past five years, the public hospitals have reported three cases of alleged medical negligence that went to trial. In three cases, the institution and the doctor were not found to be negligent. In addition there were, on average, eight cases a year where the hospitals made an out-of-court settlement with the patients, usually as part of the mediation process. In these cases the hospital or staff concerned may have had some liability or been negligent but as the settlements are usually undertaken with non disclosure requirements, my Ministry is unable to determine the true nature of these cases. Not all claims of medical negligence are valid. Some adverse outcomes do happen in hospitals, despite the best efforts, and may not be due to medical negligence. For example a patient can develop a serious drug allergy after receiving an antibiotic that is medically indicated for the first time. This may be an acceptable adverse outcome of the drug. Nevertheless, we can and should learn from each adverse event. That is why we have a Sentinel Event Reporting System in our hospitals. Whenever an adverse event has occurred, the hospital's Quality Assurance Committee is required to promptly review the event to determine the root causes, recommend risk reduction strategies and follow up on their implementation. The primary aim of the review is to improve the system so as to prevent future adverse events.”
“Retrenched and workers suffering pay cuts should not be adversely affected by means-testing. For practical reasons, we have to rely on the average wage statistics as reported to the CPF Board during the past 12 months. However, if any Singaporean worker has experienced a significant change to his wage data in recent months, we will take that into account. We will need documentary evidence from the patients for certification purposes. Means testing has been implemented smoothly as planned. The design parameters have been deliberately set to be generous. As a result, the vast majority of patients, 91%, were not affected by means testing at all. The other 9% belong to the higher income group and continue to be heavily subsidized, though at reduced levels compared to other patients in the lower income group. MALFUNCTION OF SINGAPORE FLYER (Safety measures) 16. Dr Fatimah Lateef asked the Deputy Prime Minister and Minister for Home Affairs in view of the recent malfunction of the Singapore Flyer (a) which agency/department provided safety clearance for the Singapore Flyer to commence service in February 2008; (b) what was the time lag for activation of the rescue department, SCDF and the police; (c) whether there was any communications delay; and (d) what will be the course of action taken to ensure future safety. 17. Mdm Cynthia Phua asked the Deputy Prime Minister and Minister for Home Affairs (a) what safety processes and requirements did the Singapore Flyer operator have to comply with before they were granted a licence to operate; (b) why a manual cranking installation is not required to be installed at the Flyer; and (c) at what point in any incident is the operator required to call in the Singapore Civil Defence Force.”