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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“Check BMI but there will be many people who will say, "I am born, for some reason, fat. The fat cells are more and therefore I am fat. It is very unfair." So these are the problems that we will face, but I think we should try to keep it on our mind and see if they are practical to do, we will.”
“The resignation of public sector doctors to the private sector is a problem that we have to manage day by day, year by year, because so long as the private sector exists and they pay better, some of our staff will be tempted to go there. Therefore, we have to be competitive in our remuneration terms. Dr Lam mentioned about some adjustments "umpteen years ago" – those were the words he used – but that was not quite right. We have been adjusting and last year, for example, there were some adjustments, and I am quite sure this year we will look at it again. Maybe the KK Hospital did not make an adjustment, but I believe that we certainly provided budget for the hospitals to make such adjustments. But the key point remains that we must compete with the market and we have to retain them. I am always grateful that we have so many very good doctors. They could have easily crossed the road and make more money, but they stay because they know that the bottom half of Singaporeans have no choice, that if they do not stay, their expertise will be lost to this bottom half of Singaporeans. We are truly grateful to them. But being grateful is not enough, we should also pay them properly, which we will. On staying trim and the incentives for doing so, I have been watching this development with interest. Many insurers talk about it. When I probe more deeply, it is fluff. The theory is easy – if you engage in healthy lifestyle and, therefore, your health should be better, I reward you. The difficulty is always this – how do you certify? Everybody will put up their hands and say, "Yes, I exercise three to four times." What am I going to do? Put a CCTV and watch their movement? Impossible.”
“So let us see how we can share it out as fairly as we can but, at the margin, be flexible, so that those we think are of the high income group, if they have genuine difficulty, if they are not able to buy an insurance because of some complicated congenital illnesses, I am sure whoever is the Health Minister, or the hospitals running it, will take a flexible approach to that.”
“And if you do, you do not have to go to class B2 or C because if your insurance entitles you to class B1 stay, and, of course, you go to class B1. So why go there (B2/C) and compete with the poor? In fact, the more we tightly implement means testing, the more we can do for the really poor. Why is it that the standard drugs list which Mdm Halimah talked about expands so slowly? It is because many can afford to pay for the more expensive non-standard drugs and they should be paying out of their pocket or get their insurance to pay for them. Without means testing, they can easily go to class C and they know they will be entitled to these very heavily subsidised expensive drugs. But it is the same limited budget. Of course, every year, we grow that budget but when more people are putting their hands in for these drugs, surely, each will get less. This was similar to our family planning slogan many years ago – "more mouths to feed, so less to each". This is the situation. So, let us be practical. This is the reality: between demand and need, there is a wide gap. Therefore, let us take a realistic and practical approach to this. Face the fact and the way I am doing it is extremely gentle. Mr Low asked how long will Annex A stay as it is. It depends because situation will evolve and income group adjusts. As the economy grows and income profiles change, we will adjust with time. So whether it is PA's rates, or whatever means testing criteria for housing and education, they are adjusted periodically and, surely, whoever is the Health Minister prevailing at that time will do that kind of adjustments too. But the fundamental policy remains, that health subsidy is limited.”
“So even the poor can see their service level improve over time and, over the next 10 to 15 years, I hope we can continue to do so, so that no matter how poor you are, your healthcare continues to rise up in accordance with the economic status of the whole country. So, that is the approach we take. But if you do not put in this filter, which is the means testing, and if you keep on doing that, today, it is all right, only less than 10% of the top 20% stays in class C. But without means testing, do you think it will stay at 10%? Surely not, unless, as suggested by Ms Sylvia Lim, we freeze: no more development of class C wards. But I think that will be unfair to the poor in 10 to 15 years' time, and they may not agree that today's current standard of class C will be adequate by the year 2020. That is the problem we are trying to resolve here, and I think it is a very practical way forward. So all patients, rich or poor, you are eligible to go into class C, and if you look at the subsidy for the rich, it will still be very heavy. At class C, you only pay one-third of the cost, and for those who are earning $8,000 to $9,000, you can well afford it. I have checked the Medisave balances of all those of the higher-income group – largely $28,000, $27,000, more than $25,000. So there is enough money in their Medisave, even if they are not insured. But my key message remains the same. Means testing is not to deliberately upset people or that we want to means test you and charge you more. Means testing is to remind Singaporeans that, going forward, please think about hospitalisation and, therefore, buy insurance. Everyone must buy basic MediShield, and if you are of the middle-income group, let us say you earn more than $4,000, please top it up with a rider.”
“So, at $3,200, it is almost 60% of the Singaporean working population. And so for those 60%, full subsidy remains and even then, if you cross that one, it is a graduated scale – which happens to be a suggestion that came in from the public which we then incorporated. I think the key point is this – which was a question that I posed in my earlier speech – what are class C and B2 wards built for? That is a fundamental question. Is it built for every Singaporean? In other words, 100% all go to class C, which is really the British National Health System. One class – rich or poor, millionaire or pauper, you go into that one class, take it or leave it. In fact, then there is no choice. Here we provide full freedom of choice. You can go to a private hospital, or you can go to different classes in a public hospital. So that is the way we handle it. But things, as I have said, have now developed in such a way that today, the situation is quite different from 30 years ago. We cannot unwind the clock. When I started my career, class C ward was really for the very poor, and I spent time walking the ward floor, and I talked to patients who were clearly the poor. Thirty years later, today, it is very different. Yes, the poor, some of them, remain in class C, but many do not look poor to me at all. This is the current situation which I think is not a bad development, in a sense, because over the years, the economy does well, so we share out the economic growth with all strata of the Singaporean population.”
“Madam, the first point on whether Singaporeans are being denied as to choice of wards, my point is that nobody is denied any freedom of choice. Anybody can put up his hand and if he wants to go to class C, provided he is sick and he requires medical treatment, then he will have a choice of classes, and, in the hospitals, at the admission counter, we have been doing this for many years now, what we call financial counselling, because we also want to make sure that the patients choose the right class of wards. At the point of admission, once we know what are the patient's medical conditions, we can counsel the patients. We have a lot of statistics, average figures and percentiles, to tell us that for this particular condition, there is a likelihood that you will stay six days and if you go to class A, this is the bill size; if you go to class B2, this is the bill size; and C. The patient can then make an informed choice. So that freedom remains. Means testing allows us, once we know your salary level and which subsidy band, to churn out similar tables accordingly and customise it to the particular illness the patient is being admitted for, the patient then makes his or her choice. That is how it will work. Mr Low's point is that means testing will hurt the middle class. Yes, potentially. The lower class, the low-income group, has no means testing and precisely because of this, that is why if you look and study carefully Annex A, we have purposely "erred on the side of generosity" – I used those words – and I think nobody can fault me for not doing so. That we have deliberately included a substantial number of the lower-middle and the middle-middle and perhaps even part of the upper middle-income group.”
“So while we keep on increasing our health budget, if the economy is doing well, there is always a limit to things, and that is why it is so important how we target our subsidy, so that those who genuinely need it will get it, and those who can afford to pay more, they should co-pay more. I am glad that Mdm Halimah finds the parameters that we have finalised on, which is in Annex A, an acceptable scheme. As to the $88 million fund for mental health, how much of it will go into community groups, I do not carry those figures on top of my head. I do not know whether Mr Heng does.”
“I thank Mdm Halimah for the three queries. For medical tourism, the projected million more tourists coming to Singapore, yes, surely as I explained in my earlier reply, all this must impact the supply on the manpower side, particularly at the specialist level. The key, I think, is not to stop them from coming, but to make sure that we ramp up supply at the same time. So part of the big increase in the health budget this year will go towards enlarging our manpower pool, as I elaborated earlier. On local training, we will always be short, and that is why it is crucially important that we continue to tap on external sources as well. In my earlier reply, and I think it is worth repeating, last year, while we graduated slightly more than 200 doctors here, we recruited more than 400 from overseas with recognised degrees. This is the approach that we will take on this particular subject. As for means testing and standard drugs list, we have a medical committee of experts to advise us and they regularly review the standard drugs list. Each year, they will add some but there is hardly any year when they withdraw some. They will top up the list as and when they have better evidence of the cost-effectiveness of the new drugs and I stand advised by the medical professionals. But a key theme that ran through my earlier speech – which is also the point that Mdm Halimah shared with us just now – is moderating public expectation. The easiest thing in the world is to keep on expanding the standard drugs list. In fact, why have a list? All drugs should be allowed. Then you have Avastin, the example that I gave, but it is US$100,000 per drug, per patient.”
“Dr Lam Pin Min commented on the manpower strategy to cope with a rapidly ageing population. And I agree with him that the current numbers will not be sufficient. We will study and we will try to increase them. In the earlier speech, I mentioned about wanting to step up the training as well as recruitment of many of these allied health professionals. In this sector, really, they are the most important resource. Sir, everyone wants to live long and live well, without being a burden to the family. In Okinawa, the ladies told me, when I asked them what is their top wish: "pokkuri shinu". It is a Japanese word. Pokkuri means pop, like bubble that pops. In other words, they want their lives to be like a bubble – bubbly, active, happy and then, one fine day, in the sleep, just "pop" and die in the sleep. My father led such a life. He worked hard, loved the family, had no vices, and one night, in front of the TV, went into a coma and drew the last breath a few hours later. I missed him by an hour because I was not in Penang. Not everyone is so lucky. My mother suffered nearly three years of cancer pain. We had to try high-tech medicine first. When the poor prospects became clear, we went for "slow medicine". She was able to die peacefully at home in familiar surroundings. This time round, I was able to return to Penang in time and be there as a loved one passed on. As we busy ourselves with our work and our family, we should sometimes take a pause and reflect on how people spend their last moment. Death is not a taboo subject to be left unspoken. In fact, the more we think seriously about death, the more likely we will know how to live life to the fullest and to make each moment and each day the most meaningful possible. Mental Health”
“Another key focus for MOH is to ensure patients get the most appropriate treatment in the right place, or what we call "right-siting". Mdm Halimah and Dr Lily Neo suggested that we subsidise home-based care for the elderly, including home hospice care. I think we do but of course we can always do more. But we have to study the implications: what does it mean? Last year, the Ministry of Health provided $3 million in funding these providers. We will do more, but we are taking a careful approach, as the direct home care model actually is very expensive. So I am at a dilemma. We know that the elderly prefers to age at home. And to strengthen family bond, treatment should be at home, instead of in an institution even if it is a day-care facility. But between the two, it is a lot cheaper to do it at an institutional level because you can have economies of scale, rather than at home. So these are the balancing acts that we have to do. We need to study the underlying patient needs carefully. Mdm Halimah commented on ElderShield. We have enhanced it last year, as she noted. Those who require more payouts, they can subscribe to supplements. Unfortunately, partly because the product is not an easy product to market and public awareness is not good, only a single percentage point of ElderShield policy holders top up with the ElderShield supplements. But we will study this problem. And of course, we will have to expand the step-down care infrastructure. Much of this may be care that is not medical in nature. In fact, in this area, we should be careful that we do not "over-medicalise". If it is just simple care, just keep it at that level. We will work with MCYS to see how we can develop new services here.”
“Dr Lam Pin Min and Dr Fatimah described the problems faced by caregivers of patients with dementia. And it is a real problem. Talking to them in nursing homes, you cannot help not to be affected when the loved one can no longer recognise them. Sometimes, it is easy for outsiders to say, "You terrible children: never visit your parents in the nursing home after dumping them there." But when you go there, one month, two months, three months and then six months, the patient cannot recognise you at all. It is heartwrenching. So for caregivers, we will try to support them as much as we can in a professional way, in a technical way, how to cope with all these difficult problems, forming them into support groups so that they can support each other. But whether we should pay them, I think let us think through this carefully. This is part and parcel of the children's duty, this is family duty. I think if the Government steps in to turn children into employees, we are walking backwards. Third, I agree with Mdm Halimah, Dr Lily Neo and Dr Fatimah that we must better integrate the healthcare system with the community to provide appropriate care for the elderly. From next month, we will upgrade the Integrated Care Services into what we call Agency for Integrated Care (AIC) with upgraded capabilities. Starting with Changi Hospital and National University Hospital, the AIC will equip our hospitals with additional resources, including additional care coordinators. This will cost us $20 million over the next four years. These coordinators will help ensure that patients who are fit for discharge but, who have multiple complex care needs, are transferred to appropriate step-down care providers and that they will receive the necessary medical or social services.”
“Mehta, that when medical care is needed, primary care is the best first point of contact for the chronically ill and elderly patients, unless of course, it is genuine emergencies. Good primary care is particularly essential to meet the chronic disease challenge. Medisave can now be used for outpatient treatment of four chronic diseases. As noted by Dr Fatimah, half of GP clinics are now participating in this scheme. 4.30 pm Overall, we are pleased with the progress. So, from next month, we will extend the scheme to the remaining two major chronic diseases: asthma and chronic obstructive pulmonary disease (COPD), and we will extend it under similar terms. This will benefit up to 180,000 more Singaporeans. Dr Fatimah asked if we would extend this scheme to other illnesses, for example, mental illness. We keep our options open, but for the moment, we focus on the key chronic diseases with established treatment protocol and measurable clinical outcomes. We also must not forget that Medisave at current contribution rates are only designed for inpatient care. It was never designed for outpatient care. Extension to expensive outpatient care is an exception, and we should resist any temptation to broaden its use liberally, or it will surely be depleted prematurely. Mdm Halimah proposed that we extend the Primary Care Partnership Scheme (PCPS) to cover some chronic diseases. Currently, it does not. It only covers acute care, coughs and colds, but chronic care, it does not. Any extension to chronic care will raise the risk of over-consumption and over-servicing. But a case for extension can be made if we can manage the potential problem of abuse. So I am studying this very carefully.”
“Better think through, start small, test the market, rather than rashly committing to any long-term financing that our society may not be in a position to afford. Let us discuss some of the points raised. First, I agree with Dr Lily Neo that we must promote healthy living and healthy ageing. But Singaporeans must participate actively in order to benefit. This is a continuous and often uphill endeavour. But we persevere. Healthy living starts with awareness. This year, HPB will roll out the nurse educator programme. This is a new programme which we are starting. We will place some of these nurse educators at community centres where they can hold classes for patients and their families on how to manage their chronic conditions. We will work with PA and the grassroots to promote these programmes. We will leverage on screening. Many MPs, I remember during the early years Dr Lily Neo actively championed community screening, and a lot of work has been done promoting this. We are consolidating the programme and we will raise it to a new level. From this year, HPB will roll out what we call an Integrated Screening Programme. All Singaporeans above the age of 40 will receive a letter from us, a reminder to go for screening for some of the major chronic diseases. We are embarking on preventive efforts to promote healthy ageing. Last year, we embarked on a pilot "Wellness Programme" at six constituencies. This came under the framework of the committee chaired by Mr Lim Boon Heng. We are trying out at six constituencies, and if it works, we will scale it up. This includes a platform for health agencies and service providers to encourage positive changes in seniors' lifestyles and health behaviour. Second, I agree with Prof.”
“Some elements or operating philosophies are better researched and appear sound, but we cannot be sure until they are tested through time and actual experience. This calls for carefully-planned experimentation and small-scale pilots, close monitoring and review, and if proven, scaling up. Such initiatives include, among many others: (a) Greater emphasis on preventive medicine; (b) Better management of chronic diseases at outpatient level; (c) Better integration of care between hospitals and step-down care facilities; and (d) Right-siting of patient care in more appropriate and lower-cost settings. Many Members have shared their thoughts on this important subject and I thank them. I have noted Dr Lily Neo's comments on possible public-private- people partnership as a model of providing eldercare. And indeed, we should widen participation, both in provision as well as in funding. Ageing of the population is a growing problem, and we should not underestimate its impact. The Japanese are well-known for doing very careful research and wide consultation before they launch any new scheme. Yet, when they launched their national long-term insurance scheme just a few years ago, they found that their initial projection of demand and funding needs were off by a wide margin, just after one year of implementation! They have since been trying to curtail demand and raise premiums. I think this is a very important lesson for us who are involved in the planning of eldercare services. Do not underestimate demand, especially if it is going to be subsidised generously. And make a strong distinction between demand and what is genuine need. Demand does not equal need. If service is provided, heavily subsidised or provided for free, demand will grow, much more than the actual need.”
“And home tests for blood in the stool may replace the draining routine of a colonoscopy. Very practical tips. He added that the pace of care should be slowed to a crawl, and hence the title of his book. For doctors, that means starting the medications at low dosage and increasing them gradually. And for children, that means learning not to panic and yell for an ambulance on every apparent bad day. Though both comforting and worrying, it is a valuable contribution to the global discussion on ageing and how best should families cope with it. Indeed, modern healthcare systems are not well-designed for the demands of ageing. They are geared towards acute care in hospitals, that is, treatment for only brief but severe episodes of illness, sometimes requiring high-tech care. But insufficient thought has been given to long-term chronic care. Good models are rare and far-between anywhere in the world. Proper chronic care should be carefully designed for the long term, with appropriate level of resources, usually low-tech care, and most critically with strong cooperation, participation by patients and their families. Chronic care is a very different care regime from acute care. But when high-tech acute care is mindlessly extrapolated to cover long-term chronic care for the elderly, it is not at all surprising that problems in the US and the West have arisen. Everyone is searching for a better model to handle long-term chronic care of the elderly. We too are evolving our model. So I agree with Mdm Halimah that there are gaps, many in our current step-down care sector, and we must fix them. Fixing them, however, requires careful thought.”
“And, of course, this naturally raises many questions about the appropriateness of such spending. One reason is that current healthcare systems largely skew the practice of medicine towards high-tech medicine, a point Prof. Mehta made just now, and therefore at great financial cost and often poor quality of life for the patients. Someone showed me this book, "Slow Medicine" written by a geriatrician at Dartmouth Medical School. He promotes a different approach and I quote him, "a family-centred, less expensive way", as he puts it. He felt that for many elderly patients, "modern medicine in its hospital-based, medication-obsessed, high-tech impersonality may hurt more than it helps". He has many practical tips for children of elderly parents and they are worth sharing. First, while the parent is still vital and lively, children must not fool themselves that this happy situation will last forever. This is the time to re-insert themselves back into the parent's life, to accompany them to doctors' visits, and at the right moment raise unpleasant topics like the advanced medical directive or living will. And I see a cut on this by a Member later today. After a few more years, this geriatrician said, it is time for the children to address the "can you still manage at home?" issues and to help create routines that compensate for the elderly's slipping memory and slightly wobbly balance. And then, inevitably, medical crises will arise. The children should then be vigilant to protect and "rescue the elderly from standard medical care". By that, he meant medical care should, all the while, favour the tried-and-true, over the high-tech. For example, instead of a yearly mammogram, a manual breast examination for the very old may suffice.”
“Seventeen of them are above the age of 100: 16 female, one male. And the man, with dementia, lying in a nursing home, I visited him. I have never, in one sitting, met so many over-90 years of age, mostly ladies. I have met many Singaporeans in similar age groups here, but they are largely in nursing homes or chronic sick hospitals. The Okinawans are different. They are active, they are busy, they are happy, fun loving. I did folk-dancing with them. And they live independently. They still cook their own meals. Very few are bed-ridden in nursing homes – they do have nursing homes there – but when I spoke to them, they said they came from other villages, not from this village. And they were quick to share their secrets with me. Less scientific and more anecdotal, their prescription is: sleep well, meaning have a good night's sleep, not necessarily at night, it could be during the day, but have a good sleep. Be happy, eat lots of vegetables, very important, and they eat fruits too, but they treat fruits like vegetables, they cook their fruits into their dishes and, of course, stay active. These are some positive aspects of ageing. But ageing of the population is not all bed of roses. Dr Lam Pin Min's comment on dementia is just one illustration. Indeed, the ageing of the population is the greatest challenge confronting healthcare systems around the world. Just look at the US. They spent 16% of their GDP on healthcare and you look at the component called Medicare which funds the medical care of the elderly, anybody more than 65 years, that takes up 3% of the US GDP. So 3% of US GDP just to look after those who are more than 65, and we spent 4% treating everybody. And one quarter of Medicare spending goes towards supporting the last year of the patients' lives.”
“Sir, last week, I came across an article with a seductive promise: "Five easy steps to living long and well". It is a serious article quoting the evidence gathered from a study on more than 2,300 healthy men over many years. When the study began in 1981, their average age was 72. At the end of the study, 970 men or 41% had survived into their 90s. The study was published last month in The Archives of Internal Medicine. "The take-home message", said Dr Laurel Yates, a geriatrician at Brigham and Women's Hospital who led the study, "is that an individual does have some control over his destiny in terms of what he can do to improve the probability that not only might he live a long time, but also have good health and good function in those older years." The prescribed five easy steps are: abstain from smoking, manage weight, control blood pressure, regular exercise and avoid diabetes. I score 5 out of 5, but I believe that good genes and good karma play an important part too. The study focused on men but the prescription is probably applicable to women as well. In fact, in the same issue of the journal I read another study which monitored 500 women and 200 men ranging in age from 97 – so the youngest was 97 – to 119. This study showed that a large proportion of people who lived that long, with minimal or no assistance, did so despite long-term chronic illnesses. In other words, some of the oldest of the old survive not because they avoid illness, but because they were able to delay or even prevent disability. As life expectancy grows, there will be many more such studies and articles. Dr Lily Neo mentioned Okinawa and how they deal with longevity. I went there last year and I spent several days there. I visited a village called Ogimi with 3,500 villagers.”
“Many end up paying nothing - we just waive the whole bill - which means a subsidy of 100%. But, of course, they have to be properly means-tested. So there is nothing wrong with the concept of means-testing in healthcare at all. 3.45 pm We are now working out the implementation details and we are confident that implementation can be automated and hassle-free. Like Mdm Ho Geok Choo, we want to keep the cost of implementation low. Some cost in computerisation has to be incurred, but the incremental cost should be manageable. I agree with Mdm Halimah that we should simplify implementation. That is why we adopt a simplified approach to means-testing, just by looking at personal income, rather than per capita household income. I agree totally with Mdm Ho, Ms Denise Phua and Mr Siew Kum Hong that per capita household income is a more correct gauge of financial ability, but implementing such a scheme for acute hospitals with very high turnover, large numbers of patients, short stay, will be extremely costly and, of course, intrusive to every patient, when the majority will actually not be affected by means-testing. So you are subjecting people to a lot of hassle for nothing. However, if specific patients feel that the simplified approach has been unfair to them, we will then do a thorough means-testing on such patients upon their appeal. So, in a way it is a hybrid system, a simplified approach - a first cut for everybody - and for those who feel aggrieved, we will look at them individually.”
“Members will notice that the criteria and income thresholds are more generous than was discussed during the public dialogues. As Members can see, the vast majority of patients will not be affected by means-testing. All those who earn below $3,200 per month - individual income, not household income - will continue to enjoy the full subsidy. All housewives, retirees and children, in other words, non-working, living in HDB flats and lower-Annual Value private properties will similarly be unaffected. We have taken such an approach after taking into account the feedback from several MPs, including Mdm Halimah, Dr Amy Khor, Dr Lam Pin Min, Ms Jessica Tan, Dr Maliki, Dr Fatimah Lateef and Mayor Zainudin, who have helped me to conduct some of the public dialogues. Mdm Ho Geok Choo asked if means-testing will deter the higher-income patients from continuing to use B2/C. I will not be able to forecast how individual patients will respond to the change. But what I hope will happen is a greater awareness on the part of Singaporeans that we all should subscribe to MediShield, and that those who earn more than, say, $3,000 or $4,000 per month, should top up with a rider which would enable them to use the higher ward classes. And if they do so, there is no reason for them to go to Class B2/C to compete with the poor patients. So, this means-testing is as much about getting Singaporeans to get a proper level of medical insurance. That, to me, is the key motivation and a very important motivation. Mr Siew Kum Hong suggested even more subsidy, higher than 80%, for the very needy patients. In fact, we do so today. *Cols. 1797-1798. Through Medifund, patients who cannot afford the current Class C subsidy get additional assistance.”
“Today, the bottom half of Singaporeans form the bulk of Class C and B2 patients. It is now a very different scenario from the days when Class C and B2 wards were first conceived. And budget permitting, I would like to continue to upgrade the subsidised wards in response to rising expectations. But as we raise their service levels and narrow the differences between the subsidised and the private wards, we must expect more and more higher-income Singaporeans to be attracted to them, because there is no barrier to entry. Today, any Singaporean who wants a B2/C ward can just put up their hands and they would be admitted to Class B2/C and they would enjoy the high subsidy. This must mean greater competition for the same health subsidy. This is the rationale why we need to introduce means-testing in the subsidised wards now. Over many dialogues, I have explained this to a good cross-section of Singaporeans. The concerns raised by various MPs were similar to those I have heard during the dialogues. I am heartened by the people's understanding and support for this policy, after hearing my explanation and clarification. I have assured Singaporeans - and I give them my word - that we will take a practical approach to means-testing. We will be flexible at the margins to help those who may appear to be high-income but who may have exceptional financial liabilities, either because of large families or maybe some family members with congenital complex illnesses. We have decided to set the criteria more loosely so as to mitigate the impact on those who may be affected. The Clerk of Parliament will now distribute the parameters which will define our means-testing framework. [Copies of Annex A* distributed to hon. Members. ] Please refer to Annex A of the handout.”
“But we do need time to gather more local data to correctly establish the premiums for those in higher age groups, taking into account the prevailing life expectancy. Later, during clarification time, if Mdm Halimah would like to, we can have some discussions over this very difficult topic. It is not simple. It is not straightforward like, "Let us just raise the maximum age." It has to do with critical size, ie, the size of the risk pool. When the risk pool is too small, the premiums will have to be very high. I have checked the numbers. Those who are more than 80 today, in MediShield, number only a few thousands and they are largely the very sick ones. That is the problem. Above all, the main strategy to help lower-income Singaporeans cope with rising healthcare cost is our heavy subsidies for Class B2/C patients. At 65% or 80% of cost, these are very large subsidies. Last year, direct subsidy for these patients was $1.5 billion. This year, very likely, it should exceed $1.7 billion. Indeed, the bulk of the budget increase will go towards caring for subsidised patients. The question is: who should constitute "subsidised patients"? Who are Class B2/C wards created for? I put these questions forward during my public dialogues recently. The vast majority of the participants were clear in their reply: Class B2/C should serve the bottom 20% or at most 30% of Singaporeans. In fact, this used to be the case when I started my career in the Ministry of Health exactly 30 years and three days ago. When we first started, Class C beds were clearly for the poor, at the bottom 10% or 15% of Singaporeans, and they were furnished as such. But over the years, with rising public expectations, we improved Class C wards and services, more lower-middle income patients choose them.”
“Many Singaporeans are still under-insured, probably due to inertia or possibly ignorance. So we will continue to educate them. The Government, of course, will do its part. First, we are strengthening Medifund and Eldercare Fund. This year, the $600 million top-up to these funds will provide our hospitals, community hospitals and nursing homes with more funds to help patients who need additional assistance. Second, I am finalising the details of the next reform to MediShield, to further improve its coverage of large B2/C bills. I welcome Mr Yeo Guat Kwang's strong support for the proposed reform. This is taking some time as we are trying to keep premium increases as affordable as possible, while increasing the payout to cover, I hope, nearly 80% of large bills. But these are two contradictory objectives. For most of the age groups, balancing these objectives is not too difficult. But for the very old, especially those above 80, this is simply not feasible. We are making our actuarial consultants earning their consultancy fee by doing many iterations. I want to see whether we can find an optimal point for the trade-offs. But no matter what, the old will have to face a larger premium increase. To help them cope with this, the Government will be topping up the Medisave Accounts of elderly Singaporeans. With this top-up, combined with the MediShield loyalty discount, an affordable package may be possible. I target to finalise the details next month. We will time the Medisave top-ups to precede the implementation of the MediShield reform. Mdm Halimah suggested that we raise the maximum coverage age for MediShield. It was raised to 85 in 2006. We will review this periodically.”
“We must persuade them to do so and do more for their own good and the good of their families. And let us not forget the housewives too. Husbands should help contribute to their Medisave accounts. CPF Board has a voluntary contribution scheme and, now, there are some tax incentives that go along with it. I urge all husbands to top up their wives' Medisave accounts, especially if they are full-time homemakers. I think this must be one of the basic duties of husbands, and we should remind them. Second, subscribe to MediShield. I totally agree with Mr Yeo Guat Kwang that all Singaporeans should subscribe to MediShield. It is as simple as that. Every one should have MediShield at least. Nearly 80% of Singaporeans do, fortunately. But what about the remaining 20%? They must come in too. Big numbers of uninsured are young kids. So, last December, we changed the rule. Now, all newborns are automatically covered. We are working with the CPF Board and the Ministry of Education, and we will proceed to sign on all the students who are in schools. In addition, we are working with NTUC, especially with Mdm Halimah, to get workers to buy MediShield for their spouses. This is the second basic duty of husbands. Get them MediShield. Through these efforts, we aim to raise MediShield coverage, first, to 85%, and when we arrive, we will shoot for 90%. Third, the middle and high-income Singaporeans should top up their basic MediShield with riders. Basic MediShield is not enough for the middle and upper-income group. So, buy MediShield but also top up with a private rider, which is provided by so many private insurers, because that will then enable you for admission to private hospitals, Class A/B1 wards. MediShield is designed only for Class B2/C. It is not designed for private wards.”
“Our population is not growing at 7% or 11%. Are Singaporeans getting sicker? Are we getting into more accidents? Or are we now rushing to Emergency Departments too readily and perhaps unnecessarily? There is therefore a need to price our services properly so that we do not inadvertently attract non-emergency patients to our Emergency Departments. Non-emergency patients should go to their family GPs. Every Singaporean must have a family GP to whom they consult all the time, who knows their whole family well. They should not rush to Emergency Departments and compete for the resources which are really meant for the critically ill. We will do our best to manage cost escalation, difficult as it is, and during this period of high inflation, our public hospitals will be particularly careful. They cannot freeze their charges, because imported inflation will have to be passed through. So for expensive drugs - unfortunately, the tender price has gone up - the fees have to go up. But they will not add to other cost increases unnecessarily. They will also play their part by promoting greater use of generics instead of brand name medicines, and standard medical supplies instead of non-standard appliances like stents or implants. And they will help the patients to get treated at the right settings. For these, our hospitals require the cooperation of our patients. Indeed, in healthcare, patients have a big part to play. How? First, stay within our 3Ms framework. Contribute to Medisave. All employees do, because it is compulsory. Otherwise, we will take the employers to task. But many self-employed and casual workers are still not regular contributors to Medisave or are not contributing enough.”
“He said he almost fainted when he received the bill – more than $2,200 for a two-day stay. I did some mental calculations. It cannot be a public hospital. So I queried him during the break and asked him, "Which hospital did she go to?" "A private hospital", he said. Public hospitals are not spared such imported inflation. But part of the cost increases is also due to higher public expectation and their demand for higher-end care. Just now, Ms Sylvia Lim said that we should not raise public expectations. I agree. As a strategy, I would be the last one to want to fan up public expectations. But I cannot ignore rising public expectations. Her message to me just now was to keep still. Enough Class C, remain like today, or even scale back so that it is absolutely no frills, very basic. Do you think Singaporeans will agree and say, "All right, let us do it, scale back, and we go back to the Class C of 1970s"? I do not think that would be the case. 3.30 pm So, while we should be the last one to want to fan up public expectation and will constantly remind Singaporeans: please moderate your expectations because the higher your expectation, the higher must be the cost. While we will bear most of the cost, you have to co-share, too. So, it cannot be just keep on raising public expectation and demand without wanting to pay something for the additional cost that will be incurred. Let me give Members an example: attendances in our Emergency Department. I have been tracking this number because it has been worrying me for quite some time. Last year, the number went up 11%, a very high rate. In the previous three years, the rate of increase was 7%, which had already alarmed us because it was higher than the previous 10-year average of 4.5% per annum. What is happening?”
“These are good medical schools. The increased budget will also allow us to double the number of scholarships for the allied health professionals to 120 this year. We are starting a new scholarship to sponsor some graduates from Nanyang Polytechnic to pursue a one-year degree conversion course overseas. Many are doing physiotherapy diploma and they want to go to Australia, one year conversion course, and come back with a degree. So I thought, let us offer the best students scholarships each year, say, a dozen or two and we can always ramp up the number later. We can bond them to return to work in Singapore. These increases should lead to better service levels, but they will also add to our costs. Our health spending will go up from 4% of GDP to 5% or 6% in the medium term. They will also fuel healthcare inflation, which Mdm Halimah, Mr Yeo Guat Kwang and others expressed a lot of concern about. In the previous Parliament sitting, I have explained the high healthcare inflation in Singapore in the past one year. At 6.3%, updated to 7.4% recently, it was exceptional to the norm of about 2% per annum for several years. And there were several contributing factors to this exceptionally high rate. Huge imported cost increases were a major factor, pushing up prices of medical supplies and medicine, both western as well as traditional Chinese medicine. Those of you who are familiar with cordyceps " dong chong cao" will know how much it has gone up – mind boggling! It just reflects the rise of the middle class in China itself so that there is strong demand for this limited supply, and prices go up. The imported cost increase have affected the private sector. Last week, I heard Dr Ahmad Magad relating a personal experience when his daughter was hospitalised.”
“Healthcare workers are going to have other opportunities outside healthcare. And we need to keep them at least to retain a fair share of them in healthcare with comparable pay and working conditions. That is why I have sought a substantial increase in budget. As noted by Mdm Halimah, this Health budget will go up by 19% over the last budget, a significant increase of $421 million. It will fund both hardware and software and more initiatives to improve clinical outcomes and increase productivity. Our bed-to-population ratio will go up from 1.6 to 1.8 (per 1,000 population) by 2015, but it will still be lower than the rates in other developed countries today. We will also watch over our average length of stay in the acute hospitals which, at 5.3 days, is among the lowest in the world and must remain so. This means that a patient who is medically fit for discharge must vacate his bed to go home or to a nursing home, if necessary. Over the break, I had an interesting conversation with Mdm Cynthia Phua over an incident of a friend or relative who was being asked by a hospital to go home. And this is the reason. We need to price our hospital facilities correctly, so as to discourage unnecessary prolonged hospitalisation. Dr Fatimah and Mr Zainudin stressed the importance of getting more manpower to cope with rising demand, and I fully agree. That is why we are spending $1.9 billion over the next five years to expand our pool of doctors, nurses, pharmacists, physiotherapists and other allied health professionals by 40%. We are actively recruiting from abroad to supplement the local pool, and we have some success to report. Last year, for example, NUS graduated 230 doctors. But we recruited 438 doctors, almost double, who graduated overseas, largely from our approved list.”
“Back here, in Singapore, we know we need to improve the doctor-to-patient ratio to allow enough time for each patient. Our doctors and healthcare professionals are over-worked, and they need a life too. I know our Director of Medical Services, Prof. Satku, is sleeping less and less, juggling between his surgeries at NUH, meetings at MOH and with international counterparts. And the situation is the same with the other senior consultants – Prof. Tan Ser Kiat at SGH, Prof. Philip Choo at Tan Tock Seng Hospital and Prof. Benjamin Ong at NUH. But it is not just the senior consultants. Our young doctors too are also working day and night to meet the needs of increasingly more demanding patients and relatives. I am sure Dr Fatimah Lateef, Dr Lim Wee Kiak and Dr Lam can testify to this. And some of the parents of these young doctors are in this House too. I doubt you see much of them at home. Doctors like everybody else would like to enjoy a better worklife balance but the patients just keep coming, and not just local patients. An increasing number of foreigners are coming here for treatment. This is good for the economy, for the hotels, and a testament to our high standard of care, but it does put pressure on manpower. At least two new private hospitals will open in three years' time. We will face a worsening staff shortage. Our specialists are trained at top centres around the world and they are much sought after. We need to ensure our remuneration packages are competitive to retain this key talent. And it is not just our doctors we try to retain. This is a point that Mayor Zainudin mentioned. The booming hospitality sector driven by the IRs will put great pressure on other manpower. They are poaching not only from the zoo, but poaching from the hospitals too.”
“Instead, it is through a series of deliberate, carefully considered incremental policy changes over many years that we can build a sustainable healthcare system. And that is how we have built up our 3Ms framework over 25 years and how we are continuing to make it stronger. As a result, Singaporeans can be proud of our healthcare system. It is far from perfect. But the World Health Organisation has rated it No. 6 in the world. It has enabled Singaporeans to enjoy the high standard of care. With less abuse in the system, our health spending at below 4% of GDP is the lowest among developed countries. And we should try to retain this ranking. Hence, we continue to build for the future. Last year, I announced a 10-year capital development plan, costing $2 billion. This will expand our capacity further. We are busily implementing this plan. Like Mdm Halimah, Mr Yeo Guat Kwang and Dr Amy Khor, I worry a lot about rising healthcare costs. Our population is expanding and rapidly ageing. New technology is generating more sophisticated treatment which is almost always more costly. There is a big debate right now in US and UK over this new drug calls Avastin, which is for treating late-stage breast cancer. It is not a cure but some studies show that it could prolong the life of a patient by about a couple of months. But it comes at a huge price tag: US$100,000. Many families will be financially ruined just to try to extend the life for a few weeks, with much suffering for the patient. But two weeks ago, US FDA against expert advice approved the drug for late-stage breast cancer. Immediately, on the same day, the share price of the company went up 8% against this current sub-prime concern and possible economic recession.”
“Sir, last year, Er Lee Bee Wah nearly brought the House down with a colourful Hokkien proverb. She wanted to stress the importance of forward planning and preparing for the future. In ancient China, the Prime Minister of the State Qi (chun qiu shi qi qi guo ), Guan-Zhong put it strategically: "yi nian zhi ji, mo ru shu gu, shi nian zhi ji, mo ru shu mu, zhong shen zhi ji, mo ru shu ren." Guan-Zhong's political thought is that public policies must look far beyond one or even 10 years as affairs of the state impact people's lives and one important public policy is to nurture talent and cultivate people. I try to bring this philosophy into my work. As Health Minister, my job is to look at healthcare, not just for today or tomorrow, but over a much longer timeframe. Within a few years, I would be retired and potentially become a customer of healthcare providers for the subsequent 20 years, like Dr Amy Khor. To me, health policies are not drawn up in a vacuum or just about focusing on numbers. Health policies are about creating a good healthcare system that is sustainable and relevant to real people, like you and me. I have some advantage of a long association with the Health Ministry. I had the opportunity to study other healthcare systems and think through many issues. There is no perfect healthcare system, but there are positive elements in some which can be incorporated, just as there are clear pitfalls we must avoid. Health policies need a long lead time to see results. And as healthcare is an emotive subject, we need to consult the people widely and patiently with every policy change. So a radical, big-bang complete overhaul approach to healthcare reform is not advisable.”
“The ElderShield severe disability insurance scheme underwent two major changes in October 2007. First, the basic ElderShield was upgraded to provide a higher payout from $300 to $400 per month and a longer maximum payout period from five to six years. Second, ElderShield policyholders who prefer additional severe disability coverage can now purchase ElderShield Supplements, on top of the basic ElderShield. Basic ElderShield and its Supplements are insurance schemes run by three private insurers (namely, Aviva, Great Eastern Life and NTUC Income). They are actuarially- and commercially-structured and have to be fully funded by the premiums paid by the policyholders. As at end-December 2007, there were about 790,000 ElderShield policyholders. 38,000 policyholders upgraded from the former basic ElderShield to the new basic ElderShield. There are nine ElderShield Supplements and thus far, 14,000 policyholders have bought additional coverage through these Supplements. Column No : 435 PERSONS RELEASED FROM JUVENILE HOMES 8. Ms Sylvia Lim asked the Minister for Community Development, Youth and Sports (a) for each of the years 2004, 2005 and 2006, what is the proportion of children and young persons released from The Singapore Boys' Home and Singapore Girls' Home who have continued their studies in public sector schools or educational institutions; and (b) for each of the years 2003, 2004 and 2005, what is the rate of children and young persons released from these institutions who have become repeat offenders within two years of their release.”
“The vast majority (more than 96%) of restructured hospital patients settle their bills promptly, within two months of discharge. Over the past two years (2005 and 2006), hospital arrears that exceeded two months averaged about $73 million per year. The hospitals provide various forms of financial assistance for patients who have difficulties paying their medical bills, including payment through instalments. Those who are needy are assisted through Medifund. Some arrears become bad debts after many repeated attempts to recover them and have to be written off. Not all such cases are due to financial difficulty as hospitals have schemes to assist the needy. Some are foreign workers involved in industrial accidents. Some are employees of companies, some of which have wound up. As bad debts are eventually borne by Singaporeans, the hospitals do their best to minimise them. In 2006, the write-offs amounted to $11 million. Column No : 433 ELDERSHIELD SUPPLEMENTS 7. Dr Fatimah Lateef asked the Minister for Health following the implementation of ElderShield Supplements (a) how many more eligible Singaporeans have signed up; and (b) how much will it cost the Government in terms of expected payout.”
“The inspection team's role is to ensure that environmental conditions at the site are reinstated to a satisfactory level before the site is re-opened. Therefore, the same team that issued the Stop Work Order must undertake the re-inspection to ascertain that the contractors have undertaken the appropriate measures to comply with environmental regulations they had previously failed to meet. I would like to assure Mdm Cynthia Phua that NEA officers carry out their duties professionally and there is no conflict of interest even though the same inspection team handles both the issuance of Stop Work Order and the re-inspection. PUBLIC LISTED COMPANIES (Powers of financial officers) 18. Mr Chiam See Tong asked the Senior Minister whether the Government has any plans to promote greater confidence in our market by introducing greater internal controls in public listed companies to check the powers of financial officers to single-handedly make big payments over a period of years, causing huge losses to their companies.”
“The Senior Parliamentary Secretary to the Minister for the Environment and Water Resources (Dr Amy Khor Lean Suan) (for the Minister for the Environment and Water Resources): In dealing with lapses in complying with environmental regulations, NEA takes a tiered approach, starting first with advice and warnings, and later progressing to fines. Stop Work Orders are only issued when NEA assesses that immediate corrective actions are required to clean up the site to prevent conditions which would pose a danger to public health. In 2007, NEA issued Stop Work Orders for 39 sites, which is about 3.7% of the total number of construction sites, for mosquito breeding and unsanitary conditions. How soon a Stop Work Order may be lifted is entirely dependent on how fast the contractor takes remedial action on the lapses. The contractor may contact NEA for a re-inspection as soon as he has spruced up his site. NEA will lift the Stop Work Order once the site has been reinstated to a satisfactory state. In 2007, it took a contractor an average of 10 days to spruce up the site so that the Stop Work Order could be lifted. There were a few instances when the contractors took only one day to reinstate the site to a satisfactory state. The average cost to the contractor for each day of work stopped depends on the size and type of the project. NEA does not have nor does it compile such information. Regardless of the scale and type of their projects, all contractors should ensure that their construction sites are always satisfactorily maintained, without a need for NEA to serve Stop Work Orders on them. A Stop Work Order is issued so that corrective work can be undertaken immediately to clean up the construction site to avert a potential disease outbreak.”
“Mr Speaker, Sir, currently, MediShield does not cover the treatment of mental illness and accordingly its premiums do not price in such a liability. The financial burden of treating the mentally ill has therefore fallen largely on the Government and psychiatric treatment is heavily subsidised. More than 90% of patients treated in the Institute of Mental Health belong to Class B2 or C where the average bill per day was about $30. This is largely affordable for most families, through the use of Medisave. For those who cannot afford the treatment because of prolonged hospitalisation, Medifund will come in to assist the patients. Last year, Medifund disbursed $10.5 million to assist them. We are not closed to the idea of using insurance to help fund the treatment of mental illness. We will study how this is being done in some countries and whether there is general support for such an idea. STOP WORK ORDERS ISSUED TO CONTRACTORS FOR PEST INFESTATIONS 17. Mdm Cynthia Phua asked the Minister for the Environment and Water Resources (a) how many Stop Work Orders were issued to building contractors for pest infestation over the last 12 months; (b) what is the average period that contractors had to stop work in such cases and the average cost to the contractor for each day work is stopped; (c) what is the average amount of time taken to book and obtain a re-inspection of the worksite to lift the Stop Work Order; and (d) whether the Ministry has considered the potential conflict of interest if the team that handles the issuance of the Stop Work Order is also responsible for carrying out the re-inspection.”
“Based on the latest available data, our National Healthcare Expenditure (NHE) amounted to $7.45 billion in 2005. This included expenditures in public and private hospitals, clinics, drugs, medical supplies, health supplements, herbs, traditional medicine, spa treatments, nursing homes, dental expenses, medical research and education, and many other items. Detailed breakdown among these items is still not available. However, if we assume the same breakdown from 2004, then individuals' cash spending would amount to $3 billion or 41% of NHE. Half of this spending would be for medical treatment in hospitals and GPs, the rest for items like over-the-counter drugs, vitamins and TCM treatments. Medisave withdrawals would amount to $422 million or 6% of NHE. NET INVESTMENT INCOME FORMULA 8. Mr Siew Kum Hong asked the Minister for Finance if he will provide an update on the proposed Constitutional amendment to revise the Net Investment Income formula.”
“Mdm Halimah Yacob asked the Minister for Health out of the total expenditure spent on healthcare in Singapore, what is the amount in percentage terms and in dollar quantum that individuals have had to spend out of their own pockets, including Medisave, for their medical treatment in 2007.”
“Most patients settle their bills promptly, with the vast majority within two months of discharge. Less than 4% of patient cases were in arrears after two months of discharge. The arrears averaged $409 per bill. Arrears exceeding $3,000 were uncommon. Generally, hospitals would allow such patients an instalment plan of up to 24 months. On selected cases, the instalment plan can be further extended, to even a few years. USE OF MEDISAVE FOR CHRONIC DISEASES (Outpatient treatment) 6. Mdm Halimah Yacob asked the Minister for Health in 2007 (a) out of the total pool of patients who are eligible to use their Medisave to seek outpatient treatment for certain chronic diseases, such as diabetes, how many have made use of the scheme; (b) how much is the total amount withdrawn; and (c) how many doctors out of the total number of eligible doctors have applied to be put under this scheme. Mr Khaw Boon Wan: 91,000 patients have made use of their Medisave to pay for the outpatient treatment of their chronic diseases. They have withdrawn a total of $17 million from their Medisave Accounts. We estimate a total of one million Singaporeans who can potentially benefit from this scheme. Many however are probably unaware of their condition. That is why it is important for everyone to go for basic health screening and to consult their family GP if they have such a condition. The Medisave scheme is now available to help pay for their treatment. Chronic diseases can be competently managed by all qualified GPs. 734 or half of all GP clinics are now participating in the Medisave scheme. This means that there is at least one participating clinic within walking distance for most Singaporeans. EXPENDITURE ON HEALTHCARE 7.”
“A patient with end-stage renal failure will require renal dialysis until he receives a kidney transplant. Some patients will need dialysis in a hospital if their conditions are complicated by other illnesses. We refer to these patients as requiring high-dependency dialysis. But most patients are otherwise medically-stable, and they can be dialysed in the community on an outpatient or even home setting. Subsidised high-dependency dialysis is available in public hospitals. Renal dialysis would start as soon as his medical condition requires it, for example after discharge from an acute stay. For the other patients, they can get dialysis from a number of dialysis centres operated by both charities and the private sector. If they need financial assistance, they could apply to the dialysis centres run by charities. The largest operator is the National Kidney Foundation, followed by the Kidney Dialysis Foundation and the People's Dialysis Centre. The subsidy to patients comes from both the Government and the charities. Some means-testing is done by the charities. The processing of such applications will generally take about two weeks. Where the needs are urgent, the charities could fast-track the process so that subsidised treatment can start sooner. Interim arrangements are available to ensure continuity of care for these patients. GREEN TECHNOLOGY IN PUBLIC HOUSING (Sustainability) 39. Mdm Ho Geok Choo asked the Minister for National Development given the expected demand for green lifestyles (a) how cost-sustainable is the construction of such neighbourhoods in the long term; and (b) can the Government maintain a stable supply of green technology and materials to be offered to residents at a low cost.”
“The Medisave for Chronic Disease Management Programme is still quite new, being launched only in October 2006. We are still gathering data and analysing them. Whether the withdrawal limit of $300 per account per year is sufficient depends on patients' needs. This was decided upon based on the data from public hospitals and clinics. The average annual cost of treating normal diabetes or hypertension was about $250 for subsidised patients. The claims experience so far seems to confirm this. Three in four Medisave (77%) withdrawals under this Programme were below $300 per withdrawal. For those who require more than $300 per year, they can tap on the Medisave accounts of their family members. But few did. It is perhaps too early to draw firm conclusions on the adequacy of the $300 limit. But we are closely monitoring the scheme. SUBSIDISED TREATMENT FOR END-STAGE RENAL PATIENTS 37. Dr Ong Seh Hong asked the Minister for Health what is the turnaround time for an end-stage renal patient to receive subsidised treatment from the point of applying for the treatment.”
“Ms Ellen Lee asked the Deputy Prime Minister and Minister for Home Affairs in light of rising life expectancy and the encouragement for older Singaporeans to work longer (a) what is ICA's position with regard to the maximum age for which a Singaporean will be allowed to apply for a permanent residence for his foreign wife; and (b) if his foreign spouse does not obtain permanent residence due to his failing to meet the age criterion, whether her Long Term Social Visit pass will be renewed indefinitely as a matter of course.”
“Mdm Ho Geok Choo asked the Minister for the Environment and Water Resources if he is able to provide an update on the recent reinstatement of the Island-wide Cleanest Estate Competition and how will the Government ensure that there is a fine balance between the competition among cleaning companies and engaging residents to be more responsible for their own neighbourhood. Assoc. Prof. Dr Yaacob Ibrahim: The Government adopts a three-pronged approach to keeping Singapore clean - public education, enforcement and public cleansing. We place strong emphasis on public education so that each individual takes responsibility for keeping Singapore and their living environment clean. At the same time, we conduct regular enforcement against litterbugs to deter irresponsible behaviour. NEA together with land agencies such as Town Councils, SLA and NParks also ensure that adequate cleansing services are provided in areas under their charge. We want Singapore to be clean because each one of us takes responsibility to keep our surroundings clean, and not because we have an efficient team of cleaners. The recent reinstatement of the Islandwide Cleanest Estate Competition (ICEC) by the 14 PAP Town Councils has the following objectives: (1) Raise community awareness and promote social responsibility in keeping our living environment clean; (2) Promote residents' sense of ownership of the common areas; and (3) Reduce obstruction and eliminate killer litter in our estates. In line with these objectives, I understand that the judging criteria of ICEC gives greater weightage to community efforts in promoting social responsibility amongst residents, than to efforts by the cleaners. PERMANENT RESIDENCE APPLICATION FOR FOREIGN SPOUSES (Maximum age for a Singaporean to apply) 34.”
“The MOH survey on poor health refers to ill-health of varying severity. This could be mild ill-health due to a short-duration, self-limiting disease such as influenza, or a treatable condition such as a fracture, or a chronic disease such as diabetes. Being in ill-health does not necessarily mean a person requires hospitalisation. Many of us continue to lead a normal life with our health being less than perfect. Most health problems are preventable and everyone can actively do something to improve their health. Eat a balanced diet, exercise regularly and avoid health-risks like smoking. Let me take this opportunity to thank Ms Olsen for helping us to promote healthy lifestyle among Singaporeans. Medisave is designed to help Singaporeans cope with their hospitalisation expenses at the Class B2/C level. On average, Singaporeans have $13,600 in their Medisave accounts. This amount is sufficient for 13 Class C or 10 Class B2 hospitalisations. Coupled with MediShield, it should take care of most Singaporeans' basic hospitalisation needs. But as we upgrade hospital services to meet rising expectations of patients and bring in new medical technology, costs will continue to increase. The demand on Medisave will therefore grow. We need to preserve our savings in Medisave for our old age, and whenever possible, work to increase these savings. That is also why we have to periodically adjust the Medisave Minimum Sum, currently set at $28,500, and the Medisave Contribution Ceiling currently set at $33,500. ISLAND-WIDE CLEANEST ESTATE COMPETITION (Update on reinstatement) 29.”
“Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Khaw Boon Wan]. Bill considered in Committee. [Mdm Deputy Speaker in the Chair]”
“You can opt out for a cornea or heart, but your priority in other organs which you have not opted out will be unaffected. She also asked the question about organs being transplanted between races, ie, from Muslims to non-Muslims, or from non-Muslims to Muslims. There is a waiting list for each organ and we have an expert committee formally chaired by Prof. Goh Lee Gan to decide on the priority of distribution. The Committee has, over the years, evolved quite a scientific way of computing points for each of the objective criteria. Relying on memory, there are three important sets of criteria. One, because you want a successful transplantation, ie, to maximise the chance of a successful transplantation so that patients survive and live for a long time. Therefore, tissue matching is paramount. Maximum points go to those tissues which match the closest. Second, because of HOTA, those who opted out enjoy lower priority than those who do not opt out. Third is how long the patients have been on the waiting list. Those who have waited longer will have a better chance than those who are still new. So, using this system of scoring, the Committee decides on the patients' priority. Race does not come into it. The example that I gave in my Second Reading speech just now was about a Malay businessman who had a liver which came from a Chinese. As Mdm Halimah put it, this Bill marks an important and significant change. Muslims will soon be included under HOTA. The change comes too late for some who died while waiting, but better late than never. I thank Members for joining me in this fight to save some more lives "without having even to lift a finger", as Mayor Zainudin put it. Mdm Deputy Speaker, I beg to move. Question put, and agreed to.”
“Each year in Singapore - and this is a sad figure - there are close to 700 patients who have amputations involving their lower limb as a result of uncontrolled diabetes. That means, every day, two patients lose part of their lower limb because of diabetes which is not well-controlled, but it is largely avoidable. Many more suffer from other complications such as heart disease, stroke and blindness. All these conditions cause unnecessary suffering and loss of productivity. Let us be proactive to reduce such miseries. Let me thank Prof. Thio for sharing with us her insights on "legal pluralism". It is a new word for me. I learn something today. As a layman, I interpret that to mean that we take a practical approach in Singapore. Our laws evolved gradually and take into account that we are a multi-racial and multi-religious society; we cannot simply just apply one law for all. I thank her for giving us a very good account of how HOTA has gradually evolved over the years and, within the Muslim community, how fatwa has evolved over the years in response to the needs of the society, and as we understand the science better. She also asked whether we could simplify opting out, for example, electronically. I believe our current system of opting out is quite simple and highly simplified, but we will always see whether we could simplify it further. Online opting out has a bit of problem because we do need witnesses to witness the opting out. She also asked how is the distribution of organs organised. For instance, can you opt out of one organ and not for the others? If so, what happens to your priority for each organ? Yes, we manage each individual organ separately as far as organ transplantation is concerned.”
“We will ensure that our enforcement officers will receive the necessary training and instruction, both internally and from the Police, so that they can carry out their work professionally. In fact, some of these officers are likely to be ex-Police officers with relevant experience. They will all be closely supervised by a chain of command and be required to carry identification cards which they must produce on demand when exercising their powers. In substance, the change will not differ much from today. The key difference is that we will build up investigation and enforcement capabilities internally within the Ministry of Health so that we do not have to rely on the Police which has so many other responsibilities. Hopefully, this will speed up investigation and enforcement. Dr Fatimah reminded us about being sensitive to patient confidentiality, and we certainly would. Prof. Thio asked how section 15I relates to Article 9 of the Constitution. Certainly, the intention is that we have to be consistent with what is in the Constitution. I am not familiar with legal details to know what does that mean, but certainly, constitutional supremacy must apply here. Dr Ahmad Magad stressed that even as we amend HOTA to help save lives, the best approach is still prevention, and I cannot agree more. Those who are predisposed to develop kidney failure should actively change their lifestyle and diet. They should start exercising regularly if they have not already done so. They should work with their family GPs, take medication diligently and test their blood sugar and cholesterol regularly. Sorry for this commercial, but it is such an important message that it is worth repeating.”
“There was also a request that hospital mortuaries should provide for what it called "washing and shrouding" facilities for the use of the family members. Our hospitals will proceed to set up such facilities in the mortuaries. Dr Ahmad Magad spoke about living donor organ transplantation and how this could augment cadaveric transplantation. Since this House legislated on living organ transplantation in 2004, the number of living organ transplants has risen. There were 111 living organ transplantations last year. My Ministry encourages living organ donation. This is a viable option for many patients but cultural hindrances remain. We will step up patient and professional education efforts. We are supporting a pilot programme to counsel newly diagnosed kidney failure patients on the benefits of living kidney donation so that living donor transplant is considered ahead of dialysis. We do provide some subsidies to live organ recipients to help defray the cost of organ transplantation and long-term immuno-suppressive medication, but we should not unwittingly end up promoting the trading of organs. The problem of organ shortage is worldwide. Not surprisingly, an international organ trade has emerged, as observed by Mdm Halimah. We should not be a party to it. The beefed-up investigative and enforcement powers in the Bill will further help keep Singapore stay clear of organ trading. Dr Ahmad Magad would like to know the difference between MOH officers conducting investigations under HOTA and the Police conducting such investigations. He has asked what would be done to ensure that MOH's enforcement officers are properly trained.”