Lim Hng Kiang
Singapore
“The company has made commitments to recycle the ash, and as for renewable energy, the gasification project is not an energy project, it is not a generation company (genco). It is to produce hydrogen and carbon monoxide or, essentially, carbon. Because as feedstock to the petrochemical sector, you need more C and more H2.”
“The Government will continue to recover the IIA awarded if the company fails any conditions or breaches the legislative amendments. I would like to highlight that there are no errant cases in the last five years for IIA and the current amendments are, therefore, not reactionary in nature, but are being made for legislative clarity.”
“In addition, the IIA scheme will be extended till 31 December 2022. Clauses 10 to 13 give legislative effect to this change. The remaining legislative changes arising from our periodic review of the income tax system are either administrative or technical in nature.”
“Data on household and individual savings rates by income groups are not available. However, data on the aggregate level of household financial assets can be obtained from the Household Sector balance sheet compiled by the Department of Statistics.”
“The aggregate level of financial assets owned by Singapore’s household sector6 in each of the past five years is provided in Table 1 below. Data on the amount of financial assets owned by households and individuals in the different income percentiles is not available.”
“The Second Review of the Comprehensive Economic Cooperation Agreement (Second CECA Review) is ongoing. The review is taking some time as both countries have our respective interests to work through, such as in the area of labour mobility. Our agencies regularly engage Indian counterparts to work through issues collaboratively.”
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“In doing all these, the public, the private and the people sectors will have important roles in this framework. So let me first address preventive healthcare. These are the points raised by Mr Bernard Chen and Dr Lily Neo. The challenge is how to keep the elderly fit and healthy for as long as possible. I think we agree entirely with the speakers on this. We all realise that a healthy lifestyle is really the key to the prevention of many chronic diseases which can eventually lead to disabilities. This applies not only to the elderly but also the general population. Therefore, my Ministry sets high priority on preventive healthcare, health promotion and public education to prevent the onset of chronic diseases. I think Members are all familiar with the various campaigns that my Ministry runs to educate Singaporeans on a general healthy lifestyle as well as on specific illnesses. These programmes all adopt a multi-strategy approach which involves the media, direct contact and many avenues to try and raise the awareness of Singaporeans on this. The second stage is health screening. Through health screening we can check whether the various health promotion messages that we have put forward have been translated into good health. I agree with Mr Bernard Chen that regular health screening is very useful. The issue is what do we look for in the screening. Members are aware of the National Health Survey in 1998 which showed that the prevalence of diabetes, hypertension and high blood cholesterol level increased markedly from the age of 50 years and above. If these conditions can be detected and treated early, then we will be able to avoid the high social and medical costs associated with them. The next issue is how do we encourage regular health screening for the elderly.”
“We will increase the starting salaries of Assistant Nurses and Registered Nurses by 21% and 10% respectively. Corresponding adjustments will be made to the rest of the salary scales. The new salary package will include better shift allowance and other measures to better recognise the efforts of the nurses in providing 24-hour care to patients. We expect that the proposed revision will increase costs for the hospitals by an estimated $33 million. 2.15 pm Sir, I would now like to turn to the second theme which Members raised, which is how do we approach the problem of the ageing population. As I mentioned in previous sittings, this is not the first nor the last time we are going to discuss this issue. So, again, today, let me take through with Members what we intend to do to address this tremendous challenge. As we all know, the number of elderly persons in Singapore, aged 65 and above, is currently 7% of the population and will rise to almost 20% by the year 2030. This will put some pressure on our healthcare services. My Ministry recognises that therefore we have to start preparing ourselves early and put in place a framework to meet this challenge. So what is this framework? As can be seen from the various points raised by Members, I think the first step we must take is to keep the elderly fit and healthy for as long as possible. Second, to encourage regular health screening so that health problems can be picked up early for treatment. And, third, for those who fall ill or acquire severe disabilities, there must be a whole continuum of healthcare facilities, programmes and services to provide care in the most appropriate setting to the elderly and at affordable cost to them, their family and the Government.”
“At the same time, I would convey the comments of Mr Peh Chin Hua to the networks to make sure that doctors are more communicative and go beyond the two words 'How' and 'Next'? On the issue of nurses, my Ministry is also concerned about the shortage of local nurses. We have to anticipate the demand that would come from the development of step-down care services to meet the healthcare needs of our ageing population. This need will include nursing homes, community hospitals and home care services that both Dr Tan Cheng Bock and Dr Jennifer Lee talked about. In the short term, we will need to recruit well-trained foreign nurses. But for Singapore, it is better for us, in the long term, to ensure that the nursing profession is attractive to young Singaporeans. Nurses form the backbone of the healthcare system. We want to encourage capable and bright young people to join the nursing profession, to build up the profession and raise the level of nursing services. Over the years, the Ministry has taken various measures to enhance nursing as a profession. But I think the key thing is still competitive remuneration. Therefore, we have recently reviewed the nursing salaries together with the restructured institutions. The nurses' salaries have fallen behind those in the other professions with people of equivalent educational level. There is therefore a need to adjust the nurses' salaries so that we can continue to attract a sufficient number of Singaporeans to take up nursing as a career. There must also be incentives to compensate for the onerous nature of the job. The restructured institutions will, therefore, be taking action to increase nurses' salaries in FY2000. The proposed revisions will increase the nurses' salaries by around 13%. This is not an across-the-board increase.”
“All these suggestions are worth exploring. If it is mutually beneficial, I see no reason why the two networks should not take this up. I envisage that, with the reorganisation of the public healthcare delivery system, the networks will be able to work out new and innovative ways to involve private sector specialists and general practitioners in the provision of healthcare services and together provide Singaporeans with good quality health care. To run this system, we need the people. So let me now turn to the concerns raised by Mr Bernard Chen and Mr Ibrahim Othman. First, the issue of doctors. Over the past 10 years, the number of doctors in Singapore has grown steadily. As at end 1999, we had about 5,320 doctors in Singapore, or around 1,750 or almost 50% more than in 1990. While at the national level we may have sufficient doctors, we share Mr Bernard Chen's concern that the public sector should continue to have its fair share of the national talent. With the re-organisation of the health care system into these two networks, one of the key tasks of the networks is to come up with innovative methods to develop and retain their medical specialists. For example, development of talent would be done across the hospitals in each of the networks. The remuneration system would also be more sensitive to market conditions and commensurate with the calibre of the talent. The networks will also provide a more conducive environment for good calibre doctors to practise, teach, do research and develop themselves professionally. In this way, the two networks can be more competitive in training and retaining their staff.”
“The changes will be made to the integration of the backroom support and services. Next, let me turn to the integration between the private and public sectors. I agree entirely with Dr Lily Neo that in addition to the vertical integration between the hospitals and the primary care, there should also be greater lateral integration between the private sector and the public sector. We already have several avenues for the private sector doctors to contribute to health care in the public sector. Let me give a few examples. Firstly, we have the Visiting Consultant Scheme that Dr Lily Neo also talked about. I think there is room for improvement in that scheme. Secondly, we involve the private sector doctors to contribute their expertise in complex procedures, like heart and liver transplant programmes. The transplant teams involve doctors from both public and private sectors. Thirdly , private sector doctors are appointed to various committees to assist the Ministry to formulate policies in clinical practice, medical research, medical ethics and training matters. Dr Lily Neo has suggested that public sector doctors be allowed to practise in the private sector. This is already done. The issue is really how to extend the scope. Currently, consultants in the public sector hospitals attend to both subsidised and private patients. My Ministry is studying whether we could introduce greater flexibility to the private practice scheme by allowing public sector doctors to practise part of the time in the private sector. There could also be other ways to extend the scope. Dr Lily Neo also made several suggestions on the shared use of expensive equipment, bulk order of standard medical items, and the centralised sterilisation of medical equipment.”
“The national centres will continue to deal with the more complex cases requiring more expensive equipment or highly specialised expertise. They will centralise all the more complex cases so that the workload can sustain the very special skills and expertise needed. Based on this rationale, my Ministry has worked with the national specialty committees to define the level of medical care that will be provided at the national centres and the acute hospitals. The acute hospitals will continue to provide secondary care in these specialties, and refer the more complex cases to the national centres. The national centres will also be the centre for research and teaching for their respective disciplines. The national centres are to treat the more complex and rare medical conditions, and therefore understandably the fees would be higher because more resources are incurred for these very specialised treatments. We have centralised these specialised manpower and equipment in the national centres, thus avoiding the higher cost which would have resulted if we duplicate all these in all the hospitals. For B2 and C class patients, the costs of land and buildings are fully subsidised by the Government. In addition, they are provided with 65% and 80% subsidy of the running costs. The national centres are grouped with the network that they are co-located with so that they can leverage on the network's administrative support. However, the services and expertise of the national centres will continue to be made available to patients across the two networks. Patients from one network can be referred to the national centre in the other network and will be given the appropriate level of service and standard of care. So as far as the patient is concerned, there is no change.”
“Sir, first, I would like to thank all the Members who have spoken for their various comments and suggestions. I will take them up individually and follow up, even if I may not have the time to give them a full reply today. First, I would like to address the key themes that are raised by the Members and then I will take the specific issues point by point. The first theme is really how to ensure that we have the best delivery of health care services in Singapore. In this, we are talking about how to make the healthcare providers in the public sector, the polyclinics, the hospitals, the national centres work together and how to get the public sector and private sector to work together. My Ministry announced its plans to reorganise the public healthcare providers into two vertically integrated delivery networks last November. Each network will comprise healthcare providers ranging from the polyclinics, the regional general hospitals, the tertiary hospitals to the national specialty centres. The networks will provide more integrated and better quality healthcare services through closer cooperation and resource sharing. This will then minimise the duplication of services and ensure the optimal development of clinical capabilities. This vertical integration will involve interfacing the polyclinics with the regional general hospitals, the regional general hospitals with the tertiary hospitals, and the acute hospitals with the national specialty hospitals. Mr Bernard Chen asked how would the national centres fit into this framework and their relationship with the acute hospitals. The role of the national centres as spelt out in the White Paper remains unchanged after the two networks are formed.”
“As I have explained in my answer, it is a multi-faceted problem and we have to look at all avenues to solve the problem. One of the avenues we have to consider is adjusting the fees so that it reflects the value of the specialist. EXTERNAL DEGREES 2. Mr Ong Ah Heng asked the Minister for Education, since there are many mature individuals pursuing external degrees, whether statistics have been compiled to show that these individuals are able to derive any increase in their compensation package or improve their economic wellbeing.”
“Sir, I thank the Member for trying to help me out. There is a tremendous subsidy in our SOCs. More than half of the patients going to our SOCs enjoy a subsidy of 65% and all the rents and GST of our SOCs are fully subvented by the Government. Even for those who do not enjoy the subsidy, the so-called private patients in our SOCs, the fees which they are charged in the SOCs are much lower than the private sector. Therefore, as I have explained in my answer, one can understand why many Singaporeans troop to the SOCs straightaway without seeing the family physician. I am not saying this is a good practice. I am saying we are trying to change it through better patient education, through upgrading of the physicians. But to have an edict to say that, tomorrow, nobody is allowed to go and see the SOCs unless they are referred to by a family physician is a step which I am not prepared to take for the time being.”
“Mr Speaker, Sir, I did not say that. I said that the family physician should upgrade himself so that he understands the full range of problems that the patient is likely to raise with him and be in a position to provide the confidence to the patient that he will refer him to the correct specialist. It must be cost effective for the patient to do so. If the patient thinks he has got a specific problem and the cost is not so significant in going straight to see a specialist, he will want to do so. We could make it a compulsory system to say that you are not allowed to see a specialist until referred to by a GP. We can do that. But today we are not doing that. We encourage everybody to do that, but we are not making it a compulsory system. So I am keeping the system as it is without making it compulsory. If all the MPs feel that this is crucial and that it will reduce health care cost by forcing everybody to the GPs first, I must be satisfied that the GPs can undertake their role. I do not want to force patients to the GPs if they are not equipped to handle their requirements.”
“I agree entirely with Dr Neo that we want to have a cost effective health care system. But as I said, the fee structure of our SOCs today is not so significantly higher than the private sector family physician. Singaporeans now are better educated. They want choice and, therefore, we have not moved to a compulsory system. Today, they have a choice. We discourage them. We try to educate them. We try to work with the College of Family Physicians to upgrade themselves so that the public can have more confidence in the ability of their family physicians. It is not just one side of the coin. I think the family physicians must also show to the public that they can handle a wide range of problems when a patient sees them, if not, the patient would want to see a specialist straightaway.”
“Mr Speaker, Sir, I have got no idea what is the Member talking about. Could she clarify?”
“Sir, I agree with the Member that it is an ideal case, but I am keeping to the present system of having the flexibility.”
“We have to be quite realistic. The specialists in the private sector run their clinics. They charge private sector fees. Many of these specialists are involved in community work and we encourage them to do so. But to expect private sector specialists to run voluntary clinics on a fee or subsidised basis is something that is not so pragmatic.”
“Mr Speaker, Sir, in my answer, I attributed to two main reasons for the long queues in the SOCs. One, is the tendency for people to want to see the specialists rather than their family physicians. And I agree with Dr Lily Neo that it is not the ideal practice. In fact, my Ministry encourages and is putting in place measures to encourage Singaporeans to see their family physicians first before seeing the specialist. The share of the workload between the family physicians and the specialists today is weighted to the specialist, because Singaporeans operate on the understanding that if they have a specific problem, they want to see a specialist before seeing the family physician. The second point which I put in my answer is cost. Not that it is more expensive to see a specialist, but that the cost of seeing a specialist in our SOCs is not significantly higher than seeing a private sector GP. So the price differential between a private sector GP and SOC is not so big that Singaporeans will be encouraged to see a family physician first before seeing SOCs. Singaporeans can afford to see a specialist. The differential is not so high. So they go straight to the specialist. The Member suggested getting doctors to provide voluntary services. I am sure if doctors are prepared to do so, we will work with them.”
“Sir, I think we have to be quite pragmatic about the situation. Singaporeans now serve the Net. They read all kinds of things on the Net. They do quite a bit of self-diagnosis. It is not the ideal thing to do. But when Singaporeans think that they have a problem with, say, incontinence, they would want to see a specialist first. They do not want to see their GP. Unless we say no, that is not allowed, and we change to a completely different regime, but today the rules allow them to go to the specialist and we accept that practice.”
“I think the Member also did not get my answer. We do not enforce a compulsory referral system. Today, we are a bit more relaxed and we allow patients to refer themselves to the SOCs. Of course, we can adopt a compulsory referral system, meaning that if a patient is not referred by a private sector or a polyclinic GP, then he is not allowed to see the specialist. We can discuss and see whether that is indeed a better system. But today, the practice is that we allow Singaporeans the flexibility to go to the SOCs. In a way, I think it serves us well. Of course, it leads to a longer queue in the SOCs, but this is the trade-off. And Singaporeans seem prepared to accept this trade-off. If the feedback from all the Members is that Singaporeans want to have a compulsory referral system so that the queues in the SOCs will be shortened, I am prepared to consider that.”
“Sir, compulsory referral is the ideal situation, but I think we want to be more flexible. In some cases, patients make appointment with the SOCs. In some cases, they are discharged from the hospitals and they have recovered. But if they think that something has recurred, they may want to make an appointment with the SOCs. Today, we have adopted a more flexible approach. Unlike some countries, for example, they may insist on a compulsory referral. We have not reached the stage where we feel we need to insist on a compulsory referral situation.”
“Mr Speaker, Sir, I agree entirely with the Member. Ideally, every patient should be managed by his family physician, and see the family physician first and if the condition requires the care of a specialist, then he should be referred to the specialist. In Singapore, we do not enforce a compulsory referral system. We encourage referrals by the polyclinics and family GPs. We do not make it compulsory that if a patient is not referred by a private sector GP, he is not allowed to see the specialist. This is the situation today. I think we have to work on the education of the general public that they should see their family physicians first.”
“The Ministry and the public hospitals have instituted the following specific measures to improve the waiting times at the SOCs: (1) To increase the number of clinic sessions for specialists with long waiting lists; (2) To extend clinic operating hours for specialists with very high patient-load; and (3) To initiate an active discharge plan for patients no longer requiring specialist care for follow up by their family physicians. These are, however, short-term palliative measures to deal with the high patient load at our SOCs. We need to do a more fundamental review of outpatient care by specialists and family physicians to achieve our objective of ensuring that patients receive care appropriate to their needs. Ideally, patients should turn to their family physicians first when they are ill. The family physicians will manage their medical condition with appropriate referrals and collaboration with the specialists. However, this is a complex issue which would involve patient education, ensuring high quality of family physicians, and review of the specialist referral system and fees charged. With the formation of the two networks, we will make a start by interfacing the polyclinics with the SOCs. Where the patient is adequately looked after by the polyclinics, it will be done there, and not at the SOCs. The networks will extend this collaboration to the private family physicians subsequently.”
“Mr Speaker, Sir, our Specialist Outpatient Clinics (SOCs) see a disproportionately large number of patients, some of whom could have been treated by their family physicians. This situation arises because patients, by and large, prefer to be seen by the specialists and the charges at the SOCs are not significantly higher than those charged by the family physicians. Patients therefore may experience long queues and waiting times at the SOCs from time to time for the following reasons: (1) Patients' preference to be seen by certain specialists who have a long waiting list. To shorten the appointment waiting time for patients, the clinic sessions for these specialists are therefore overbooked, which would invariably contribute to a longer queue and waiting time; (2) Appointments made at the SOCs are scheduled assuming that they are "normal" cases with average length of consultation time. However, in the clinic situation, some consultations turn out to be more complex and require more time. This leads to a cascading effect whereby the waiting time for consultation for subsequent patients would be affected; (3) From time to time, a patient's medical condition changes or deteriorates such that he requires to see the specialist earlier than the given appointment date. In such instances, based on medical need, the SOC may have to arrange an urgent appointment for the patient even though the specialist is already fully booked for the day; and (4) Occasionally, the specialists are called away to attend to emergencies in the ward or operating theatres.”
“This is nothing new. This was already anticipated in the 1993 White Paper. ESTIMATES OF EXPENDITURE FOR THE FINANCIAL YEAR 1ST APRIL, 2000 TO 31ST MARCH, 2001 (Paper Cmd. No. 2 of 2000) Order read for consideration in Committee of Supply [2nd Allotted Day]. [Mr Speaker in the Chair] Head O (cont.) - Resumption of Debate on Question [8th March, 2000], "That the total sum to be allocated for Head O of the Main Estimates be reduced by $100." - [Dr Ong Chit Chung]. Question again proposed.”
“We do not have a fixed ratio that we target for. It is not to say that if you have one doctor to 700 population, you are going to get so much better medical care than 1:750. These are not critical numbers or planning norms. Basically, the indigenous population of Singapore can be quite easily projected. What happens is in 1996, we made a major strategic decision to increase the intake of PRs and that changed the scenario quite drastically. Now, we are considering the second strategic decision that we have to take probably this year and, that is, we have to look at doctors not just as servicing the healthcare industry, but also as participants in this new life sciences industry. So I see these as two major changes in the strategic scenario. Other than that, you cannot project accurately how many will stay after they have passed out from their university. Give and take 10 or 20 every year, it does not change your situation that drastically. What we are looking for are significant changes in direction, ie, the 1996 population intake of PRs, and now what we are going to do strategically for life sciences. These are major decisions which of course will have an impact on the production of doctors. Beyond that, we are quite comfortable. Our primary care sector is well taken care of. We are building new hospitals, and all these projections are taken care of.”
“I thought that has been the purpose of my whole answer. In 1993, we changed from 170-odd universities and we trimmed it down to 20. People made their decisions based on this list of 20 universities. They have committed their children to study in these 20 universities. If now we change without good reasons, I think if I were a Singaporean parent, I will be quite upset. But if there is a significant change in the direction that is needed, say, for example, life sciences, and we cannot generate the graduates to meet this requirement from within - that is the subject of a task force set up by Dr Tony Tan - then, of course, we may have to broaden or widen the list to take in the necessary numbers from overseas. But, today, we have expanded from 50-odd to 80 doctors and the 20 universities can provide the 80 doctors that we are recruiting every year. Those who do not come from these universities, we will put them under temporary or conditional registration, that means they work under certain hospitals or VWOs for very specific purpose. The situation today is that our needs are met through temporary and conditional registration of these foreign doctors. My primary concern is if you tell Singaporeans that you will recognise these 20 universities and they have gone overseas for studies, I will be very reluctant to chop and change so frequently.”
“I do not have the detailed breakdown with me. But I presume the 80 doctors that we recruit every year will come from these 20 universities. Because the people who can come in and are registrable without having to go for extra examinations are the ones listed in these 20 universities. So I assume the 80 doctors come from the 20 universities.”
“That is indeed one of the considerations, that it takes many years to train a doctor, and also the people, particularly Singaporean parents and students, make their decisions based on what we put up. When we say that there are 20 registrable universities, they would put their children in these universities and those who have done so since 1993 will have reason to be upset if we chop and change every other year. So when we do projections for medical personnel, particularly doctors, we have to do so in a very deliberate manner. And we did so in 1992-1993. The situation has changed somewhat. We have adjusted it in 1998, not so long ago, by increasing the intake in our university and allowing more registrations from overseas. Now, there is another new consideration, how to position ourselves for life sciences. As I said, this is something that we are studying and it is conceivable that, because of this very major change, we may have to make further modifications to our plans. But I would be reluctant to chop and change because people are making very important decisions based on what we publish as registrable universities. Assoc. Prof. Chin Tet Yung (Sembawang): May I just ask the Minister whether he has the figures for the number of doctors per year that come from the overseas institutions?”
“We are constantly reviewing our requirement for doctors. The need for doctors for an ageing population is in fact factored in the White Paper when we studied the issues in the White Paper in 1992/1993. The population profile and the ageing phenomenon in Singapore are quite well understood. This is something that you can project 30-40 years ahead of time. What is new now is our thrust into life sciences. That is a new factor which we are taking into consideration. As you may know, Dr Tony Tan has set up a task force to look at how Singapore should respond to life sciences. It is entirely possible. Because of this new requirement, we may have to increase the intake of doctors, both in servicing for clinical trials as well as for research. So I do not rule out the need for more doctors from both our local intakes, local training as well as from overseas sources. But for the time being, the 20 universities that we have, as registrable under the SMC, serve our need because we can recruit what we want from these 20 universities. And those who do not come from these universities, we can put them either on temporary or conditional registration.”
“When we debated the health policy in the White Paper in 1993, we made it quite clear that we want to prevent over supply of doctors and specialists in Singapore. Because if there are too many doctors and specialists, the demand for medical services will be inflated and healthcare costs will go up. So that has been the fundamental pillar of our policy. In the White Paper, we would control the output from NUS at 150 per year and also from foreign trained doctors at 50 per year. Because of the change in population policy, we have increased the intake in NUS to 200 and also the intake from foreign trained doctors from 50 to 80. So we have made the necessary adjustments to meet the higher population that we have. The situation is quite comfortable today.”
“The routine medical examination of newborns in public hospitals includes a test for hearing loss. Babies who are suspected to have hearing loss or who are at higher risk (eg, premature babies or those with family history of deafness) are referred to audiologists for further tests using more sophisticated equipment and techniques. Those with confirmed hearing loss will be referred for treatment and rehabilitation. My Ministry recognises the value of early detection and treatment of hearing loss to minimise speech and learning disabilities in children. It has therefore appointed a Committee in October 1999 to Study the Early Detection and Treatment of Hearing Loss in Children in Singapore. This Committee comprises ENT surgeons, paediatricians, audiologists and family physicians from both the public and private sectors. The Committee will be reviewing the current system of hearing loss detection in children to see how our present screening methods and coverage of newborns can be further improved. It will also make recommendations to strengthen the intervention programme for hearing impaired children to support the expanded screening efforts. COMMUNITY DEVELOPMENT COUNCILS' NATIONAL HELPLINE 4. Mdm Claire Chiang See Ngoh asked the Minister for Community Development (a) how many calls were registered by the Community Development Council (CDC) National Helpline between 1997 and 1999; (b) what are the main problems faced by the callers; and (c) what measures are adopted by People's Association to help to enhance the community skills of young CDC General Managers in problem-solving neighbourhood challenges.”
“Sir, when the Member pointed this out to me, I accepted her reasons for wanting to make the amendment. It is not our intention not to give any reasons. It is just one of the standard clauses. I think it is a very jarring phrase. So I have no problems at all with the deletion. I concur with the Member's amendment. Amendment agreed to. Clause 23, as amended, ordered to stand part of the Bill. Clauses 24 to 47 inclusive ordered to stand part of the Bill. The Schedule ordered to stand part of the Bill. Bill reported with an amendment; read a Third time and passed. SINGAPORE ARMED FORCES (AMENDMENT) BILL Order for Second Reading read.”
“Before you grow old! Question put, and agreed to. 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 Lim Hng Kiang]. Bill considered in Committee. [Mr Speaker in the Chair] Clauses 1 to 22 inclusive ordered to stand part of the Bill. Clause 23 -”
“Dr Lily Neo is always moving at the speed of a train. I said that we start off first with nursing homes run by VWOs. We build up the experience and, in future, we can extend the scope to the next step, which is nursing homes run by the private sector. Then we can extend it to another step, which is other types of homes, not just nursing homes, but community hospitals, chronic sick, and also facilities in the void decks. We can also extend it to home care. I know the real challenge and the difficulties of providing subsidies or financial assistance to home care, the very issues that the Member raised, whether it is the provider or the recipient; who gets, who approves. It is a huge problem. I prefer to go about it systematically. Let us start with the easy part first, which is nursing homes run by VWOs. Then we extend it systematically, but I can assure Members that we will reach home care in due course. An hon. Member: When will that be?”
“I do not want to give the impression that because we come to this House on our plans for setting up nursing homes and our financial arrangements for the ElderCare Fund that we are giving focus or attention to institutional care, and not to the other aspects of the problems confronting our aged. As I said, this would not be the first or the last time that we would be talking about the issue. I am sure we will be addressing it. Members can have my assurance that my Ministry and MCD will tackle this problem systematically, and we will come back to the House for support for the other components of looking after the elderly.”
“But if the nursing home continues to meet the medical criteria of running a nursing home, but gets suspended for other reasons, for example, for not keeping good accounts or for whatever reasons, then of course, it would not affect the patients. Mr Gerard Ee asked why we exclude facilities meant for pregnancy, etc. As I explained, complications arising from pregnancy will be dealt with either in the acute hospital setting or if it is something that requires nursing home care, then it will be dealt with in a step-down nursing home care facility. Under the latter circumstances, the patient will qualify for ElderCare funding. Dr Jennifer Lee made several very good points. I just want to say that all these are very important. We do recognise the full range of the challenge facing us. As I said, the Bill tackles 3% of the elderly who require nursing home care. My Ministry, working together with MCD, would also look at the other very important areas. I agree with her entirely that we first have to set up the framework for preventive care so that as few as possible of our elderly actually fall into acute or chronic problems. So preventive healthcare and public education are very important, and we are also working on programmes that will address this. Both Dr Jennifer Lee and Mr Thomas also talked about the very important role played in home care facilities. This is a tremendous challenge. It requires a lot of resources. I can assure both of them that both MCD and my Ministry are working to improve the home care facilities and services that we have in Singapore but Members have to give us some time to work on it. The particular problems of Categories I and II, I think, require a joint effort between MCD and MOH to deal with.”
“She asked whether the Government would give a matching grant of 3 to 1. At this moment, I do not see the need because the Government is pledging to build up the ElderCare Fund to the tune of $1 billion. That is a lot of money, so there is really no need to have further incentives to ask the private sector or the individuals to donate. In fact, I would urge the private sector and individuals, if they want to make donations, not necessarily to make donations to the ElderCare Fund because the Government is going to build it up to $1 billion, but to make donations directly to the VWOs, because they need the donations to help pay for the patients' portion of their bills. Dr Lily Neo also asked whether we can work through local councils like the CDCs. This is something that we are thinking about and this is one of the reasons why we are making some of the amendments, in particular, the amendment to section 6 where we did not stipulate the number of advisory councils. This is to give us the flexibility to appoint enough people to match the CDCs, depending on the number of members in the CDCs. So, the intention is to involve the community in the form of the CDCs. They are the people who know the residents on the ground and can understand their needs and make sensible decisions on who qualifies for Medifund assistance. Dr Lily Neo asked what happens to the patients if we have to suspend a nursing home. That really depends on the reasons for suspending the nursing home. We may suspend nursing homes for several reasons. The most drastic reason is when we have to remove the licence from the nursing home because it does not meet the medical criteria of continuing to run the nursing home. Under such circumstances, the patients will have to be taken care of in other homes.”
“In the first phase of the sickness, she would be cared for in an acute hospital setting. Then later, when she is more stable, when her recovery is better, we would probably transfer her to a nursing home. And when she is in a nursing home, and if she belongs to the low and lower-middle income, then the financial assistance would kick in. We call it ElderCare because the vast majority of the people who would enjoy this funding would be the elderly. But it is not restricted to just the elderly. People whose medical conditions satisfy or require us to provide medical and nursing care, ie, those in Categories III and IV, would be eligible for the financial assistance. Having defined the medical condition and the premises, we can now define the relevant patient, that is, the different categories of people who deserve the different levels of financial support. Mr Seng Han Thong made a plea for the sandwiched group, the middle-income group whose income is too low to afford private nursing home and too high to enjoy the subsidies. We try to take care of this by having a three-tier framework. Previously, it was only either above or below $2,000 household income. Now we have three tiers, so it is no longer a sandwich. It is now a three layered nonya cake. But of course, there would still be people who fall outside the criteria. I do not think we need to go into a kueh lapis, with so many layers, but we can obviously extend the layers and provide more assistance when we build up the fund and when we build up the experience. Now, I would turn to the specific suggestions and points raised. Dr Lily Neo asked whether we accept private donations. The answer is yes. All donations and bequests can be paid as capital monies into both the Medifund and ElderCare Fund.”
“As Mr Seng Han Thong has asked, this is addressed in the definition in the Bill and it does not cover the elderly frail. Elderly frail, who are out of this 3%, would not be covered by this ElderCare Fund. Having defined this group whose medical condition requires us to look after them, then it really does not matter whether we look after them in an institution setting or in a home setting. But for purposes of implementing the financial support, we are saying that we start off first with supporting the nursing homes run by VWOs. This would be extended in due course in future to nursing homes run by the private sector when we are familiar with running such financial support. The subsidies are meant for people meeting the medical condition, and passing the means test. In future, we can also extend to other institutional care settings, whether it is a community hospital, chronic sick hospital or such facilities set up in the void decks. When we are able to develop home care facilities and services in a better way, such financial support would also be extended to home care services for this 3% of elderly sick. I think we start off with this category that requires the medical attention and financial support. As a start, to implement this programme, my Ministry suggests we do it first with the nursing homes run by VWOs, develop some expertise, and then we can systematically extend it to widen the coverage. Mr Gerard Ee asked does the ElderCare Fund only cater for the elderly? The answer is no. It is mainly the elderly who would require such nursing home care, but there would be others who would also require such rehabilitative and nursing home care, for example, the case that he cited of a pregnant lady who suffered a stroke.”
“Sir, I would first like to thank the Members for their contributions to this debate. This whole issue of looking after the aged sick is a very big challenge for us. This is not the first nor the last time that we are going to discuss on how we are going to approach this challenge. At the outset, I would like to say that I agree entirely with Dr Lily Neo and Mr Seng Han Thong that our entire approach must emphasise the personal responsibility for looking after one's health and also counting on family members to look after you when you grow old or when you fall sick. I think these are two pillars that would not change - personal responsibility and family support. But at the same time, there would be this small percentage of the elderly who would fall sick. This elderly sick is quite well-defined in medical terms. This is defined through some criteria of how a person can go about his daily living with different levels of assistance. For those categories that require a very high level of nursing care, what we designate as Categories III and IV, the medical conditions of such people would affect approximately 2% to 3% of the elderly above 65 years old. So, what we are discussing today is a fairly well-defined group of about 2% to 3% of the elderly above 65 years old. Of course, this is part of the whole issue of how you address the challenge of the ageing population and many issues have been raised by Members. But I just want to concentrate Members' minds that the ElderCare Fund is set up to target at this 2% to 3% of the 65 years and above who fall sick, categorised as Categories III and IV under these medical conditions, and who require care in an institution or in a home setting. Sir, the first definition is the medical condition of the person that requires such care.”
“Singaporean patients in B2 and C class wards of public hospitals and subsidised outpatients who face financial difficulty, and are unable to pay their charges, can continue to apply for Medifund assistance at the hospitals. Their applications will continue to be considered by the hospital Medifund committees. Sir, I beg to move. Question proposed.”
“Endowment fund will not replace community support Sir, I have mentioned that VWOs fund their operating expenditure through community donations, patient fees and Government subsidies. The introduction of ElderCare Fund will not displace the role of community donations in helping the poor to pay for VWO nursing home care, as this is part and parcel of the community support structure. This spirit of community help must be preserved and encouraged. Hence, VWOs should continue to raise funds from the community and do their part in helping the needy and indigent patients foot their share of the charges using the donations raised. No change to administration of Medifund Sir, this Bill also proposes some amendments to the existing provisions on Medifund. Today, each approved hospital sets up a Hospital Medifund committee, comprising persons of standing with grassroots or social work experience, to consider and approve applications from needy patients. Funds are then paid out from the hospital's Medifund Account to defray the charges incurred by the applicant. Although this system has worked well, we need to build in greater flexibility for the administration of the scheme to adapt to changing circumstances, so that patients' needs will continue to be well served. For instance, instead of setting up one Medifund committee for every approved hospital, it might be more desirable in future for community organisations to be responsible for disbursing Medifund to needy residents living in the community. The proposed amendments to the existing provisions on Medifund will allow for such alternative arrangements to be made, if necessary. At present, however, no changes will be made to the administration of Medifund.”
“Instead of continuing with today's practice of paying subsidies to the VWO nursing homes directly out of the Government's budget, the Government will establish the alternative mechanism of an endowment fund. Purpose of ElderCare Fund The proposed endowment fund will be called ElderCare Fund. We will gradually build up a large enough capital sum in the ElderCare Fund, so that the interest income can be used to fully finance the subsidies for patients who are cared for in VWO nursing homes. By setting aside funds now while we can afford it, we will ensure that funding of subsidies for step-down care facilities for the elderly of the future can be sustained in the long term. Top-ups of capital sum during budget surpluses The ElderCare Fund will start off with an initial capital injection of $200 million. During years of strong economic growth, the capital sum can be topped up with budget surpluses, so as to generate more interest income. Only the interest income can be used to finance the nursing homes. In the initial years, subsidies to VWO nursing homes will be partially funded from the interest income of the Fund, and partially funded direct from the Government's budget. The goal is for the Fund to reach a capital sum of $1 billion by the year 2010. By then, the capital sum should be large enough for subsidies to VWO nursing homes to be completely financed from its interest income. For a start, ElderCare Fund will provide subsidies only to VWO nursing homes. Other kinds of step-down care provided by VWOs and supported by the Government, such as community hospitals, will continue to be funded from the Government budget. However, when ElderCare Fund has more resources, extension of its coverage to other kinds of step-down care services can be considered.”
“Further, those with per capita incomes between $500 and $700 will receive 25% subsidy, where they now receive none. Under this three-tier subsidy framework, therefore, a higher proportion of Singaporeans will be eligible for subsidy. The financial burden on low- and lower-middle income households supporting disabled elderly family members who require nursing home care will be considerably lightened. Need to safeguard affordability of care in future, against shrinking tax base Having decided on this subsidy framework, we need to consider how best to finance it. Sir, our population today is still relatively young. Many of us are able to contribute actively to the economy and help generate tax revenue to finance Government programmes, including health care subsidies. However, this will change. Not only will a rapidly ageing population require more step-down health care services such as nursing home care, it will also result in a shrinking tax base where a smaller working population will find it harder and harder to pay for health care subsidies consumed by a larger ageing population. Without these subsidies, health care for the future elderly may not remain affordable to individuals from low and lower-middle income households and their families. Yet, at the same time, we need to preserve our economic competitiveness in an increasingly globalised economy, where countries maintain competitive tax rates to attract investments. Hence, it would not be realistic for us to continually count on taxpayers to pay for the subsidies to our nursing homes. We need to ensure the affordability of nursing home care in future years.”
“Nursing homes that are funded by Government now receive capital funding of up to 90% of the cost of building and equipping the homes. In addition, Government also provides full subsidy for land rental and input GST. At the same time, Government also funds 50% of the recurrent cost of providing care to patients with immediate family incomes of less than $2,000. Patients on public assistance receive 75% subsidy. Higher proportion of Singaporeans will be eligible for subsidy The Inter-Ministerial Committee on the Ageing Population, in its report released late last year, had recommended that the Government consider expanding its operating subsidies to VWO-run nursing homes. The Government has considered this recommendation and decided to implement a three-tier subsidy of 75%, 50% and 25% for VWO nursing homes this year. The highest quantum of subsidy will be given to those with the least ability to pay. To ensure that subsidy goes to those who most deserve them, the introduction of the new subsidy structure will be accompanied by refining the means test conducted in VWO nursing homes. In addition to the financial means of the immediate family, it will also take into account the size of the immediate family. This is fairer because larger families would necessarily require a larger income to live on. VWOs will also continue to take into account the patient's assets in evaluating his financial circumstances. The three-tier subsidy will result in higher funding support by the Government to the VWO nursing homes. In addition to patients on public assistance, those with immediate family per capita incomes below $300 will receive 75% subsidy. Those with per capita incomes between $300 and $500 will receive 50% subsidy.”
“Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time." Sir, the Government has decided to introduce a new endowment fund to finance operating subsidies to nursing homes run by Voluntary Welfare Organisations, or VWOs. This Bill is to repeal the Medical Endowment Scheme Act and re-enact it as the Medical and Elderly Care Endowment Schemes Act, to set up this new endowment fund. Need for step-down care increases as population ages Our population is rapidly ageing. Today, we have about 220,000 people aged 65 years and above, making up about 7% of our population. By 2010, we will have about 312,000 elderly persons, comprising 8% of our population. Most elderly persons will remain healthy and independent. However, it is estimated that about 3% of those aged 65 and above do acquire severe disabilities and are unable to go about their daily lives without considerable nursing care, medical attention or assistance. Yet, at the same time, their conditions are not severe enough for them to be warded in acute hospitals. These elderly persons should be looked after in their own homes, or if residential care is required, in "step-down" facilities such as nursing homes. As our population ages, the demand for nursing home care will rise. Currently, some two-thirds of our nursing home beds are in VWO-run facilities. VWO nursing homes receive assistance from the community, in the form of volunteers and cash donations. Community assistance thus supplements the patients' payment for their share of the cost of care. At the same time, the Government also provides financial assistance to keep nursing home care affordable to those from lower income households.”
“I will send a doctor to take a look at the Member! Is he cured? If he is not, he should not come to this crowded place. BY-ELECTION FOR JALAN BESAR GRC 9. Mr J. B. Jeyaretnam asked the Prime Minister whether he has any new reason for not holding a by-election for the Jalan Besar GRC.”
“First of all, I do not take it upon myself to find out when an epidemic occurs in the US or Europe before the Health Ministers there. We keep track with all the various agencies around the world and it is part of professional cooperation that we keep each other informed where epidemics are imminent. Similarly, my Ministry keeps in touch with its counterparts around the world. So, when an epidemic has broken out or is imminent, it is professional practice to keep each other informed. And our job is to let Singaporeans know and we send out the advice so that those who are travelling to such countries could take the precaution of being vaccinated. The transmission of such epidemics, particularly flu epidemics, from temperate countries like the US to Singapore is limited, unless we have huge numbers travelling there and coming back to spread the flu around Singapore. For this particular epidemic, for example, we have not seen the transference of the epidemic to Singapore, but we will continue to take precautions and if the numbers do build up in Singapore, then we will advise the public accordingly.”
“We love to do many, many studies. We will do this if it makes any sense or it gives us the numbers to do something about it. In Singapore, colds and flus happen throughout the year. To some extent, our population builds up some immunity. When there is a very bad outbreak, we take precautions. We send out advisories to advise Singaporeans to avoid crowded places, etc. As to how useful it is to know how much is lost to the economy, I think that leaves to be seen.”
“Basically, the system has two components. One is whether there is an epidemic in Singapore, and we have a tracking system where we look at the attendances in the hospitals, polyclinics and the private clinics, to see whether an epidemic is imminent or is already here. If there is, then, of course, we put out an advisory to advise the Singapore public. The second component is, of course, overseas epidemic, and it only affects Singaporeans if they travel to that area. For this, we also put up advisories as and when necessary if the epidemic is of a very severe nature in the countries that Singaporeans are likely to travel to, and then advise Singaporeans to take vaccinations if they are travelling to such areas.”
“However, the hospitals have put in the orders for new vaccination doses, and 1,000 doses of such vaccines arrived last week. Another 3,000 doses will arrive this week. So, the shortage is overcome.”
“Sir, the Ministry of Health has a comprehensive and well established surveillance system to monitor and detect epidemics, including influenza outbreaks. This enables the Ministry to take the appropriate preventive and control measures, including giving health advice to the public on precautionary measures, when necessary. Influenza is a self-limiting illness and patients usually recover within a week. In temperate countries, when epidemics occur during the cold winter season, the elderly as well as children and adults with chronic medical conditions such as heart and lung diseases, are at higher risk of having serious complications. They are therefore advised to have annual influenza vaccinations as a preventive measure. However, in tropical countries like Singapore where influenza occurs throughout the year, influenza vaccination is generally not introduced on a routine basis. There is currently no recommendation from international health agencies, such as the World Health Organisation, for countries to restrict travellers and visitors from outbreak areas. The Ministry, however, has advised travellers, especially older adults, going to countries with influenza epidemics, to protect themselves with influenza vaccination. Influenza vaccination is available at Tan Tock Seng Hospital, Changi General Hospital and many other private clinics. While it is difficult to anticipate the demand for vaccination, over the years, the hospitals have maintained a sufficient supply of vaccine to meet the demand. The recent increase in local demand for vaccination due to the influenza epidemic in the West is unprecedented. This, coupled with the world-wide shortage of influenza vaccines, has led to a temporary shortage in Singapore as well.”