Debate on President's Address

Mr Speaker, I join other hon Members in expressing my support for the Motion of Thanks to the President for her Address.

To heed the President's call for us to forge a cohesive, caring and inclusive society, particularly for our seniors, I would like to take this opportunity to raise three ideas about how we can smoothen some of the bumps and ripples in our healthcare landscape and to remove some of the friction where it is not needed, so as to promote more equal access to medical services. As my following comments do concern some adjustments of a fiscal nature, I would like to declare my interest currently as a medical practitioner in a public healthcare institution.

First, let me talk about MediSave. I would like to propose that we think once again and hard about further liberalising the use of MediSave in a bolder and more decisive manner. Over the years, I and many others within this House have called for the liberalisation of MediSave use, in particular for outpatient treatments. The Ministry of Health (MOH) has certainly done very much in this regard, by introducing and expanding many schemes such as the Chronic Disease Management Programme (CDMP) and, more recently, the Flexi-MediSave Programme. They have also allowed greater use of MediSave for medical scans, and so on. These measures are effective but can be complex and, at times, may be too restrictive. The concern, of course, and it is something we all appreciate, is that too loose a policy on MediSave withdrawals could lead to an earlier depletion of our accounts, leaving nothing for us to rely on in later years when medical needs and expenses could be greater.

However, I am not sure that this worry is always necessarily well founded. If you look at the statistics over the past few years, the mean MediSave account balances among Singaporeans have been increasing steadily, and a significant number do pass on with remaining balances of fairly appreciable amount in their accounts.

For some Singaporeans with multiple chronic diseases or whose illnesses cannot be adequately controlled by medicines on the Standard Medication list, the out-of-pocket cash outlay for medical treatment, even at polyclinics and with Pioneer Generation (PG) benefits, can still remain quite high due to the current utilisation limits on MediSave. I would like to propose that Singaporeans who are above the retirement age be allowed to pay for a greater amount of their subsidised outpatient treatment costs at Government clinics using their MediSave. Perhaps, as a start, up to 80% of the expenses, and this can be adjusted as needs arise. This should be subject to a doctor's certification.

Such a move would not change matters for the majority of elderly patients, for whom the current chronic disease withdrawal limit of $400 and the Flexi MediSave limit of $200 would already more than adequately covered 80% of their annual outpatient treatment costs. But it could make a meaningful difference to the elderly with multiple or less common conditions requiring more specialised and expensive medications, or who require more medical investigations to better manage their conditions.

Presently, for a patient who has exceeded his MediSave claims limits and who finds it challenging to pay the remainder in cash, he or she has a few options. One, he can appeal to the Ministry to withdraw more from his MediSave. Two, he can apply to the Medication Assistance Fund and other welfare schemes. Or three, he or she could just simply choose to forego treatment or to forgo some of the treatment in excess of what he is willing to pay for in cash. Allowing for greater MediSave withdrawal in these cases can help a patient avoid trying the welfare route, which ultimately adds to public expenditures, and also encourage compliance with treatment.

If the patient follows on with treatment, then the future consequences of his condition, if left improperly managed or sub-optimally managed, would be less and the eventual costs to both the patient and society would ultimately be lower.

I am of the opinion that further loosening of the MediSave purse strings would not lead to over-servicing or over-consumption. I would like to remark that we are talking about patients here who are adhering to treatment protocols that a public service doctor has deemed to be necessary and who has to certify that it is necessary without a cheaper alternative.

There also remains an element of co-payment. Our treatment management schemes have been strengthened over the past few years. For example, agencies such as the Agency for Care Effectiveness (ACE) are now putting in place guidelines about what constitutes effective treatment and what is not. The introduction of the PG package, for instance, a few years ago, with very generous benefits, has also not led to worrying levels of over-consumption or over-servicing within the public healthcare system thus far.

Second, I think it is just and right that the Government has been absorbing the GST charged to subsidised medical services in public healthcare institutions for many years now, at considerable cost to the Ministry. We are also trying, of course, to shift our model of care beyond the hospital and back to the community by strengthening our primary healthcare networks.

While the majority of hospital care is now provided for by public hospitals, the majority of Singaporeans still choose to visit their family doctors or general practitioners (GPs), rather than polyclinics, for their primary care needs. The CHAS and PG schemes have helped to deliver Government subsidies to our family doctors and have strengthened general practice through the reduction of market distortions due to larger subsidies received by polyclinic patients. I believe we can do even more in this field, or in this regard, and I would like to consider or for us to think about potentially exempting primary healthcare services from the Goods and Services Tax (GST).

This would be a major deviation from our GST framework, which favours a flat system with later reliefs or Government transfers. Philosophically, I realise this is a slippery slope, but in practical terms it would be very much in keeping with the intent of current policy that already absorbs GST from subsidised healthcare services. Removing this consumption tax from all primary healthcare services could nudge more patients back to family doctors or GPs for care, and encourage compliance with treatment and follow-up, by reducing costs. I wish to emphasise that this suggestion refers only to primary care services and not for hospital or other types of medical care. I also appreciate that, at present, most solo practices, for instance, are not GST-registered. But with the emergence of more group practices and with the increasing cost of healthcare, the number of healthcare providers that need to pay GST may increase in the future.

What constitutes a provider of primary healthcare services can be defined and licensed, and this is also an issue that can perhaps be addressed when we debate the Healthcare Services Act later this year. I appreciate that there will be issues with the implementation of such a scheme, but I certainly believe that it merits consideration.

Lastly, a little bit about insurance coverage. The introduction of MediShield Life, which provides universal health insurance or coverage for Singaporeans, marked a proud day for Singapore’s healthcare system, exemplifying the caring and inclusive society that President Mdm Halimah Yacob spoke of.

Although a hallmark of MediShield Life is that no one is excluded, including those with pre-existing conditions, like virtually all medical insurance systems, there remain some gaps. For instance, I would like to draw your attention to two areas. First, with regard to pregnancy-related complications; and, second, about conditions related to mental health. These are still not covered under MediShield Life when hospitalisation is required. I believe that we should consider expanding coverage to these conditions as well. We have been strongly encouraging parenthood and it would serve as greater assurance to would-be parents that the mother’s medical care can be covered in the uncommon instances of complications related to the pregnancy.

We have also been slowly but significantly expanding our support for mental health, even as the disease burden inches up within our community. I hope that when MediShield Life is reviewed, consideration can be given to expand coverage to some, if not all, mental health-related hospitalisations.

We have come a long way; we have passed 50 years successfully as an Independent nation, and we are now moving on to 200 years after the founding of Singapore. We now have a new generation of Singaporeans and Singaporean leaders that will steer us towards SG100. It is my hope that our healthcare system remains future-ready, and also friction-free where it counts. I support the Motion.

1.56 pm

Mr Speaker, Sir, thank you for allowing me to speak in support of the Motion of Thanks to the President.

I was moved when the President reminded us that we are an exceptional country. Sometimes, some of us take our existence, rights and privileges for granted because we compare ourselves with other developed nations of the world. But as we all know, we do not have what they have – no hinterland, no natural resources, not even enough natural sources of water. Due to these insufficiencies, despite our stability, prosperity and progress, anxiety and insecurities about our future surface from time to time.

On quite a number of occasions, people I met asked me whether Singapore would be able to continue to survive and if a bright future would remain for our children. One person I met recently asked if Singapore would continue to do well in 20 years’ time. I think citizens all over the world ask themselves similar questions about their nations’ economic and political future, but not questions about their countries’ existence and survival. I do not think any of our ASEAN neighbours have any doubt that their countries will still be around for their future generations, regardless of political turmoil or economic crises.

My answer to the question about our existence is another question. What is our raison d'etre? There are many answers to this question, including our roles as a global transportation, commerce and financial hub. It all boils down to our usefulness and relevance to the world. Therefore, as long as we have value, our survival is guaranteed; and when we add value, we thrive. Every generation has to find its own raison d’etre.

Because we are so small and there are so few of us, literally, we have to work exceptionally well as a team. In all the best teams, leaders and team members are constantly communicating and updating one another to facilitate the necessary adjustments and corrections. We must keep channels of feedback open and continuously address the issues affecting our people. People have to be able to trust our leadership and Government which must remain honest, have integrity and be free from corruption.

Our leaders must exercise fiscal prudence and grow our Reserves, which is absolutely vital for our long-term survival and stability. We need to keep our currency stable and strong to counter imported inflation, so that we will have more levers with which to manage local inflation and cost of living.

Very importantly, the Government must ensure a fair and equitable system for all, which will assure Singaporeans and motivate everyone to put in his best effort. They will be able to see that there are multiple paths to success and unlimited opportunities. As long as they work hard, they can be assured of upward social mobility. Even better, the Government has put in place a framework to make guidance and assistance available to all, such as SkillsFuture and Adapt and Grow programmes. Perhaps the Government can look into providing such guidance and assistance services permanently to Singaporeans.

How do we resolve the inherent conflict between meritocracy, which rewards ability, skill and talent, and the resultant income inequality? It is through compassion and inclusiveness. A compassionate community which is inclusive of people from different strata will help to ensure our country’s stability and success.

Life is like a marathon. When one of ours trip and fall, we should stop to help him get up again so that we can continue the race together. It is important that our system has values, such as mutual support and cohesiveness. This is the essence of nationhood.

In the face of challenges posed by a disruptive innovative economy, we need to ensure that Singaporeans can manage such rapid advancements confidently and leverage upon them for our benefits and life improvement. We shall not be limited by our physical and ability constraints. The disadvantaged can also benefit from technological innovation and get elevated socially. Increasingly, in an integrated globalised economy, opportunities are no longer limited by borders.

The cost of living remains one of the key concerns among those I meet. Perhaps it would be good to reach out to every household in the low- and lower-middle income with guidance and assistance in addition to the GST vouchers. We have Pioneer Generation offices (PGOs) that did the good job to support those in the PGs. A similar approach could be considered to ensure that such households are assured of attention and assistance by the Government. The Government also needs to keep in tune with the younger generations and ensure that the polices are up to date that could be tailored to meet their aspirations as they are vital to our nation building.

We need to continue to strive for real income increase and guard against the rise in cost of living as the impact on the middle- and low-income groups may not be easily eliminated by redistribution through grants and subsidies. The lower income groups are not only affected financially but emotionally and psychologically as well, as they perceive escalating prices pushing items beyond their reach. We have to put in more effort to monitor the challenges faced by our lower-income and middle-income groups closely and policies are updated to ensure that their aspirations are within reach. Perhaps a new scheme or a Household Transformation Map – since we have the Industry Transformation Maps (ITMs), I think we can consider the Household Transformation Maps (HTMs) – in totality of all relevant programmes can be looked at by the Prime Minister’s Office (PMO) to reach out to all these families to assist and guide them to achieve their aspirations. This “upward mobility elevator” instead of “poverty elevator” would be a step forward in building a cohesive and progressive nation.

There are many good policies and schemes that benefit Singaporeans, for example, our Build-To-Order (BTO) flat prices are pegged against the average income of an income group, there are various housing grants, special employment credit, job credit and various Ministry of Manpower (MOM) schemes to help our workers. These should be continued. There could be further think-out-of-the-box approaches for existing policies, for example, to review the existing childcare grant to include parents who have left the workforce temporarily to look after their young children and to grandparents, nannies, or babysitters who help look after the grandchildren or children to support parents to increase the total fertility rate (TFR).

Our existing public housing policies have been successful and should be preserved. HDB shall remain the key developer of housing for 80% of our population. I urge prudence in changing the ratio as it serves Singaporeans well in racial and community harmony while meeting the aspirations and dreams of Singaporeans. HDB should or could challenge its present parameters and further expand the provision of flat types and facilities to meet the higher expectations of Singaporeans while retaining affordability and reach. For example, a new type of flats could perhaps be privately designed with condominium standard or the like but are built and managed by HDB and Town Councils without fences to encourage integration with the other HDB flats around.

Sir, I note that condominium Management Corporation Strata Titles (MCSTs) do not allow non-residents to share the facilities with the condominium residents, while HDB residents feel that it is also not fair for condominium residents to use their multi-purpose halls at HDB estates for private functions such as wakes. A fence has divided both worlds apart. It warrants a rethink of the potential impact on the efforts to build a cohesive and inclusive society and preventing widening social impact of income inequity. Sir, in Mandarin,

(In Mandarin): [Please refer to Vernacular Speech.] Foreigners always attribute Singapore's success to the three characteristics of Singaporeans – "kiasi" (怕死), "kiasu" (怕输), "kiabo"（怕无）. These three characteristics have their pros and cons. They have generated the spirit of perseverance and the drive for progress of our people. However, they also created some problems at the same time. If they are not dealt with appropriately, they can also generate utilitarianism and make people profit-driven and indifferent towards each other. This will hinder our efforts to build an inclusive and united society.

I feel we need to redefine what success is. I agree that the Government should broaden the definition of success. Success should not be just about academic achievement and material comfort. It is about lifelong learning. We continue learning as long as we live. We should emphasise skills training, create opportunities for each Singaporean to fulfil his potential and achieve success, thereby building a prosperous society enjoyed by all.

Here, I would like to suggest that we further strengthen and broaden the Edusave Progress Award to encourage Singaporeans to improve themselves proactively by giving incentives to lifelong learners. Where there is a will, there is way. Even a small step counts. We should turn the three "K"s to three "B"s – “bo kiasi"（不怕死）, "bo kiasu" (不怕输), "bo kia jingzheng" (不怕竞争). In other words, not afraid of dying, not afraid of losing and not afraid of competition.

You may remember that during the five-kilometre run in the 2016 Olympics, an American and a New Zealand runner tripped but they helped each other to get up. During the 2017 UK Marathon, a runner, Swansea Harrier Matthew Rees, stopped to help another runner, David Wyeth, to complete the last segment of the run. Both athletes demonstrated great sportsmanship.

This is how we should build an inclusive, caring and prosperous society.

(In English): Sir, there are many challenges ahead of us with our rapidly ageing population, rising protectionism and the threat of terrorism, just to name a few. However, we are descendants of people who had created a miracle island and I am confident that we will be able to overcome these challenges and build a stronger Singapore for our future generations.

2.09 pm

Sir, the President spoke eloquently of five thrusts for the Government moving into the future, one of which was to forge a caring and inclusive society, leaving no Singaporean behind.

Two approaches to achieve this are: first, tackling inequality by providing the right support to those who need it, such as in skills training and employment; and second, rolling out policies for the growing elderly population, such as helping older workers stay employed. I speak in support of this with special focus on older workers and, especially, baby boomers, and women at the workplace.

Let me first declare that I belong to the baby-boomer generation and am, therefore, happily classified as an elderly, plus I am a woman.

One barometer of an inclusive society is having an inclusive workplace. This means helping different groups of Singaporeans who are able and willing to work, to stay employed and find fulfilment, even as circumstances change. An inclusive workplace is not an automatic nor easy outcome. But there are concrete ways the Government and our partners can work towards in order to create and sustain it, such as being inclusive in helping mature workers and being inclusive in creating flexible work arrangements, which is especially helpful for women.

Indeed, these are precisely the outcomes that the Ministry of Health (MOH) is working towards, together with our healthcare institutions, for a diverse healthcare workforce, as we expect to increase our healthcare manpower by a further 9,000 between 2017 and 2019 to staff new and expanding facilities in our public healthcare and aged care settings.

We need to help our mature workers, including the baby boomers who are now entering the retirement phase of their lives, by keeping them active and connected to society. This way, they can age positively. While some seniors will want to retire to spend time with their grandchildren and hobbies, some will find purpose in continuing their current roles, and others may wish to take smaller, bite-size roles. Some mature workers are also in transition between careers and welcome opportunities in the care sector. We will need to cater to their different wants to keep them integrated in society while playing a meaningful role.

Mr Francis Tan of UOB recently pointed out that this year, 2018, is the first year in our history when the share of the population that is 65 years old and above will match that of those younger than 15 years old. Globally, the trend is also accelerating elsewhere. The World Economic Forum points out that by 2020, the global population of those over 60 years of age will reach one billion. By 2050, it is expected to reach two billion. This trend, combined with a general decline in birth rates, is leading to a situation where the world’s old will outnumber the young. This is not just a statistical quirk, but a demographic result of great significance.

The consequence of ageing is well documented. Oxford Economics and Haver Analytics posit that there will be sharp deceleration and, indeed, negative labour supply growth, and Singapore could be among the worst hit in terms of its impact on economic growth. However, in Singapore, as Minister Chan Chun Sing said on Monday, we should not let challenges define us. Instead, we should see ageing as an opportunity to do things differently, or as Mr Ravi Menon, Managing Director of the Monetary Authority of Singapore, puts it, “Demographics is not destiny”.

The good news is that our healthy life expectancy is also increasing, with people staying healthier for longer, and there is also an opportunity to better leverage the abilities of those over 60, by adjusting workplace policies and redefining what “retirement” means.

Seizing opportunities arising from productive longevity is, therefore, crucial to Singapore’s success as a nation and it is a key priority. Extending working life and promoting senior entrepreneurship are increasingly perceived as economic drivers. Fostering both can enable older people to leverage their institutional knowledge, wisdom and insights to continue contributing positively to the community and economy.

For existing healthcare workers who wish to continue in their current roles, we facilitate their re-employment through strategies such as job re-design, training and re-employment facilitation workshops. Today, nine in 10 staff at retirement age are re-employed. The public healthcare sector raised the re-employment age for staff before legislation kicked in, from 65 to 67 since July 2016. In the case of nurses, who form the bulk of the healthcare workforce and where we most need manpower, we have also seen an increase in the number of nurses working past the retirement age. In 2017, over 1,400 retired nurses aged above 62 were working, compared to 1,200 in 2015, and 20% percent of them are working part-time. This flexibility supports older nurses so that they can continue to contribute at a pace that they are comfortable with.

Our public healthcare institutions have also implemented workplace initiatives such as elder-friendly features like placing a magnifying glass on medication carts, and larger fonts for signages. We are also automating some labour-intensive care activities such as lifting and transferring of patients using mobile hoists and bed transporters. This will reduce the strain on older workers and allow them to continue in their roles.

For those who wish to take on part-time or smaller, bite-sized roles, we have also been working with our partners to increase the number of micro-jobs. For example, several of our public hospitals have created Basic Care Assistant (BCA) positions, where locals with no prior healthcare experience are trained to provide care in areas such as feeding and patient transfer in the wards on a part-time basis.

For mature workers looking to switch careers, we provide multiple pathways and training to facilitate picking up of new skills to join us in our care transformation journey. In 2017, we supported about 150 mid-career locals through healthcare conversion programmes, such as the Professional Conversion Programmes (PCPs) and the Senior Management Associate Scheme (SMAS), to help individuals acquire skills and take on good jobs in healthcare in a variety of roles such as Nursing, Allied Health and Administration. And this is triple the number compared to three years ago.

We enhanced the PCP for nursing by providing employers with more funding to support the training of mid-career nurses. Earlier this year, MOH together with the National University of Singapore (NUS) and Workforce Singapore (WSG) also introduced a new degree-level PCP-Registered Nurses (PCP-RN) to attract more mid-career Singaporeans into the nursing profession.

This PCP will complement the current PCP-RN diploma programme at Nanyang Polytechnic and provide an additional pathway for mid-career conversion into nursing. The course commences in July this year, with an estimated inaugural cohort of about 40 mid-career trainees.

We are also working with WSG and e2i on programmes to facilitate employment and transition of mature workers, especially professionals, managers, executives and technicians (PMETs) who may be displaced due to restructuring in other industries, into suitable roles in the healthcare sector.

Older workers as a segment of the workforce do not represent a monolithic group. They are of differing ages, educational backgrounds and circumstances. While some work simply because they want to remain gainfully employed, others, like Minister Ng Chee Meng said yesterday, need to work as they have expenses, mortgages and dependents relying on them. Hence, I support Minister Ng's idea of forming a new Tripartite Committee to take a closer and perhaps more granular look at ways to support mature workers to continue working if they choose to.

Secondly, we must step up flexible work arrangements to cater to Singaporeans with different needs, especially women. Singaporeans in different life segments and at different life stages have varying needs in their careers. Those starting a family or looking after their elderly parents or grandchildren may be looking to balance their work with family commitments.

Many women ask for this support in flexible work arrangements (FWAs) and actually the men too. Adopting FWAs will help us better cater to the needs of our healthcare workforce at different life stages, and retain them in the workforce, especially our women and older workers, for a win-win. For instance, we have piloted FWAs for nurses, who are the largest staff group in the public healthcare sector. We have engaged nurses, and we know that this is important for many of them. Today, more than 100 wards across the public healthcare institutions have adopted FWAs for nurses, in the form of more flexible shift work hours. This helps them to avoid the binary option of either being employed or unemployed.

To further scale up FWA adoption for nurses, the public healthcare institutions will progressively move to electronic rostering, or e-rostering, starting from the second half of 2018. This shift will help to support nurse managers in managing more complex shift rostering of staff and empower them to support FWAs in a bigger way.

Globally, gender pay gap persists, including in Singapore, although we rank relatively well even among the Organization for Economic Cooperation and Development (OECD) countries, ahead of countries like Australia and the UK. A reason often attributed to this pay gap is men's greater share of senior jobs as more women drop out of the workforce due to family care-giving duties.

An article in The Economist noted that men’s and women's salaries start diverging from the child-bearing years. This "motherhood penalty" is often followed by a "good daughter penalty" when elderly parents require care and daughters often prove more conscientious than sons. So, here, I am tempted to note that the men just do not get it! Quoting figures from the UK's Office of National Statistics, the median pay gap is only 2% among full-time workers in their 30s yet jumps to 14% in their 40s and 16% in their 50s.

As our population ages, a so called "caring economy" is emerging. The need to provide care to the elderly can have a significant impact on the workforce. Working caregivers must often take time off or leave the workforce altogether.

As The Economist article highlights, the "caring economy" disproportionately affects women because they make up the majority of caregivers, which also negatively impacts gender parity. FWAs, such as flexi work hours, work from home arrangements, or part-time work would better allow caregivers to remain in the workforce. Besides providing funding support and the Tripartite Standard on FWAs, moving forward, we could, adopting a tripartite approach and help companies who may not have the know-how to implement FWAs to do so.

Over the years, we have been increasing support for caregivers, such as expanding day care and home care capacity, providing caregiver training grant and training, respite care and elder sitter service for dementia patients. Nonetheless, as our population ages and caregiving needs increase, we must look at more ways to better support caregivers.

Mr Speaker, Sir, we have made some progress, but we must press on in creating and sustaining an inclusive workplace, so that work opportunities are maximised for everyone who are able and willing to work; and that no Singaporean, young or old, woman or man, is left behind. Policymakers can continue to roll out initiatives to foster and support such an environment but creating a truly inclusive workplace would require individuals and companies – shareholder, management and staff – changing within themselves in terms of mindsets and prejudices and changing their corporate culture. Sir, with this I support the Motion.

2.24 pm

Order. I propose to take a break now. I suspend the Sitting and will take the Chair at 2.55 pm.

Sitting accordingly suspended

at 2.35 pm until 2.55 pm.

Sitting resumed at 2.55 pm.

[Mr Speaker in the Chair]