Committee of Supply – Head O (Ministry of Health)

Mdm Chairperson, the prospect of rising healthcare costs is a cause for concern, especially for the middle-income or the sandwich class. In fact, rising MediShield Life premiums will be a reality for many Singaporeans as the subsidy threshold is progressively reduced from this year up to the year 2019, when MediShield Life subsidies come to an end.

MediShield Life means coverage for all, including the most vulnerable among us. In fact, when MediShield Life was introduced, it was expected to account for a bigger chunk of Integrated Shield payouts. However, this prospect was quickly put to rest with the announcement by the various insurers that any rise in the top-up portion of premiums would only be frozen for 12 months. As this moratorium will only last until November this year, what are the prospects of higher premiums next year? Can the Ministry consider informing the insurer that the moratorium should also include a freeze on riders as well, since this would have been a backdoor to work around the moratorium, insofar as keeping healthcare costs affordable as a whole?

Secondly, while rising healthcare costs for a number of public reasons, such as larger bills, greater healthcare consumption and costly procedures, are a reality, can the Ministry share how it intervenes, if at all, to ensure that any rise in premiums from the Integrated Shield providers are audited by the Government? How does the Government work with the insurers to check on any unjustified rise in premiums and to what extent can the Government intervene, if and when premiums are unjustifiably raised?

In view of this new environment of data analytics, will the Ministry release more data in conjunction with the insurance companies so that the public will be in a better position to track and appreciate the rising trend of claims and specifically identify areas of over-consumption? What does the Ministry do to ensure that private hospitals and doctors do not take maximum advantage of private insurance plans? Does the Ministry consider this to be a growing problem and how does it plan to mitigate it?

Finally, details of the standardised B1 plan were recently made public. Prior to launch, the plan was framed as an affordable Integrated Plan providing greater choice to consumers. To this end, will the Ministry consider increasing the MediSave withdrawal limit amount for Singaporeans of all ages, especially older Singaporeans who choose this plan, so that they can be paid for completely through their MediSave account?

Mdm Chairman, "prevention is better than cure" is a dictum that we would accept wholeheartedly. Preventive medicine is a topic I am passionate about and I have been advocating this preventive healthcare.

In the year 2000, I was privileged to spearhead the two-year islandwide "Check Your Health" programme to screen those above 50 years of age for diabetes, hypertension and high blood cholesterol. Some 40,230 people were screened. About 60% of them had never attended any screening before and 60% of them, who had no past history, were detected with abnormal results. Although we are in a better situation now with more people readily going for regular health screening, we must continue to push for the detection and treatment of these three chronic diseases, and especially so for diabetes.

Diabetes is a killer disease that slowly steals life away. It can slowly destroy body organs, resulting in blindness, lower-limb gangrene, kidney failure, stroke, cardiac disease and so on. If we can promote better control of diabetes, we will see less of these complications that cause pain and burden upon sufferers and their family members. Presently, one in three diabetics has poor control of their diabetes.

Non-compliance is a serious problem in diabetes. Patient non-compliance is not only limited to the failure to take medications, but also the failure to make lifestyle changes, undergo tests or keep appointments with physicians. Non-compliance can be due to factors that are patient-centred, therapy-related or healthcare system-associated. The patient-centred factors can be demographic, such as age, gender, educational level and marital status, and psychological, such as patients' beliefs and motivation towards the therapy, negative attitudes, patient-prescriber relationship, patients' understanding of health issues and general knowledge.

The therapy-related factors include the route of medication, duration of treatment, complexity of treatment and the side effects of the medicines. The healthcare system-related factors include availability or accessibility of care and the physician. Could MOH address these non-compliance factors and mitigate them in order to have better success with diabetes?

An area that can make a difference is to enhance lifestyle-change reinforcements. Thus, would MOH consider promoting less-calorie food intake within our population, such as disclosure of calorie content in the food available? Would MOH also incentivise people to stay healthy with token rewards?

Our home palliative care services do good work for Singaporean patients from all walks of life. I have seen it myself when I visit residents and attend funeral wakes in Clementi. They tell me about how their loved ones were helped at home during terminal illness. I have seen how they looked after my own cancer patients that I see in a professional capacity. And I also saw how they brought comfort to my father, during his last days, as a cancer patient, terminally ill.

These nurses and doctors make the greatest difference because of the human touch. A human touch for patients at home, patients from all walks of life. Home visits, listening to patients and their families, giving advice and guidance to caregivers. And they can teach us as well, at the systems level, how to look after other patients at home – the chronic sick, the frail, the very elderly – because travelling to a clinic takes time. It can be challenging for some patients and their families if the patient is bed-bound after a stroke or if your loved one cannot sit up for long because of pain.

Can MOH give an update on our home-care and community care plans? Can MOH tell us how we can further empower and support caregivers? And can MOH advise us on how we can ensure care can be delivered near to home – or even at home – in a holistic, integrated, sustainable way so that we can look after all our Singaporean patients, those who are mobile, those less mobile and those who are unable to leave the home easily?

Mdm Chair, the Action Plan for Successful Ageing report contains several initiatives to improve healthcare for seniors in areas, such as health and wellness, active ageing and aged care services.

For many seniors, age becomes almost irrelevant when they are physically, mentally and socially healthy, and they will have the freedom to do as many things as the young can do. I would like to know what are the initiatives to help our elderly live healthy lifestyles, monitor their health conditions and exercise.

As a firm believer in preventive health, I would like to know how the Ministry can encourage and enable medical follow-ups of seniors found to have at-risk conditions. I have always found it challenging to encourage our seniors to go for their follow-up treatments and therapies. Some are worried that they would discover more serious medical conditions and would prefer not to know. Others are concerned about costs. And yet others claim they have no time.

Whatever medical conditions they have, if treated early, it can prevent deterioration, escalating healthcare costs and poor quality of life. An idea I would like to propose is to tap on the community network of seniors, where elderly neighbours and friends can encourage their peers to see their doctors for follow-ups.

Seniors want to age in familiar environments surrounded by people they know and who understand and care for them. They also need easy access to care centres and doctors. Their caregivers also need support from the community in caring for their senior family members. What are the major initiatives for aged care services?

Assoc Prof Fatimah Lateef (Marine Parade): The Action Plan for Successful Ageing includes about 60 initiatives covering 12 areas. The Action Plan, "A Nation for All Ages", is targeted at the individual level, the community level, as well as the city level.

Can I ask about MOH's action plan for community level health promotion for our seniors and what community networks they can tap on, bearing in mind that we also want to align with those that are existing in the constituencies?

As we know, we cannot disengage an individual from his/her community and, in fact, the latter has a value-added effect and positive impact on well-being, mental wellness and happiness. Having a trusted group of friends and "kakis", the seniors can be made to feel differently and a lot better.

Will we see a more well integrated range of services and networks, readily available to our seniors at no or low cost, up close and personal, near their residences? Can we make these stimulating, broad ranging and exciting as well for our seniors in their active ageing years?

As we also plan to integrate the seniors with their multigeneration families and extended families, can the Ministry also consider family-friendly activities and networks which will be appealing to all ages, in order to target multi-generational involvement? One of the initiatives that has been announced include co-locating eldercare and childcare facilities in new Housing and Development Board (HDB) developments to maximise opportunities for interaction among the different generations.

Mdm Chair, it is important to promote good health in seniors so that they can enjoy and spend their longer years meaningfully. One of the initiatives of the Action Plan for Successful Ageing is the National Seniors' Health Programme. The programme will include healthy lifestyle campaigns, community activities and interventions for mature workers at workplaces.

I welcome these initiatives for I have encountered many elderly who may not know how to select nutritious food and do the appropriate physical activities to keep fit. Would the Ministry consider providing general guidelines, taking into account age bands, that show the recommended types of physical activities that a senior can do if he has certain medical conditions?

Teaching them, their family members and community volunteers to recognise signs of illnesses, including dementia, is also important as early detection and intervention will contribute to more effective treatment.

Would the Ministry share further details of the National Seniors' Health Programme to promote good health in seniors? What kind of interventions will be introduced at their workplaces? How does the Ministry plan to encourage more seniors to participate in such programmes and activities?

Madam, there is a concerted push for active ageing amongst our seniors in Singapore. One critical aspect that we must not neglect is the health of our seniors. Without health, our seniors cannot be active and lead a meaningful life. We must also ensure that seniors do not think that active living is only for the young and fit. That would undermine this important exercise. Therefore, I would like to ask the Minister to share and update what is his plan in promoting and supporting seniors to keep healthy.

I am heartened by the slew of pro-elderly measures introduced over the past years. These are needed to enable a graceful and meaningful retirement for all Singaporeans. But to achieve a truly caring society, we cannot rely only on the Government or a few charitable organisations. Every one of us has to do our part.

I see the Community Networks for Seniors being critical in this aspect, as they have the potential to ensure our seniors continue to be plugged in to social and support networks. It also ensures that the human touch will not be lost as we work towards more efficient eldercare and as we embrace greater use of technology.

I would like to ask the Ministry, firstly, how does the Ministry see the Community Networks for Seniors fit into the Action Plan for Successful Ageing?

Secondly, does the Ministry see scope within this initiative for the more abled seniors to be recruited to reach out to and help other seniors? I believe this is a very meaningful way of engaging seniors who are fit and keen to do something constructive in their retirement. This keeps them active. Moreover, seniors can also relate to seniors better, as they may share common challenges and language. Perhaps, this initiative can be akin to the Pioneer Generation Ambassador (PGA) programme in which volunteers are empowered through proper training and given a modest honorarium. Some of the PGAs in my constituency are Pioneers themselves and they take great pride in their work as ambassadors.

Thirdly, can the Community Networks for Seniors help to simplify the process of delivering assistance and care to our elderly, so that the elderly only need to approach one touch point? The coordinating nature of the Community Networks for Seniors can also ensure that resources and support are fairly distributed to all seniors.

Madam, our healthcare system has served Singaporeans well. The average lifespan of Singaporeans born in 2014 is now 82.8 years, 7.5 years longer than in 1990. Life expectancy in Singapore is among the highest in the world and our Health Adjusted Life Expectancy, which measures years lived with "full health", is among the top three globally. In short, Singaporeans can expect to live longer and healthier.

There are encouraging signs that more Singaporeans are choosing a healthier lifestyle. The proportion of adult smokers fell from 18.3% to 13.3% over the last 20 years. We are also choosing healthier foods. Today, more than a quarter of Singaporeans consume at least one serving of wholegrain products per day, more than three times the rate in 2004. But the picture is not all rosy. There are some worrying trends which I will elaborate later.

But, first, let me give an update on our Healthcare 2020 Master Plan.

First, on accessibility. Over the last five years, MOH has expanded our capacity in all sectors. In 2015 alone, we opened three new acute and community hospitals progressively and added over 900 beds − Ng Teng Fong General Hospital and Jurong Community Hospital in the West, and Yishun Community Hospital in the North. The three hospitals will continue their ramp-up this year and are expected to bring online another 270 beds.

Mr Low Thia Khiang asked about wait times for our Specialist Outpatient Clinics (SOCs). From 2013 to 2015, SOC attendances increased by 5%, largely due to the increase in subsidised attendances by our seniors, which grew by 26%. These patients would have benefited from higher subsidies, especially for the Pioneer Generation (PG). During the same period, private SOC attendances actually fell by 5.3%.

Despite the increasing workload, the median wait times for subsidised new appointments remained fairly constant, at about 29 days over the past three years, while the 95th percentile wait times increased from 110 to 125 days. For private patients, median wait times stayed about the same at eight days, while the 95th percentile wait times also increased, from 47 to 58 days.

Nevertheless, we have made improvements in the 50th percentile and 95th percentile wait times for specialties, such as Rheumatology and Immunology, Gastroenterology, Ophthalmology and Neurology, despite increasing attendances at these SOCs.

SOC wait times vary across hospitals. At Alexandra Hospital, for example, the overall median wait time is less than a week and, at the 95th percentile, 12 days. So, patients who need an earlier appointment can ask their doctor to refer them to hospitals with a shorter wait time.

For patients with more serious and time-sensitive conditions, our hospitals and polyclinics have protocols in place to arrange for faster appointments at our SOCs. For example, the median wait time for new subsidised appointments for urgent cardiac conditions and suspected cancers was around one week. In fact, for cardiology and cardiothoracic surgery, the median wait time has improved from 14 days to six days.

We have been managing the wait times for our SOCs in three ways. First, we optimise the SOC appointment system to give priority to urgent cases. We also reduce "no-shows" by reminding our patients of their appointments via messages. Second, we are working with polyclinics and general practitioners (GPs) to ensure that only patients who need a specialist's care are referred to our SOCs and, for patients who have recovered and are well, to help them transition back to primary care. Third, we have added new SOC capacity through developments, such as the Nnational University Hospital (NUH) Medical Centre, National Heart Centre and Ng Teng Fong General Hospital.

Mr Low Thia Khiang cited the case of a patient experiencing a long wait for an appointment and biopsy results. I would like to explain that the usual turnaround time for laboratory biopsy results is around three days. So, I would be happy to look into the circumstances of the specific case if Mr Low can provide the details.

Mr Low also asked about the time taken for computed tomography (CT) scans. For the first quarter of 2016, the median wait time for a routine subsidised outpatient CT scan was between one and three weeks for most hospitals and has remained stable over the past three years. I should explain that the timing of the CT scans may also be a result of scheduling to coincide with the reviews by doctors. For conditions that require urgent scans, hospitals are able to fast-track these cases, whether in the wards, in the SOCs or at the accident and emergency (A&E), on the same day or the following day.

Other than hospital capacity, we have also added about 1,200 nursing home beds and 60% more home-care, day care and home palliative care places between 2011 and 2015.

Looking forward to 2020, we are on track to add more than 6,600 places in community care, home-care and palliative care, as well as 7,900 beds in acute hospitals, community hospitals and nursing homes.

Mr Leon Perera asked about wait times at our polyclinics. Polyclinic attendances have been growing over the years, from 4.5 million attendances in 2011 to 4.9 million in 2015. Median consultation wait times have improved from 32 minutes in 2011 to around 14 minutes in 2015. Mr Perera is correct that wait times for patients with appointments is, indeed, lower than wait times for walk-in patients. Over the past few years, polyclinics have been encouraging more patients to use the appointment system. Currently, all patients with chronic conditions, many of whom are elderly, are offered appointments for their next chronic visit. In 2015, 70% of these chronic patients visited the polyclinics by appointments. We will continue to help more patients use the appointment system.

In the meantime, we are adding capacity and improving processes to meet the primary care needs of our population. The last four years, we redeveloped the Geylang and Tampines Polyclinics and have just completed an expansion of Marine Parade Polyclinic. Currently, we are redeveloping Bedok, Ang Mo Kio and Yishun Polyclinics and are on track to open new polyclinics in Jurong West, Punggol and Bukit Panjang, and a new primary care facility in Sembawang by 2020.

Madam, many Singaporeans choose to visit polyclinics, instead of private GPs, because of the significantly lower costs at polyclinics as a result of Government subsidies. Lower and middle income patients and all PG patients now have an alternative as they can tap on the PG package and the Community Health Assist Scheme (CHAS) to enjoy subsidised primary care at private GP clinics instead.

Madam, our healthcare professionals are at the heart of delivering quality patient care. To meet the increasing healthcare demand, we have grown the healthcare professional workforce of doctors, nurses, pharmacists and allied health professionals by 24% from 46,000 to 57,000 between 2011 and 2015.

We have also made significant moves in addressing Singaporeans' concerns over affordability. In 2014, we launched the PG Package which provided 450,000 Singaporeans with more help with their healthcare costs.

For lower- to middle-income Singaporeans, we have raised the subsidies for outpatient drugs and specialist care. As of December 2015, 715,000 Singaporeans have benefited from these enhanced subsidies.

With CHAS, I spoke about this just now, about 1.4 million Singaporeans, including Pioneers, are able to benefit from Government subsidies at participating GPs and dentists close to their homes. Since 2012, we have more than doubled the number of participating clinics to 1,500.

We have introduced more flexibility in the use of MediSave to help Singaporeans with their healthcare costs. Today, Singaporeans can also use up to $400 per MediSave account per year to pay for their outpatient chronic disease management.

Last November, we introduced MediShield Life to provide better protection for all, for life. To date, many Singaporeans have benefited from MediShield Life. Take, for example Mdm Sung, a Pioneer living in Ang Mo Kio. Late last November, Mdm Sung had a stroke and her family brought her to Tan Tock Seng Hospital where she was warded for 11 days. She continued her rehabilitation and recovery for eight days at the Ang Mo Kio Thye Hwa Kwan Community Hospital near her home.

The total bill for the stay came up to $16,900 and, after subsidies, Mdm Sung needed to pay $6,400. Before MediShield Life, Mdm Sung, who was uninsured, would have had to pay the full $6,400, but with MediShield Life coverage, she only had to pay about $3,300, close to half the original bill. And all of this was paid through her MediSave.

Today, Mdm Sung is back to living with her son and his family. She has four children, 10 grandchildren and six great grandchildren – a great example for our population strategy. A few weeks ago, the whole family came together to celebrate her 85th birthday. We wish Mdm Sung and her family the best of health.

Overall, from last December to February this year, MediShield Life approved about $136 million for 95,000 claims, or about $45.3 million per month. This is a 29% increase, compared to the average monthly claim for MediShield in 2015. MediShield Life, together with Government subsidies, MediSave and MediFund, will continue to help many Singaporeans like Mdm Sung and low-wage workers mentioned by Nominated Member Thanaletchimi in her Budget speech earlier, giving them greater peace of mind that their medical treatment will be affordable.

Ms Sylvia Lim asked about the coverage for overseas Singaporeans. MediShield Life was introduced to give all Singapore Citizens and Permanent Residents assurance of universal healthcare coverage, regardless of their health condition, situation and background. MOH is aware that Singaporeans based overseas are concerned that MediShield Life coverage is mandatory. We recognise that the overseas Singaporean community is diverse and individual circumstances vary considerably.

The MediShield Life Council will conduct targeted engagements with overseas Singaporeans as part of their MediShield Life coverage review, while bearing in mind the principle of universal coverage.

Madam, the report on the Action Plan for Successful Ageing released in February outlined our strategy to develop a senior-friendly nation and a caring community.

The effort to pilot Community Networks for Seniors announced by the Minister for Finance earlier, is a whole-of-Government approach to "close the last mile" in supporting successful ageing for seniors in our community. As highlighted by Assoc Prof Fatimah Lateef and Ms Tin Pei Ling, this pilot is not about introducing another new service for seniors in the community, but an effort to strengthen partnership and coordination among key stakeholders, such as agencies and community organisations, so that we can work together, as a team, to better meet the needs of our seniors and build a stronger community for our seniors to age in place.

We have studied the system in other countries. Many developed countries with ageing populations are facing similar challenges as us. One important lesson we can learn from them is that doing more of the same cannot be the solution. We need a paradigm shift in our approach to ageing and health.

Singapore can and must be different. It will take time, but we must start now. We must make good use of the next few years to plan ahead and design a system that meets our growing needs in a cost-effective and sustainable manner beyond 2020. We can do so, with three paradigm shifts: first, to move beyond the hospital to the community; second, to move beyond quality to value; and third, to move beyond healthcare to health. Let me elaborate.

Beyond hospital-centric to community-based care, we are transforming our healthcare delivery system from one that is built around the hospital, to one that is directed at meeting the needs of Singaporeans. We will make it easier for patients to access appropriate care, help them recover faster and enhance health outcomes while keeping costs affordable and sustainable. To do this, we need to reshape our health delivery system.

The first aspect in reshaping our system is to link up care through the Regional Health System (RHS). Over the last few years, we have done this by building up the primary, intermediate, long-term and home-care sectors, and the networks between hospitals and these care partners. These have helped to streamline processes, enable shorter hospital stays and support faster recovery for patients. We will need to further strengthen the integration of RHS.

An example of this is to develop structured care pathways to better care for patients across settings. Let me illustrate. The Eastern Health Alliance RHS has introduced an integrated care pathway for patients with hip fracture, across providers. Patients who have sustained hip fractures are quickly identified and put on the hip fracture pathway. The pathway organises the different care providers in the RHS into a coherent workflow to efficiently care for the patients, allowing for a more timely surgery, shorter acute hospital stays, and faster transition to rehabilitation at St Andrew's Community Hospital next door. This is crucial, as starting the rehabilitation process early leads to better mobility outcomes. Upon discharge, patients attend day rehabilitation near their homes, as needed, to optimise their functional outcomes.

Such pathways require various partners in the RHS, and sometimes among RHSes, to work closely to deliver seamless care to patients, for better outcomes.

Our vision of "One Singaporean, One Family Doctor" remains relevant. We want to transform primary care to be the first and continuous line of care so that Singaporeans can access good quality care in the community. As Dr Chia Shi-Lu pointed out, the key is to build a trusted relationship between GPs and Singaporeans, so that your family doctor has a deeper understanding of you and your family's health needs and can, therefore, provide better guidance and more appropriate treatment when needed. Minister of State Lam Pin Min will elaborate on how we are strengthening the primary care sector later on.

As we reshape our health delivery system and move beyond the hospital to the community, we need to make similar shifts in how we develop and deploy our healthcare workforce. Our healthcare workforce must be future-ready, so that healthcare professionals can continue to enjoy fulfilling careers and can readily acquire new skills and capabilities. Senior Minister of State Amy Khor will talk about how we are creating good healthcare jobs for Singaporeans and fostering industry-relevant skills through the national SkillsFuture framework.

MOH, together with our public healthcare institutions, will be looking into job redesign and the use of technology to not just simplify the work for our healthcare teams, but to also work in a different way to deliver care to our patients. Minister of State Chee Hong Tat will share how productivity and innovation can support our healthcare workers and improve patient care.

Dr Chia Shi-Lu said we must care for Singaporeans from birth to death, and I agree. The issue of death is a sensitive one, especially in our "pantang" Asian society. These are difficult conversations which we must have, not just among family members, but also at the national level, that is, if we want our loved ones and family members to have dignity, comfort and peace of mind as they walk through their last journey. This requires a whole-of-society approach and we are encouraged to see organisations, such as the Lien Foundation, raise these topics at the national level.

Through the Agency for Integrated Care (AIC), we have also been working with our hospitals and community partners to raise the awareness of Advance Care Planning (ACP). ACP allows individuals and their families to better understand their preferences towards the end of life and to fulfil their wishes.

Take, for example, the late Mr Phang who was admitted to Dover Park Hospice after being diagnosed with terminal cancer. Through ACP, the hospice staff were able to establish that his preference was to pass on at home, so that he was able to spend his last days in a familiar environment, together with his wife. This was a great source of comfort to his wife. She was grateful to the hospice staff for establishing his end-of-life wishes.

Madam, we need to continue this conversation. Minister of State Chee Hong Tat will be elaborating on further enhancements we are making in palliative care.

As we transform our healthcare system, we have to be mindful of the long-term implications on sustainability. Our healthcare budget has more than doubled from $4.7 billion in financial year (FY) 2012 to $11 billion this year. This has come about partly because of ageing and the need to invest in infrastructure, but also because of the Government's policy shift to take on a greater proportion of healthcare costs.

The current challenging economic outlook is a timely reminder of the need to ensure sustainability, not just for ourselves but for future generations. Therefore, we need to choose care that is appropriate to needs, so that we can make the best use of our limited resources.

It is for this reason that we have a co-payment feature throughout our healthcare system. For example, MediShield Life has co-payment features like claim limits, deductibles and co-insurance to help guard against over-consumption or over-provision of services. However, many Singaporeans have private Integrated Shield Plans that are "as charged", which means they have no claim limits, and some buy extra riders to cover the deductibles and co-insurance.

Such features could lead to a "buffet syndrome" since all the cost will be paid for by third parties, by someone else. This contributes to rising healthcare costs for everyone and eventually pushes up premiums. We will need to study this carefully to ensure sustainability.

Emerging healthcare technologies are becoming increasingly expensive and we need to ensure that the outcomes derived from these technologies are commensurate with the costs. As part of the "Choosing Wisely" campaign, medical bodies in the United States (US), Canada, the United Kingdom (UK), Australia and Japan have identified 400 areas of unnecessary or low value tests and treatments.

We, too, have recently set up the Agency for Care Effectiveness (ACE) to expand our capacity in evaluating the clinical and cost effectiveness of health technologies. ACE will look into high-cost treatments and technologies, systematically evaluate and develop guidance to guide the proper use of such treatments and technology, and encourage providers to manage costs while providing quality care.

This will help patients, care-givers and physicians to make more informed decisions on treatment and avoid over-provision of services that will eventually drive up costs.

As we move beyond hospitals to the community and beyond quality to value, we also have to move beyond delivering healthcare and focus on providing good health to nurture a healthy nation and a healthy people. To do this, we need to arrest the causes of ill health early and reduce the progression of long-term chronic diseases.

While the Health Adjusted Life Expectancy has improved over the years, as I mentioned earlier, Singaporeans are also living with ill health longer – one-and-a-half years longer than in 1990. We have observed several worrying trends in recent years. Decreasing activity across all age groups and the increasing consumption of excessive calories and fat leading to a rising obesity rate. Obesity is the major risk factor for chronic diseases, such as Type 2 diabetes.

As noted by Dr Lily Neo and Dr Chia Shi-Lu, diabetes is, indeed, fast becoming a major global healthcare concern. The World Health Organization (WHO) recently announced that the global number of adults living with diabetes has quadrupled since 1980 to over 400 million in 2014; and of this 400 million, over 400,000 are in Singapore – they are Singaporeans. Among Singaporeans, about 400,000 have diabetes, and one in three Singaporeans has a lifetime risk to develop diabetes; 30% lifetime risk.

What is one in three? When I sat in my seat, I looked to my left and I looked to my right. On my left is Mr Lim Swee Say and on my right is Ms Grace Fu. I looked at Mr Lim. I asked him yesterday, "Do you have diabetes?" He proudly declared, "No". So, I turned to Ms Grace Fu. I was too polite to ask her, but she does not look like she has diabetes. That is the good news. The bad news is: one in three means I have the highest risk of getting diabetes. [Laughter.] That is one in three.

But the good news is: we can change. We do not have to accept it and we can reduce the risk. Of those who have diabetes, one in three Singaporeans has not been diagnosed. And among those diagnosed, one in three has poor control of their condition.

The following images on-screen may be graphic but they are examples of what some Singaporeans endure daily. Left undetected, untreated or poorly managed, diabetes can lead to heart disease, stroke, kidney failure, blindness and amputations. In fact, four Singaporeans a day lose a limb or appendage due to diabetic-related complications. These complications reduce the quality of life for the patient and increase the burden on the individual, families and society as a whole.

A Saw Swee Hock School of Public Health study estimated the total economic burden of diabetes for working-age adults at more than $1 billion a year. However, the long-term cost of diabetes, taking into account the psycho-social burden, is far more than this.

We need to tackle the diabetes challenge. Therefore, I am declaring War on Diabetes. We want to help Singaporeans live lives free from diabetes, and for those with the disease, to help them control their condition to prevent deterioration.

This is a multi-year effort. We will engage stakeholders and develop detailed action plans together, but let me outline our broad strategy.

First, we will work on upstream prevention to promote a healthy lifestyle and reduce obesity rates in order to cut down on new diabetes cases. Broadly, we are doing this by ramping up our health promotion efforts through a twin food-and-exercise strategy. We will improve the dietary quality in schools, communities and workplaces, and learn from successful international regulatory strategies.

To encourage more people to exercise, we will expand ongoing programmes, such as the National Steps Challenge and Sundays@The Park, as well as introduce new programmes and bring them to schools, workplaces and our community. The risk of developing diabetes is 30% to 40% higher among active smokers than non-smokers, and we will be doing more to curb smoking rates as part of this plan.

Healthy habits start young. Minister of State Lam Pin Min will be leading our efforts in developing the NurtureSG Plan to tackle many of the preventable risk factors for our youths. We will be working closely with the Ministry of Education (MOE) to develop and implement this plan.

Second, we will strengthen early screening and intervention to identify the disease early, especially those at risk. Screening plays an important role in our war by picking up cases earlier, starting interventions and, thus, reducing the likelihood of the gory images I showed you previously. This is like intelligence in warfare. But, follow-up after screening is equally important.

We hope that earlier intervention and basic lifestyle changes can even reverse the pre-diabetes state and get such individuals back to health.

In a US study published in the New England Journal of Medicine, pre-diabetics can reduce the overall incidence of diabetes by 58% through diet, exercise and behaviour modification. That is why I said we still have hope. These lifestyle changes worked particularly well for participants aged 60 and older, reducing their risk by up to 71%. So, you are never too old to make lifestyle changes and take back your health.

Third, we will support better disease control to slow disease progression and reduce complications. For those with diabetes, we need to do our best to help them have a good quality of life, at all stages, by having good control over their disease. This can help to reduce or delay complications and give patients better quality of life. Madam, let me speak in Mandarin.

(In Mandarin): [Please refer to Vernacular Speech.] This year, we are going to declare war on diabetes. Many of my colleagues asked me, "Why so serious? Why do you want to say, 'declare war'? Why so aggressive?"

Diabetes is a problem that is getting more serious by the day. Our Singaporeans have a one-third possibility of contracting diabetes during their lifetime. The possibility of them contracting diabetes as they grow older also increases. And it is not just them who suffer. Their families and relatives will also suffer. Therefore, we have no choice but to mobilise the entire population to declare war on diabetes. We should not just talk. We should also, each of us, play a part by eating responsibly and exercising and ensuring our own health. At the same time, we also need to do intervention earlier and do screening much earlier. Together, we can also seek help if we need to. Together, nationwide, we can have a healthier lifestyle.

(In English): The key to winning the war on diabetes is for all Singaporeans to be engaged in the battle. The key partners in this war are the individuals, his family and the community. By working together, we hope to create an environment that makes healthy choices easy, but Singaporeans also need to play their part by eating healthily, exercising often and going for the recommended screenings and follow-ups. We can also play a part in encouraging and helping others to do so. We will be increasing public awareness about diabetes and empowering individuals to take control of their health.

To coordinate the strategies on the war on diabetes, I will be co-chairing a Diabetes Prevention and Care Taskforce together with Mr Ng Chee Meng, Acting Minister for Education. The task force will include representatives from Government agencies, private sector, patient advocacy and caregiver groups and will: (a) develop and implement a multi-year action plan for the war on diabetes; (b) reach out and mobilise the nation to fight the disease together; and (c) monitor and evaluate the outcomes of our efforts.

The war on diabetes will not be a quick battle, but a long war requiring sustained efforts. Results of our efforts can only be seen in the long term, but we must persevere. And if we succeed in shifting mindsets and changing habits, we will be able to curb not just diabetes but other related chronic diseases, such as heart disease, as well. And we will improve the lives of Singaporeans and reduce the burden on their families.

Madam, health is, ultimately, a personal responsibility. All Singaporeans need to play an active role in their health journey and in the war on diabetes. We all need to make sensible lifestyle choices and informed decisions in our health. The Government will do its part to provide a supportive environment, but we cannot do this alone. If we are able to do this together, we will achieve better health, better care and a better life for all Singaporeans.

Mental health is very much an integral part of general health. Good or normal mental health is a state of well-being in which the individual, amongst other things, can realise his or her own abilities, can cope with the normal stresses of life, can work productively and is able to function normally in the community.

May I beseech MOH to review mental healthcare and to improve it? This is especially urgent for community mental healthcare which is almost non-existent. There is a problem of undiagnosed and under-treated mental patients in the community. They tend to be more prevalent in lower-income households and they usually cannot cope with employment and cannot fit well in society. Those that suffer from substance abuse also have violent tendencies. As the majority of Singaporeans live in densely populated HDB estates, we must be cognisant of the harm that mental patients can bring not only to themselves and their family members but also to neighbours and people in the community. There are many types of mental disorders; from mild ones like anxiety, personality disorder and depression, to moderate ones like kleptomania or compulsive stealing, compulsive gambling and substance abuse, to other severe psychotic diseases. In general, mild cases have good prognosis if treated early.

Is it possible for MOH to maintain a staff of psychiatric nurse practitioners or psychologists at Social Service Offices (SSOs) to diagnose and refer undiagnosed mental patients for follow-up? Many such mental patients also need other social assistance and thus SSOs can facilitate that simultaneously.

I know that there is a Community Mental Health Team set up by the Institute of Mental Health (IMH) to provide psycho-social rehabilitation for people suffering from mental disorders in the community. However, the purpose of the team is to facilitate patients to be discharged from and not to be re-admitted to IMH. I am concerned in this respect, as there are already too many undiagnosed and untreated mental cases in the community. Will it be better for IMH to discharge such patients to community hospitals or psychiatric nursing homes instead? I really hope IMH is not so psyched up to prematurely discharge patients without considering the overall implications.

Non-compliance has been a problem, especially for mental patients, to the detriment of the patients themselves and the community. Will MOH consider an "outpatient commitment" law, similar to Kendras' Law in the US, where there is some restrictive form of commitment for a mentally ill individual, whereby the individual is free to live in the community, provided he is subject to close monitoring by a physician or agency?

Madam, I have been speaking up on mental healthcare issues in this Parliament for many years now. And I would say that Singapore has made progress in mental healthcare over the years; I have seen it. There is greater awareness, better intervention and more support. I would also say that few, if any, in our society would dispute the importance of ensuring mental wellness. However, there is still much that we can do. One critical obstacle to effective mental healthcare is the stigma faced by sufferers.

Stigma may be perpetuated by the lack of understanding and media portrayal, but also, by real day-to-day problems that are left unsolved. I have raised examples about this in my speech last year, so I will not touch on it again this year. Together, these threaten to deepen the prejudices that people have of those suffering from mental health issues. The animosity, in turn, makes it more difficult for those suffering from these conditions or even their family members to consider the issue and seek professional help.

Therefore, I would like to ask the Minister, looking ahead, what does the Ministry plan to do to de-stigmatise mental health? Meanwhile, efforts to strengthen community mental healthcare must not stop, so that those who need care will continue to get the care they need. Hence, I would also like to ask: one, whether there is any update on the Community Mental Health Masterplan; two, how are patients who have "graduated" from IMH reintegrated back into the community and workplace; and third, and lastly, some communities have implemented networks involving voluntary welfare organisations (VWOs), Government agencies and grassroots leaders. MacPherson, for instance, has a Community Mental Health Programme supported by AIC, IMH and the South East Community Development Council since 2012.

There has been some positive feedback. At the very least, amongst the volunteers and staff who have to frequently face residents, there is greater awareness of the signs and symptoms which aid early detection, greater appreciation of the challenges people with mental health issues face and greater sensitivity in how to engage them. I am wondering if there are plans to roll this out more extensively to more communities.

Madam, as our society ages, we have been paying close attention to our healthcare costs as an ageing population. It is also time for us to put more focus on mental health.

Mental illness, while perhaps less understood, is no less real than physical illness. There is also the stigma and lack of understanding which patients and their loved ones combat daily. Some studies estimate that one in six of our population would suffer from mental health issues at some stage of their lives.

Currently, our MediSave, MediShield and MediFund (or 3Ms) framework allows support for mental illnesses, but it is limited. For example, MediSave has a withdrawal limit of $150 per day for inpatient psychiatric treatment, with an annual cap of $5,000. Compare this with a daily limit of $450 for other patients who have been hospitalised.

For MediShield Life, the difference is even greater, with a daily coverage of $700 in a normal ward, but $100 for a psychiatric ward. Mental illness is as real and debilitating as other illnesses. Funding from the 3Ms and other insurance plans should be on par with coverage for other conditions. Companies, too, need to be encouraged to provide equal levels of support and coverage for employees who suffer from mental health issues.

Another equally important issue is how prepared is Singapore to deal with the rising numbers of patients with dementia. It was recently estimated that 10% of us aged above 60 suffer from dementia, with a rise in younger patients being diagnosed.

This may not always be classified as a mental or even physical illness, but the strain on our healthcare costs and infrastructure can be massive. Can the Minister give an update on what has been done in the last few years to ensure our care systems are able to deal with the future increase in the number of dementia sufferers and whether there are plans to expand pilot projects, such as "dementia-friendly" town?

Assoc Prof Fatimah Lateef: Madam, mental health is as important as physical health. As there is stigma, many are not coming forward to be diagnosed early enough or for follow-up regular treatments. Thus, it is important to have services and counselling in the community, in a less threatening environment, compared to being in an institution or a ward.

At Geylang Serai, I have got Silver Ribbon sited at my community club (CC) at My Wellness Centre and they do house visits and counselling at the CC as well as the residents' homes. Therefore, we need to have more such programmes. What we do at Geylang Serai is we create awareness of mental health problems. We give talks, organise mental wellness seminars, hold World Mental Health Day celebrations annually, launch suitable books and educational materials, mental health road shows and we even have a Geylang Serai Mental Wellness Taskforce operating for the last several years, comprising 10 partners from the relevant industry. Therefore, we hope that this model can be initiated and replicated elsewhere as well. This is under the initiative of WeCare@geylang Serai.

In fact, this year, we are actively involved in organising and partnering other agencies in The Asia Pacific Mental Health conference in October. My grassroots leaders (GRLs) will be sharing programmes, experiences and initiatives and we need such initiatives in the community. What are MOH's plans to strengthen community mental health support network and framework at the national level? Will we be seeing a new blueprint as well?

As we face the silver tsunami, the number of seniors who suffer from dementia is expected to rise. One in 10 people aged 60 and above, and half of those aged 85 and above have dementia. The number is projected to increase from 28,000 in 2012 to 80,000 in 2030.

What preventive measures can we introduce to the public so as to reduce or temper the expected surge in dementia cases? In Mandarin, please.

(In Mandarin): [Please refer to Vernacular Speech.] As we face the silver tsunami, the number of seniors who suffer from dementia is expected to rise. What preventive lifestyle changes can Singaporeans be encouraged to adopt to reduce the risk of getting dementia?

An MOH study shows that the risk of dementia is 25 times higher for housewives and retirees than the working people. This figure deserves our attention. Working and participating in community activities actively may help to slow down brain degeneration. Hence, we should encourage and help more housewives and retirees to stay active and healthy.

(In English): Would the Ministry share with us the latest initiatives for the early detection and treatment of dementia? Also, what is the Ministry's long-term plan to support persons with dementia who are living in the community? Research has shown that allowing them to age-in-place would be less costly to society.

Those who care for dementia sufferers are three times more distressed than other caregivers. Many have to stop work, which may put them in financial situation. What kinds of support schemes are there to help and relieve family caregivers?

Will MOH consider allowing standard health screening, including dementia screening, to be done at private GPs at subsidised rates?

Mdm Chair, with an ageing population, we will see more Singaporeans with dementia. Not all will need institutional care; many will still want to live in the community. We must find ways to help our senior Singaporeans with dementia, such as helping them to lead as normal a life as possible, reducing their risk of getting lost or confused during their daily activities, and ensuring they do not become socially isolated because ongoing mental stimulation is healthy for the ageing brain.

These issues will affect all our housing estates, especially mature estates, with many Pioneers, many senior citizens. Can MOH tell us what the Ministry is doing to support Singaporeans with dementia who are living in the community, as well as their caregivers and loved ones?

Mdm Chair, it is expected that the demand for palliative care at home will double by 2020 to more than 10,000 patients. However, some reports suggest that the current supply of nurses providing home-based care may not be sufficient to meet the expected increase in demand. Several providers of home nursing care are employing foreign nurses on foreign domestic Work Permits. This could compromise the quality and development of home-based care in Singapore. Furthermore, the 10,000 patients only refer to those needing palliative care.

I would like to raise two suggestions for the Ministry to consider in their efforts to expand home-based care service and raise standards.

First, there were over 5,700 registered and enrolled nurses who were not active in 2014, comprising over 15% of the total number of nurses. This is an existing pool of qualified nurses that can be tapped on if appropriate flexibility, allowances and incentives are given to encourage them to provide home-based healthcare within their neighbourhoods and communities.

I ask the Ministry to consider developing a community nursing core to attract retired, inactive or underemployed nurses to return to active nursing and to cater to existing active nurses who need job flexibility due to family or other reasons, so that they do not leave active nursing. These nurses can be provided with the right training to become professional community nurses attached to hospitals to provide home-based care.

Second, will the Ministry consider developing a comprehensive Hospital and Home Programme modelled on the programme in Australia? Under the Hospital and Home Programme, hospitals will provide inpatient treatment for acute care patients whose conditions allow them to receive treatment in their own homes. This is not limited to seniors or the terminally ill. The community nurses could then act as key care providers, conducting medical check-ups and providing portable medical services to the home-based patients. The community nurses could also make use of telehealth technology to engage in non-site consultations with hospital-based doctors in the homes of the patients.

Madam, as a developed nation, with the challenge of a rapidly ageing population and also a longer lifespan, which means longer duration of chronic illnesses and thus, more potential complications, the need for homes, day care and rehabilitation centres will continue to increase.

For specific problems, specific services will be required, for example, day care rehabilitation, physiotherapy, speech therapy, nursing care and even for mental diseases and dementia as well as mood management services.

How is MOH planning to ramp up some of these services, which means not just the infrastructure but also the needed manpower and trained personnel? For those with significant physical disability and mental health issues, their families need to make arrangements for their care, as the former would have to go out to work. With the call for a later retirement age and also more active employment for our seniors and women, therefore, more day care facilities will be required in the future.

With these centres, we will also have to ensure that care standards are met and the ratio of patient-to-caregiver is acceptable. Here is where I would like to suggest that perhaps we seek and tap on the retired nursing pool as well as train active retirees so that they can help to contribute a few hours a day at least to this required pool.

Mdm Chair, as our seniors grow frail, they develop multiple health problems and will need varying care needs and repeated visits to various medical specialists and therapists. This can be very tiring for them as well as for their caregivers. It is important that they have access to integrated and holistic care so that they will not end up shuttling from one place to another. What are the Ministry's plans to enable senior-centric care to take place?

An example of an ideal situation would be like this. A senior goes to an SAC daily to take part in activities, socialise and exercise. The staff at the centre are familiar with his general health conditions and problems, and assist him to take his medications. When the elderly exhibits certain health symptoms, they are able to take note and alert his family members or, if he lives alone, to refer him to the appropriate agencies.

When he goes for his medical appointments, the tests and treatments are preferably arranged on the same trip to minimise travelling. In addition, when he needs to move around different departments within the hospital, there will be volunteer guides to help him, especially for an elderly who can only communicate in his vernacular language.

When he grows more frail and has to stay at home, he or his family will be able to get assistance from day/night nurses or part-time care-givers at affordable rates.

With reference to this scenario, I would like to ask the Minister and the Ministry if we will have enough eldercare centres, step-down community hospitals and hospices to cope with an increasing number of seniors. How will we recruit, train and retain enough volunteer carers, volunteer guides, nurses, nursing assistants, professional caregivers and therapists? What kind of support or resources can we provide their families and caregivers, especially if they have long-term patients, to take care of challenges like dementia or depression?

Madam, with an ageing population, demand for eldercare services and facilities will increase as well. Also, the incidence of dementia will rise, too, making care for our elderly even more challenging as this requires certain care specialisation and adjustments in the communities.

Hence, could the Ministry share the projected demand for eldercare services and facilities, such as day rehabilitation centres, dementia day care centres and home-care? What is the Ministry's plan in meeting this demand? What are the constraints or challenges anticipated, if any?

Also, are there lessons that we can draw from countries more experienced in caring for the aged? For instance, Japan is the world's fastest ageing society and it was said that the "epidemic of dementia" had already arrived. Given that it had to address this challenge much earlier, what can we learn from Japan about the needs of our old, especially those with dementia, and what can we do to address these needs?

With an ageing population, demand for palliative care will be expanding. I would like to declare that my daughter is a palliative care doctor with HCA Hospice Care.

Many terminally ill patients prefer to be at home with their family members and staying in their familiar surroundings in their final days. They feel more comfortable compared to being hospitalised. But for hospice care at home, cost is always an issue, besides other factors. Many families are apprehensive about how to cope with their terminally ill family members even though they want to fulfil the final wishes of their loved ones. Thus, they may be more prepared to do so, if they can get more support on hospice care at home.

This is also right siting, compared to occupancy of acute hospital beds by such patients. Thus, could MOH review the subsidies for hospice care? Could MOH expand palliative care with more personnel and facilities? These terminally ill patients need home visits by palliative care doctors to control symptoms, such as pain. They need social workers to support the psycho-social needs of patients and their family members as well as recognising and facilitating the final wishes of the patients. Many patients and their family members also need counselling. The purpose of palliative care is to make life more comfortable for these patients by adding life to their days.

There is an urgent need to expand the number of palliative care doctors, nurses and social workers, as the shortage now will be even more pronounced in years to come with our ageing population. Presently, not many doctors and nurses are interested in palliative care. Increasing numbers of terminally ill patients will also impose an increasing demand on palliative care in-patient beds and services. Hence, we need an expansion in these facilities as well.

Palliative care can be costly and it may be a strain for many patients. Therefore, I urge MOH to consider ways to reduce the burden of patients of hospice care.

Madam, inpatient hospices and palliative care facilities charge patients on a day-by-day basis, and it has been estimated that a month's stay at a hospice will cost about $7,000 before means testing. I understand that patients whose families have a per capita monthly household income of $2,601 and above will not receive any subsidies for inpatient hospice care.

With one in four Singaporeans estimated to be over 60 by 2030, the demand for such specialised care will increase. The additional factors of increases in healthcare material costs and remuneration for healthcare workers will also drive up the costs of hospice and palliative care.

I would like to know what the average length of stay in a hospice was from 2012 to 2015. How many people have benefited so far from the last increase in the income ceiling? And how many have written in to appeal for subsidies for the high costs of inpatient charges at the hospices? In light of the gradual increase in gross monthly income and the increase in cost of living, I would like to know if the Ministry is considering raising the income ceiling so as to allow more families to benefit.

I would also like to propose that ElderShield be extended for the use of hospice and palliative care. A thorough review of the ElderShield scheme is long overdue and it is perhaps the right time for the Ministry to not only include hospice and palliative care under the scheme, but to also review the adequacy of the subsidies and payout period of the ElderShield scheme.

I declare my interest as an educator in empathy awareness. According to the 2015 Quality of Death Index, Singapore is the 12th best place in the world to die. Benchmarked against 80 countries, we are sixth in the affordability of care, eighth in the quality of care, and our weakest score was in community engagement at 22nd.

By 2020, more than 10,000 people a year here are expected to need palliative care. Yet, a 2014 survey by Lien Foundation showed that two in three Singaporeans still do not even understand what palliative care is. Only about 20% to 30% of those who pass away each year use palliative care services when research shows that up to 70% to 80% of all deaths might have actually benefited from such care. This lack of public awareness and hospice referral is partly because our doctors and nurses struggle with handling death. A Lien Foundation survey showed that six in 10 doctors and four in 10 nurses said their basic training did not prepare them to handle patients with life-threatening illnesses.

I can testify to what it is like to encounter such a statistic in real life. A junior doctor that attended to my father in a hospital here exhibited zero empathy in the way he broke the news to us that my dad had terminal cancer. This highly educated, articulate young man told us, "Here is the result, it is not good. You know what that means? You know, right? You know? You know?" I am not kidding. Even when we broke down in front of him, he was completely blank and indifferent, and that is very disturbing to me.

Thankfully, the rest of the doctors I encountered on the journey were much more sensitive. My dad passed away in a hospice and it was a very gentle place for him to die, thanks to the staff there. So, I am deeply grateful to every Singaporean who is involved in palliative care. It is an incredible gift to the dying, as well as the living. My experience made me wish that more families here could experience the mercy of a good death.

So, I have just two simple requests: one, keep up the good work of making palliative care even more accessible and affordable; two, make socio-emotional awareness a core component of training for all healthcare professionals. Training our next generation of doctors and nurses in the art of navigating complex human conversations with humility and kindness should not be treated as less important than technical training.

Madam, innovation is not just about investment in expensive technologies, data and subsidies. Those are necessary. But sometimes, innovation can also be found in simply going back to mastery of the basics. In the case of healthcare, it is the art of treating people beyond the science of treating disease.

Renowned surgeon, Dr Atul Gawande, contends in his ground-breaking book "Being Mortal" that courageous doctors who help patients explore these three questions achieve far better outcomes for end-of-life care. One, what is more important to you than living longer? Two, what are you scared of? And three, what are you willing to give up to get the life you want in the time you have left?

Madam, many of our young doctors and nurses today will get the extraordinary power to write something in the last chapters of our own lives. May we give them the ability to write something that is worth remembering?

Second, support for caregivers. Much has already been said by other Members of this House before about legislating caregiver leave and giving financial support, so I will not dwell on that but focus on issues of emotional and psychological support. Navigating a fragmented landscape of caregivers' subsidies and services can be frustrating and intimidating to an average Singaporean, let alone one who is already acutely stressed by caregiving or limited in their English language proficiency.

Currently, AIC plays intermediary between caregiving bodies and care receivers. Could AIC consider having a team of AIC coordinators who can journey with our caregivers, especially those from the lower-income bracket, from start to end? These coordinators can serve on two fronts.

First, making sense of the system. Caregivers need practical help to figure out where to start and how to end. Just trying to make sense of the system might compound the emotional stress they are already under. Frustrated caregivers might not have time or space to explore their options objectively. When they randomly cobble together their own solutions, they end up providing haphazard and even inappropriate care for their own loved ones. So, they do need someone experienced in the system to come alongside, help them coordinate their piecemeal needs to ensure the full range of needs of both caregiver and care receiver are adequately met.

Also, though there is a good range of formal care services already being offered in the landscape, from home therapy to adult day care, a Ministry of Social and Family Development (MSF) survey of 20,000 caregivers shows that usage of these services is surprisingly still very low. The coordinators' intervention can not only help to increase the take-up rates, it can also investigate the real reasons why utilisation remains low in the first place.

Second, monitoring psychological well-being. The Organisation of Economic Cooperation and Development (OECD) 2011 report found that long-term caregivers were 20% more likely than non-caregivers to suffer mental illness. That same MSF survey discovered that spousal caregivers and caregivers of lower socio-economic status are more likely to be badly impacted by caregiving. Under siege, these caregivers may slip into depression or even some form of extreme behaviour like abuse of patient or abuse of self.

An AIC coordinator can spot early signs of caregiver mental or physical breakdown and provide timely intervention. If we believe family should be the first line of support, we must keep finding ways to better support the very people trying their utmost to live out that value, especially those who are far less financially privileged than us.

Mdm Chair, I declare my interest as the President of the Healthcare Services Employees' Union. I would like to touch on the topic of progressive wage and career model.

In 2012, the National Nursing Taskforce (NNT) was set up by MOH to look into strengthening the development of the nursing profession to better meet the population's healthcare needs. This helped to push for better career progression for the nurses and helped overcome many issues. We acknowledge that the review of non-nursing staff group, Admin, Ancillary and Allied Health, is currently ongoing at the various cluster levels and would like MOH to play a larger role in the coordination and implementation of Progressive Wage/Career Model for the Admin, Ancillary and Allied Health Workers across the healthcare clusters in the public healthcare sector.

On the jobs of the future and being future-ready, as our economy transforms itself against the cyclical headwinds and structural changes, jobs need to be redesigned and keep pace with technology. The questions I have are: what are the jobs that will be at risk in the healthcare sector as a result of automation, robotisation and job redesign? How can we better manage the foreseeable challenges to protect the interest of workers who will be affected? What kind of programmes will be rolled out to assist affected workers to transit to other roles within and outside the industry? What measures are taken and which policies are refined to attract more Singaporeans to work in the Intermediate Long-term Care (ILTC) sector?

In order to raise the overall standards of the healthcare industry, there is a need to refresh and refine the industry as a whole. As our healthcare model evolves, the ILTC services will play a larger role. Hence, there is a need to make sure that this sector's services step up, transform and grow so that the standards of healthcare can also improve dramatically over a short period of time.

Through our interactions with healthcare workers in the ILTC sector, we know that there are locals who have switched careers to the ILTC sector and found meaning in their work. However, as their income and career pathways are not as clearly defined compared to those in the mainstream hospitals, some have struggled to sustain with these incomes and eventually left the industry. I would like to urge MOH to support the aspirations of our locals who want to carve a meaningful career in the growing industry by enhancing their skills and career progression pathways and providing wage support.

From my involvement in the Healthcare Cluster Tripartite Workgroup, I have seen how collaboration on productivity improvement projects has brought benefits to the hospitals, employees and patients. I believe that closer collaboration amongst the ILTC organisations, MOH and healthcare union will help raise the level of ILTC industry practices and bring benefits to patients, too.

I would like to call upon the industry to consider forming an association for ILTCs to champion a progressive movement for ILTC organisations. Such an association will help foster an ecosystem for the ILTC community to thrive in and enhance the professionalism of healthcare workers. It will serve to provide a platform for industry players to network, share concerns and challenges, and allow them to collaborate with one another. As a start, MOH, through AIC, could provide manpower and resource support to speed up its formation.

Madam, on flexible work arrangements (FWAs) in public healthcare. To promote FWAs, the Government introduced the Work-Life Grant which provides funding and incentives for companies. As the demand for the healthcare sector rises, more needs to be done to encourage the public healthcare sector to make FWAs more pervasive across all institutions and all job types.

At the same time, there is a need to comply with the legislation and tripartite guidelines. We could share more stories and examples of staff who have successfully converted to FWAs. Increasingly, healthcare workers are facing more challenges to switch to FWAs due to higher expectations and demands at work. FWAs should be one that supports a pro-family environment and staff who decide to request for FWAs should also be accorded an equal level of recognition and opportunity for the work they produce. Whilst the need of the organisation needs to be fulfilled, many are struggling to cope with caring for their families. We need to help them so that they can continue to work and contribute meaningfully to care for our patients.

I would like to touch on the review of the MediSave withdrawal limit. The Chronic Disease Management Programme was first introduced in October 2006 to reduce out-of-pocket cash payment for outpatient bills. It now covers 19 disease conditions. I would like to propose a review of the current MediSave withdrawal limit, especially to help those below 65 years of age, in view of the high costs of medications for managing these chronic diseases. This is particularly critical for those who need advanced care and are treated with non-standard drugs.

During this volatile economic period, many of the mature workers are concerned about the uncertainty of their continuous employment and therefore the fear of losing their employers' medical benefit. Alternatively, MOH could regularly review the list of non-standard drugs to standard drugs to bring down the costs of medication.

Long-term healthcare models in Nordic countries focus on home-care, rather than on hospital-based care for the sick elderly. With reference to this, I would like to ask the Minister if there are plans to study further on these models.

Madam, I know MOH is proactively looking at manpower ratios and numbers. We have also now got three medical schools, but the output of doctors will, of course, take time due to training duration. In the various sectors, such as acute and ILTC care, there is an ongoing demand for staffing. I would also go on to say that we have manpower deficits in many departments across many disciplines. Even with our residency programmes, aligning with the US' Accreditation Council for Graduate Medical Education (ACGME) guidelines, we do always have to grapple with explaining our heavy patient load to our site visitor every accreditation year.

Our doctor-to-patient ratio quoted seems to fall within the global range given, as in a previous response to our Parliamentary Questions. But when it comes to work on the shop floor, we are really, really, very busy and very heavily loaded. With the newer institutions being built and the opening of their doors, the manpower competition is from the same central pool and, thus, it is the same warm bodies that we are competing for.

And in healthcare, Madam, the words automation, value chain, productivity and quality will have to take a customised definition. What plans and framework does MOH have to handle this manpower situation?

Mdm Chair, I am glad with the clear intent in the 2020 Masterplan to strengthen the ILTC sector and, like many of the Members here, I would like to ask what measures the Ministry is considering to address the expanded manpower needs as this sector is particularly labour-intensive.

We all know that our nurses play an essential role in the ILTC sector and the National Nursing Taskforce's recommendations for the future of the nursing profession have already been accepted by the Ministry.

Would the Ministry share details about how it will provide our nurses with more career advancement opportunities, greater authority and autonomy, and implement flexible and part-time work arrangements? What can be done to improve their work conditions and remuneration? In addition, what will the Ministry do to protect our nurses from abuse from patients and their family members? This comes about because there was a worrying report in the Annals of the Academy of Medicine that estimated that about seven in 10 of our healthcare workers have suffered from such abuse.

Madam with an ageing population, demand for manpower in the ILTC sector will increase. However, the labour market is already tight across all industries and sectors. There is stiff competition for workers and control over foreign manpower will only get tighter. Moreover, even as we look to leverage technology more, the human touch cannot be replaced in delivering quality care.

Therefore, I would like to ask, firstly, what is the Ministry's plan in tackling the manpower challenges in the ILTC sector. Secondly, how has the response been in terms of attracting mid-career professionals? How does the Ministry intend to attract more? Would scholarships with bonds be helpful? Thirdly, will the Ministry consider requiring and assisting ILTC providers to redesign their processes and systems where necessary, so that more older or retired workers can join to supplement the manpower needs?

Thank you, Madam. I have the privilege of giving a response to Ms Joan Pereira and Ms Tin Pei Ling for their earlier cuts.

Mdm Chair, Ms Joan Pereira and Ms Tin Pei Ling asked how the Government would promote good health in seniors and how we plan to encourage more seniors to participate in these health programmes. Indeed, health promotion is a key plank of our active ageing initiatives under the Ministerial Committee on Ageing. This is because good health is the basic condition for successful ageing. We will expand our efforts to promote seniors' health both in the workplace and in the community.

Many of our seniors are still gainfully employed and this is a good thing. It is a good thing also in relation to mental health maintenance, as pointed out by many Members earlier. In order to further extend their longevity in the workforce, MOH and the Health Promotion Board (HPB) are bringing health screening and health education to the workplace and going "deeper" by customising the programmes for seniors working in different work environments.

HPB started with a programme at the taxi service centres for taxi drivers of the ComfortDelGro group in June 2014. HPB knows that taxi drivers are always on the road and, therefore, have very little time to attend health-related activities. By observing their schedule, HPB found that taxi drivers need to send in their taxis for servicing every month and the golden opportunity to reach out to taxi drivers is, therefore, during this time when their taxis are being serviced and the taxi drivers are waiting for the taxis to be serviced.

HPB brought health screening to the service centres and stationed health coaches there. Taxi drivers get to check in with the health coaches every month when they send their taxi for servicing. The health coaches will help the drivers understand their health screening results and customise a health action plan with specific health goals, working together with the taxi drivers.

The programme was extended subsequently to bus captains and it was customised to address other issues that are pertinent to bus captains, such as hydration, ergonomics and stress management. As the bus captains have even more challenging work schedules, HPB and the National Transport Workers' Union (NTWU) had to organise the health screening at bus depots very early in the morning with the active support of the Public Transport Operators, namely, SBS Transit and SMRT. I was there at one of these screenings, at 4.00 in the morning and I saw for myself the bus captains coming in, reporting for work. They were excited about getting screened so that they could know about their health status. After that, we followed up with a series of workshops and coaching at bus interchanges over a few months in order to improve their health outcomes.

This sustained effort paid off. Mdm Chair, I am pleased to share that in less than two years, some 15,000 mature workers in the transport, retail, cleaning and security sectors have participated in this series of workplace health programmes. More importantly, it is not only about activities, it is also about outcomes. The outcomes, in terms of their health screening results, have improved. Almost half of the bus captains with abnormal screening results initially showed at least one improvement, either in their blood pressure, blood glucose or cholesterol at their second health screening which was about eight months after the first one. And of these, about half achieved normal health status in all aspects of their health screening.

We are very encouraged that many of our mature workers have made a real transition into a healthier lifestyle. An example is Mr Loh Ah Tee. An SMRT bus captain who has been driving buses for the last 32 years, he took part in HPB's "Healthier Workers, Happier Workers" programme in June 2015. Following a first screening where he found out that he had borderline high blood pressure and a high body mass index (BMI), Mr Loh was followed up upon by his polyclinic doctor and he attended health coaching sessions at the bus interchange almost every month. From doing little exercise, he progressed to performing about 30 sit-ups and 40 push-ups every morning. Mr Loh and his wife have also made changes to their diet, swapping for wholemeal options and reducing their food intake. Over a period of eight months, Mr Loh has already lost 4.5 kilogrammes, which was a big step towards a healthier BMI. At the recent health screening in January 2016, Mr Loh's blood pressure returned to normal.

We will continue to customise workplace health programmes for mature workers in other sectors, such as healthcare, logistics and education. Our target is to reach out to 120,000 mature workers in seven sectors by 2025.

Next, about the efforts in the community. In the community, we are systematically promoting seniors' health education via the People's Association's (PA's) Wellness Programme. In particular, we want to multiply and expand the access to health education programmes by leveraging the PA's existing community and social nodes. We hope that more seniors will be encouraged to participate in preventive health and health education activities, if these are just a few steps from where they live. So, bring it closer, make it more convenient and, at the same, really urging our seniors to come and participate.

In several communities, we are bringing preventive health and seniors' health education right down to the Resident's Committee (RC) centres. For example, in Bedok, a "Wellness Time" has been set aside each week in each of the four RCs in Bedok. Seniors are invited to come to the RC regularly to take part in workshops run by community organisations on caregiving tips, mental wellness, preventive health and chronic disease management. This is the seniors' personal wellness time and they also build strong friendships and provide peer support to one another.

For example, Ms Celia Teo, a retired teacher who lives in Bedok, lives alone and often found herself staying at home feeling restless. Since starting to attend the Happy Kopitiam programme as part of the Sunflower RC's Wellness Time on Fridays, Ms Teo has gained a better understanding of various health-related topics, including dementia. She also says that she feels happier because she has something to look forward to every week at the RC, and the RC is close to her home.

Beyond physical health, cognitive activity and social interaction are also important for overall health and wellness amongst our seniors. In Tampines Central and several other locations, we have started a weekly news sharing programme done in collaboration with journalists from the Singapore Press Holdings. These journalists from Lianhe Zaobao and Lianhe Wanbao volunteer their time to drop by the Neighbours' Hub which is a cosy corner in the void deck every Friday. They go there to read news articles from the newspapers to our seniors and to engage our seniors in discussions over current affairs.

In addition, MOH partners organisations to bring preventive health services to the doorstep of our seniors. We are experimenting with putting health checks, vaccination, dental, eye and foot checks and even hearing tests on wheels so that they can come to locations closer to our seniors in the community. For instance, many seniors find it inconvenient to travel to SOCs to get a proper hearing test or for the fitting out of hearing aids, even though the Seniors' Mobility and Enabling Fund subsidises such hearing aids.

The National University Health System has thus retrofitted two Hearing Buses to bring audio checks to different neighbourhoods instead. This mobile Hearing Bus has started its journey of screening hearing for our seniors in Yuhua, Bukit Panjang, Nee Soon Central, Whampoa and Tampines West as a pilot and we will see how that goes.

An example of an integrated system of preventive health, health education and social wellness activities have also been rolled into one at Paya Lebar. PA has worked with The Goodlife Cooperative (TGLC) in Paya Lebar to integrate preventive health services with social outreach and wellness programmes. Seniors can access basic health monitoring services weekly at the Paya Lebar Wellness Centre where retired volunteer nurses provide health advice and help seniors take their blood pressure, monitoring their blood glucose level, their height and weight measurements. Therefore, they know their BMI.

TGLC actively reaches out to the community to encourage them to drop by to check their health. This is complemented by daily programming and interest groups at the Paya Lebar Wellness Centre to encourage seniors to take part in physical exercise whilst keeping in touch with neighbours and friends.

Mdm Chair, the best way to enable seniors to age well is to enable them to stay healthy. This is a meaningful effort that can succeed only with the support of everyone – community-based organisations, grassroots, healthcare providers, family members, employers, unions and, most of all, our seniors themselves. By working together in every workplace and in every neighbourhood, we can and will build a nation for ages.