Ministry of Health Committee of Supply 2017 – Cuts by WP MPs and NCMPs

(Delivered In Parliament On 9 March 2017)

Meeting the Needs of an Ageing Population – Low Thia Khiang

Madam, the percentage of our population aged 65 years and above increased from 11.2% in 2014 to 12.4% in 2016, and will rise further. It is crucial that we plan ahead in tandem with the expected ageing population to ensure that we have the necessary infrastructure and manpower to meet present and future healthcare needs of Singaporeans.

In recent years, the construction of hospitals and medical centres has been ramped up, resulting in significant increases in the development expenditure.

Yet according to a report published by the Lien Foundation and the Khoo Chwee Neo Foundation, the government’s efforts to ramp up capacity lags behind the rate at which the population is ageing. The report found that “Singapore had around 26.1 nursing home beds per 1,000 people aged 65 and above in 2015, – the lowest proportion in 15 years – down from around 28 beds in 2000 and well below the OECD average of 45.2 beds.

A Straits Times article goes on to add that based on the percentage of the elderly population living in residential aged care facilities in developed countries such as US, Australia, and Finland, there will be 50,000 seniors in Singapore who will require such facilities by 2030. The government’s current plan is to bring the total number of nursing home beds to slightly over 17,000 by 2020. Is this sufficient to cope with projected demand?

I would like to find out from the minister, what is the progress of the plans to increase the physical capacity of our healthcare system, and is the current expansion of existing infrastructure sufficient to meet the healthcare needs of the population?

On Manpower

The government’s Healthcare Manpower Plan 2020 seeks to add 30,000 healthcare workers by 2020.

In early 2016, in a reply to a parliamentary question filed by my colleague, our doctor and nurse to population ratios still lag behind other developed countries such as Australia, Japan, UK, and the US.

I have a few questions for the minister. Given that the number of nurses and allied health professionals graduates have fallen since 2012, while the number of medical graduates have also fallen since 2013 – all these despite great effort by the government to make these jobs more attractive – how confident is MOH in meeting the targets in the manpower plan 2020?

It was reported that there were 2,100 foreign doctors in public hospitals and polyclinics at the end of 2014. What is this number today? Also, what is the ratio of foreign nurses to local nurses currently in public hospitals and polyclinics, and what is the ratio that the ministry hopes to achieve by 2020?

 

Cost of Medicine and Vaccines – Low Thia Khiang

Mdm, the government has been talking about keeping long-term healthcare costs affordable for Singaporeans. Based on feedback from residents, some Singaporeans still find the cost of medicine high.

I believe this is partly due to doctors prescribing drugs for a long duration or prescribing non-standard drugs. I would like to ask MOH what measures have been taken to reduce the cost of medicine for patients, and how effective have these measures lowered the cost of medicine for patients, especially those with chronic disease.

The Minister said in 2012 that the profit margins for drugs sold in public hospitals typically ranges from 5% to 30%. I would like to ask if the profit margins today are still the same, and what the profit margins are for drugs sold in polyclinics.

Two years ago, WP suggested that the government look into publishing drug prices for public hospitals. The minister rejected this saying that, “drugs constitute only one aspect of the overall treatment.” I would like to repeat the call to publish drug prices at public hospitals for better transparency.

Next, under the National Childhood Immunisation Programme, all recommended vaccinations are fully subsidised and provided free of charge at all polyclinics for children who are Singapore citizens, except pneumococcal vaccinations.

Pneumococcal disease manifests in illnesses such as pneumonia and meningitis, and is the leading infectious cause of death in children and adults worldwide. According to MOH’s figures, pneumonia is the second most common cause of death in Singapore, and one of the top five conditions of hospitalisation.

I understand that Pneumococcal meningitis is a disease that is difficult to detect in early stages, but progresses rapidly and could result in death or cause long-term health complications such as paralysis or brain damage. Children below 5 and adults above 50 are at greater risk of being affected by such disease.

In 2013 and again in 2015 when WP called for fully subsidised pneumococcal vaccinations, the minister said that this was not necessary since “the potential for a public health epidemic or outbreak is relatively low.”

A complete series of the vaccine doses costs around $500, which is costly for parents. I ask the MOH to consider providing subsidy to encourage parents to use it.

I believe that the government stands to benefit from providing subsidised pneumococcal vaccinations in the long run through the reduced burden on Medifund and MediShield Life. It could also save on expensive treatments, hospitalisations, and medications down the line.

 

Means Testing – Dennis Tan

Madam, the Government provides means-tested subsidies for MOH-funded Intermediate and Long-Term Care (ILTC) facilities as well as treatments at public hospital. I am appealing to Ministry of Health to implement a grace period for the withdrawal or reduction of subsidies instead of effecting the changes immediately when the per capita household income rises.

Let me give an example of a household with per capita monthly income of $650. Under the framework, a Singapore citizen will qualify for 75% subsidies. Subsequently if the per capita monthly household income rises to the next tier that is, between $701 to $1100, due to salary increment, bonus, or commission, subsidies will drop to 60%. This is a 15% decrease, which is considerable especially since we are talking about Singaporeans with lower household per capita monthly income. This would apply even if their income only rose by about 10% to $710.

For Singaporeans in this position, this can be very discouraging and may feel like two steps forward, one step back. A grace period should be given before the subsidy is withdrawn or reduced. This will give people some breathing room to consolidate their finances or even pay off some lingering debts, instead of hitting them with an immediate increase in medical expenses. I would like to ask the Ministry to review this to see how best we can help fellow Singaporeans who are in such situations.

 

Innovative Anti-diabetes Strategies – Leon Perera

At the last COS, I spoke about how social impact bonds could help drive outcomes-based social policies in Singapore such as reducing recidivism among ex-offenders.

Pay-for-success contracting or PSFs and social impact bonds or SIBs have been growing world-wide since 2010. One estimate has identified over 40 SIB and PSF projects world-wide in 2015, spanning subject areas like early childhood education, healthcare and recidivism.

In Israel, a SIB is underway to help prevent “pre-diabetics” from contracting diabetes.

The NUS School of Public Health estimates that diabetes could cost Singapore $2.5 billion a year by 2050, not to mention the cost in human suffering.

In Singapore, MOH could explore launching a SIB to raise funds for reliable NGO partners who can work with pre-diabetics and diabetics to improve health indicators like blood sugar levels and emergency hospitalisation events. Philanthropic donors, foundations and so on could buy the bond. Such NGOs could then focus on programs to help at-risk individuals manage their diets, for example. The state would redeem the bond and pay the donors only if outcomes are achieved, which makes for better use of state monies.

NGOs may be better placed than state entities to dream up and execute creative ideas that can nudge behavioural change in the face of entrenched habits, thus solving tricky social problems.

I hope that MOH will look into the possibility of launching a SIB or PSF initiative to work with NGOs over the social challenge of diabetes.

 

War on Diabetes – Chen Show Mao

Last year the Minister declared War on Diabetes to great fanfare, as befitting the importance of the campaign.  Our children and young people are increasingly overweight.  One in three Singaporeans has a lifetime risk of developing diabetes, with serious and costly consequences.  Could the Minister give us a report of progress from the front?

On sugary processed food, would the government consider requiring warnings on containers of sugary processed food — cans and packets of candies, soft drinks, for example.  This could be similar to requiring warnings on tobacco packaging in order to discourage smoking, which is another risk factor for diabetes.  Smokers are 30%-40% more likely to develop diabetes.

Similarly, would the government consider requiring retailers to display signs encouraging shoppers to choose low-sugar options.  Or school canteens and hawker centres to display signs warning about the dangers of diabetes and encouraging healthier options.

Would the ministry consider working with MTI to apply existing incentives to support local food manufacturers to release low-sugar snacks and drinks? The ITM for food processing is more advanced than most other ITMs, and for that reason seems well placed to develop and promote low-sugar products on an industry basis.

 

More Help for Senior Caregivers – Daniel Goh

Madam, caregivers of seniors need a lot of support. The stress of caregiving goes up exponentially when the elderly develops chronic illnesses, dementia or disabilities. This issue will deepen with the rapidly ageing population. I note that the Government will be setting up a Disability Caregiver Support Centre.  I propose that the Government set up similar caregiver support centres for senior caregivers.

As senior caregiving is of a scale larger than disability caregiving, I believe that there is a need to set up multiple support centres to provide the same level of support to senior caregivers.  These centres are a natural extension to existing Senior Care Centres. Since SCCs are specially situated in places with higher demand for eldercare services, Senior Caregiver Support Centres can be co-located with SCCs. Like the Disability Caregiver Support Centre, Senior Caregiver Support Centres can provide information, planned respite, training, peer support and offer various VWO programmes to help caregivers.

There is one more important function the support centres can perform. Senior caregivers face greater risk of health and financial vulnerabilities as they get older due to lower lifetime earnings. Many are women who leave the workforce to be full-time caregivers and who find it difficult to re-enter the labour market. These support centres can also act as the main touchpoints for caregivers to receive important health and financial assistance, and even advice on finding part-time work to support themselves.

 

Nursing Homes  – Dennis Tan

The Government announced in 2014 that 7 new nursing homes would be built to accommodate up to 17,150 residents by 2020, to meet the growing demand arising from the rapidly ageing population.

Even as we are ramping up new nursing homes, sadly, the care model in our nursing homes remains the so-called “medicalised model” similar to hospitals. This is not the most suitable model to enhance the quality of life for our seniors who are residing in these homes. Does each of us want to live in such an environment in the winter of our lives?

Countries like US, Japan and Australia have moved away from the ‘medicalized’ model. We should move away from the ‘medicalized’ model now and aim for the rehabilitative model, making the living environment more like homes, and less like hospitals. We should move away from the dormitory-like environment, go beyond basic physical care to a home like environment with care specialists attending to the social well being as well as nursing needs of elderly residents so that they can live and age with dignity.

MOH set up the Enhanced Nursing Home Standard in 2014 providing basic standards for medical and nursing care, facilities maintenance and hygiene. We should go beyond these basic standards. MOH should consult as many stakeholders as possible, as well as the specific medical interest groups most associated with the care of patients afflicted with specific illnesses (such as the Alzheimer’s Disease Association, Kidney Dialysis Foundation, etc.) in order to better understand how the clinical and social needs of different and specific types of patients can be best met. This would allow for a range, rather than a bare minimum standard of care in each nursing home.

The standards of nursing homes in Singapore do vary considerably. Recently a Fengshan resident shared with me her concern to transfer her mother from one nursing home to another and one of the reasons cited was poor and indifferent care by staff. I understand that right now the Ministry conduct regular audits on nursing home. However, the audit reports are not disclosed to the public. I would like to suggest that these audit reports should be made available to the public so that families of nursing home residents are aware of the compliance standards of the homes. I believe that such measures may enhance standards and weed out operators who are not able to provide suitable services.

Fighting Dementia – Dennis Tan

In 2012, about 28,000 people in Singapore aged 60 and older had dementia; the Minister estimated that this figure is expected to rise to 80,000 by 2030. Based on projections from the Alzheimer’s Disease Association, by 2050, we will be faced with 187,000 people aged 65 and above who have dementia.

We are also starting to see growing numbers of younger dementia patients. In an article last year, Associate Professor Nagaendran Kandiah at the National Neuroscience Institute (NNI) estimated that of the 40,000 people with dementia in Singapore, 10% are below the age of 65. The rapid increase in the number of people with dementia is a cause for concern, especially if we do not have enough resources to support them.

As such, I would like to ask the Minister for an update on the progress in preparing for the rise in dementia cases. Is enough being done to educate Singaporeans on the risk factors for dementia? There has been an initiative to build dementia-friendly communities in Singapore, piloted at Yishun, Hong Kah, and MacPherson. These communities feature “community touch points” that act as go-to points for those who have lost their way, and training is provided to persons and businesses within the area so that they may render assistance to persons with dementia. What are the findings of this initiative so far, and how does it compare with plans to address dementia in other countries? Are there plans to roll out this initiative islandwide; and if so, what is the schedule for this?

I would also like to raise the issue of dementia assessments. Currently, dementia assessments are usually carried out at hospitals (with referrals from polyclinics) and IMH. Will the ministry set a target to eventually have trained staff at all polyclinics to perform the assessment?