Ministry of Health Committee of Supply 2016 – Cuts by WP MPs and NCMPs

(Delivered in Parliament on 12 & 13 April 2016)

Waiting Time in Polyclinics – Leon Perera

Madam Chairperson, in business when a target is surpassed by a wide margin, sometimes it is due to good performance, sometimes it is due to good fortune and sometimes it is due to the target being set too low.

In the 2016 Budget book, the KPI for Polyclinic waiting time is set at a maximum of 100 minutes. By this standard, over 95% of cases consistently met the KPI for the last few years.

I urge MOH to review this performance indicator. 100 minutes or one hour and 40 minutes is not an acceptable time for our patients to wait. I suggest we change this time to 45 minutes to provide a more meaningful benchmark of good performance.

The MOH publishes median and 95th percentile waiting times for Polyclinics. In Feb 2016 total waiting time for registration plus consultation was roughly half an hour for the median but closer to a shocking two hours for the 95th percentile. It was 2 hours and 16 minutes for the 95th percentile at Bedok Polyclinic.

This points to what is probably the huge difference in waiting time between those who make appointments and those who walk in.

I suggest that waiting times be published separately for those who have made appointments and those who walk-in.

I am aware that internet, phone and mobile applications are available for Polyclinic appointments. However in SMU’s recent customer satisfaction survey, satisfaction with Polyclinic waiting times fell in 2015. What is the reason for this?

Is there more we can do to cut waiting times for those elderly Singaporeans who tend to walk in?

I suggest we explore several options. Firstly can we provide real time data for the expected walk-in waiting time on the internet as well as on a digital signboard outside the Polyclinic. We see this at theme parks, where there is a signboard that displays the expected waiting time for different rides. I believe this is done at some Polyclinics but not all. Secondly, can we deploy staff fluent in different Singaporean languages to talk to walk-in patients and convince them to try to use their phones to set appointments in future.

Waiting Time for Specialist Consultation – Low Thia Khiang

Long waiting times for appointments and medical investigations at Specialist Outpatient Clinics (SOCs) for subsidised patients, have been a longstanding problem. I asked about this during the COS debate three years ago, and was assured by the Minister that MOH adopts a “multi-pronged approach” to address the queues at our SOCs.

However, three years have passed and the situation does not seem to have improved. I have received feedback from a patient who needed to wait for 6 months to see a lung specialist, and another 3 months for the biopsy results. During this long wait, a patient’s condition could deteriorate and he could develop complications which are harder and more expensive to treat.

Can the Minister share from the time the appointment is made to the consultation with the specialist, what are the average, range, median and 95th percentile waiting times for consultations at SOCs for subsidised patients ?

After the consultation, what are the average, range, median and 95% percentile waiting times for the conduct of investigations and tests like MRI or CT scans, and for elective surgery?

How do these numbers compare with 3 years ago? Has there been any improvement?

Moving forward, to help benchmark SOCs’ performance, will MOH publish SOC appointment waiting times regularly on its website for the median and 95th percentile, like it does for waiting times for admission to wards and for registration and consultations at polyclinics?

The long waiting times seem to affect subsidised patients much more than unsubsidised patients. Are these long waiting times a way that SOCs regulate subsidised patients’ demand for their services? Or are they due to insufficient resources being made available to meet subsidised patient demand?

Patient Downgrade from Private Care – Dennis Tan

I understand that currently there are two ways for patients to downgrade their outpatient status from private tertiary care to being patients on public care at the Specialist Outpatient Clinics at the structured hospitals.

The first is by being referred to a medical social worker who will do a financial assessment for the patient. The second is for patients to get a referral letter from the doctor at the hospital, which they are instructed to take to the polyclinic. This letter will provide that the polyclinic should refer the patient back to the hospital.

The first method may not be suitable for patients who do not need a financial assessment from a medical social worker to justify a downgrade. For the second method, the patient needs to see the doctor at the SOC first to get a referral letter to the polyclinic. The patient then sees another doctor at the polyclinic.

At the polyclinic, such patients have to wait in the same line as patients who are genuinely sick, to see the doctor. The polyclinic doctor then directs patients to the referral counter for a letter referring them back to the same hospital. The polyclinic doctor may charge for consultation even though the patient did not actually require a medical examination for the referral.

What is the basis for requiring two consecutive referral letters from doctors (one at the SOC and one at the polyclinic)? Does the polyclinic doctor really have to do any medical consultation, since he would know from the SOC’s specialist’s referral letter the purpose for the visit?

From my description of the typical scenario, it would seem that much time is wasted on the part of the patients (by way of waiting and transport time) and on the part of the polyclinic doctors in having to attend to what seems essentially an administrative task.

The whole process becomes unnecessarily inefficient and bureaucratic. It also involves unnecessary medical expenses on the part of the patients. One would have thought that a request to transfer from private to public care can be dealt with adequately by an administrative staff at the hospital.

At most, perhaps the patient only need the attention of the doctor at the SOC who can even handle this outside his clinic hours as an administrative task done without requiring the presence of the patient. The doctor can always ask to see the patient if he has some questions for the patient.

I have described the details of the process to try and highlight the inefficiency and needless bureaucracy of the process.

Will MOH consider allowing patients who downgrade from private to public tertiary care to avoid having to seek a medical social worker to recommend the downgrade or to skip the step of obtaining a polyclinic referral, if patients are willing to go to the back of the queue and have their appointments pushed back to the end of the doctor’s appointment schedule?

The process could be done in the hospital itself. This would help to relieve some of the workload on the polyclinics and the medical social workers, and reduce unnecessary waiting and travelling time for patients. It will also reduce queues at the hospital as well as the polyclinic. It will be a win-win situation for patients, doctors, hospitals and the polyclinics.

MediShield Life and Overseas Singaporeans – Sylvia Lim

Medishield Life provides Singaporeans and Permanent Residents some coverage for hospitalization bills and certain outpatient treatments, without age limit and for life.  While the scheme benefits those of us based here, requiring all overseas Singaporeans to pay for compulsory coverage does not seem fair to some of them and merits a review.

MOH has stated that overseas Singaporeans should contribute to the national risk pool as “part of collective responsibility”.  The Ministry says this will also enable them to benefit from Medishield Life protection, anytime they choose to return to Singapore.

This stand makes sense for those overseas Singaporeans who know that they expect to return to Singapore to live.  However, there are Singaporeans who have made their home in other countries for decades.  These include Singaporeans married to foreigners and raising children overseas, sometimes because the foreign spouses are not able to find suitable work in Singapore.  They enjoy high standards of healthcare in these countries, which they pay taxes for.  Others have emigrated as families, and now have access to healthcare at prices more affordable to them.  Some chose to live abroad because they could only obtain adequate coverage for their serious health conditions there.  These Singaporeans are better-covered overseas, and will probably never tap on Medishield Life.

Will the government review how it could allow such overseas Singaporeans to opt out of the scheme?   Is there a compelling case that no opt-out should be allowed at all?

Integrated Shield Premiums – Pritam Singh

Madam Chairperson, the prospect of rising healthcare costs are a cause for concern, especially for the middle-income and sandwiched 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 the Medishield Life subsidies come to an end.

Higher Medishield Life premiums meant more 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 till November this year, what are the prospects of higher premiums next year? Had the Ministry considered informing the insurers that the moratorium should also included 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 the reality of rising healthcare costs for a number of public reasons – such as larger bills, greater healthcare consumption and newer and costlier 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 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 overconsumption? What does the Ministry do to ensure that private hospitals and doctors do not take maximum advantage of private insurance plans – anecdotes of which can be found in the mainstream media, thereby adding to medical inflation and eventually, increased premiums too. Does the Ministry consider this to be a growing problem and how does it plan to mitigate this problem?

Finally, details of the standardized B1 plan were recently made public. Prior to launch, the plan it was framed as a more affordable integrated plan providing greater choice to consumers. To this end, will the Ministry consider increasing the Medisave Withdrawal Limit amount (MWL) for Singaporeans of all ages, especially older Singaporeans who choose this plan, so that it can be paid for completely through their Medisave account?

Mental Health – Low Thia Khiang

As our society ages, we have been paying close attention to our health care costs of an aging 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 illnesses. There is also 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 3Ms framework allows support for mental illnesses, but are 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 daily limits 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 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 to our heathcare costs and infrastructure could 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 if there are plans to expand pilot projects such as  ‘dementia-friendly’ town.

Community Nursing – Daniel Goh

Madam 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 worker 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 in active practice 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 corps 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 don’t 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, would the Ministry consider developing a comprehensive Hospital in the Home programme modelled on the programme in Australia. Under the Hospital in the Home programme, hospitals would 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 the 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 on-site consultations with hospital-based doctors in the homes of the patients.

Hospice – Low Thia Khiang

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 $7000 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 65 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 the costs of hospice and palliative care up.

I would like to know what the average length of stay in the hospice was from 2012 – 2015? How many people have benefitted so far from the last increase in the income ceiling?  And how many have written in to appeal for subsidy 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 under the Eldershield Scheme.

Enhanced Primary Care – Daniel Goh

Madam Chair, primary healthcare at general practitioner clinics should be seen as a form of preventive healthcare to arrest the development of illnesses before they escalate to the need for costly hospitalisation. Costly, that is, to the public purse and the public, given the universal hospitalisation insurance of Medishield Life. The monthly household income per member cap to qualify for Community Health Assist Scheme or CHAS subsidies in short  should be raised from $1,800 to the prevailing median monthly income from work for an individual, which stands at $3,900 in 2015. This is so that retirees who live with their working children who are themselves parents are not excluded. This would also provide some relief for the children of the retirees who belong to the sandwiched middle-income group. Another benefit is that this would provide support for and promote multi-generational households, where the elderly would not be disadvantaged to live with their children and grandchildren.

Sugar Content Labeling – Daniel Goh

Madam Chair, the harmful effects of excessive sugar consumption has led to Britain recently introducing a sugar tax. Singapore, like the UK, is experiencing an ageing population and the prevalence of obesity and heart disease. There are also local characteristics to the problem, as Asians are at a higher risk of developing Type 2 diabetes. In fact, over 10% of adult Singaporeans are diabetic, the second highest proportion in the developed world. It would therefore appear we should seriously consider a sugar tax. However, the effectiveness of a sugar tax is questionable, at least in Singapore, as it will likely turn out to be a regressive tax on vulnerable Singaporeans. We should focus instead on empowering Singaporeans towards making healthier choices and adjustments to their lifestyle.

I request the Government consider mandating the labelling of free sugar content in processed foods, where the calories and percentage of daily intake for free sugar need to be prominently displayed on food packaging. The sugar content should also be colour-coded with green, amber and red. Labelling should be in line with WHO guidelines of cutting free sugar consumption to less than 10% of daily calorie intake. This can be rolled out in phases, starting with canned and packet drinks – for example, a can of Coca Cola contains added sugar amounting to 80% of the current WHO guidelines, and should be labelled red. Health warnings that read, “drinking beverages with excessive added sugar contributes to obesity, diabetes and tooth decay”, should be attached to drinks that are labelled red.

Studies to track whether labelling has resulted in consumers making better choices should be conducted to improve the labelling and gauge its success before we even consider a sugar tax.