13th Feb 2019
Caring for our Caregivers
1. Mr Speaker Sir, there have been many thoughtful and considered points which have been raised by various members in this debate, on an issue which is not only urgent and pressing because of our socio-demographic profile and trends, but also one which helps to shape the type of society we want to foster and the kind of place we want to grow old in. In particular, members have spoken about the need for a whole-of-society effort to help seniors age with purpose and with dignity. Members have also affirmed the critical role that caregivers play in achieving this, so that our seniors can better age-in-place, and, as far as possible in the company and care of those who love them the most. I agree, and the Government intends to introduce measures to help caregivers on their journey.
2. As our population ages and more Singaporeans live longer, we will see a rise in informal caregiving. By 2030, one in four residents will be aged 65 years and above, close to where Japan is today. Our family sizes are also shrinking, and as a consequence, our old-age support ratio will also decrease – from 4.8 in 2018 to an estimated 2.7 in 2030. This is a significant shift. As Dr Chia Shi-Lu noted in his speech at the outset, Singaporeans will need support in caring for their loved ones, and working caregivers will need to balance employment and their family responsibilities as well.
3. I am mindful that there is a broad range of different caregivers, and we have heard different stories from different perspectives, all of which are very relevant to the debate today. There is a broad range of different caregivers who operate in a variety of circumstances and in a very broad landscape. They also wear multiple hats. Some may care for different groups of care recipients, such as seniors, or children, or Ms Denise Phua mentioned, Persons with Disabilities (PwDs), or any combination of this. Their needs are diverse, as with their own particular family or caregiving circumstances, so, over time, we will need to look carefully at what these needs are, and whether further assistance might be needed. As a start, and particularly given our demographic shift over the next decade which I have outlined above, I will focus on how we can support senior caregivers as vital partners in our health and social system. Some of the measures that I will outline will also apply to other groups of caregivers, for example, those looking after PwDs. My colleague, MOS Sam Tan will touch more on this when he speaks.
Supporting Caregivers through Community Care
4. As Mr Murali Pillai and Dr Lily Neo noted, many caregivers naturally prefer for their loved ones to age-in-place at home, in familiar surroundings and in the community of people they know and they love. We agree entirely; it really goes without saying. As such, the Government has been taking the lead to anchor care in the community. Over the years, Ministry of Health (MOH) has strengthened the broad ecosystem of support for senior caregiving by expanding the capacity of aged care services. We have also deepened the range of care options available for our seniors, through new models such as the Integrated Home and Day Care programme. We are encouraged to see higher take-up of home and community care services. As of late 2018, around 16,000 clients have benefitted from subsidised home and community care services, an increase from around 14,000 seniors in 2017.
5. I would like to assure Ms Anthea Ong that beyond just growing capacity, from a hardware perspective, we are also working to strengthen the quality of our aged care services through appropriate regulations, developmental services, education, guidelines, service audits, as well as capability-building programmes. Ultimately, for whatever additional hardware that we put in place, it is the people talent that is the most important, and we agree with both Ms Anthea Ong and Mr Melvin Yong that healthcare professionals play a key role in providing quality aged care services for our seniors. Between 2012 and 2017, MOH had provided funding support to raise the wages of workers. Salaries of workers across participating providers saw a 30% increase in aggregate over this period of time. MOH also supports skills training scholarships and grants, and productivity improvement and job redesign initiatives, to raise the value of jobs alongside salary increases in line with the intent of the Progressive Wage Model. We will continue to work with the employers to review salaries of workers regularly to ensure that they are adequately recognised for their efforts. MOH will study if further efforts are needed, including whether to introduce a Progressive Wage Model for the eldercare sector with tripartite partners.
6. We have also put in place long-term care financing measures to ensure affordable and also, sustainable healthcare. Today, we see means-tested subsidies for aged care services, which is complemented by our long-term insurance care schemes like ElderShield and CareShield Life, and a range of disability schemes such as Interim Disability Assistance Programme for the Elderly (IDAPE), which Dr Intan Azura Mokhtar just mentioned, and the Pioneer Generation Disability Assistance Scheme (PioneerDAS). For those who still have difficulty, notwithstanding these programmes, paying for care after Government subsidies, grants and insurance scheme payouts, there are also Government-funded safety nets, such as MediFund and ComCare which can provide further assistance.
7. Ms Rahayu Mahzam has suggested updating the Community Health Assist Scheme (CHAS) eligibility criteria. We agree, and MOH is already in the process of reviewing and where necessary updating the per-capita household income criteria for CHAS, so that more Singaporeans can benefit from CHAS subsidies. At the same time, we will also take the opportunity to review the household income criteria for other healthcare subsidy schemes as well.
8. Taken together, these efforts support ageing in place, living with purpose, with dignity, and provide caregivers with peace of mind.
Caregiver Support Action Plan
9. But we can still do more to directly address the needs of caregivers. In the various engagements that we have had with caregivers since September last year, many shared with us the challenges they face in caring for their loved ones. Whilst they face challenges, they also left us in no doubt how the caregiving journey is itself a very rewarding process. That is also the sentiment that members here today have expressed. No two caregivers’ journey would be similar, but each of these experiences is bound by the same common desire to care for, and give their best to the care recipient. We need to help them on this journey.
10. Therefore, drawing on feedback from the caregiver ecosystem and the people operating within the system, MOH, together with partner agencies have developed a Caregiver Support Action Plan to strengthen support for caregiving. This action plan outlines key initiatives that we will embark on in the next two years.
11. There are five broad themes which underpin our action plan. Let me set them out before I go into these in some details. They are: (i) Care Navigation; (ii) Financial Support; (iii) Workplace Support; (iv) Caregiver Respite Services; and (v) Caregiver Empowerment and Training. Let me now outline our key directions in each of these areas.
Better care navigation in the community
12. First, on better care navigation. As mentioned by Dr Chia Shi-Lu, many caregivers, and particularly the new caregivers, need ready access to information and referrals to services, but they may not know so well how to navigate the landscape, who to turn to for help and who to consult in their time of need. Particularly, new caregivers may suddenly and very quickly embark on this caregiving responsibility. Today, we have physical touchpoints – AICare Links, operated by the Agency for Integrated Care (AIC) in acute and community hospitals and AIC Office at Maxwell Road that cater to walk-ins from caregivers and seniors alike, and provide information and assistance regarding eldercare services, grants and schemes. The public can also obtain information through AIC’s helpline, the Singapore Silver Line. These are all useful, but perhaps not enough. We need to do more to help caregivers feel supported and confident in making informed decisions regarding the caregiving needs of their loved ones.
13. AIC will create four more AICare Link touchpoints and also embed them in the community at Silver Generation Office satellite offices by the second half of 2019. We agree with Dr Lily Neo that we need to synergise our efforts with Social Service Offices and other government touchpoints within the community, to make service delivery more cohesive, more unified, which overall will then better serve the needs of seniors and caregivers alike in the community. Ms Cheng Li Hui highlighted earlier the need to look out for elderly caregivers. We agree, and through our Community Networks for Seniors initiative, Silver Generation Ambassadors will identify these elderly caregivers during home visits, and link them up with services and support schemes relevant to their particular circumstances and needs.
14. As Mr Melvin Yong also noted, technology is fast becoming a key enabler in providing caregivers with useful information. The web portal on eldercare and caregiving, Singapore Silver Pages, will be revamped this year, to improve the overall user experience. We will also develop a Health Marketplace e-platform by 2020, where users can more directly access services such as Medical Escort and Transport, and purchase regular consumables. For such services, it helps that the caregiver has the option of not having to make a trip to a physical office or to speak to someone over the telephone, in order to access those services.
15. As part of our Smart Nation efforts, MOH has been working with GovTech and other government agencies on a cross-agency Moments of Life Digital Portal to aid Singaporeans, including caregivers, with pre-planning for the end-of-life journey. Features will include step-by-step guidance on issues such as Advance Care Planning, making wills and settling post-death estate matters as well. We will roll out the beta version by the end of 2019 and will work with the relevant touchpoints to raise awareness of these pre-planning tools.
Improving financial support for caregiving needs
16. Next, let me turn to improving financial support for caregiving needs. Several members, including Ms Joan Pereira, Mr Christopher de Souza, Dr Intan Azura Mokhtar and Mr Chen Show Mao, have suggested providing further financial support to manage caregiving expenses, especially for those being cared for at home. From our engagement sessions, many caregivers have indeed shared with us that the cost of caregiving is amongst the uppermost issues in their minds. Currently, we already have several schemes in place to support ageing in place. These include the Seniors’ Mobility and Enabling Fund to defray the cost of assistive devices and home healthcare items, the Foreign Domestic Worker (FDW) Grant to offset the costs of hiring a foreign domestic worker, as well as the Caregivers Training Grant to subsidise training. We will build on these, to boost support for caregiving in home and community settings, so as to achieve, amongst others, a delay or even a reduction in the need for institutional care for our seniors.
17. On that score, I am pleased to announce that we will introduce a new Home Caregiving Grant (HCG) by the end of 2019. The HCG will be means tested, and available to care recipients with permanent moderate disability, regardless of age, and granted on criteria which is similar to what we now use for the FDW Grant. The HCG can be used to offset the costs of long-term caregiving in the community. The HCG will complement severe disability schemes like ElderShield and CareShield Life, by providing support earlier, and at a stage when care recipients are still able to perform these Activities of Daily Living albeit with some assistance. In other words, HCG will be available at an earlier and less severe stage of disability, when compared to the criteria in disability schemes such as ElderShield or CareShield Life.
18. The grant will replace the FDW Grant, with an enhanced quantum of $200 per month. Let me explain this. I have said earlier that no two caregivers’ journeys are similar. Indeed, there are very many differences in the journey and also the way in which care is expected to be delivered. We have noted Mr Christopher de Souza and Ms Tin Pei Ling’s point that care arrangements may vary from person to person, or indeed may even vary depending on which stage of care the recipient might be in. We want to be able to provide financial support which will better meet the range of diverse caregiving needs. At present, the current FDW Grant can only be used to offset the cost of hiring an FDW. It is therefore limited because not all caregivers might need or want an FDW. So we will replace this with the HCG of $200 per month, which is also an increase over the present $120 FDW Grant, and also allow caregivers greater flexibility on how they choose to use this fund. Some might use it to help with the cost of hiring an FDW, if that is what is needed, whilst others could choose to use this sum to defray the cost of caregiving expenses, such as the costs for home and community-based services, and transportation to medical appointments. There is much greater flexibility in how this grant can be used, and care recipients who qualify can choose to nominate their caregiver to receive the HCG.
19. Ms Joan Pereira has also suggested that we broaden the definition of family members in government policies to strengthen familial support. On that score, we agree that family caregivers are first of all, usually the first port of call, and fundamentally, in the entire ecosystem, they are key to supporting our seniors to age-in-place. Therefore, we will allow caregivers to use their MediSave to help pay for the healthcare expenses of their Singaporean siblings by the end of 2019. These measures will complement our existing suite of long-term care financing measures supporting family caregivers, so they come on top of those measures.
Supporting the working aspirations of our caregivers
20. Next, more and more families face a growing caregiving burden, but also coupled with their own work commitments. The workplace environment is a key consideration as we chart this landscape. Employers therefore also have a part to play in creating supportive workplaces. Caregiving leave has been mooted by several members in this House here today and also before this. While we acknowledge that there are merits to extending leave provisions, we also need a sustainable approach that balances the needs of not just employees, but also employers in the long term. This was a point which was widely discussed at the various consultations we had with caregivers. As Dr Chia Shi-Lu noted, many caregivers see Flexible Work Arrangements (FWAs) as being more useful to helping them meet both their work and caregiving commitments, and balancing them in a longer term and on a more sustainable way. For example, working caregivers would like the flexibility to be able to take time-off to tend to their loved ones’ needs. Often they do not need a full day or even half a day, and perhaps two to three hours might be sufficient in certain circumstances. Other caregivers might require flexibility to work offsite on occasion whilst they take care of their dependents. In our view, a better and more sustainable, long-term approach to this issue would be for employers and companies to develop their own FWAs, which can best support caregivers in the workplace.
21. In addition to FWAs, as Mr Melvin Yong noted, some caregivers wish to re-enter the workforce, and need more support as well, such as in up-skilling and job-seeking.
22. My colleague, SPS Low Yen Ling will be sharing more details of our recommendations to support these groups in her speech later.
Enhancing caregiver respite options
23. I turn now to the point made by various members on the importance of caregivers being able to take occasional breaks during their journey to rest, to recharge, and sometimes due to their own particular circumstances as well. Sometimes, the respite is not even a luxury because some caregivers might require the respite at short notice due to their own exigencies. They cannot always anticipate when they might themselves fall ill, or when they may have an urgent matter to deal with. How they are going to be able to take some time-off to tend to these exigencies, whilst at the same time ensuring that their loved ones remain cared for remains a significant burden.
24. Respite services within home and institutional settings are already presently available. To date, over 2,400 clients have benefitted from respite services in senior care centres and nursing homes. But again, we can do more, and MOH will be enhancing our suite of respite options so that more caregivers can benefit from respite services. We also want to ensure that caregivers can access such services in a shorter period of time.
25. For instance, we have heard from caregivers that seniors with dementia can sometimes have difficulty sleeping and resting at night. In fact, some of these seniors with dementia can be quite active at night. Ms Tin Pei Ling shared about caregivers who find it challenging as their own sleep then becomes disrupted when they need to tend to the senior at night, especially if they also have to juggle work commitments in the morning. To support such caregivers, AIC will pilot a new night respite service for seniors with dementia who have sleep and behavioural issues. AIC will partner a few nursing home providers, to provide this new option where seniors with dementia can be engaged with through activities at night, while their caregivers can catch up on their own rest.
26. As I mentioned earlier, the need for respite services can be unpredictable and we need to be able to cater for caregivers getting respite quickly and efficiently. Dr Chia Shi-Lu suggested allowing families to pre-register essential information with providers. We have been studying this idea and will pilot a pre-enrolment system this year to further reduce the time required to activate respite services. Under such a system, caregivers can pre-register their loved ones and complete some of the otherwise lengthy and somewhat laborious administrative processes upfront. Later on, when the time comes for the respite services to be available, providers would already have some of the key information, and this will help to cut down the administrative process and time required to enrol the senior. AIC will try this out with a few providers first, iron out any operational matters as they study it for a period of time, and then look to expand this to more providers.
27. We will also pilot a home-based respite service for caregivers of palliative care cancer patients. Caregivers of terminally ill patients are fulfilling the desires of their loved ones by caring for them and also enabling them to pass on at home. This is often physically and emotionally tiring. The pilot would provide custodial care service for home palliative care patients so that caregivers can take a break with the knowledge that their loved ones will still be well taken care of at home.
Caregiver Empowerment and Training
28. Next, let me touch on caregiver empowerment and training. As members have noted, beyond just having a strong suite of formal services to support caregivers, good socio-emotional support for caregivers is also crucial.
29. We already have community outreach teams who currently reach out to those at risk of or those with mental health illnesses. We will evolve some of these teams to provide a more dedicated focus on caregivers. These teams will provide outreach to caregivers, provide case management and support through counselling, and also offer socio-emotional programmes. AIC will pilot these community outreach teams with community providers such as Caregiver Alliance Limited by the end of 2019.
30. We will also facilitate more caregiver support networks being set up. Caregiver support networks provide a safe environment for caregivers to come together, share their caregiving experience, lean on each other, and to support each other, which is often needed during the long, and often times, difficult caregiving journey. Take the example of Mdm Theresa Toh, who cares for her 68-year-old sister with schizophrenia and attends Queenstown Caregivers Connect, a support group for caregivers. Queenstown Caregivers Connect helps Mdm Toh with self-care by organising talks on mindfulness and communications with her loved ones. She has also, through this programme, met with fellow caregivers with whom she has strong friendships with now. And there is someone to lean on, a group to lean on, and someone with whom she can empathise with. We plan to expand more of such caregiver support networks, through our Dementia-Friendly Communities.
31. Ms Anthea Ong noted that it is critical to equip our caregivers with the right skills and the relevant knowledge through training. Many households rely on FDWs to support their caregiving needs, and we want to equip them with the relevant caregiving skills upstream, so that they can better take care of seniors. On that note, we will enhance eldercare training for family caregivers and also new FDWs, early on in their employment in Singapore.
32. On this note, I am very encouraged to hear about the several community and ground-up initiatives to recognise and support our caregivers mentioned by members, such as Mr Murali Pillai and Er Dr Lee Bee Wah as well, to build a support structure to reach out, to empathise with and to help caregivers on this journey. I think we would agree that everyone in society has a part to play in this caregiving journey. I have heard many members express that sentiment, and I agree entirely. For instance, the Caregiver Alliance Limited partnered with the Chinatown Heritage Centre and Nanyang Polytechnic (NYP) this year to organise an event for caregivers and their loved ones at the Centre. Caregivers had the opportunity to network and share experiences while nursing students from NYP role-played characters from the past and conducted therapeutic and fun activities to engage the young and old alike including baking, childhood games and also paper art. We will continue to work closely with community partners, such as Community Development Councils and grassroots organisations, to strengthen community-level support for caregivers, as Mr Murali Pillai has suggested. In response to Mr Mohamed Irshad’s suggestion to more systematically track caregivers, our various initiatives will give us the opportunity to collect more comprehensive information on caregivers, to better understand the profile, their needs and what else could be done to enhance the support given to them.
Conclusion: Call to Action
33. Mr Speaker, my belief is that all caregivers are committed to providing the best care possible for their loved ones. They don’t complain, and they are often determined and resilient in overcoming the challenges that come their way. Caregiving journeys may be long, but we can go the distance, if families and communities come together to support caregivers in our midst.
34. This is not just about grants, or hardware, or programmes. It is also about appreciation and empathy, and in the words of Ms Anthea Ong, about embracing caregiving as a society, to ensure that we not just provide the physical and hardware support, but also the socio-emotional support that we owe caregivers. It is about nurturing the kind of society we want to foster. The Action Plan reflects the Government’s commitment to strengthen support for senior caregiving, and our call for a whole-of-society effort to partner caregivers in their caregiving journeys. Each of us must do our part to recognise, to value, to support and to celebrate caregivers.
35. Together, we can support and empower caregivers, and in turn help our seniors in Singapore to age-in-place with dignity, in an environment which they know well, and with people who care and love them.
36. On this note, Mr Speaker, I support the motion.