Speech by Dr Amy Khor, Senior Minister of State for Health, at the MOH Committee of Supply Debate 2018

CARING FOR OUR SENIORS TOGETHER, INTO THE FUTURE

Introduction: Planning Ahead for “New Seniors” 

1.         Singapore needs to prepare for a rapidly ageing population in the next one to two decades. By 2030, the number of seniors aged 65 years and above will almost double to over 900,000. The largest increase will occur between 2020 and 2025, with about 179,000 baby boomers entering 65 years and above.

2.     Our vision is a Nation for All Ages, where all our citizens can age healthily, purposefully and gracefully in place. Hence, we are investing efforts at three levels:

a) First, at the individual level: we will create new options for ageing in place and empowering self-care;

b) Second, at the community level: we will build a strong community care system for seniors; and

c) Third, at the national level, we will develop enablers to better deliver care services for seniors.    

Individual Level: New Options for Care

Assisted Living

3.         Our models of care will need to evolve, as there is no one-size fits all option for seniors.

4.         Mr Leon Perera spoke about silver towns. MOH is working closely with MND, HDB and URA to pilot new forms of housing developments that are twinned with care services, and integrated within our public housing estates. This will be Singapore’s model for assisted living. Both Ministries are already studying potential sites for such “assisted living” developments, within public housing as well as in the private residential market. Basic domestic services such as housekeeping, and 24/7 monitoring and response could be offered to support independent living. Home care could be layered on as needed for frail seniors. We are collaborating with the Singapore University of Technology and Design and various agencies to explore how design interventions can help make our neighbourhoods age-friendly, as suggested by Ms Tin Pei Ling. SPRING also works with public agencies and private organisations to develop national standards to support active ageing and senior-friendly infrastructure design.

5.         Beyond new “housing plus” models that combine housing with care, we also need to enhance current services to support the majority of seniors who are already staying in existing residential estates, to age in place.

6.         For seniors in ageing rental precincts who are unable to afford domestic help for example, we had piloted the Care Close to Home (C2H) programme in 2014 where care services are provided out of Senior Activity Centres (SACs). To date, over 2,500 seniors have benefitted from the C2H programme. This year, we will expand the programme from the current 11, to another four sites in the Beach Road, Chai Chee, Chin Swee and Lengkok Bahru areas, so that more seniors can benefit.

7.         Today our Active Ageing Hubs (AAHs) provide a suite of care services for seniors as their needs evolve over time. We have started two AAHs at McNair and Kampung Admiralty, and will be opening three more AAHs in the Toa Payoh, Queenstown and Bukit Merah planning areas.

8.         Overall, I am encouraged to know that home and community care services have gained traction among seniors in Singapore. Around 14,000 clients have benefitted from subsidised home and community care services as of late 2017, more than the 10,000 clients who have taken up subsidised nursing home places. This has been the trend for the past three years.

9.         MOH will do more to support ageing in place, in the coming months. Today, seniors with complex medical conditions may be taking multiple medications prescribed by various doctors. There is also the risk of non-compliance or medication errors. We will launch a new community-based Pharmaceutical Care Services pilot, so that in the future, seniors can get help with their medications at community touchpoints such as Senior Care Centres (SCCs) where community pharmacists will be stationed, saving them multiple trips to the doctor or hospital. We will start with a pool of some 20 pharmacists from our polyclinics and retail pharmacies such as Guardian, Unity Pharmacy and Watsons.  

10.       This year, we will enhance the Seniors’ Mobility and Enabling Fund (SMF) to enable seniors with frailty to age confidently. To date, we have disbursed close to $100 million since the launch of the scheme in 2011, with over 49,000 beneficiaries. As earlier announced at Budget, we will top up another $100 million over the next five years to further extend SMF subsidies to benefit more seniors.

11.       To lend more support to end-of-life care, we are extending SMF subsidies to clients on home palliative care services in the coming months. MOH will also review the SMF means-testing tiers for devices so that our subsidies remain effective and targeted at those who need help.     

Research, Innovation and Technology

12.       Ms Tin asked for an update on Our National Innovation Challenge on Active and Confident Ageing. I am pleased to report that we have launched six grant calls to date, with around $33 million awarded across 23 projects. These include projects in areas such as home monitoring solutions and assistive devices.

13.       To improve care navigation, we are leveraging on technology which Ms Cheryl Chan spoke about, to develop a Health Marketplace. Many consumers are already using e-platforms such as “Amazon” and “Redmart”. We hope to create an equivalent platform to make it easy for seniors and their caregivers to find, customise and order community-based eldercare services such as home care, medical escorts and transport, and meals on wheels. They can do so via a mobile app, and will also have the opportunity to give ratings on services and providers. We plan to collaborate with industry to start a Health Marketplace over the next year or so. 

Community Level: Building Communities of Care

Community Networks for Seniors

14.       We believe that it is also important to integrate seniors within supportive communities so that they do not feel isolated as mentioned by
Dr Lily Neo. Our goal is to build an inclusive “Kampong for All Ages” through the Community Networks for Seniors (CNS) programme.

15.       As announced at Budget 2018, we will be expanding CNS island wide by 2020. The Silver Generation Office (SGO) placed within AIC, also puts us in good stead through our SG Ambassadors to proactively reach out to new cohorts of Singaporeans aged 65 years and above, bringing health and healthcare to them. And where help is needed, various government agencies and partners will come together to deliver coordinated care to the senior, closing the “social last mile” for our seniors.     

16.       Ms K Thanaletchimi and Dr Lily Neo asked about the benefits of our integration efforts. The transfer of functions from MSF to MOH, including services under the Senior Cluster Networks (SCNs), will be accompanied by a transfer of staff and resources. No jobs will be lost. This will allow MOH to plan and develop health and social support services for seniors more holistically. The staging of SCN services already takes into account the demographics of each planning zone and will continue to do so. The consolidation allows us to make the delivery of services more citizen-centric, increases productivity by minimising duplication, and ensures that no needy senior falls between the cracks. MOH will take the opportunity to review and inject more programming to enhance the SACs such as conducting preventive health and wellness programmes to keep seniors active and well in the community. 

17.       Ms Thanaletchimi also asked about a one-stop centre for all relevant senior services. AIC currently provides a one-stop service to help seniors and their caregivers navigate services and schemes in the community, with several touchpoints to facilitate this. Many of our voluntary welfare organisations (VWOs) are also go-to points for seniors and caregivers.

Community Nursing

18.       In parallel with our nationwide rollout of CNS, MOH will also invest in community nursing. Our healthcare clusters are doing more to support this shift to community care. In the past year, they have piloted eight geographically-based community nursing teams, to anchor population health and care for residents. To date, our community nurses have reached out to more than 10,000 patients. Our nurses are familiar with the services in hospitals and the community, and can bridge patient care needs across both settings. 

19.       We currently have a pool of about 130 community nurses from our three clusters providing care for residents with different needs across care settings, and we hope to increase this to 200 by end 2019. In the area of preventive health for instance, community nurses can reach out to residents in the community and coach them to manage their health better. For residents who have been discharged from hospital, and may have complex medical issues, the community nurse can provide direct care in their homes, for example in wound care management. And for those in need of end-of-life care, they can be supported by community nurses trained in palliative care.

20.       Senior Staff Nurse, Noormala Hamid, from the National Healthcare Group is one example. Noormala is experienced in managing palliative care patients, and works closely with other healthcare professionals to coordinate care plans, administer medication and monitor patients at home. She serves as a bridge between her patients and their doctors, and also provides support to families and caregivers who experience the psychological and emotional challenges that come with end-of-life care.

Community Mental Health

21.       A strong community care system also includes community mental health. Ms Joan Pereira asked how we are making mental health services more accessible, while A/Prof Daniel Goh suggested a national dementia plan. Dementia support has been a central component of our community mental health plan, which I announced last year. We have strengthened measures to provide care for persons with mental health conditions and dementia, including making services more accessible for them. We have made good progress to date. Over 6,000 frontline staff from various government agencies and community partners have been trained to identify and respond to persons with mental health conditions. AIC is the key agency that coordinates care and support for persons with mental health needs in the community, across health and social care sectors including Social Service Offices (SSOs). More than 1,900 individuals have benefitted to date.

22.       In addition, AIC has worked with social service partners to establish a network of 33 community outreach teams to reach out to persons at risk of depression or dementia. They also educate the public on mental health and dementia conditions as part of our outreach efforts. 

23.       In the area of Primary Care, we have rolled out a combination of mental health and dementia services in eight polyclinics. We are on track to meeting our target for one in two polyclinics to implement mental health clinics by 2021. More than 140 General Practitioner (GP) partners have been trained to diagnose and support persons with mental health conditions in the community, supported by allied health-led community intervention teams. To date, 16 of such teams have been established to support the GPs, community and grassroots organisations in caring for persons with mental health conditions.

24.       To date, some 8,800 patients have also benefitted from the Institute of Mental Health’s (IMH’s) post-discharge “after-care” support, transiting smoothly from hospital to home. MOH will continue to work closely with IMH to enhance its capability to monitor these patients post-discharge.

25.       As mentioned by Ms Cheng Li Hui, we have established six dementia friendly communities (DFCs) to create a culture of awareness of dementia and inclusivity so that persons with dementia and their families feel at home and supported in the community. We plan to expand to 15 DFCs in the next three years or so. To date, we have reached out to over 23,000 people to support persons with dementia and their caregivers, and will continue to do more.

26.       Similar to the Singapore Civil Defence Force Community First Responder app, AIC is developing a “Dementia Friends” mobile app to support seniors with dementia and their caregivers. We had initially considered building a national database of persons with dementia, which A/Prof Goh spoke about. However, families we consulted preferred a voluntary approach where caregivers can register their loved ones. Going forward, caregivers can do so by using AIC’s mobile app, and also access useful resources. Members of the public can also register as Dementia Friends to learn about the signs and symptoms of dementia and to help keep a look out for persons with dementia who are lost or wandering.  We plan to launch this app later this year.  

27.       Mr Murali Pillai asked about how we will work with MSF to implement the change for persons with disabilities (PWDs) who need to apply for foreign domestic worker (FDW) schemes.  MOH will accept the client assessment form which is already administered by disability care services such as Day Activity Centres, so that the PWDs need not have to go through an additional assessment.       

National Level: Building Enablers

28.       Next, let me touch on our healthcare workforce, a critical enabler achieving our vision for community care. Given the twin challenges of rising demand for healthcare and slowing local labour force growth, we need to ensure sustainability of the healthcare workforce over the long-term. Our approach, as reflected in our Healthcare Manpower Plan 2020, must be to equip our healthcare workforce with future skills to provide better care, achieve higher productivity in healthcare and grow a strong local core.

Growing a strong local core

29.       The growing healthcare industry offers good jobs, and we are stepping up efforts to attract more locals into the sector, from school leavers to mid-career professionals and older workers. Our local medical intake has grown from 350 to 480 students over the past five years, and we are on track to reach our target of 500 in 2018. The total nursing intake has also increased by 30% from 1,500 in 2012 to around 2,000 students in 2017. To attract more mid-career Singaporeans into the nursing profession, I announced last month that NUS Nursing will launch a two-year Bachelor of Science (Nursing) Programme later this year under the Professional Conversion programme for Registered Nurses (PCP-RN), and will complement the existing PCP-RN at Nanyang Polytechnic.

30.       I agree with Ms Pereira and Ms Thanaletchimi that the silver workforce is an important resource and can be an engine for national development. Today, more than 9 in 10 public sector healthcare professionals who reach the age of 62 are re-employed, and we will do more to attract seniors without prior healthcare experience into the sector.

31.       In going beyond hospital to community, we have also accelerated recruitment efforts over the past year to place more than 1,000 Singaporeans with some 29 aged care service providers in the community. This includes over 40 professionals who made a career switch to the community care sector in 2017 under the Senior Management Associate Scheme.

Building future skills

32.       Mr Henry Kwek and Ms Thanaletchimi asked about our plans to develop the healthcare workforce as we grow the sector. Ms Tin also asked for an update on the training and career pathways for nurses.

33.       MOH has been working closely with SkillsFuture Singapore to develop a Skills Framework for nurses, allied health professionals and support care staff to facilitate a national recognition of skills in the healthcare industry and the development of career progression pathways and remuneration frameworks. This is targeted to be developed by the end of this year, and we will be engaging employers and the healthcare union on its adoption. I note that Ms Thanaletchimi has also called for the formation of an Association for the ILTC sector. As SMS Lam mentioned in Parliament on 1 March, we already have existing structures in place to promote collaboration among sectoral bodies, AIC and MOH, and will continue to strengthen existing partnerships and build new ones.

34.       MOH will be investing in developing a more robust Continuing Education and Training system, which is skills-based and industry-focused, for our nursing profession, to complement pre-employment training, in a few ways.

35.       First, we want to develop a more comprehensive and coordinated system of upgrading to higher qualifications. We will collaborate with our institutes of higher learning and healthcare institutions to design skills-based, modularised and stackable courses for nurses, that can add up over time to higher qualifications. Both Nanyang Polytechnic and Ngee Ann Polytechnic have introduced part-time skills deepening programmes such as the Specialist Diplomas in nursing gerontology, community gerontology and clinical education. As of end 2017, about 90 nurses have enrolled in the three specialist diploma courses.

36.       Later this year, NUS Nursing will introduce a new part-time and modular graduate diploma in Community Health Nursing to equip nurses with the clinical skills to manage population health needs in the community, including clinical decision making and chronic disease management. The new programme will allow nurses greater flexibility in pursuing part-time study while continuing to work. They can obtain a graduate certificate upon completion of each module that will ‘stack up’ towards a graduate diploma. 

37.       Second, we want to build a more robust system of in-employment training, across the acute as well as ILTC sectors. Given the dynamic healthcare landscape, our nurses will have to continue to learn and deepen their skills on the job. MOH, together with the Singapore Nursing Board will engage the nursing leadership to look into a stronger system of skills recognition, so that nurses who are trained by any accredited healthcare institution, can have their skills recognised for portability across the healthcare sector. This may mean that a stronger national skills credentialing capability will have to be built. 

38.  Third, we want to nurture and build up stronger institutions for nursing education. As a start, we will be working with NUS Nursing to strengthen the nexus of its curriculum with practice, by forming a new advisory council comprising key nursing leaders from both the acute and community care sectors. In the future, we envisage new national centres of excellence in specific areas of specialised nursing education that will train practicing nurses across the various healthcare clusters, in specific skills such as geriatric care. 

39.       Taken together, we hope to build a first class nursing education system that can empower our nurses with deep skills and give them the confidence to be at the forefront of driving care transformation. 

40.  During last week’s Budget debate, A/Prof Goh called for an increase in the salaries of our local nurses, citing a lag when benchmarked against the pay ratios in other countries. Let me highlight that the basis of the local income statistics he quoted are not comparable. The median monthly income for full-time employed residents had included employer’s CPF contributions, but the amount cited for registered nurses had not. If we exclude employer’s CPF contributions for both, the local ratio is in fact not 1.06 but 1.2, which is actually comparable to the pay ratio in Australia as cited by A/Prof Goh. However, as workforce demographics and income profiles vary across countries, benchmarking purely based on pay ratios is not meaningful. 

41.  Over the years, we have reviewed the salaries of nurses, which have increased in tandem with their expanding roles and responsibilities. Beyond pay, we have also enhanced professional development and career advancement opportunities for nurses. Through these efforts, we are encouraged that our nursing intakes have increased by 30% over the past five years, and the proportion of males in nursing has also risen from 8% to 10% during the same period. 

42.       I am personally inspired by the experience of Dr Pauline Tan. Currently the Chief Executive Officer (CEO) of Yishun Community Hospital (YCH), Pauline started out as an enrolled nurse at the age of 18, and actively pursued training opportunities to upgrade her skills and knowledge. Over the years, she has made invaluable contributions in various roles within the healthcare sector. Pauline is testament to the capabilities and potential of our nurses and the many career progression pathways available. 

43.       As we deepen the skills and capabilities of our nurses and other healthcare professionals, we can also enhance their scope of practice to support the implementation of more
person-centred care models. Today, all prescriptions drafted by nurses and pharmacists require a doctor’s countersignature. Moving forward, we will revise our rules and put in safeguards to allow experienced and qualified nurses and pharmacists in the public healthcare sector to legally prescribe medicines through collaborative prescribing, under the supervision of doctors, so as to increase patients’ access to quality care. Let me illustrate with an example of 77-year old Mr Tan. Diagnosed with prostate cancer in July last year, he was referred to a home palliative care team upon discharge. With the introduction of collaborative prescribing rights, Mr Tan’s palliative care nurse can assess his condition, and issue the prescription for antibiotics for example, saving his caregiver an additional trip just to collect the prescription. 

44.       We recognise the need to also upskill our allied health workforce as highlighted by Mr Christopher de Souza. MOH and our public healthcare institutions have established various initiatives and grants to support the training and development of allied health professionals (AHPs). These include skills attachments, postgraduate qualifications, and fellowships, in clinical, education and management related areas. We have been supporting the development of close to 250 AHPs annually. 

45.       Our therapy support staff are an equally important group who work alongside therapists to provide rehabilitation care to patients. As a further boost to their training and development, the Institute of Technical Education will be rolling out a new Work-Learn Technical Diploma in Rehabilitation Care in April 2018. The new apprenticeship-based diploma, where a majority of the training is conducted in partnership with the employers, allows newly hired and in-service therapy assistants to take on larger roles to provide rehabilitation care to seniors, and progression in their careers as senior therapy assistants.

Abortion 

46.       Mr Alex Yam asked whether MOH will be reviewing the abortion time limit. This upper gestational limit of 24 weeks for abortions is based on scientific evidence of foetal viability outside the womb. Medical experts from our healthcare institutions note that foetal viability below 24 weeks remains low, while neurodevelopmental disabilities are very high among premature babies who survive. This is also supported by international studies and professional bodies. Only 1% of all abortions in 2017 were performed between 22 and 24 gestational weeks, of which more than half of these were due to foetal anomalies or other medical reasons. MOH will continue to monitor and review this issue as new evidence emerges.

Conclusion

47.       Chairman, to conclude, let me affirm MOH’s commitment to build communities of care for seniors across Singapore so that they benefit from preventive health and affordable quality healthcare that is person-centric. Together with a capable workforce, we can meet the needs of our ageing population in a sustainable manner, enabling our seniors to age gracefully in place and with peace of mind.

48.       Thank you.