Speech by Senior Minister of State for Health, Dr Amy Khor at the MOH Committee of Supply Debate 2016

BETTER HEALTH AND AGED CARE SUPPORT FOR SUCCESSFUL AGEING

(A)         INTRODUCTION

1.            Madam Chair, population ageing presents a unique opportunity for us to redefine ageing, and make Singapore an icon of successful ageing. Ms Joan Pereira asked about MOH’s detailed plans under the Action Plan for Successful Ageing. We have planned a suite of initiatives along two directions.

2.            First, going beyond healthcare to health by investing more in health promotion and active ageing to help seniors live longer and live well. Second, going beyond hospital to home and community by building up a good system of home and community-based care that can provide person-centric care for our seniors. Let me elaborate on each of these.

(B)         ACTIVE AGEING

3.            Health is wealth. I always tell seniors that they need to achieve three “wellness” for successful ageing – physical wellness, mental wellness and social wellness.

4.            Under the Action Plan, we will step up efforts to promote seniors’ health education at different levels – at the national level, in the community, and at workplaces. At the national level, MOH and HPB will embark on a series of public education campaigns on seniors’ health issues this year. HPB will roll out campaigns on topics such as Seniors’ Nutrition, Falls Prevention and Dementia, to raise awareness among seniors on how they can keep healthy.

5.            We will launch a new National Seniors’ Health Programme which is a set of “healthy ageing 101” programmes on health issues important to seniors such as nutrition, exercise, mental wellness and chronic disease management. Seniors will be encouraged to go through this series of six basic health workshops as a start and can attend other additional workshops depending on their interest. This set of programmes will be delivered in the community, as elaborated by SMS Heng earlier.

6.            To enable seniors to be cognitively and socially active as well, MOH has worked with MOE to establish a new National Silver Academy to enable seniors to pursue learning in diverse areas according to their interest.

7.            The Academy is not a physical campus, but made up of a network of education institutions and VWOs offering courses in various fields to seniors. I am pleased to announce that the National Silver Academy will offer over 10,000 learning places across 500 courses this year, and that seniors aged 50 years and above can start to register for courses from next month onwards.

8.            The Academy will offer new learning opportunities for seniors in three areas.

9.            First, Singaporeans will be able to take selected courses offered by ITEs, polytechnics and universities without taking exams. The post-secondary education institutions are making selected modules from their full qualification courses available for seniors to attend without being assessed, for a token fee. Seniors will be able to sit in the same classroom, and learn together with the regular students attending the course.

10.          Second, seniors can now receive subsidies for short courses offered by post-secondary education institutions and VWOs that cover a whole range of topics. Today, such courses offered by the post-secondary education institutions are largely unsubsidised by the government. Under the Academy, Singaporeans aged 50 and above will receive a subsidy of up to 50% off the course fee.

11.          Third, seniors can look forward to a wider range of courses. The Academy will not only include courses from educational institutions, including the two art colleges LaSalle and NAFA, but also those from community-based organisations and other ad-hoc learning opportunities as well. For instance, seniors can also attend inter-generational learning programmes conducted by students in school after school hours, on topics such as technology or music. We hope that the National Silver Academy can not only fulfil seniors’ aspirations to keep learning, but also help shape a new mindset regarding ageing. I think having seniors learn with younger students in the same classroom will foster inter-generational interactions and inspire our younger generation that learning does not stop at any age.

(C)         HOME AND COMMUNITY CARE MASTERPLAN

12.          Madam Chair, together, we can give health and wellness to more seniors and extend the health span of Singaporeans even as their life span increases.

13.          But when our seniors grow frail eventually, we need a comprehensive range of care options to enable seniors to age in place. A/Prof Fatimah Lateef, Ms Tin Pei Ling and Ms Joan Pereira asked about ramp-up plans for eldercare services. In the past five years, we have expanded home and community care capacities to 6,900 home care places and 3,500 day care places today.

14.          We will continue to work hard to develop more infrastructure and manpower needed to grow our services, and we are on track to meet the projected demand of 10,000 home care and 6,200 day care places by 2020.

15.          I agree with A/Prof Fatimah Lateef that beyond capacity, we need to continually enhance the quality of care. We introduced the Guidelines for Home and Centre-based Care last year and are committed to support providers in working towards these Guidelines. In addition to training courses and capability building programmes, AIC is also developing a voluntary baseline assessment framework based on the Guidelines to help providers understand how they can improve.

16.          MOH and AIC regularly engage the sector on various fronts such as in the development of these Guidelines and the Enhanced Nursing Home Standards, in our manpower and quality improvement councils for the sector, and through dialogues such as with the Association of Private Nursing Home Operators. We will study ways to further strengthen our tripartite partnerships, including the suggestion by Ms K Thanaletchimi to set up an ILTC association.

17.          Dr Tan Wu Meng and Ms Joan Pereira spoke about delivering home and community care in an integrated manner. Indeed, this is one of our key strategies going forward. MOH will pilot a number of new initiatives under a new Home and Community Care Masterplan this year to better support seniors to age at home.

18.          First, we want to train and assess a new “corps” of domestic elder carers so that they can anchor good care for seniors at home. We have introduced a Foreign Domestic Worker Grant and lowered the concessionary levy so that it is more affordable for caregivers of frail seniors to hire foreign domestic helpers. But some caregivers still find it difficult to obtain domestic helpers who are proficient in eldercare.

19.          MOH will launch a new “Eldercarer” pilot to provide comprehensive training to domestic helpers before they are deployed to families’ homes. The new training programme, developed in consultation with experienced nurses from nursing homes and community hospitals, includes four days of classroom learning and on-the-job training. Trainers will go to homes to observe the domestic helpers at work and check that they can perform the required eldercare tasks competently. These pre-trained elder carers can then be deployed to families in need. Existing employers who want to send their domestic helpers for this in-depth training can also contact AIC.

20.          Second, we will complement domestic maids with informal caregivers in the community. Dr Lily Neo and Ms Joan Pereira spoke about befriending and support for seniors at risk of isolation. MOH piloted a community befriending programme a year ago where seniors are paired with befrienders living in the neighbourhood who can visit them often, keep an eye on their condition and help them with their needs. Since the start of the programme, some 15 communities have come on-board with over 230 befriendees and almost 90 befrienders. These befrienders are given a small token to cover the costs of their befriending work. Our target under the Action Plan for Successful Ageing is to grow the befriending movement to 50 communities by 2020, which means more than 1,000 befrienders and some 3,000 befriendees.

21.          Third, we will further strengthen our community based home and day care services. To serve the needs of seniors more holistically, MOH has worked with some providers to pilot new Integrated Home and Day Care packages that bundle both home and centre-based care services together. Today we have such a combination – the SPICE programme – for frail seniors. We are now expanding the original SPICE package to pilot three or more new care packages which offer different combinations of care services to meet the needs of seniors with a wider range of frailty.

22.          Let me illustrate this. Madam Lim Miau Chew has multiple health conditions including Parkinson’s disease, which makes it challenging for her to walk, perform activities of daily living and keep track of her multiple medications. During the day, Mdm Lim attends the Peacehaven Bedok Multi-Service Centre, where she receives rehab and nursing care and does recreational activities. The centre will also help her pre-pack her medications. On days when she is feeling unwell, the centre’s staff will check on her at home. They also arrange for basic housekeeping services and meals delivery for her during the weekends, which are additional add-on services not included within the current SPICE. All these services are conveniently bundled within a single, comprehensive care package for Madam Lim.

23.          Some three eldercare providers will be offering these packages with a capacity of over 300 places in the pilot phase. If successful and well received by caregivers, we will scale up the packages. We will also test a new tool to capture seniors’ needs – functional, cognitive and social – holistically for better matching with services.

24.           Fourth, we will build more and better centres to support the new care services. Under the Action Plan for Successful Ageing, MOH is working with HDB to pre-build larger spaces within new Build-to-Order HDB developments to serve as “Active Ageing Hubs” or AAHs. These are one-stop centres for seniors that can serve a range of needs – from active ageing programmes for ambulant and healthy seniors, to day care and rehab services for frail seniors, to “assisted living” services such as grocery delivery. The size of these AAHs will depend on the space available in the developments but can be up to twice as large as the eldercare centres today. We launched the first Request-For-Proposal (RFP) for operating two AAHs at Kallang-Whampoa last month. At least ten future HDB housing developments will have AAHs by 2020.  

25.           Fifth, to close the last mile, we need to improve the system of transportation to care services. In the past year, AIC piloted a programme with Comfort Delgro to engage taxi drivers to send seniors from home to their care centres. The effort is off to a promising start with 25 taxi drivers on the scheme. More than 130 seniors have benefitted from the service, and we hope to expand the service to serve 200 more seniors this year.

26.           Sixth, Regional Health Systems are piloting new programmes to strengthen their support for frail patients in the post discharge period. For instance, SingHealth is piloting a new system of deploying its nurses to provide home nursing care to its patients living nearby, beginning with Bukit Merah.  

27.           Finally, we are investing in research and innovation to pioneer new models of home and community care. We have set up a National Innovation Challenge (NIC) on Active and Confident Ageing to support research and innovation in ageing-related issues including the use of technology. Last year, MOH made two grant calls under the NIC to seek innovative ideas to improve manpower productivity of home care services and enhance dementia care in the community. We received close to 100 proposals and will select the best ideas to be implemented on the ground.

(D)         PERSON-CENTRIC CARE

28.          Ultimately, home and community care must work together with good residential care options to form a robust system of care for our seniors. Thus far, we have largely tendered out our aged care facilities individually or in pairs. Going forward, we need to better integrate different forms of aged care services so that seniors can receive continuous, seamless and person-centric care even as their care needs evolve. To give integration of care a bigger push, MOH will pilot a new Integrated Operator (IOP) Scheme this year. MOH will launch RFPs to appoint operators for bundles of “three-in-one” care facilities and services comprising nursing homes, eldercare centres and home care, within the same area. Under the new IOP scheme, the sector may see up to 500 nursing home beds, 240 day care places and 150 home care places, within one tender.

29.          There are a few objectives to the IOP scheme. First, we want to encourage a single operator to integrate residential and non-residential aged care services into patient-centric care options. Second, we hope these large tenders will enable us to grow bigger players with the economies of scale to provide better and more affordable care for our seniors. Third, by packaging different care services in a region into a single tender, we hope to develop strategic partners who can partner our Regional Health Systems to provide integrated and seamless care from acute to community hospital to long term care, for Singaporeans.

30.          Integrated operators will need to demonstrate that they are able to achieve higher standards of care. They are also expected to do more in terms of workforce development, that is, to train and build up the manpower capabilities in this sector. We will start with a RFP for one bundle – for the South region – later this year, subject to market conditions.

31.          I assure members that even while we roll out IOP bundles, we will continue to call smaller tenders with individual facilities and services for providers who prefer to specialise in a particular care setting.

32.          Our eventual aim is to develop a sizeable, diverse, and resilient sector. We will continue to support all players, both big and small, in developing their capabilities. MOH and AIC have partnered SPRING SINGAPORE to outreach to private sector aged care providers and enable them to tap on the Capability Development Grant to embark on new manpower development or productivity initiatives.

(E)         COMMUNITY NETWORKS FOR SENIORS

33.          Beyond individual services, we need to better integrate the programmes, services and resources within each community, to build a strong “community of care”.

34.          It is for this reason that we are piloting community networks for seniors, as mentioned by A/Prof Fatimah Lateef and Ms Tin Pei Ling. Let me elaborate more on this new initiative and MOH’s role in this.

35.          The aim of the community network for seniors is to enable more systematic collaboration between government agencies and community-based stakeholders, enabling us to leverage on each other’s strengths and resources to jointly support our seniors. A small group of staff from different agencies will work together to drive the development of these networks. There are three objectives of these community networks.

36.          First, we want to expand outreach. The government agencies will coordinate our efforts with local VWOs and grassroots so that we combine forces and collectively reach out to a bigger pool of seniors, rather than visit the same senior a few times over. For instance, Pioneer Generation Ambassadors can inform Pioneers of relevant active ageing and social activities in the community, as part of their current house visits to explain Government schemes.

37.          Second, we want to link the programmes and services across government agencies, VWOs and grassroots organizations together so that we can serve our seniors better. For instance, we can join up healthcare services provided by Regional Health Systems with the social care provided by community-based organizations to support vulnerable seniors better in the community.

38.          Third, we want to engage stakeholders and recruit more resident volunteers in a particular community, to help fellow elderly neighbours. As part of this pilot, MOH wants to work with different partners in the community to recruit and train more neighbour carers that can include the more able and active elderly, who can be paired with seniors living alone in the community.

39.          With Community Networks for Seniors, we hope to build kampongs for all ages, where our seniors can age happily, healthily and actively in place, for as long as possible. If we build up strong community networks over time, caregivers will also have greater peace of mind that their elderly loved ones will have many caring neighbours and agencies on the ground looking out for them.

(F)          GROWING AND DEVELOPING OUR HEALTHCARE MANPOWER

40.          A/Prof Fatimah Lateef, Dr Chia Shi Lu and Ms Tin Pei Ling asked about our plans to grow the healthcare workforce. In the midst of a more uncertain economic climate, the growth in the healthcare sector will provide good job opportunities and meaningful new careers for Singaporeans. MOH is stepping up efforts to attract fresh school leavers and mid-career professionals to join the healthcare industry. For instance, we are enhancing information and outreach, through career talks and exhibitions, engaging the ECGs, to secondary school students.  

41.          We will also continue to support providers to recruit nurses, allied health professionals and care staff for the aged care sector. We launched the online ILTC Careers Portal in 2013 and a branding campaign earlier this year to raise awareness of opportunities in the sector.  We have facilitated the recruitment of 107 locals through our job fairs over the past one year. MOH has also provided funding support to enhance the pay competitiveness of healthcare workers in VWO providers, in tandem with the pay increases in the public healthcare sector.

42.          We will do even more this year to enhance recruitment for the aged care sector. A/Prof Daniel Goh suggested recruiting retired nurses to deliver home and community care. Today, some of our home care providers are already doing so. To better attract non-practising local nurses back to work in the growing aged care sector, we have enhanced the Return-To-Nursing scheme in April this year. We have strengthened training in areas such as geriatric and palliative care in a 3-month refresher course and enhanced training allowances. There will also be a new one-time Community Care Placement Bonus at $3,000 for Enrolled Nurses and $5,000 for Registered Nurses who join the aged care sector.

43.          There is also an increasing need for PMETs who can take on management and supervisory positions in new aged care facilities. We have therefore launched a new Senior Management Associate Scheme to attract mid-career talents with supervisory or managerial experience, who are interested to explore a career switch to the aged care sector. We aim to recruit 10 mid-career talents per year. They will undergo three months of training with AIC to understand the sector before taking up senior positions like Centre Directors in the institutions. MOH will provide funding support to the institutions for the remuneration and benefits given to these mid-career talents.

44.          Even as we explore more initiatives to grow local workforce participation in the sector, there is still a need to bring in foreign healthcare workers to augment our local supply. We will continue to help these workers adapt to our practices and working environment, so that they can be effective members of our teams. A/Prof Daniel Goh spoke about home nursing providers who bring in foreign nurses under foreign domestic worker permits. I would like to clarify that providers can only deploy nurses registered under the Singapore Nursing Board to deliver home nursing services. The providers A/Prof Daniel Goh mentioned are actually employment agencies who bring in care aides to assist senior clients and they hold foreign domestic worker permits.

45.          In parallel with efforts to grow the workforce are efforts to deepen skills and build new capabilities. To date, more than 7,000 ILTC staff have undergone various training, from care skills training to leadership programmes under the AIC Learning Institute. Under the national SkillsFuture initiative, we will introduce the Healthcare Skills Future Study Awards to support skills upgrading of the healthcare workforce. The $5,000 study awards will support learning and development in the areas of aged care, healthcare IT and analytics and healthcare system design, organisation and delivery, and will benefit 50 healthcare staff this year. The awards will open for application from June 2016.

46.          MOH will also champion initiatives within the public healthcare sector to make our healthcare institutions age-friendly and enhance the workplace longevity of older experienced staff. Our healthcare institutions will be systematically introducing mechanisation to take away the physical strain of healthcare jobs. We will also redesign jobs, introduce flexible work arrangements (FWAs) and provide retraining to create more opportunities for older Singaporeans to work in the healthcare sector. For instance, the National University Hospital has started a flexi-work pilot for Singaporeans to help ward nurses with basic care duties so that the nurses can focus on clinical nursing work. NUH targets to have up to 50 of such Basic Care Assistants and has already hired 16 under the pilot phase.

47.          Ms Thanaletchimi and Dr Chia Shi Lu will also be pleased to note that all healthcare clusters today have FWAs in place to help workers balance work and personal demands. These include part-time employment, compressed work week, flexible work schedules and hours. Last year, four hospitals piloted new FWAs for nurses in selected wards, where the timing of the afternoon shift was brought forward to allow the nurses to spend more time with their families and friends after work. MOH is currently working to facilitate electronic rostering systems so that more FWAs for nurses can be scaled up to all public healthcare institutions.

48.          Our healthcare institutions will also strengthen workplace health programmes and introduce new retirement planning programmes for their mature workers. These include pre and post retirement workshops, to guide older healthcare workers through career transition issues.

49.          In short, despite the current economic uncertainty, the health and aged care sector is expanding and will be able to offer many different good jobs for Singaporeans of all ages.

(G)         COMMUNITY MENTAL HEALTH AND DEMENTIA SUPPORT

50.          A/Prof Fatimah Lateef and Ms Tin Pei Ling asked for an update on community mental health. Last year, I updated the House that we will systematically strengthen our community mental health efforts in a few ways. I am pleased to report that we are making steady progress.

51.          First, to enhance the mental wellbeing of Singaporeans, HPB has rolled out initiatives to equip the public with knowledge and skills to keep mentally well and seek help early, if needed. For example, their “Working Minds” talks and workshops in workplaces impart skills on managing stress and developing resilience so that employees can perform at their best. 4,500 employees from 90 SMEs have participated in these workshops since they started in 2013.

52.          Second, to help detect and support the treatment of mental health patients in the community, AIC has trained and partnered over 100 GPs and set up six specialist-led community based teams to guide our primary care providers in managing patients with more complex issues. Six allied health-led community teams have also been set up to support GPs by providing counselling and psycho-education to clients and caregivers. This is an increase from the 70 GP partners and nine specialist and allied health-led teams last year. As at end 2015, these teams have seen over 7,000 clients, an increase from 4,700 the previous year.

53.          Third, we have reached out to 36 constituencies, 16 in the past one year alone. Over 800 grassroots leaders, volunteers and community partners have been trained in basic mental health knowledge and symptoms of mental illness, which allows them to identify, respond and support residents with mental health challenges. This is an increase from the 400 trained in 2014. AIC has also trained over 500 staff from ground agencies, such as HDB, Town Councils, SPF and Family Service Centres. In addition, advisors in all 89 divisions have been given a single AIC contact point for easier referral to assist residents with suspected mental health issues. AIC will be the first responder and lead in coordinating further assessment and care. To address Dr Lily Neo’s suggestion, SSOs today can refer persons with suspected mental health issues to AIC for assessment as well as help provide the necessary support if needed as part of the overall care plan.

54.          Fourth, IMH is strengthening its after-care services to better support clients post-discharge, so that they could be better managed and supported to continue to live in the community. Together with AIC, IMH is piloting an integrated model of after-care case management for clients with moderate to complex social and healthcare needs. Case managers assigned to these clients will assist in their transitional care upon discharge and link them to community support partners. These after-care teams have reached out to over 150 clients since 2015.

55.          IMH is also enhancing its capability to monitor higher risk patients post-discharge and ensure that they comply with follow-up treatment. If a patient refuses or defaults on treatment, IMH will work closely with family members, caregivers and other community partners to engage the patients. Currently, the Mental Health (Care and Treatment) Act does not provide for enforced treatment of psychiatric patients in an outpatient setting. We can study Dr Lily Neo’s suggestion whether to compel outpatient mental health treatment, taking reference from overseas models such as Scotland, England and Australia. Nonetheless, the experience of these countries is mixed so far, and there is no robust evidence to show that community treatment orders are effective in achieving key outcomes such as reduced hospital readmissions, improved medication adherence and patients’ quality of life. Even as we study such an approach, it is important that we continue to enhance access to mental health services and continuity of care.

56.          We share Mr Low Thia Kiang’s concern about funding for mental health, and take a calibrated approach in ensuring comparability in coverage. Patients requiring inpatient treatment can enjoy government subsidies similar to other medical treatments. The MediShield Life claim limit and Medisave withdrawal limit for psychiatric treatment are lower, as its bill size is generally lower as well. The median post-subsidy bill per day in 2014 was $60 for psychiatric treatment, compared to $350 for non-psychiatric treatment. Taken together, the MediShield Life and Medisave limits were sufficient to cover 7 in 10 subsidised inpatient psychiatric bills. Medifund assistance is also available for those who are unable to afford treatment even after subsidies, Medisave and MediShield. Patients requiring outpatient mental health treatment can receive government subsidies at our SOCs and polyclinics, which were recently enhanced for lower to middle-income patients who also enjoy CHAS subsidies at CHAS GP clinics. Pioneers can receive special subsidies at SOCs, polyclinics and CHAS GPs. All patients can also use Medisave for psychiatric conditions under the Chronic Disease Management Programme and our seniors can further tap on Flexi-Medisave.

57.          We recognise the stresses of caregiving highlighted by Ms Cheng Li Hui and Ms Kuik Shiao Yin and have enhanced support for caregivers to make it easier for them to navigate our care system. Caregivers can approach AIC’s AICarelinks at AIC’s office and our hospitals. These are one-stop points to get information and advice on the appropriate services for their loved ones. They can also contact AIC’s Singapore Silver Line for support on all matters relating to mental health and eldercare services. Besides the four major languages, there are dialect speaking agents available for seniors who are more comfortable speaking in their native dialects. We have also put in place programmes to help patients and their caregivers transit more smoothly from the hospital to home. Since 2008, AIC has care coordinators who help patients look for services required after their discharge, and follow-up with them to provide further support post-discharge through phone calls, home visits or both. To ensure their well-being, we have also made respite care more accessible for caregivers and enhanced subsidies to help defray the costs of caregiving. AIC also works closely with community touch points to look out for caregivers who may be stressed and render assistance where needed.   

58.          As noted by Mr Low Thia Kiang, Ms Cheng Li Hui and Dr Tan Wu Meng, the focus for our community mental health efforts going forward will be on dementia. With a fast ageing population, and a dementia prevalence rate of about 10% amongst seniors aged 60 years and above, we can expect the number of seniors with dementia in Singapore to grow with time.

59.          We are strengthening community-based support for persons with dementia and their caregivers. We have three home intervention teams to support caregivers in managing challenging behaviours of their loved ones with dementia at home, which have reached out to close to 200 clients and caregivers to date. The 10 outreach CREST teams have also reached out to more than 39,000 seniors at risk island-wide. We are also expanding capacity of dementia care services in the community. By 2020, we will have 3,000 dementia day care places, 1,970 dementia nursing home beds and 160 eldersitters.

60.          Madam Chair, we need to rally the whole Singapore “kampong” to play a part in supporting seniors with dementia and their caregivers within our communities. Last month, I launched an effort to build a Dementia-Friendly Community in Hong Kah North, after the first such community was launched at Chong Pang. We are working with other divisions such as MacPherson, Queenstown and Bedok to embark upon this initiative too.  Under this initiative, we will build up networks of Dementia Friends who are trained to recognise and provide assistance where necessary to persons with dementia. We will also pilot a safe return system for lost seniors and step up efforts to raise public awareness such as through AIC’s dementia toolkit. We hope to encourage more communities to come together to build a dementia-friendly Singapore.

(H)         WOMEN’S HEALTH COMMITTEE

61.          Moving on to women’s health issues,  I am pleased to update that I will be chairing a revamped Women’s Health Committee to focus on three key health issues among women. These are increasing cancer screening uptake, promoting bone health and fighting diabetes, particularly diabetes linked to obesity and gestational diabetes which Ms Tin Pei Ling and A/Prof Fatimah Lateef asked about. Specifically for gestational diabetes, the Committee will complement the work of the diabetes taskforce and look into providing support for women with gestational diabetes to reduce the risk of complications during pregnancy and risk of Type 2 diabetes and cardiovascular disease for the child. Promoting bone health is also important for women who are at higher risk of osteoporosis than men. The Committee will also encourage women to promote good health in our families, such as by breastfeeding our infants, which may reduce the risk of obesity and hence diabetes for them later in life, provide them with the best possible nutrition and protect them against illnesses and allergies.  

(I)          CONCLUSION

62.          Madam Chair, the Action Plan for Successful Ageing is our blueprint to prepare for rapid population ageing. A Nation for All Ages has to be built by all Singaporeans together. With many hands and many hearts, I am positive that we can face population ageing confidently and successfully.

Thank you.