With wisdom, realism and humanity

04 Mar 2011

By Health Minister Khaw Boon Wan

1. Last month, I tossed vegetarian “lo-hei” with Prof William Haseltine. He is an outstanding academic, inventor and entrepreneur, a rare talent. At Harvard University, he became a founding father in an evolving branch of research which sequenced DNA and used the human genome to identify and treat diseases. He holds many patents and founded several biotech companies. His current interest is to seek out healthcare innovations and apply them globally to bring about cheaper and better healthcare.

2. I first met him at an NUS Healthcare Forum last year. He was intrigued by our healthcare system, delivering first world standards at only 4% of our GDP. Many OECD countries spend more than 10%. He was in town to find out more, with the intention of writing about it.

3. Prof Haseltine’s assessment corroborates with several commentaries about Singapore’s healthcare system that appeared during Obama’s health reform debates. For example, a Wall Street Journal article in November 2009 described Singapore as having “world-class quality care at world competitive prices”. The article added that “Singapore’s example might have something to teach them about the kind of reform Americans really need.”

4. The Austrian Health Minister was also in town last month. After spending some time at the Khoo Teck Puat Hospital (KTPH), he remarked that many of the policies that he was planning to introduce in Austria were routinely done here. I took that as a compliment from a well-informed peer.

5. We do not claim our system to be perfect. But we achieve a better outcome for our people, because we have more readily acknowledged the hard truths of healthcare and forged our system based on such insights. What are the hard truths?

a. There is no free healthcare; someone has to pay the bill;

b. While most people are honest, some patients and some providers do abuse the system at the expense of the vast majority of honest people;

c. More healthcare does not always deliver better health; beyond some point, there are limits to medical science;

d. Many healthcare problems are self-inflicted (Mr Lam gave the example of the patient with COPD); no medicine, for example, can help a patient with COPD (chronic obstructive pulmonary disease) unless he quits smoking;

e. Incentives can work in healthcare but poorly-designed though well-intentioned health policies can end up distorting behaviour; and

f. And lastly, most importantly, we are all mortals and will die one day.

6. Many other healthcare systems choose to ignore these hard truths, and are for instance, based on wishful thinking that people can live forever, that more treatment is better, and there is a cure for every disease, “a pill for every ill”. For the terminally ill, they will strive to prolong life at all cost, never mind the quality of life nor the futility of such efforts. The US spent 18% of its GDP on healthcare and they know that much of that is unnecessary.

7. My recent heart bypass has sharpened my sense of my own mortality. I have regained my fitness level. In fact today is exactly 10 months after my bypass and I have become even more diligent in my regular exercises, but I know the score of living with a heart disease. I am 59 and do my best to keep my body in good condition, live a full life, and hope to grow old with dignity. But I am under no delusion and I know that someday I too will leave.

8. The question is how? Like others, I have my share of worries. Will I suffer a stroke that condemns me to severe disability? Will I develop dementia and lose my mind?

9. At every Chinese New Year, I wish my residents “健康长寿” (good health and longevity). They said yes to the good part, good health. But on longevity, many said: “not too long please”. I know what they meant. We strive for a long meaningful life But the two words “long” and “meaningful” come together to make a happy person. A long life of pain and suffering is a miserable life.

10. I am reading Susan Jacoby’s latest book: “Never Say Die”. She was most critical of the American approach to end-of-life care. In it, she related her last conversation with her grandmother in a nursing home when she was nearly 100 years old. This was what she recalled: “A small boy tossed a beach ball in our direction. Gran(dma) tried to rise from her chair and throw the ball back, but she was too frail to stand without help. Collapsing backward, she said in a soft voice devoid of either self-pity or anger, ‘the worst thing about having lived too long is you know you are of absolutely no use to anyone.’ It was agonising for me to hear my grandmother say this, because she defined herself by her usefulness.”

11. I often visit nursing homes with my grassroots leaders. Some patients welcome our visit as it breaks their daily routine and we do bring cheer to them. But many with severe dementia live in their own lost world, oblivious to what is going on around them. Many others are clearly suffering. Often, I looked at my grassroots leaders and by body language, without a word being spoken, say to one another: “Let’s hope we do not end our life this way.” I would silently offer a prayer for the patients.

12. In my Ministry, we crafted a phrase “with peace of mind” into our vision to help Singaporeans “live well, live long and with peace of mind”. We meant this seriously. I took this vision diligently. My personal mission in life is to help serve the young and the old so that they have peace of mind: “老者安之，少者怀之” (Confucius). We cannot eliminate death and suffering. But we can avoid inflicting unnecessary pain and suffering to the natural process of dying by being wise in our healthcare policies and in how we structure our healthcare system.

13. In her book, Susan Jacoby wrote about an American woman who, just a month before her 100th birthday, underwent surgery to install a special defibrillator and pacemaker in her failing heart. When it happened, it was front page news on New York Times. That is a great achievement in medical science. The surgery postponed her death and extended her life for a while. But her life was one of suffering, requiring the full-time services of a home health care aide, and being confined to a wheelchair with both failing vision and hearing. This may be an extreme example, but in the US healthcare system, such cases of aggressive medical intervention during one’s last few months or weeks are not uncommon.

14. We have a good and relatively inexpensive healthcare system because we have sensible and wise doctors. We must not port in mindlessly foreign practices based on fallacies and unrealistic expectations. That will only bring misery to the patients and their families, at great cost to society. Singaporeans are living longer and with it, there will be greater demand for healthcare services. They also want to age in place, at home and in the community, except for the occasional emergencies to the acute hospitals. Much of the healthcare services for the elderly can be competently delivered in the community, away from costly hospitals. That is why Budget 2011 places so much emphasis on long term care. Even as we improve our hospitals, we will do even more to transform our long term care sector and many MPs spoke about this.

15. We have started this journey and we are on track. The new KTPH illustrates how we are making progress. Most MPs have visited it. You have seen how we have raised services, especially for the patients in Class B2 and Class C, to a higher level, delivering a “hassle-free” hospital experience. You have also heard how KTPH is reaching out to the community outside of the hospital, and supporting them to look after the discharged patients. All the hospitals’ CEOs know that their responsibility extends beyond the hospital walls. It is not just KTPH. There is also a quiet revolution in CGH, TTSH, NUH, and polyclinics, and we have made progress in mental health, chronic disease management, integrated care between hospitals and the community.

16. But the work is not finished. I still have a substantive agenda of things to accomplish. If we stay the course, over the next 5 to 10 years, we can further transform our healthcare, to be among the best in the world. Let me sketch out our plan in 7 areas.

Build A General Hospital In Every Region

17. First, we will realise our vision of a general hospital in every region. In the north, KTPH has added 550 beds to our bed capacity. In the west, the Jurong General Hospital is on track to open in 2014 with 700 beds.

18. Dr Lam Pin Min will be pleased to know that a new general hospital will come up in his constituency to serve the residents living in the north east. The new Sengkang General Hospital will be located next to the Cheng Lim LRT station. It will also be within walking distance to the Sengkang MRT station, which is in Mr Charles Chong’s constituency. It will open by 2020. Given a lead time of 6 or 7 years to design and build, it is not too soon, nor too late, to start planning. I have asked the SingHealth Cluster to assemble a young outstanding team to take charge of this project. I will challenge them to build a hospital, even better than KTPH and JGH, measured from the patients’ point of view.

19. All the 3 new general hospitals will have community hospitals adjoining them, and this will significantly expand our current community hospital capacity. These are multi-billion-dollar investments. But they are worthy investments. Together with TTSH serving the central and CGH serving the east, they will realise our vision of bringing healthcare close to the residents living in each region of Singapore. Good healthcare will be within 30 minutes of every patient.

Match Global Best In Health Outcomes

20. Second, we have achieved very good mortality indicators, including life expectancy, child mortality and other disease-specific death rates. We will now measure how specific diseases impact on the overall well-being of Singaporeans. To do so, we will track morbidity indicators and strive for further improvement. My vision is to get our morbidity indicators to match the top tier of OECD countries in the key disease areas which matter to us, like heart disease, diabetes, mental disorders and cancer. We are currently about average, among the OECD countries. Let’s move up to a higher tier.

21. This means knowing how to better treat these common diseases, whether in terms of prevention, early detection, treatment, rehabilitation or continuing care. For example, the example mentioned by Prof Straughan just now on mammogram. This will require us to raise the capabilities and outcomes of our national specialist centres to match the best elsewhere. Where appropriate, we will invest in building new capability peaks in areas such as organ transplant, geriatrics and rehabilitation.

Redevelop Our Polyclinics

22. Third, we have been redeveloping our polyclinics to meet the challenges of an ageing population. Over the past 5 years, we have upgraded 8 polyclinics, including Woodlands, Bukit Batok and Pasir Ris Polyclinics, and also Hougang Polyclinic. As Dr Fatimah Lateef put it, strengthening primary care is important. Several MPs toured the upgraded Pasir Ris Polyclinic recently. The upgraded polyclinics are now paperless, fully computerised. They are film-less with tele-radiology services. X-rays are being read in Indianand being returned within half an hour. They are scriptless, with e-prescription capability. They are piloting tele-ophthalmology, to cut down unnecessary referrals to the hospital ophthalmologist. The use of technology addresses a point that Cynthia Phua brought up and all these are being done in our polyclinics.

23.  They are also multi-disciplinary, with Advanced Practice Nurses, clinical pharmacists, podiatrists and clinical psychologists providing consultations, side by side with Family Physicians. Patients with chronic diseases are given clinic appointments for their regular follow-ups. It is no longer just simply walk-ins. This has cut down their waiting time.

24. Our polyclinics are no longer like in the past. That is why I have arranged for some MPs to visit them. One patient emailed me last month, pleasantly surprised by the transformation: “I visited the Marine Parade Polyclinic...The service was fast, friendly and efficient. The time from registration to payment was less than half an hour. A far cry from the days when a visit to the polyclinic was a two-hour affair.”

25. I know that waiting remains a problem in polyclinics for walk-in patients without any appointment. But for those with appointments, waiting is now manageable. And we will continue to upgrade the other polyclinics. Over the next 5 years, Ang Mo Kio, Bedok, Geylang, Tampines and Yishun Polyclinics will benefit from this Polyclinic Redevelopment Programme. This will cost us $50 million.

26. For the rapidly expanding population in Punggol, we are also planning a new polyclinic in that town. This will help relieve Sengkang Polyclinic.

Transform Our Long Term Care

27. Fourth, we will transform long term care, like community hospitals, nursing homes, day rehabilitation, and home healthcare, which many MPs spoke about. Done well, this will particularly benefit the elderly with chronic diseases. The objective is to help them manage their diseases well, so that they can have a good quality of life. Transforming long term care is our top priority in the next decade.

28. We will sharpen our focus on geriatric care. We will equip all our doctors, nurses and allied health professionals with knowledge of geriatric medicine as a core competency. Of course the health care professionals must also acquire the soft skills to cater to the concerns of the patients. We have begun preparations to set up a Geriatric Education and Research Institute this year to develop, coordinate and implement various initiatives to strengthen geriatric education and research.

29. We will develop integrated care pathways starting with five groups of patients with: hip fractures, stroke, heart failure, COPD and diabetes. By standardising critical elements of care and defined clinical indicators, these integrated care pathways will enable patients to transit smoothly from one healthcare provider to another across the care continuum. This is what I meant by a “hassle-free healthcare system”. This is also the sort of preferred outcome that Mdm Fatimah said earlier.

30. Our AIC – the Agency for Integrated Care is just a year old, and is already making impact in the long term care sector. They are doing what Dr Lam described as supportive services to facilitate care in the community. For example, AIC stations teams of Aged Care TransitION (ACTION) care coordinators in hospitals to help patients with complex needs transit smoothly from the hospital back into their homes and communities. Their services include helping the patient to arrange relevant community services for the patient and their caregivers. And they have already touched the lives of over 10,000 patients. “Hassle-free”, “integrated care”, “clinical pathways” are abstract technical terms. But when translated into actual actions on the ground, they make a world of difference for the patients and their family members.

31. Ask Mdm Samsiah Saifi. Her husband suffered a stroke, became paralysed and bed-ridden. Overnight, she became both sole bread-winner and sole care-giver. She was at her wit’s end. Her ACTION care coordinator from NUH slowly coached her on the appropriate home-care services, and followed up by visiting her husband to check on his condition and medication. Mdm Saifi has her hand-phone number, to consult round the clock. This has given her confidence and peace of mind. AIC has brought cheer back to her life and that of her family. With AIC, there are now many such success stories. We are scaling up AIC operations nation-wide to benefit more patients.

32. One primary objective is to help Singaporeans avoid unnecessary hospitalisation. For example, old folks falling resulting in emergency hospital admission are common stories. You avoid falls, you avoid hospitalisation. TTSH works closely with the elderly in the community to assess falls-risk and then coach the high-risk seniors to improve their balance. As a result, their re-admission rates have been cut.

33. Every day, some seniors in some nursing homes will develop some complications. Without resident geriatricians, the only recourse is to call for an ambulance to send them to a hospital A&E. KTPH works with St Joseph’s Home on tele-consultation, so that the nursing home can consult the hospital geriatrician, over the internet, before they call the ambulance. Not all admissions are necessary and timely advice from the hospital geriatrician is often what is needed. Patients, doctors, nursing homes and hospitals’ A&Es save time as a result. Everyone benefits.

34. For our healthy elderly who are living at home, we want to help them stay active within the community. Some eventually may suffer from age-related functional decline. In particular, mobility can become a problem. It raises the risk of falls and the need for caregiver support. A simple mobility device like a walking frame or a wheel chair can make a difference. But VWOs have told us that some of their clients could not afford such devices. They cannot pay, so they make do with umbrellas. But umbrellas are poor substitutes, and they still fall. The VWOs have to raise funds to help the patients obtain the proper devices. But the needs are larger than what their limited donations can cover.

35. We are setting up Senior’s Mobility Fund with $10 million. The objective is to help the VWOs reach out to more such low-income elderly, and provide them with basic mobility devices. This will require some means-testing, needs assessment and co-payment. This will be done by the VWOs. This way, we allow greater flexibility and responsiveness in adapting the scheme to local needs. For example, there may also be cases where some sort of transport assistance to help seniors go for their regular rehab exercises may be greatly beneficial. The desired outcome is to enable the elderly achieve independence so that they can move around with greater ease, to perform necessary tasks like getting to their day rehab exercises, or simply just going downstairs to the void deck or to the coffee shop.

36. Transforming our long term care includes transforming our nursing homes. One significant step is our Nursing Home Development Programme to build new nursing homes in HDB towns. I have discussed this before, including on how to raise their rehabilitative capabilities to help their patients get well and go home. In other words, as Ang Mong Seng put it, for them to regain their mobility in nursing homes, not old folks’ homes.

37. Such improved outcomes also require us to transform our home healthcare sector. Ms Ellen Lee and Dr Lam stressed this point. This means putting in place supportive structures and services in the community. We are ramping up the Home Nursing Foundation (HNF). They now have nurses in TTSH to connect up with patients about to be discharged to ensure a smooth handover for patients who are likely to require home healthcare. Once the patient is home, HNF coordinates with other providers to meet the patient’s care needs in the community. There are now over 300 patients under their care. We will expand this programme to other regions so that more Singaporeans can benefit from home care. But it is not just HNF, we will similarly support other VWOs like Touch Community Services and other providers such as NTUC ElderCare to expand home care.

38. For home and community care to work, I agree with Members on the central role of the caregivers. They are the unsung heroes and heroines, making huge personal sacrifices, whether out of love, filial piety or simply just plain human decency. My Ministry will do all we can to support them, with skills training, counselling, psychological support, and sometimes a shoulder to cry on. Dr Lam Pin Min asked about caregiver allowance. This goes beyond my Ministry’s purview. I believe Minister Lim Boon Heng has addressed this point a few days ago. But let me give you my personal take on this. I believe paying caregivers to provide care-giving is an insult, it cheapens the care given. If you believe in this cause, the whole society ought to support this. This is how we should address this whole issue of caregiving, as a society.

Exercise And Go For Regular Check-Ups

39. Fifth, we will step up efforts to help Singaporeans stay healthy. As stressed by Dr Lam, this is ultimately the most basic strategy: Singaporeans must take ownership of their own health, and embrace a healthy lifestyle. We have increased the budget for the Health Promotion Board to $120 million. They will find creative ways to promote the healthy lifestyle message and to involve the community extensively. Taking SM Goh’s advice, we will shift the National Healthy Lifestyle Campaign from being top-down to a more ground-up initiative. Soon we will be coming to MPs to seek your support and active involvement to help us achieve this breakthrough.

40. A healthy lifestyle includes a habit to go for regular health checks. Last month, the Academy of Medicine published very useful guidelines on what to screen. My Ministry has accepted the guidelines in full. It will help Singaporeans, in consultation with their doctors, to choose the appropriate health screening tests that they should undergo, given their age and individual risk profile.

41. Among the guidelines, there are two relatively costly items: colonoscopy and mammogram. I agree with Dr Lam Pin Min that we should make these tests affordable through Medisave. Dr Lily Neo and Mdm Halimah made a similar call for mammograms before. I agree with them. We will extend Medisave, within withdrawal limits, to cover mammograms for breast cancer screening in women aged fifty and above, and colonoscopies for colorectal cancer screening for persons aged fifty and above. We will get this implemented as soon as we can make the necessary changes to the computer programmes.

Keep Our Community Strong

42. Sixth, we will strongly involve the community on healthcare issues. There are several aspects to it. Keeping Singaporeans healthy requires the community to collectively keep the environment clean. Peer support helps to sustain a healthy lifestyle among all Singaporeans. Fighting viruses requires a united community response.

43. Our society is built on meritocracy and equal opportunities for all. But some will do much better than others. The more successful in turn help the less fortunate. That is how philanthropy underpins social bonding and unites people as one. Hence, the Chinese saying “滴水之恩，当涌泉相报”, to exhort people to pay it forward in society when able to do so.

44. Our migrant forefathers walked such talk. For example in healthcare, the late Mr Tan Tock Seng and Mr Lee Kong Chian left behind their philanthropist legacies in the Tan Tock Seng Hospital and the Lee Kong Chian Medical School. They were the eminent philanthropists of the last century.

45. In the US, Bill Gates and Warren Buffet are spearheading a modern version of philanthropy by pledging at least half of their fortune to charity. At least 40 billionaires have joined their cause. Their efforts are softening the “winners take all” capitalist model. The American system has always had philanthropists who supported their top universities and hospitals. What is different this time is that they are parting with their fortune while they are still alive. As Mr Michael Bloomberg, one of the 40 billionaires, put it: “You don’t have to wait to die to give it away. It never made a lot of sense to me why you’d want to change the world for the better and not be around to see it.”

46. Several years ago, the family of the late Tan Sri Khoo Teck Puat indicated that they would like to donate to the healthcare sector. I suggested that they consider supporting the new hospital which we were then building in Yishun. They readily responded with a generous donation of $125 million. Tan Sri Khoo was an eminent philanthropist of this century and deserved the recognition when we named the new hospital at Yishun after him. There are other eminent philanthropists. I am happy to inform this House that the family of the late Mr Ng Teng Fong has decided to donate $125 million towards the new hospital in Jurong. That is a big boost to our effort to provide high quality healthcare for Singaporeans living in the west. In recognition of the significant donation, we will name it Ng Teng Fong Hospital. Both are Government hospitals, fully funded by the Government. But the private donations provide additional assistance to needy patients, besides funding other worthy services.

47. In similar spirit, through the $1 billion Community Silver Trust, we hope to inspire successful Singaporeans to come forward to co-develop our long term care sector. This sector has always been served by the VWOs, with passion and compassion. For the next stage of the development, we need to inject more funds, more skills, more resources, and more diversity to help raise capabilities and make them world-class. By matching donations, we preserve the legacy of the long term care sector being driven largely by VWOs and the community. By matching public donations, we hope to attract larger donations into this relatively less glamorous sector.

48. Community support does not merely come in the form of financial donations. Many Singaporeans have been volunteering their services in the hospitals. For example, a team of volunteers has been nursing the roof-top garden at KTPH and contributing their labour and expertise every day. All kinds of vegetables and fruit trees have taken root. I go there quite often and I see the volunteers sweating away and they told me they are happy to do it. Why? Because they know that their harvests will benefit many patients in the wards. We will continue to encourage and support such community spirit.

Keep Healthcare Affordable Always

49. Finally, our commitment to continue ensuring that healthcare remains affordable for all Singaporeans is firm. Our 3Ms framework – Medisave, MediShield and Medifund – is time-tested. It is an important supplement to the government subsidy framework which is the main financier of inpatient care. This year’s Budget will put nearly $7 billion into healthcare: $4 billion in MOH budget and $3 billion in various top-ups to help Singaporeans pay their medical bills. This has enabled us to help more needy Singaporeans and we will also continue to enhance our 3Ms. In the new financial year:

a. We will increase the Medifund budget allocation to $85 million, from $80 million to help more subsidised patients;

b. We will double the Medication Assistance Fund (MAF) to $20 million, to help needy patients pay for expensive drugs. MAF will be extended to cover six more drugs, including Candesartan and Valsartan to treat heart diseases, Trastuzumab to treat breast cancer and Rituximab to treat non-Hodgkin’s lymphoma;

c. We will double the subsidy cap for surgical implants to $1000. Mdm Halimah made this request in this House recently. This will cover up to 90% of implants used in our public hospitals;

d. We will expand Medisave to cover outpatient treatment for two more diseases, dementia and bi-polar disorder, in addition to 8 existing chronic diseases, making it a total of 10. This should have practically cover all the major chronic diseases;

e. We will expand PCPS, the Primary Care Partnership Scheme (PCPS) that Mr Low mentioned just now, to cover all the 10 major chronic diseases. This will make it convenient for the elderly to receive subsidised care from the many participating GPs in their neighbourhood; and

f. We will also extend PCPS to cover two specialist dental procedures: root canal treatment and crowning.

Other Matters

50. Before I conclude, let me briefly address some specific comments made by Members.

51. Ms Ellen Lee asked whether we would operate 24 hour polyclinics. I am not keen. There are only so few polyclinics but there are thousands of GPs outside. I think we should leverage on the network of GPs and through PCPS. This is a much more cost-effective solution.

52. Dr Lam and Prof Paulin Straughan suggested that we incentivise healthy behaviour, like giving credit for citizens who participate in community-based health screening programmes. We do subsidise community-based screening for seniors. But I am not persuaded that we have to bribe them to do what is good for themselves.

53. Dr Lam Pin Min had a question on the utilisation rate of Medisave overseas. So far, only 58 patients have withdrawn about $125,000 from Medisave for their treatments in Malaysia. What is the benefit of the scheme when I introduced it? It is to widen the choice for Singaporean patients. I still believe it but the low utilisation rate re-affirms the confidence Singaporeans have in Singapore healthcare. We should be proud of that.

54. Dr Lam also asked about our preparedness for pandemics. We have experienced two pandemics: SARS and H1N1. We did very well in both. But I agree with Dr Lam that we must not become complacent or arrogant. We must always be prepared for surprises. Our preparedness plans are multi-sectoral and they are regularly reviewed, tested and enhanced. The plan includes stockpiling pre-pandemic vaccines as soon as they become commercially available. We have also secured new funds to support infectious diseases research.

55. Sylvia Lim talked about Standard Drug List (SDL) and also osteoporosis. She asked a question about SDL before in the house and I have answered it. SDL is prepared by experts and chaired by Director of Medical Services. I want to clarify that in many countries, for their national health insurance system, the insurers will only pay if the drug is in the SDL and if it is not on the list, one cannot even get it. In Singapore, however, the SDL is designed for the purpose of receiving subsidies for them in public hospitals. If a drug is not in SDL, it does not mean it is not available. One can still get it from the pharmacies. The only difference is that you have to pay for it without subsidies. This is the reason why we do think it is necessary to make it a public document but it is not a secret. Ask any government doctor, he will know what the list is. If it is a private doctor, he may not know about it since he does not work in a government hospital. As for osteoporosis, her concern is a real one, With an ageing population, women seem to be more affected by osteoporosis more than men and it is something we should not take lightly and we won’t. HPB, in fact, is in the midst of including screening for osteoporosis in the national integrated screening programme.

56. Dr Fatimah Lateef asked about our medical intake. The third Medical School is on track to take its first batch of students in 2013. Together with the other medical schools, they will train about 500 doctors annually. Supplemented by foreign graduates, this should be adequate for our needs. Current efforts have already improved our doctor to population ratio to 1: 580. But I agree with her that ill distribution among specialties is a bigger challenge that must be addressed. Meanwhile, the public hospitals’ Pre-Employment Grant for Singaporean medical students overseas in their final years of study has been well received. More than 30 students studying in UK have committed to return under this scheme. I expect a bigger number from those studying in Australia. Applications from students studying in Australia are currently being processed.

57. Mr Low Thia Kiang talked about PCPS and found it to be a useful scheme. He asked if we could reduce the criteria to make it less stringent. He suggested having a tier subsidy system. I am not keen because the current subsidy is already quite substantial. I don’t know how much more tiering we can do. He also mentioned the end of life care, which I also discussed in the house before. As a ministry, we will do all we can to support end of life care but it does not have to be solely by the government, which will be sub-optimal.

58. Dr Fatimah Lateef and Dr Lam Pin Min asked if Medisave or MediShield can be extended to cover congenital diseases. I am sympathetic to this request, but I am not ready yet to reform MediShield, but when we do, I intend to extend it to cover congenital illnesses and also mental illness.

59. Mdm Halimah asked about Medisave300, whether we can raise the annual withdrawal limit to above $300 per year. The cap is subject to periodic review. An immediate adjustment is not necessary as the vast majority of patients do not have difficulty with this cap. She also asked about the adequacy of the Medisave Minimum Sum (MMS). This is currently at $34,500. To ensure its adequacy, we adjust it annually, taking into account medical inflation rate. 60% of active CPF members reaching age 55 are able to attain MMS. The increase in Medisave contribution rate by 0.5% in September last year will help more Singaporeans attain MMS.

Conclusion

60. Mr Chairman, in the past 5 years, we have made a lot of progress towards making our healthcare system better. In independent surveys, our patients rated our public hospitals and polyclinics as either “good” or “very good”. 3 in 4 rated them as “excellent value for money”. Many foreign experts have studied and praised our healthcare system. But we must press on with reforms, underpinned by wisdom and realism, and a generous dose of humanity.

61. If we stay the course, in another 5 years, Singapore healthcare will be even better than today. I thank Members for your continuous support for my Ministry.