SINGAPORE (Sept 3): It is 11am at HoviClub in Bukit Timah, and Glenn Miller’s In The Mood is on the speakers. An elderly lady and a nurse are swaying together to the jazzy tune. In another corner, a few seniors are engrossed in a game of mahjong. “We are very flexible here. We let the seniors come in when they want to, and do what they enjoy most,” says Andrew Kwek, managing director of Hovi Care, which runs the one-storey facility as a day care centre for seniors.
Kwek, 62, used to work in finance, at one point as CEO of Deutsche Asset Management (Asia). But as part of his “second career”, the corporate don is now hoping to make a difference in eldercare. “Care for seniors is best when it is personalised. Here, we aim to have at most two elderly to one staff member. Otherwise, there is no point to this,” says Kwek.
With the low staff ratio comes higher costs, which limits this service to the well-heeled. Hovi Care charges $3,600 for 20 full-day sessions, with no subsidies available. The company was started last year, and Kwek notes it will be challenging to make money. “But that should never be the aim of starting an elderly day care business,” he adds.
For the broader population of seniors, more accessible options tend to be home care or elderly day care centres that are run by the public sector and charities. But these have limited capacity, even as demand is growing.
The Lien Foundation recently released a report, Care Where You Are, which highlights these gaps. In 2015, the Agency for Integrated Care, which was set up by the Ministry of Health (MOH), received 7,800 referrals for day care services, but had only 3,500 places available. Applicants for general day care waited for a median duration of 20 days, while dementia patients waited for 35 days, note the report’s authors, associate professors Elaine Ho and Shirlena Huang of the National University of Singapore’s geography department.
To be sure, MOH has been ramping up capacity in long-term eldercare, though perhaps not quite quickly enough. Between 2011 and 2017, places in home and centre-based care have more than doubled to 8,000 and 5,000, respectively. Singapore aims to have 10,000 places in home care and 6,200 places in centre-based care by 2020. These figures exclude the private providers serving self-funded clients.
Still, this will take time, and current gaps remain unfulfilled by the private sector. At present, the private centre-based eldercare sector comprises many small players such as Hovi Care. Amid all the hype about the silver economy, why is this sector lagging?
Experts and industry watchers say a fundamental shift is required in viewing eldercare as a charity-led sector to one ripe for consolidation and more innovative models. “We shouldn’t look at the ageing market as a philanthropic venture. We have to start moving away from this mindset and looking at business sustainability,” says Janice Chia, managing director of ageing market consultancy Ageing Asia.
Ageing in community
When Selina Lim’s 88-year-old father recently fell at home, she was thankful to have two domestic helpers by her side. “It took the three of us to lift him up,” recounts Lim, a consultant in her 40s. “Caring for the elderly at home is not easy. You have to be prepared to stay up all night; to make do with three hours of sleep when taking care of someone.”
Lim, who is single, had hired the domestic helpers to provide for both parents. She also switched to a part-time job, to spend more time with her parents. After her mother passed away last year, however, she decided to retain both helpers, seeing her father needed help with everyday tasks such as going to the toilet. Sending him to a nursing home is “not an option”, she says, given his mental agility and preference to stay home.
As Singapore faces an ageing population, the government has advocated “ageing in place”. This means enabling seniors such as Lim’s father to stay in their own homes for as long as possible, with support from the community. Lim’s career compromise and spending on helpers has enriched her father’s silver years. But she adds a caveat: “I can afford to hire two helpers, but I know that many people cannot. Services like home nursing and day care can also be expensive if you do not qualify for subsidies.”
Indeed, the fragmented state of the industry could be a factor in driving up costs, reckons Laurence Lien, chairman of the Lien Foundation. “There are many small players in the private sector, each serving a small number of clients. This increases costs, which are passed on to the consumer. I think we need fewer larger players with economies of scale. With higher volume, you are also in a better position to ensure minimum standards of care as well,” he says.
The Lien Foundation’s report calls for legislation covering home and centre-based care, as well as training and accreditation, auditing of on-the-job capabilities and the quality of care by private providers. Lien’s view is that raising industry standards will help to accelerate consolidation, which will see the emergence of bigger and more cost-effective players.
In the case of home care, being unable to operate by location adds to inefficiencies, says Chia of Ageing Asia. “In any given day, a block of elderly people in say, Toa Payoh, may be served by home care operators from all over Singapore. Right now, there are no economies of scale for the home care operators. There’s no central coordinator [in the private sector] that can ensure the block is served more efficiently by fewer operators,” she says.
Chia believes that more government support could help the industry. “For a healthy private sector to emerge, we may need to consider more access to government funds and subsidies, like tax incentives or discounts on rent for a certain period. The time to break even for an eldercare service is longer than that of a regular business.”
There are mixed reactions to the call for regulation. Yeo Wan Ling, CEO of caregiving services aggregator CaregiverAsia, welcomes stricter standards that could be included in the imminent Healthcare Services Act. “It will be good that players are clearer about the industry standards, but moderation is also required. Regulations should not be too onerous to prevent individuals from entering the industry,” she says. Yeo also thinks that industry consolidation is bound to happen, sans regulations. “We expect that more small players could gather strategically to serve a particular location, or perhaps provide a specific service,” she adds.
Others such as Hovi Care’s Kwek outright disagree with the call for regulation. “Enterprise thrives on innovation, and what we need now is more players. Sometimes, we need to learn not to rely on the government for everything,” he says. Kwek suggests that to make private care more affordable, perhaps insurers should start to cover such services.
Indeed, roping in private insurers could be a viable solution benefiting non-profit providers as well. “If home care can be recognised as a healthcare service to support ageing in place, then it could be supported by insurance plans,” says a spokesperson for the Home Nursing Foundation.
New models overdue
In the 1980s series The Golden Girls, four elderly women become housemates. Despite arguing incessantly, they enjoy each other’s companionship. The sitcom comes to mind as Dr Belinda Wee relates her experience of running Singapore’s first retirement village-styled facility at a recent seminar.
“Yes, they do argue with each other,” Wee says of the eight residents in St Bernadette’s Lifestyle Village in Bukit Timah, one of two assisted living facilities (ALFs) she co-founded. “But isn’t that what keeps you alive? It is relationships that keep you active, and give you something to look forward to every day.”
To be sure, ALFs in Singapore are few and expensive at the moment. Wee’s cheaper ALF charges close to $4,000 a month. But Wee thinks that ALFs do not have to be purpose-built facilities. “Our greatest vision is that ALFs can actually be set up in your own homes. You don’t have to build a special facility, but reorganise space. First, you would have to make the house barrier-free and put a toilet in every room. If you can get some people together and a pool [of trained caregivers] that is sustainable, then you have an ALF,” she says.
Chia of Ageing Asia is already exploring tie-ups with condominium developers to offer ageing in place services via her other enterprise, ASPIRE55, which runs two clubhouses with gyms for the elderly. “ASPIRE55 wants to work with property developers to create clubhouses within their developments so that we can collate services and deliver [them] to their [elderly] residents. Many condominiums have a large number of older residents. Instead of asking them to move out to an ALF, we could go to where they live instead,” she says.
While home and centre-based care cover the medical and social needs of the elderly, society tends to focus on the former rather than the latter, says Lim Sia Hoe, executive director of the Centre for Seniors. “Ageing in place is not just about healthcare. It should not be medicalised,” she says. “It is also about psychological and social well-being… When we are able to coordinate services around an elderly, instead of them approaching different organisations, the community takes the burden in caring for them. This becomes more sustainable.”
Similarly, former nominated member of parliament Eugene Tan emphasises that alongside the government, the private sector has to be part of the solution. “We should be bold in trying out different care models and funding mechanisms. We must avoid being fixated with any one particular approach. Sure, we can have a preferred approach where public policy is concerned, but we should not shy away from providing a variety of options.”
While Singapore has some way to go to enable ageing in place for the masses, caregivers such as Lim hope that the industry will catch up soon enough for when she retires. “Ageing cannot just be about nursing homes or hiring a helper. For the growing number of singles like myself, I hope that there will be more options to age in a supportive community,” she says.
This story appears in The Edge Singapore (Issue 846, week of Sept 3) which is on sale now. Subscribe here
