Last month, The Straits Times reported on the growing number of infirm Singaporeans who have been admitted to nursing homes in Johor Baru.
I was one of the reporters involved. Back home, I had a hypothetical discussion with my grandma on considering that as one of her retirement options.
Across the Causeway, you can get a room in a bungalow for half the price here. The elderly person can tend to the spacious garden outside instead of being cooped up in an eight-bedded ward reeking of stale air, or worse, urine.
Grandma, usually cheerful and mild-mannered, snapped in Hokkien: "I'd rather jump from this building than go there."
Despite her visceral objection, the fact of the matter is that more people in Singapore will soon need to have this discussion on nursing home care for elderly family members.
Sending Grandma to JB is, of course, not the default option.
But the economic case is compelling. Cheaper land, construction and labour costs in Malaysia can halve the cost of nursing home care.
Singapore is also short of nursing home beds, with an average waiting time of several months to be placed in a nursing home. That's because many homes here have been full for years and beds are freed up only when occupants die. All 401 beds at Peacehaven nursing home, for instance, have been occupied for at least the last 10 years.
Already, some nursing home players are expanding to as well as in Johor to cater to Singaporean demand. Last month, Singapore company Econ Healthcare Group, which runs eight nursing homes here, opened a 57,000 sq ft, four-storey home in Taman Perling, a 30-minute drive from the Tuas Checkpoint. Besides offering single rooms with attached toilets, it has barbecue pits, outdoor exercise gardens and an in-house medical centre.
Aged sick: The new export
THE idea of sending the old and sick to low-cost neighbouring countries may attract unease, as in 2009 when then Health Minister Khaw Boon Wan suffered much flak for suggesting it as an option.
But, in fact, the idea has taken off in other developed countries, where there is a shortage of qualified nurses and facilities amid soaring costs and a rapidly greying population.
More than 10,000 German pensioners have moved into care homes in Hungary, the Czech Republic and Slovakia.
Alzheimer's patients are moving from Switzerland, known for its quality of healthcare, to facilities in Thailand.
Cost plays a big part in this exodus. The Philippines is offering Americans care for less than half the US$6,900 (S$9,400) a month needed for a private room back home. For one third the average price of nursing care, the British can receive individualised care from three to four nurses 24 hours a day in a home in Thailand.
But is this arrangement what our elderly folk and their caregivers really want?
There is general resistance, moral or otherwise, to people sending their kin to be cared for abroad, with newspapers around the world labelling this trend "Grandma export".
Munich's leading newspaper Sueddeutsche Zeitung denounced it as "gerontological colonialism" and compared it to nations exporting their trash.
Others say it does not matter where seniors live out their last days, as those with dementia will not know the difference.
My colleague and I spoke to three old people in JB nursing homes who thought they were still in Singapore. Dementia patients make up about half the elderly residents in local nursing homes.
But senior social worker Jasmine Wong at Hua Mei Centre for Successful Ageing says that dementia patients benefit from being in familiar, not strange, surroundings: "Persons with dementia retain old memories while struggling with recent events - so being in a familiar place helps relieve their anxiety and familial visits play an important part in that assurance."
Some research links family involvement and visits to better life satisfaction and early discharge back into the community.
So while nursing homes in JB may make sense as cheaper options, they are at best a niche solution for some. For one thing, their cost is not subsidised. Even a bed in a shared home in JB costs $600 a month - beyond the reach of poorer families.
For the masses in Singapore, there is no running away from the challenge of having affordable, quality nursing homes, especially as the population ages rapidly.
The cost of care
MOST nursing home patients in Singapore pay about $450 to $500 a month for a place, after government subsidies. Nursing home fees in Singapore range from $1,200 to $3,500 a month. This is before government subsidies of between 10 per cent and 75 per cent.
Eight in 10 of all nursing home patients have a per capita monthly household income of $700 and below. They receive the maximum subsidy of 75 per cent, which brings their share to $450 to $500 a month. Many poorer families cannot afford that amount. Ms Winnie Chan, deputy executive director of St Andrew's nursing home, says 90 per cent of her 300 residents need help with fees. The home applies for Medifund for them or raises funds to cover costs.
Nursing home operators cite rising labour and land costs as one reason for fee revisions. Econ, for example, raised fees by 10 per cent three years ago. This year, fees went up another 10 per cent, or between $220 and $440 a month. In that same period, wages went up 16 per cent.
What can be done to keep fees low?
SINCE 2012, the Health Ministry (MOH) has operated a new Build-Own-Lease (BOL) model where it builds and owns nursing homes and leases them to operators who have to bid to run them.
This puts downward pressure on fees because affordability is a key evaluation criterion in awarding such leases. Appointed operators are held to their proposed fees for the duration of the bid.
The BOL model also helps to reduce the capital outlay for operators. However, it will apply only to most of the 19 homes coming up over the next five years. There are 66 nursing homes now.
Another way is to incentivise existing operators to keep fees down in exchange for grants. This has worked to slow down fee increases in the childcare sector, where "anchor operators" have to satisfy fee requirements in order to get grants.
New approaches to care
BEYOND cost, there is much that can be done to raise quality. Chief executive of Lien Foundation Lee Poh Wah considers the state of nursing homes here dismal. "I view most of them as cold, clinical factories housing warm bodies which are awakened, cleaned and fed on a regimented schedule. There is an institutionalised absence of life and joy."
Single rooms are the norm rather than the exception in countries such as Australia, Japan and Britain. It is the reverse here, he said, with most people housed in six-bed to eight-bed wards.
To bring back the "home" aspect in the nursing home, the Lien Foundation is setting up a new $15 million building for elderly dementia patients next year.
Besides having single or twin rooms with en-suite toilets, the home will feature a rooftop garden, hair salon and grocery store. Residents can engage in social and recreational activities whenever they wish instead of adhering to fixed schedules.
More operators could develop care models that create homely environments where residents can choose their own schedules, not adhere strictly to regimented ones.
The time is right for a revolution in nursing home care.
MOH is targeting a total of 17,150 nursing home beds by 2020, up from 10,000 now.
This year, all nursing homes will have to meet higher standards under new rules.
MOH is also encouraging new care models. It said late last year that it will release suitable land sites and state properties for the private sector to own and run their nursing homes with their own care models.
One area crying out for a change is facilities for dementia patients. One in 10 of the older adults already has the brain disorder. But many nursing homes here are not purpose-built for them and they can often be seen wandering aimlessly along the corridors.
With a spike in the number of nursing homes, there should also be a way to assess the quality of homes, and publish these ratings, as the United States does.
Already, Singapore is one of the fastest-ageing countries in the world. As of last June, there were more than 430,000 people in Singapore aged 65 and above. That is a whopping 100,000 more elderly folk than just four years earlier.
The numbers are likely to rise to nearly one million by 2030.
It is clearly not feasible to think about exporting Singapore's elderly en masse to low-cost neighbouring towns.
In the end, sending Grandma to JB is not the best solution to the issue of providing aged care.
The cost of nursing homes in JB may be lower than in Singapore, but at about $600, they can remain out of reach for some of the masses without government subsidies. For now, state subsidies should remain strictly for local nursing homes.
Instead, Singapore needs to step up efforts to make nursing home care both more affordable and of a higher quality.
As for me and my grandma, hypothetical discussion on JB notwithstanding, it is my fervent wish that care will remain affordable, and I can continue to enjoy her presence here, when twilight comes.