Home big read The Big Read: With more seniors needing care, is assisted living the answer for S'pore's 'missing middle' and their caregivers?

The Big Read: With more seniors needing care, is assisted living the answer for S'pore's 'missing middle' and their caregivers?

The Big Read: With more seniors needing care, is assisted living the answer for S'pore's 'missing middle' and their caregivers?
With Singapore society ageing rapidly, one particular eldercare option has sprung up in recent years — community or assisted living to help seniors with basic daily activities It is touted as a possible solution for the “missing middle” — seniors who cannot live independently but are not too ill to be cared for in nursing homesBut experts, industry players and caregivers pointed to various factors on why assisted living services has not taken off faster, including costs, regulatory ambiguities and manpower shortagesAt the same time, there are different challenges in expanding other caregiving services such as foreign domestic helpers and day care centres  Experts believe that the right way forward is a shift in approach from reactive to preventive measures in eldercare, and more sustainable public-private partnerships

By Renald Loh & Navene Elangovan Published June 30, 2023 Updated July 4, 2023 Bookmark Bookmark Share WhatsApp Telegram Facebook Twitter Email LinkedIn

SINGAPORE — The last domestic helper who cared for Mr Christopher Tan’s wheelchair-bound 76-year-old mother packed her bags and took off without a word in the early hours one day in 2021, leaving her all alone in a small apartment. “(My mum) needs help to go to the toilet, to shower (and) to change,” said the 51-year-old accountant, who told TODAY that it was fortunate that “nothing bad happened” following the helper’s sudden departure.She was the fifth helper whom Mr Tan had hired over the course of two years, but none had worked out or managed to get along with his mother for one reason or another. 

As Mr Tan and his sister both live with their own families, they began to look for other care options for their mother after the incident.

For caregivers like Mr Tan, searching for the right care arrangement for their elderly parents can be a long and stressful process, especially when their needs fall in the middle of being able to live independently and having to be constantly looked after in a nursing home.“I think the gap exists when you’re somewhere in between — you’re not that healthy, but you’re not that sick, and you’re still well enough to be in the community,” he said. 

Experts such as Ms Chia Hui Xiang from the Saw Swee Hock School of Public Health at the National University of Singapore (NUS) calls this group of seniors the “missing middle” — people who face difficulties in one to three activities of daily living and do not have enough family support, but are not so severely disabled that they require a nursing home.

These activities of daily living refer to bathing, feeding, dressing, toileting, transferring and mobility — the ability to sit, stand and move independently. 

Mr Tan is among an estimated more than 210,000 caregivers in Singapore — many of whom have had to compromise their careers, finances and sometimes their own health to look after their aged loved ones. 

Those unable to care for the seniors full-time themselves typically turn to hiring a foreign domestic helper, and more seem to be doing so.

The total number of foreign domestic workers as of December last year is 268,500, more than 8 per cent higher than five years ago, according to statistics from the Ministry of Manpower (MOM).

Other caregiving alternatives include engaging home care service providers on an hourly basis and sending the aged to senior day care centres, though this can sometimes be easier said than done due to cost and capacity issues, among others. 

Many of these seniors may also not qualify to stay in nursing homes, which typically have a wait list and accept only those who are physically or mentally impaired, unable to be cared for at home and have exhausted all other care options. 

Experts interviewed by TODAY said that the issue of caregiving options has become even more pronounced in light of a rapidly ageing population.

In 2010, about one-tenth of Singaporeans were aged 65 and above. In 2020, this figure rose to one in six, and by 2030, about one in four Singaporeans will be over the age of 65.

Last Tuesday (June 20), the Urban Redevelopment Authority (URA) and MOH announced that the tender for a Parry Avenue site intended for a private assisted living facility was awarded to Pre 20, a subsidiary of developer Perennial Holdings and one of three tenderers.

The development in the Kovan area will comprise 200 assisted living apartment units, a nursing home with 100 beds, a wellness clubhouse and a geriatric care centre.Its residents have the option of renting one- or two-bedroom units ranging from 366 sq ft to 666 sq ft for a minimum of three months, and the development will come with private lifts and access to balconies, sky terraces and lush green communal areas, said a spokesperson from the company.

It hopes to start operating in 2026 or 2027. 

Industry insiders and experts cited manpower constraints, land costs and regulatory ambiguity as some factors why assisted living has not taken off in Singapore earlier.According to Dr Wee, several developers had previously approached the Assisted Living Facilities Association to enquire about the possibility of setting up assisted living facilities in Singapore. 

However, the cost of land and labour shortage served as major barriers — leading them to opt for other markets like Malaysia or China. “Many people actually are very interested in this space, but they can’t really come on board until the Government actually gives a clear guideline on how to go about starting assisted living facilities,” she said. Ms Chia agrees, adding that the authorities should have specific regulations for assisted living facilities to provide guidance for providers and protection for residents.The researcher said that assisted living service providers had informed her that it was unclear if they should follow regulations for residential housing or nursing homes. Such regulations include fire safety regulations or the number of foreign domestic workers or unrelated people who can live in one residence.“From our conversations with providers, we understand that they have to check with various government authorities on which government regulations should apply…and there is a lot of uncertainty and red tape because they are assessed on a case-by-case basis,” said Ms Chia.She also noted that the long-term care sector is very heavily dependent on foreign workers and that it is challenging to attract local healthcare workers to work in community settings. The high cost of land also raises the cost of assisted living services, as operators seek to recover their investment, said Ms Chia.She pointed out that currently, private assisted living facilities use residential land which is more expensive than land zoned for nursing homes.

“The high price of residential land has been a challenge for service providers to enter the assisted living facilities market and provide affordable assisted living options,” she said. 

Indeed, seniors and their loved ones interviewed by TODAY also cited concerns about the affordability of assisted living services, especially in the long run.

Ms Lee Joo Lian, an 82-year-old resident who moved into St Bernadette Lifestyle Village at Bukit Timah in April, described the facility as “homely” and said that she appreciates the care provided by the staff.While the former junior college teacher who is single and has no surviving family can afford the fees of S$4,600 monthly now, she does not know “how long (her) finances can last”. Her “back-up option” is to sell her existing three-room HDB flat in Toa Payoh.“There should be more places (like this in Singapore), but it is expensive,” she said.

Similarly, another resident, 84-year-old Tay Kay Siong, said that he had not been keen to move in as he felt that the cost was “a bit pricey”. He pays close to S$5,000 a month.“It’s a lot because all our working life…we don’t even earn up to that amount when we retire,” said the former primary school teacher.Nevertheless, Mr Tay, who has walking difficulties, said that he eventually chose to stay there as he could still afford the price and it suits his needs. Among other things, Mr Tay has the privacy of a single room and the location is close to Tan Tock Seng Hospital where most of his medical appointments are. 

At present, the Government provides subsidies for various caregiving needs via MOH and the Agency for Integrated Care (AIC), including the Home Caregiving Grant — which goes up to S$400 a month to ease caregiving costs. According to the AIC’s latest statistics, more than 45,000 beneficiaries have received the Home Caregiving Grant since its launch in October 2019. 

MOH also provides subsidies for residential long-term care services like nursing homes, which covers anywhere from 20 to 75 per cent of the total cost, depending on the applicant’s monthly per capita household income. 

For non-residential long-term care services like home care or centre-based day care, which can cost up to S$1,600 a month, subsidies covering 30 to 80 per cent are also available. However, none of these grants covers seniors who live in assisted living facilities.


In response to queries from TODAY on how it is boosting caregiving capacity for seniors and whether there are specific plans to help the “missing middle” group, MOH said on Sunday that it has “significantly expanded aged care capacity”.

A ministry spokesperson noted that since 2015, MOH has provided around 4,800 more day care places, 4,800 more home care places and 4,900 more nursing home beds to provide a total of 8,300 day care places, 11,700 home care places and 16,900 nursing home beds as of end 2021.

“These services support seniors with a range of care needs, from those who need some help with activities of daily living, to those who are home-bound. We will continue to monitor demand and add more capacity where needed,” said the spokesperson.

MOH is also working upstream to help seniors stay health for longer and reduce their rate of fraility.

It will double the number of Active Ageing Centres (AAC) island-wide from 119 to 220 by 2025. The centres offer a range of active ageing activities, befriending or buddying programmes, referral to care services and health-related initiatives.

The 220 centres also include AAC (Care), which provide AAC services and additional care services such as day care and community rehabilitation, it added.

At a community level, the ministry is also encouraging greater community involvement by seniors.

For example, it is strengthening senior volunteerism to encourage mutual support, and creating safe and dementia-friendly communities to support persons living with dementia, said the MOH spokesperson.

On assisted living, MOH noted that some seniors may opt for such services.

To meet demand, the Government has launched Community Care Apartments at Bukit Batok and Queenstown which integrates senior-friendly design features with care services that can be scaled according to care needs.

Similarly, the first purpose-built private assisted living development at Parry Avenue will add to the range of options that cater to different preferences, lifestyles and housing needs of seniors.

“The development’s operator will need to comply with specific service requirements set by MOH,” said the spokesperson. 

The ministry did not elaborate on what service requirements the Parry Avenue operator has to follow and whether these also apply to current assisted living operators St Bernadette Lifestyle Village and Red Crowns Senior Living.

“MOH will continue to engage seniors, caregivers, and eldercare service providers as we review our plans to further anchor ageing in communities,” the ministry spokesperson added.

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To manage the ageing population better and provide caregivers with more help, there has to be a fundamental shift from “reactive” to “preventive” measures in the country’s approach to tackling the issue, said experts and eldercare services providers.  

Mr Tommy Tan of Hovi Care, which provides various eldercare services, said that it would be a “mammoth task” to meet the growing demand for nursing homes and day care centres given the ageing population projection.

“We are seeing the Government’s efforts over the last few years to increase capacity in manpower through enablement, education and facilities in active ageing centres, nursing homes and even recently assisted living, however we are unsure if the Government could ramp up the supply fast enough to meet the demand as we moved into super-aged society in 2030,” he said. 

“One possible way is for the Government to support and encourage the private sector to build up more facilities to augment the public-funded centres.” 

Dr Tan of SUSS also suggested having co-living spaces with shared caregiving services for seniors as this would be the most feasible option for seniors in land-scarce Singapore.

To encourage private operators to set up assisted living facilities, they will have to be convinced that they can make money and sustain their business model in the long term, said Dr Tan.Dr Thang Leng Leng, an anthropologist from NUS and president of the Gerontological Society of Singapore, said that Singapore could also learn from countries such as Japan and Australia, where there is housing provided within the same institution ranging from assisted living for more able seniors, to nursing care for elderly that need more care.Such “continuum housing” is a good option for people to know that they can receive care within the same site when they need more support, she said. Nevertheless, she noted that unlike Singapore, these countries also have large grounds to provide retirement housing alongside nursing homes. 

In their statement announcing the tender for the Parry Ave site, HDB and URA had said that the concept proposal submitted by Pre 20 “demonstrates a comprehensive care model that provides residents of the proposed development with a continuum of care to enable them to age in place”. 

The possibility of expanding options and support for caregivers at a grassroots level was another idea mooted by experts.

For example, while only Community Care Apartments will have community managers to help its elderly residents with their needs, experts said that such community managers can be embedded at other HDB blocks to assist seniors living there. Such a community manager can be a point-of-contact for seniors and their caregivers in a block, and assist them with questions about senior services or in case of emergencies, said Dr Thang from NUS. Unlike case managers at eldercare centres who only provide assistance to their own clients, a community manager would assist all seniors at a block, she said. 

Ms Joan Pereira, a Member of Parliament for Tanjong Pagar Group Representation Constituency, said that the common feedback she receives from residents on issues related to caregiving are the cost of engaging caregivers and helpers, waiting lists at nursing homes, and dealing with caregiver burnout.As Singapore ages, she expects to see more families facing situations where working adult children must support both their ageing parents as well as their young children.