HEAD O - MINISTRY OF HEALTH

Head O – Ministry of Health (cont.)

Resumption of Debate on Question [9th February, 2009],

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"That the total sum to be allocated for Head O of the Estimates be reduced by $100." – [Mdm Halimah Yacob].

Question again proposed.

The Senior Parliamentary Secretary to the Minister for Health (Mr Hawazi Daipi): Sir, when we are hungry, we buy food to eat; if we are looking for entertainment, we watch a movie; and when we fall ill, we go to see the doctor. However, unlike food and movies, no one really enjoys being sick. There is wisdom in the old saying, "Prevention is better than cure."

Sir, let me touch on how Singaporeans can play their part to stay healthy, detect and treat diseases early.

Our children spend up to eight hours a day in school. Besides the home, the school also lends itself as a natural setting through which we can help keep them healthy. Over the years, working closely with the Ministry of Education, we have developed a very successful and very comprehensive school health programme, comprising immunisation, regular medical check-ups, dental services and health promotion.

The result? Our school children are among the healthiest in the region, if not globally. They receive essential immunisations against conditions like polio, mumps and measles. Pre-schoolers receive vision screening annually at their kindergartens and childcare centres. In school, all students are provided with regular screening to ensure healthy growth and development. All this points to the hard work and dedication of our school healthcare professionals.

We should build on this strong foundation. Our vision is for Singapore to have the healthiest young population in the world. To this end, the Health Promotion Board (HPB) will actively engage more schools on health promotion

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initiatives, such as the provision of healthy canteen food and active participation in physical education lessons and co-curricular activities. It will also focus on enhancing the mental wellness promotion programme to build the mental resilience of our youths to help them weather challenges in life.

Schools and community youth organisations can also tap on HPB's two grants for their programmes, namely, School Health Promotion Grant and Community Youth Health Promotion Grant. A similar grant has been extended to pre-schools from 2008. Exemplary schools are recognised with the Championing Efforts Resulting in Improved School Health (CHERISH) Award, which is part of MOE's Masterplan of Awards. For Dr Fatimah Lateef's information, 80% of our mainstream schools have already achieved this standard, and more will join in the ranks with these initiatives.

The CHERISH conference is another platform for engaging schools. The inaugural Conference last year gave Award winners the chance to share their success strategies and learn about international best practices in Hong Kong and Australia. For example, Princess Elizabeth Primary School shared how canteen vendors are taught to serve healthier food. The school even encourages students to play health-related games in the canteen to reinforce the health promotion messages.

At the other end of the education spectrum, the Institutes of Higher Learning (IHLs) can help the seed of health promotion sown in the earlier years grow as our youths pursue higher education. More customised health promotion programmes on various pertinent health issues, such as smoking and drinking, will be developed and extended to these IHLs. To effectively reach out and engage our youths, HPB will continue to use the new media and organise

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activities that young people like, such as music, dance and sports.

Parents also play a vital role in shaping the lifestyles of their children. HPB will help empower parents to be positive role models so that they can inculcate a smoke-free lifestyle in their children, and take time to talk to them about many health issues, such as sexuality issues.

Our youths will eventually graduate and enter the workforce. Our health promotion must therefore be extended to the workplaces. Apart from improving the health of employees, these efforts would also bring down healthcare cost for both employers and employees. For example, Jurong Shipyard, an active advocate of workplace health activities saw its average medical cost per employee fall by 33% over the period 2000-2007.

This is why MOH and HPB have embarked on a multi-year tripartite effort to roll out health screening, health promotion activities and chronic disease management programmes in workplaces. I am grateful to HPB Chairman, Mr Lucas Chow and Mr Yeo Guat Kwang, our Member here from NTUC, for spearheading the work of the Tripartite Committee.

One focal area for the committee is our SMEs, as they employ more than 60% of our workforce. In these difficult times, we are exploring how we can better support SMEs to do workplace health promotion. For example, we are looking at enhancing the Workplace Health Grant so that SMEs receive more funding to implement our recommended package of health screening, follow-up services and healthy lifestyle activities.

At the same time, we cannot neglect the mental and emotional well-being of our workers. HPB will expand its workplace mental well-being programme to

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help workers better manage stress, as well as strengthen their resilience to cope with change positively.

We must tackle the twin dangers of smoking and obesity head-on. We have successfully contained the smoking problem over the past 25 years, through the efforts of HPB, NEA and their partners. The incidence of lung cancer today has dropped by 20% since 1984. Similarly, the premature death rate from heart disease has dropped dramatically, by two-thirds from 25 years ago. We have one of the lowest smoking rates in the developed world, at 13.6%.

We will press on in our anti-smoking efforts this year through targeted measures. This includes enhanced regulatory measures. HSA will also continue to take action against retailers who persist in selling tobacco to minors, such as the recalcitrant Cheers outlet whose retail licence was suspended last week.

Smoking cessation programmes and campaigns will also be enhanced, particularly for under-aged smokers. Partnership with MOE, schools and the community will be key in reaching out to the youths. An opt-out smoking cessation programme for expectant mothers will also be introduced. NEA will complement our efforts by stepping up enforcement against smoking in public places.

I am confident we can control obesity too. Obesity is the second important cause of global mortality and morbidity after smoking. And both of them are preventable. This year's National Healthy Lifestyle Campaign will focus on obesity prevention and control, by emphasising the importance of maintaining a healthy body weight. We will encourage supermarkets and eateries to increase the availability of healthier food choices. The Singapore Sports Council, NParks, People's Association and its grassroots organisations will also contribute by

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promoting physical activity amongst Singaporeans.

We will also tackle childhood obesity. HPB and its partner agencies will ensure that our children have access to healthier food and drinks in schools. More commercial dining outlets should join in the fight by developing healthy children's menus with guidance from HPB. Youngsters can do their part too by adopting an active and healthy lifestyle through regular exercise.

Let me now move to chronic disease management. I would like to respond to Dr Muhammad Faishal's question about the state of health of the different ethnic communities. The prevalence of chronic diseases varies among different communities, due in part to genes and environmental factors. In 2004, diabetes was most prevalent amongst Indians, affecting 15% of the Indian community, followed by Malays at 11% and Chinese at 7%. The prevalence of high cholesterol was highest amongst Malays at 23% followed by Chinese (18%) and Indians (17%). However, the Malay and Indian communities had a lower prevalence of high blood pressure at 23% and 22% respectively compared to the Chinese community at 26%.

Regardless of race, however, the treatment is the same. Patients should go for regular follow-ups with their doctor, take their medication on time, and make appropriate lifestyle changes, eg, in their diet. This will ensure that they enjoy a high quality of life despite their medical condition.

I share Dr Faishal's concerns regarding Malay kidney patients. There was a 17% increase in the number of Malay kidney patients from 2005 to 2007. Part of the solution lies in helping diabetic patients manage their condition better. From 1997

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to 2006, the proportion of end-stage renal disease due to diabetes increased from 39% to about 60%. Certainly, we need to do better. The Chronic Disease Management Programme (CDMP) guides our GPs to do this, using evidence-based treatment protocols. Patients are also tested regularly to detect the onset of kidney problems early, so that we can intervene and slow any deterioration of the kidneys.

HPB has made headway in facilitating lifestyle change among the Malay and Indian communities, to prevent the development of chronic diseases. It will continue to build on this good work in the year ahead. For example, " Kebayarobics " and " Aarrokia Attam " workout routines have been started for Malay/Muslim women and the Indian community respectively. Healthy cooking classes tailored for the Malay/Muslim community have also been conducted at mosques and community clubs since 2006. This programme will be extended to Malay caterers and restaurants this year.

To encourage Malay smokers to quit smoking, HPB has been collaborating with mosques, family service centres and sports associations like the Singapore Silat Federation and Singapore Sepak Takraw Federation, to organise smoking cessation intervention programmes. In 2009, HPB will introduce a programme of talks and cessation measures to be held around Ramandan (the fasting month). Smoking cessation counselling will also be included in the marriage preparatory course for couples that smoke. As you can see, this is going to be a very comprehensive approach in helping the community to kick their smoking habit.

On the public education front, HPB has been tasked to coach the public on how to better manage their chronic diseases. As part of this effort, HPB will reach out to the Malay and Indian communities through Suria and Vasantham television

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channels respectively, beyond efforts on Channels 5 and 8. It will supplement this with targeted messaging via print and online media. HPB will also be rolling out a pilot skills equipping programme to help Singaporeans at high risk of developing diabetes reduce their risk. HPB will commit an additional budget of $4.2 million over the next three years for these public education activities.

Let us not stop here. We should take a step back and spot and address problems early. Singaporeans must take charge of their own health. That is why I want to encourage more Singaporeans to go for regular health screening. MOH has already made evidence-based screening more affordable for Singaporeans through the Integrated Screening Programme introduced last June. Most Singaporeans need only to pay $8 for blood test for glucose and cholesterol. This is free for low-income Singaporeans. People's Association and its grassroots organisations promote the screening services through their pilot Wellness Programme. We have some initial success that we should build upon: about 70% of Singaporeans go for regular screening. Going forward, we need to encourage Singaporeans to go for the appropriate follow-up after screening, so that they can manage the detected conditions well. Again, this is another comprehensive approach to help Singaporeans, not only to understand their body conditions and whether or not they have chronic illnesses, but also to take measures to ensure their conditions do not worsen.

12.15 pm

Sir, let me now move to mental health.

The Minister for Health announced yesterday that the Chronic Disease Management Programme (CDMP) would be extended to cover outpatient psy

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chiatric treatment. Beyond this, the Government is pumping an additional $35 million over the next three years, on top of the $88 million committed in 2007, to identify and treat potential mental health problems early in the community. For Mdm Halimah Yacob, Mr Zainudin Nordin and Mdm Cynthia Phua’s benefit, let me outline some of the initiatives we will be undertaking.

Other than IMH, all our restructured and some private hospitals also provide specialised psychiatric services. In the community, there are currently three psychiatric rehabilitation homes and six psychiatric day care/day rehabilitation centres. These provide rehabilitation and vocational training to help stabilised patients re-integrate into society. We will monitor the adequacy of such facilities and build more if required. We heard you yesterday and we will look into this in the future.

We will also invest in community support services. Today, the multi-disciplinary Community Mental Health Teams (CMHT), which is made up of healthcare professionals, follow up with patients discharged from IMH. The teams also render psycho-social support to patients and their families. IMH also has a crisis hotline and crisis teams conduct home visits if needed. The CMHT will achieve national coverage by 2011. Annually, about 700 more staff from our community partners such as GPs, schools, CDCs, grassroots organisations and VWOs will be trained to detect, counsel and care for individuals in need within the community.

Family members can also receive caregiver training and support under a Specialised Caregiver Support Service that MOH, NCSS and the Alzheimer’s Disease Association are enhancing. Aside from this project, we are open to supporting viable programmes offered by VWOs upon application.

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Thanks to the Yellow Ribbon Project, ex-offenders are gradually being reintegrated back into the community. The same can be done for recovering mentally ill patients. One way is to help patients find and keep meaningful jobs so that they are able to regain confidence and lead fulfilling lives. IMH has started a new "Job Club" initiative to provide employment readiness training and work placement services for these recovering patients. Educational talks and forums will be conducted to educate the public on mental health issues in the workplace and general community.

Let me now address Ms Sylvia Lim’s question on the funding of essential programmes such as psycho-therapy. There are many types of psycho-therapy. IMH provides subsidised psycho-therapy to patients who need it, and needy patients can apply for Medifund assistance. As the Minister for Health mentioned, Medifund assistance will be increased to $80 million this year to assist more needy patients, including IMH patients who have genuine difficulty affording their bills. IMH offers another non-standard form of treatment called dynamic psycho-therapy as a pilot; it is currently not subsidised. Needy patients undergoing this treatment are assisted through donation funds received by IMH.

Sir, on breast cancer. I am heartened that Dr Lily Neo is concerned about the impact of breast cancer on female Singaporeans. MOH echoes her concerns. Through the various initiatives undertaken over the years, we have made significant progress in the fight against breast cancer. In 2002, HPB introduced BreastScreen Singapore, a subsidised breast cancer screening programme to make mammogram screening affordable and accessible. We have also brought mobile screening buses to the community and workplaces. The response to the

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various screening programmes has been good. In 2007, 61% of Singaporean women in our target age-group for breast cancer screening went for mammograms, an increase of 27% from 1998. So all in all, 317,000 women have undergone the BreastScreen Singapore screening since its inception in 2002.

The challenge ahead of us is to ensure that women make breast cancer screening a regular part of their life. Our long-term target is for at least 70% of Singaporean women in the at-risk group to go for mammograms once every two years, up from the current 41%. We will ensure that screening is kept affordable for these women to facilitate that outcome.

Public education and awareness is also critical in our fight against breast cancer. In 2007, 83% of Singaporean women in the target age-group for breast cancer screening knew about mammogram screening, a marked increase of 36% from 1998. We can do more. Going forward, HPB and its partners will continue their proactive outreach efforts to women through media campaigns, promotional activities at workplaces and community events, and through GPs to encourage them to go for regular breast cancer screening.

On strengthening primary care, Members of the House would agree that staying healthy is about building strong relationships. Relationships with our loved ones, colleagues, neighbours, and, yes, our doctors! Every Singaporean should stick to one family physician. If you have not, I urge you to identify your family physicians and work with them to screen and manage your health. The family physician is your long-term partner in ensuring good health.

To further enhance the role of family physicians in the community, MOH has augmented the training programmes for doctors to achieve the required quali-

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fications to be family physicians. In FY2008, we began to provide up to 50% co-funding for young doctors who want to take the post-graduate diploma training leading to Graduate Diploma for Family Medicine. At the same time, we also created more programmes for doctors to receive Masters level training. The College of Family Physicians will be the key content provider, with an MOH-appointed Joint Committee for Family Medicine Training overseeing these programmes.

The Director of Medical Services also shared last month that we are amending the MRA to include a Family Physician Register. This will set the standard for future family physicians. Public consultation is underway and we look forward to presenting the finalised amendments to this House in due course.

We are considering other avenues to support family care and achieve better integration within the national health system. First, we will leverage on IT to better link up polyclinics and GPs with the acute hospitals and ILTC providers to help provide patients with seamless, integrated care.

Second, we will continue to experiment with various primary care models to see which best suits Singaporean’s needs. We have conducted various pilots in the past, e.g. Jurong Medical Centre for patients and GPs to access Specialist Outpatient Clinic facilities in the community. Going forward, we are considering other initiatives like supporting infrastructural development, and incentivising GPs to come together and practise in groups.

Sir, we believe that all these enhancements will benefit patients. Four hundred and fifty GP clinics have partnered us under the Primary Care Partnership Scheme to provide subsidised care for the acute and chronic conditions of needy patients. Patients can be assured of the quality of care rendered as the GPs

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are required to adhere to MOH’s treatment protocols.

As the GPs take on a greater role in healthcare management in the community, waiting times at polyclinics should shorten. In the meantime, Mr Ong Ah Heng will be pleased to know that our polyclinics are already adopting measures to manage waiting times, which may be 40 minutes or longer, depending on time of visit and other factors.

Patients can also view, among other things, the patient load at the polyclinics online so that they know when is a good time to visit the polyclinic. For those with chronic conditions requiring regular or frequent reviews, they can choose to make appointments at the dedicated Family Physician Clinics, to see their regular doctors and save on waiting time as well.

Sir, in conclusion, I have outlined the policies and systems that MOH will put in place over the coming years to strengthen the primary care sector and help Singaporeans stay healthy. I urge Singaporeans to join us as we shape the healthcare landscape – take personal responsibility for your own health and encourage your loved ones to do the same.

Human Organ Transplant Act

Mr Zainudin Nordin (Bishan-Toa Payoh): Sir, cadaveric organ donation is an emotional issue. And for Muslims, we must also recognise the religious sensitivity attached to organ donation. I empathise with those who are involved in handling cadaveric organ donations. Their task is a difficult and delicate one.

Sir, the passing of a loved one is always heart-wrenching and an emotional and stressful affair for the next-of-kin. Yet, we must not avoid confronting difficult questions because the benefits of

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organ transplant are obvious. For some, getting a timely transplant makes the difference between life and death, or between prolonged suffering and hope for a better quality of life.

Sir, with that, I would like to ask the Minister to revisit the issue of cadaveric organ donation and see how the system can be further improved. To begin, Sir, perhaps the Minister could advise this House how many Malay/Muslim patients have benefitted since the introduction and the Amendment of the Human Organ Transplant Act (HOTA).

In line with religious obligations, we will also need to arrange for the prompt recovery of the cadaver once the organs are harvested in order to proceed with an earlier burial. Can the process be improved to minimise the time taken to recover the body of a departed loved one? I believe if this issue can be resolved, then perhaps we can allay some of the prevailing concerns of the Malay/Muslim community with regards to HOTA.

Mdm Halimah Yacob (Jurong): Sir, last year for the first time, Muslims were automatically included under HOTA. That was a good move as the earlier opt-in system which requires individual Muslims to opt into HOTA did not work. Could I ask the Minister for an update on the response of the Muslim community to HOTA after the amendment? How many more Muslims have benefitted from kidney transplants after the Amendment came into effect? How many more Muslims donated their kidneys after the Amendment came into effect? What feedback has the Ministry received from the community on the change to HOTA? Could I also ask the Minister, other than the law, what other measures have been put in place to actively secure the support of the community and increase their confidence in the implementation process? For example, are there now more

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Malay-speaking counsellors familiar with the religious and cultural practices of the Malay community at our hospitals to effectively communicate with families before organs are removed from a donor, so as to smoothen the process? Also, do our doctors, nurses and other paraprofessionals involved in the transplants understand well the religious requirements of Muslims, such as the need for burial rites to be done quickly once death is pronounced, to enable them to refine the processes accordingly? Could the Minister also update this House on the number of Muslim patients who are now waiting for kidney transplants and whether the number of Muslims who suffer from kidney failure have increased? If so, what are the causes and whether there are any other plans to increase awareness and public education programmes for the community to address this problem.

Hospital Disinfection Measures

Mr Low Thia Khiang (Hougang): Sir, I understand that Singapore is currently ranked as the sixth best nation in the world for its medical advances, and the best in Asia by the World Health Organization. Hospitals and medical centres have achieved high marks in clinical indicators that equal or even surpass those in the developed world. However, it is important for us to strive to maintain the high standards and quality of our medical and healthcare services. Recently, I received feedback from my constituents that some patients who were admitted to the Tan Tock Seng Hospital were infected by a virus in the hospital and died of pneumonia. I would like to ask the Minister for Health was there an unusual increase in the number of patients at Tan Tock Seng Hospital who died of pneumonia?

12.30 pm

Sir, during March 2005, when SGH first identified Vancomycin-resistant

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entercococcus (VRE), it decided to screen all its patients with a view to identify the carriers so that they can be properly isolated. In parallel, SGH staff was reminded to set up good infection control practices, such as mandatory handwashing in between patients, and stricter compliance of the two-visitor rule in the hospital.

According to statistics, in year 2007, pneumonia was the third major cause of death after cancer and heart disease. I would like to know how hospitals monitor whether the wards are affected by infectious viruses. Are there routine measures that hospitals take to ensure that there is no outbreak of infectious viruses in the hospitals?

Human Cloning and Other Prohibited Practices Act 2004

Mr Christopher de Souza (Holland-Bukit Timah): In 2004, Mr Chairman, MOH introduced the Human Cloning & Other Prohibited Practices Bill. This Bill was subsequently enacted.

The Act strictly prohibits reproductive cloning. However, the Act does not prohibit what scientists term "therapeutic cloning". This was back in 2004. It is now 2009. Five years is a long time in the field of stem cell research which continues to grow at a meteoric pace. We should take a fresh look at the advances in stem cell research from around the world, and decide for ourselves whether there are any more practices that should be prohibited. If yes, the Act should be amended to include these prohibitions.

One major consideration is the use of cybrids. I will just give a quick layman's summary of what cybrids are.

In "normal" therapeutic cloning, human eggs and human DNA are fused,

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the egg is then stimulated, and the resulting embryonic stem cells are removed.

However, due to the shortage of human egg donations, scientists have resorted to using animal eggs. Animal eggs are fused with human DNA to create embryonic stem cells. So in essence, cybrids are a fusion of animal eggs with human DNA. Cybrids are very advanced methods in stem cell research.

The Government's bold vision of being at the forefront of bio-medical research is admirable. The desire of scientists to find cures for diseases is just as admirable. But we must also be prudent about the methods we choose to achieve these aims.

The prohibition on reproductive cloning in the 2004 Act was a wise step by the Government. The Government saw in 2004 that there are OB limits in scientific research beyond which Singapore should not accept. We are now five years down the road. There have been rapid advances in the bio-medical field in the past five years. The time has come for a fresh look at these OB markers. And I would urge that one such OB marker is cybrids.

I am of the view that the Government should not permit the use of cybrids in the therapeutic cloning for the following reasons.

Firstly, the danger of cross-species diseases. The cybrid's human-animal genetic composition triggers the danger of retroviruses migrating from the domain of the animal kingdom to mankind. Significantly, there can be no assurance that these viruses, residing within the cytoplasm or mitochondria of the animal egg, will not mesh with or integrate into the human nucleus within it. Such occurrence will significantly reduce the utility and raise the harmfulness of any stem cell line derived from cybrids.

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Second, by fusing animal eggs with human DNA, a fundamental concern arises about the dissolution of the very nature of man. Our existing legislation already cautions against cross-species development.

Underlying these prohibitions, ie, against women surrogating an animal embryo and animals surrogating human embryos, is the legislation's apprehension towards cross-species tandem-development. If the Act specifically prohibits the growth of humanity in an animal, how then can the growth of human life within an animal egg be allowed?

I hold the view that the creation of cybrids is intrinsically incorrect since to create something part human-part animal at the stage of conception of life is to dissolve the very nature of Man.

These fundamental objections against cross-species development arise regardless of whether cybrids are statutorily required to be destroyed within 14 days of development.

Thirdly, there is the danger of tumours arising from embryonic stem cells. The 2005 UK Pattison Report raised the danger of tumours arising from embryonic stem cells. In contrast, the danger of tumours arising from adult stem cells is believed to be insignificant, based on the past 40 years of bone marrow transplants.

I would urge therefore – my fourth point – that the Government consider the recent scientific breakthroughs and economic benefits of adult stem cell research, as opposed to embryonic stem cell research and the use of cybrids.

A recent 2009 article – 31st January – by Mr Andy Ho in the Straits Times gives evidence of why adult stem cell

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research is the more promising of the two, ie, between embryonic stem cell research and adult stem cell research.

In conclusion, in light of the meteoric pace at which this industry is advancing, it is our duty to carefully discern what to permit or prohibit on our shores. I believe for the best interests of Singapore that the creation of cybrids ought not to be allowed on our shores and an amendment to the 2004 Act should be made to list the creation or use of cybrids as prohibited practices.

Would MOH consider these proposals?

The Minister for Health (Mr Khaw Boon Wan): Sir, I do not know whether I have time to complete the reply but in case I do not, perhaps I will ask Mr Christopher de Souza to seek a clarification during clarification time so that we can complete the reply.

Yesterday, Mr Chiam spoke on dental care. He is not here but I have better reply to his cut first. He quoted a few examples, from his point of view, very expensive dental care treatment in Singapore. The figures sounded very high and I told him so, when Parliament was adjourned. For example, he mentioned "capping" which I presume he meant "crowning", costing $2,000 and he mentioned root canal treatment costing $3,500. So I told him he must have been to a very expensive dentist. Either that or he was mistaken. But he said maybe he was mistaken or the patient had very severe complications and actually received many more treatments and not just, for example, root canal treatment. Last night, I checked and say, in our National Dental Centre, root canal treatment typically ranges from $300 to $800 versus the $3,500 mentioned by Mr Chiam; crowning about $600 to $800 versus the $2,000 that he quoted. In any case, Chiam’s proposal was that we should subsidise dental care. And in fact we do.

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You can get subsidised basic dental services at dental polyclinics. Dr Chiam mentioned filling, and a filling at polyclinics typically ranges from a few dollars to $25, depending on the condition of the cavity. For the elderly, it is further subsidised. As for specialist care, we provide subsidised services in the National Dental Centre, where typically patients will get at least 50% subsidy. So that is how we go about handling dental care for Singaporeans.

Mdm Halimah and Mayor Zainudin asked about HOTA (Human Organ and Transplant Act). Currently there are more than 100 Muslim patients on the waiting queue for kidneys. And as noted by Members, we achieved a major milestone when the Muslim community joined HOTA last August. I was very happy for the Muslim community because I have wanted to be able to do this for sometime. We knew as a fact that it will save lives but there were various difficulties that prevented the Muslim community from joining. But better late than never and it is truly life-saving – the numbers speak for themselves. Just to give an example, say 2007, this is before HOTA extension, the number of Muslim patients receiving a transplant was only 19, less than 20. Last year, and bear in mind last year was incomplete, with only five months of HOTA for Muslims, the number has already doubled to 38. From 19 for a full year to 38 for less than half a year: quite an achievement. I expect a record number this year.

Similarly, if you look at it in terms of percentage of all patients receiving transplants, the Muslim recipients have increased their proportion from 11% in the past, before HOTA, to last year 19%, comparable to the percentage of Muslims in the total population.

Whilst some Muslims have opted out of HOTA, and we respect their decision,

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the vast majority of Muslims, just like non-Muslim Singaporeans have stayed within HOTA and they support organ donation. So far, over five months, four Muslim cadaveric donors have saved the lives of 15 organ recipients.

Our hospitals are very sensitive to the need for relatives to take the bodies of their loved ones as soon as possible for religious rites. Our organ donation teams work through the night to ensure that the donation process is completed within hours, certainly well within 24 hours. Adequate washing facilities in hospitals and a second sitting for Coroner’s cases are now available to reduce any possible delays. And we have prepared our hospital staff quite thoroughly for the HOTA extension to the Muslims. There are always some Malay speakers around and staff are briefed by MUIS on the religious and cultural sensitivity of the Muslims. So from my point of view, the last five months of implementation has been quite smooth. While there were a little kinks here and there, I am sure over time we will improve further.

I am particularly grateful to the support rendered by Muslim religious leaders. Last night when I met Haji Mohd Alami Musa, MUIS President, I told him so. They were wonderful. We have a list of their handphone numbers because this thing can happen anytime. We will call them if the family members require religious clarifications and they will come to the hospitals even in the middle of the night to help support the family through the grieving process and also to clarify any religious doubts. Their work, excellent work, complements the work of our medical staff and social workers. We will continue to monitor and make improvements where we can. But as noted by the Senior Parliamentary Secretary just now, the number of Malay patients struck with kidney failure continues to rise so the key is still, as Dr Lily Neo always reminds us, prevention,

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prevention and prevention. It is quite preventable. Certainly the complications are quite preventable. So HOTA cannot be the key, it cannot be the full answer. Prevention is, and that means changing lifestyles for those who are on the wrong side of the healthcare divide. They have to disrupt their lifestyle as Ms Jessica Tan reminded us yesterday.

Mr Low Thia Khiang asked if there has been an unusual increase in the number of patients who died of pneumonia in Tan Tock Seng Hospital. I checked. We did not observe any unusual trend. Tan Tock Seng Hospital recorded about 600 pneumonia deaths every year. Nationwide, as Mr Low noted, pneumonia is our third killer. It is a major cause of death, just like in many other countries, probably all countries. Our national data show that pneumonia death has hovered at around 2,300 every year; it fluctuates a little bit, plus or minus. But by and large about 2,300 every year and it has been so for many years. The reason it is a major killer is because pneumonia is an outcome with many different causes. I mean there could be many other underlying causes and typically patients with stroke, with cancer, with COPD, or who are bedridden for a long time due to other illnesses, they somehow die of pneumonia as the terminal event. Some pneumonia deaths are caused by viral infection and I think SARS outbreak was a dramatic example of that.

SARS taught us many lessons and one of which is to remind us to be constantly vigilant. So hospitals have to put in surveillance systems to monitor patients with atypical pneumonia, patients with unexplained fever for more than 72 hours and relevant travel history, and sudden unexplained death cases with acute respiratory symptoms.

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12.45 pm

All hospitals adopt strict infection control protocols; so staff are required to clean their hands regularly and correctly, infectious patients are isolated with regular environmental disinfection. And the hospital infection-control teams carry out regular audits to make sure that the SOPs are being followed.

I visit hospitals quite regularly, impromptu, and find that hospital staff requires me to do various hand rubs. I think the procedures are, by and large, in place. But I acknowledge that, globally, hospital-acquired infection is one of the complications, even in the best hospitals, partly because we are talking about human behaviour here. It is not only our staff. It is the patients and also the patients' visitors, and the weakest link will be in the weakest link, and whoever is less than careful, infections just spread. What is important is for us to constantly remind ourselves and try to bring down the rate to as low as we can. To eliminate it to zero, I think no other hospital has done it and I doubt we can ever reach that stage.

I have time for Mr de Souza's clarification. I thank him for sharing his views on therapeutic cloning and cybrid research. I heard his view that he is against cybrid research. I agree with Mr de Souza that the science on stem cell research is evolving and, of course, our law must try to keep pace. We do monitor developments globally and we are further advised by an excellent Bioethics Advisory Committee (BAC), comprising some of the top names in the world. They scan global developments and then they do very extensive public consultation before they firm up their views on what would be their recommendations and, typically, we will then review their recommendations and, where appropriate, change the law to do so. One issue for which they have been conducting public consultation is precisely on this aspect of cybrid research, or research on human-animal

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combinations. I remember they did a public consultation last year. I took part in one of those discussions, and I assume Mr de Souza must have also shared his views with them.

I await the BAC's recommendations and, in due course, if we need to change the laws, we will do so. So I have not taken a position yet. Mr de Souza's view is one, but I think he knows too that there are many others who feel quite differently on this topic.

Mrs Josephine Teo (Bishan-Toa Payoh): Sir, I would like to thank the Minister for his reassurances on Medifund. I would also like to seek a point of clarification. Does the Ministry have a target within which to cap medical inflation, for example, no more than 5% above general inflation? To what extent do the various initiatives, undertaken by the Ministry of Health, keep medical inflation in check?

Mr Khaw Boon Wan: I thank Mrs Teo for the clarification because this was a query which I forgot to reply yesterday. Not that I forgot, but I was not sure of my data, so I did not respond immediately. I heard she quoted a rather high health inflation rate of 7.4% which, relying on memory, I thought that was high. I checked and yes, I was not wrong. She talked about 2007 health inflation figure and asked me about the 2008 data. She thought 2007 was 7.4%. Actually, it was 4.1%, and not 7.4%. 7.4% could be for a particular month in a year, maybe, I do not know. And she asked about the 2008 figure. The 2008 figure was high, and it is not just in healthcare. We all know the reasons for the high inflation rate last year when oil prices went up sky high. Health inflation was high at 5.6% but it is, in fact, below CPI, which was 6.5%. So we did better from that point of view. If you take a longer period, 2005 to 2008, for example, health inflation averaged 2.8% per annum. and CPI was 2.5%. So we were just 0.3%

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higher than CPI. However, the point is taken, globally everyone tried very hard to control healthcare cost. But still in every country, the health inflation exceeds the general CPI, and it is quite a challenge trying to control healthcare cost. I think our data suggest that we have been doing a relatively good job.

Ms Sylvia Lim (Non-Constituency Member): Sir, two clarifications for the Minister. The first is relating to my query about means testing for nursing home subsidies. I think the Minister missed my point about the difference between taking gross pay and net pay. My point was that the net pay is a more accurate reflection of affordability because it tells us how much disposable income the family has actually to pay for the nursing home charges. That was my point with regard to the means testing. I wonder if the Minister would agree with me that that is a more accurate test. The second clarification is that yesterday, the Minister spoke about the nursing home in Johor in a rather positive term, I would say. I would like to clarify whether he is actually suggesting that this should be an option for families in Singapore to consider because I think this would be quite a bad indication of affordability of our own healthcare services here and also a reflection of our national values.

Mr Khaw Boon Wan: Sir, I thank Ms Sylvia Lim for seeking the clarifications. No, I did not misunderstand her point about "gross versus net income". What I said was that we must be consistent. If you want to look at gross income, then you must be consistent in setting threshold criteria based on gross income. But if you prefer to look at net income, then your threshold criteria for means testing should also be based on net income. At the end of the day, we are talking about targeting subsidy and who do you want to subsidise. In the case of the nursing home, the current rule is we will subsidise the bottom 50% of

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Singaporeans. You can argue about whether it should be 50%, 60%, or whatever. But that was the policy - we will subsidise 50%. So that will include all the low income plus part of the middle income as well. Having decided that it is the 50th percentile, if you decide to look at the gross income, then, of course, you set the threshold based on the gross income data. Or if you want to look at the net income, you can do so too, in which case, then the threshold criteria will have to be lowered to suit the net income. For practical reasons, we use gross income because it is harder to get the net income data comprehensively, as there are all sorts of complications. On the other hand, we have more readily available CPF data on gross income.

On the nursing home in Johor, I mentioned it in passing because I made a trip there. Actually my main purpose was to look at the hospital because Members have asked me to consider the possibility of Medisave to be used for hospitals there. I used the opportunity to look at the Iskandar Malaysia region; I have not been to that part of Johor for many years and wanted to see how the development is shaping up there. It was a very pleasant trip. I went by the Tuas Second Link, then from west to east to Pasir Gudang, ended up with a nice seafood and cheap lunch near Pasir Gudang and came back through the new CIQ Checkpoint to our Causeway. At the Iskandar Malaysia region, I also took a look at the site where I heard they have investment from a medical school from England which is coming to set up. I also went to take a look at the Legoland theme park where the land is being prepared. Sorry, for digressing.

But many Singaporeans, including many residents in my constituency, go to Johor very regularly, top up their car tanks, which many do, and also to have a

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nice seafood meal at much cheaper prices. I think these are natural activities, and that is part and parcel of globalisation. In fact, this is not even globalisation; this is regionalisation, and there is nothing wrong with that. Consumers are free to choose. I know many go over to the pharmacies there to get cheaper drugs. It is not our fault. The pharmaceutical companies have a way of setting prices: Third World, they set lower prices; First World, like Singapore, they set higher prices. By allowing the flexibility of consumers walking over the Causeway, they benefit. I do not think we should constrain them from doing so. Our cost will always be higher because our wages are different. Nurses are paid very differently here compared to Johor and ditto for doctors; likewise construction cost.

I just want to point out to Singaporeans that there are options like these. In fact, it is already happening. This free flow of patients across borders, so much so that there is a term called "medical tourism". Singaporeans go to Bangkok, I know, for lasik, and vice versa. Americans come here. Russians come here. Singaporeans go to Penang and Malacca. I think we should allow that. In any case, how can we prevent it? We cannot prevent it. But in fact, by keeping the borders "open", it puts some competitive pressure on our local providers which eventually will be good for our own consumers. Because if they price themselves too high, the patients will start going across the Causeway and they lose customers.

Mr Christopher de Souza: I would like to thank the Minister for his reply and in reply to his request, I am asking for a preemptive clarification. Three points, Sir.

First, given the promise that adult stem cell research has shown, both in the US and around the world, and given the amount of resources that we are pumping

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into this new biomedical field, would MOH consider a push for adult stem cell research over and above embryonic stem cell research? I ask this question because it leads to the second point. If there is such a push, then it obviates or avoids the issue of cybrids because cybrids only come into play in the field of embryonic stem cell research.

My last point of clarification is: if the 2004 Act was introduced so as to keep up with times and to immediately prohibit what we think as a Government, as a people, what ought to be OB markers? Surely, the 2004 Act must continue to be fluid and up-to-date with the times. I must confess that five years is a very long time in the biomedical field. Would more amendments to the Act be made more expeditiously in future?

Mr Khaw Boon Wan: I am not too familiar with the technicalities of the research on stem cell. I believe there is a lot of work on stem cell in general. Are our scientists doing cybrid research – I stand corrected – but I doubt they do. I think part of the reason the Bioethics Advisory Committee wanted to study this subject is because the researchers want clarity. Can they or can they not? They are, by nature, very conservative people. And I think, because of the uncertainty, they stay out. So the Member's point that we should emphasise more on adult stem cell and not do cybrid research, does not even arise because, as far as I know, I do not think there is anybody doing cybrid research at the moment. Meanwhile, I think we let BAC conduct their public consultation first. I attended one of the sessions and I was educated along the way, but not sufficiently to be able to do a meaningful dialogue with him today. I walked away from the session with the impression that there are strong views and similarly cogent views on both sides of the camp. So it is not as straightforward as, say, we should not clone a human being and grow it into an

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adult. The law against human cloning was straightforward. But for research on human-animal combinations, there are

other issues involved. There are possible upsides, which the researchers are looking for, that will benefit mankind. That is why they want it to be discussed much more, and not put a clear-cut prohibition, which may then miss out on possible upsides that will eventually benefit mankind. That is as far as my understanding goes.

The last point is about keeping pace. Yes and no, because it is such an evolving field. Understanding of this subject and the implications of it is not obvious or intuitive. The global consensus, actually, is that the law should be slow. Do not be too fast. You may be drawing a line in a rush, and that line may be drawn in a wrong place. Then, as we all know, when you want to move the line after it has been drawn, it is typically very difficult.

Mdm Halimah Yacob: I thank the Minister for his reply. I have four clarifications to seek from the Minister. It is with regards to questions I have raised which were not answered.

I asked about the low subsidy that is currently given to implants, other than the stent implants. The case I cited yesterday, where the procedure was carried out in a B2 ward. $2,457 was the implant cost, the subsidy was only $500, and the patient had to pay $1,957. For a low-income worker, that represents more than one month's salary. So I asked whether the Ministry could review this policy to provide a higher level of subsidy for implants for those in the B2 and C wards, particularly now that we have means testing, and the objective of means testing is to provide better support for those who need it and make it more affordable for those in the B2 and C class wards.

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The second question I asked was the issue of affordability. Now that the general guidelines on fees have been removed by Singapore Medical Association (SMA) because it is supposed to be anti-competitive – what, then, is the alternative if a patient has a complaint about overcharging? What mechanisms are in place for the patient to seek redress? Could doctors then turn around and say that there is no overcharging because market sets the rate and a patient knows how much is to be charged? We know that there is a great asymmetry when it comes to information between patients and doctors. I would like the Minister's comments on that.

The third question I raised was on MediShield coverage for patients with mental illness. It is a very serious problem for families taking care of mentally ill people, because it is a long-term illness. It is a debilitating illness. It will break their backs if there is no insurance coverage. I would like to ask the Minister to respond to that point.

My final point is to ask the Minister whether he will also include dementia in the Medisave coverage for outpatient treatment of mental illness because that is also a serious and increasing problem. And dementia treatment does take up a lot of a person's finances.

Mr Khaw Boon Wan: Mdm Halimah, I am sorry that I missed out a couple of your cuts.

First, the implants – the problem is that there is a wide range of implants. It is just like drugs, medication. We, typically, set our subsidy based on generics. So we are looking for the generic equivalent of implants – which we call standard implants – versus more fanciful ones. If you set your subsidy rate too high, who will want to go for the

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lower cost, even though the lower cost may be good enough? It is a problem, and hence we have to, typically, set our subsidised rates, which from a patient's point of view, more on the low side.

But for knee transplant, the example that Mdm Halimah mentioned, I have actually done quite a few things over the last few months. We have adjusted MediShield implants reimbursement rates. In fact, it is now quite substantial. Say the example of knee replacement, most of the hospital bills will now be picked up by MediShield. And yesterday, the Medisave liberalisation rules that we talked about for surgical patients will further benefit patients with that kind of operations. But, certainly, we review implant rates periodically because of inflation, and if the original cap is really too low, we will raise it in due course. It may not be immediate. But, we look at those data quite often. The bottomline is this – patients, rich or poor, can afford the essential treatment that they need. But we, certainly, cannot set subsidised rates too high as to encourage the use of fanciful stuff, which may not be necessary.

The second point is about SMA and the Competition Commission's arguments – quite intellectual arguments – on whether having fee guidelines is anti-competitive. I leave it to them to sort it out. Unfortunately, they have dragged in lawyers now, so I think that will take quite some time. But, patients who feel that they have been overcharged – maybe Mr Chiam's patient with the $3,500 root canal treatment – can complain to Singapore Medical Council (SMC) or in the case of dental, the Singapore Dental Council (SDC). SMC will review them, to see if there is gross overcharging. In fact, we have cases like that which the Committee had looked at in the past. My advice to patients is this: get a second opinion. And the best second opinion is from the public hospitals. If you are not sure if it is too expensive, just ask the

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restructured hospitals and you will know their rates. Hence, with or without fee guidelines, in fact by getting a second opinion, you get a more precise advice on whether you are being overcharged or not.

Related to this point is the earlier advice that the Senior Parliamentary Secretary gave: have a family physician. The fee schedule covers tens of thousands of fee items, and the layman may not understand the details – what is it and how much does it cost. And the one to give you that guidance, really, is a family physician whom you trust and have known for years. Go to him and he will be the best one to advise you that, "you have this medical condition, you need a specialist, better go to that group of specialists. This group, I think, they tend to be on the high side, don't go". That is the best way to handle this issue of overcharging.

MediShield on mental illness – we will be moving on Medisave for outpatient mental illness. As for MediShield on mental illness, I have some sympathy. Mdm Halimah has been advocating this for a few years. I am sympathetic but, if you want to cover more conditions, then the insurance premium has to go up a few dollars. I doubt this is a time to talk about raising MediShield premiums. So the next time when we need to revise MediShield – presuming that is after the economy has fully recovered – we will put a file record for whoever is the Minister for Health, to take a look at mental illness.

In the case of private insurers who are riding on the basic MediShield, many of them already provide this coverage. But this is more for the middle-income group. For the lower-income group, they will not be able to afford. Meanwhile, the way we do this is through subsidising IMH and the psychiatric departments in general hospitals heavily. We subsidise mental illness much more than the traditional

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80%, 65% for class C, B2 wards. In fact, often, the subsidy goes beyond 90%. If you look at the usage of Medifund, a big chunk goes to mental illness, where the bills are completely written off. This means a subsidy of 100%. Sometimes, quite unfortunately, the patients are just dumped onto our laps. We have to treat and house them. So this is how we handle mental illness. But, long term, I agree that risk pooling offers a way out, and at the next round of MediShield reform, we will bear this point in mind.

Medisave for dementia – I thought Dr Fatimah gave a very good prescription yesterday: step-by-step. So I am taking her prescription. So we do the biggest group first which is depression and schizophrenia.

Dr Lam Pin Min (Ang Mo Kio): I would like to seek Minister's clarification on the issue of mental health. We know that regular intake of medication is important in the treatment and control of symptoms of many psychiatric illnesses, such as schizophrenia and even depression. And we know that it generally is beneficial for the patients with mental illnesses to receive social rehabilitation in the community. I would like to ask how is the Ministry or IMH or the mental institutions going to monitor the recovery process of patients who are discharged from hospitals. Is there a system whereby this institution can actually track these patients, should they default follow-up?

This is important because the omission of any medication and the necessary review by the professional can actually lead to other potential complications or even pose a threat to the safety of the patient and even the community at large. We have heard cases where patients were discharged, defaulted follow-up, omitted medication, failed to follow up until something big happens in the news.

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Mr Khaw Boon Wan: I thank Dr Lam for his comments. This is indeed a great challenge. Not just here, but all over the world for the mentally ill. How do you ensure compliance? Chronic diseases always have this problem. We all know the way to treat it is consistent lifelong low-tech treatment to avoid complications. The mentally ill presents another different aspect as, sometimes, the patients just deny that they have mental illness. At the MPS occasionally, we see these cases and some of them come to me and complain that the doctors insist they must eat this or eat that. So I learn from them how they tricked the doctors to think that they were taking the medication when they did not. The problem, I think, is well-defined, but the solution not so straightforward.

Part of my motivation for supporting Medisave for outpatient mental illness is because I want to also, through this, build up a way of monitoring how GPs, psychiatrists handle their mentally ill patients. Just as the Medisave scheme for diabetes, I now have more than a year of data on how diabetic patients are being handled by their GPs: clinic by clinic. What is the number of cases they have? What is the blood-sugar level of the patients over time? Does it improve statistically for the whole group, does it stay the same, or does it worsen? One year is a little bit too short, but as we build up the data series over the years, we will get valuable information from the data. My intention is to publish it. Not to witch-hunt or to blame, but to let doctors learn from each other how they handle diabetes, for example, their performance level versus other GPs. And I am hoping that, in the case of mentally ill, likewise – depressions and schizophrenics – if we find that there are clinics which are able to handle their mentally ill patients better than others, then they may be able to share their experience, how they are more effective than other GPs, for example, in getting their patients to comply. So, along

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the way, I hope we all learn from it, and the industry improves and patient care improves as well.

Mdm Cynthia Phua (Aljunied): Sir, thank you for allowing me to make a point of clarification.

After IMH where the patient seeks treatment, this could be followed up by the daycare centre. And then later on, more VWOs can be encouraged to come out to set up some silver ribbon centres, where the patients are cared for more on a voluntary basis. On this basis, we have more community support on the ground.

1.15 pm

Mr Khaw Boon Wan: I note Mdm Cynthia Phua's observation, and I think we discussed this yesterday too, that clearly we need to do more. But it is not just more resources thrown in, but to also find a way how to integrate and coordinate better. VWOs have a lot of passion to help but they may not have sufficient clinical knowledge. Our professionals know what to do but may not be able to have the same social outreach as the VWOs. So it is to get them to really work together. And like all things, we have to pilot and experiment. And this is certainly what we want to do. But let me also make an appeal to the family members: you have a major role to play as well, because talking to some of these patients and the professionals who have to manage these cases, sometimes there is just no family support and the poor fellow is just left in the lurch. The incident of the attack on our colleague, Mr Seng Han Thong, involves many issues. One of my big concerns arising from that incident was that we have been trying very hard over the years to de-stigmatise the mentally ill, and I was very worried that the case will push our efforts back several years. Then after that there was the incident involving Ms Denise Phua. And I worry that the society will group all mentally ill together as one

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group. No doubt there are such patients out there who need help but mental illness is a wide range of illnesses and many are reversible if we give them a chance, if we give them jobs, if we are able to accept them in the community. If you institutionalise them, which is the traditional way of doing things in the last century, lock them up in the mental asylum, they do not improve, they just go downhill, just like in the movie "One Flew Over The Cuckoo's Nest". That does not solve the problem.

Mr Zainudin Nordin: Sir, may I have clarification from the Minister on two points?

Has means testing brought any behavioural change in the way Singaporeans spend on healthcare and do we have any study on the impact of means testing?

Second point is, we have seen low-wage workers sometimes attending private clinics or co-op clinics because these are the clinics they could get benefits like the subsidies provided by their employer or NGOs. I would like to know whether they would be penalised by considering them as A Class patients just because they attend private clinics outside as outpatients. Could the Minister clarify, please?

Mr Khaw Boon Wan: Whether means testing has caused a behavioural change, it may be a bit too early to conclude. But as I shared with Members yesterday, less than 10% were means tested out, which suggests to me that most Singaporeans, by and large, chose the right class of ward. So the middle-income, they go Class A, Class B1. It is only a small percentage who actually can afford Class A, Class B1, even private hospitals, but they chose subsidised ward. We do not begrudge them, we still subsidise them, except what we are asking is maybe we will subsidise them less than those who

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come from a lower income group than they. So far, I consider the implementation quite smooth, suggesting that there is general support by Singaporeans for this policy. Some patients, because of company benefits, end up in private GP clinics or private hospitals, but may then require subsidised care in the public hospitals, we treat and accept them and there is an avenue for downgrading. But if they do not ask for it, we will just treat them as private patients. If they express difficulties, then we would assess and downgrade them. The example of that obstetric patient who was going to deliver the second baby in KK Hospital, which I mentioned yesterday, was one of those cases. I think she paid for private sector healthcare all the time, but she wanted to reduce costs. When she came in, we treated her as a subsidised patient, and she was able to save about $2,000, according to the newspapers.

Mr Low Thia Khiang: Sir, I have two clarifications for the Minister.

Sir, I refer to the Minister's earlier reply on his nice trip to Johor, which I suppose must have inspired him to contemplate new healthcare policies. I would like to ask the Minister is he now suggesting that Singaporeans who cannot afford medical treatment or step-down care here, should now consider such facilities in Johor.

Second clarification: is the Minister outsourcing the Government's responsibility to provide affordable healthcare service to Malaysia now?

Mr Khaw Boon Wan: A simple and robust answer is "no". Everybody can afford healthcare in Singapore, whether acute or long-term care. I think this is our pride, our healthcare system, as quoted by Mr Low himself just now, is the best in Asia and the sixth in the world. And I think we have reasons to be proud of our healthcare system. Our doctors, nurses,

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work very hard. We have thought through carefully about how to bring about this very good outcome – that even if you are unemployed, or low-income group, you can afford a standard of healthcare which is comparable to the US. You look at the 40-50 million American citizens there who just cannot afford to even buy medical insurance because their insurance rate for a family of four runs into five-digit US dollars per year. Mr Baey, who is familiar with US, nodded his head. This is just for premium, let alone talking about hospital bills. You step into an emergency department in an American hospital, it is triple-digit US dollars.

But in Singapore, we make sure that healthcare of good standard is available to all – rich or poor. If you are rich, we will subsidise a little bit less. But if you are poor and if you need to write off your whole bill, we do. That is what the 3M system is all about. Yesterday I spent some time discussing with Members to think about long-term care. It is not a big problem today because we are still a relatively young society. But we will not be. I am already 57 and there are many in my generation. And very soon this Silver tsunami will come but we have 10, 15 years to prepare for this. So Minister Lim Boon Heng is absolutely correct. We have 3Ms which render this very good system that we have today, for acute care; let us make sure that we have an equivalent for long-term care.

So, no, I am not saying that if you are poor, I will put you in an ambulance, send you across the Causeway to Johor nursing home. That is not what I said and please do not twist my words. But what I am saying is for those in the middle-income group, you have choices, you are paying out of your own pocket, you decide. Do you want to have a seafood meal in Singapore or you want to have a family reunion in JB? It is up to you, this

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is your own choice. Do you want to fill your car tank in Singapore or you want to drive across and have a haircut? That is up to you. You are spending your own money. And I am just sharing with Singaporeans that there are alternatives of that kind. But for low-income Singaporeans, we look after and heavily subsidise them. There is no need for them to walk across, because they enjoy a heavy subsidy here. They have to pay unsubsidised rate in JB. It will be more expensive than what they can receive in Singapore. So that is the way we do our systems and I hope to get the Member's support for it as well.

Dr Lily Neo (Jalan Besar): Mr Chairman, I would like to seek clarifications from the Minister. He earlier said that the Ministry of Health will invest more on the treatment of psychiatric cases and many of them do not have enough family support. He also said that, for many years, MOH has followed the policy on encouraging psychiatric cases to stay in the community as much as possible. May I ask the Minister, in view of a small densely populated state, is there a necessity to tweak such policy of discharging patients to stay in the community as much as possible. Is it to the best interest of the patients if he or she does not have enough family support or community support? Are such patients causing dysfunction to their own families and to the community they live in?

And, lastly, the Minister earlier said that many people deny their psychiatric problems. So may I ask him how many psychiatric cases are undiagnosed and untreated but are living in our present community?

Mr Khaw Boon Wan: I am not a doctor, so my knowledge is that of a layman, and I would not be able to discuss seriously some of the queries that Dr Neo has raised. How many are undiagnosed? I would not know. I do not know whether

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there are such surveys. Probably there are. Globally, my journal readings suggest to me that this is one of their big problems as well. Even the definition of what is mentally ill, there is no consensus: you can be strict or loose.

I remember reading an article in New Zealand when I was there for a meeting, where the front page headline screamed out to say "Half of New Zealanders are mentally ill", following a survey that they have done. So I think this is a difficult problem. But whether our professional policy is to discharge mentally ill patients "as much as possible", whether that is correctly worded, I do not know. I have to check with our professionals. I do not think that is the policy. The policy is to make sure that the patients get the best care, and they have to decide whether that best care is rendered in the institution or in a community. And to be fair to them, talking to them, the impression I get is they are not just dumping the patients out of IMH. They are a bunch of very nice, passionate people. I met some of them recently when I opened a community outpatient facility that they started in Queenstown Polyclinic: a nice bunch of people, very passionate about their patients and wanting to do the best for their patients. So it is not a case of the psychiatric doctors just dumping the patients out of the hospital and leaving it to the community to sort itself out. More correctly is the other way round: that we have seen many families who dumped their mental patients into IMH and on our laps, and we have to look after them for life. But instead of accusing each other of dumping, I think let us focus on how to make sure that the patients get the best of care, and that requires cooperation from everybody all round. I am quite sure IMH's psychiatrists will be looking at how best, when they discharge patients to the community, to maintain contact with the patients, perhaps, through the GPs. I know they started a programme working with the GPs, so that there is shared

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treatment. If a specialist is needed, he is always there for consultation, but the day-to-day treatment is done by the GPs.

I know this because one of my former classmates is a very good GP outside, and one day he told me about this programme. He said that it is very good for his patients who have some mental illness, and now he is able to handle them with confidence. And the patients prefer that too, again because of the stigma associated with IMH. They rather go to a GP if they can, rather than go to IMH and to report to their friends or families that they went to IMH.

1.30 pm

Ms Jessica Tan Soon Neo (East Coast): Sir, can I ask the Minister for a clarification with regard to long-term care? We discussed about being disruptive. What more proactive actions can be done so that chronic illness patients can get preventive and constant care, and that they do not fall off from treatment due to unaffordability? One of the ways, as the Minister touched on earlier, is technology, how patients' information and tracking allow for more proactive actions to ensure that they do not fall off, and that they can manage the cost of treatment.

The second clarification is that the Minister did not answer my question that I asked with regard to what more can be done in terms of affordability in these difficult times, specifically on long-term care and chronic illnesses. Can more be done for the cost of treatment as well as cost of medication to help patients in these difficult times?

Mr Khaw Boon Wan: Sir, on affordability, all my speeches yesterday and today were directed at it. That is what motivated me and that is what motivated my Ministry – how to make sure that healthcare remains affordable and of a high standard. Frankly speaking, it is easy to keep healthcare cost

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affordable if the standard is not an issue. Many third-world countries achieve that – absolutely free healthcare or very cheap healthcare. But what kind of healthcare?

Mr Low mentioned JB when I discussed my trip there. Was it two weeks ago, a Singaporean had an accident in the northern part of JB? He was "semi-treated" in a hospital there, but he was dissatisfied. He called an ambulance and, I think, he was sent to Changi General Hospital or SGH. He was quoted by the newspapers to have said that it was a blessing for Singaporeans to have such a high standard of healthcare, and yet affordable.

So, to keep healthcare cost affordable is the easiest thing in the world. But to also keep it of a high standard and yet affordable, very few countries have done so. I like to believe that, while we are not perfect, we have done a fairly good job. Just a while ago, I was sharing with the Finance Minister. There is this monthly journal that the Japanese publish called Japan Echo , which has serious articles on contemporary issues in Japan. The latest issue which we just received this morning, the front page headline is about how to create a sustainable healthcare system in Japan. I was sharing with the Finance Minister that I felt very sorry for Japan because, for a long time, they had one of the best healthcare systems in the world, and they could be truly proud of that. I flipped through a few articles in the journal, they all screamed out that their healthcare system is on the verge of collapsing. On and off, we read of such stories. Just last week, there was a pregnant woman who subsequently died, and this is in Tokyo, because the ambulance had to negotiate with every hospital, "Please take this patient, urgent, dying." They said, "Sorry, full house." Or at least they gave the excuse that it was full house. After several hospitals, by the

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time one kind-hearted hospital took her in, it was too late, she died. And this is in Tokyo, Japan. It is not a third-world country or rural town. It is first-world and second richest country in the world.

I flipped through the journal and one article was written by my Japanese counterpart, and I saw his first paragraph. He blamed all the problems of the healthcare system in Japan on pandering to political populist measures, which then just collapsed the whole system. Let us not fall into that trap. We are not in that hole. My job is to make sure that we do not walk into that hole, and please do not lead Singaporeans into that hole.

On long-term care, what else can we do? We have done a lot. If it is not enough, we will do more. We will certainly do more prevention, more screening. But let me just say a word of caution, which is that at the end of the day – what is the Cantonese expression – we cannot drag the cow to the water unless it is willing to, and it must cooperate. All smokers know that smoking causes lung cancer. They still smoke. It is not as if they do not know. What can I do? So, it is motivation. We organise health screening. We subsidise screening so that it is affordable. Money is not an obstacle. Lack of motivation is the obstacle because, often, after a person has been screened, the follow-up is the big difficulty. Follow up requires even greater motivation. If he is not willing to change and disrupt his lifestyle, his health will just go downhill. It is inevitable.

The Chairman: We still have three minutes. Any more clarifications? Yes, Dr Neo.

Dr Lily Neo: Sir, I just want to clarify that I did not use the word "dumping" in my speech. I agree with the Minister that the consideration is best care for the patients. The words he used were "best

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care for the patients" which should be the consideration, and I agree with him totally. My only point was best of care in the community for psychiatric patients without sufficient family or community support, or best of care in having regular follow-up with psychiatric nurses and psychiatric doctors, even if it means institutional care.

Mdm Halimah Yacob: Sir, first of all, I would like to thank Minister Khaw and Senior Parliamentary Secretary Hawazi for their very comprehensive and very patient responses to our questions. I would also like to thank all my colleagues who have participated in this debate and made their contributions. I am deeply reassured of the commitment by Minister Khaw that during these very difficult times, retrenched workers and those who suffered pay cuts as well as others needing subsidised care will not be deprived of affordable healthcare.

On that note, Sir, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The sum of $3,083,813,300 for Head O ordered to stand part of the Main Estimates.

The sum of $621,110,900 for Head O ordered to stand part of the Development Estimates.

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