HEAD O - MINISTRY OF HEALTH

ESTIMATES OF EXPENDITURE FOR THE FINANCIAL YEAR 1ST APRIL, 2007 TO 31ST MARCH, 2008:

(Paper Cmd. 2 of 2007): Order read for consideration in Committee of Supply [5th Allotted Day].

[Mr Speaker in the Chair]: Head O - Ministry of Health (cont.)

Resumption of Debate on Question [6th March, 2007],

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

Question again proposed.

The Minister for Health (Mr Khaw Boon Wan): Mr Chairman, Sir, I will continue with my reply yesterday which was interrupted.

Mdm Halimah's queries are related to two important subjects, ie, how best to subsidise the needy, and how to ensure that care for the rich does not affect care for the poor. We do not apply the subsidy formula mechanically, eg, every Class C bill, subsidise 80% or Class B2 bill subsidise 65%. This is because there are many ways to treat the same illness. For instance, we promote generic substitution, ie, the use of generic medicine which is cheaper but effective, instead of branded goods. This way, we save on healthcare costs. But sometimes, some subsidised patients insist on getting the more expensive branded medicine. We oblige, but we get them to pay more for the non-standard drugs or implants. Otherwise, the subvention budget would be depleted by such subsidised patients who obviously can afford better care and are demanding more. This will disadvantage the truly needy who accept the basic but adequate care that we prescribe. And there is an added reason. For very expensive care, such as in the intensive units, we actually subsidise much more than the standard 65% or 80%. The cost of running ICU is very, very high. And if we were to simply apply the standard subsidy rate, many such patients would not be able to cope. This is the reason why subsidy rates differ from nursing homes to expensive acute hospitals and why we apply a lower subsidy rate for outpatients than inpatients.

After all the mathematics are done, what patients are really most concerned about is the dollar quantum they have to pay and not so much how many percent of the bill that they are paying. This way, we better ensure that the needy can afford their healthcare.

As for rich foreign patients crowding out the poor, I am very alive to this concern. The solution is to ramp up supply of doctors, nurses and bed, and this is what we are doing, as I outlined yesterday. The solution is not to say we do not treat rich or foreign patients in public hospitals. Remember that doctors are mobile. While they are mindful of their public duties, they also want to treat a range of patients, rich and poor. If we unduly restrict their practice, some will simply pack up and go, and the poor will then be denied of their expertise. But I agree fully with Mdm Halimah that our accounting should be clear and that we do not end up with subsidised patients subsidising the rich patients by unwittingly shouldering part of the cost of private care.

Ms Denise Phua Lay Peng (Jalan Besar): Sir, I refer to the Minister's vision of one Electronic Medical Record (EMR) for one Singaporean, and also for both public and private sector medical practitioners to share the information when the database is up. Can the Minister comment on:

(1) How Singaporeans' medical records can be kept confidential under such a system?

(2) Whether each citizen is empowered with the decision to share or not his personal medical records, because it can be quite intrusive and, in fact, dangerous for such personal medical records to be go around if it is not protected.

Mr Khaw Boon Wan: Sir, this is indeed a very important subject, and that is part of the reason why "one Singaporean, one EMR" will take some time to implement. Therefore, we will have to do it gingerly and carefully. Otherwise, once information starts going around in the virtual world, it is very troublesome. All countries are grappling with this problem. My approach is to take it step-by-step. That is why we focus on public hospitals first, because it is easier for us to manage our own doctors and nurses. Once we are confident - and we are reasonably confident - my next step is going down to step-down care, eg, nursing homes, VWOs, etc.

The key point is that we will have to decide what are the critical data. Some data are so sensitive that they will never be shared. So it does not mean that "one Singapore, one EMR" means all the gory details are out in outer space. It cannot be. We have to decide. For example, issues like HIV and sexual diseases, these are data that we keep highly confidential. In any case, do not get the wrong impression that electronic medical records will worsen this problem. This problem exists even in paper form. When we run hospitals, we know that with medical records on paper, any hospital staff with a badge, can walk into the records office, in the name of checking out the medical records of their patients. You never know what happens in the office. Whereas now, with electronic medical records, we can actually audit them. So, let us say, we have a staff who, for various reasons, checks into the medical records of all kinds of patients who are not his patients, in the paper world, it is very hard to audit. But in an online world, it is so easy. There are softwares that can pick up very quickly; if you have a hundred patients, why are you accessing 1,000 patients' records? There is no reason for you to do so. Unfortunately, it does happen. The system is able to pick it up. I remember there was a case where we have to terminate the service of the staff.

Dr Lily Neo: Mr Chairman, Sir, may I ask the Minister how does he maintain the high standard of our medical personnel? In the past, doctors were sent overseas for training under the HMDP scheme. Are there better avenues and more funding presently? Does he have any plan to scale greater heights of medical expertise and medical excellence? The Minister said yesterday that MOH is getting hundreds of foreign graduates to join our Ministry. Could I urge him to be mindful of the quality of doctors and not just the quantity?

Mr Khaw Boon Wan: On both points raised by Dr Neo, I totally subscribe to her views. One is that we must continue to train, because medical science continues to evolve and we cannot stand still. HMDP, which is a programme that we created many years ago to send doctors overseas and to attach them to some of the best centres of the world, continues to expand, and we are pumping in more money each year. More importantly, in recent years, we have extended it beyond doctors, because the medical system comprises - no doubt, doctors form a big part - also nurses and allied health workers who are very important. Each year, when I give away such scholarships to our staff, I am glad to see that besides a large number of doctors, also large numbers of pharmacists, radiographers, etc, and we should continue this way.

The second point is about the quality of intake of foreign doctors. Yes, that is why we study the medical degrees very carefully before we put them on the approved schedule. I have progressively expanded it. My operating principle is a simple one: all the top medical schools of major countries ought to be on our approved list. There is no reason to exclude them. But it does not mean that once a degree is recognised, you can just come in and set up shop, because, first, we only give a conditional registration. So when you come in, you must have an employer and, practically all the time, it is the public hospitals. My point to the CEOs is this: yes, you can have a recognised degree, but you never know until the fellow appears and works for a few weeks or months. Please watch over him very carefully in the first few months because, whether it is medical competence, or more importantly, it is his ethos and values, and those are very hard to check on paper. If we are too strict in taking them in, then we are missing out on opportunities. So I would rather be a little bit loose in taking in, but be very prompt, firm and decisive in throwing them out. If you find that the fellow is just not up to our ethical standards and competence, we will be the first one to throw him out. So, yes, it is not chasing numbers. Numbers are important, but quality as well because, at the end of the day, it is the Singapore brand of medicine which is at stake here.

Assoc. Prof. Kalyani K Mehta (Nominated Member): Mr Chairman, Sir, I have three points of clarification. The first one is very straightforward. In the step-down care system of health and social services, is the RAF form mentioned yesterday used across all the 20-odd services? Is there any system of seeking feedback from all the different professionals, such as doctors, nurses, social workers, etc? Is there any system of seeking feedback as to the adequacy of the form in order to improve it? Lastly, for means testing of MOH and MCYS services in the step-down care sector, are there steps being taken to make the two consistent, because I believe there is a little bit of inconsistency there?

The Minister of State for Health (Mr Heng Chee How): Mr Chairman, Sir, my understanding is that the RAF form is used within the system. The form was introduced to enable a simple way to assess those needs. As I explained yesterday, the process of looking at the adequacy of the form is a continuous one, and we constantly look out for new methods, including the interRAI.

The question on whether stakeholders are consulted as to the adequacy of the form and what might be its shortcomings, this would also be an important part of the ongoing communications. If there are inadequacies, then they can also be improved upon.

Finally, on the possibly different criteria in means testing used in nursing homes versus the homes run by MCYS, I do not have the details with me here. But I would certainly take the Member's feedback and we would make a check of it, and if there is a need to synchronise and harmonise them, we will do so.

Mrs Josephine Teo (Bishan-Toa Payoh): Mr Chairman, Sir, I would just like to thank the MOS for responding to my question on mental healthcare yesterday. I was glad to note that mental healthcare patients are given proportionately more support through Medifund. I would like to ask the question of whether the IMH has sufficient capacity to cater to demand because, from time to time, we hear of cases of mental healthcare patients who are discharged and have returned home where it would appear that they would be better off with longer term care at the IMH.

Mr Heng Chee How: Mr Chairman, Sir, I thank the Member for her comment. From the perspective of the Ministry, and certainly from IMH, supply adequacy will be a factor we will always bear in mind. In other words, it is not a question of defining a certain supply and then, once you reach that, you push everybody out even though they may need inpatient care. But neither do you want to then make every case an inpatient case unnecessarily, because the considerations must be the early re-integration of the person into wider society so that he or she might be able to function normally and live a full and fulfilling life. So there is the medical aspect of this, ie, the assessment by the doctors as to what might be the right thing to do for an individual case, and this is also ongoing. Certainly, as the population changes in profile, as it ages, and as more stress comes upon society, the demand patterns may shift and this is something that is also monitored by the Ministry as well as by IMH.

Suitable resources will be directed to the improvement of the supply, if need be.

12.30 pm

Mdm Halimah Yacob (Jurong): Sir, just a couple of clarifications. Whilst I agree with the Minister that in those cases of subsidised patients where they request for more expensive medicine or implants, then that should not attract subsidies, but in the majority of cases, these patients are not in a position to request for more expensive implants or medicine. In those cases where it is the doctor who prescribes that as part of the treatment procedure, would the Ministry then consider extending the same level of subsidy, rather than excluding them completely from the subsidy, because there are still some items which are completely excluded from subsidy and that is expensive and causes hardship?

My second point is that the Minister said that what is important to the patient is, at the end of the day, the dollar quantum. I would like to ask whether the Ministry tracks, in terms of dollar quantum, whether there has been an increase. And if so, does the Ministry have a mechanism in place in the hospitals and other care providers to check why these increases are taking place? That leads me to the third question about wastage and duplication. I think there are two hospital clusters. The concern continues that there are duplication and wastage. Are there any initiatives in the Ministry to track to ensure that cost does not increase because of wastages and duplication between the two clusters?

Mr Khaw Boon Wan: Sir, I thank Mdm Halimah for her further elaboration. I spent some time yesterday in my speech talking about the diverse needs of the patient and, therefore, the need for diversity. From my point of view, that is a critical point. You can have a very uniform system which was what I grew up with when I was a young officer starting my career in Singapore. From the headquarters' point of view, it is the simplest - one circular and everybody follows, everybody wears the same uniform, etc.

But I think that world is gone. And I gave some illustrations yesterday - different kinds of needs. It is very hard for us to group them into simple boxes. For general policies, we have no choice but to simplify. But reality requires us in each case, to try to be able to meet the unique needs. That is why we restructured the hospitals and we have clusters, and we continue to evolve. I do not see that the current structure will go on forever. I am sure we will continue to evolve. Even during my term as Health Minister, I am quite sure that it will continue to evolve.

And yes, what it means is that, once you allow that kind of diversity, we are paying a price for it. We are paying some price for diversity. So the challenge in management is to know what we should standardise and centralise, and what we should allow diversity. There are always trade-offs and we will continue to make that kind of trade-offs and judgement calls. Sometimes, we miss something and when a feedback is received, we will take a look at them. That will be my general comments on this point about duplication and higher costs. I think it is inevitable, provided the price, compared to the benefits that we get out of diversity, is worthwhile.

As to the question of what subsidised patients are paying, I monitor those carefully. Part of my reason for publishing many information is that it gets into the consciousness out there, both among the public, the referring GPs and also, very importantly, to the doctors and the hospitals. Once we allow diversity in management, we cannot be micro-managing every issue and decide on how much we should charge for Panadol or Lomotil. I think I would have no time to sleep and it is a wasteful way of doing things. It is better that we make sure we have the right people in charge and they make their individual decisions. My job as regulator is to collect relevant information and periodically analyse those data and publish them so that the doctors in hospitals can then learn from this collectively. If their fees go up ridiculously, there will be a restraint on them. I think the efforts have been, at least from my point of view, positive and we will continue to push along this line.

The bottomline is the question that Mdm Halimah asked: are our services still good and reasonably affordable? My honest answer is: it is good and it is affordable. For a small number of cases, it is not affordable, sometimes, through their own fault, because we have always stressed that we have a good 3M system, but it is good only if you are in. If you work as a self-employed and refuse to pay Medisave, then of course, even a $100 bill may be unaffordable. But even if you earn $1,000, but provided you save in Medisave regularly for many years, a $2,000 bill is affordable. So that is the key, you must be in. Let us persuade our residents who are out to be in. I think Workfare this year is formulated to encourage the casual workers to come in. Provided everybody comes in, buy a MediShield or ElderShield, it should be all right for maybe 90% of the cases. But still, there will be some who drop through the net. Then, we have Medifund. We will look at each case individually and the Medifund Committee of wise men and women will take a look, and I am sure they will assist them.

I think this is a much better system than to have a very generous subsidy system that applies to all and sundry. When you do that, you will be over-subsidising many who actually do not need that level of subsidy. And because money is not unlimited, what it means is that the budget which is left to help the really needy, would be reduced and diminished. I do not think we should do that.

Dr Ong Seh Hong (Marine Parade): I would like to seek clarifications from the Minister or MOS. Yesterday, it was mentioned that there will be a review of the ElderShield criteria. I would like to ask whether we would consider making it easier for those patients, who are mentally disturbed or demented, but physically, are still able to do some of those functions, but very disturbed in their behaviour and require a lot of attention from the carers, to be also eligible for ElderShield.

Let me illustrate. Currently, the five criteria for ElderShield are mobility, whether they can walk, bathe or dress themselves, or whether they are incontinent. Whereas for some of the demented patients, they may still able to do all these, can still move around, ie, can do some of these activities, but are mentally disturbed and have disturbed behaviour like wandering, etc, and excluded under the ElderShield. I wonder if the Minister or MOS would also kindly look into this group of patients and to include them under the coverage.

Mr Khaw Boon Wan: I must admit that this is a level of details which I am not too familiar. But since the Member has mentioned it, I would take a look as we are at the stage of reforming ElderShield.

We have two objectives. I want to keep the basic product as cheap as possible and, secondly, I want to allow payout as high as possible, so that more people can benefit. There is always a trade-off and we have to make that judgment call. That is why, at the end of the day, I still prefer my approach, which is, to keep the basic cheap and really basic, with no frills, and then let people who can afford, top it up.

How do the mentally ill then come in? It is a tricky problem which we have to spend some time thinking about that.

Assoc. Prof. Kalyani K Mehta: On the same subject of ElderShield, Sir, I would like to give a little feedback and seek some clarifications since the Minister is looking into ElderShield, to revising it.

One of the feedback has been why are women asked to pay higher premiums than men for ElderShield? I know this is to do with actuarial figures and stuff like that, that women live longer, therefore, there is a higher chance that they are likely to use ElderShield. But it would be good if the Minister could look at this again and perhaps find a way to make it gender equitable.

Mr Khaw Boon Wan: This gives me the opportunity to explain a little bit about ElderShield, and the difference with schemes like MediShield.

ElderShield is more like life insurance. MediShield is based on reimbursement. So if you stay three days in hospital, you get so many dollars, if you stay five days, you get so many dollars, and you claim accordingly. But ElderShield is really like life insurance. The premium is a fixed rate for the rest of your life, depending on when you come in. If you come in earlier, your rate is cheaper. If you come in late, your premium rates are higher. Likewise, for life insurance, there are gender differences. There are differences between the tropics and temperate countries because life expectancy is shorter in the tropics than in the temperate countries. All these are actuarial computations of probabilities and so on. Women, being a stronger sex, live longer, so their premium rates are higher. I would like to be a woman in that regard.

The Chairman: Mdm Halimah, do you want to withdraw your amendment?

Mdm Halimah Yacob: Sir, I would like to thank the Minister and also the Minister of State for their very comprehensive replies. We have heard some policy changes and we also had an interesting debate. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The sum of $2,058,203,710 for Head O ordered to stand part of the Main Estimates.

The sum of $229,301,900 for Head O ordered to stand part of the Development Estimates.