ATTENDANCE FEES AT ACCIDENT AND EMERGENCY DEPARTMENTS AND OUTPATIENT DISPENSARIES AND DENTAL SERVICE CHARGES

3.29 p.m.

Mr Ivan Baptist: Mr Deputy Speaker, Sir, I am most grateful to you for giving me this opportunity to raise this matter which is of grave concern and has caused much anxiety to Singaporeans. In this House that ill-fated day, 23rd March last, the Hon. Minister saw fit in his Ministerial Statement to unfairly and to the detriment of Singaporeans revise upwards attendance fees at Accident and Emergency Departments and Outpatient Dispensaries and Dental Service charges. That was an unwarranted revision which has left a most sour taste in everyone's mouth.

On the 1st, April fool's day, Singaporeans had to pay more at A & E, OPD and for Dental Services and this, Sir, was no joke. 604,492 employed persons in Singapore earn $399 and under, of the 870,442 employed, according to the Ministry of Labour's "Report on the Labour Force Survey of Singapore 1976". So, some 69% of employed persons are now faced with the possibility of scraping the bottom of an already empty pot if they or their families should have the misfortune of being ill or having teeth problems. That April 1st, staff at A & E and OPD, especially the nurses, and dental nurses, not the Hon. Minister, came under severe and heavy fire from patients or their parents for the most inconsiderate hikes in rates. This still carries on. Is the Hon. Minister aware of the buffers that protect him from the public wrath?

Let us examine the hike in A & E charges closely. It shot up from $4 to $10, a 150% increase. For whatever reason, a hike of that extent is profiteering. But the Minister will contend that A & E Departments are heavily subsidised. What would the subsidy be and should accidents and emergencies not be subsidised? Accidents are unplanned events leading to injuries or damages. No sane person would want to be involved in an accident and it could be caused at any time or place. So treatment, if necessary, is as essential as food or drink. But the prohibitive charges will most certainly force many who need treatment to keep away, much to their immediate and long-term detriment.

Those who are poor are so because they earn less. They have lesser skilled jobs due to lesser education and educational achievements. Most of them, therefore, due to lack of knowledge in matters pertaining to health either panic when the ailment is slight or seek no treatment until it is too late. The introduction of this excessive charge at A & E Departments will most certainly result in their taking the latter recourse. And this I am sure is not what the Hon. Minister wants. Or is it?

For those who can afford, raising fees would only inhibit them for a short period of time or if they have cash to spare, not at all. Has the Minister any figures to show the success of his sieving method introduced on 1st April to cut down on unnecessary visits to the A & E Departments? Has he also figures to show the income brackets of those who visited the A & E Departments these lest seven days?

In his Ministerial Statement on the 23rd March, he mentioned that 61.9% of patients were discharged after treatment, but he did not mention what portion of these deserved treatment as accident and emergency cases. Are we to understand that only those warded are termed by him bona fide accident and emergency cases? He has allowed them to be credited with the $10 deposit which patients have to pay on admission.

How does he propose to implement the waiver of charges for destitute patients? Does he expect patients presenting themselves at the A & E Departments to produce documentary evidence of their destitution? How many patients have obtained this waiver since the implementation of that unfeeling rate? Is the Hon. Minister aware that some of the nurses and staff at the A & E Departments have contributed towards the payment of attendance fees for patients who had just no money to pay for emergency treatment?

Is there really a criterion to determine who indiscriminately utilises the A & E Departments? Who can actually determine whether patients turning up are serious or emergency cases? The Hon. Minister did mention that doctors require longer time to examine patients to determine whether a stomachache is due to acute appendicitis. How much time does a layman therefore require to determine whether he should consult a doctor immediately when he suffers from an unbearable stomachache in the middle of the night? Does he wait for it to subside or should he proceed to the A & E Departments? Until the Hon. Minister can come up with a sensible sieving method to prevent the indiscriminate use of the A & E Departments, he should revert to the status quo which prevailed before 1st April. Is it not his objective to stop this indiscriminate use of the A & E Departments? Or is it his objective to prevent those who cannot afford to pay from visiting the A & E Departments?

Allow me now, Sir, to turn to the increases in dental service charges. For 21 years the scheme for the fluoridation of the water supply of Singapore has been an excellent preventive measure for the control of dental decay among the Singapore population. The Public and School Dental Services have been developed over the years and dental care is now afforded to practically every Singaporean, especially primary school children in more than 110 school dental clinics.

Campaigns, publicity and the like have achieved much over the years and the difficulties faced by the dental nurses who worked hard to convince parents of the necessity of dental care for their children, and to break down the psychological fears, were bearing much fruit. The turn around is now beginning with the infinite percentage increase in dental services charges for primary school children. Treatment used to be free but now an extraction costs 60 cents. a simple filling, scaling, polishing, repair of denture each costs $1, a single root canal treatment, $3, a partial upper or lower denture, $5, and a space maintainer. $15. For other treatments, various charges have also been revised upwards. Does the Hon. Minister realise that this is a retrogressive step towards enhancing dental care among the young?

The role of the dental nurses has been reversed. They were responsible for promoting good dental habits, the brushing of teeth, regular visits to the dental clinics and so on. But now they have to stand with outstretched hands collecting money first and then treating the patients later, I believe, since the imposition of fees for dental services in primary schools, some children have even absented themselves from school on their dental appointment days. This rarely happened before. I also believe that few pupils are responding to the treatment, which used to be free, offered by the Institute of Dental Health. Prior to 1st April, the vans sent by the Institute to schools returned with sufficient numbers for the student dental nurses to treat. The experience gained by the student dental nurses enhanced their skills for their future stints in school dental clinics. With the lack of pupils to sharpen their skills, the Institute might run foul of their main objective of producing skilled dental nurses. A student dental nurse would require some five patients to work on a day and there are some 40 student dental nurses being trained at present.

A pupil visits on average the school dental clinic ten times a year if he needs treatment. This would at the present rates cost between $6 to $10 yearly at the minimum. At this cost, which most certainly would revive the impression in most parents, especially those in the lower income groups, that dental treatment is not essential. There would consequently be a dwindling of numbers visiting the school dental clinics. Has the Hon. Minister mustered enough figures to show that this imposition of his has not caused a reduction in visits to school dental clinics and the Institute of Dental Health?

As extractions are cheaper than fillings and as most parents feel that milk teeth would come off after a time anyway, preference would be for extractions and this could be detrimental to the permanent set of teeth.

School Dental Nurses now wear badges sporting the cliche "Sedia Berkhidmat", which when translated means "Ready to Serve". When the service was free this could have applied, but now we would need to redo the badges to read "Pay and we will be ready to serve".

I believe, Sir, I must inform the Minister for Education that charges should now be levied on the Ministry of Health for the utility services, space and so on that were previously supplied free-of-charge by the Ministry of Education to the Ministry of Health. When a free service was provided by the Ministry of Health to pupils, levies would be unfair. But now that the Health Ministry is doing business in schools, should they receive gratis all these facilities?

I believe the NTUC and the AUPE will also need to come into the picture now that School Dental Nurses, skilled persons who deal with oral cavities, have been imposed the additional task of administration and accounts. They have to collect monies, issue receipts, bank in monies and so on. The added responsibilities and hazards merit salary, insurance and escort coverage. Is the Hon. Minister considering these? I could, however, offer a much better suggestion - rescind the dental service charges and all will be well.

There is also the question of waste of material. Where before a phial of anaesthetic could be used to extract two teeth and a batch of amalgam for filling in two teeth, half of each of these are being wasted as most children, the ones that can afford, want to pay for only one extraction or one filling at a time. The introduction of school dental service charges has, therefore, increased costs for the Ministry in the form of wastage.

Mr Deputy Speaker, Sir, much hardship has been caused to many Singaporeans by the Hon. Minister over the last seven days and much greater hardship will be caused if he fails to rescind the charges he has levied for attendance at the A & E Departments and school dental clinics. I hope the Hon. Minister truly realises this.

The question, therefore, Mr Deputy Speaker, Sir, is that the Hon. Minister should now consider rescinding the Ministerial Statement made on that ill-fated day of 23rd March.

Mr P. Govindaswamy: Sir, I rise to support the Member for Potong Pasir in his bid to oppose the increase of fees at the Accident and Emergency Departments which was made known by the Health Minister in this Chamber on the 23rd of last month.

Sir, Members of this House will recollect that during the debate in the Committee of Supply on the estimates for the Health Ministry on the 14th of last month, I did raise the point on the speculations of an intended increase of fees at the Accident and Emergency Departments. I gave my humble opposing views on the subject and I had wanted the Minister to give me an assurance that the fees would not be increased. However, my question was not answered satisfactorily by the Health Minister during the debate. Instead an official announcement on the increase of fees was made by the Health Minister on the 23rd of last month in this House.

The majority of the people were taken by surprise and were dumbfounded by this drastic move. Apparently the lower income-group has been hit below the belt. Since the announcement, public opinion has not been favourable and the majority of the people have been complaining silently among themselves, and some have written to the press.

Sir, when the Minister first hinted on the move during the Budget debate to back his argument he gave the flimsy reason that some people had been misusing the Accident and Emergency Departments, resulting in congestion, and that this increase of fees would deter many non-emergency cases from going to this unit. But as laymen, the general public would not know exactly what really constitutes an emergency and what is not.

In the past, I had supported various increases of taxes on non-essential items which could be done without. But on this particular measure, I strongly oppose this increase of the fees at the A & E Departments. Nobody would like to be referred to a hospital, and it is not a pleasant place to visit either.

The Minister for Health (Dr Toh Chin Chye): I see the Member there so often!

Mr P. Govindaswamy: Sir, if the Minister thinks that there has been an abuse of this department, it would be wiser to educate the public as to what constitutes an emergency case and what is not, instead of suddenly imposing this drastic measure that digs into the pockets of the lower income group. I say this because it is the lower income group that usually patronises the Government hospitals. The rich in most cases get their medical attention from private hospitals or private family doctors, and therefore they are not in the least affected by the move. Even if they should go to Government hospitals, this increased fee means nothing to them.

But what about the plight of the poorer group of people? Where are they going to get emergency medical attention when they cannot afford to pay the fees? Do we expect them to commit crime in order to raise money to pay for their medical treatment? I wonder whether the Minister is aware of the consequences and the social problems that may arise later on as a result of this drastic move. If anyone in genuine need of emergency medical treatment should postpone such treatment his condition would deteriorate from bad to worse.

Sir, usually, those cases that are referred to the A & E Departments are not without reason. They are accident cases brought about by unforeseen circumstances. So why blame the innocent people and penalise them just because of a few black sheep whom the Minister thought had abused the facilities at the A & E Departments? Most private medical clinics are closed at night and when a person is injured and requires stitching of his wounds, where can he go to for emergency treatment other than the A & E Departments? I wonder whether it is fair to penalise this kind of a case that needs immediate medical attention.

I am told that since the fees have been increased from the beginning of this month, the number of cases referred to the A & E Departments has not dropped. Is this proposal therefore really a practical one? What I have gathered is that there have been numerous complaints and confusion at the A & E Departments over the past one week, because many people were unaware of the increased charges.

I know of a case that happened a few days ago when a schoolboy during a drill in the school collapsed. He was transported home by the school bus. His mother, who was then alone in the house, panicked on seeing the condition of the boy and she decided to rush him to the hospital. At the hospital she was taken by surprise at having to pay $10 attendance fee and she had not brought enough money to pay. Fortunately, there was a relative around to help in paying the required fee. This poor lady is in the lower income group and the $10 fee is rather stiff to her. She had no choice but to pay and become indebted. How are these poor people really going to survive if we go on raising fees at this rate? I even heard that many people had no transport fare to go back home after visiting the A & E Departments.

Sir, if I may quote a further case. To a layman if he is in pain as a result of a perforation of the appendix which requires an emergency operation, he might decide to delay seeking treatment because of the increased charges at the A & E Departments. He is also likely to postpone a visit to the doctor to the next day thinking that much of it is a simple abdominal pain which could be attended to at the Outpatient clinic. By that time he will realise that many valuable hours have been lost and it may cost him his life.

Cases of cuts too cannot be postponed because they have to be attended to immediately for cleansing and stitching. Such injuries cannot wait for treatment as they will not be properly healed if medical attention is delayed.

Again, many asthmatic patients too require treatment immediately and because of the chronic nature of the sickness they may get an attack every other day. Most of these patients come mainly from the lower income group and the increased charges will hit these people very badly. Besides losing out on their monthly pay, an injured worker may be forced to take more medical leave owing to the frequent attacks of asthma.

Sir, this increased fee too would in a way give the private doctors a reason to jack up their consultation fees immediately or gradually. For instance, if their fee was $6 previously they may gradually increase to about $8 which is still below the fees charged at the A & E Departments. Though private doctors have made the statement that they will not increase their consultation fees, what guarantee is there that they will not revise their rates? This move will also lead to a further brain drain of doctors in the civil service. Some doctors may go into private practice because there is much profit to make because of the extra earnings from increased fees.

Sir, I would suggest, like my good friend the Minister for Home Affairs when he introduced the Pedestrian (Crossing Rules) Act that we should educate the public first before taking any action. Indeed, this is a wise and practical move.

Some hon. Members: Hear, hear!

Mr P. Govindaswamy: But in the case of the present increase of fees at the A & E Departments, there was nothing of this sort. Instead all of a sudden an official announcement was made and everybody was taken by surprise. Even many Government doctors do not give their blessing to this move. They say that this increase of fees is not the right solution to cut down the workload at the A & E Departments or to deter those who abuse the A & E Departments. I am sure there are better ways of solving the problem at the A & E Departments. I therefore urge the Minister to reconsider his decision on the increased fee at the A & E Departments.

I therefore strongly support the views of the Member for Potong Pasir and oppose the increased fees introduced by the Health Minister for the A & E Departments.

Sir, the A & E Department has just been rebuilt. So the Minister increased the fees for the building of the Department. But the Dental Unit has not been demolished or rebuilt. So why the increase in the dental charges? Recently, they have spent millions of dollars on the new building. Most probably the Minister for Finance had instructed the Minister for Health to increase the fees for the A & E Departments in order to recover the cost for the new building. Is this logical? We have a surplus of millions of dollars. Why do we have to tax the poor people? The Hon. Minister for Finance should tell the Hon. Minister for Health not to increase the fees for the A & E Departments. This is a socialist government. We are only paying lip service to socialism. This is very bad. The people will say, "This is a very bad Government." We must get the blessing of the people. Therefore, the Minister for Health should consider reducing the fees. The Minister for Finance should also support and subsidise the Health Ministry.

Mr S. Dhanabalan (Kallang): Mr Deputy Speaker, Sir, from the constant punctuation of laughter, one would think we are discussing a very humorous subject. But I can assure you that to the poor low-income workers outside, this is no joke.

It is important to consider and understand the reasons why people go to the A & E Departments, especially in the evenings. Many working parents can only take their sick or injured children for medical treatment in the evening hours after their work. In fact, it is active Government policy to encourage wives and mothers to go to work and this situation is likely to arise more and more in the future. Others who are not so ill as to stay away from work seek medical attention after work. This again is something that should be encouraged. It is better to go to work in the day and seek medical treatment in the evening. The OPD closes at 4.30 p.m. and these people have the choice of either seeking treatment at high cost from the few private clinics which open in the evenings or of going to the A & E Departments in the hospitals. Most of the poor choose to go to the A & E Departments. Such people will now have to pay $10 per visit which is more than a day's wages for most workers. I am sure many private practitioners will follow the cue from the Government and also increase their charges, making private practice even more lucrative thereby attracting more officers from the Government service into private practice and making the situation even worse in the Government service.

For much the same reasons of circumstances and convenience, people seek medical treatment on Sundays and public holidays. No sane person enjoys spending a holiday in an OPD and it is quite unreasonable to charge a higher rate on such days.

Service in the A & E Departments is not so efficient, pleasant and quick that people find pleasure in going there for minor ailments, if they are aware that they have only minor ailments. The patient or those who bring the patient must be convinced in their own minds, however mistakenly, that the illness is serious enough to go through the harrowing experience of treatment at the A & E Department. How is the patient or the parents or others who bring the patient to know that the ailment is minor? They are laymen with no medical knowledge. In addition, a parent, for example, is emotionally involved with his child and quite naturally fears the worst. To a doctor, treating a child with a cut requiring some stitches or a child with high fever is a run of the mill affair. To a child or the parents it is a traumatic experience and one which cannot wait for treatment till the next day when the OPD is open. To only consider cases deserving hospitalisation as cases that should not be penalised with the $10 fee is most unreasonable. There must be many cases which are serious enough to warrant immediate attention but not hospitalisation. In fact, it may be precisely because the patient comes for treatment in the very early stages of the illness that he avoids hospitalisation. For this he is going to be punished under the new system.

In fact, it is a good sign that people in Singapore are keen to seek modern medical treatment in the very early stages of their illness instead of trying self-medication or going to some quack medicine man or waiting until their condition becomes very serious. Instead of adapting to meet this change resulting from increased health consciousness, we are trying to set the clock back.

To tackle the problem in the A & E Departments, consideration should be given to opening the OPDs for longer hours or beefing up the staff in the A & E Departments. These are measures which we can well afford as the present taxes and Government revenues can easily withstand the relatively small increase in costs of such upgrading of medical services. Consideration should also be given to using para medical personnel such as nurses and medical orderlies, to screen, advise and even treat minor ailments so that the doctors would only treat the more serious cases. One of the implications of the present policy is that the patient should be able to determine what is a minor and what is a major ailment. Surely the para medical personnel would be in a better position to determine this.

I sincerely feel that the Minister should reconsider the increase in charges that he has announced in Parliament.

Mr Ahmad Haleem (Telok Blangah): Sir, I rise in support of the Member for Potong Pasir. I think the Minister said that the reason for the increase in charges of the A & E Departments was the congestion at these departments. May I say that increasing the fees is really not the right way to decrease congestion. After all, in the evenings and weekends many people who are ill do not really know where to go. So the logical place to go is the hospital. Many people do not even know that it is an A & E Department. All they are concerned with is to go to the hospital to seek treatment. They cannot tell whether or not their illness is serious. If we increase the fees they will think that the best way is to go to the quack doctors or seek self-medication which, in the long run, will cost more to this country because their illnesses will get more serious and will require hospitalisation. We will, therefore, need more beds to accommodate these people. So instead of doing that why do we not have one outpatient dispensary open for 24 hours a day on a rota basis? It can be published by the mass media - the press, radio and television - that such and such an outpatient dispensary will be open 24 hours a day. Anybody who is ill but not serious can go to this outpatient dispensary for treatment if he or she wishes. In this way congestion at the A & E Departments will be lessened. There are others who normally do not go to the outpatient dispensary but go to private doctors. However, in an emergency in the evenings or during the weekends they find that their own doctors are not available. They may not know the doctor's home telephone number and they do not know where to go. They too turn to the A & E Departments for treatment. Perhaps the Ministry of Health could also help in getting the mass media to publicise where doctors and drug stores are available in the evenings and weekends so that people need not go to the A & E Departments. In this way, they can have a choice of either going to the outpatient dispensary or to the clinic which is open in the evenings and weekends. In this way, congestion at the A & E Departments will be lessened and there is no need to increase the fees. I hope the Minister will reconsider this point.

Mr Tan Cheng San (Paya Lebar): ( In Mandarin): Sir, according to the revision of charges for Government medical services made by the Minister for Health in this House on the 2 3rd of last month, the attendance fee at the OPDs will be increased by 50 cents, that is, from $2.50 to $3 on working days and by $1 on Sundays and public holidays. The attendance fee at the A & E Departments in the General Hospital will also be increased from $4 to $10 and there will be great increases for dental charges for adults, students and children.

Everybody knows that when a person is ill, he will generally look for medical treatment in order to get well and continue with his work to maintain the livelihood of his family. The medical facilities in our country are very advanced in this region. This is a fact which everybody recognises. Because of this, our people have been able to live in peace and remain in good health for the past many years. There have been few outbreaks of dangerous and infectious diseases in our country. In any case, the situation was quickly put under control and the disease did not spread. All this could be attributed to the diligence and the high degree of vigilance of the Ministry of Health and its staff at all times.

Now, the increase in public medical charges this time will undoubtedly increase the burden of our workers and people of all strata. The increase of attendance fees at the A & E Department at the General Hospital is as high as 150%. This is really shocking. Of course, I am convinced of the evidence produced by the Minister for Health. I do not doubt that there has been an excessive utilisation of medical services. But I must point out that the large majority of our workers and people do not have a good understanding of medical matters. A sudden symptom of illness in the still of night or pain and suffering occurring in the small hours of the morning very often causes them to lose their head. So they are taken to the hospital. And perhaps after medical examination, it turns out that they are not seriously ill. But this is not their fault, and they should not be penalised for this, because nobody will trouble himself to go to the hospital for an injection and to take medicine without any reason.

As regards the increase of 50 cents in the attendance fee at the OPD, this will undoubtedly increase the burden of the broad masses of our workers. In fact, everybody may fall ill at any time. The Government has the duty to look after the health and hygiene of the people. Therefore, the increase of medical charges this time is entirely unreasonable. Since this increase will not curb the number of people going to the Government's OPDs for treatment the motive is obviously to increase Government's revenue at the expense of our citizens who fall ill. Is this reasonable?

Regarding the increases in dental treatment charges, the intention is more thought provoking. We know that every cent that a student or child has comes from the parents. Will it not mean that the increase will be borne by the parents? From this it can be seen that the increase in fees this time will greatly increase the expenditure on medical charges for all the households in our country. May I ask how out ordinary workers are going to bear this burden? The increase of Government medical treatment charges will no doubt provide private practitioners with a very good excuse to adjust their charges. Therefore, I earnestly hope the Minister will be able to reconsider the revision for increased charges.

Encik Sidek bin Saniff (Kolam Ayer): ( In Malay): Mr Deputy Speaker, Sir, the problem before us is a basic one. It is an issue which directly involves the whole community. The community can accept an increase in TV licences because it is more concerned with entertainment. People can accept an increase in PUB charges because there are elements of costs which can be saved as a result of the world crisis. Nevertheless, the fact is that there are people who will be unhappy if the Minister concerned build a luxurious building and a swimming pool on top of it, as in the case of the new PUB building. About a decade ago in 1964, 40% of the people's incomes ranged between $100 and $200 only. Now there are 18% within the group earning between $100 and $200. If they were to see a swimming pool on the top of a tall building, which they cannot make use of, they will feel that their money has been spent unreasonably. If a person is given an opportunity to pay a lower rate of charges he would appreciate it more than a show of such beautiful things. However, the principle of conservation is there.

Today, we have incurred the wrath of the people for the increased charges at hospitals. But more importantly, we should give reasons for such an increase. If the reason is simply that we need more revenue, because of the increases in medical expenditure, I think the community will understand it and make an attempt to pay. But if we say that one of the reasons for the increases is that people in the community do not know how to use the A & E Departments, then I feel that this is an insult to their intelligence because they have been taught, through education, to use the hospitals since the times when bomohs and sinsehs were common. Now, suddenly when they visit the hospitals they are accused of abusing the facilities. If an ordinary person is sick today and he has to go to work tomorrow for the sake of his family, he has to be medically treated and remain healthy to maintain them. Perhaps, in the final analysis, he feels that he can make a little contribution to the country that he loves. But we charge him for abusing the facilities. I think that kind of statement should be retracted by the Minister.

I can give an illustration of an actual incident. A person was living in Changi when his mother fell sick at 4.30 a.m. He went out early in the morning and took a taxi. He was not sure whether it would take one hour to reach the hospital. There were no buses. He went to the A & E Department with some money. On arrival the doctor said, "It is nothing. Just give her two or three pills." When he reached home he discovered that the pills just cost $1 whereas the trip had cost more, in addition to the waste of time and energy. And we say that this is ignorance l We find here that on the one hand we teach the people how to use the facilities but on the other we expose them of being ignorant. I sincerely hope that the Minister would reconsider this, particularly for the sake of children at schools. The problem of dental care is very important. From the point of view of our Islamic faith, our Prophet encourages that we brush our teeth five times a day before Prayer. This is not just to show our handsomeness. If a young man like me has got no teeth I will look ugly. At the same time, those who often suffer from toothache will know the experience. So, for those children who are afraid to go to the hospital for extraction, let us not give excuses that their parents are reluctant to send them to the hospital because they have to incur expenses. There will then be a situation where the people of Singapore will be a toothless society!

Mr Ng Kah Ting: Mr Deputy Speaker, Sir, it has been said of this Government that it always introduces a painless Budget and increases taxes throughout the rest of the financial year, whether they be taxes on motorcars, petrol, etc. This year's Budget was not exactly painless. There were new taxes but there were also tax reliefs, for example, those on personal income tax. But, on the other hand, there were tax increases on motorcars. On the whole, Sir, in my view, it was a good budget. Therefore, my question is: why was it necessary, so soon after the Budget, to increase the attendance fees payable by persons who are very sick or who are in need of immediate medical attention? The increase in fees was announced by the Minister for Health in a Ministerial statement on 23rd March and came into effect, of all days, on 1st April, as pointed out by the hon. Member for Potong Pasir.

Dr Toh Chin Chye: On 23rd March.

Mr Ng Kah Ting: With immediate effect?

Dr Toh Chin Chye: I made my speech on 23rd March.

Mr Ng Kah Ting: That is right. But on 1st April the increased fees came into force.

Dr Toh Chin Chye: That is the financial year.

Mr Ng Kah Ting: I thank the Minister for reminding me but it is a day -

Mr P. Govindaswamy: A bad day!

Mr Ng Kah Ting: That day has been well described by my friend, the Member for Anson although the statement was made on 23rd March. I would say, with the greatest respect to the Minister for Health, that the timing was bad. Amongst other reasons given by the Minister for revising these fees sharply upwards is that the services of the Accident and Emergency Departments at the hospitals are being abused by people who are not sick enough to need medical attention. There was an illustration of a person who had a stomachache and believing that there was something really wrong with him, he went to the hospital. But I will go a step further on this illustration. This is with regard to the poor Singaporean who has a stomachache or what may be described as an abdominal pain at the right side. I am sure he himself cannot diagnose whether it is a simple case of stomachache or acute appendicitis. If I may go further, suppose he vomits and has diarrhoea. When he turns up at the emergency unit he surely has to pay the penalty of this 150% increase.

Dr Toh Chin Chye: $10!

Mr Ng Kah Ting: An increase of $4 to $10 is 150% increase.

Dr Toh Chin Chye: Fifty cents over 50 cents is a 100% increase. Do not misuse statistics.

Mr Ng Kah Ting: Sir, I am not an economist and I do not juggle with statistics. But I base my remarks on the facts and figures in the best way that I can.

Sir, what happens if this person's condition deteriorates? He must go to the emergency unit of the hospital to check whether it is a case of severe diarrhoea, food poisoning or even cholera. If the Government increases the fees beyond the pocket of the poor and sick person I fear that there is a danger that he may not seek medical attention. This may prove detrimental to the society because it may result in the person dying or spreading a disease like cholera.

My next point is on the role and function of hospitals. Health services are provided under social services for the people and that is what the Government is doing. It has spent vast sums of money in providing such services. Again, with due respect to the Minister, along with my colleagues who have spoken so well by giving good reasons, I feel that this increase in fees should be rescinded. Otherwise, as pointed out, not only the workers but there will also be others who cannot afford to pay the increased fees as in the case clearly illustrated by the Member for Anson. Had it not been for a relative who paid the fee of $10 for a school boy, he would not have received medical attention. So I am sure even the Hon. Minister and Members of the House will agree with me that nobody likes to go to a hospital unless he is sick at the odd hour.

Dr Augustine Tan: Bad.

Mr Ng Kah Ting: It may be bad for the Member for Whampoa. For the constituents in my constituency, which is a rural constituency, the nearest hospital is the Toa Payoh General Hospital. This hospital is out of the way. The stretch of road leading to it is at least more than a quarter of a mile from Thomson Road. After midnight, there will be less buses and after 12.30 a.m. there will probably be no bus services. There are very few taxis plying along Punggol Road after midnight. So anybody who has the misfortune to fall sick and cannot get the attention of private doctors will have to seek medical attention at this hospital which is supposed to be the nearest. In this respect, I would like to ask the Minister why there are so few hospitals. He might turn around and say, "We took over Sembawang Hospital, Changi Hospital and Alexandra Hospital". Those were military hospitals. But we will be spending millions of dollars to build a new general hospital next to the Singapore General Hospital. This is a modern general hospital. In keeping with the conceptual planning of Housing Board estates like Ang Mo Kio, Toa Payoh, Woodlands, Bedok and Au Kang New Town, why are hospitals not planned in those areas so that the people will not have to travel a long distance to a hospital?

On this note, Sir, I share the sentiments expressed by my other colleagues and earnestly hope that the Hon. Minister for Health will kindly consider our appeals.

Dr Augustine Tan: Mr Deputy Speaker, Sir, I rise to support the views expressed by the Member for Potong Pasir.

Sir, I ask myself a number of very simple questions, the answers to which put me very much at variance with the position taken by the Minister for Health. The first question I pose myself is: Is there an abuse of the services in respect of A & E Departments, Outpatient dispensaries and dental clinics? The Minister gave us figures to prove that there have been abuses in respect of the A & E Departments. For 1977, there was a 1 7.6% increase in the number of attendances and he drew attention to the last three months of 1977, in particular, which showed about 25% increase over the corresponding three months in 1976. But, Sir, in 1977 there were only 282,853 cases which amounted only to 23,571 cases per month, or only 786 cases per day, or only 131 cases per hospital. We have a population of 2.3 million. Even on a monthly basis, the attendances amount to 1.02%. I cannot see where the abuse comes from, and if the Minister knows any statistics at all he should not be using figures on the basis of three months and comparing them with another three months. There might be seasonal factors involved. People may tend to fall sick during the later months of the year because of the rain, flu and so forth. In my mind, Sir, I do not think there is any question of abuse. At the back of the Minister's mind is the fear that our health services will mushroom to unmanageable proportions as can be witnessed in the advanced countries where people really do abuse and take advantage of their health services. I believe we are far from that particular situation. If we look at the total health expenditure for this year which we have approved only recently, it amounts to $254 million out of a total Government expenditure of $5,7 56 million 'Or only 4.4%.

The other question which I put to myself is: can our workers afford the increases? Quite clearly, as indicated by hon. Members who have spoken on this subject, the answer is no. Sir, if one looks at the CPF figures for 1976, the number of workers earning below $300 per month, that is, $10 per day, is 45.96% or nearly 46% of the total number of workers. And yet the Minister has increased the A & E charges from $4 to $10 per visit. But $10 is equivalent to the daily wage of a worker.

The Ministry of Labour Annual Report 1976, Table 20, gives us information of wage-rates in selected occupations within industries in the private sector. I will quote some examples of the daily wage rate: Manufacturer of bread, cakes and confectionery: $ Chief baker . . . 11.72 Ovenman . . . 9.28 Baker . . . 8.15 Driver . . . 8.46 General labourer . . . 7.14 Spinning, weaving and finishing of textiles: Loom fixer . . . 6.83 Spinner . . . 7.80 Weaver . . . 7.21 General labourer . . . 7.41 Sir, I am not conducting a filibuster here, otherwise I could have read to you all the wages of ordinary workers in Singapore. They are available to hon. Members as they are in the Ministry of Labour Annual Report 1976. My point is very simple: that our workers cannot afford these very exorbitant increases. I suspect that the people who do the planning in Singapore are in one respect overly paid in the sense that they are paid at a level so many times that of an ordinary worker that they have lost all sense of perspective. I would like to invite just one Permanent Secretary, or his Deputy Secretary or even the Minister himself to try budgeting on $300 a month. In many cases people have to make do with less than that. Take a widow who is earning $200 or $230 per month with four children to support. On this kind of wage, how can we expect such a poor person to pay the charges which are being levied? Even the old charges were exorbitant enough.

The other question which I put to myself is this. Can our Government afford not to increase these rates? As an economist, I would say the answer is yes, and a resounding yes, for the simple reason that in fiscal matters, we have been very conservative, if not overly conservative. We have been prudent, which is to the good. But at the same time, Sir, I am also beginning to suspect whether there is not a loss of a sense of proportion. Just a few days ago, 36 Members of Parliament visited the new PUB building. I was told that the cost was about $64 million. There are other new buildings being put up by the CPF and other statutory bodies. If one looks at the facilities being provided in these buildings there is only one word that can describe it adequately - magnificent or extravagant. But this is a very serious matter for us to consider. If our civil servants think that they can simply spend money on luxuries of that sort when they should really be concerned with providing adequate services to the people of Singapore, then we say something is wrong. If it is a money-making concern and the facilities are needed to entertain, that is fair enough. But if they have to levy charges on the ordinary people to support such expenditure then we say something is wrong. Let us again have a sense of proportion. There are 282,853 cases in the A & E Departments in 1977. A $6 increase for each one of these cases would only amount to $1.69 million compared to the expenditure of millions of dollars or tens of millions of dollars on buildings and on facilities for civil servants.

Sir, we should sometimes stop to think what is the philosophy of this Government. I agree and I think hon. Members also agree with the principle that people should not feel that everything is for free. But I think that lesson is well taken in Singapore. If we want to increase the fee in respect of any category of service, let it be proportionate. An increase of 50 cents or $1 to people who earn several thousand dollars a month means nothing. But an increase of 50 cents or $1 to a person who earns $220 or $300 a month means "plenty". It can mean that some of these people may have to starve in order to get the necessary medical service. The Minister may turn around and say, 'Why do they not go to the Social Welfare Department? If they are social welfare recipients, they will be entitled to waiver of charges, etc.' But, Sir, let us thank our lucky stars that in Singapore the ordinary worker is still dignified enough not to want social welfare. Because he is dignified enough he is penalised in the process. But if we keep on adding these charges we will force people to get on to social welfare if only for the simple necessity of getting these services which they cannot otherwise afford. Sir, I think we should give very serious and due consideration to the points which have been raised.

Dr Toh Chin Chye: Mr Deputy Speaker, Sir, I think I owe the House an explanation why the revision of charges in the A & E fees, dental fees and the OPD fees was not included in the Statement of the Minister for Finance during the Budget debate. My Ministry took four months to survey the position at the A & E Departments arising out of continuous complaints that I have been receiving regarding the congestion, the long waiting time and inefficiency at the A & E Departments. We discussed the problem and before making a decision we took another three months to confirm what the previous survey had shown. All in all it took us seven months of monitoring the A & E Departments before we made this decision. It was not a hasty decision, neither was it made off the cuff. I thought I had some respect for the Member for Whampoa as an economist. But after listening to him, I thank my lucky stars that I was not one of his students. I do not know which side he is really on. He is beating the poor and speaking on behalf of those who can entertain to make money. I think we can dismiss the Member for Whampoa as just presenting arguments which really do not have any logic. But, of course, they were very emotive, as every Member who has spoken has been.

It could have been very easy indeed for the revision of charges to have been included in the statement of the Minister for Finance. But the paper presented by my Ministry to the Cabinet took some time to be cleared and it was too late to be included in his speech. That was why I thought it was a good opportunity to make a statement in the House. It would have been very easy indeed to avoid a debate just by publishing the revision of charges in the newspapers and leave it at that. But I have made it a point and I did say so at the end of the 1976 elections that any financial charges, fiscal or policy measures should be debated in Parliament. When I made my statement, many of those who spoke today were sipping tea in the Members' room. They should have been here when the bell rang. I am afraid that some Backbenchers had forgotten the Parliamentary procedure that when the bell rang it was their duty to be at their seats, I was indeed taken by surprise that nobody stood up to ask me any question when I made my speech.

The Member for Anson has been following very closely with the Straits Times and I have a feeling that he is in cahoots with the young man who wrote a specious editorial, 'Below the belt' on 12th March. If there is any Member in this House who, like the editorial writer has any complaint below the belt, I can give one advice: The place to go to is not the A & E Department. It is either the Kandang Kerbau Hospital or the Middle Road Hospital.

The Member for Punggol has griped about his constituents having to take long taxi rides to go to a hospital. Everyone has to travel to go to a hospital. The last hospital that was built was in 1957. It was called the Thomson Hospital. It has now been renamed the Toa Payoh Hospital. We then took over the Alexandra Hospital and Changi Hospital, which I did not want, and the Sembawang Hospital which is a small hospital. As far as the Ministry of Health is concerned, it has been very much a cinderella Ministry, neglected to a large extent. It could have played a far more prominent role in social development but it has not been able to do so because of fiscal measures. I have been asked to educate patients first before we raise the A & E charges. Let me ask the Members present here, how do they go about educating patients when to visit the A & E Departments or when to visit the OPDs. It is quite different from the Minister for Home Affairs who has Vigilante Corps members on roadside corners and if a car driver happens to cross -

Mr P. Govindaswamy rose -

Dr Toh Chin Chye: Sir, the Member for Anson has already spoken, I am sorry. I am not giving way.

It is quite easy for Vigilante Corps members to give a ticking off to motorists who do not give way to pedestrians. That is enforcement with a threat of a fine and that means education with a rod. I do not think my nurses or the doctors are prepared to spend their time educating patients. We have only four major A & E Departments in the centre of Singapore, if we are to exclude Changi. We are faced with the problem that the whole of Singapore is converging upon these four A & E Departments, bypassing the Outpatient Dispensaries, where patients could go to. On the one hand, I cannot allow complaints about A & E Departments and not doing anything about them. On the other hand, Members are saying that the doctors in the A & E Departments are being put to the test. And if there is any doctor in the House, I can tell Members that posting to the A & E Departments is the most unpopular posting in the hospitals.

Let me come back to the Member for Whampoa. I do not know whether he calls himself a statistician or an economist. I did not use three months' statistics. I gave the House statistics from 1974 to 1977. Members can see that in 1975, the number of attendances increased by 3.5% over 1974. In 1976, the increase was 12.1% over 1975. In 1977, the increase was 17.6% over 1976.

Dr Augustine Tan: Sir, may I clarify? It is in Appendix II.

Dr Toh Chin Chye: I am talking about Appendix I. Appendix II just substantiates Appendix I. If the Member has not read his homework, then he should not have spoken out. If we allow this arithmetic progression to go on in 1978, we must face a collapse of the A & E Departments. Doctors do not like to work in the A & E Departments because, firstly, they have got to make quick decisions involving matters of life and death. Secondly, it involves night shifts. No doctor wants to work on night shifts or even to be on night duty. Let me put it that way. So let us not have double standards. This is what I am trying to put across; there are double standards in the House and in Singapore. On the one hand, doctors who are in public service are good game for attacks. On the other hand, private practitioners who equal the number of doctors in numbers are always covered up. Why do Members not direct their attacks at the private practitioners for their lapses? I say it is a double standard of reporting by the press. Worse still, I am aghast that Backbenchers who are supposed to have a higher IQ cannot even see through this double-standard way of reporting.

Now, let me disabuse those who are concerned over the inability of hardship cases to pay A & E fees. During the months of October to December last year there were 75,882 attendances, of which 29% were exempted from paying fees.

Those dental patients whose treatment had begun but not been completed before 1st April will pay old rates. However, new items of service begun on 1st April will be charged new rates.

Members have all read the story, that is, if Members read newspapers at all, of the 81/2-month pregnant woman who endured the hazards of travelling from Kampung Balai in Tanjong Pinang in a sampan for 12 hours in the middle of the night and without travel documents so that she could deliver her baby in Singapore.

When I compare the ordeal she was prepared to undergo with the bellyaching about the increase in A & E fees by $6, it makes me wonder whether some Singaporeans will ever understand that the everyday facilities they take for granted are other people's good fortune. To enjoy a sip of water one must first live in the desert. It is no use for the Member for Whampoa to pretend that he is speaking for the poor. He works in the University. He does not have to work on a budget of $300. He never has.

But let me phrase the question of health costs in another way. When people take out life insurance policies, it means that they place a premium or a cost on their health and they are prepared to pay that premium according to what they think their health is worth. The only people who believe that their life is not worth $10 are those who are already dead - long before A & E charges were raised from $4 to $10. The ballyhoo that Members have been following in the Straits Times is tub thumping - an opportunity for advertising the paper in the name of the poor. And equally in the name of the poor, the Straits Times Press with only a paid-up capital of $4.3 million made a profit of $3.6 million before tax, paying out a dividend of 30% to its shareholders and it has made a bonus issue of one for two. So much for crying out in the name of the poor. Now I am beginning to understand how the poor have been so abused. Revolutionaries use the poor for their cause. Now it seems that the capitalists also use the poor to enrich their cause.

So let us stop the cant and hypocrisy and get down to the facts of why these things have got to be done. I anticipated the bellyaching that would arise when I announced these fees. Do not tell me that my nurses and the doctors do not know that there is going to be an increase in the fees. By the time the Member for Anson knew this rumour it was a public secret. As a matter of fact, the decision to increase the fees was made after my discussion with the heads of the A & E Departments who are in a better position to know what their staff are facing than Members in this House.

Singaporeans are not that poor as Members and followers of the Straits Times paper that is monopolising the English educated make them to be. Perhaps we need a second English language newspaper in Singapore!

Some hon. Members: Hear, hear!

Dr Toh Chin Chye: Singapore's GDP per capita has increased from $1,974 in 1968 to $4,020 in 1977 at 1968 prices. It is a common sight now to see hundreds of people queuing every Saturday and Sunday to buy 4-digit lottery tickets even though there are only ghost horses running at Bukit Timah. Members can even see the so-called poor, their own constituents, rubbing shoulders in these queues, and back-street bookies have just as many 4-D customers. So every person has his own choice - either he saves $10 for a rainy day when he has to be attended to in an A & E Department if he feels that his life is in dire emergency or spends $10 on horses.

My Ministry is monitoring the attendances at the A & E Departments. For the period 25th to 31 st March after I made my statement, the daily average attendance was 762. When the A & E fees were increased on 1st April, the daily average attendance from 1st to 6th April was 760. What does it prove? It suggests that $10 is no hardship. Is a person's life worth $10? If a person has a sick dog and he takes it to the Kampong Java Road Veterinary Centre, the surgeon will charge him a fee. If he thinks that his life is not worth a dog's life, then he should not go to the A & E Department. I feel that it is too early to make any conclusion from this short period of survey. We will do our analysis after four months of monitoring.

Members know this lollipop [indicating]. It has a name that rhymes with pork-chop and costs 25 cents. I see on my TV that one is supposed to suck it if he is caught in a traffic jam. If grown-ups love it, children love it even more. Yet every dentist will tell those with a sweet tooth that toffee and lollipops are dangerous factors causing tooth decay. The price of indulgence in the sweet things of life is a toothache. Here again, one has a choice. A parent can let the child live with his toothache, have the tooth extracted for 60 cents or have it patched up with a filling for $1, which is the price of four of these lollipops. So let us stop the cant about poor children not attending schools because their dental appointments are due. The Ministry of Education has not given me a report that there has been a dramatic decrease of students in schools or students are playing truant. Far from it. The report that I get from the Dental Division is that the attendances are just the same.

The Dental Division teaches primary school children to brush their teeth correctly and through annual health campaigns, more and more parents have become conscious of their children's dental health. They even send their children to the orthodontist to correct irregularities of the teeth. Charges have already existed for this cosmetic dentistry but they have not been increased in the new revision. For the child it may mean wearing dental braces for 11/2 to 2 years. Currently, there are 2,586 children under treatment and 1,247 on the waiting list. The duration of the waiting list is 15 to 18 months. So I do not believe the newspapers, neither do I believe Members, that parents will grudge paying for their children's dental care. Otherwise, Members know the song, Burong Kakak Tua, Gigi Tinggal Dua!

The subsidy for dental treatment for school children is already 94%. If there are no revisions in dental fees, this subsidy will increase as there are now 93 dental clinics in primary schools.

It seems to me and this is the point that I wish to drive home, that there are some Singaporeans who are living in a make-belief world where the value system is upside down. Spending money to suck lollipops with the risk of dental decay is perfectly all right, but when it comes to paying to preserve a tooth there is protest. Losing money on a horse is all right, but paying $10 for emergency medical attention leads to griping. I wonder what sort of Singapore we are building.

I am receptive to practical suggestions and one practical suggestion which has emerged from this debate was that of the Member for Kallang.

He has suggested what I think is a very good suggestion, that doctors in the A & E Departments should be assisted by para-medical staff. As a matter of fact, they are already using nurse practitioners in outpatient departments. I have given instructions that the training of nurse practitioners be institutionalised in the School of Nursing as a post basic course and these nurse practitioners will also be used in the A & E Departments in due course.

My attention was also drawn to the idea proposed by a private practitioner that we should provide the freest access to medical attention. I do not know what he means by "freest access". It may be freest access, but it may not be free. We have only four A & E Departments, excluding Changi, which is remote. So it must be apparent to all that these centres do not have the capacity to handle all patients who go to them. As I have pointed out to Members, doctors in the A & E Departments make the assumption that patients whO go to the A & E Departments require a longer examination. Therefore, there must be a piling up of patients and hence I get complaints of congestion and long waiting times. But what then can be done? Private practitioners can come to the rescue and live up to their Hippocratic oath, that is, if they still subscribe to it. They can list their charges for a 2-minute, 3-minute or 4-minute consultancy and the injection or medicine that goes with the treatment. And if they have to stitch a wound, the charge per stitch.

Patients are consumers of medical services and even the poor should have the right to know what the tariff rates are. At least the Government is bound to let the people know what Government rates are. That is why we announce them in the House and gazette them. After all barbers put up a list of what they charge for a hair-cut, a shave or a shampoo but private practitioners keep their charges a secret and in doing so not only prevent the freest access to medical attention but also prohibit freedom of choice by patients who are poor.

Those private practitioners who find that their patients are difficult and take more than four minutes of their time should not send them to already congested A & E Departments with a mere chit, on which it is written "please treat", and that also in very bad handwriting. They should refer such patients whom they cannot or will not treat to a specialist. I mentioned in my Statement that among those referrals to A & E Departments, 9.2% came from private practitioners. Private practitioners can open their clinics at night. It will be a good idea for Members in the House to agitate the private practitioners to do so in their own constituency or they can even help organise A & E Departments with private hospitals. Why not? Members are not doing their job if they leave the private practitioners out and just keep on harping on the poor who is going away without treatment. In this way they can make even the poorest Singaporeans proud that they have the freest access to medical attention, if that is what they really want.

The Member for Punggol wants a hospital in Punggol. The Member for Sembawang wants a hospital in Sembawang.

Mr Ng Kah Ting: Sir, I did not ask for a hospital in Punggol. I merely suggested that hospitals should be built in the big housing estates.

Dr Toh Chin Chye: May I remind Members of an Arab saying: "If the mountain does not go to Mohammed, Mohammed must go to the mountain."

Mr Deputy Speaker, I have taken notes of what have been said. I find that the tune is the same: "The poor." Yes, the poor. Every Member is saying, "The poor". The Member for Kolam Ayer is quite happy to pay more PUB charges. Why? At least he sees the swimming pool on top of the PUB building.

Encik Sidek bin Saniff rose -

Dr Toh Chin Chye resumed his seat

Encik Sidek bin Saniff: ( In Malay): Sir, I think the Minister misunderstood me. What I said was that 40% of the people were earning between $100 and $200 a month. When these people saw such an imposing building as the PUB building, they felt that part of the money which they paid for the PUB bills was used to pay for the PUB building, whereas they themselves could not swim in that swimming pool.

Dr Toh Chin Chye: I apologise to the Member for Kolam Ayer. I thank him for his clarification. If it was not the Member for Kolam Ayer, it was one of the other Members who said, "Yes, PUB has got to entertain the customers because it is going to buy equipment for the new power station or for the water treatment plant." So it is all right. Pay. But when a man has been treated and he is cured, you see nothing. You see a healthy man. But that is not appreciated.

Mr Deputy Speaker, I know you are thirsty and waiting for tea time. So let me conclude just on one note, that is, the perverse distortion of news in the Straits Times, all under the cloak of freedom of the Press. The Clerk of Parliament handed out the revised scale of dental charges to a reporter of the Straits Times, but the newspaper in its issue of 24th March said that the scales were not set out in my statement.

I have never mentioned civil servants in my statement to the House but the Straits Times reported that "a private patient calling at a dental clinic will have to pay $12 more for a simple filling in future while a civil servant will have to foot an additional $2."

I cannot understand such obtuse journalism. The only advice I can give to the News Editor is that he should really consult his dentist for holes in his wisdom tooth.

Question put, and agreed to.

Resolved,

That Parliament do now adjourn.

Adjourned accordingly at Nine minutes past Five o-clock p.m. to a date to be fixed.