MAIN AND DEVELOPMENT ESTIMATES OF SINGAPORE FOR THE FINANCIAL YEAR 1ST APRIL, 1988 TO 31ST MARCH, 1989

Order read for consideration in Committee of Supply [11th Allotted Day].

[Mr Deputy Speaker in the Chair]

Head P -

Resumption of Debate on Question [29th March, 1988],

"That the total sum to be allocated for Head P of the Main Estimates be reduced by $100." - [Dr Aline K. Wong].

Question again proposed.

The Acting Minister for Health (Mr Yeo Cheow Tong): Sir, first, I would like to thank the Members for Fengshan and Changkat for their support of the community hospital concept and also for the cautionary notes from the Member for Fengshan.

Sir, the community hospital concept developed from the recognition that acute hospitals are expensive to build and even more expensive to operate. Case studies of patients in acute hospitals revealed that 10-15% of them need not be occupying such expensive beds. Many of these patients are in the convalescent phase of their illness. Examples will be orthopaedic and other patients recovering from major surgery, and stroke patients requiring active rehabilitation. These patients will make up a major portion of the community hospital's patient load.

The community hospital will also provide respite care to the elderly sick patients so as to relieve the strain on the care givers. However, the hospital is not meant to be a chronic sick hospital nor is it meant primarily for the elderly sick. It will provide rehabilitative services and basic laboratory and X-ray services. It will have a small complement of doctors and will receive support from a nearby acute hospital. However, it will not be offering accident and emergency services.

As the Member for Changkat has pointed out, we are considering leasing out clinic space to the general practitioners. But these GPs will only be responsible for their own patients who need to be hospitalized.

The Member for Changkat also asked why is the community hospital is to be located in Ang Mo Kio and not Toa Payoh or Queenstown. In the planning of a new hospital, we have to take into consideration the availability of hospitals in the vicinity. Both Toa Payoh and Queenstown are already adequately served. With the intensive housing development in the north-eastern part of the island, the new community hospital in Ang Mo Kio will conveniently serve residents in Ang Mo Kio, Yishun, Bishan, Hougang and, of course, Toa Payoh.

The Member also asked whether the hospital, since it will be having community participation at the board level, will be autonomously managed. The answer is yes. It will also have subsidized wards. My Ministry will be giving the hospital a subvention to provide subsidized services. The details have yet to be worked out and I will keep the Member for Changkat's views in mind.

Sir, I also want to thank the Member for Fengshan for his concern as to whether such a hospital will be cost effective. That was also my concern when the details were first presented to me. If the community hospital is designed as a mini acute hospital with full-fledged medical departments and equipped with a whole spectrum of investigative equipment along with the whole team of para-medical personnel, then I can assure this House that it will be a disaster, cost-wise. However, by keeping the hospital as a low-activity institution, overheads can then be kept to a minimum level. With 200 beds, the hospital will be able to justify its own management and administrative personnel and it will also be able to link up with our existing hospitals, tap their expertise and utilize the various operating systems thereby minimizing the costs.

Sir, of course, the ideal solution will be to build the hospital as a wing of Toa Payoh Hospital. Unfortunately, Toa Payoh Hospital suffers from a severe lack of space. It will not be able to accommodate an additional 200-bedded wing. On the other hand, SGH and Tan Tock Seng Hospital are already far too large. Members may be interested to know that in many countries, hospitals as large as SGH and Tan Tock Seng Hospital are, in fact, the exceptions rather than the rule. In fact, hospital planners believe that a 200-bedded to 400-bedded hospital is probably more cost effective because they are easier to manage.

My Ministry also shares the concern of the Member for Fengshan that it may be regarded as a second class hospital. We will be reviewing what must be done to prevent this image from developing. As with any new concept, education of the general public is very important. Likewise, with the staff and the medical fraternity that will be using it.

Sir, this concept of a low-activity community hospital is not new. It has been introduced in many countries and it has worked. We are confident that given the proper preparations, this concept will work in Singapore too.

Mr Chew Heng Ching (Kaki Bukit): Sir, our total health expenditure as a nation is about 3% of our GDP today. This ratio is indeed low when we compare with the 8-12% ratio experienced in most developed countries. But as our population ages and as we become wealthier, our demand for health care will inevitably increase. Our health expenditure as a proportion of our GDP will increase.

Sir, my concern is: as demand for health care continues to increase, where do we strike a balance between the supply and demand for health care without unnecessarily pushing up the price of health care services? We could continue to increase the supply in Government hospitals through additional and better facilities and this means heavier health expenditure on the part of the Government. Private hospitals could increase their hospital resources to meet greater demand and this means heavier investment expenditure.

Sir, we cannot continue to increase supply indefintely. I think the supply of health care is finite. There is a limit to which supply resources can grow. At some stage, these increases will have to be passed on to consumers in the form of higher prices. Then there is a danger that the price of health care may be pushed up to a level which will go beyond the reach of the man in the street.

The solution to this fear lies in our keeping demand for health care as low as possible. One way to achieve this is through continuous health education and preventive health care. Currently, the Ministry of Health spends about $20-$30 million a year on these activities. This amount is small. It is peanuts compared with the total Ministry's budget of $500 million. I think greater emphasis should be placed in these areas and more should be spent on these activities. May I ask the Minister what is his Ministry doing to try to reduce the demand for health care in the long run? Is there a role for the private sector here? And how can the private medical sector play that role? Is it not in the interest of the private medical sector not to try to reduce demand for health care, bearing in mind that that sector has its own economic interests?

Dr Koh Lam Son (Telok Blangah): Sir, it is a fact that the demand for health care of our ageing population is growing year after year. In 1987, the aged, 60 years and above, numbered 212,000, 9,000 semi-ambulant and 1,300 bedridden. By the year 2000, the aged is projected to reach 300,000. What impact has this on our health service? Has the Ministry a long-term strategy to meet this changing needs on our health service? What about its impact on our present health plans? Should there be a revision of the present health plans?

As an example, I understand that the Kandang Kerbau Hospital is due to be extensively upgraded or even replaced by a new maternity hospital. The question is: is there a need for such a large maternity hospital in the future, bearing in mind the declining birth rate problem? Who will demand our health services more in the future? The newborn or the elderly?

Sir, the basic objective of health care to the elderly is to prevent a decline in the quality of life in old age caused by the development of degenerative diseases. Or to quote the experts, "to add life to years and not years to life". Towards this objective, the Government is encouraging the elderly, including the sick, to stay at home to be looked after by their families. This is right. For who can give better care, love, respect and dignity to a sick elderly other than his or her own family. However, to look after a sick elderly in the home is not an easy task. And I hope the Minister is aware of the many problems faced by these families. I want to encourage the Minister to look into more ways and means to help these families. I think up to now, the help given is rather limited. But I am not asking for a welfare scheme. I am asking the Minister to find all ways and means to help these families to help them to look after the sick at home so that they will not be forced to have to go to hospital or to go to nursing homes.

Sir, there is no comprehensive programme aimed at helping all these families who have aged sick at home. Yet the Government is encouraging families to keep their aged sick at home. For example, the Home Nursing Foundation is supposed to be a national organization to help give assistance and advice to some 10,000 disabled and sick elderly. But how big is this organization? Can it really look after all these elderly sick and give help to the families? I am surprised to learn, for example, that the Ministry is only providing 42 nurses for the Foundation. As far as I know, no medical staff has been seconded to the Foundation. Can the Minister tell me how many of the total number of elderly sick in Singapore are actually receiving help from the Foundation? The Foundation has set up two senior citizens' health centres and plans to build three more in the next four years. My question is whether the number and the size of these centres are adequate to cope with the increasing number of elderly sick? For example, how many elderly sick can be accommodated in the day care centre and the rehabilitation facilities that it has within these centres? What I want to know is, is the Ministry pursuing a policy of helping only those who seek help from them or, a more enlightened one, to help all those who need help?

I have heard of a number of problems faced by these families. One is transport. It is very difficult to transport a disabled elderly from the home to the outpatient clinics, the polyclinics, and even to the day care centre. The ordinary vehicles are not suitable for this purpose and taxi drivers are quite reluctant to accept the disabled elderly. I want to know whether the Minister would consider perhaps providing the ambulance service for this purpose.

The other point I want to make is that the problems faced by the sick elderly are not only health problems. In fact, they are mainly social problems. The social problems are looked after by the Ministry of Community Development which recently has introduced a number of home-help schemes. The point is, as the health and social service are inter-related, should there not be a coordinating committee between the two Ministries to ensure a more efficient service to the elderly and to avoid any miscommunication between the two Ministries. As an illustration, the Ministry of Community Development provides a meal delivery service to the homes. This to them seems a very good idea. But from the health point of view, it may not be so. This is because keeping the disabled elderly physically inactive and serving them without regard to their actual physical capabilities will actually make their disability worse. So instead of delivering cooked meals to these people, maybe the Ministry should arrange for the neighbours or volunteers to do the marketing for these disabled people and encourage them to do the cooking and other light household chores. This will increase their mobility and help them to cope better with their physical disability. In this respect, keeping the disabled mobile at home is such an important thing. Would the Minister consider giving some assistance to set up simple physiotherapy devices in the home, such as those bars and pulleys to ensure that the disabled elderly are kept active on a daily basis.

Mr Yeo Cheow Tong: The Member for Kaki Bukit has asked about health education. Sir, I would like to seek the Member's concurrence for me to give him the reply later, as another Member has also raised a cut on the same item.

Sir, the Member for Telok Blangah asked whether my Ministry takes into consideration the long-term demographic changes to our population when planning our health services for today and the future. Sir, the answer is a definite yes. Long-term planning must take into consideration the relevant changes that are happening to our population. We are very careful because health services are expensive, especially new institutions. This way, money is not spent unnecessarily. The same applies to the redevelopment of Kandang Kerbau Hospital. Sir, although the crude birth rate is declining, the Member would be happy to know that in terms of actual babies the number need not necessarily be decreasing. In fact, our projection is that because of the large cohort of women that were born during the 1950's and 1960's, in the next 10 years the number of births will peak at about 50,000 a year versus today's 40,000 to 43,000 a year. After that, we expect the number of babies born to stabilize at about 45,000, a number which is again slightly higher than today's figure. So I would like to assure the Member for Telok Blangah that the redevelopment of Kandang Kerbau Hospital is very much warranted.

Sir, in terms of the elderly sick, the Ministry is looking into the various ways and means of helping the elderly sick at home. He asked whether we are only helping those who approached us or are we helping all who needed the help? We would like to help all who need to be helped. But how do we know that they need to be helped. We must get the feedback somehow. And we do get referrals to our Home Nursing Foundation, which is the key organization providing home care for the aged. These referrals are from our hospitals, the outpatient clinics, the private sector doctors and, of course, the Ministry of Community Development. So we do get as much feedback as we can. Also to keep Singaporeans aware of the availability of such a service, last year, we sent out together with the PUB bills, pamphlets on the Home Nursing Foundation to a total of 760,000 households. So we do try to publicize the availability of home nursing by the Foundation.

With regard to the number of patients who are being cared for, last year a total of 3,311 patients were home-nursed and the Home Nursing Foundation provided a total of 33,663 home nursing cases. None who approached us were rejected. So the manpower is adequate to cater for their needs. Of course, in line with the ageing population over the next 5, 10, 15 years, should the demand increase, we must make sure that we help the Home Nursing Foundation to adequately staff its nursing ranks.

Sir, he asked about transportation for the elderly sick who need to go to the senior citizens' health care centres. The Home Nursing Foundation does have ambulances available and, when requested, they will fetch these patients to the senior citizens' health care centres for their rehabilitation, for the day care.

We are also coordinating very closely with the Ministry of Community Development in terms of provision of services to the elderly sick. In fact, my Ministry is also represented on the MCD's Committee for the Aged and there is a lot of cross-sharing of information and data between the two Ministries.

Sir, he asked about the meal delivery service being provided for by MCD. I am not too sure whether what he says is correct because the meal delivery is only provided for those who are so sick that they are unable to help themselves in terms of cooking their food requirements. If they are too sick to cook, it is going to be very difficult to force them to cook their own meals. That is why the meal service has been made available. Of course, the emphasis must be to teach our elderly to keep themselves fit, to keep themselves mobile, active and to be able to exercise. So we do try to encourage them not to be confined to the bed and that they should come out to exercise, stretch their legs a little bit, because it is necessary.

As to the installation of simple rehabilitative devices at home, I will ask my officials to look into it.

Dr Koh Lam Son: Sir, can I seek a point of clarification, a very quick one. I think the Minister is wrong to say that the meals delivery is only provided to those people who are very sick. I think it is provided to any disabled who cannot go out of their home or have help from the family or neighbours to go and buy their meals. So it is not for people who are so sick that they cannot cook.

The other disagreement I have with the Acting Minister, I am sorry to say that, is that he does not have to wait for referrals to reach out to these families who have sick aged. There is other feedback that you can look into. If there is a will to help, you will find a way. I am happy to give him the figures in Telok Blangah if he wants.

Mr Yeo Cheow Tong: Sir, the channels are always open. It is up to those organizations who are aware of such patients to make use of the channels. It is not possible for us to go round, checking every household to see whether there are elderly sick. The emphasis must be to make sure that the availability of the services is publicized so that families with elderly sick who require help, who require home nursing, can easily pick up the phone and call up the HNF. W must also ensure that the community organizations are also aware that HNF does exist and when they come across people living in their vicinity who require help, they can also help these people by calling up the HNF. So the key is to make sure that channels are open, the service is widely known and that HNF will be able to react and help them.

With regard to the meal delivery, I do not want to belabour the point but I think the MCD does vet the request carefully to ensure that the requests are justified.

The Chairman: Dr Ang Kok Peng is not here. Dr Aline Wong.

Dr Aline K. Wong (Changkat): We would like to thank the Minister for his replies. Maybe I would like to take just one or two seconds to make a few comments on his response on the catastrophic illness insurance scheme. Sir, the Acting Minister told the House that his Ministry has actually started to look at this matter about two years back and he is going to send some people from his Ministry to the United States to make a thorough study of how health insurance schemes work in the United States, partly to avoid the kind of pitfalls the schemes have fallen into and partly to learn from their experience. I would like to remind the Acting Minister that apart from seeking overseas' opinion, seeking to learn from the experience of the United States, there are also some people here in Singapore who have that kind of knowledge and capacity to be able to offer some advice, apart from those who sit on the Health Advisory Council. These include the academics at the NUS as well as other medical professionals who have been trained overseas and have come back with first-hand knowledge of the problem.

While his team is making a study on the health insurance system of the United States, may I also ask him to bear in mind to study the health maintenance organization scheme which seems to be gaining increasing acceptance in the United States among the private sector. It seems to be a rather effective way of keeping down health costs and keeping down health costs is a very important concern in the minds of my GPC members, as the Member for Kaki Bukit also just pointed out.

With that, may I thank the Minister and I beg to withdraw my amendment.

Amendment, by leave, withdrawn.

Dr Ho Tat Kin (Boon Teck): Sir, I beg to move,

That the sum to be allocated for Head P be reduced by $10 in respect of Code PA 1000 of the Main Estimates.

Sir, admission to Government hospitals and visits to Government outpatient clinics have risen steadily in the last 10 years. Between 1971 and 1980, the annual rate of admission to hospitals increased from 76 per thousand population to 110 per thousand. The rate of increase over the decade averaged 4.3% per annum. This will continue to increase as the population grows and age, becomes more affluent and health conscious. In fact, the Ministry of Health projected that by the year 2000 the admission to hospitals will increase to 135 per thousand population. Sir, here I share the same concern as the Member for Kaki Bukit on the increasing medical expenses needed.

People are generally more interested in having good health and, when that fails, good health care. Promotion of better health will in the long run help to reduce the rate of hospital admissions. Good preventive medicine and health education are important for good health and the key to good health is to educate the people to change their bad lifestyles such as excessive smoking, excessive alcohol consump- tion and excessive food and undue stress. The Ministry of Health's Training and Health Education Service has been doing a good job in the past and I feel they can do more.

Most of us only consult a doctor when we have some disturbing symptoms or feel physically or mentally below par. We seldom go for health checks or screening. It was found that in the United States of America, one out of 10 men is in need of treatment for high blood pressure and four women in every 1,000 have been found to have breast cancer where a quarter of these could have been detected by X-rays. Health screenings, therefore, help to give early warning of our health conditions. I would like to suggest to the Minister to promote health screening for the people either on an annual basis or bi-annual basis. Health screening should not be just tests taken for blood, blood pressure, ECG and chest X-rays. It should include the opportunity for the person and the doctor to discuss any medical, pyschological and other problems with a view to helping the person to improve his health by changing to a better and healthier life-style. And to encourage people to go for health screening, I would like to urge the Ministry to allow the Medisave scheme to be used. But to prevent abuse, the Ministry should set a ceiling equivalent to that charged at Government hospitals for similar screenings.

Dr Wong Kwei Cheong (Cairnhill): Sir, the 1985 report of the Economic Committee has emphasized the need for Singapore to be developed as an international medical centre of excellence. May I ask the Acting Minister for a progress report on what his Ministry has done to help Singapore achieve this objective. More specifically, I hope the Acting Minister can enlighten this House on the manpower development plans, especially in the training of doctors, nurses, medical specialists, technologists and technicians.

I understand that there are currently only about 2,600 doctors in Singapore, giving a doctor to population ratio of about 1:1000. Can the Acting Minister confirm if there are sufficient doctors in Singapore to serve 2.6 million Singaporeans as well as the additional potential market of thousands of Indonesians, Malaysians, Thais and Filipinos who may come to Singapore for their medical treatment. Can the Acting Minister inform this House the projected doctor to population ratio that his Ministry is targetting for, and are we producing enough medical graduates to meet our goal of establishing Singapore as a Centre of Medical Excellence?

There is a tremendous demand from Singapore students to study medicine, but the National University of Singapore seems to limit the intake of new students into the Medical Faculty to about 200 a year. Can the Acting Minister inform this House the additional doctors required over the next 10 years so that NUS can expand its Medical Faculty accordingly?

Another serious complaint that I have often heard from overseas visitors is the high cost of our medical treatment, especially in the private hospitals. May I therefore ask the Acting Minister if his Ministry has been able to monitor the medical fees charged by our specialists so that they will not overcharge their patients and give Singapore a bad image. Can the Acting Minister also inform this House the kind of incentives, for example, accelerated depreciation allowance and pioneer service status for investments in specialized medical facilities and services to help the medical profession to be more cost competitive?

Dr S. Vasoo (Bo Wen): Sir, I shall be brief otherwise I know you will conduct a verbal surgery. The health services are at the moment undergoing restructuring. I am all for restructuring provided that at the end of the day, after restructuring, the health services will remain within the reach of many. If at the end of the day, after the health services have been restructured, it does not come within the reach of the ordinary people, then I say we have failed in our restructuring effort and exercises.

I have a few pertinent questions in my mind. Firstly, is the restructuring going to improve the efficiency and the effectiveness of the health services? Secondly, is the restructuring going to incur a steep increase in terms of medical fees? Thirdly, as a result of this restructuring, would there be more emphasis on preventive and community health programmes? These are some of the pertinent concerns raised by many ordinary citizens who are and will be using the health services. I gather that in their mind, restructuring connotes basically an increase in fee structure at the end of the day and I feel that the Ministry has to take much effort to reassure them that restructuring means that there will be more efficient and effective services.

The average citizen has no difficulty in using our health services when these are required. However, the situation is changing because the cost of health care is increasing. The hospital charges have so far increased steadily over the years and I hope that the hospital charges will remain within reach for the ordinary citizens who would become consumers of health services. It is hoped that the restructuring of the hospital will not push up hospital charges so steeply that those who really need health care would find it inaccessible.

Sir, it is good in trying to have good buildings, sterile environment, but it will be no good if such buildings and services become not accessible to the ordinary people who need health care and attention. I hope that our health services will not run into that situation.

The nagging concern among many people is that C class beds will be phased out and it will be eventually replaced by B2. Sir, one must not forget that the frontiers of medicine have no barriers. I urge that we do not create much financial burden so that health care becomes less affordable to those who need it.

In conclusion, I have two pertinent questions for the Minister. Would the restructuring phase out the C class beds completely? Would charges of C class and B2 class beds be increased this year?

Mr Yeo Cheow Tong: Sir, I will take the points from the Members for Kaki Bukit and Boon Teck together. Both Members have expressed their concerns on the prospects of increasing demand for health care, especially as Singaporeans become even more affluent in the future. They have asked that the Ministry focuses more on preventive health care and health education.

Sir, I would like to assure Members of the House that my Ministry does strongly emphasize the role of preventive medicine in Singapore. In fact, we have adopted a three-pronged approach to preventive health care. The first approach is that of immunization which began many years back. The immunization against childhood and various other diseases continues to play an important role in our disease-prevention programme. We do continually evaluate the immunization programme and expand the type of immunization available when necessary. For example, we made immunization against measles compulsory in 1985 and last year we started encouraging Singaporeans to be immunized against Hepatitis B because of the close correlation between Hepatitis B and liver cancer.

Sir, our immunization coverage for infants is today about 90-95%, and is exceptionally high. In fact, it is a target that many developed countries are still striving vainly for. We will continue to monitor and ensure that this level is maintained.

The second approach is health education which the Members have touched briefly upon. There are many diseases, many of them fatal, which cannot be immunized against but which can be avoided. Conditions like heart diseases and cancer are directly or indirectly linked to unhealthy lifestyles. During the past few years, we have been increasingly using the mass media, giving public talks, exhibitions and talks over the radio. The press has also been very supportive in carrying almost weekly articles on healthy lifestyles. Our health education programme stresses very much on the individual's own responsibility for his own health and it encourages all Singaporeans to change their lifestyles to a healthy one, eg, a diet of low cholesterol content, and our very, very strong anti-smoking campaign which has been fairly effective in the past few years. We will continue with all these programmes.

Health information in the form of pamphlets and booklets is also very readily available. These are available for free from many channels - our poly- clinics, hospitals, private GP clinics - and Members may be interested to know that last year, we distributed 2.8 million booklets and pamphlets directly to Singaporeans.

The third approach, which is very important and which has also been pointed out, is that of medical screening. The early detection and treatment of diseases will allow us to prevent complications and recurrences. Catch them at the early stage, chances of a cure are very, very good and the cost of the cure, even more important, is much lower. We are emphasizing on medical screening and our health education programmes play a role as well in this respect because it also encourages Singaporeans to come forward to attend our screening sessions that are available at the hospitals as well as at the polyclinics. For those whose companies provide for it, we encourage them to make use of the services being provided for them.

Our screening includes annual blood pressure being taken for all outpatients who regularly attend our polyclinics and hospitals. We have also introduced screening for cancer of the womb and breast for women as well as chest X-ray. A new service will be introduced soon, and that is, coronary risk screening which should be implemented at the new Toa Payoh Polyclinic and will be extended to other new polyclinics in the future.

Sir, we will continue with this programme. We will find ways and means to enhance the programme and make sure that whatever money we put into it is utilized effectively and meaningfully. This way it will ensure that Singaporeans do not just live longer but they will be healthier as they grow old.

Sir, the Member for Cairnhill made a very short and brief speech, but in his brief speech he raised so many points that I am not too sure whether I have enough time to cover them. But I will focus on the main questions that he raised. First, what is the projected number of doctors required and whether we have the capability to train them, and will this projected number be able to cater effectively for Singaporeans as well as, hopefully, patients who come from the surrounding regions for treat- ment in Singapore. Sir, my Ministry does carry out regular reviews of our requirements of doctors. The last one was only carried out last year. The projection is that Singapore will need a total of 4,700 doctors by the year 2000 compared with the 2,900 doctors today, ie, an increase of 1,800 doctors between now and the year 2000. I can assure you that NUS is more than able to train the required number of doctors because the intake capacity of NUS is about 180 to 200. In fact, NUS now has more than enough capacity to meet the needs of doctors in Singapore.

He has also asked about the high cost of treatment. Sir, my Ministry has also received some feedback from foreign patients as well as from local patients and some local doctors too about the high fees that are being charged by some specialists in Singapore as well as the high cost of hospitalization. As Members know, my Ministry does not regulate private sector medical fees. We believe that it is not practical because medical service is very personalized and there is a tremendous variety of factors involved in this treatment. It is best to leave the setting of such fees to market forces. Doctors must be very careful in how they price their services. If they overprice, they will do themselves irreparable harm. They will find that once they lose their patients to other doctors, whether other doctors in Singapore or in other countries, it will almost be impossible for them to attract these patients back. Patients, on the other hand, need to be educated as well. They should not hesitate to ask the doctor as to the likely cost of treatment. And if the estimate given is much too high, the patient would be well advised to go back to his family doctor and ask to be referred to another specialist. I am sure most of the family doctors would be very happy to assist them in that regard.

Sir, with regard to the question on incentives for investments in equipment, medical equipment also enjoys the accelerated depreciation that is available in other industries. So doctors who invest in expensive equipment can apply for accelerated depreciation and that, I believe, would give them quite substantial savings in terms of the tax payable.

With regard to the points brought up by the Member for Bo Wen, Sir, I have stated many times in this House that the restructuring of the hospitals is meant to give our hospitals greater autonomy, greater flexibility in their management with the objective of being able to control future cost increases. Members may know that our health expenditure has been increasing at the rate of about 15% per year over the last decade. It is a rate that is unsustainable. We must find ways and means of becoming more efficient and of capping these rapid cost increases, and I believe restructuring, is the correct way to do that. If we are able to cap the cost increases, then the future increases in fees will also be lower as well. So it is to the benefit of the patients that we cap cost increases.

He has asked specifically whether the Class C beds would be phased out. Sir, the answer to that lies not with the Ministry but with the patients themselves. Singaporeans today are more affluent than 10 or 15 years ago. Together with the availability of Medisave funds, Singaporeans today find that they can afford greater privacy and that they can afford a better level of accommodation. This is reflected in their choice of wards when they are hospitalized. The result has been a tremendous demand for our Class B1 and B2 wards. Because the supply of these better wards is limited in our older hospitals, patients in such older hospitals are being forced to go into C Class wards. As a result, they complain to the hospital administrators that they are being forced to go down to a lower class ward although they are able to afford a higher class ward.

The example of Tan Tock Seng Hospital, I think, would be useful. During the last financial year, Tan Tock Seng Hospital had an occupancy rate of 91% in its Class B1 wards and an occupancy rate of 78% in Class B2 wards. In terms of hospital management, a 80-85% occupancy rate means that the beds are already well occupied. The reason is that during the weekends, occupancy tends to be low but during the weekdays occupancy tends to be high. So 80-85% occupancy means that during the weekdays they are almost 100% occupied. For the Class C wards, only 66% of the beds are occupied. Many unhappy patients in the Class C wards are clamouring to be allocated Class B1 and B2 wards as soon as they are available.

Sir, as we redevelop the older hospitals, this situation will be corrected. However, we will ensure that there will always be adequate Class C wards available for the low income group that genuinely need them.

Sir, with regard to the fees for Class B2 and C wards, the Member has asked whether these fees would be increased this year. I wish to inform him that the Ministry has no plans to increase those fees this year.

Mr Chew Heng Ching: Sir, on a point of clarification. I asked whether the private medical sector has a role in helping to reduce demand for health care, bearing in mind that it is against the economic interest to do so, and whether the Ministry is doing something to get the private sector to play that role.

Mr Yeo Cheow Tong: I must apologize to the Member for Kaki Bukit for this oversight. Yes, the private sector does have a role. The Member is correct in stating that unfortunately there may be a conflict of interest there because it may not necessarily be in the economic interest of private sector doctors to ensure that Singaporeans remain healthy. But I personally believe that most doctors are very aware of their responsibility towards their patients. It is not unusual for family doctors to look after one or two generations of patients. So there is a close link built up between family doctors and such patients. And I am sure that these doctors do take their responsibilities very, very seriously and that they do provide health education for such patients. The problem is how do we make sure that this philosophy extends to all the doctors. In that regard, we are working with the various professional bodies to see how that message can be emphasized more strongly and to persuade doctors to devote more time to health education whenever they see their patients.

Mr Teo Chong Tee (Changi): Sir, in my question for an oral answer previously, the Acting Minister for Health told me that the Government was looking for a site for a new hospital to serve the eastern part of Singapore. It came as a surprise to me to hear that the Government is still looking for a site. I wonder when will this site be found.

Sir, I recall that when the Bedok New Town was first planned more than 10 years ago, a piece of land was said to have been earmarked for a new hospital. What has happened to this plan? Today, several new HDB housing estates have already risen from vacant land, swamp land, squatter kampongs and reclaimed land in the eastern part of Singapore, and yet a suitable site for a hospital to cater for the needs of the population has still not been found. The people are surprised that there is no hospital built in conjunction with the HDB's housing development in the eastern sector of the island.

Sir, when the HDB plans its estate or new town, many corresponding facilities are also included in this plan. But why is there no provision for a hospital, despite the heavy concentration of population in this part of the island?

As the Changi Hospital is poorly located and not designed to equip with modern facilities, many patients have no choice but to make use of the hospitals in the City area. In the event of serious accident either at Punggol or Changi, the victim has to be transported to one of the hospitals located in or near the City area which is very far away. By the time he reaches the hospital, he may have been dead already.

Sir, a fully-equipped modern hospital is urgently needed in the eastern sector of Singapore. On behalf of the people living in these housing estates, I urge the Acting Minister for Health to expedite his plan for a hospital.

Dr Ho Tat Kin: Sir, since the launching of the Medisave scheme, more and more medical expenses have been loaded on to this scheme. The original philosophy of Medisave is to set aside every month a small but regular savings to ensure that we will be able to pay for our hospitalization expenses, particularly for old age health care as we expect the major portion of a person's lifetime hospitalization expense to be incurred after age 55. The 6% CPF contribution for Medisave was designed to meet the basic hospitalization needs of the average Singapore worker and his immediate family. It will not be adequate if he thinks of better than Class C wards in a Government hospital.

As at 30th September 1987, 43.5% of Medisave accounts have an average of only $287 in balance. This means that about half the account holders do not have enough money for old age medical expenses. There is therefore an urgent need to educate CPF members to be conservative in using their Medisave money. At the same time, I feel the Ministry should consider some form of national health insurance scheme which could be used to cover most hospital expenses and allow the premium of this health insurance scheme to be deducted from Medisave. Once the national health insurance scheme is implemented, all other Medisave deductions should be stopped. And to encourage people to maintain themselves in good health, this national health insurance scheme should also carry a good no-claim bonus.

Mr Yeo Cheow Tong: Sir, hospitals, unlike community centres and sports complexes, are extremely expensive to build and even more expensive to operate. For example, the National University Hospital costs $230 million to build and when fully commissioned, it will cost about $90 million each year to operate. Much deliberation must be carried out before we decide when to build and where to build our next hospital.

Sir, in the planning of hospitals, we have to consider, firstly, the total number of hospital beds that are required in Singapore based on the projected population growth and the projected level of hospitalization. Secondly, the number of hospitals that are required will depend on the optimal operational size of each hospital. Lastly, the location of the hospitals must be decided in relation to the population density and the accessibility.

Despite the population growth in the last 15-20 years, the total number of beds in the Government acute hospitals has not changed much. This is due, firstly, to the changing disease patterns and, secondly, the better treatment procedures leading to a shorter number of days being spent in hospital. As such, other than for NUH, there was no need for a new Government hospital to be built in the last 20 years. However, we are planning for one in the eastern part of the island in the future.

Sir, as the Member has pointed out, a site in Bedok has been reserved and is still reserved for hospital development. This was done in 1981. However, in view of the development of new expressways, the MRT and the various new HDB estates in the eastern part of Singapore, we have decided to investigate the availability of alternative sites in the eastern part. It is important to ensure that should a better site site available, we should reserve it so that it will be in a better position to serve the whole eastern part of the island.

Sir, we hope to finalize the choice before the end of the year. However, the development of the new hospital is not expected to begin until the early 1990s and its commissioning will not be due until the latter part of the 1990s. In the meantime, patients in the eastern part of Singapore can still continue to make use of Changi Hospital. It may be old physically and operationally; its layout may be inefficient while its A & B class wards may not be as good as those in SGH or NUH. But I can assure Members and Singaporeans living in the eastern part of Singapore that Changi Hospital's medical and para-medical staff are equal to those in our other hospitals. In fact, because of its low occupancy rate, patients are more likely to be given longer consultation time than in other hospitals. The staff are also perfectly capable of handling all A & E cases.

Sir, Singapore is a small island. It has excellent expressways and road system. Members can be assured that accident victims can be swiftly taken to the nearest hospital today. The lack of a modern hospital in the eastern part of Singapore has not in any way had any impact on the treatment of accident victims.

The Member for Boon Teck talked about the inability of a large number of Medisave account holders to afford medical attention in the future because of the low level of balances. He asked that we consider the setting up of a national health insurance scheme as well as educate Medisave account holders to be more careful in the use of their Medisave funds. As I mentioned yesterday, we are continuing the educational programme for Medisave account holders. We are encouraging them to be very careful in the use of their Medisave and to only opt for hospitalization should their medical condition warrant it.

With regard to the national health insurance scheme, the Medisave scheme was introduced to avoid a very dangerous pitfall of the general insurance scheme. The experience of the countries with such a scheme has been that it gives the consumer the illusion of free medical services. It has led to the development of a buffet lunch syndrome. The people fel that since they have paid the insurance premiums, they might as well use the medical services indiscriminately. The end-result is that everyone, the whole population, end up paying much much more because of this overuse. My Ministry does not propose to introduce a general medical insurance scheme. But for Singaporeans who prefer to opt for that, such schemes are freely available today and they are provided for by the private insurance companies.

Dr Arthur Beng Kian Lam (Fengshan): Sir, I would like to seek two points of clarification from the Minister. Firstly, regarding health education pamphlets. I would like to congratulate the Ministry on the very good quality health education pamphlets that are distributed. I would like to ask the Minister whether the booklet that is produced by the Maternal and Child Health Clinics can also be sold to GPs so that our patients can also use it because this is an extremely good booklet.

An hon. Member: Declare pecuniary interest.

Dr Arthur Beng Kian Lam: Yes, Sir, I must declare my pecuniary interest.

My second point is in regard to the Hepatitis B vaccination. This, I understand, is also being done in Accident and Emergency units. Is this the correct place to do it? Will the Minister please comment?

Dr Tan Cheng Bock (Ayer Rajah): Sir, I just want to seek a point of clarification. The Minister has been talking about building a hospital in the Bedok area. I am wondering why is there a concentration of hospitals on that particular sector of the island. We have to consider areas in the north and in the Jurong area.

Mr Yeo Cheow Tong: Sir, I would like to thank the Member for Fengshan for his very encouraging remarks. I am sure my staff will appreciate it.

Sir, I cannot see any reason why that booklet cannot be sold to GPs and I will ask my staff to look into it very quickly.

With regard to the giving of Hepatitis B vaccination in A & E departments, I am sure there must be good reasons for that. But I will ask my staff to review whether it is appropriate.

With regard to the comments by the Member for Ayer Rajah why there is a concentration of hospitals in the eastern part of the island, I am sure the Member for Changi will strongly disagree with him on that. There is a general lack of hospitals in the eastern sector of Singapore. There is only one hospital there at the present moment, and that is, Changi Hospital. Unfortunately, the Member probably did not hear very well my previous reply on Changi Hospital. I did inform the House that Changi Hospital is due for redevelopment in the future. However, we will not be redeveloping it on the existing site. We will be looking for a more appropriate site. Once the new hospital is developed, Changi Hospital will then cease to exist.

Dr Tan Cheng Bock: What about Jurong?

Mr Yeo Cheow Tong: Jurong is already well served by NUH and Alexandra Hospital.

Dr Ho Tat Kin: Sir, I thank the Minister for his reply and I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Mr Teo Chong Tee: Sir, I beg to move,

That the sum to be allocated for Head P be reduced by $10 in respect of Code PD 1000 of the Main Estimates.

Sir, I would like to further comment on the problem of the shortage of nurses in Government hospitals. Nursing not being the most glamorous career, unlike that of the Singapore Girl, cannot be expected to attract many young aspiring school leavers.

The Minister has identified the problem that contributed to the shortage of nurses and promised to revise their salaries. I shall not delve on the subject further apart from appealing to the Minister for Finance who is here this morning to be on the generous side when revising the pay scales. We have to be realistic and face the hard facts of life in a modern materialistic society. We can only get what we are prepared to pay for. We will be most unrealistic and we will only be kidding ourselves if we expect to reproduce Florence Nightingales of yester year. It is high time the Government boosted the nurses' public image not only to raise their salaries but also to improve their welfare and general working conditions. It is also high time something concrete is done to make nursing a more rewarding and satisfying career for school leavers who may have an inclination for it.

Sir, I have a few suggestions to make for the Minister to consider. Firstly, to provide child care centres at the workplace for nurses who are married and have young children. The charges should be minimal. Secondly, to provide scholarships and bursaries for deserving nurses to pursue relevant courses to upgrade themselves. Thirdly, to promote a better public image of nurses along the line of what is being done for teachers by using the mass media. Fourthly, to provide study awards to children of nurses with outstanding school results. Fifthly, to present long-service awards to nurses who have served more than 10 years. Sixthly, to give special incentives, eg, free holiday tours to outstanding nurses. Lastly, to provide better and more comfortable rest areas for nurses.

Mr Yeo Cheow Tong: Sir, I would like to thank the Member for Changi for his long list of suggestions. I will ask my Ministry officials to review them and see how they fit in with the fringe benefit system of the civil service. But there are a few points which I can reply on immediately.

First, child care services. I believe that these were provided in certain hospitals earlier on, but unfortunately they proved to be unpopular and were therefore withdrawn.

Scholarship to nurses for upgrading: yes, these are being provided. Every year we do send quite a good number of nurses for upgrading courses.

Long service awards: I am not too sure how much flexibility we have in this area. Also, Incentives for outstanding nurses: all this have implications for the civil service. I will ask my officials to look into them.

Mr Teo Chong Tee: Sir, I just want to find out from the Minister how soon will this revision of salaries come about.

Mr Yeo Cheow Tong: Sir, the review of the salaries is already underway and, as I have informed the House two to three weeks ago, we hope to be able to get a positive reply from the Ministry of Finance soon.

Mr Teo Chong Tee: Sir, I thank the Minister for the reply. I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The Chairman: Amendment No. 4, Dr Tan is not here. Amendment No. 5, Dr Koh.

Dr Koh Lam Son: Sir, I beg to move,

That the sum to be allocated for Head P be reduced by $10 in respect of Code PE 1000 of the Main Estimates.

Sir, the subject which I want to raise has already been raised by two other Members and the Minister has responded but I would like to add further comments.

Preventive medicine plays an important role in reducing the mortality and morbidity of many diseases, particularly by diseases known as the degenerative diseases of old age, which now constitute the number one killer in Singapore. The Minister has stated in his reply to the Member for Boon Teck and the Member for Kaki Bukit and highlighted a rather comprehensive preventive health programme. The Member for Fengshan has congratulated him and I would like to add my congratulations to him and his staff. However, I would still like to ask the relevant questions. Has all this publicity reached out to the population? Have we reached one and all about this very important message? For example, the pamphlets and the posters that you put up in clinics and in the hospitals' outpatient departments. This, in theory, is only accessible to people who visit those places, and I guess this would constitute perhaps 1% of the population. So how effective is your anti-smoking campaign? Just now the Acting Minister said that it was fairly effective. What does that mean? How does he measure the effectiveness of that programme? What I want to state is that we must continue to find ways and means to mobilize and motivate the so-called healthy Singaporeans to come forward and participate in the preventive health programmes.

I would like here to make two suggestions. First, for a preventive health measure to be effective, there must be this element of compulsion. Look at our immunization policy. Before the Immunization Act, the response rate was very unsatisfactory. After legislation, every parent upon birth registration receives a notification of his obligation to vaccinate or face a fine of $500. The response, as the Acting Minister has stated, is practically 100%.

So as far as this group of people is concerned, this is the group that suffers from degenerative diseases, the target group. These are people like ourselves here, in the 40s now. In the next 10 to 20 years we will be in the group that will form the aged. So is it not possible for the Minister and his officers to come up with a legislative measure to make it compulsory for all employees, aged 40 and above, to undergo periodic screening tests, urine tests and blood pressure tests, which are very simple and very low-cost tests? He may think that this is a rather harsh thing to do. But think of the cost, the death that can be prevented and also the social economic cost brought about by these diseases.

Another suggestion which I would like to make is that there is a golden opportunity to implement a mass screening programme, ie, on election day. This may sound ridiculous to the Acting Minister - to conduct a health screening programme on election day - but this is the day where the whole electorate has to turn up. It is not so difficult to set up a nursing station either before or after the polling booth, and make sure that every voter has his urine test done and his blood pressure measured. I am sure you will not find any shortage of voluntary medical personnel to come forward to demonstrate their civic spiritedness.

I have two other small suggestions. One is to offer free urine test and blood pressure screening at, say, the outpatient clinics and the polyclinics and also to encourage general practitioners to offer free tests in their clinics. Install more audio-visual aids in all public places, waiting rooms and clinics, hotels, shopping complexes, to run filmlets on the causes of hypertension, diabetes, heart diseases and their prevention.

Sir, I do not know whether I heard it correctly just now from the Minister, but I thought he said that the doctors in the private sector may not share the Ministry's philosophy of preventive medicine, of keeping every Singaporean healthy. I do not know whether he actually said that. If he did, I think this is really preposterous. Because as he said just now, the reputation of a doctor, whether he is in the Government service or in the private sector, depends on his responsibility towards his patients. If he is irresponsible in looking after the needs and this includes the need of apparently healthy people, then his reputation will suffer. The gynaecologists in the private sector, and I am not advertising here, do carry out preventive measures. We do breast screening and pap smear, cancer screening. So I do not think it is right to say that we do not share this philosophy. Of course, we do. I have great faith in all doctors in Singapore including those in the private sector, unlike the Minister.

Mr Yeo Cheow Tong: Sir, I suspect that the listening capacity of the Member for Telok Blangah is better when he is in his clinic than when he is in this House. Sir, I had said that the Member for Kaki Bukit may be correct because it appears that there are conflicts of interest, but I went on to give a very long explanation as to why I think he may not be correct. I talked about family doctors looking after one or two generations of patients and all that. I hope he recalls what I have said, and if he has recalled what I have said, then I hope he will take back his words.

Getting back to the rest of the issues that he has touched on. Sir, I believe that whilst preventive health care is very important, however, one must adopt a very balanced approach. I do not think it is necessary to legislate compulsory screening tests. His suggestion about providing free blood pressure test and urine test during election day is a very novel approach to this problem. I dread to think of the logistics involved. Imagine taking urine tests for about a million people on one day, as well as taking blood pressure for that large number of people. I think there are better ways and one of the ways, as he has mentioned, is that whenever a patient comes into a clinic, the doctor gives him a blood pressure test. This we are already doing in our polyclinics. I am sure many of the doctors in the private sector do that too because each time I see my own family doctor, he checks my blood pressure. I think that is a practice that is fairly practised by doctors.

Sir, as for degenerative diseases, these are due to harmful lifestyles and diet. These are being catered for very strongly in our health education programmes. So I think we are coping with it.

The Chairman: Dr Koh, can you withdraw your amendment?

Dr Koh Lam Son: Can I seek a point of clarification first, Sir? The point that I was making just now which the Acting Minister missed is that if you wait for these people to come to the clinic, you are not going to screen the population. How many people come to see the doctors? They only come when they are not well. So you are not really doing a mass screening programme. The main point here is that it is people that you are not reaching out to who will later on come up with problems which will then be late for us to look after. That is the point I am making. That is why I start to think of ideas like having a mass screening on election day.

I wish to apologize to the Acting Minister if I had heard him wrong. But I thought he did say that it may not be in the interest of the doctors in the private sector to want to promote healthy Singaporeans. Because we are more interested in curative medicine rather than preventive medicine. Is that not the point that you are saying?

Mr Yeo Cheow Tong: Sir, the answer is no.

With regard to mass screening, I think it is the concept that is important. The concept is that we should try to screen as many people as possible. We will try to find all ways to attain that objective.

Dr Koh Lam Son: He has also not answered the point I made about introducing this element of compulsion.

Mr Yeo Cheow Tong: Sir, I have already replied to that earlier on. Obviously he was not listening.

Dr Koh Lam Son: Are you going to do it?

Mr Yeo Cheow Tong: No.

Dr Koh Lam Son: Sir, I think this debate ought to continue, but I withdraw the amendment.

Amendment, by leave, withdrawn.

The sum of $460,008,430 for Head P ordered to stand part of the Main Estimates.

The sum of $81,587,400 for Head P ordered to stand part of the Development Estimates.

Head W -

The sum of $36,218,260 for Head W ordered to stand part of the Main Estimates.

Head Y -

The sum of $172,000,000 for Head Y ordered to stand part of the Main Estimates.

Question, "That the sum of $5,901,816,690 shall be supplied to the Government under the heads of expenditure for the public services shown in the Main Estimates for the financial year 1st April, 1988 to 31st March, 1989, contained in Paper Cmd. 5 of 1988," put and agreed to.

Question, "That the sum of $6,505,997,700 shall be supplied to the Government under the heads of expenditure for the public services shown in the Development Estimates for the financial year 1st April, 1988 to 31st March, 1989, contained in Paper Cmd. 5 of 1988," put and agreed to.

Resolutions to be reported.

Thereupon Mr Deputy Speaker left the Chair of the Committee and took the Chair of the House.

The Minister for Finance (Dr Richard Hu Tsu Tau): Mr Deputy Speaker, Sir, I beg to report that the Committee of Supply have come to certain resolutions.

First Resolution reported -

"That the sum of $5,901,816,690 shall be supplied to the Government under the heads of expenditure for the public services shown in the Main Estimates for the financial year 1st April, 1988 to 31st March, 1989, contained in Paper Cmd. 5 of 1988."

Second Resolution reported -

"That the sum of $6,505,997,700 shall be supplied to the Government under the heads of expenditure for the public services shown in the Development Estimates for the financial year 1st April, 1988 to 31st March, 1989, contained in Paper Cmd. 5 of 1988."

Dr Richard Hu Tsu Tau: Mr Deputy Speaker, Sir, I beg to move, "That Parliament doth agree with the Committee on the said resolutions."

Question put, and agreed to.

Resolutions accordingly agreed to.