MAIN AND DEVELOPMENT ESTIMATES OF EXPENDITURE FOR THE FINANCIAL YEAR 1ST APRIL, 1989 TO 31ST MARCH, 1990

Order read for consideration in Committee of Supply [10th Allotted Day].

[Mr Speaker in the Chair]

12.45 pm

Head P (cont.) -

Resumption of Debate on Question [28th March 1989],

"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 Chairman: Dr Lee Siew-Choh, you have three minutes left.

Dr Lee Siew-Choh (Non-Constituency Member): Only three minutes?

The Chairman: Yes. You used up seven minutes yesterday.

Dr Lee Siew-Choh: Sir, yesterday, I was speaking about the corporatization of the Singapore General Hospital. I was saying that a stay of two weeks in Class B2 would have cost $602 instead of $280 if there were C beds available. It is a big jump of two and a half times, and the low-income group will suffer. Sir, if you will notice, there are now only three classes of beds in the Singapore General Hospital, A, B1 and B2. And you will notice that Class B2 is right at the bottom of the list. It has, in fact, taken the place of Class C. It is not difficult to see that the scrapping of the C beds is part of the process of giving new names to old things. What was Class A remains as Class A. What was Class B has been changed to B1. What was Class C is now B2. This giving of a rather high-sounding name to what was Class C may make it a bit easier for the poor to accept the higher charges. I suppose the Government has employed psychologists to help in the and exercise thus hope that people will not realize all this. In the airlines, Sir, the economy class is in fact class C, but the airlines do not call it class C. Similarly, in the General Hospital, our Class B2 is in fact Class C. Therefore, you can see that the whole exercise is a matter of renaming old things and using that as a means to an end namely that of raising hospital charges, somewhat imperceptibly perhaps, but nevertheless resentfully felt by the patients.

Sir, the Government always speaks of subsidized beds and whatnots. Let us remind ourselves that subsidies, in this instance, are merely small sums which the Government returns to the people after having taxed them to the hilt through direct or indirect taxes and now consumption tax. Although Government speaks of subsidies, Sir, on occasions, there could well be profits instead of subsidies. Let me give you an example. The Government has now extended the use of Medisave to Hepatitis B vaccination. The Government's charges for a course of 3 injections are: for new borns to 1 year olds, for those age 19 to 40, $90. What is the cost to the Government? The cost to the Government, as far as I know, is just $20 or $17 per phial of Hepatitis B vacinnine. But the charges for the newborns to 1-year olds are $30. You just work it out. They give only one-quarter of a phial for the under 1 year old. It works out to the cost of only $16 at the most for three injections. But the charges are $30. There- fore, there is no subsidy. Instead there is a profit of $14. Similarly, for 1 to 18 years, although the cost works out to also only $16, that is $29. For the 19 to 40 age group, the charges are $90. Here they give more than a quarter cc; they give half a cc and the cost comes to $32. If you have $90 minus $32, the profit is $58. For the over 40 years age group, the profit is $39.

Sir, I will be very quick. Although Government speaks of subsidies and what nots, actually the Government is not subsidizing the people at all. Moreover, Hepatitis B so far as I understand, is a public health issue. Therefore public immunization against Hepatitis B should in fact be carried out completely free of charge. Nevertheless, Government is charging a lot of money for it. Now, after all the big increases in salaries for Ministers and civil servants, I think it is time that the Government stopped all these so-called subsidies talk, and really give the people free Hepatitis B vaccination. I hope Government will give what I have just said - serious consideration.

Dr S. Vasoo (Tiong Bahru GRC): Sir, I have two subjects. May I take them together?

The Chairman: Yes, you have to.

Dr Vasoo: Sir, we have an efficient health care system. It has provided health care for people of various socio-economic groups. I trust that with the reorganizations which are being planned, health care will still remain affordable to various socio-economic groups.

The corporatization of hospitals beginning with the Singapore General Hospital has raised many questions in the minds of people. People are concerned whether corporatization plans will make medical treatment affordable. Will the cost of specialist treatment be reasonable? I think the main concern here is whether the specialists, at one time available to the ordinary people, will still be available to them at reasonable cost.

Sir, I support the idea of the corporatization plan because it is a good move. If it allows more independence, flexibility to the medical system, I support this move. However, health service must be cost effective and efficient. At the same time, hospital treatment must be within the reach of the working class. Public hospitals should not become an exclusive domain of a few, but for those who have and for some who have a little and for others who have nothing.

The success of a good hospital care system is judged by its accessibility to the people who need to be treated. There are a number of people, particularly older people, who have low Medisave accounts. They have to draw on one or more Medisave accounts to meet the payments. And if you do an analysis of multiple usage of Medisave accounts, you probably know what are the types of problems and the impact it will have on the older end-users in the years ahead. For these people, the phasing out of C class wards will create difficulties for them. And they might be deterred from using the services which have been available to them at one time. This will in the long run incur more costs for treating people who have other complicated illness, resulting from not seeking treatment earlier.

The old also fear that they are not getting the quality treatment that they require. Therefore, they opt to go to the better class in the hospital. And there has been this trend as they are not sure because they may be ill-advised in terms of the possibility of going to use subsidized beds. I feel that at the hospital where intake is being considered, patients with very low Medisave accounts should be advised in terms of the classes that they should. In the light that there is still a sizable number of people with low Medisave accounts, would it not be appropriate to retain more C class beds?

Sir, the corporatization of Singapore General Hospital is likely to affect the older hospitals which are at the moment not undergoing reorganization. These hospitals will face difficulties in retaining their staff. Good staff will leave to work in better-equipped hospitals. As a consequence, these older hospitals may become second-class hospitals. I hope that this does not happen. If it does happen, then the people who are less able to pay will probably be end-users of hospitals which provide less efficient service. Sir, I want to ask the Minister what steps he will be taking to ensure that the standard of health care service in older hospitals is not affected.

Sir, the other area that I would like to touch is the rise in the number of nursing homes. Of late, the number of nursing homes run by private operators are on the increase. These homes provide varying standards of care, particularly for the chronic sick and the aged. Some are of good standard, some are of poor standard, and others are sub-standard. There is a need to monitor these nursing homes to ensure that they provide at least a minimum standard of care for the consumers. I am interested to know whether the Ministry will be taking any steps to monitor and maintain the minimum standards of care in these nursing homes.

Encik Abbas Abu Amin (Pasir Panjang GRC): Mr Speaker, Sir, the Minister has made known the Ministry's policy that the Government acute hospitals will be redeveloped and restructured. I fully understand the rationale for the proposed plan to restructure the Singapore General Hospital and subsequently other hospitals, to enable the hospitals greater autonomy in managing their own affairs with a view to improving the standard of services to the patients. I support this move. However, I would like to ask a few questions of the Minister:

(1) What is the progress on the redevelopment of Government acute hospitals?

(2) Would these hospitals be similarly restructured as in the case of the Singapore General Hospital? How would the interest of the poor patients be safeguarded? For example, will there be enough subsidized beds and what assurance can be given to the public that the poor and lower-income workers will continue to get the services that they are now getting at affordable prices?

(3) Finally, how will this restructuring exercise of the Government hospitals affect the employment and terms of service of the medical staff, the doctors, the nurses, etc, in these various hospitals that are going to be redeveloped?

Mr Choo Wee Khiang (Marine Parade GRC): My GPC Chairman, Dr Aline Wong, and Dr Vasoo and others have spoken so far on corporatization of hospitals and I would just like to take this opportunity to reiterate some points. In my view, drastically reducing the number of beds for Class C wards is actually not appropriate and should be reviewed. Because the poor still need them. The availability of Medisave should account for the major reason for them to opt for Class B wards instead of Class C. I think the Government should encourage people who have lower Medisave accounts to take up Class C wards. One of the ways in which we can do this is to really upgrade the Class C wards. For example, haviang lesser beds for each Class C ward so that they would not be too congested and is more comfortable for the patients. I was told by some others that when Class C wards are mostly occupied, it is like a wet market or supermarket.

However, as far as corporatization or privatization of hospitals is concerned, many still fear that hospital charges will be increased tremendously. Because to them, corporatization means privatization which means it is set up with a view to profit. Sir, I am for corporatization because in giving more autonomy to hospitals, I think they can do a marvellous job, but I am not in favour of reducing the subsidy. As a nation we need to have hospitals, we need to provide medical services, medical care, to our fellow citizens, especially the poor ones. The cost of maintaining hospitals is high. However, the cost of maintaining hospitals and other health services, in particular manpower, in my view, can be seen as sunk costs. Therefore, when looking into subsidies one should give due consideration to such sunk costs.

I hope the Minister will enlighten the House as to how privatization will help us in achieving medical excellence and also how the Minister will appraise and assess the performance of these privatized hospitals.

Dr Tan Cheng Bock (Ayer Rajah): 1DPM, when he opened the National University Hospital, said that the idea behind this restructuring is not profits but cost effectiveness, not more expensive services, but better services and greater efficiency. I believe that the Ministry has employed an American company to help in restructuring. I am not against employing Americans to help us to restructure, but I believe that their approach is profit-orientated and I want the Minister to prove me wrong.

In every restructured hospital autonomy inevitably will be given to the hospital. And accompanying autonomy there will be a need to account for the use of manpower and equipment, and I am sure this will lead to a lot of self-interest in the hospitals that have gone private. The terms "restructure" and "private", as far as I am concerned, mean the same. Therefore, there will be no sharing of manpower, no sharing of equipment and no sharing of facilities. Let us look at the present arrangement. Under the present arrangement, Singaporeans have a chance to get expertise advice from neighbouring hospitals. They can also enjoy the facilities of each other's hospitals. For example, in Tan Tock Seng Hospital, there are specialists in neuro-surgery, in SGH orthopaedic surgery, open heart surgery, radio-therapy ENT, in Toa Payoh Hospital, endocrinology and, of course, in Kandang Kerbau Hospital, obstetrics and gynaecology.

My concern is, how does restructuring affect this arrangement? At present specialist doctors can move from hospital to hospital so that the hospitals that do not have a particular speciality do get this speciality expertise by way of secondment of the doctors to the hospital concerned. And also, patients can move from one hospital to another hospital. For example, if a patient from TTSH has a need for radio-therapy treatment, he will just be sent across to SGH for his radio-therapy treatment. I think that is a very good arrangement. But what disturbs me is that recently I met a couple of doctors who spoke to me and said that this present arrangement will not continue after restructuring. I asked them to give me an example and one of the doctors said there was a case of a patient who needed some specialist opinion from SGH concerning a renal problem or a kidney problem, but the response from this particular doctor in SGH was, "Look, now we are a different body altogether. We are restructured. We need to get permission and, of course, cost is going to be different." This is very worrying because I think the present arrangement is quite fair and patients do get a chance to get expertise management and advice. So I do hope the Minister will look into this.

My next question is, how do you ensure integration of hospitals? Privatization, restructuring - I fear you might cause some disintegration. Integration of hospitals, to me, is very fundamental because there will be no duplication of services, no duplication of manpower and, in so doing, health cost will come down. Of course, the ideal would be to allow each hospital to specialize in a particular branch of medicine. But then do you leave it to market forces to decide? Or do you in the Ministry decide for the hospital which particular speciality that the hospital should move into?

The other thing is conflict between having to serve the hospital and serving the patient. I give Members a very simple example. There are four surgeons, all working pretty hard. Three surgeons, let us say, make plenty of money for the hospital but the fourth surgeon works very hard and he is prepared to see C class patients. Therefore, he would not make money for the hospital. Will his head be chopped at the end of the day when accountability is important? So either he joins the three surgeons and continues to make money for the hospital, or he quits. Then what happens to those departments that are not profitable? For example, Pathology department, Forensic department? They do not make money but they provide a service. What do you do? Chop them also? Maybe the Forensic department will be hived off to the Ministry of Home Affairs. They have to do some police work too.

SGH has got no C class beds. This is unfortunate. But you expect the other hos- pitals, Alexandra Hospital, Tan Tock Seng Hospital, and Toa Payoh Hospital to have C class beds. If I am in charge of TTSH or the other hospitals outside SGH, I will have to show profits also at the end of the day. And I will surely make my C class beds less attractive to Singaporeans. TTSH will have to finally close the C class beds and opt for B2. I think Dr Goh Keng Swee's principle of equal misery should also be applied here.

Lastly, my concern is the teaching of medical students will be a problem if all the hospitals are restructured. How much time must a lecturer give to teaching, at the same time not losing his post by not earning enough for the hospital? I hope the Minister will respond to all these comments I have made.

Dr Wan Soon Bee (Pasir Panjang GRC): Mr Chairman, Sir, medical care is one of the basic necessities of life which every modern government has a duty to provide. Let me first begin by applauding our Government of its diligent efforts in providing and constantly striving to improve the medical services which all Singaporeans utilize.

In the past two decades, our medical services have improved by leaps and bounds, providing Singaporeans with health care that is comparable to the finest in the world. This amazing achievement has resulted in a healthier population, with an increased life expectancy and a very low mortality rate. There are currently, however, three issues which are of concern to the people. Firstly, there is the issue of the restructuring of Government hospitals. Secondly, the question of the level of subsidies for the different classes of beds in these hospitals. Lastly, there is the issue of Medisave.

The aim of restructuring Government hospitals is to give them greater autonomy so that they can develop greater efficiency and flexibility by freeing them from the constraints and regulations of the Civil Service and therefore to allow them to improve the quality of services that they provide. I personally support the restructuring of the Government hospitals.

Sir, but the fear of the public is that this restructuring in effect means privatization of Government hospitals. We have also heard from Dr Tan Cheng Bock just now, that the restructuring in effect means privatization of the government hospitals. If the hospitals are going to be profit-oriented and they are not going to look after patients who are not able to pay, then I think the objective in restructuring the government hospitals and make them efficient and flexible will be defeated. The people are indeed very worried that the high cost of medical care will be shifted from the Government to the individual consumer, making the cost of health care prohibitive and inaccessible to the lower income group.

Another fear is that these hospitals, in fact, as what Dr Tan has also mentioned, will become too profit-oriented. If they do not make money, the doctors will be chopped. If this happens it will lead to a loss of compassion and the human touch. These are two vital elements in the provision of health care for our population. Yet another problem is that foreigners will start to compete for the medical services that we are providing in these restructured hospitals.

I urge the Minister to reassure the people that the restructured government hospitals will continue to provide excellent medical care to all Singaporeans and not just those who can afford to pay. Secondly, I hope the Minister can assure the House that the cost of medical care, particularly that of C class patients will remain affordable. The cost of medical care has escalated over the years, not only because of inflation but, more importantly, because the quality of medical services has improved tremendously. New equipment, new facilities and better equipment and better facilities cost money and therefore the cost has actually gone up substantially. The Government's medical bill therefore has correspondingly risen at an increasing rate. This has led to the necessity of shifting some of the burden of the cost to the individual consumer. The reduced level of subsidies coupled with the higher cost of medical care has dealt a double blow to the people, the hardest hit being the lower income group who can least afford it. Therefore, my particular concern is for C class patients. The increase in costs and the reduction of subsidies may mean that in the near future even C class beds will be unaffordable by a portion of the lower income group.

I would like to suggest to the Government that in deciding the question of subsidies for C class beds, our Government should not be too concerned about the level of subsidies. Instead the decision should be based upon the affordability of the lower income group. It is true that patients can request a waiver or remission of hospital fees. However, a waiver is only available to those who really cannot afford to pay. What about the greater number of people who could afford to pay but only at the cost of immense sacrifice to the family? Who are these people to turn to? Will they be forced to neglect their medical problems or avoid necessary hospitalization because they cannot afford to pay the fees for a C class bed? Surely we cannot allow this to happen. It is my opinion that the waiver is not an effective aid to the poor. The fact that every year the number of waivers is so small may be an indication that it is difficult to qualify for a waiver and not necessarily that health care is affordable.

The issue which our Government must concern itself with is affordability. The level of subsidies for C class beds may be high but the crux of the issue is not the level. The vital consideration is whether or not the lower income group can afford medical services at the present level of subsidy. In other words, it is pointless to say that our Government subsidizes C class beds at the level of 85% of the running cost if the lower income group cannot even afford to pay the 15%. 85% is a high level of subsidy but is it an affordable level? Will lower income Singaporeans still be able to afford medical care if the level is reduced further? Perhaps the Ministry can reconsider its policy on subsidies and reduce the level where subsidies are unnecessary while maintaining the present level for C class and maybe B class beds.

Lastly, I should like to talk about Medisave. As a consequence of Medisave people have tended to spend more liberally on hospital bills firstly because they believe that the money in the Medisave account is not really their money and they can never get it back; and, secondly, because they want better medical services for their families by upgrading the class of beds used. This is because some patients believe, and maybe justly so, that the quality of medical care is differentiated according to class. Therefore, they prefer to spend more money on a higher class of bed - whether or not they can afford it in the long term - in the mistaken belief that they will be getting better medical care. In effect, all they are getting may be just greater comfort. I hope that is the case. Clearly, if a person wants and can afford greater comfort he is free to spend his money as he chooses. But if the only reason for choosing a more expensive bed is the erroneous belief that he will be getting better care, then clearly it is a waste of precious funds which will be more urgently required in old age.

It is up to our Government to assure the people that in effect all classes of patients receive the same care and I hope the Minister will assure this House that this is the case and that the only difference is the comfort factor. Further, our Governnment must constantly remind the people that the money in their Medisave accounts belongs to them entirely. They must be reminded not to squander this money while they are young because the need for it will be greater in their old age. People must be discouraged from being extravagant with their Medisave money on the basis of these two erroneous beliefs. I think it is a very serious problem and the Government should put in the effort to really correct the belief of the population.

The Chairman: Order. Your time is up. Mr Heng Chiang Meng.

Mr Heng Chiang Meng (Cheng San GRC): Sir, Singapore has total defence for the whole of society. I see no reason why we should not look at total defence for the individual. Such total defence would be (1) defence of personal security as embodied in the objectives of the Ministries of Defence and Home Affairs; (2) defence of the body as in the Ministry of Health; and (3) defence of the mind as in the Ministry of Education.

Sir, these are very fundamental responsibilities of any government and must be provided for through the various taxes collected by the Government. In this respect, I would like to compare the provision of health care by the Government to the provision of national security by the Government. The sole purpose of this comparison is to demonstrate that the need to maintain bodily defences is no less important than the need to maintain national border defences.

Yet, as I look at the direction in which the Health Ministry is heading, I am not too sure that the Government places health care on the same scale. From 1982 to 1985, the increase in the Health Ministry's total expenditure was 46%. As a comparison, the Ministry of Defence had a similar increase, about 47%. But from 1985 to 1989, the increase in Health expenditure was only 6%. This compares poorly with the Defence Ministry's increase of 24% for the same period.

Sir, if you look at these respective expenditures as a percentage of total Government expenditure, an even clearer picture emerges. Defence expenditure increased from 10.6% of total expenditure in 1982 to 11% in 1985 to 17% in 1989. During this same period, the Health Ministry's expenditure remained at about 2%-3% of total expenditure. Sir, please do not get me wrong. I am not saying that defence of the nation is not important. But what I am saying is that defence of the body is just as important. So why therefore the declining importance paid to health - at least in terms of relatively declining subsidies to the Ministry of Health? For example, the subsidy for Government hospitals has been reduced from 73% in 1982 to 61% in 1985 and now to 56% in 1989.

Sir, every time hospital charges are increased, the Minister always says that they are affordable. But, Sir, that is just his opinion. So far, we do not have any findings of any sort that these increasing fees and charges are really affordable. Could such a study be done? In this respect, it may be worthwhile to find out whether there has been an increase in the number of multiple Medisave accounts to pay one single bill, especially if it is by sons and daughters for their aged parents. If so, surely it is an indication of some inability to pay so that all of them must pool together. More significantly, in order to ensure medical health for their parents, filial sons and daughters may be depleting their Medisave accounts which they will, and I say they will definitely, need it in later years.

Sir, overall, I must say that I do not disagree with the policy that the subsidy for public health care must be kept to a realistic figure - a figure which must straddle the line between State affordability and personal affordability. My issue is that of the level. Piecemeal ad hoc reductions in the subsidy without any overall objective in the level itself is not the answer. All it does, Sir, is to periodically increase fees and charges. What is needed is a comprehensive conceptual plan on health expenditure. As a nation, how much can we, how much should we subsidize public health care? What is the expenditure of private health care so that it can be dovetailed into public health care and its subsidies? Where should the subsidy start? In which area should subsidy be emphasized?

These are important questions to an important issue. The Acting Minister cannot simply say that the charges are affordable. He must prove to the people that these fees and increases are truly and really affordable. I think only an overall conceptual comprehensive paper can do this. I strongly urge him to consider this. This is important for future planning in the light of our aging population for in the coming years this situation of the aging population will only mean one thing - health expenditure will go up and up.

Medisave will not be enough for many of us as we grow older. It is said that a person spends more on health care during the last year of his life than the sum total prior to the last year. If this is true, then with increasing fees and charges, we are just pushing the problem into the future. Surely, Sir, this cannot be the objective of the Ministry of Health.

Sir, I have got another cut, may I continue?

The Chairman: Yes.

Mr Heng Chiang Meng: Sir, earlier in this sitting, the Acting Minister for Health told the House that 23 cadaveric kidneys were transplanted in 1988. Of these, 16 came from the Human Organ Transplant Act while seven were from the Medical (Therapy, Education and Research) Act. Yet, Sir, for 1987, without the enforcement of the Human Organ Transplant Act, the number of available kidneys was 16. Looking at these figures, one can put up a case that without the Human Organ Transplant Act, the number of cadaveric kidneys would have gone down from 16 in 1987 to only seven in 1988. Yet, about 250 new cases of end-stage kidney diseases are diagnosed in Singapore every year. Out of these, only about 50 are accepted for either transplant or dialysis. I believe this is due to the lack of donor kidneys and dialysis treatment facilities more than anything else.

With such statistics, how long does a person have to wait before he can get a transplant? In the meanwhile, while waiting for a donor kidney, the affected person has to undergo dialysis treatment. This is not cheap, even at subsidized rates. I understand that the actual cost of treatment is in the region of $1,500 to $2,000 per month and if we consider the number of new cases every year one can see that the cost of caring for these patients is not an insignificant amount.

Sir, there too is a personal cost to himself, to his friends, to his beloved ones, to his relatives and also the cost to the State because kidney problems are not only confined to the aged, they can happen to anybody of any age at any time. Yet looking at the statistics of available kidneys from sources other than voluntary donations from living persons, there is still much work to be done. The proposed Medisave withdrawal scheme for dialysis treatment is welcome. But it is only tackling the symptoms, not the root of the problem. I believe the root of the problem is the lack of donor kidneys. Dialysis treatment only keeps the patient alive while he waits for a donor kidney. Are there no other ways of encouraging more people to be willing donors? I would like to ask why is the opting-in scheme a failure? Is it because of lack of publicity and public education?

I suggest that the Ministry could step up its efforts to educate the public to be more willing donors to their beloved ones. After all, one can still live a normal life with only one kidney. Perhaps this could be complemented by amending the Human Organ Transplant Act to ensure that such willing donors would get top priority in the receipt of kidneys should they themselves be in need in later years. The Minister should also consider extending the Human Organ Transplant Act to cover removal of kidneys for all types of death, so long as the kidneys are usable. Currently, kidneys can only be removed from deaths resulting from accidents.

Sir, I would also like to appeal for financial assistance for the National Kidney Foundation. Currently, the Foundation runs two satellite dialysis centres. These centres are heavily subsidized. The Foundation has to raise funds for the establishment of the centres. They also need to raise funds to operate the centres. In respect of what they are doing, they are in a way like mini-hospitals - at least in respect of providing dialysis treatment. In other words, they have, by providing these facilities, taken over a small part of health services which ought to be provided by the Government. I am thus suggesting that the Government provide the Foundation with an annual grant to cover part of the centre's operating costs. In this way, the funds raised by the Foundation can be channelled to building more of these centres and they are much needed as long as donor kidneys are in short supply.

The Acting Minister for Health (Mr Yeo Cheow Tong): Sir, first, I would like to thank the many Members who have spoken yesterday and today on the first cut of my Ministry's budget. For the benefit of new Members, let me first briefly re-state my Ministry's main policy objectives. The aim of my Ministry is to build a healthy nation and to achieve a high standard of health care for all Singaporeans. We will continue to emphasize the prevention of disease and the education of the public on all aspects of health, healthy habits and lifestyles and this is the only way to reduce the cost of health care for Singaporeans, ie, by their remaining healthy.

Unfortunately, in spite of all health education and preventive medicine, people will still fall ill and require hospitalization. We must therefore ensure that our hospitals and their professional staff are competent and efficient in restoring back the sick to good health. We must also ensure that the physical condition of all our acute hospitals meet the higher expectations of Singaporeans. Today, because they are our most modern hospitals, the NUH and the Singapore General Hospital are viewed by the general public as being more desirable than the older hospitals such as Toa Payoh Hospital and Tan Tock Seng Hospital. This situation will be corrected when the other three major acute hospitals, namely, Tan Tock Seng, Toa Payoh and Kandang Kerbau Hospitals, are redeveloped by 1994. Planning for the three hospitals is in progress and we hope to commence building works by the middle of next year.

Sir, my Ministry will also be setting up several speciality centres. This will allow specialists from both the private and public sectors to pool and upgrade their expertise and to develop them into centres of medical excellence.

An Oncology or Cancer Treatment Centre is scheduled to be opened in SGH in July this year. A National Eye Centre will also be set up within the SGH complex and renovation works for this will commence within the next few months.

The new Kandang Kerbau Hospital, as I have informed the House this morning, will specialize also in paediatrics. This way, we can then develop the new KK Hospital into a centre of medical excellence for both women and children.

Sir, let me now deal with the subject of restructuring which is the concern of many Members who have spoken. Restructuring has been supported, I think, by all, except one, and that is the NCMP.

Let me first reiterate the objective of restructuring. This is to enable the Government hospitals to be more responsive to the needs of the general public and to be able to provide a better level of service to all Singaporeans. Restructuring will provide all our hospitals with the necessary management authority, autonomy and, more importantly, the responsibility to achieve this objective.

By subjecting the restructured hospitals to commercial accounting practices and strict financial controls, there will be greater cost consciousness and better cost controls. The end result of restructuring will then be Government hospitals which are more cost effective, efficient and highly responsive to public needs. Singaporeans will therefore be the ultimate beneficiaries of this whole programme.

While all the Members have supported the objective, they, as well as many Singaporeans, are understandably fearful as to how this will impact on the availability of subsidized beds and as to whether they will remain affordable. This is especially important for the lower income group. Let me reassure Members that the Government's policy of providing subsidized hospital care for the lower income group will not be affected in any way by the restructuring programme. Heavily subsidized C class beds will still be available in sufficient numbers.

I will first deal with the question of subsidized beds before going on to discuss the subsidy level.

Dr Aline Wong had anticipated that my answer to her would be that we are cutting down on the number of C class beds because people preferred the B2 or higher class wards. Indeed she is correct. That is my answer. But that is the fact facing us. Increased affluence, particularly over the last 15 years, has also resulted in an increased preference for B2 or higher class wards because these offer a higher level of comfort.

Dr Aline Wong and Dr Lee Siew-Choh have attributed this also as being due to the availability of Medisave funds. In fact, I think other MPs have also mentioned that. Sir, Medisave is a factor. I will not deny that. However, the preference for the better class beds, in fact, started way before Medisave was launched in 1984. We had to start closing the unoccupied C class beds from 1980. And since then, the number has been gradually reduced from 4,000 in 1980 to about 2,000 today. Yet the occupancy rate has, in line with our closing, gone down to 65%. That means, as at today, 35% of the beds still remain unoccupied. And while these beds are unoccupied, there is a long queue of patients clamouring to be upgraded from the C class beds to B2 or B1. We receive such requests almost daily.

Sir, Singaporeans are supposed to be able to choose which type of ward they wish to be admitted into. Unfortunately, this is not so. Many have chosen to be admitted into the B2 or higher wards. Unfortunately, we do not have enough of them and there are no vacancies, and instead such people are being forced, therefore, to stay in the C class wards. I think if we have additional B2 and B1 beds today, the occupancy of the C class wards will plummet again.

Sir, the large number of C class beds is a carry-over from the colonial days and the time, not so long ago, when unemployment was high in Singapore and wages were low. Wages have gone up significantly over the last 15 years, and most Singaporeans can afford and do prefer something more than just basic facilities. They can afford also to not take advantage of the subsidies that are available in the C class wards.

Sir, the redeveloped hospitals will be configured to meet the actual demands of the public. When completed in 1994, they will continue to have C class beds, but in much reduced numbers, as pointed out by the Member for Tampines GRC, Dr Aline Wong. We will, however, closely monitor to ensure that no one is denied a C class bed should he require one.

Let me move on to hospital fees, the topic of much great concern to all our Members here. I will first address this topic generally, before going into the details later.

Hospital care is highly labour intensive, with staff salaries making up over 80% of the total running cost. The cost of running a hospital will therefore continue to rise as wages and salaries are increased. Modern equipment, sophisticated technology and operations also contribute significantly to these higher costs. Hence, irrespective of whether a hospital is restructured, our hospital fees will have to be increased periodically to take into account these cost increases.

However, Members may not be unduly worried that the lower income group will be denied medical care as a result of these cost increases. My Ministry will continue to ensure that as fees are increased in the future, subsidized wards will still remain highly affordable to the poor and the indigent. For the indigent, since they cannot afford to pay even the highly subsidized fees, we will continue to liberally grant them waivers or partial remissions. However, those opting for greater privacy and greater personalized services that are available in the A class and the B1 wards must be prepared to pay the full cost of these services without subsidies.

Sir, yesterday the NCMP claimed that those in the subsidized wards would not have access to specialists and consultants. Some of our Members here also fear that and, not being doctors themselves, that is quite understandable. But being a medical doctor himself, the NCMP must surely know that this is not true. He must know that the medical team in each ward is headed by a consultant and he is supported by a team of specialists as well as housemen and medical officers. In fact, the likelihood of the subsidized patient being treated by a specialist has never been higher today. In 1980 we had only 378 specialists in both the University and the Government hospitals. Today, this number has increased to 677, almost doubling of the strength. Members can therefore be assured that the proper level of care appropriate to the medical needs of each patient will be provided, regardless of the class of wards he is in.

Sir, let me go into a detailed discussion of the level of subsidy and as to whether the Members' fears on the affordability of the subsidized C class wards are correct.

First, the bill size for C class patients. In 1984, the average bill size for the C class patients came to $160. Four years later, this figure has increased to $203, an increase of $43. The cost to the patient a day in that case has increased from $29 in 1984 to $38 today, an increase of $9 per day to the patient staying in a C class bed. On the other hand, the cost of providing the service to the patient has increased from $151 in 1984 to $195 today. That means the cost has gone up by $44 within these four years, as compared to the $9 a day that a patient is paying. This means that the average subsidy for a C class patient amounts to $850 for each stay of about 5� days. This subsidy that is being provided to him has increased by $180 over the past four years. So of the $180 subsidy that has been increased arising from the increase in running cost, he only pays $43. Sir, this shows that the Government has been very generous and fair.

Let us see how a C class bill and a B2 class bill compare with an A class bill for a patient who is receiving the same treatment but enjoying the comfort of being in a single-bedded ward. For a Table 5 operation which involves the removal, for example, of part of a stomach (this is a fairly major operation), the A class patient will end up paying $4,600 (operation plus stay in hospital). The B2 class patient will end up with a bill of only $790, 17% of the A class bill. The C class patient will end up paying $493, that is about 10.6% of the A class bill. And for a very major operation, for example, open heart surgery or multiple digit replantation, the class A patient will be facd with a bill of $13,700. The B2 class patient will be paying $2,200, which is about 16% of the A class bill. And the C class patient will only be paying 8.8% of the A class bill, and this amounts to about $1,100. Sir, the figures show that the subsidies are very significiant.

Members must take care that they do not confuse the public when discussing subsidies. There are two aspects to subsidies. One is the available subsidy, the other is the utilized subsidy. We must not confuse the two, thereby confusing the public.

Let me give an example. Supposing we have a service where the subsidy today is $10 and there are a thousand people using it a year. It means that the total subsidy that we are providing for this service is $10,000. Supposing tomorrow or sometime in the future we increase the subsidy, we double it to $20. But for various reasons, the public prefer to use alternative treatment and only 100 people use it. The total subsidy now has dropped to $2,000. The question is: has the subsidy to the user dropped or increased? This is the situation facing our hospitals today.

The subsidy for C class beds has gone up significantly. Fewer people are using this service. More are opting for the higher class wards which are less subsidized and this has therefore slowed down the growth of the total subsidies required.

Let me give you a profile of the C and B2 bills, because sometimes averages may hide what is actually facing the patient. The average bill for a C class patient is $203. What does this represent? For 1988, the 75th percentile for C class bills was $235. That means 75% of all C class patients pay $235 or less. And the 90th percentile, 90% of all C class patients face a bill of $414 or less.

What about B2 patients? The average bill for a B2 patient is $346, not very high. The 75th percentile comes to $392, whereas 90% of all B2 patients pay $690 or less.

The question asked by the Member for Pasir Panjang GRC, Dr Wan Soon Bee, is: are these figures affordable? It is not a subsidy. It is the actual bill size. Are these bill sizes affordable? Sir, undoubtedly, Medisave has made it very much so. It is therefore much easier for them to pay the bill and the reason is this. In today's labour market, a household income of $700 is, I think not uncommon. In fact, most people earn much more than that. But taking $700 per month as being the income for the household, the Medisave contribution comes to $42 a month. The average C class bill of $203 will require only five months of Medisave contributions. The average B2 bill size will only require eight months' worth of Medisave contributions from a person in the low income group.

Let us look at the 90th percentile, some of the highest bills that are being faced. For C class bill, $414 which is the 90th percentile will require 10 months of Medisave contributions. Similarly, for the B2 90th percentile bill of $690, the low-income worker earning $700 per month will only require 16 months to accumulate that quantum.

In terms of hospitalization, Singaporeans thankfully are quite healthy. So most people do not require hospitalization especially when they are within the age group of 20-50. For a married couple, for every 10 years of their life within the age of 20-50, they will on the average expect to be hospitalized a total of 12 days, which means that during that 30 years, they can expect to be hospitalized a total of 36 days, which is about 5 hospitalization episodes. So in terms of hospitalization requirements, if you are hospitalized five times, each time you require anything from 5 months to 10 months of savings. Or if you opt for the B2, you require 8 months to 16 months of Medisave contributions.

What about those without Medisave? What do these bill size and the expected hospitalization requirements mean to a person who is self-employed or who does not have Medisave?

Sir, a husband and wife team together will need to put aside $4 every month, between the ages of 20 to 49. That is only one-tenth of what the Medisave contribution would have been. And this would have allowed them to go into a C class ward and pay the bill quite easily.

Sir, as regards the litmus test as to whether our bills are affordable, which the Member for Cheng San GRC, Mr Heng Cheng Miang, has asked for, if they are not affordable, then we will expect the settlement of Class C bills to be very low with plenty of bad debts or people asking for waivers. Most C class patients have no problem settling their bills. This is understandable based on the figures I have just given. For financial year 87 which ended at the end of March 1988, 92.7% of all patients had settled their bills within six months of the ending of the financial year. 1.44% have been granted waivers. The remaining 5.9% which are outstanding will be investigated by our medical social workers. If we find that they cannot afford to pay but they are not very comfortable about applying for waivers, we will still proceed to grant them the waivers. That has always been our policy. And this is reflected in the number of waivers and partial remissions that we granted in 1987. For the financial year 1987, 1,444 of those who applied for waivers received the waivers. On the other hand, upon investigations, 22,190 of the other patients were either granted waivers or partial remissions, mainly partial remissions, because we found that they required some assistance. And the total amount waived came to $1.87 million or about 1.3% of our total revenues.

So our commitment to a liberal grant of waivers and partial remissions is something that we take very seriously and that is a very important safety net for all Singaporeans, especially those in the lower income group.

Sir, the NCMP yesterday claimed that the fee increases over the years have deprived poor Singaporeans of hospital care, and that the Government is shirking its duty to look after the medical needs of the poor. Singaporeans, and the NCMP himself, know that hospital services have been vastly improved over the last 20 years. We have today a hospital service that is the envy of many, including those in the developed countries. And it is available to all Singaporeans, regardless of his social status or his income level. This would not be so if the Government had shirked its duty.

Hospital fees have risen because, as I have shown, costs have gone up. In particular, the general salaries of Singaporeans have gone up because of the strong economic growth generated by Government policies. But because the actual quantum of subsidy has increased substantially for the Class C and B2 wards, and because Singaporeans are generally better off and most have Medisave funds, we are in the happy situation today of patients and their families complaining that they are being deprived of beds in the less subsidized wards.

Sir, on the other hand, the indigent and those who are genuinely poor are given the same medical treatment, free of charge. And that is the true measure of how well the Government has discharged its duties.

Sir, Dr Aline Wong yesterday also cited Britain and the USA as examples of countries with generous health care funding because they held deeply the beliefs about social responsibility towards the needy and the under-privileged. She mentioned that these systems are now facing problems and they are now trying to reform the systems rather than doing away with them completely. And she suggested that we could perhaps learn from them.

The British and the Americans started their systems with good intentions. Where the British went wrong was that instead of focusing on those needy and under-privileged who required help, they gave free treatment to everybody, regardless of whether they required subsidizing. That was a big mistake. And the result is a tremendous demand for treatment, leading to long queues and waiting time. In fact, in some parts of Britain, a patient requiring elective surgery may have to wait up to two years before he gets one. In Singapore, anyone requiring elective surgery gets it within a week, two weeks at the very most. The British government has just set out to introduce some drastic reforms, to decentralize control over the hospitals and to allow them some autonomy. Sir, this is what we have already introduced way back in 1985, with the opening of NUH. As to whether the British can focus more on the target groups who require heavy subsidies, I am not too sure as to whether they can succeed in this. But I wish them well.

The American system is also facing tremendous problems. They are spending over 12% of their GNP on health care and this is projected to go up to 15% within the next few years and to 18%, maybe 19%, by the turn of the century. Yet despite this heavy expenditure, over a third of all Americans cannot afford to obtain medical care. If you are involved in an accident in America and you are not covered by health insurance, your chances of getting into a hospital that is prepared to accept you are extremely slim.

In Singapore our philosophy and policy is also aimed to help the needy and the under-privileged. That is our commitment. Our total expenditure on health care equals 2.7% of our GDP. But no one is deprived of medical care.

Sir, the Singapore model is a far safer one and a more effective one. Our aim must be to ensure that our economy continues to grow and that everyone is gainfully employed, hopefully and preferably with ever increasing wages. This way we help them to build a safety net through their Medisave contributions and they can then choose how they wish to spend their money and their Medisave funds. We also encourage them and help them to stay healthy at the same time so that the best option is they do not have to spend anything on health care.

We also let everyone have a choice of service according to what they can afford. The luxury of the A class or B1 beds or for those who cannot afford it, provided we make-do with the less privacy, the B2 and the C class wards which, whilst heavily subsidized still accord them the necessary and same level of medical treatment. In our system there is very much less wastage and abuse and no one is denied medical care.

Sir, let me move on to some of the other points raised by the other speakers. The NCMP made some very strong remarks. He accused the Government of playing a dirty trick on Singaporeans. He said that in SGH what we have done is to convert C class wards into B2 and call them B2. That means giving them the same C class facilities but charge them more by just a neat trick of changing the name. Sir, I guess the NCMP has not been to SGH since it was opened. If he had, he would have seen that the B2 beds in GH are highly superior to any B2 beds that we have in the other hospitals, NUH included. That is why our B2 wards in GH are so heavily utilized that we have in fact, unfortunately, turned away patients or delayed the operations until beds are available. Singaporeans are no fools, despite what the NCMP would like them to believe. They know whether they are getting value for money. If those are C class beds at such a much higher cost, those beds would be empty today. They will all be using the C class beds in the other hospitals.

The NCMP accuses us of profiteering. He gave the example of Hepatitis B vaccinations. Sir, the Hepatitis B vaccincations in the Government hospitals and clinics are far cheaper than any that can be obtained elsewhere in Singapore and the reason is because we are able to use our purchasing power to tender for the vaccines and obtain extremely low prices. All these savings are passed on to our patients. Unfortunately, because we tender, it also means we are locked in to a price for a certain time. We started off offering Hepatitis B vaccinations, for example, for newborns at $45 and in June 1988, because we had used up the old stocks we were able to obtain new stocks at a lower price, we have reduced the vaccination price to $30, and for adults we have reduced it from $120 to $90. Sir, that is not the end of the story. I am happy to inform Members that stocks are being used up. We expect when the new tender is delivered that prices for the new supplies will further go down and we would, as we have done before, pass on the savings back to Singaporeans. Sir, we do not believe in profiteering.

Dr Vasoo, among his points, talked about the older hospitals losing the staff to the hospitals that have been restructured. Sir, we have made it clear and we will enforce it very strictly that a restructured hospital will not be allowed to poach staff from the other hospitals that have not been restructured. He is right. If we leave it to them all the best staff will go to the restructured hospitals and why not? Because they can expect to have better conditions of work, they can have greater authority to do what is correct, they do not have to wait months and years before their requests are approved because all the requests have to go up all the way to the Ministry of Finance for approval. So it is highly efficient and therefore highly desirable in terms of staff perceptions. Sir, we will also be ensuring that the standards in our restructured hospitals do not deteriorate. And in fact we expect the standards in the hospitals that are restructured to improve because with the authority and the responsibility being given to them, there is no other person they can pass it up to. The buck stops at the table of the Chief Executive Officer there, not at the Ministry of Finance or the PSC. So therefore we expect results and we expect results to be obtained relatively quickly.

He talked about nursing homes. Sir, at the present moment our policy is to allow the development of private nursing homes to provide care for the convalescent and the chronic sick and the nursing homes are at present not subject to any legislation. However, they will be subjected to periodic checks by the Ministry of Health when the relevant legislation is brought into operation. In the mean time the Ministry of Health will work with the Ministry of Community Development on the licensing of nursing homes and homes for the aged and we will ensure that certain minimum standards are being complied with.

Encik Abbas asked about the progress of the redeveloped hospitals. I have already replied to that. In terms of what restructuring will mean to the terms and conditions of the staff, Sir, the staff will be entitled to no lesser terms than what they are presently enjoying, except for pensions. They will have their pensions recomputed into a lump sum and henceforth they will be paid the full CPF.

Mr Choo Wee Khiang has made a suggestion that we should perhaps rename the B2 into C class. I find that suggestion rather strange and in fact if he had done that earlier, I think the NCMP would have jumped on it and said, "See, you do not have to ask him. They have already done in GH." Sir, there must be the clear gradations between A, B1, B2 and C. C is a basic level of care. No frills but full medical treatment. Anyone who prefers to have a little bit more luxury must be prepared to pay for that little bit of luxury and those who want to go all the way to an A class bed, they had better be prepared to pay for the full cost for the A class bed.

He has also asked about how the restructured hospitals will achieve excellence and how do we assess them. I will address that afterwards when I come to Dr Tan Cheng Bock's questions.

Sir, Dr Tan is worried that whilst he has no objection to our brining in American consultants to help us manage SGH in the interim period, he is afraid that being profit-oriented they will also bring their profit motive into SGH. Sir, there are two aspects to profit, as all accountants will tell him, maybe more, I do not know. One is the cost. The other is the revenue. If you can increase the revenue you make more profits. On the other hand, you can reduce your cost and make more profits. Our objective, Sir, is to ensure that we are able to reduce our cost or at the very least ensure that our costs do not go up rapidly. And to do that we must have all the modern management tools to allow us to monitor what is being done, what is being used, how much time is being spent, so that we can ensure that everyone is cost effective. At the same time we will have a full team of medical professionals, a medical board, which will ensure that whilst we look at costs, medical standards are not jeopardized. So these are two independent bodies. One is a day-to-day management, the other is the professional standards.

How will the restructured hospitals continue cooperating with each other? How will we ensure that their self-interest does not lead them to preclude cooperation? Sir, we have ensured that by having all the restructured hospitals under one holding company. This way there is still a policy setting body that would guide the hospitals on what they should be doing in terms of cooperation, in the sort of specialities that they should be developing or they should not be developing in order to avoid duplication. So whilst they have the autonomy for their day to day operations, developmental and policy decisions will still have to be vetted by a central body. Patients will still continue to be transferred as and when required. For example, radiotherapy is highly expensive. Each machine costs a million, two million, the latest one, maybe even $3 million. It does not make sense for every hospital to have a radiotherapy department. So whilst we have cancer patients spread throughout the hospitals, we will still have them ambulanced to SGH whenever they require radiotherapy. In this way, the links will still be maintained. Also, the support which is presently being given by the Singapore General Hospital to the various regional hospitals, for example, Tan Tock Seng Hospital, in terms of eye, ENT, will still continue. SGH will still continue to send the specialists and consultants to help out in the smaller hospitals. Nothing will change.

As to conflict on whether a specialist would be penalized if he spends too much time with a subsidized patient, Sir, specialists are required to spend a certain amount of time with the subsidized patient. At the present moment, it is between six and seven sessions per week out of 11 sessions and we will closely monitor to make sure that they do not spend less time but if they are more efficient, they can spend more time, so be it. We will be quite happy but what we want to be sure about is that their time is efficiently utilized.

Sir, as to the profit motive, he says that the hospitals must show a profit. The hospitals will have to continue to receive subsidies, like NUH, SGH. The subsidy level for financial year 1989 will be $60 million for SGH, and about $22 million for NUH. The subsidies are still very significant.

Sir, Dr Wan Soon Bee has raised some very pertinent points. I agree with him that in terms of use of Medisave we have to try to ensure that Medisave account holders do not see their Medisave funds as being someone else's money but money which must be conserved because they will need it in their old age. We will be looking into how we can better communicate with the account holders and educate them more effectively.

The Chairman: Mr Yeo, you are running out of time on this amendment.

Mr Yeo Cheow Tong: I think I am almost finished, Sir. Mr Heng Chiang Meng, most of his points I have already addressed in my earlier answer. I will just talk about the Human Organ Transplant Act. He suggested that we should give priority to those who have opted in. We only have priority for those people who have not opted out, that means, by default they have opted in under the Human Organ Transplant Act. But I think what he means is that for those who have opted in under the earlier legislation we should perhaps give them an even higher priority. I will ask my officers to look into it but I doubt whether that will be any more effective than our earlier efforts to encourage people to opt in actively.

With regard to the National Kidney Foundation, we are already providing help to NKF. We are providing them with the premises for them to carry out their dialysis operations and these centres which we are offering them are being charged at a nominal rate of $1 per month. So far, NKF has accepted the following premises: our Kim Keat Road Maternal and Child Health Clinic which we have vacated, Holland Road and Serangoon Road OPDs which we have vacated. We will continue to offer them our vacated premises and space will also be offered to NKF in the new community hospital when it is built. We also provide professional expertise to NKF. Our doctors serve as the Medical Director and advisors to the organization. We also provide training of NKF nurses and the NKF patients who are undergoing dialysis. We also make available to NKF the consumable items at cost and these items are a lot cheaper than if NKF had to buy them from the private sector because we have the advantage of bulk purchasing.

Dr Lee Siew-Choh: A point of clarification, Sir. The Minister says that I have said that class C patients do not have access to consultants. I do not think I said that. What I said was that the people who were in class C feared that they might not have access to consultants. That is why they opted for class B2. That was entirely different from what he has said. He also says that his aim is to help the needy. Then why phase out class C? Why? And, of course, let us not forget about Hepatitis B vaccinations. At the present moment, is he saying that the Singapore Government does not make any profit from the vaccinations?

Mr Yeo Cheow Tong: Sir, I may have heard him wrongly but I thought I heard him say the patients in C class beds are deprived. If his statement was that members of the public fear, then I hope that as someone who knows the real situation he would tell them the truth and explain to them that that is a misconception.

As to the question: if we are so concerned about the needy and we wish to help them, why do we close off C class beds, Sir, the answer is very clear. At the present moment, there are more than enough C class beds. We have 2,000 beds, of which only two-thirds are occupied.

As to Hepatitis B vaccines, there is a lot of cross-subsidy going on because certain babies requiring Hepatitis B vaccination come from mothers who are already Hepatitis B carriers. Dr Lee knows that for these babies they require additional shots and that these cost more and we are not charging them. So there is some degree of cross-subsidy going on and when the new supplies are delivered we will make sure that the savings are passed on to all the patients.

Mr Heng Chiang Meng: Sir, I have a clarification.

The Chairman: May I remind Members that we have one minute left.

Mr Heng Chiang Meng: What I meant just now when I talked about priority for willing donors is that if a normal healthy person is prepared to donate one of his kidneys to somebody for whatever reason and subsequently that person, who is still alive, needs one in future, then I am saying that perhaps there should be some scheme to give him immediate priority so that he does not have to wait, since in the past, he has actually shown his concern by willing to donate one of his kidneys.

Mr Yeo Cheow Tong: Sir, I will ask my officers to look into it.

Dr Aline Wong: I would just like to ask the Minister to answer my suggestion that the Medisave Auditing Unit be expanded. I think he has forgotten to answer that point.

Mr Yeo Cheow Tong: My apologies. I totally agree with what Dr Aline Wong has brought up in terms of the Medisave audit. We are looking into how we can strengthen the unit and how to introduce automated systems for processing the claims and, more importantly, to allow us to set up a database where we can then closely monitor usage in terms of by doctor, by disease group and by hospital. I think that will allow us to have a better idea of where the money is going to and how it is being utilized.

Dr Aline Wong: We would like to thank the Minister for his reply and may I withdraw my amendment.

Amendment, by leave, withdrawn.

The Chairman: Amendment No. (2), Dr Wong is not moving. Amendment No. (3), Encik Abbas.

Encik Abbas Abu Amin (Pasir Panjang GRC): Sir, I beg to move,

That the sum to be allocated for Head P be reduced by $10 in respect of Code PD 1500 of the Main Estimates.

Sir, I am going to talk about shortage of nurses and health therapists. The Ministry is aware of the shortages of nurses and health therapists. Some of the reasons given so far are as follows: no local training course, insufficient number of candidates taking up PSC scholarships and uncompetitive salaries. Sir, I would like to know what further steps are being taken by the Ministry to train more health therapists in view of the problems of the aged in the future. Would the Ministry consider improving the salary scheme of health therapists with a view to encouraging more school leavers to take up health therapy as a career?

Mr Choo Wee Khiang (Marine Parade GRC): Sir, in terms of subventions I recall what the Minister said earlier on. As far as class C beds are concerned, I do not think I would like to rename class C to class B, but I would really like to see that in line with economic growth we should actually upgrade the class C beds. He said that class C should be very basic and with no frills. In my opinion, if you were to upgrade ---

The Chairman: Mr Choo, we have finished with that subject already. Can you move on?

Mr Choo Wee Khiang: I am coming to the point of subventions. Therefore, in order to upgrade class C beds, there should be more subsidies, more funds given. I hope the Government will consider giving more money to various privatized hospitals to enable them to buy more equipment, train more staff and not at the expense of raising hospital charges.

Mr Yeo Toon Chia (Ang Mo Kio): Sir, I would like to touch on Accident and Emergency Services. Although consultations at the Government hospitals' A&E units are on the rise, I doubt that all those making use of the services are of an emergency nature. I believe a good percentage can be classified as non-emergency cases which could have been treated at the Government or private clinics.

The increasing number of people seeking treatment at A&E is a cause for great concern as they will not only overload the staff and facilities at A&E but also defeat the purpose and intention to which these units were set up. To discourage the misuse of A&E services, a publicity campaign was launched in 1985 to educate the public. Would the Minister enlighten the House as to the position of A&E attendances since then?

Sir, I have no doubt that the Ministry is doing its best to find solutions to overcome the overcrowding problem at A&E departments. However, I feel that the Ministry should examine in greater depth the reasons behind the rise in demand. Is the increase due to the population growth resulting in more people using A&E services? Or is it because the charges attract the lower income group who feel that they can get a more comprehensive check-up at a comparatively lower cost than that offered by the private specialist clinics?

Sir, the main reason I feel is the lack of clinics operating after office hours. As our society becomes more affluent, doctors can afford to work only during office hours. This seems to be a growing trend as it is increasingly difficult to get to see a doctor after office hours or weekends and public holidays. Staff at Government polyclinics and outpatient clinics work only during office hours with many private clinics now doing the same. In fact, experience in developed countries has shown that it is not only difficult to see a doctor during this period of time, but that a doctor will not attend to anyone, except those who are his patients. This is a worrying trend which we would not like to see happening in Singapore.

Sir, I feel that one solution to discourage the public from misusing the A&E services is to extend the opening hours of the polyclinics and other outpatient clinics so that those who do not require emergency treatment would be able to seek medical assistance at these places. Towards this end, would the Minister inform us if he would consider extending the opening hours of the Government clinics and what plans does his Ministry have to encourage doctors, both in the Government and private sectors, to make full use of the facilities at these clinics during off-work hours.

Sir, it is the responsibility of the Government to ensure that there are always readily available clinics open outside working hours to enable people who are sick to get medical help. The Ministry must also realize that without alternative clinics to go to, it is only human nature that people will always turn to A&E services when the need arises. Only when there are real alternatives for people to go to, can the Ministry think of taking strong measures such as revisions in fee structures to prevent the public from misusing the A&E services.

Mr Heng Chiang Meng: Sir, we are all aware that living in a city state, such as Singapore, is a highly stressed one. Our people so far has coped with this very well. But I think stress is becoming higher and higher as we strive for greater excellence. My question to the Minister is whether our mental health programme is keeping pace with the need to treat the mentally ill at different stages of their illnesses. Sir, not only the seriously mentally ill but also those suffering from mild psychiatric disorders and stress.

Sir, in this respect, I would like to ask the Minister to enlighten the House on a number of questions:

(i) Besides the current outpatient facilities available at Woodbridge Hospital, the Child Psychiatric Centre at the Institute of Health, the four outpatient clinics, is the Ministry considering expanding outpatient facilities in other areas?

(ii) Will the Government consider expanding the facilities for day-care treatment?

(iii) Are there plans to improve and upgrade the Child Psychiatric Service in line with the plans to establish a children's hospital?

(iv) What is the status on the redevelopment of Woodbridge Hospital? Will it also be restructured? and

(v) Is the Ministry considering introducing an aftercare programme to better help mental patients to better integrate back into the family and the community?

Mr Yeo Cheow Tong: Sir, Encik Abbas has expressed his concern about the shortage of health therapists, and he has asked what we are doing to train them.

Sir, we are taking various steps to train more health therapists. At the present moment, the Ministry has 26 vacancies in the areas of physiotherapy and occupational therapy. The first step we are taking is to award more scholarships for the training of these people. Six scholarships were awarded last year which is a vast improvement compared to the two that were awarded in 1987. We hope to be able to attract more applicants this year, and if we are able to, we would be happy to award at least 10 to 15 scholarships this year.

Sir, the staffing position of therapists will also improve with the return of the scholars who are presently under training abroad. Four will be returning end of this year and another five will be returning next year, making a total of nine.

He has also asked whether we are considering a revision of the salaries. Sir, we have proposed to the Ministry of Finance on this but unfortunately we were not successful. We will try again.

Mr Choo Wee Khiang has stated that in view of our economic growth and the increased standard of living in Singapore, C class beds should no longer be basic beds, but we should improve on them. Sir, the needy and the underprivileged will be catered for and we will provide them with the full medical care. But the facilities that we will be providing will be basic level. For those who feel that they are entitled to a better level of accommodation, they should then contribute a little bit more towards that higher level of comfort.

Mr Yeo Toon Chia has talked about the A&E services. Sir, towards the end of 1985, my Ministry launched a campaign to educate Singaporeans on the proper use and the function of the A&E Department in the hospitals. The monthly A&E attendance prior to the campaign was about 37,000 per month for the years 1984 and 1985. And this monthly figure fell almost immediately after the campaign, to only 29,000. So the campaign was very effective. However, I think the message has started to wear off and the numbers have been increasing gradually. Today, we are back to a very high level of 34,000 a month. And the non-emergency cases formed about 34% of all attendances. This compares with only 20% after the campaign period. The non-emergency cases are fairly spread out, even spread out between office hours and after office hours. So there is no change. During office hours when clinics or GPs, outpatient clinics are opened, we are also getting about 30-odd% of non-emergency cases.

Sir, we feel that there is a very high demand for the A&E services largely because it is a very comprehensive service and one which is being offered at an extremely low cost. It therefore attracts non-emergency cases even when such patients could easily go to a neighbourhood GP or clinic.

With regard to the availability of doctors after office hours, we carried out a survey and we found that about two-thirds of all the private clinics do open after office hours. These two-thirds spanned over all GPs, and since most of the doctors in the central business district do not work after office hours, it means that the percentage of those operating in HDB estates after office hours is very high.

Mr Yeo has asked whether we are prepared to open the polyclinics after office hours. We have no plan at the present moment to do that. But we will consider and see how we can perhaps make the polyclinics available to other doctors who are prepared to run it.

The main measure that we are using now to discourage the non-emergency cases from utilizing the A&E clinics and thereby depriving those who require emergency treatment is to give the lowest priority to those non-emergency cases which can afford to wait. So even if an emergency case comes in much later, we will make sure that the emergency case is treated immediately and the non-emergency cases, even though they may be waiting for an hour, would be pushed further back until we have cleared all the emergency cases. I think that is a fair measure.

Mr Heng Chiang Meng has asked quite a few questions on the psychiatric services. Sir, we are taking all possible steps to treat the mentally ill and those who require psychiatric care on an outpatient basis, rather than institutionalizing them in Woodbridge Hospital. We now have several outpatient clinics and we will extend the services to other polyclinics that are being opened up in the coming years.

With regard to the child psychiatric services, Sir, we will be extending the child psychiatric sessions to the new polyclinics that are being opened in Tampines and Yishun. We will also extend the age range of the children who are being treated in those clinics. Children, up to 12 at the present moment, will include children ages 13 up to 20. To cope with the expected increase in workload, we will increase the staffing strength of these clinics and units over the next three years with the addition of three specialists, a psychologist and a medical social worker.

Sir, he asked about the aftercare programme. We have existing day-release employment scheme in which patients work in open employment during the day with companies and return to the View Road Hospital at night. This programme was started in 1984, and we now have 31 patients who are participating in this scheme. For 1988, 34 placements for employment were made for the patients and we are still trying to encourage more employers to participate in this scheme.

With regard to day-care centres, we now have two day-care centres at the Mandalay Day Care Centre which is situated in Woodbridge Hospital and the Alexandra Day Care Centre. These two day care centres provide rehabilitation and sheltered work for the discharged psychiatric patients. The training activities include clerical, hairdressing, embroidery, toy making and various other industrial work. Altogether, 21 firms have supplied contract work to these two centres and we again would like to encourage more companies to assist by providing work to these two centres.

Sir, with regard to Woodbridge Hospital redevelopment, the piling work will begin shortly, and there are no plans at the present moment to make Woodbridge a restructured hospital.

Encik Abbas Abu Amin: I thank the Minister for his reply and I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The Chairman: Order. Time for suspension.

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

Mr Speaker: Order. I suspend the Sitting and will take the Chair again at 3.15 pm.

Sitting accordingly suspended at 2.46 pm until 3.15 pm. Sitting resumed at 3.15 pm

[Mr Speaker in the Chair]

Debate in Committee of Supply resumed.

[Mr Speaker in the Chair]

Head P (cont.) -

The Chairman: Amendment No. (4), Mr Choo.

Mr Choo Wee Khiang: Sir, I beg to move,

That the sum to be allocated for Head P be reduced by $10 in respect of Code PD 5100 of the Development Estimates.

Sir, the children of today are the citizens of tomorrow. We need to provide the highest possible paediatric care to ensure healthy population for the future. Therefore, I am so pleased to learn that the Government will build not a hospital but a children's wing with 400 beds, which will no doubt provide the best standard possible for the care of our children. I hope the Minister will enlighten the House as to the detailed plans in terms of manpower, size of wards, charges and the amount involved in building such a children's wing.

In a way, children's hospital or children's wing will help the young parents to have more children if they can afford to. Because they are assured of excellent paediatric care for the kids. However, the cost of bringing up children and the cost of medical care are the two main reasons for Singaporeans to opt for fewer kids. If you look at today's newspaper, Sir, at the forum page, it says, "Self centred Singaporeans may opt for fewer kids". Two main reasons have been highlighted, one is the cost of bringing up children and the other is the cost of medical care.

In helping the younger parents to have more kids, I would like to make a suggestion, ie, to provide free paediatric service for children in Class C wards. In such a case, I think the younger parents will be eased off with the load, lesser burden in terms of finance and care for the children. Therefore, I think they will go for more kids.

Lastly, I would like to ask the Minister whether he has any plan to so-call corporatize the children's wing in future.

Mr Yeo Cheow Tong: Sir, as I have mentioned this morning, we are in the process of planning a children's wing and so I am in no position to provide the details.

Sir, Mr Choo has asked whether we are going to corporatize the children's wing. The new Kandang Kerbau Hospital will be corporatized. And since the children's wing forms part of the new hospital, obviously it will also be under the autonomous management of the new hospital.

He has asked for free paediatric treament for all children.

Mr Choo Wee Khiang: For Class C children.

Mr Yeo Cheow Tong: For Class C children. I think our policy is that even for the low-income group, we give free services only for those who really cannot afford to pay. Having children definitely will result in increased cost to the parents. That is why we are encouraging only those parents who can afford to have more children, to proceed to have three, four or more. So the message is, first, to be able to afford more children and then have them. For those people with one or two children, I think, being young and having Medisave accounts, they should have no problems paying for the various subsidized fees that are presently applicable to the Class C patients. So I do not see any need to provide free paediatric treatment for children in the Class C wards.

Mr Choo Wee Khiang: I just like to add a point before I withdraw my amendment, Sir. We always say that we have no natural resources and the only resource that we have is human resource. If we want more people to produce more children, and those who can afford are not going to produce more, I think we really have to look at the borderline cases. By providing free paediatric services for all children in Class C beds, I think it will help. It will go in a very small way to increase our population growth.

Sir, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

Dr Aline Wong: Sir, I beg to move,

That the sum to be allocated for Head P be reduced by $10 in respect of Code PE 1500 of the Main Estimates.

Sir, medical services for the elderly have become a pressing concern in view of our ageing population. At present, primary health care for the elderly is coordinated by a special department of health service for the elderly within the Primary Health Division of the Ministry. This department was established in 1985. This department plays a pivotal role in the coordination of health care services for our ageing population. However, the GPC notes that up to the present, this department is under the charge of two medical directors only. Given the amount of responsibility this department has to take, we would like to urge the Minister to strengthen the support of this department in every possible manner. Apart from giving this unit more administrative back-up, more doctors should be deployed to the senior citizens' health care centres so that they can have first contact with the elderly patients.

We also feel that the support given by this department to the Home Nursing Foundation should also be increased. The Home Nursing Foundation was established as a voluntary organization in 1976, more than 10 years ago. While the demand for its home visit service has gone up steadily over the past 12-13 years, it has constantly been strapped by the lack of manpower and financial resources. The number of nurses seconded to the Foundation has not increased significantly over the years. And here I think we really should pay tribute to the 26 full-time staff nurses who have been seconded from the MOH to the Home Nursing Foundation. Between them, they have carried out over 50,000 home visits in 1987-88 alone. There is no question that they require more help from both the MOH and the volunteers.

Sir, the demand for home nursing visits has gone up steadily, from 42,500 in 1978-79 to 63,500 in 1986-87. In June 1986, a graduated fee scheme was introduced for such service, with the charge varying according to household income. Before that date, the service was provided free of charge. With the introduction of the fee, the number of home visits in 1987-88 dropped by some 6,200 visits as compared to the year before. This implies that the number of visits per patient has gone down, possibly because of the charges.

Elderly patients requiring home nursing actually need repeated visits. And because the charge is the same for every visit, some families may find it unaffordable to pay for the subsequent visits. So may I suggest that the fee structure for home nursing services be further refined. The charge for second, third or subsequent visits could be reduced along the same line as subsequent visits to specialists are charged at lower rates after the first visit. In this way, patients may be encouraged to request the number of visits actually required for effective treatment.

Coming back to the Home Nursing Foundation or the home nursing programme, there are several ways in which the Ministry can strengthen its support for the Home Nursing Foundation. First is to deploy more doctors, nurses and paramedical staff to the home nursing programme. Second, to work more closely with MCD and the Singapore Council of Social Service and other voluntary organizations to raise funds and recruit volunteers. Third, the MOH to negotiate with the HDB, or in the future the town councils, for more void deck senior citizens' health care centres to be established. This would be close to where the old people are and also at a rental which is lower than what is now granted by the HDB to ordinary community organizations.

Finally, the Primary Health Division should be given more funds to promote health education and provide health screening as well as rehabilitation services to the elderly. To cut down on total health costs for the nation, the Ministry must put a greater emphasis on primary health care, including preventive medicine, health education and health screening. I would like to ask the Minister a question. With Government hospitals becoming corporatized - now it seems to be the current term in this debate - what would remain of MOH's function in future? With the tertiary care and secondary care being hived off, so to speak, to the restructured hospitals, what would remain of MOH's major functions? Should we leave the provision as well as the quality of secondary and tertiary health care to the forces of the market alone? I do not believe so.

The rationale behind the restructuring is to raise efficiency so that the Government hospitals would become more cost effective. While this may make the restructured Government hospitals more competitive with the private hospitals, this should not be a goal in itself. I believe that the Government hospitals must play the lead in cutting costs. They should show the way how better quality care can, in fact, be provided at reasonable cost to the consumers. They should set the standard for the private sector. I believe this is expected of the role of restructured Government hospitals. Otherwise, it is going to be very difficult to persuade the people that the Government hospitals are not going into the market just for the share of it.

Dr Koh Lam Son (Telok Blangah): Sir, I have two cuts under this amendment. May I take them together?

The Chairman: Yes.

Dr Koh Lam Son: Sir, the bulk of the Ministry's expenditure, about 80%, is allocated for hospital services. In contrast, the primary health services cost only a small fraction, about 15%. Moreover, in the long term primary health care, including preventive health care, will achieve a healthier population and free up the demand on hospital services. It therefore makes good sense to pay more attention to our primary health services.

Sir, the majority of the doctors in the primary health services are general practitioners in the private sector. GPs operate as individual practices and there is little coordination between the GPs and the Ministry of Health. The Ministry is not involved in the planning or the directing of our GPs in the service to the population. Neither is the role of the GPs spelt out in the National Health Plan. Sir, I do believe that the time has come for the Ministry to have a comprehensive review of the role of our GP in the context of our overall national health plan.

As single-hand practices, the GPs are faced with many constraints. They work long hours and often over the weekends. Because of their heavy workloads they have little time to spend with their patients, let alone find time to attend medical talks and seminars. Yet, Sir, it is so important for GPs to spend time with their patients, particularly when they have to educate their patients on preventive medicine. As an example, young couples who come in for their first ante-natal consultation are usually filled with anxiety, questions, and expectancy and are most eager and motivated to learn. Instead of shoving impersonal pamphlets and books at them, I would like to see doctors taking time to allay their anxieties and fears of the unknown, and to teach them positive health styles in order to provide the optimum conditions for the unborn child. In this respect I would like to ask the Minister how the optimum doctor/patient ratio is determined. Should not the consultation time per patient be used as the guideline?

Sir, the appropriate doctor/patient ratio would enable the Ministry to assess the workloads of the GPs and to determine how it can facilitate and regulate the workload for the benefits of both the GPs and their patients. In the future, with an ageing population and an increasing number of elderly people with chronic illnesses, the long term management of chronic ailments may be frustrating and taxing on the GPs.

Sir, in other countries, trained nurses are employed by doctors to make routine home visits and to act as the vital link between the doctor, patient and other professional groups involved in patient care. Her role involves routine biodata collection, supervision of treatment prescribed, provide simple physiotherapy and occupational therapy and training the relatives in patient care. In most instances, the nurse is well accepted, enjoys good relations with all parties involved and is invaluable in ensuring the continuity of care.

In Singapore can the Ministry evolve such a system and get the public to accept the role of the nurses? This will be a big step forward in providing preventive care for our elderly, in improving the professional image of our nursing and in solving the nagging house-call problem.

Sir, by assessing the workload of GPs with a view to relieving GPs of some of the tasks handled by them, the Ministry will also be able to achieve its larger objective of helping our GP to stay up to date on medical advances. With more discretionary time, GPs will be motivated to upgrade themselves and to participate in preventive medical care such as giving health talks in schools.

Sir, at the moment health education in school is delegated to lay teachers. I do not know if they are doing a satisfactory job. Natural reticence in talking about subjects like VD, teenage pregnancy, and social hygiene is understandable. This is an area where the GPs with their experience in handling and relating to people can help. Subject topics such as the basic anatomy and physiology of the human body, puberty and adolescence, sex education, teenage pregnancy, VD, smoking, drugs, diet and exercise and acoustic trauma in modern living, etc. would be appropriate to form a fairly large platform for discussion with today's precocious school children. I would like to ask the Minister whether he would, in consultation with the Ministry of Education and the Singapore Medical Association, consider a scheme to enable the GPs to fulfil this social role in the health education of our young.

Sir, I would like to next talk about the obesity of our school children. I read with great concern a report in the Straits Times of February 22 that more than 12% of our school children are facing problems with obesity. Although it is heartening to note that with great affluence problems such as poor dental health and malnutrition no longer exist, I am concerned that these are replaced by other equally serious problems such as obesity. Obesity stems largely from improper diet and lack of exercise. The Straits Times report on March 27 found that soft drinks contain a high proportion of sugar are easily available in schools. School children also have a preference for soft drinks compared to plain water or milk. This is unhealthy and should not be left unchecked. The poor habits of the young are easily carried into adulthood where it becomes a lot more difficult to correct. I would like to encourage the Ministry of Health to look into the possible measures to control or limit the consumption of soft drinks, sweets and food with low nutritional value in schools and other outlets frequented by school children. One way will be to require schools to employ dieticians or to operate their own food services. Parents should also be educated on the value of proper diet so that they can better guide their children in good eating habits. Manufacturers must be encouraged to reduce the proportion of sugar in soft drinks and to provide more healthy alternatives.

I think it is also important for the Ministry of Health to work with the Ministry of Education to develop a more vigorous programme to emphasize physical education in schools. School children must be encouraged to take part in more robust sports and games and not to shy away from activities involving physical exertion. Campaigns and educational programmes on physical education should be developed to publicize the importance of regular physical exercise. One good way is to have compulsory work out following the daily assembly session in the morning or evening.

In summary, I think it is important to take active steps to arrest this problem of obesity in school children now. The physical well-being of our school children affects their performance in other areas, such as in their studies. More importantly, the lifestyles and habits of our young determine the productivity and capabilities of our adults in the future.

The Chairman: Mr Heng?

Mr Heng Chiang Meng: I am not speaking, Sir.

Mr Yeo Cheow Tong: Thank you, Mr Chairman. Sir, I had earlier informed the House that my Ministry places a strong emphasis on preventive and primary health care.

We are reorganizing and further upgrading the primary health service to meet the challenges of the next two decades. Over the next five years we will be phasing out the old and inefficient outpatient dispensaries and polyclinics and replacing them with eight new polyclinics in the HDB new towns. By the early 1990s we will then have a total of 16 modern polyclinics or health centres strategically situated throughout the island to provide primary health care service.

Sir, one of these services will be a general health screening programme for adults. It will include taking comprehensive medical history and examination, and tests on the blood, urine and stools. It will also include a chest X-ray and an ECG examination of the heart. This comprehensive medical examination will cost only $60, and will be available at various new polyclinics later this year.

We are also laying the foundation for community health services for the elderly by working very closely with the Home Nursing Foundation or HNF.

My Ministry will be providing accommodation in all new polyclinics for Senior Citizen Health Care Centres to be run by the HNF. The plan is to have a total of such 10 centres based in the new polyclinics situated in the new HDB towns.

Currently, my Ministry is providing 38 nurses to HNF to run the Senior Citizens Health Care Centres and to provide nursing care for the bedridden or semi-ambulant who require home nursing. These nurses visit the homes of such patients three to four times a week and we will increase the number of nurses should the need arise.

My Ministry is also providing one medical officer to each of these Centres in order to strengthen the services provided. The HNF is also upgrading and expanding its rehabilitation, counselling and day care programmes at these Centres.

In addition, my Ministry, together with the HNF, will work together for the further expansion of the health screening programmes for the elderly which will be provided free at all the Senior Citizens Health Care Centres.

The polyclinics will also continue to provide medical treatment for the elderly at half the fees charged to the general public.

Sir, another facility which will greatly benefit the elderly will be the first community hospital at Ang Mo Kio. Building work will begin in August this year. It will cater for elderly patients and others with simple illnesses who do not require the expensive and sophisticated treatment offered by the acute hospitals.

Sir, my Ministry will also be working very closely with the private sector to upgrade the level of health care provided by the family physician.

We are currently working with the College of General Practitioners on a vocational training programme for all young doctors wishing to specialize in family medicine. A special two to three year training programme in paediatrics, general surgery, emergency medicine and other specialities has been planned for these doctors before they take up private practice as family physicians. This way, we can upgrade the standard of primary health care in both the government and private sectors.

Sir, the other point brought up by Dr Aline Wong is: what is the Ministry of Health's role after the hospitals are restructured? Sir, the role will be no different from what it is today. Although the Ministry now controls all the hospitals the day-to-day running of the hospitals is still left to the Medical Director of the Hospitals. The Ministry provides the crucial policy decisions and we do some supportive work in terms of the finance systems, manpower, planning and all that. With the restructured hospitals, the policy decisions will still have to be vetted by the Ministry and we ensure that they comply with the Government objectives. We will also be vetting to ensure that the hospitals remain efficient. They are really today very efficient. As I have explained earlier on, with a very low percentage of the GDP being used in the medical care area, we have been able to achieve a very high level of medical care. We will be monitoring to make sure that this remains so.

Dr Koh Lam Son has asked for the Ministry and the Government to monitor the work and to regulate the work of the GPs in the private sector. Sir, our private sector GPs have been doing a tremendous job. They are now accounting for over 70% of the patient load in the primary health care area and they are doing it at a fairly low cost to the patients. They have achieved it without regulation from the Government and I do not see why the Government should intervene and run the risk of making it even more expensive.

He has asked for visits by nurses as is being done by doctors in other countries. Sir, that is the role being performed by the HNF at the moment and this will continue.

He has asked for the GPs to be allowed to fulfil the role of educating school children in health matters. I will ask my Ministry to consult the Ministry of Education on this subject.

In terms of obesity, he is correct in raising concern about the obesity level of our children today. The number of obese children has increased significantly over the last 10 years. In 1976, in the Primary I intake only an average of about 1.3% of the students suffered from obesity problems. In the latest survey carried out last year, the percentage was 11%. So there is a very significant increase over a period of just 12 years. This increase is largely attributed to the increased affluence among Singaporeans. Parents have more money to spend, they have fewer children, therefore they tend to indulge in spending more money on their children. This is not only being done, but amongst other things they are providing their children with more pocket money so that they can buy more things. Children tend to spend a lot on food, especially food which has a high level of sugar and which tends to be very fattening. Children are also less inclined to be involved in highly active activities. They tend to bemore oriented towards sedentary activities. Our programme is to encourage parents to ensure that they control the diet of their children. We are also working with MOE to see how this can be done in the schools.

With regard to the level of activity of children, we have been working with MOE to modify the content of the physical education programme in schools to make them into one which is more aerobic and which should keep the children more active during their physical education period. I understand the Ministry of Education is introducing in stages this new physical education programme and they are also training teachers and acquiring the necessary equipment in the primary schools. I am hopeful that with all these programmes we should be able to cap the rise in the number of obese children and hopefully with the supportive activities, in fact, get them to trim down.

Dr Aline Wong: Sir, before I withdraw the amendment, I would just like to ask the Minister for a clarification. What does he mean when he said that he would deploy more nurses to the HNF programme if there is a demand for it? If he said that there is a shortage of nurses generally within the Ministry or Government service, I can understand him. But if he says there is no demand, what does that mean?

Mr Yeo Cheow Tong: Sir, let me clarify. There is a shortage of nurses in the Government hospitals and in the Government service. Therefore, we have to vet very carefully the conflicting demands. It is up to HNF to put up the case and if we find the requirements have a higher priority than the other competing requirements, then we would try to allocate whatever scarce resources we have to help them.

Dr Aline Wong: Thank you for the clarification. With that, may I withdraw the amendment.

Amendment, by leave, withdrawn.

The Chairman: Amendment No. (6). Dr Wong is not moving. Mr Choo and Dr Wan are not here.

The sum of $448,553,590 for Head P ordered to stand part of the Main Estimates.

The sum of $63,954,070 for Head P ordered to stand part of the Development Estimates.

Head U -

The sum of $12,474,660 for Head U ordered to stand part of the Main Estimates.

The sum of $2,742,790 for Head U ordered to stand part of the Development Estimates.

Head W -

Dr Lee Siew-Choh: Sir, I wish to speak on the allowances given to pensioners and the taxation of interest earned from their savings.

The Chairman: Dr Lee, can you move the amendment?

Dr Lee Siew-Choh: I am sorry. Sir, I beg to move,

That the total sum to be allocated for Head W of the Main Estimates be reduced by $100.

Sir, those who have been pensioned off in 1981, before the salary revisions came into operation in 1982, draw comparatively very low pensions. They were all on the old salary scales. Since then, the cost of living has gone up tremendously, and the Government has given salary increases to the Government servants, and recently again to the civil servants and also the Ministers. But what of the lowly paid pensioners? Those with a pension of less than $800 a month get an allowance of only $75 a month, I am told, and that too was given in two stages. Those who draw above $800 a month do not get any extra allowance whatsoever. All the pensioners have not benefited from any salary increases so far and it is time the Government gave them more allowances.

The other matter I want to touch on is that some of the pensioners have accumulated savings throughout the years and have put such savings into savings banks to earn some interest. Certainly such interest earned by the pensioners should not be taxed by the Government. I have been told that it has been taxed and I am just wondering whether the Government is willing to be more lax on such matters for pensioners and allow them to earn this interest tax-free.

The Minister for Finance (Dr Richard Hu Tsu Tau): Sir, this question of pensions has been raised several times in the past and I do not think the position has really changed in that the calculation of pensions is based on past services rendered and are therefore dependent on length of services and the salaries earned during such service. They bear no relation to salaries of serving officers which take into account the labour market forces and therefore the basis for calculating pensions is completely different from the basis in which we have to determine whether current wages of serving officers need to be reviewed. Therefore, I do not see there is any way in which I can amend the method in which pensions are calculated. However, ex-gratia adjustments have been made in the past, starting in April 1974 in order to take account of the rather unusual and abnormal inflation situation which followed from the first oil crisis. A Singapore Allowance was paid, starting in that year, and subsequently these were reviewed three further times, twice more, in 1980, 1982 and the last revision being in April 1986. Since the CPI change between 1986 and this year is very small there is no basis for a further revision at this time.

As to the question from Dr Lee about whether the income from savings earning interest in banks could be tax-free, this is a completely separate issue because we do not exempt interest earnings generally and it would be a major departure. One has to be very careful in making changes of this type as it affects the whole basis for assessing tax.

Dr Lee Siew-Choh: The Minister says the CPI has not changed very much. Surely, the CPI is not very representative of the actual situation in Singapore, Sir.

Dr Richard Hu Tsu Tau: If the CPI is not relevant, then what is relevant?

Dr Lee Siew-Choh: I think it will be easy for the Minister to find out when he goes to buy things. The prices of many things have gone up tremendously. All this is not reflected in the CPI at all.

Dr Richard Hu Tsu Tau: I think Dr Lee would have to be more specific on the items which he has spoken.

Dr Lee Siew-Choh: Sir, prices of flats, cars, oil have all gone up very much. So these are some of the items, for example, that I can give him.

Dr Richard Hu Tsu Tau: I hope that Dr Lee is not suggesting that pensioners should be buying brand new cars. And HDB flat prices have not, in fact, changed substantially as far as I am aware.

Dr Lee Siew-Choh: Sir, I beg to withdraw my amendment.

The sum of $39,233,710 for Head W ordered to stand part of the Main Estimates.

Head Y -

The sum of $300,000,000 for Head Y ordered to stand part of the Main Estimates.

The sum of $300,000,000 for Head Y ordered to stand part of the Development Estimates.

Question, "That the sum of $6,741,003,170 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, 1989 to 31st March, 1990, contained in Paper Cmd. 8 of 1989," put and agreed to.

Question, "That the sum of $5,127,537,180 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, 1989 to 31st March, 1990, contained in Paper Cmd. 8 of 1989," put and agreed to.

Resolutions to be reported.

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

Dr Richard Hu Tsu Tau: Mr Speaker, Sir, I beg to report that the Committee of Supply have come to certain resolutions.

First Resolution reported -

"That the sum of $6,741,003,170 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, 1989 to 31st March, 1990, contained in Paper Cmd. 8 of 1989."

Second Resolution reported -

"That the sum of $5,127,537,180 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, 1989 to 31st March, 1990, contained in Paper Cmd. 8 of 1989."

Dr Richard Hu Tsu Tau: Mr 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.