AFFORDABLE HEALTH CARE (Motion)

[Mr Speaker in the Chair]

Order read for Resumption of Debate on Question [10th November, 1993],

"That this House endorses the principles and approaches set out in Paper Cmd 16 of 1993 on "Affordable Health Care" as the basis for Government policies to contain health care costs and to keep good basic health care affordable to all Singaporeans.". -[Minister for Trade and Industry].

Question again proposed.

Mr Chiam See Tong (Potong Pasir): Mr Speaker, Sir, while I was speaking yesterday I was interrupted by the call to order to adjourn Parliament. Anyway, I have only a final point to make. I note that there was no report in the White Paper on the recruitment and training of nurses. I observe that, in Appendix B, our hospitals have a low number of beds to population ratio as compared to the other countries listed in that Appendix. I would just cite the best ratio and the lowest amongst the other countries that have been listed in Appendix B. West Germany has one bed to 93 persons. In the USA, the ratio is 1:210 whereas in Singapore, there is one bed to 327 persons. This obviously shows that the number of beds in Singapore is low proportionately compared to the countries listed in Appendix B. Is this due to the fact that we do not have enough nurses to look after the number of intakes of patients in our hospitals? If that is the reason, then there is a weakness in our hospital system which we need to quickly rectify.

In this respect, the Government should increase its nurse training programme and also to look into their working conditions and the reasons why Singaporeans are reluctant to become nurses with a view to encouraging more Singaporeans to take up nursing. After all, nursing is a noble profession.

Dr Kanwaljit Soin (Nominated Member): Thank you, Mr Speaker, for giving me the opportunity to speak. I would like to declare my interest as a surgeon in private practice.

Mr Speaker, Sir, Singapore enjoys high standards of health care. We are a centre of medical excellence in this region. We should aim to build on our past and present achievements by providing even better health for our citizens and better service for patients. We have to ensure that the quality of health, the standard of health care, and the response to emergencies remain among the best in the world, and able to fulfil our aspirations and needs and match our resources.

Sir, the White Paper on Affordable Health Care is a well written document with some good and innovative concepts but is weighted towards the subject of affordability as the title suggests. The focus on health has to be addressed not only on affordability but also on equity and quality.

Let us first look at national health expenditure and see the trends for the past 10 years so that we can predict the future direction of health care costs to the nation.

From 1982 to 1984, national health expenditure accounted for 2.5% of the GDP each year. In 1985, it was 2.9% and then 3.4% in 1986, after which it came down to 3% in 1989 and it was 3.1% in 1992. Thus, for the last 10 years, the figure has stayed static at around 3%. Hence, there is nothing in the pattern of our past and present history to suggest that we are going to have an explosion of health care expenditure.

Between 1980 and 1990, the average yearly increase in health expenditure for both public and private sectors was 11.2%. However, part of this increase in health spending occurred by virtue of the larger population size. If there is an adjustment made for this population increase, then the average yearly increase comes down to 10%.

When inflation is factored into the analysis, the average yearly increase is reduced much more. Thus, the average rise in yearly increase in health spending is also modest and will remain so as our health system is not based mainly on taxation or insurance.

On the other hand, Singapore's economic growth, as captured by the per capita GDP or PPP, is something that we can be proud of and even boast about. The per capita GDP for Singapore is US$17,000 while for Japan it is US$18,000. Japan spends about 6% of its GDP on health and this figure has remained relatively constant in spite of social insurance and universal coverage since 1961.

However, in the US, the figure has increased alarmingly. It was 11% in 1989 and 14% in 1992. Drastic surgery is needed to mend America's health care system because it is the biggest public policy mess of the past two decades. There is no valid comparison at all with Singapore's generally well conceived health care system and we should stop this practice of comparing two entirely different entities.

With health expenditure of only 3% of GDP, Singapore is getting first world standards of health care at less than half the cost that is incurred in some first world countries. Thus, there is no great burden on the nation as a whole where national health expenditure is concerned.

Now, let us look at the burden of health expenditure on the Government. In 1964, Government health spending was high and accounted for 20% of its main expenditure. It then began declining steadily to 7% in 1970 and in the 90s, the amount spent on health is only about 5-6% of the total Government expenditure. The comparable figure for education is 17% and a whopping 24% for defence.

Thus, the Government's budget for health is a very prudent figure of 5-6% of the total expenditure. Not only has this figure come down but the Government subsidy of national health expenditure has also been coming down.

According to the main report of the Review Committee on National Health Policies, and I quote from it:

"As a share of Government health expenditure, the subsidy has been falling steadily from 88% in 1965 to 75% in 1985, after which the percentages of subsidies dropped to 57% in 1990."

As a percentage of total private consumption expenditure, private health expenditure was only 5.4% of the total compared with 18.6% of the total for education. Thus, we cannot refute the fact that both public and private expenditure on health in Singapore has remained steady and constitutes a very reasonable and manageable proportion of the total national expenditure. Of course, the absolute amount spent on health has increased but so has the absolute amount spent on education, housing, defence, etc. What is important is that we do not spend an increasing percentage of the GDP each year on health so that the other sectors of national life are affected adversely and, so far, there is no evidence to suggest this.

Thus, I feel that the Ministerial Committee's fears that health costs will escalate much beyond 3% of GDP and we will get into the predicament of the US where the country's competitiveness has become blunted because of the high health component cost are not justified on present evidence. Our experience with health care expenditure has been a positive and heartening one and we should be congratulating ourselves and the Government for a job well done. In fact, many countries can learn from our experience. Instead, we have adopted an unnecessarily dismal and fearful attitude that our health care costs will escalate beyond control and this has coloured our whole outlook and philosophy towards health care so that affordability has become the key word and excellence seems to be taking a back seat. I think we do ourselves an injustice by thinking along these lines. We can continue to be prudent about health expenditure but excellence will be compromised if there is an over-riding emphasis on cost control.

In fact, we have to recognise that since we have become an affluent society with higher expectations and since we are also aging, we can afford to think about changing our mindset to allow national health expenditure to rise gradually, judiciously and equitably without developing a crisis mentality. In fact, the aged of tomorrow will be better off than the aged of today as the former will have better Medisave accounts and more personal financial resources than the aged of today and, therefore, again the picture is not going to be so bleak.

Instead of viewing basic health as a commodity, and I am talking of basic health, we have to some extent adopt the human capital or investment approach which holds that a certain amount of Government subsidies on health care is justified because the social costs and benefits of good health outweigh its private costs and benefits, not least in improving the productivity of the labour force. A worker is only as good as his health.

Now, I would like to refer to the health care philosophy propounded by the Government in the White Paper and make some suggestions.

1. To nurse a healthy nation by promoting good health. The primary health care budget has remained at about 11-13% of the Ministry's recurrent expenditure over the last few years although the absolute amount has gone up. The Health Review Committee recommends that "the Government should substantially increase its budget for health promotion and health education to improve the quality of life for Singaporeans." This recommendation has to be pursued with political will and commitment.

2. To promote personal responsibility for one's health and avoid over-reliance on state welfare or medical insurance. We have to recognise that health is determined by a whole range of influences from genetic inheritance, through personal behaviour, family and social circumstances to the physical and social environment - so opportunities and responsibilities for action are widely spread from individuals to Government.

Let me give you one ordinary but pertinent example. Let us look at a household spending less than $1,000 per month. According to the Household Expenditure Survey, this includes 40% of the households in the 1987-88 Household Expenditure Survey.

Such households spent proportionately more on food, especially cooked food. Of the main income earners in these households, 47% were production workers and 68% had primary or no education. 72% lived in 3-room or smaller flats. With a female labour force participation rate of just over 50%, many of these households would have both parents in the workforce. This family would have to rely more on hawker food for their daily needs. How can we expect these households to exert personal responsibility for their own health because:

(a) the parents lack the education to understand and be motivated by the healthy lifestyle knowledge disseminated by the Ministry of Health and thus, inadvertently, there are long-term ill effects on the helpless and innocent children;

(b) the parents do not have the time or energy to cook meals at home;

(c) the parents cannot do anything much about the type of oils and other unhealthy ingredients used by the hawkers in their food.

Therefore, responsibility for one's health has to be shared by the people, the Government and other relevant personnel and organisations. Where there are threats to the individual's health from the external world, over which people have little or no control, it is the responsibility of the Government and others to take effective action on behalf of the community as a whole.

Another instance of people being unable to take personal responsibility for their own health is when they are born with congenital deformities and inherited medical conditions.

Now, I would like to touch on some aspects of Medisave and health financing. The Cost Review Committee concluded that with Medisave, the average Singaporean should be able to meet the cost of hospitalisation comfortably, especially if he or she chooses a ward class according to his or her means. This does not always happen because, in 1992, 18% of patients in Class A wards who used Medisave to pay for their hospitalisation had household incomes of less than $1,000.

To help patients use their Medisave prudently, I would like to offer the following scheme. The withdrawal of Medisave for daily ward charges should be pitched at only B2 and C Classes and not at A Class which is the situation at present. The present system allows a daily withdrawal of $300 for ward charges and, therefore, patients dare to opt for A Class. However, if for Class B, there is a co-payment component of, let us say, 20% for ward charges by the patient himself or herself, and for A Class, a co-payment component of 50%, then the Medisave holder will be deterred from opting for a ward class outside his or her means as ready cash will be needed to pay for A and B1 wards. I am sure the Ministry of Health could change the co-payment figure to one that is more reasonable.

The scheme suggested whereby employers can make voluntary contributions into the Medisave accounts of their employees in lieu of part of their traditional medical benefits in kind, up to a limit of 2% of salary, I think this is a regressive scheme as the lower income workers will get less Medisave contributions than the higher income workers (I am aware of the cut-off level at $7,000). We will have the inverse law operating - "those that need it most, get it least". If a company buys an insurance scheme for all its employees, then the lower income workers are equally covered by the insurance medical benefits as the higher income workers.

I propose that the new Medisave scheme should not replace the current medical benefits scheme provided by employers. The fear that if we allow tax free employer-provided medical benefits, it will aggravate the problem of over-use of medical services and inflate health costs as in the US is unfounded because, in the US, there is no tax cap, while in Singapore, there is a tax cap at 2% of the payroll.

Furthermore, it is important to retain employer-provided medical insurance to benefit all employees equally because there is, in Singapore, a rising curve of chronic morbidity, especially from diabetes and hypertension. Diabetes affects about 12% of the population above the age of 35 and there is a similar trend for hypertension.

Another suggestion I have is for old age. We can think of another form of financing for health care. We could take 1% of the employee's salary from either the Ordinary or Special Account and sequestrate this into an account called "Old Age Medisave" which should only be used by the account holder after the age of 55 years. This scheme will allow self-reliance in old age for medical needs when there may not be much left in the ordinary Medisave account.

Next, to provide good and affordable basic medical services to all Singaporeans. Conceptually, this appears sound but there are difficulties in practice. There is a lack of national consensus on what is basic medical care (I am talking of treatment as well, not just the conditions) and what is the treatment for many common medical conditions. Let me give you an example. In some subvented hospitals, patients with gallstones are treated conservatively, while in other subvented hospitals, the gallstones are quickly whipped out using video laparoscopy. Similarly, for osteo-arthritis of the knees, the treatment can vary from conservative treatment to surgery consisting of total knee replacement. Therefore, we need to have a national consensus on the scope and extent of basic medical care for both patients and medical personnel. Guidelines and protocol systems for common medical conditions have to be worked out.

Next, to rely on competition and market forces to improve services and raise efficiency. The public sector currently provides 75% to 80% of hospital care and 25% of primary health care. This sector employs just over 50% of the doctors in Singapore. Because of the public sector's large share of the medical services, the Government's rate setting influences that of the private sector and cannot, therefore, be considered competitive or market-determined.

Another step that will help to improve services and raise efficiency is to integrate our rather fragmented medical health system. Too many admissions into the subvented hospitals occur through the Accident and Emergency Unit and are, therefore, unplanned. There can be better coordination between the referring physician and the speciality in the hospital to which the patient needs admission.

Another area that needs looking into is the payment to subvented hospitals for subsidised patients on the basis of adjusted patient days. This encourages keeping subsidised patients longer in hospital to maximise the subsidy and discourages ambulatory care. The private and public sectors should be able to learn from each other, to support each other and to provide services for each other. Anyone needing treatment can only benefit from such a development. People who choose to buy health care outside the subvented hospitals and polyclinics benefit the community by taking pressure off the public sector and add to the diversity of provision and choice.

Mr Speaker, Sir, to achieve our health objectives require a shared commitment from all those with responsibilities for health - from Government, medical personnel and from each individual. What we want is a system whose main objective is quality, the efficient pursuit of health and the equitable distribution of health care resources.

Finally, Mr Speaker, Sir, I would like to express my dismay and disappointment with the Finance Minister's statement that female civil servants will continue to be discriminated where medical benefits are concerned. It is very disheartening to the female half of the population that when it suits the policy-makers, they choose not to apply the principle of meritocracy. By announcing this new discriminatory medical financing scheme for civil servants, two basic principles are not being respected. One, the principle of equal pay for equal work that has been adopted by the civil service and, two, the Women's Charter which states that the husband and wife have equal rights and responsibilities in the running of the home and care of the children. I would implore the Finance Minister to reconsider the position if he wants Singapore women to give their full support towards nation building.

Mr Umar Abdul Hamid (Ang Mo Kio GRC): ( In Malay): Mr Speaker, Sir, I rise to support the motion. The findings made by the Committee in its mission to identify and resolve the problems of health care costs are welcomed. I agree with the stand that Singaporeans must play the principal role in this matter. All of us must bear the duty of being health-conscious. Staying healthy is a personal responsibility and the incentives provided by the Government should not become an excuse to take health for granted. Moreover, being too dependent on Government handouts and guarantees is not an attitude to be encouraged. We should take advantage of Government subsidies only as a last resort, when we fall sick despite having taken good care of our health. They should not be an incentive to neglect our health.

Mr Speaker, we maintain good health not through exercise alone, although that is one of the most effective ways. Controlling our diet is equally important. Cutting down on cholesterol intake helps us avoid heart problem and other diseases. Singaporeans should be more careful about their diet, and this message goes especially for the Malays.

Malay food tends to have high cholesterol levels, which is a cause of heart problem. According to 1991 statistics, out of 1,850 deaths among Malays, 845 were due to heart disease. That is 45% of deaths in the Malay community. The percentage is even higher viewed in comparison with other communities. The percentage of all Singaporeans who died of heart disease in 1991 was only 36%. I would like to urge community organisations, which are in closer touch with the masses, to enhance awareness of this issue by conducting dialogues and exhibitions and by distributing pamphlets, especially for the benefit of the Malay community. The Government can also play a role by promoting health-consciousness among Singaporeans while they are still in school. Our school curriculum should include subjects which emphasise the importance of health care and how one can stay healthy. A 'healthy body, healthy mind' campaign should be launched in our schools as a foundation on which we can develop greater health awareness.

I would like now to touch on the issue of additional Medisave contributions by employers. This proposal is a good one as more workers, faced with unforeseen circumstances, can thereby find a way out. The existing system only benefits those who fall sick frequently and need prolonged treatment, but provides no incentive for those who have been taking care of their health. The proposed system, where employers have to channel up to 2% of payroll to Medisave, as an incentive, favours those who stay healthy. This is because when an employee stays healthy, the balance in his Medisave will accumulate and the money can then be used to buy insurance to protect him against high medical bills should he fall sick later. This is a better form of assurance, especially for younger workers.

However, there is concern among some older workers who will be changing jobs after 1st January 1994. They fear losing out because of this scheme. They fear that the money contributed into their Medisave account will not be sufficient to pay their medical expenses or to buy insurance coverage against prolonged treatment. I hope the Government will provide guidelines for employers so that this group of employees will not be adversely affected by the scheme.

I would also like to support the proposal to use Medisave for purchase of insurance under MediShield II or for purchase of private insurance. This is a wise idea as it enables the buyer to ensure his ability to pay hospital bills and, at the same time, encourage him to save. In the Malay community, insurance schemes like life and family insurance are still not well-accepted. Maybe as a start, this health insurance would convince some quarters that the benefits might one day save their lives and alleviate their families' burden.

Health insurance is rather different in objectives and functions from other insurance schemes. Health insurance is like a tree that provides us shelter. The money saved through the scheme is like the seeds we sow that will grow and flourish and one day yield the benefits for us to reap.

No one can anticipate illness or misfortune. The existing Medisave might not be sufficient when needed. The flexibility given to CPF members in the use of their Medisave, which is protected by Government, is an opportunity not to be missed. I hope the Government will not impose too many conditions like in the case of CPF endowment policy. The scheme to allow purchase of health insurance through Medisave should be simplified so that many will be able to afford and take advantage of it.

Finally, Mr Speaker, I would like to take this opportunity to congratulate the Committee members for their contributions to the standards and control of the cost of health in the country. I support the motion.

The Minister of State for Health (Dr Aline K. Wong): Thank you, Mr Speaker, Sir, for allowing me to join in this debate.

As I was listening to various Members of the House over the last two days, I heard several of them, including Mr Lau Ping Sum, Dr Wan Soon Bee and Mr Sinnakaruppan, and this afternoon, Dr Kanwaljit Soin as well as Mr Umar Abdul Hamid, mention the importance of preventive health care and health promotion in our overall strategy to combat rises in health care costs. Let me stress that I cannot agree with them more.

In fact, one of the fundamental objectives of the Government's health care philosophy, which is stated very clearly in the White Paper, is that we aim to nurture a healthy nation by promoting good health. The most cost effective way to achieve good health and contain the rise in health care cost is through health promotion and disease prevention.

I think we should look at health promotion and disease prevention not simply from the point of view of the services provided by the Ministry of Health itself. We should include the environmental public health services provided by the Ministry of the Environment. The clean air we enjoy, the clean water that we drink, the excellent sewerage system, even the garbage collection system, all the things that pertain to environmental public health have added to and contributed towards the improvement in our nation's health.

Apart from the Ministries of Health and the Environment, we also have to consider the work done by the Ministry of Labour in occupational health services. When we talk about the emphasis on preventive health care and health promotion, particularly in terms of the proportion of the budget spent by MOH itself, I think we have to take this broader perspective of other Ministries being involved in the work concerned. We cannot deny that all these efforts have been sustained over the last two and a half decades and have resulted in improvements in the health status of our nation. And we must keep up with these efforts. There are no two-ways about it. In fact, the principle of emphasising preventive health care and health promotion was given the most prominence, the greatest priority in the Report of the Review Committee on National Health Policies which Dr Kanwaljit Soin also quoted.

We have seen the offshoots of our emphasis. In future years, we are going to sustain the Healthy Lifestyle programme which includes various major thrusts to educate Singaporeans and encourage them to lead a healthy lifestyle, including having a healthy diet, regular exercise, control obesity, avoid smoking, etc.

A healthy diet, nutrition. We have in this programme put a great deal of emphasis on educating the Singapore public to eat a healthy diet - less fat, low cholesterol, low calories - and this will help to reduce the risk factors associated with lifestyle diseases.

Dr Kanwaljit Soin mentioned the low income families and perhaps generally families where the wives are working, that they have no time, they have no choice, they have to eat at hawker stalls. I question her hypothesis that people have no choice. I think if they are educated enough, they will know how to choose. There is a great variety of food in the hawker centres. In fact, the health promotion effort of the MOH does not say, "Thou shalt not eat in hawker centres." We just say that you should plan your diet in a more balanced manner. You can have a good meal combining vegetables with, say, fish, tahu and other food which is good in nutritional value. You can do that.

In the school canteens, we have been promoting healthy food. We have been educating the teachers who have been educating the food vendors about providing a more balanced and more healthy diet. Some schools and workplace canteens have adopted green labelling of foods - green labelling not in terms of environmental friendliness, but in terms of healthy nutrition, healthy diet, which will promote our health.

I think education is a very important part of our health promotion effort and we must continue to pump the message. We must continue to encourage Singaporeans and provide a conducive environment for them to sustain this healthy lifestyle.

Singaporeans must take responsibility for maintaining their good health. You have to make some effort to learn about these things because it is good for you. If you keep fit and healthy, you do not need to see doctors. You do not need to be hospitalised. You do not need to draw from your Medisave.

Yesterday, some Members mentioned that we should offer incentives for people to keep fit and stay healthy. While we are all out for innovative ideas, lucky draws, incentives, rewards and prizes for doing exercise regularly would not be the things to do. In Medisave there is already an in-built incentive for people to stay healthy. If you do not need hospitalisation, Medisave is your money, you keep it. And then the rewards also come from your enjoying a much better quality of life, apart from the nation having a more productive workforce.

The White Paper reiterates the Government's commitment to providing good and affordable basic medical services to all Singaporeans. I think good primary health care services are part and parcel of good basic medical services. By all accounts, we have a good primary health care system, and services are at affordable prices. When we talk about the proportion of the health budget spent on primary care and how this proportion has not increased over the years, we must look at the quality of the service that we have already got. We must look at the outcome of all the efforts that we have made, in terms of the health and improvements in Singaporeans' quality of life. Do you mean to say that you must spend an increasing percentage of the budget before you say there have been improvements in the status of people's health? I do not think so. Do you mean to say that absolute amounts do not matter? I do not think so. You build a clinic. It costs so many millions of dollars. The absolute amount matters. It is not just a matter of percentage. And we have done very well by all accounts.

We should also note that the bulk of primary health care is delivered by the general practitioners in the private sector. We must not always just say that the Government must do this and must do that. We must work together. The private sector and the public sector must complement each other. In this case, in primary health care, we have always had the private GPs who have delivered very good primary care to the greatest majority, three-quarters of the population. The Government's role is to concentrate its resources on the lower income groups who need the subsidies most.

Polyclinics offer services with about 50% subsidy. Over the years, and I think Dr Kanwaljit Soin once quoted the number, not on this occasion but previously, the attendances in polyclinics have declined from 3.9 million in 1980 to 2.7 million in 1991, and 2.9 million in 1992. This is mainly due to two reasons. Firstly, there are now more GPs and their clinics are conveniently located near to the patients' homes. Secondly, Singaporeans are generally better off. They can afford the more personalised services of the GPs. And the GPs' charges are affordable. So the Government's role is to complement the role of the private sector, concentrate resources on the lower income groups and indeed among our patients, we have been seeing more lower income patients. Also, we have been seeing more patients with chronic illnesses. With the Government's subsidy, patients with chronic illnesses pay much less as compared to when they see a GP. So patients, especially elderly patients, with chronic illnesses are benefiting from the subsidised services of the Government polyclinics.

The GPs, being the main provider of primary health care, have a very important role to play. And I hope to see them playing a greater role in future in patient education, in teaching the patients how to adopt healthy lifestyles, to prevent the onset of disease and also to teach them how to take care of themselves in managing their illnesses.

For certain chronic diseases such as hypertension and diabetes which Dr Kanwaljit Soin mentioned, as well as Mr Lau Ping Sum yesterday, they are two very good examples of illnesses where management by GPs and self-care by patients can help to control the illness as well as prevent further complications. In my view, the GPs in the private sector have a very important role to play. They must, as Dr Wan Soon Bee said, not just cure disease, but they must also be teachers. They must have a caring heart and the compassion for the patients' suffering to educate them on how to manage their illness and take care of themselves.

I would also like to see GPs work more closely with the polyclinics. For example, they can utilise more of the services provided, such as diabetic eye screening that we have introduced in our polyclinics, the laboratory services, the X-ray services, which the GPs may not have on their premises. They can also work more closely with the specialists in Government hospitals when the patients need to be referred for specialist care. In fact, some of the hospitals are already taking the initiative to reach out to the GPs in their catchment zones, such as offering continuous medical education courses and holding monthly focal discussions on how the specialists in the public sector can work more closely with the private sector GPs in order to better take care of their patients. So we are working with providers of health care in the various sectors.

Many countries with huge national expenditures are coming to realise the importance of primary health care doctors acting as gatekeepers to the expensive specialist care. The most effective way that the GPs can serve as gatekeepers is through the practice of family medicine. I think one of our goals in the immediate future is to encourage the population to stick to the family doctor. Do not hop among doctors. Allow doctors to know your medical history and that of your family members, so that they can follow your progress closely and become the gatekeepers for your health. When you need specialist care they can refer you to a specialist with the particular expertise.

Are we giving up on excellence when we say that we cap the rate of increase in the number of specialists? Are we back tracking on excellence? I do not think so. Excellence is already a social ethos among Singaporeans. We should continue to nurture the idea of excellence. We reach for excellence in many fields. But we must also realise that our resources are limited. We must concentrate resources in areas where we are likely to do well, where there is a bulk of patient load and where there is a concentration of expertise. So we, each and everyone, must not go for excellence in all kinds of areas. This is the strategy that we adopt in developing excellence in certain medical services.

We have the national centres such as the Eye Centre, the Skin Centre, and we are going to have a Heart Centre and a Cancer Centre. Tan Tock Seng Hospital is going to develop a neuroscience institute. All these will allow people to develop medical excellence in these areas. It does not necessarily mean that we would adopt the most recent high-tech and most expensive equipment. I think excellence should also be interpreted in terms of excellence in rendering basic medical care which will cure you and which will allow for a better quality of life. I do not see back tracking. In fact, we should interpret excellence in terms of our limited resources and how we strategise to achieve the most cost-effective and the best results for us.

Finally, I would like to touch on the very important issue of the care of the elderly. Some Members of the House, including Mr Chin Harn Tong and Mrs Yu-Foo, have mentioned this yesterday. As the proportion of the elderly increases rapidly in the coming two decades, we are making preparations to provide a whole range of health care services for them. But let me emphasise that the care of the elderly is not and should not be confined to the provision of geriatric beds in hospitals. These should be used mainly for acute illness. Hospitalisation is for acute illness. Very often, the elderly patients do not require hospitalisation for their chronic illnesses. Hence, we are developing a whole range of services, including community hospitals, day hospitals, rehabilitative services and community-based care, such as nursing homes, home nursing and home support services as well as hospice care. These are cost-effective methods of providing care for the elderly which will reduce the financial burden of medical care for them.

Recently, we have announced the formation of regional networks of services for the elderly. Based on the present catchment zones of the acute hospitals, there will be three regions. In the western region will be the Geriatric Department at Alexandra Hospital; in the central region, the Geriatric Department at Tan Tock Seng Hospital; and in the east, the Geriatric Department at Changi Hospital and the future general hospital in Simei. Each of these Geriatric Departments will act to coordinate its own regional network of services, such as community-based services, community hospitals and so on, in order to provide for the appropriate level of care for the elderly.

So we are working closely with the private sector. We are working closely with both the specialists and the GPs, and with the voluntary organisations, in order to provide Singaporeans with a very good and well integrated network of services. The Ministry of Health will work very closely with all the care providers. Thus, I do not see how the Government can be accused of over-emphasising self-responsibility of the individual and not doing its bit. Provision for the health care needs of the population is shared between the public sector, private sector and the voluntary organisations.

Dr Ow Chin Hock (Leng Kee): ( In Mandarin): Sir, I support the motion standing in the name of the Minister for Trade and Industry.

I also accept the Government's objectives and principles on health care, as mentioned in the White Paper, particularly two of the principles which I think are the most important. First, the role of the Government. The Government assures all Singaporeans, including the poor, that they will receive medical and health care, and that the Government shall intervene, if necessary, to compensate for any market failure. In so far as medical service is concerned, the Government is not only the regulator but also the provider and, for that matter, the biggest provider.

The second important principle is the personal responsibility in health care. Every individual must be responsible for his or her own physical and mental health. Maintaining good health will reduce one's demand for medical services. As it is said, prevention is better than cure. The hon. Member, Mr Cheo Chai Chen, said, "Nobody wants to be sick." The hon. Member, Mr Low Thia Khiang, also said, "The individual should not be held responsible for his sickness." I strongly believe that the Government does not wish any of its citizens to be sick because this will affect our manpower, reduce production and productivity; the Government will also have to pay more medical subsidy. However, growing old, getting sick and dying is a process which is inevitable in life. When a person has unfortunately fallen ill, he or members of his family will have to pay at least part of the medical cost. On the other hand, the individual has, to a large extent, the right of choice. He could choose the hospital, the type of ward that he wants to be admitted to, and the method to pay for his medical fees and even the choice of doctors. However, the degree of freedom to choose must be directly proportional to his willingness to pay for the medical fee.

On 3rd November 1993, the Feedback Unit held a dialogue session with some 45 doctors, unionists, community leaders and employers to discuss the White Paper. I have already submitted the minutes of the dialogue session to the Ministers in charge. Here, I would like to sum up some of the main points at the dialogue sessions, and add on my personal views for the Ministers' consideration and response.

First issue - demand and expectations. The Cost Review Committee's Report mentioned that in 1980, 80% of the patients were hospitalised in Class C wards. By 1992, the number of C class patients dropped to only 21%. This may be due to rising expectation of our people, but can it also be a reflection of the fact that our Class C beds are being reduced drastically? The Government has been emphasising that the standard of medical treatment in Class C wards is no different from that in the Class B or Class A wards. In a market economy, people's perception of "you get what you pay for" is deep-rooted. Therefore, it is not easy to convince the people that patients in different class wards would receive the same standard of medical treatment. Coupled with the problem of face-saving and the availability of Medisave, it is extremely difficult to ask the people not to opt for higher class wards beyond their means. At the same time, this would also involve some "emotional" and "rational" issues. When a patient is hospitalised, he or members of his family, in order to relieve the patient of his suffering, more often than not, would make some very emotional rather than rational choices. High cost or not, they would not care. They would stay in first and think of the consequences later. So under such circumstances, is the Government's plan to reduce Class C beds from the present 26% to 18% by the year 2010 and to reduce the combined Class C, B2 and B2+ beds from 53% to 50% and at the same time to increase private hospital beds from 21% to 30%, a move in the right direction? Will this further encourage the trend of staying in higher class wards?

The second issue that was raised at the dialogue session was the question of euthanasia, which is an act to terminate the pain and sufferings of terminally-ill patients by allowing them to pass away painlessly. The objective is to terminate the patient's pain and sufferings, and at the same time to alleviate the burden and hardship of the family members, and of course, the medical expenses. The basic medical package does not include the extension of life by artificial means. According to a report in the Lianhe Zaobao on 9th November, in the United States, approximately 1/3 of a person's total lifelong medical expenses are spent on the last year of his life. On the other hand, some people hold the view that life is a gift from God. It is therefore not for the doctor or, for that matter, any layman to decide when to terminate the life of the patient. Children who are filial would normally urge the doctors to try and extend the life of their terminally-ill parents. This is a sensitive issue. It involves not only medical judgment but also religious, legal and social issues as well. A number of participants in our dialogue session advocated that the matter be discussed publicly.

With our aging population, I think we should formulate the proper policy on this matter as soon as possible. For example, will the Government consider making euthanasia legal, or whether Government accepts "living will" by the individual, permitting the doctors to choose not to extend his life with artificial means in the event of his falling into a coma, or to authorise his next-of-kin to make a decision? Yesterday, the Minister for Health announced that the Government will not accept this practice of euthanasia. However, I think we should look into this matter more carefully.

The third issue is the supply of doctors. Several doctors who participated in the dialogue session agree to limit the number of doctors. They felt that the private clinics in HDB estates were competing very fiercely with one another and the clinics have to meet the ever increasing rental and manpower costs. One participant suggested that the HDB should limit the number of neighbourhood clinics in each estate. This is a very natural response by the doctors. But two community leaders who participated in the dialogue session also agreed to limit the number of doctors. They are worried that over-competition would result in a drop in the number of patients per clinic and, thus, prompting the doctors to increase their consultation fees, in order to recover their overhead expenses.

When touching on the supply side, the focus of the discussion was diverted to the issue of traditional medicine. Some people felt that the Government should regulate the practice of traditional medicine. But some others felt that the Government had never recognised the legality of traditional medicine and hence it has no moral authority to regulate it. After the publication of Dr Aline Wong's Report, I mentioned in this House, for the benefit of the Ministry of Health, that traditional medicine had reached out to the people and were generally cheaper than western medicine. On the other hand, among the physicians who are practising traditional medicine, the good and bad ones are intermingled. Moreover, the herbs used are not systematically authenticated. I suggest that the Ministry of Health should not neglect the value of traditional medicine, but it should look squarely at the roles that traditional medicine can play in our health care system.

The last issue in our dialogue session was on the financing of health care. Generally speaking, most or almost all the participants at the dialogue session accepted the principle that the patients should bear part of the medical expenses. Even the poor people who request for waiver of medical fees or for instalment payments would not talk about their problems openly for fear of "losing face", they too have self-respect. So we must not assume that everyone in the lower-income group would keep on asking for free medical service.

Our people are worried that with the ever increasing medical cost, there will come a day in future that they will not be able to afford medical and health care. I agree with the Minister for Trade and Industry that this is not just a question of who is paying the medical expenses, but also a question of how to pay the expenses. Each of the individual methods of financing has its own problems. For example, on the provision of medical benefits by employers, the employees consider it as a benefit over and above their wages, but the employers take it as part of their labour cost. The employees feel that the capping of 2% on the total payroll for tax deductible medical expenses for them will result in their employers reducing the provision of medical benefits. On the other hand, the employers feel that the unions may exert pressure on them to increase medical benefits for employees because total medical bill is currently still lower than 2% of the total payroll. Both sides are having mutual doubts and suspicion, and it is certainly not doing any good to our employer-employee relationship.

The White Paper's recommendation to incorporate the medical benefits provided by employers into the national Medisave and MediShield systems is indeed a constructive suggestion. On the use of Medisave and the question of balance billing for Medisave patients, some of our colleagues in Parliament had already touched on and, in fact, the Minister for Health had already given his answer yesterday. I do not wish to repeat it.

Finally, I would like to raise an observation as a conclusion. The objectives and guiding principles in the White Paper form the basis for MPs and people to discuss. I hope the Ministers concerned would accommodate the different views and perspectives of the various quarters, and consider implementing some of these suggestions which are feasible. This is not a debate in which we want to find a winner. Even if our own reasoning and perspective are correct, we should also try to explain to our people to convince them in order to ensure that our medical and health care system is excellent beyond doubt. 1.38 pm

Dr Toh Keng Kiat (Nominated Member): Mr Speaker, thank you for allowing me to join in the debate on this White Paper. I must first declare my interest as a practising physician in the private sector.

Singapore spends only 3.1% of our GDP on health but our citizens enjoy a standard of care that surpasses the OECD in many areas. Why then have we needed three Ministerial Committees in the last two years and now three days of parliamentary debate to discuss this issue of cost of health care? The answer must be the Government's determination not to allow Singapore to be bogged down in the same quagmire of stifling health care costs that Britain, the United States and some European countries are in today. The message is clear: it is not how much one spends on health services but what one spends it on that matters.

Good medicine alone does not make our citizens live longer nor by itself give our infants a better chance of survival. Let me illustrate. The morbidity and mortality from rheumatic heart disease has fallen, not because the surgeons and cardiologists are better at treating them, but also because of the lower incidence of rheumatic fever due to better living conditions, cleaner environment and better nutrition. I am glad Dr Aline Wong has already mentioned these points, and I share her sentiments that the accolades for what we have achieved in health care today should not only belong to the profession or to the Ministry of Health, but be shared by those in the Ministry of the Environment as well as the Ministry of Labour.

The White Paper has outlined what will keep health care cost down. But the first question is: is it already beyond affordability? Apparently, this is so.

Two events are responsible for this - the liberal use of Medisave by CPF account holders and the restructuring of Government hospitals. Medisave, which is a savings scheme to meet hospitalisation expenses after retirement, was at one time wrongly perceived by the people as citizens' money which was locked away by the Government. This, of course, was fuelled in some ways by Opposition politicians during elections. Therefore, on every occasion that it could be or had to be drawn upon, the practice was to use the maximum allowable or available. The problem was compounded in the early days of restructuring of the Government hospitals.

I was at the dialogue session with Dr Ow, and I would like to reiterate his comments on the C Class beds. The removal of the highly subsidised C Class beds drove those who could not afford it to opt for the more costly ones at the upper end of the scale. They were exposed to creature comforts and costly high technology medicine which was subsidised. Therefore, when a reduction of these subsidies and upward revision of charges came, matters worsened. A more liberal and lucrative consultancy fee scheme, which was introduced to keep specialists from resigning, did not help. It led to excesses which have only now been put right. It was this limitation of choice and the narrowing of the differential in prices between the private and the public sectors, coupled with the ready availability of private hospital beds and a more personal care by a specialist of one's choice, even within the ward beds, which were the push and pull factors that led to increased use of private sector health care services.

For a while, the intense rivalry between the two public institutions which offer tertiary health care exposed our population to esoteric, expensive and equivocal treatment modalities in high-tech medicine. The public were treated to an almost daily media blitz on advances in medicine which each had acquired. Expectations were raised and, with it, the demand for more health care.

Sir, I have outlined what I believe are the aggravating factors on perceptions of unaffordability in health care. The philosophies in the White Paper cannot be faulted. I subscribe to the ideals fully but I cannot agree with the reasons put forth for some of the changes that are to come. The private health care sector has significantly contributed to Singapore's economic growth as a regional medical centre of excellence. Its personnel-intensive services employ a large number of Singaporeans. It takes care of 75% of the outpatient and 25% inpatient health needs of Singaporeans. Its only fault seems to be that it has done its thing too well. For this, it has earned the opprobrium for what has gone wrong in health care and inflicted upon itself the curbs that are to come.

The high earning capacity outside has been identified as the cause of specialists migrating to the private sector. Some have even hinted of less than honourable means for this high income. Most doctors are still men of honour who abide by the tenets of the Hippocratic Oath and the teachings of Aesculapius. To deny that this is so is to admit the failing of our medical school which selected and trained them. Admittedly, there must be errant doctors just as there are dishonest politicians and crooked lawyers. Do we need to punish a whole community for a few black sheep? When good men were hard to come by for ministerial posts, the then Prime Minister Lee proposed better salaries for the Cabinet so that members would not leave to become bankers or CEOs. When the RSAF lost its pilots to the commercial airlines, the Minister for Defence suggested higher pay to retain them. We did not cap the salaries of our bankers, our CEOs, or our SIA pilots so that Cabinet will have its Ministers and the RSAF its pilots. Why cap the fees of doctors in the private practice so that the ranks of Government consultants will stay repleted?

The White Paper on Affordable Health Care is not just about costs. It is also a total reform of the health services. From being a provider, the Government has changed its role to that of a broker for health services, as well as an auditor and a policeman. It has taken upon itself the onus of determining a basic medical package for all Singaporeans. Yesterday, we heard the Minister for Health reassuring us of the comprehensiveness of this package. But I would like to emphasise that it is not the extent of this coverage but rather the content, or level of care, that we want to give to each specific sickness within this package that matters.

The definition of "basic" must, therefore, always remain clear. At OECD levels, "basic" will be state-of-the-art to the underdeveloped and the developing. During the Cultural Revolution, I had occasion to travel in China. My guide appeared to be a commissar of the Communist Party. Like his countrymen, his basic clothing needs were taken care of. Everyone wore the universal Mao jacket, but I noticed a difference. His was tailored in garbedine, theirs in drill.

Sir, one of the most common and obvious political issues related to health is based upon the charge that access to medical care is inequitable. Too drastic a return to basic health services will leave Singapore in the backwaters of medical progress when the rich and those with the power and the connections can go abroad for second opinions or the best in care but children of a lesser God will have to make do with second best.

Managed health care is also not necessarily the best although it may be the cheapest. The Rochester New York experience had often been cited in the past as a good model in the USA to follow where against a national budget of 14% GDP, there were surpluses. Large companies, like Xerox and Kodak, call the shots and hospitals and physicians were made to charge 30% less than elsewhere in the US for an equivalent service. I have been to Rochester, I have discussed this with doctors there, and I am told that as a consequence of this low-priced packaging, high calibre physicians are hard to come by in Rochester today and the quality of care has suffered. The White Paper has also hinted of mechanisms, like the Diagnosis Related Groups, to control hospital charges. This can only work where there is an economy of scale when what one loses on the swings one gains on the roundabouts.

On medical research and training of doctors, there will also be restraints. Research is important to teaching institutions. It keeps the academic staff in contact with the colleagues around the world and informed of what is happening at the frontiers of medicine. It nurtures an enquiring and analytical mind. It develops brain power and brain power is what keeps Singapore going. Research must not be measured in monetary terms or by a direct applicability of the knowledge gained. The White Paper has identified bone marrow transplants as research treatment that needs strong justification. Sir, I beg the Minister to reconsider this. Like renal transplant, it offers the only hope of a cure for patients with leukaemia and some forms of acquired and hereditary blood disease. Where a suitable donor is available, bone marrow transplant should be offered, otherwise it makes the treatment of leukaemic patients temporary and futile, for cures without a marrow transplant are anecdotal and relapses, after a brief remission, almost a certainty. In most countries, the bone marrow transplant is always a part of the leukaemia package.

On the question of supply of doctors, the White Paper has warned against the training of too many. Even as I was gathering my thoughts for this debate, the Government came out with the announcement that the number of overseas universities approved, where Singapore students can read medicine, has been reduced from 176 to 28. There is also a second level of control in that only 30 graduates each year from these institutions will be registered to practise. Sir, it is a moral obligation for the Government to register all graduates from these already approved institutions even if the number exceeds 30 in any one year, which I think is a highly improbable event. Many of these universities have already closed their doors to foreigners and others have set such a high standard of entry that few, if any, Singaporeans will make the grade.

A control of the number of doctors, it is said, is important because the medical market is a failed market when it comes to supply and demand. A surplus, it seems, will lead to provider-driven demand due to the profession's autonomy. Sure, doctors do have professional autonomy, but so do architects, lawyers and engineers. Few doctors have translated their autonomy into a radical monopoly. Yet market forces have been allowed to prevail when it comes to the allocation of HDB premises for medical practices. The economic research department of a local bank has found that rentals form 40%, at 1990 prices, of the recurring cost in running a clinic. Any cost must ultimately find its way into the patient's bill. Now that the curbs will be imposed, it will keep the cost of health care down if the Government will reconsider an earlier request of mine in this House for preferential rates and purchase prices of HDB units to be used as medical clinics but under restricted tenure. Other tradesmen, businesses and tenants should have no cause for complaint, unless they opt to subject themselves to the same restrictions.

The White Paper has focused heavily on the control of doctors and hospitals to curb the rising cost of health care. It has remained silent on pharmaceutical trade and providers of diagnostic or ancillary services. These must surely have a role in determining health care costs.

Sir, it is prudent planning that health care cost be controlled. It is also good politics. But sound policies must not be implemented in expediency or with ambivalence as this can only lead to more problems for the future. Until we find an even keel, I do not know what direction medicine will be heading in Singapore. When our forefathers bound the feet of their women to restrict their movement, they also hindered their growth and mobility. In carrying out the proposals of the White Paper, I would like to make some suggestions:

Medisave. Restriction on balance billing will come in late 1994. In its implementation, I hope consideration will be given to situations where there is more than one specialist looking after the same patient, or when an ill patient requires a doctor to visit him more than once a day, sometimes after office hours or at night. To discourage frivolous use of Medisave, perhaps a bonus scheme of higher interest earned for savings left undrawn for a certain period of time could be considered. Once the maximum sum has been reached, interest accrued should remain in the Medisave for use in retirement and not be channelled back into the Ordinary Account.

Basic health care. Steps should be taken to guard against the evolution of a system where the rich, powerful and those with connections can have access to state-of-the-art care overseas, or the lower-income groups have to make do with what is deemed best for them. The Government should also retain enough of facilities to cater to the needs of retirees, the aged, the poor and the pensioners instead of just being a health care broker. As the emphasis will be on primary health care and family medicine, the Department of Family Medicine in our university should be strengthened. At present, it is only an appendage of a larger unit which is basically concerned with gathering health statistics.

Integration of public and private sectors. As one perennial problem is doctor migration from the public sector to private practice, especially at the specialist level, we should think of a system where we can integrate the two. Money alone is not the push or pull force. Job satisfaction as is derived from a lower patient-load and a more personalised style of practice are also factors involved. A solution to this problem is to have a common career path for all doctors with a compulsory stint in public service for a defined period during the earlier years as junior doctors and specialists to be followed by compulsory exit by everyone to the private sector. Only the best are to be retained in Government service or in academia with commensurate financial rewards and other compensations. They will be the teachers, senior consultants, State surgeons and physicians.

The CPI plus X factor. The Minister has already assured the House yesterday that when this increases, revenue will also increase by tandem changes in the subsidy and cost recovery within the context of the long term subsidy targets and not by cost recovery alone. The White Paper, on page 34, however, states that one incentive to subvented hospitals to improve service "must be a profitable bottom line." Sir, the Public Accounts Committee must have anticipated this as it has stated in page 4 of its Report to Parliament presented on 6th November 1992 that:

"`While cost increases are inevitable over time, the MOH should bear in mind, when reviewing its fee increases, that the objective of restructuring the hospitals is not to enable them to make profits or even to recover costs, but to enable them to work more efficiently.'"

The National Health Council. The White Paper has proposed a Medical Fees Council to review fees periodically. I would like to suggest a National Health Council instead, with increased functions. There will be a committee not only to review fees but to act as an Ombudsman to arbitrate in complaints against overcharging, another to review the health care needs of Singaporeans and re-define the basic health package periodically, and a third to deal with ethical and moral issues. The Minister for Health has also commented on this. It is important because of the anticipated contraction in the number of intensive care beds. When a facility becomes limited in supply, rationing follows. In rationing, there must be priorities and someone has to suffer. By his training, a doctor will be hard put to turn off respirators or withdraw life-sustaining lines.

In conclusion, Sir, I thank you for this opportunity to participate in the debate on the White Paper. I support the philosophies expounded therein, but I must disagree with the reasons behind some of those reforms.

Mr Yeo Cheow Tong: Sir, may I ask the Member how would he rate the B2 and class C medical services being delivered in the subsidised hospitals now?

Dr Toh Keng Kiat: I think they are good value for the money that the patient spends.

Mr Yeo Cheow Tong: Sir, would he also agree that food items are more essential than medical services?

Dr Toh Keng Kiat: No, I do not think so. I think medical services are more important.

Mr Yeo Cheow Tong: You mean when food becomes so expensive, people cannot afford them and in the end we should still give priority to medical services rather than ensuring that Singaporeans have a full stomach?

Dr Toh Keng Kiat: Sir, can the Minister please repeat what he has said?

Mr Yeo Cheow Tong: Sir, he has asked that medical services be given priority, that we should put medical services on a pedestal and ensure that in all our estates, shops be specifically set aside only for doctors. If we have to set aside shops on the basis of importance, should we not set aside shops for the most basic item, which is food, and therefore we should call on HDB to ensure that certain shops in every HDB estate be set aside only for provision shops, so that the people can have access to shops which have very low rentals and therefore the food items will be even cheaper?

Dr Toh Keng Kiat: Mr Speaker, Sir, I think the Minister has missed the point. I said preferential rates of rental and purchase prices but under a restricted tenure. I think I brought this point up also at the feedback dialogue session, in the sense that there is now a free-for-all system. In other words, if there are 50 shops available in a HDB precinct for rental or for purchase, 50 doctors could bid for them. And if they overbid all the other people, we could end up with 50 clinics within a district and no clinics in other areas of the same estate. It will be a more equitable distribution if there is some kind of control. Now that we have got control on so many things, we could also control the distribution of clinics within a housing estate so that there will be doctors available in all areas within a district.

With a restricted tenure, there should be no complaints because we can control the fees. Therefore, the savings on rentals and purchase prices can be passed back to the consumers.

Mr Yeo Cheow Tong: Sir, I am glad he clarified about the B2 and C class and about his thoughts on special preferences being given to doctors. In the White Paper, we have already stated very clearly that the basic package would contain the services that are already available in the existing class B2 and C and the quality will be maintained. Dr Toh has just mentioned that people who are rich can get services, but children of workers will be left with a very poor level of service. I think that is trying to cause unnecessary alarm and trying to misinterpret what has been very clearly stated in the White Paper.

Secondly, the same scenario about HDB shops can apply to provision shops, that is, there could be 50 provision shops in one estate and zero in another estate. Surely, we must leave it to market forces to ensure that there is a good distribution of shops and that if there is a good distribution of shops, there will be enough competition and that the services will be available and affordable to everybody, rather than putting the medical profession on a separate pedestal and giving them special treatment.

Encik Harun bin A. Ghani (Hong Kah GRC): ( In Malay): Mr Speaker, Sir, we have read in the newspapers of the many comments and praises about the White Paper on Affordable Health Care. I share the public pleasure with the findings of the Committee as presented in the White Paper and I fully support them. At the same time, though I do not belong to the medical community, I would like to offer some views.

Affordable Medical Care

This topic is dealt with under two headings. Firstly, the expectations and the education of the public seeking medical attention; secondly, provision of additional care through excessive services by doctors, general practitioners, specialists, surgeons, for example, through the use of CT scan, ultrasound and scopes.

Education - Expectations of the Public

The advancement in knowledge and equipment for diagnosis and the patient management is described in newspapers and periodicals. News about a new medical equipment is usually accompanied by descriptions of how conveniently the patient can be managed with the new equipment. Usually these descriptions are true, but improper use of such equipment would increase costs with no definite benefit to the patient. For example, the use of ultrasound for normal pregnancies. CT scan is useful for diagnosis of stroke and stroke management but certainly not for diagnosis of chest infections, where a simple chest X-ray would help in such cases. Members of the public is familiar with descriptions and explanations of the use of such equipment, but the specific use of the instrument may not be known. Conducting a head scan or using ultrasound or scope without first being explained the use of such procedure is improper, because all this would increase costs. What the public must be concerned with is:

i) gaining more information on health care - this has just been dealt with by the Minister of State for Health;

ii) practising a healthy lifestyle such as refraining from smoking, over-eating or high consumption of alcohol;

iii) getting proper information about chronic diseases such as diabetes, hypertension, stroke, heart disease, occur or are hereditable in his family that he could prevent or those that can be delayed by adopting a healthy lifestyle;

iv) going for regular medical check-ups with the family doctor or at outpatient clinics, discussing medical problems with the doctors and getting advice on how to maintain one's health and prevent illness;

The patient can be referred to a specialist at a hospital for evaluation, if necessary, only after he has been advised and examined by the family doctor or the outpatient clinic doctor. Parents are willing to follow the procedures for immunization and medical examination of their children, so they should be prepared to do the same for themselves.

These are the measures the public can take if health cost is to be reduced. The public are the consumers of health cost. The public make demands on the system of health care, the public expects the system to rectify the damage caused to their bodies by their own adverse lifestyles. The public has the responsibility to educate themselves on self-care, consulting their family doctors and not immediately seeing a specialist to get advice on how to maintain their health or to redeem it when it fails on account of their poor lifestyles. We are prepared to spend on the maintenance of our car and on life insurance, but we neglect our own medical examination every year.

Research

Mr Speaker, research is expensive but it is also necessary. As noted in the White Paper, we have to carry out clinical research if we want to maintain our status as the leader in the medical field in South-East Asia. Clinical research helps us to better understand the patterns of diseases in our population and with better understanding, health improvement measures can be taken and we can even thereby reduce costs - this has also been dealt with by the Minister of State for Health earlier. For example, we know that 8.6% - this is the figure for 1992 - of Singaporeans suffer from diabetes. But we also know that, within the population, the incidence is highest among Indians and Malays - the rates are 8% for Chinese, 9.3% for Malays and 12.9% for Indians.

Alternative Medical Therapy

The costs for pharmaceuticals have continued to rise. This is due to the marketing of new drugs and claims by pharmaceutical companies that their new drugs are better, more potent, etc. Not all such claims are necessarily correct. Again, there is a possibility, and I stress "possibility", that some doctors are inclined to believe that the "new is better and the old is to be discarded". This might not be completely valid. If it was so, then many of the old drugs that are still being used today would not have stood the test of time. For instance, Penicillin V, which was discovered in 1945, is still useful today. The notion that new must mean better is apparent in the use of antibiotics. For instance, Augmentin, which is quite as good as Amoxycillin in many clinical situations. A course of Augmentin costs $20 whereas Amoxycillin is only $1. The difference is just too much. Also, ordinary, cheaper drugs might not necessarily be less effective than patented medicine. Alternative medical therapy should be looked at in view of the high cost of present pharmaceuticals. However, before alternative medical therapy can be introduced, research has to be conducted to determine the benefits and the problems that might arise with such therapies. Of course, we need to evaluate the benefits and the cost-effectiveness.

The National Institute of Health in America will introduce programmes to evaluate alternative medical therapies and it will be exciting to see the direction they will take in the selection in alternative therapies to assess, methods of assessment and what benefits to expect.

Curbing of Over-servicing

Payment for services might, and again I stress "might", lead to misuse because we cannot teach doctors not to work towards acquiring more money. The over-servicing of patients is the way through which doctors generate an income for themselves. Over-servicing includes extra investigations, surgical procedures that might not be necessary or the use of high-tech equipment, such as surgical microscope for surgery. Indications can be made for the use of high tech equipment for surgery but the doctor must ask himself honestly whether his application will benefit the patient more than it does himself financially. I think the question of over-servicing can be resolved by paying doctors in Government and restructured hospitals fixed salaries. The pay should be increased but let it be "fixed" salary. There are still good doctors and within a fixed salary structure the temptation for more money can be eliminated. Doctors should not take advantage of a patient's situation and profit from him.

Furthermore, high-tech procedures are generated by:

i) doctors seeking to promote themselves as better than their colleagues.

Equipment only assist a good doctor in his performance but does not make a brilliant doctor, whether in medicine or surgery. Advertisement on the presence of high-tech equipment attracts patients' attention to the hospitals concerned but they would not necessarily benefit from them.

ii) requests by patients themselves.

Patients nowadays tend to ask for what they want and not what is advised by the doctor. CT scan, for example, is very useful. Its effectiveness has been accepted in the medical field but the patient only thinks of the brouhaha over its wonders and would press for its use even if it might not be necessary. Doctors would normally accede to the patient's request for various reasons. One of which is that it is income generating.

iii) operations and procedures conducted by junior doctors or housemen under a senior staff are usually less expensive.

iv) excessive research, laboratory studies and X-ray ultrasound, MRI and CT scans.

v) over prescriptions in quantity and use of new and expensive pharmaceuticals.

Rectifying the mistakes caused by such excessive services is difficult. This depends on:

i) a sense of responsibility to contain cost.

All doctors serving in medical institutions must be educated on cost calculations. We must ask ourselves if there really are two standards of health care for our citizens or two standards of treatment of patients. This question must be carefully examined. If we say there are two standards of care, we are putting the less well-off section of our population at a disadvantage. If we say there are two standards of cost, then we must ask why this is necessary. Does a higher cost of care mean better care or is it due to excessive services, unnecessary services, expensive equipment, etc.? Cost comparisons can be made between the supposedly better and more expensive hospitals, such as NUH and SGH, and others like Alexandra Hospital. Data for such cost comparisons can be obtained from the authorities concerned. What we should ask ourselves is, who will benefit? The patient, the doctor or the hospital? If all existing hospitals now already have subsidised C class beds, do we need one specially set aside as a Government hospital, for the less well-off? The "no frills" hospital gives the public the wrong impression. They tend to think that:

a) since it is meant for the less well-off, the quality of medical care will be less;

b) the medicine given will be of lower quality;

c) the doctors are of lesser "quality" and that only "quality" doctors are available in the restructured hospitals.

Probably 95% of patients are already adequately treated in any hospital in Singapore and maybe only 5% really requires special care and special equipment to maznage them. This cannot be a valid reason for charging high fees, money which is then spent on advertisements and high-tech equipment and medicine. Unnecessarily allowing doctors in public institutions built with public funds to generate income for themselves and for their institutions may not be proper. Are we afraid that our doctors would leave these institutions to work in truly private hospitals such as Mount Elizabeth and Gleneagles? Singapore has a ratio of 1 doctor to 850 population. Not so much work is available in private hospitals. People with higher incomes prefer to be treated by specialists in Mount Elizabeth and Gleneagles. Even our neighbours have opened their own specialist hospitals. We should change our system of doctor payment to a fixed salary income. Only in this way can we ensure quality because of better pay.

ii) a fixed salary structure be adopted for all doctors in Government and restructured hospitals, salaries and salary increments and promotions should be based on competence, meritocracy, professionalism and teaching and research work, and the doctors must have a holistic approach and be mature in terms of medical speciality practice. The doctors should be subject to tests of their ability. They should be tested and their ability proven. They should teach and help junior doctors to gain their skills. This is the quality of a good doctor.

iii) Cost review committees are present in all hospitals, whether private, restructured or Government. If possible, the report of these committees be published so that we can make comparisons.

Sir, I support the motion.

Dr S. Vasoo (Tanjong Pagar GRC): Sir, thank you for allowing me to join in the debate.

In the last three days we have covered a lot of medical ground and I suppose they are all interesting viewpoints that have been brought up during the current debate on the White Paper on Affordable Health Care. Sir, I share many of the viewpoints expressed by my Parliamentary colleagues. They have in fact given a lot of prescriptions. The Minister for Health has also given counter prescriptions. They are all good doses to help us manage a better and improved health care plan.

Sir, a lot of healthy recommendations have been prescribed. On the whole, I must say that the Government should be given a clean bill of health for spelling out a clear health care plan. In the last few years that I have been in this House, I think the Government has come out with a clear direction in terms of the future of our health services and the types of programmes that would be implemented.

Sir, what is most important is that affordable health care is the responsibility of everyone - patients, health administrators, laboratory service suppliers, medical personnel and all the others who are related. What is most important is for all these actors to become more cost conscious and accountable in what they do. If each of these actors is able to play his role effectively, then health care cost could be contained. We must work towards this effort. So what is most important is that consumers should not be subjected to high-tech medicine when other cost effective treatments are available. I think there is this danger. If you have read the newspapers, all sorts of transplants do take place. If we run in this direction, then health care costs cannot be contained.

The Minister for Health stated that there are Audit Committees in hospitals. This is indeed reassuring but the task of Audit Committees should include expenditure audit. This is very important because other than audits on medical issues, expenditure is an area that we should watch for and I would suggest that independent Audit Committees should be set up with the involvement of some professionals outside the health care system. Audit should, in fact, be made transparent so that the public would know what is the actual cost for the delivery of our health services.

Sir, the White Paper has not fully addressed a few issues which are likely to become more challenging in the near future. Sir, firstly, much emphasis should be focused on primary health care. I cannot but agree with the Minister who stated that we have a good primary health care system. But I think we should be able to do better than that. If you look at last year's Health Ministry's report, only 11% of the Health budget for 1992 was spent on this area. You may argue that 11% is sufficient, but I feel we can review this area because primary health care is an important arena for health prevention.

Sir, we have to ensure that there are a reasonable number of polyclinics and laboratory services to deliver frontline medical services. However, only a few polyclinics are planned and this can drive more people to use the hospital services. This can choke the hospital medical system. One argues that attendance rates at polyclinics have dropped. But we should also look at the number of polyclinics that has been reduced. So the attendance rates naturally go down too.

An hon. Member: People are healthier.

Dr Vasoo: They say people are healthier. But I think people do need to go to these outpatient clinics from time to time to assess their health care problems. Sir, there is no plan to establish more polyclinics. More support must be given to family medical practitioners to set up group practice in housing estates. This would probably provide some reassurance to Dr Toh Keng Kiat who has been advocating for this.

Sir, you will realise that there is a growing number of families with elderly members who are 70 years and above. It is estimated that there are about 106,000 persons in this age group at the moment. The number will be growing further in the years ahead. MediShield does not cover them. There are, and would be, burdens of health care faced by these families. Sir, I think it would be helpful to allow children of these families to use their Medisave for MediShield to cover their parents' medical treatment. Increasingly, this elderly group will create a burden on our health care system which will be under tremendous pressure in the years ahead.

Sir, we will also be seeing an increasing number of older persons requiring treatment for terminal illnesses. This will impose serious strains on families and the hospital resources. Both families and medical staff will be faced with the issue of death and dying. There will be ethical dilemmas, and I think we cannot escape this. Hospital staff and families will have to be better prepared to deal with these dilemmas.

Sir, the White Paper noted the increased cost of various medical and laboratory examinations. The charges in this aspect need to be contained before it runs out of control. Sir, Government can play a role by encouraging NTUC and other groups to provide laboratory and medical tests. This is an area that I think we need to look at the cost, because it forms quite a sizeable part of medical costs.

Sir, there is also concern among medical professionals whether the policy changes to be implemented would affect Singapore's effort to promote itself as a centre of medical excellence. This issue has to be squarely addressed. There are a lot of specialists who are concerned about this, and we need to see how we should encourage and provide the necessary support that Singapore can maintain itself and move ahead to become a centre of medical excellence.

Sir, in conclusion, we all have the responsibility to keep our health cost trim. Where we can save in our health expenditure, we should. The prescription for all of us is, as the common saying goes: an apple a day keeps the doctor away. But, Sir, life is such that sometimes an apple a day may not keep the doctor away. In this case, we need affordable health care. I support the motion.

Mr Speaker: Order. I suspend the Sitting and will take the Chair again at 3.00 o'clock.

Sitting accordingly suspended at 2.33 pm until 3.00 pm. Sitting resumed at 3.00 pm