ESTIMATES OF EXPENDITURE FOR THE FINANCIAL YEAR 1ST APRIL, 1994 TO 31ST MARCH, 1995

Order read for consideration in Committee of Supply [5th Allotted Day].

[Mr Speaker in the Chair]

Head R (cont.) -

Resumption of Debate on Question [15th March, 1994],

"That the sum to be allocated for Head R of the Main Estimates be reduced by $10 in respect of Code RG 3100" - [Mr Goh Choon Kang].

Question again proposed.

Dr Koh Lip Lin (Nee Soon South): ( In Mandarin): Sir, before the adjournment yesterday, I was talking about the variety show programme on SBC. Although the variety show programme enjoys very high viewership, it does not necessarily mean that the programme is good but rather it is because this programme was screened at prime time between 8.30 pm and 9.30 pm and there were many lucky draw prizes to attract the viewers. I agree with the Minister's opinion yesterday that we should give SBC the opportunity to try out so that they could improve. But they should not use this opportunity to produce such meaningless programmes. They should produce entertainment programmes with higher standards. If they cannot do it every day, they should pool their resources and have only one programme a week. As the Chinese saying goes, "We would rather have one good product than have many products which are no good."

As a matter of fact, the SBC dramas have improved a lot over the years. But, unfortunately, over the years, they have been telecasting a lot of scenes with sex, violence, gambling and superstitions. I think these scenes will have very adverse effect on our young people in Singapore. The young people will learn wrong values from these TV programmes. Some people may argue that the shows on TV cannot affect real-life activities but there was a newspaper report that last year, in California, there was a TV programme where they showed some young people playing a new game, ie, to lie in the middle of the road at night and allow the cars to pass them on both sides. That was their way to get more excitement and many people imitated them by lying in the middle of the road at night. On one occasion, a driver injured a number of these young people who were lying on the road.

This shows that TV programmes have some effect on young people. SBC has a social responsibility to bear. They should not only look at the commercial benefits and forget about their social responsibility. As a matter of fact, a good programme does not necessarily have to concentrate on sex, violence and gambling. During the early years, SBC had produced some very good programmes, such as "The Awakening", "Samsui Women", etc. Why is it that SBC cannot produce more of these good programmes? Now that SBC has arrived at the standard that it enjoys today, it is because they have attracted many professionals from other countries, especially from Hong Kong. Their professional skills and experience have helped SBC to progress. I think we should thank them for their contributions. We welcome professionals from other countries to come to Singapore to become our permanent residents and we also hope that they will understand the values of Singapore. We hope that they will be able to produce TV programmes which would be suitable for our environment here. Also, SBC should have a better monitoring system so that they would make sure that all the programmes they produce are of good standard and of good moral values.

We know that producing good programmes would involve a lot of costs. We hope that the Minister will be able to persuade the Minister for Finance to give them more grants to support the progress of SBC.

Mr Chew Heng Ching (Eunos GRC): Sir, our TV programmes serve to entertain as well as to educate. SBC has a long history but our TV programmes today are largely imported. I have nothing against imported programmes. With careful selection and censorship, most of the imported TV programmes are entertaining and many educational.

Sir, TV programmes have a strong influence on our young. It is therefore of utmost importance that programmes for the children be of the right type. I observe that TV programmes for children are generally cartoons and most, if not all, are imported programmes. I feel there is a dearth of TV programmes for children which are produced locally. We should encourage our children to see TV programmes with a Singapore theme and such programmes should be set in Singapore and acted by local children. Through such programmes we can inculcate the right values amongst our young. By this, I mean SBC should run stories or programmes that reflect respect for law and order, respect for parents and elders, and portray good moral values and healthy lifestyle.

Sir, I believe places like Taiwan and Hong Kong have produced many quality children's programmes. I think our SBC should do likewise. Will the Minister tell the House whether SBC plans to produce more local children's programmes?

Another question pertains to the timing for screening of these children's programmes. These programmes are of utmost importance in inculcating the right moral values among our young. Indeed, it is part of the nation building process. I therefore advocate that such programmes should be shown during prime time, between 5.00 and 7.00 in the evening. This is a good time for screening because normally after 7.00 pm the children either retire to do their homework or they leave home to attend private tuition classes. Will the Minister consider screening these programmes during these hours?

Dr Ahmad Mattar (Brickworks GRC): Sir, after 22 years in office, I feel very, very good to speak from this side of the House.

Sir, "Channel 5 - Where it all happens" - that is the slogan we hear from SBC these days and quite often too. But I think a more appropriate slogan, Sir, is "Channel 5 - What is happening". All I can say is that lots of strange things are happening on SBC 5 and 12 and perhaps on SBC 8 too. I say "perhaps" because I do not normally watch SBC 8 for obvious reasons.

Sir, judging by the many criticisms and complaints we get, SBC is going downhill unless something is done to save it. But of course SBC will tell us how great a station it is by its so-called "New Look", by its new $8- million newsroom. But what do we, as viewers, get? The Same Boring Channel. That's what SBC stands for: Same Boring Channel.

Mr Chairman, Sir, I agree with many of the observations made by previous speakers on SBC. However, I would like to add my own comments on locally produced programmes. But before I do that, Sir, I would like to state at the outset that I am not against local talents. I am not against local groups. Indeed, there are a number of such groups in Singapore today which are worthy of our support. Singapore Dance Theatre (SDT) is one very good example. Sometimes I wonder whether Government has given the SDT as much support as it has the SSO. The Minister may want to comment on that.

Coming back to the subject of local production: Sir, if local productions are insulting the intelligence of Singaporeans, then I say we should not support them. In this respect, the Ra Ra Show and Gotcha!, which SBC considers clever, funny and entertaining, come under this category of production. Anyway, Sir, I congratulate the Minister for withdrawing Ra Ra Show although he did tell us yesterday that he did it with most reluctance. Next, I want to know from him when can we expect the demise of Gotcha!

Sir, with regard to video clip re-runs, I have nothing more to add to what has been so eloquently, so aptly, put across by my colleague, the Minister for Defence. I can see that Dr Yeo could hardly wait till July when he comes over to this side of the House to have his first public salvo on SBC. He is not here. Anyway, I welcome Dr Yeo to join the unofficial backbenchers' SBC Monitoring Club.

Dr Yeo adequately summarised the frustrations of viewers who at one time were made to listen to and watch, for example, Mariah Carey perform "Dreamlover" over and over again. Sir, I enjoy Mariah Carey's songs but to watch her perform "Dreamlover" ad nauseam, to borrow Dr Yeo's expression, is quite something else.

What did SBC do as a result of Dr Yeo's comments? They began to show the Black Knights ad nauseam. Either this was SBC's rude response to Dr Yeo's criticism or the person or persons in charge of programming did not use very much of the stuff up here [indicating] to draw up programmes for us, the viewers.

This is the problem of being a monopoly in the country and, to make matters worse, SBC keeps on telling us how good they are. I know many viewers, myself included, who have switched off SBC and given up on it. It is better to watch video tapes, laser discs or turn on a Malaysian channel or even go to the cinema.

But, Sir, my greatest concern is over the Malay programmes that Malay viewers get to watch on SBC 12. In his reply yesterday, the Minister said that SBC must go for more local productions, and good local productions. If that is the case, could I ask the Minister for the reasons why SBC is showing a number of Malaysia's TV3 Malay programmes on SBC 12? And included among these is "Muzik, Muzik 93". It is a musical, telecast time: between 2.30 and 3.30 pm on Saturday. There is another one called Pi Mai Pi Mai Tang Tu, a half-hour comedy, telecast time: 5.00 pm, also on Saturday. 2+1, another half-hour comedy series, telecast time: 3.00 pm on Saturday. I can go on with a few more but I think three will be sufficient as an illustration. [Dr Yeo Ning Hong enters the Chamber]. Welcome to the club, Dr Yeo.

What I want to know from the Minister is: what has happened to all the Malay producers of SBC? Names like Mockram Kassim, Amiruddin Abbas and Suhaimi Jais, for that matter. I know the Minister will say that Suhaimi Jais is busy producing English programmes. Okay. But what has happened to the rest of them? These are Malay producers of calibre. They have good track records of the kind of programmes they produced for SBC. I know they are still on SBC's payroll and therefore what I want to know from the Minister is: what are they doing?

Sir, in trying to defend SBC's decision to up the TV licence fee, the Minister, at the sitting of this House on 23rd February, did say that the number of viewers of SBC programmes has increased. Today, we get to see on SBC Channel 5 another of SBC's claim, namely, that 99% of housewives watch SBC programmes weekly. What I want to know from the Minister, Sir, is this: how is it that SBC always comes to these happy conclusions? Do the conclusions come from surveys or people meter, as the Minister put it yesterday? If so, who conducts the surveys or who administers the people meter? Because if SBC conducts those surveys or SBC administers the people meter, what other conclusions can we get?

Finally, Sir, I would like to urge the Minister, and certainly the General Manager of SBC, to re-look into SBC's programmes. If we do not take an interest in the way programming is being planned, then I am afraid SBC will continue to degenerate into a channel that is void of any meaningful viewing.

Mr Teo Chong Tee (Changi): Sir, educators and sociologists in the West have blamed television for many of the social ills in their societies; among them the breakdown of the traditional family units, the astronomical increase in crime rates, the shockingly high number of children born out of wedlock - as high as 70% among certain communities; the poor academic performance in schools, to name but a few. Of course, we all know that television itself is not the culprit; the real problem stems from the kind of programmes the stations dish out to the people. When incessantly fed with harmful materials and garbage over a long period of time, it is only natural that the minds of the viewers will be poisoned or filled with filth.

Sir, I am saying all this because I feel that as a Government, it is our sacred duty to help retain, safeguard and promote our wholesome traditional Asian values which have helped to bring us to where we are today. One way to do this is for SBC to produce better programmes. The first step is to employ innovative script writers, directors, actors and actresses. If such people with better talents are not easily available in Singapore, SBC may have to cast its net wider to get them from countries in the region.

As for imported programmes, SBC should be more judicious in its selection of the programmes. They should not just cater to the taste of the viewers. In a young nation like ours, maybe MITA and the Ministry of Education should work more closely together so that one may not unwittingly undo what the other is trying to do.

For example, in our schools, we try to instil in our pupils the shared national values as well as shared family values. We also painstakingly try to promote mutual respect and understanding among the different ethnic communities. But such efforts do not seem to be complemented by what they see on TV at home. In fact, what the schools are trying to do can often be erased just by a flick of a TV button. The daily staple on TV is too full of commercials, frivolous skits, soap operas, many of which are lacking in educational, cultural and moral contents. It is rather ironical to note that in its infancy a few years ago, SBC was able to produce quality Chinese programmes, such as wu suo nanyang [ ], which has valuable educational and historical content, whereas today with maturity and more sophisticated know-how and technical skills, it has resorted to producing less wholesome programmes. There are just not enough of wholesome, healthy programmes catering to the needs of the more serious viewers and, in particular, to the young. Speaking of the young, it was not too long ago when our Asian cultures molly-coddled our young in the warm cocoon of the family. But today in many families, the TV and the domestic maids have taken over.

Granted, in modern Singapore today, it is futile to lament about the good old days. But I think it is not too late to do something to arrest the erosion of our time-tested values which have seen us through thick and thin over the years.

Also, SBC should undertake a more active role in disseminating information and educating the populace on important Government policies and issues. It can make use of the SBCText for this purpose. For example, if someone needs to find out more about GST or the new medical benefits for civil servants, he can find the information he needs in SBCText.

Sir, one other area that I would like to cover is the news bulletin in English. Regarding our English news bulletin, I understand that the 7.00 pm news bulletin is meant more for students and blue collar workers while the 10.30 pm news is catered more for business people and professionals. From feedback, Sir, the two time slots are not the most convenient and suitable time for people to watch news. 7.00 pm is too early in the evening. People have just got back from work or from school and are preparing to take their dinner or to take their bath. It is just too early to watch news because people have yet to settle down after getting back from work or from school. On the other hand, 10.30 pm is a little too late for the working people. By the time the news finishes, it would already have been 11.00 pm. SBC should consider rescheduling the broadcasting time for our English news bulletin.

Mrs Yu-Foo Yee Shoon (Yuhua): ( In Mandarin): Sir, yesterday my colleagues here have discussed and debated on various topics, touching on the privatisation of SBC and its moral values. I would like to follow up today.

With science and technology being so advanced today, all kinds of information are available and easily accessible to the people. Satellite transmission, television, video tapes, laser discs, etc. have not only shortened the distance between countries but have also facilitated the exchange of commercial and industrial benefits, academic, scientific and technological updates, news and information as well as the exchange of intelligence. However, under this situation where science and technology is so advanced and information so easily accessible, it is extremely difficult to control the flow of information.

Among the information which is flowing so freely, some are good and some are bad. More often than not, it is the perception and judgment of the receivers themselves that decide whether the information they receive is to their benefit or not. This could easily lead to the receivers losing their own directions under the influence and impact of the large variety of information before them, resulting in their pursuing the extremes and moving towards an anti-social trend. When we talk of this problem, perhaps we may feel that this is something which cannot be controlled.

There is a strong influx of information coming out from other countries. Although it is difficult to control, we should build our retaining wall to prevent this flow of information or at least we should be able to survive after the impact of this information from other countries. Singapore is such a small country. Our resources are limited. When we face this influx of information, are we going to flow with the trend or are we going to pay a cost to learn from this experience? This is one very important problem for us to decide.

I agree that the television programmes produced by the SBC have been improving. The programmes that they have telecast, such as the documentaries, news reports, current affairs programmes and some art coverage over Channel 12 are very good programmes. Whereas in the drama section, the TV serials produced in the first two to three years, such as the Awakening, Good Morning, Teacher, etc. received enthusiastic following and support by the people.

However, in recent years, the TV serials produced by SBC have moved towards the trend of excessive violence, sex and the propagation of wrong values. This may lead to negative influence on our society. My colleagues have mentioned many examples. For example, the Angels of Vengeance has too many scenes on violence. Even when it was telecast in Hong Kong it was criticised by people from all stations of life in Hong Kong. The serials Ninjas in Town and Heaven's Will propagate superstitions of demons, ghosts and monsters. When the popular serial The Unbeatables was screened, every Tom, Dick and Harry in town was talking about gambling. Even school children were imitating the gamblers' tricks.

Ironically, this year, which is designated the International Year of the Family, SBC has been screening the Bond of Love which seems to give its blessings on extra-marital affairs. Take a look at the weekend programmes on TV, you will find low quality, bad taste, nondescript horror movies or action films in which big time gangsters were featured as heroes. No doubt, we need to have some story lines and some scenes which could attract the attention of the people, but we should not be featuring all these gangsters and gamblers as the heroes in the films. So we should not have all these bad guys being featured as heroes. 2.00 pm

We understand that in the Western world some 20-30 years ago, their family concepts were also very conservative. But today, why is it that the moral standards in the West have gone to such a low state? There are so many single parent families in the West. And after one or two generations, they are beginning to accept free sex. Look at the West, there is such a big generation gap and members of the family could not get along with one another. The parents could not control their children.

I am very worried that sometimes our media will influence our moral standards in society. Of course, we cannot blame it on just one film or some scenes in a film. But if this is allowed to go on, even the moral standards of our adults will be changing. No doubt, there are incidents of violence or episodes of extra-martial activities happening in real life, but they do not happen every day. But if you look at the TV programmes, these things are shown almost every night. So our children will think that this is part of life and they will accept it.

Just a few days ago one of my parliamentary colleagues told me that his eight-year old daughter was watching a television programme and when the female character was pregnant against her wish, this eight-year old daughter spontaneously remarked, "Well, ask her to go for abortion." Just imagine, even an eight-year old girl thought that pregnancy is no big deal, she can just go for an abortion!

Many teenagers are watching all these movies which suggest free sex and all these undesirable activities. They are beginning to take this as part of life. So as parents, sometimes we feel that perhaps we are being too conservative. We cannot keep on telling our children not to watch the TV and say these are wrong moral standards, wrong values.

A few days ago, we read in the newspaper that two primary students were kissing each other. So the reporters interviewed the principal and the principal said, "Well, for young children, this is a process of growing up." As adults we have to lead them. Just when the family and the school are trying to lead the young people and teach them the right values, they have been watching TV and seeing all these undesirable activities being shown over and over again. There is a conflict between our teaching and the TV influence.

During the early part of the evening, I think we should screen more shows which are "clean" and which have good content. Even if SBC wants to have more revenue from commercials and they have to introduce some stories which feature gang fights and so on, I think they should be screened at the later part of the evening. As parents, I think we have to take a stand somewhere. In one of the recent TV serials ---

The Chairman: Mdm Foo, your 10 minutes are up. As we are running short of time on this amendment, can I urge the remaining Members to be brief? Otherwise we may not be able to have a reply from the Minister. Mr Zulkifli.

Mr Zulkifli bin Mohammed (Jalan Besar GRC): ( In Malay): Sir, the matter I wish to raise here concerns Malay television programmes on SBC 12. Generally, the feedback I have received so far indicates that the Malay community has adjusted to the switch from Channel 5 to Channel 12. Programmes such as Berita 12, Tinjauan, Sandiwara, Potret Keluarga and the Malay movies are well-received. We are also seeing innovation in programmes like Sandiwara with more outside scenes being shot thus making the programme more interesting. With regard to themes, it is comforting to note that relevant themes portraying values like family cohesiveness and community living are being chosen as story lines. May I commend SBC on these efforts.

However, there is still insufficient emphasis placed in nurturing and preserving our cultural heritage in our local cultural and entertainment programmes. Our local productions could do more to promote noble values through cultural or artistic programmes. I have in mind programmes like Kalong Senandong, which was popular in the sixties and seventies, and Kelab Dondang Sayang. Such programmes can make meaningful contributions to our nation's efforts to promote and preserve our cultural tradition and heritage.

I would therefore urge SBC to have more cultural and artistic programmes. I am sure the Malay community would welcome more of such programmes. Could the Minister give his comments, please?

Mr Choo Wee Khiang (Jalan Besar GRC): ( In Mandarin): Sir, yesterday Minister BG Yeo said that we have to learn from errors because this is the process of improvement. He urged Members to be more tolerant and allow SBC to learn from its experience.

I would like to ask the Minister: how many years has SBC been in existence? We have been in existence for more than 30 years. Have we not learnt from the experience over the last 30 years? I think SBC has been learning from the past and they do try to improve with what they have learnt.

He said that we have a Committee on TV Violence and even the Police is involved in this Committee. It sounds good. But it is reported that the Police has been watching the TV shows every day and giving their feedback. I am a member of the GPC for Home Affairs. Do the Police not have better things to do? The Police should be upholding law and order rather than watching TV all the time.

MITA itself should have enough people to tell SBC what is violent and what degree of violence is acceptable. The Minister gave an assurance that a new legislation will be passed to ensure that the Minister for Information and the Arts will have enough power to regulate the production of SBC programmes. I think we have to set a standard which has to be based on experience accumulated over the last 30 years. If the standard is good, we should adopt it.

When we play a game, we have to set the rules first, eg, what is the size of the court and what are the rules that have been practised, etc. We cannot let the player play the game without knowing the rules and say, "Now, you have run foul of the rules." We cannot do that. We have to set the standard first. We set the rules before the game is played.

Another point is that if you know that the "Ra Ra Show" is going to end up like that, why must you start it in the first place? The Minister should have told the producer of "Ra Ra Show" that he should play the game according to the rules. You should not just try out and when people criticise it, you stop it. If you cannot think of enough jokes to cater for the programme as often as it was shown, then you should reduce the frequency of the show.

Mr Chiam See Tong (Potong Pasir): Sir, radio and television are powerful mass media tools. Politicians and businessmen throughout the world have realised their immense importance as a means of persuasion. The PAP Government also realises that and keeps a tight control of radio and TV broadcasts. PAP Ministers' walkabouts and other PAP activities are widely broadcast, whereas Opposition's activities, which are of equal news-worthiness, are glaringly left out. That was particularly so of election activities. During election time, SBC always painstakingly set up their microphones and TV cameras with their glaring lights at each of my party's news conferences and public rallies. But none, or hardly any of those recorded materials, were broadcast. That shows the biased stand taken by SBC as regards local political matters.

SBC should also change its rules in regard to party political broadcasts during the elections. The rules made by SBC for party political broadcasts were too arbitrary and they disproportionately favoured the PAP and against the Opposition. The minimum time given was three minutes for eight candidates fielded. The PAP always fielded the full slate of 81 candidates. Consequently, they always got the maximum exposure over TV, whereas the Opposition parties put up only a small number and, as a result, they were either shut out or got only a minimum of three minutes exposure over TV which was really not enough.

SBC should form a well-represented committee, which should include Opposition members, to decide on the rules in regard to party political broadcasts to be used in the next and subsequent parliamentary elections. I would suggest that each party with a total of six candidates be given a minimum of five minutes of TV time for a start.

As for SBC TV programmes, generally, I enjoy watching Channel 12, and it must be commended for showing very interesting and high quality nature programmes like the one under the title of "Earthvisions".

What I find lacking is high quality talk shows. At the moment, SBC has one talk show - "Talking Point" - a half-hour programme at 8.00 pm on Wednesdays. It is more a feedback programme and does not have depth. I hope ---

The Chairman: Mr Chiam, I do not want to be like SBC, but we are running out of time.

Mr Chiam See Tong: Yes, I am finishing. I hope SBC can organise a good talk show, say, once a month. I am sure this is going to be good for Singapore as this will encourage people to think of issues and to speak up and not be afraid to express their points of view in public.

The Chairman: Mr Sinnakaruppan, can I request you just to make your point quickly, so that we have time for a reply?

Mr R. Sinnakaruppan (Kampong Glam GRC): ( In Tamil): Sir, the Indian community is endeavouring to preserve its traditions and ethos in the face of increasing western lifestyles in modern Singapore. However, some local drama presentations, with the support of the National Arts Council, and a few SBC programmes have made the community angry and disgusted. Therefore, the Ministry of Information and the Arts should ensure that these programmes do not go against the tone of the community and are of good quality.

Many Singapore Indians have expressed their surprise and concern over the non-inclusion of Tamil programmes in the recently launched Singapore International Radio and Television programmes. Tamil is one of the four official languages in multi-racial Singapore and there are a number of Tamils living abroad. The Ministry must take the necessary action to include some Tamil programmes so as to reflect fully the multi-cultural aspects of Singapore.

Next, I would like to touch on SBC TV programmes.

The Tamil News is telecast at 6.30 pm and this only provides an opportunity for a few to watch the news. In order for more people to watch and benefit, the news slot should be changed to either at 7.00 pm or 7.30 pm. Moreover, it is only a compilation of news for 20 minutes. Could SBC therefore revamp the news programme to 30 minutes and include business and share market reports?

The Minister for Defence (Dr Yeo Ning Hong): Sir, on a point of clarification. I believe Dr Ahmad Mattar had earlier on attributed some comments to me. I just want to clarify that I am not waiting for July to have my views on SBC made known to the Minister for Information and the Arts. As a Cabinet Minister, I have made known very clearly on numerous occasions my views on SBC, as I have made known my views on a whole range of issues in other Ministries. In Cabinet, we discuss issues very vigorously. We share our different points of view, but we must expect, after all the discussions, the Minister who is responsible for the portfolio to take the policy decisions. I just want to clarify that. 2.15 pm

The Minister for Information and the Arts (BG George Yong-Boon Yeo): Sir, I have listened to the comments of Members in this House very carefully. Some of the comments were painful to listen to, some I would not pay serious attention to because they were exaggerated, a few are unfair but, by and large, they expressed a point of view which I, MITA and SBC have to take very seriously.

Television goes into every household. It affects all of us. All of us want it to be the perfect medium. Every Minister, every Member of Parliament, every parent, everyone wants access for himself. SBC may enjoy some monopoly power at this stage, but it is in a very difficult position to try to satisfy everyone. It is simply not possible. Yes, from time to time, they make mistakes, but they have also done many good things which, fairly, we should also recognise. Let me take a few general points, as I fear I may not have enough time to answer every Member of Parliament personally.

On the point of realism, comments have been made that there are too many love triangles, too much infidelity on television, violence, gambling, superstition, and so on and so forth, and there were calls that SBC should produce wholesome Pollyana-type shows. I do not think that is a right approach. Many of us have read Shakespeare, or the Mahabharata, or the Iliad and the Odyssey, or hong lou meng ( ). They cover all dimensions of the human experience - love, hatred, jealousy, anger, murder, incest, the lot. Does anyone here question that there is deep moral purpose in these epic stories? Indeed, for moral points to be made in any story, you have to show the different aspects of the human condition.

In our society, we like gambling. Golfers, if they do not gamble, cannot play properly. Prisoners, when they are in prison, with nothing better else to do, bet which lizard will cross the wall first, and so on. If you read history books about the Chinese in China, 200-300 years ago, about the Chinese in Jakarta, the same problem. I have long come to the conclusion that it is an inseparable part of the culture. Yes, it is a bad thing. I myself come from a family where weekends were spent on horse-racing and I know the stresses involved. But you cannot blinker your eyes and pretend that these things do not happen in society. And good dramas, if they are to drive moral points home, have to reflect some of these goings-on. Otherwise, they are too plastic, too polished for people to be able to enjoy and be immersed in them. Good drama should move us, should sometimes shock us. But at the end of the day, it must point us in the right direction. And this, SBC has always done. At the end of the day, the people who win, who triumph, are the good people and evil in the end gets discovered. But, of course, we must not be so presumptuous as to compare our producers in SBC to Shakespeare, or to Cao Xueqing.

The problem in SBC today is a lack of talent. We are a small population and we are producing programmes in four languages. It is not easy. Even in Hong Kong, Cantonese-speaking population, Cantonese production, they have problems. Malaysia has problems. Indonesia has problems. Even India with such a plethora of talent has a lot of problems. SBC is trying to make the best out of a very difficult situation. We need public funding, yes. But I think the greatest impediment to better production is talent. And this is why we have been importing talent from all over, in particular, from Hong Kong. Without producers like Jiang Long and others, we could not have gotten to where we are today. And they have done very good work, almost all of them have become Singaporeans. Their families are here and their children are here. They are committed, they have decided to burn their bridges to Hong Kong, to upstake and to root themselves in Singapore. They have an interest in keeping Singapore wholesome too. But yes, there will be cultural differences and I agree with some of the comments made by MPs that we should have a system in SBC to point them in the right direction, to induct them in, train them and acculturate them. And I will do this.

In fact, about a month ago, I discussed with Dr Ker Sin Tze the idea of setting up a committee to help guide Chinese drama productions so that the local setting is well done and we try to uplift its quality. But let me repeat myself that if we are to be good in drama, we have to be realistic. We cannot hide ourselves from some of the seedier, sleazier aspects of life. This is what good drama is all about.

On news and current affairs, in fact, SBC has made a lot of progress. Current affairs, like Tinjauan, xin qi er te xie ( ) and Money Mind, they were monthly, then they became fortnightly, now they are weekly and they enjoy very high ratings. Someone asked whether the ratings are done by SBC in-house or done by a third party. They are done by a third party. They are done by Neilsen and Neilsen's results are studied by advertisers, and a few points difference in America means tens of millions of dollars. I do not doubt the objectivity of Neilsen. If they start fiddling with the results, then their reputation is at stake and they are finished. I accept Neilsen's ratings as being objective, and we should.

Every time we change programming, there is bound to be an uproar. Mr Teo Chong Tee asked about English news. When we moved the English news from 9.00 o'clock to 10.30 pm, there was an uproar. So those people whose personal time-tables were upset jumped up and down, and some of our MPs also jumped up and down along with them. But what do the results show? The results show that the viewership on the English news at 10.30 pm is about the same as 9.00 o'clock news, about 130,000 to 140,000. But, in addition now, we have another 80,000-90,000 Singaporeans watching the 7.00 o'clock news and there are only about 12,000 overlap between the two news programmes. And those of us who listen to radio will also know that radio is now carrying a lot of news programmes. So all these are the things which SBC has done. It is not possible for SBC to please everyone all the time because everyone watches the same product, everyone has his own perspective, even within the family, different family members have different views.

Dr Ahmad Mattar talked about video clips being off-putting to him. But there is some clamour among young people for MTV. SBC discussed whether MTV should be brought into Singapore and they decided against it because if you have seen MTV in Europe, America and on Star Television, you know that a lot of it is lewd and overly sexy. So SBC, with my concurrence and support, decided to keep out MTV. Some of the video clips that we brought in are those which are more permissible.

Mr Goh Choon Kang: Sir, I have a lot of sympathies for SBC. As the Chinese saying goes shun de ge qing shi sao yi ( ), I think it is very difficult. But SBC is not just a broadcasting station, it is also a listening station, and it will take all constructive criticisms in the right attitude. And with that, I withdraw my amendment.

Amendment, by leave, withdrawn.

The sum of $103,596,600 for Head R ordered to stand part of the Main Estimates.

The sum of $77,553,600 for Head R ordered to stand part of the Development Estimates.

Head P -

The Chairman: Head P - Ministry of Health. Amendment No. (1), Mr Loh Meng See.

Mr Loh Meng See (Kampong Glam GRC): Sir, I beg to move,

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

Sir, the Government has emphasised on personal responsibility in the health care of the individual. The average Singaporean understands the need to look after himself or herself and will readily accept this personal responsibility. The main concern among Singaporeans is in the case when he cannot fend for himself when he is stricken with an unexpected major illness. Who then can he turn to?

We have said that it should be the family. Yes, the family, Medisave. But do we, as a community, allow it to stop there if the need remains?

I am glad that the Government, as an employer, has undertaken to render assistance to the civil servants when the medical need arises. When a civil servant is afflicted with a serious illness and faced with a hefty medical bill, he can approach the Government for help.

I think that is a good development because, with this arrangement, the worry in the minds of the civil servants has been put to rest. I would say that, in this instance, the civil service is acting on behalf of the collective body of employees to pool the resources together to help one of the colleagues when he is in desperate need of financial help and support.

This cooperative spirit among colleagues in the workplace is much needed to provide the support system as it could happen to any one in the workplace. It gives the staff a peace of mind in the knowledge that help is available when needed.

At the national level, I welcome the role played by NTUC Income, the only insurance cooperative in Singapore. They are already making an impact by providing medical insurance for the civil servants. As a cooperative, it deserves the whole-hearted support of all Singaporeans. It is the collective spirit that I am trying to drive at because, collectively, we can help our fellow citizens with the contribution to the medical insurance premium to be paid, and we hope that we do not make such claims because it means that we are healthy, and the money that we have contributed is put to good use to help others in need. 2.30 pm

To encourage this strong sense of solidarity among Singaporeans, I would urge the Government to use the MediShield and Medifund schemes wisely to develop the national spirit among Singaporeans. The MediShield and Medifund must be the safety net to assure our citizens that they shall have no fear when they are gravely ill. Perhaps the Minister can tell this House how MediShield and Medifund have helped Singaporeans in need to-date.

Dr Wan Soon Bee (Brickworks GRC): Sir, we have in place an excellent and efficient system of health care for all Singaporeans. Our restructured and Government hospital services are among the finest in the world. Health care costs have been kept low and, therefore, affordable for most Singaporeans, because we have adopted a co-payment system. The co-payment system helps to eliminate the wastage and abuses which are endemic in systems where health care is provided free to citizens. Therefore, the concept of shared responsibility for health care between the citizen and the state is a good one, and I fully support it.

At the same time, however, we must be vigilant and ensure that the individual citizen is never asked to carry an unnecessarily large financial burden for essential health care. I am gravely concerned that our people may be asked to bear too much of the responsibility for health care in our zeal to contain costs. Many citizens may find the burden too great to bear. The young, the healthy and those in the higher income bracket will probably face few problems. The old, the sick and the poor, on the other hand, may be tremendously disadvantaged if the burden on them is excessive, thus causing them severe financial difficulties. It is not just a question of added expenses for these latter groups. The unfortunate truth is that they would probably have to sacrifice many things in life in order to pay for health care, things which the rest of us take for granted.

Sir, while it is true that we have schemes like Medisave, MediShield and now Medifund to ensure that Singaporeans are able to afford what they consume in the unfortunate event of a prolonged illness, we must nevertheless face the fact that there will always be a significant group of Singaporeans who will find basic health care to be not affordable.

Over the years, the Government has gradually shifted more of the financial responsibility to individual citizen. I worry whether we have gone a bit too far. Would the Minister tell the House what the Government's future plans are in this area? Is the Government planning to shift a greater proportion of the financial burden to the people? If that is the case, then I ask the Government to show compassion and give special consideration to the old, the chronically ill and the poor. Please ensure that whatever policies are implemented in the future will not make their lives more difficult than they already are.

On a different note, I should like to point out that while I agree that the provision of health care is vital, we should not under-estimate the importance of preventive medicine. Our policies on health care would not be complete without the correct policy to encourage Singaporeans to be a healthy nation. I would strenuously urge the Government to give utmost importance to this area and to do even more to promote a healthy nation.

Sir, I should like to point out that we are on the threshold of the 21st century and that the problems which the health care system will face in the future are likely to be different from those faced by it in the past. For one thing, Singapore's demographic profile is changing, with the population aging at a greater speed than in other countries. By the year 2030, approximately 250,000 Singaporeans will be over the age of 75. This group of citizens will need much more medical care. The health care system will be facing major geriatric medical needs for the first time. Is it prepared for this new situation? The elderly will have smaller Medisave accounts than younger citizens while their medical needs will be greater. Will their accounts be sufficient, bearing in mind that they are not protected by MediShield and MediShield Plus? These are important questions which we must consider now and they call for a more creative approach to meeting the medical needs of our country in the 21st century.

Finally, while I support the Government's position on discouraging an abuse of the health care system, I should nonetheless like to point out that there are some instances where the question of abuse is irrelevant. This is in cases where the patient is chronically or terminally ill. Patients who are suffering, eg, from cancer, heart disease, kidney disease or stroke, to name but a few, in these cases, I would strongly urge the Government to reduce to a minimum the deductibles under MediShield and MediShield Plus or, better still, to eliminate them entirely.

Sir, I have highlighted but a few of the challenges which are likely to face us in the future. I am afraid that an aging population will see more and more people not being able to pay their medical bills despite all the present safety nets. More claims are likely to be made against the $200 million Medifund. The Medifund may not even be able to meet the growing demand. Sir, while the health care system in place now is excellent, will it be able to grow and change in order to meet the future challenges that I have spoken of? Given the added needs of a greying population, what plans does the Government have to meet these new challenges?

Dr Arthur Beng Kian Lam (Bedok GRC): Sir, first, I wish to declare my interest in that I am a GP in private practice.

When the new health care co-payment policy was announced, many civil servants were upset. Why were they upset? Largely, they were upset because they were totally unprepared for it. Although reassured that the pay rise given would more than offset the co-payments, many were sceptical. Now, with some modifications, further reassurances, and the intervention of the Prime Minister himself, allowing for pre-existing serious illnesses to be exempted from the co-payment scheme, the scheme becomes more acceptable.

I know that this subject falls under the purview of the Ministry of Finance, but I choose to bring this subject up under the Ministry of Health because I feel that the capitation of $350 per annum under Option C regardless of age is not the best way to allocate limited funds. I hope to convince the Minister for Health so that he may convince the Cabinet. All of us know that apart from a few unfortunate exceptions when the young are afflicted by chronic or fatal disease or injuries, it is the older age groups that are the heavy health care consumers. They are the ones who spend most on health.

At the Budget debate, I have put forward the rationale for this. I believe that it bears repeating. Many of the chronic degenerative illnesses, if detected and treated early, will prevent more severe complications. For example, good management of diabetes, when detected in the 40s, will prevent severe complications such as blindness and amputation of limbs later in life. Management of cardiac risk factors such as high cholesterol will prevent coronary heart disease and avert costly cardiac surgery. To provide for a higher capitation for those above 35 years is sensible and scientific. The scale should start from the region of $200-$250 per annum for those in the 20s, rising to approximately $1,000 per annum for those in the 50s and 60s. This is also in line with the concept espoused by the GPC Chairman, Mr Loh Meng See, of being collectively responsible. Let us spend this money that we want to spend for health care in the best way. It is the more senior of our citizens who will incur a higher health bill. Many will have multiple illnesses. As we do not want them to be hospitalised - a costly affair to both the individual and the State - outpatient care should be encouraged. Therefore, the capitation for outpatient care should be rationally reviewed. I hope that the Ministry of Health will make a study of this and present these statistics to convince the Cabinet.

Sir, on the topic of managed health care, the concept of managed health care is relatively new to Singapore. This is a system whereby a person is charged a certain fixed sum per annum for medical care in contrast to a fee-for-service system. Much more needs to be done so that employers, employees, the unions and the medical profession all understand the advantages and disadvantages of this system. The main aim in this exercise is to reduce wastage and abuse - wastage in terms of manpower, eg, unnecessary specialist referral or hospitalisation; wastage in terms of unnecessary consultations and expensive medications and procedures. This will require a major education exercise to educate employers, patients or employees and doctors.

The patient-doctor relationship must be enhanced if this is to succeed and not result in more expensive health care because of medico-legal suits and legal expenses. The Medical Council needs to give guidelines regarding acceptable forms of information dissemination if doctors are to make presentations to employers, so that they in turn can make informed choices on behalf of their employees. The employer then in turn needs to explain and discuss this with the unions and the staff. The doctors must also be able to have direct access to the patients to inform them regarding the packages available. Only after being well informed, will the patient or employer be able to get the best value for money spent. Will this be regarded as advertising?

Managed health care has come by swiftly. It may be a good alternative. However, to succeed, I reiterate, a sound doctor-patient relationship is fundamental. Will the Ministry mount an education campaign to explain to the public the advantages and disadvantages of these new changes? The medical profession and professional bodies must, of course, also do their part.

Dr Toh Keng Kiat (Nominated Member): Sir, I would like to declare my interest as a specialist in private practice.

Health care has been very much debated in and out of this House recently, particularly cost of health care. Singaporeans, as a rule, pay very little for the quality of the care that they have been receiving. The right to health care and the question of who pays for it is a very emotive issue. And I would like to quote from a book, The Limits to Medicine, by Ivan Illich for he seems to have put the subject into very good perspective. He has written and I quote:

'Either society must choose the same stringent limits or the kind of goods produced within which all its members may find guarantee for equal freedom, or society must accept unprecedented hierarchical controls to provide for each member what welfare bureaucracies diagnose as his or her needs.'

Singaporeans have made a choice. Out of the debate on health care, our consensus is that we should restrict health service to a basic package. On top of it, we should restrict excessive and unnecessary consumption of this by keeping cost low. The Government has proposed a set of measures to contain cost. Some of these are already operative, others will be implemented in time to come. It is on the implementation details of some of these that I seek clarification from the Minister. 2.45 pm

First, subsidies. The Government has set up long term subsidy targets for different ward classes in order to keep health care cost down. Put in another way, it is the same as the co-payment that Dr Wan Soon Bee has spoken about. My question to the Minister is: how far have we gone in this cost-recovery exercise? Have we reached completion in the recovery of cost from those who can afford it? My interpretation from newspaper reports is that we have not.

I have here an article which appeared on 22nd May, 1992, in Business Times announcing increases in ward charges for different Government and restructured hospitals. We were told that for Government hospitals, for A class, the price increase has gone up $30 from $165 to $195, and for SGH A class, either from $220 to $250 or $240 to $270. But what is more interesting is the graphic illustration which shows that even after the increases, the subsidy remains high. For A class, it was quoted as 23%. A year later to the day, this time in the Straits Times on 22nd May 1993, a second fee increase was announced. For the Government hospitals, the price increase for A class went up from $195 to $225. As for SGH, it is written here as no change. I want to quote from paragraph 7 of this article: "However, the SGH will not revise its class A1 ward charge."

Sir, if a subsidy of 23% existed in 1992 and charges have not been revised, I would have expected that the subsidy continues, in fact, it should increase, taking into consideration the normal increase in labour and other costs. The question is: why should we, using a public hospital, continue to provide private facilities to those who can afford it? I hope this courtesy will not be extended to the A class patients when GST is introduced next month.

Sir, I come next to the other cost containing measure, which is the control of the number of doctors. It has been stated time and again that the surplus of doctors will lead to increased costs on the debatable assumption that a surplus will result in profit-driven demand. To solve this problem, the Medical Council recommended that the number of doctors to meet our needs into the next century will be about 180 per year - 150 to be trained in NUS and 30 from universities abroad.

Sir, two scenarios may arise out of this. First of all, we may end up with having to exclude people who have studied in approved universities abroad, as the Council has stated that it will not register beyond 30 foreign graduates each year. This is, of course, the unlikely scenario as the 28 approved universities in the revised schedules are the toughest in the world and I doubt many Singaporeans, as historically has been shown, will make the grade to enter some of these universities. The opposite scenario may present, which is that over the years it will end up with a shortage of doctors because I envisage that less than 30 will be able to come back from these universities. If so, how are we going to meet the shortfall? The obvious answer would be to recruit foreign graduates and in keeping with our opinion that only those from the 28 universities should be allowed to practise here, then they must come from these universities.

Coming back to the question of surpluses, in any one year if there is a good cohort and more than 30 from these 28 universities return, what yardstick would the Government employ to weed out the excesses? My proposal to solve this problem is that we resort to a kind of licensing examination. By doing so, we will be able to allow more people to study in more than the 28 universities around the world. This will also fine-tune our doctor demand and supply equation and allow us a quick response in any one year where there is a shortage or a surplus. The number that we require per year should be the cut-off point. In a year of shortage, the NUS cannot suddenly produce more doctors because there is no reserve team of medical students who can be quickly put through an accelerated modular course to be trained as doctors. The Australians have practised this. They have a qualifying examination run by the Australian Medical Examination Council (AMEC). All who graduated from foreign universities, including Australians themselves, have to undergo this examination. I am told that the pass rate is about 15% per year.

I now come next to the use of Medisave in the private sector. During the debate on the White Paper, the Government has intimated that they will control the use of Medisave in the private sector by not allowing balance billing. The former Minister for Health has indicated that the details of this implementation would be let known this year. May I ask his successor in the Ministry whether this has already been done and, if not, when? I have brought up during last year's debate that problems may arise when we have multi-disciplinary care of the same patient or when the same doctor has made repeated attendances on a very ill patient within a 24-hour period. Let me illustrate. Some time ago, I was approached by a member of the public and was told that a patient admitted to the NUH ICU for one day had a bill of more than $20,000. I did not believe my ears but I have to believe my eyes when I saw this. I have here with me a copy of this bill. I am here not to debate or to question the items or the expenses, but I want to use this to illustrate the problems of limitation of balance billing.

The Chairman: Order. Dr Toh, you have used up your time.

Dr Michael Lim Chun Leng (Cheng San GRC): Sir, health care cost will always be an issue of public concern. It is inevitable that as we continually maintain a high quality of health care, cost will continue to increase. Health care today is obviously markedly different from the health care of yesteryears. Health care today is more definitive, more sophisticated and more effective. The cost of health care in hospitals has risen more rapidly because Singaporeans are no longer choosing the same old service, but a more effective and more expensive service. The rapid rise in hospital cost is not a result of the price inflation but it represents an increase in the quality and quantity of health care services. Health care containment requires a two-pronged approach, both patient education and cost containment in the health services.

Singaporeans today must be educated on this fact of life. If they want a better quality of care, they must expect an increase in health care cost. The Ministry has always maintained that consumers do not have enough knowledge in health care. It should perhaps take the lead in educating the lay public. I would recommend that the Ministry of Health educate Singaporeans about health care cost through the following:

(1) Educational videos on health care cost that can be screened in hospital waiting areas or distributed to community organisations.

An example would be a video that would portray a scene such as this: Scene One, Mr Tan walks into the consultation room, 1960. He is told by a grim-faced doctor that he has kidney failure and there is no treatment option. Six months later, you see an obituary on Mr Tan. Scene Two, you see Mr Chan walking into a hospital, 1994. Told the same diagnosis by a grim-faced doctor, but the doctor comforts him. Tells him not to worry. We can put you on a dialysis programme. Not only that, we can improve your quality of life by giving you an expensive drug called erythropoietin which will increase your blood cells and so on and so forth. We can even put you on a transplantation programme. So Mr Chan goes away happy. His quality of life is improved. His lifespan is also increased. But all these come with a price. A significant increase in health care cost. I think our Singaporeans must be educated that if they want a better quality of life, it is inevitable that cost will increase.

(2) Health care cost guide.

I think the Ministry should compile a health care cost guide and this should list the cost of consultations, bed charges, commonly utilised diagnostic services, therapeutic services and surgeries in all Government and restructured hospitals. There should also be simple examples to illustrate what are the different components in a hospitalisation bill. This should be updated when there is a major revision in the charges.

On the other hand, the Ministry should continue to contain cost in the hospitals in the following areas:

(1) Specialised medical institutions.

We already have a National Eye Centre, National Skin Centre, National Blood Centre and there will be Heart Centre, Oncology Centre, Neuro-Science Centre. Will these centres help to contain health care cost? Will they prevent the duplication of services? Will the development of a Neuro-Science Centre stop the duplication of expensive equipment and services in the Neurology Department in the Singapore General Hospital, one of the premier hospitals? With the Neuro-Science Centre in Tan Tock Seng Hospital, will there be another MRI machine in Tan Tock Seng Hospital? With the Heart Centre in SGH, does it mean that expensive cardiac catherisation laboratories will not be built in other HCS or Government Hospitals? I think the Ministry has to prove to taxpayers that the setting up of these centres is the best way to dispense health care without unnecessarily raising health cost.

(2) Hospital buildings.

The hospitals that are built should be modern and presentable but should they look like five-star hotels? Recently, my CCC Chairman told me that at a queue at the ROV which was being renovated, people lining up for the COEs made the following comment: he point nga nga kar, tsi point nga nga siew. This is in Teochew. Translated in English, what he meant was: There they were knocking and renovating the building, and here they were collecting fees from us. So similar comments have been applied to some of our hospitals. The Ministry should not ignore the perceptions of people who think that health care cost has increased as a result of unnecessary expenditure in making the hospitals look like five-star hotels.

(3) New expensive high technology equipment.

The Ministry should also audit the use of any expensive high technology equipment to ensure that it is not unnecessarily used. For example, is there any audit on the use of the MRI scan? Perhaps the Ministry should look at the last 500 MRI scans in both SGH and NUH and check whether they made a difference to the clinical decisions and whether the patient had other tests as well that gave the same information. Increasingly, if the Ministry were to contain costs in hospitals, there will be a need to have clinical audit where cost is high.

Lastly, ICU care. The highest cost that can be incurred for many patients is in the Intensive Care Unit. Is there any audit to ensure that ICU services are utilised appropriately? At the end of the day, when our loved one is ill, most, if not all of us, will want the best of care for them. The Ministry has the responsibility to educate Singaporeans to have a realistic expectation of health care cost and to continually strive to provide high quality yet affordable medical care.

Dr John Chen Seow Phun (Hong Kah GRC): Government, employers and workers are all concerned about rising health care costs. Government believes that health care is a case of market failure. That is why the White Paper on Affordable Health Care has proposed measures to control both the supply and demand of health care services.

On the supply side, Government will control the supply of doctors, regulate key areas of pricing and operations of subvented hospitals, and control charges on private sector Medisave patients. On the demand side, Government has taken the lead to emphasize personal responsibility by way of co-payment among the civil servants to moderate demand. It has also capped the tax deductibility of medical expenses by companies, and will be regulating medical insurance. 3.00 pm

Long before the White Paper was published, the NTUC was already studying how the labour movement can provide workers with a comprehensive health care scheme and, at the same time, minimise increases in health care costs. We found the Managed Healthcare System (MHS), originated in the United States, attractive, and have modified the system to suit our needs. Many US health maintenance organisations have adopted the MHS. They have been able to reduce substantially the health care expenditure of their members.

Sir, under the present system in Singapore, doctors are paid a fee for their service. The patient, if he is employed, usually claims his expenses from his employer. Alternatively, doctors bill employers directly. Under these circumstances, doctors need not be cost conscious and they have no incentive to provide the most cost effective care. Patients, on the other hand, can and do, for various reasons, doctor-hop. Sometimes, they go direct to the specialist which may not be necessary. The results of all these are that wastages in terms of over-treatment and unnecessary visits to doctors can and do occur.

However, if doctors are given a reasonable budget on a capitation basis to look after a group of patients under him, ie, they manage the patients within an agreed budget and therefore take certain financial risks upon themselves, they are likely to be cost conscious and minimise wastage. At the same time, if we can make a patient choose one doctor and always go to him under normal circumstances, then we can also promote the family doctor concept and thus provide better care more efficiently.

Sir, the MHS plan which NTUC is working on is based on the principles I have just described. For a premium, depending on age, MHS will provide a comprehensive range of health care, from primary to specialist and hospital care. Physicians providing primary care will be paid on a capitation basis. They will also be given financial incentives to serve as "gatekeepers" under a referral system to keep out unnecessary specialist and hospital treatments. To encourage personal responsibility in line with the White Paper on Affordable Health Care, MHS members will be required to make a co-payment for outpatient care. There will also be a small co-insurance for hospital care which can be met by Medisave or even MediShield. To help members meet the co-payment for outpatient care, each member will be given an annual credit which can be used for their co-payment. This is also to encourage members to stay healthy so that they can keep the balance if the credit is not used up.

At present, workers are worried that once they retire and no longer enjoy their employer medical benefits, they will be left without medical coverage, especially if they have an existing illness. To address this concern, MHS will allow members to stay in the plan by paying the premiums on their own after they retire from work. This, we believe, will be a very attractive feature for workers.

Sir, those who are sceptical of MHS have two main reservations. First, they feel that MHS works well in the US because health care expenditure there is so high that it becomes worthwhile for MHS to operate. They feel that MHS may not be necessary here because of our low health care expenditure and the competitive environment at the primary care level. They fear that whatever MHS saves, it may have to give back to the administrative costs it incurs. Second, they feel that under MHS, quality of care may suffer if doctors are too cost conscious.

I understand those concerns. But my answer to the first reservation is that health care costs are rising and MHS can help to slow down the pace. We have to start early and we will see more and more benefits as we go along. Besides, if we look at our present health care expenditure pattern, on the average and on an annualised basis, a person incurs about two to three times as much on outpatient expenses compared to his hospital expenses. I believe, therefore, there is room for improvement even at the outpatient level.

On the concern about quality, I believe most doctors will not be found wanting in delivering to patients whatever care necessary. MHS will cause them to be conscious about delivering the most appropriate level of care at the least costs. Notwithstanding this, MHS will monitor the utilisation of medical care and treatment outcomes to provide quality assurance.

Sir, NTUC is trying to provide through MHS another approach within our national health care delivery system to help curb rising health care costs. It is an uphill task because it requires people to understand and accept the new system. It is therefore very important for us to receive support from employers, unions and, not least, Government. Government can support MHS by allowing members of MHS to draw on Medisave to pay for the premiums. This will also be a strong signal from the Government that it is willing to give MHS a try. May I ask the Minister whether MHS will have his support.

Dr Arthur Beng Kian Lam: Sir, I would like to speak on the topic of optimisation of use of specialists.

Sir, it is very costly to train specialists. It takes 10 to 12 years to train a specialist. To optimise their use, whether they are in Government, restructured hospitals or in private practice, is for national gain. Time and again, we hear of unacceptably long waiting time in especially the Specialists' Outpatient Clinics in restructured hospitals. This is an indication of their success, and the trust they have gained from the public. I congratulate them on this.

One other major reason for this is that many major organisations only allow their employees to be seen in the Government or restructured hospitals for a myriad of reasons. Will the Ministry of Health consider using private specialists to man the Specialists' Outpatient Clinics in HCS hospitals to relieve the very heavy workload in these clinics and to provide better services to these patients? These specialists could be paid either on a sessional or hourly rate. This scheme may be attractive to the private specialists as it allows them to keep in touch with the wide range of cases seen in Government or restructured hospitals. I am suggesting this apart from the visiting consultant scheme which is for the elite in the private sector. I believe this scheme would be mutually beneficial and that especially the younger or new specialists in private practice may be interested in this scheme.

Sir, many large organisations prefer their employees to be admitted to Government or restructured hospitals. However, there are times when the patient would like to be under the care of a specialist in private practice. As the workload on the specialists in these hospitals is already very heavy, will the Government not consider also allowing the private specialist admission rights and the right to practise in Government or restructured hospitals on an agreed upon fee scheme to the mutual benefit of all concerned? If we consider that other Government institutions are making use of private sector services to relieve their workload, there is no reason why the medical profession should not learn from them likewise. I agree and understand that patient care is not the same as architectural or accountancy services being "farmed-out" to the private sector, but surely the administrative procedures and the professional lines of responsibility can be worked out. I am again making this suggestion apart from the visiting consultant scheme. Will the Minister consider this scheme?

Likewise, for the specialists in Government or restructured hospitals, the Government may want to consider allowing them limited hours of private practice in private hospitals per week. This would allow for a sharing of skills and better interaction between the two sectors. I do not see the logic whereby we have to import an overseas specialist when local talent is available and could be given his due recognition. Will the Minister please comment?

Dr Michael Lim Chun Leng: Sir, pragmatic reappraisal of the health care delivery system is inevitable, as it is constantly exposed to the ebb and flow of economic tides and the unpredictable march of modern medical science.

What directions should we take? Every system has its strengths and weaknesses. In a fee-for-service scheme, an impressive array of modern medical treatment methods is often readily available. Medical research and innovation blossom in this system. However, its strength is also its weakness, as it encourages the doctors to give the maximum amount of care possible, thereby increasing the number of services offered and raising health costs. At the other extreme, it is the full-time salaried system. The main drawback to this system is the disincentive to go the extra mile or, worse still, to work. In Singapore, we have our own unique system which has positive features of both systems. Of late, there is a move to introduce yet another system into the Singapore health care scene to contain health cost, that is, managed health care.

Principles of managed health care

This has been elaborated by my parliamentary colleague earlier on. But the managed health care system is basically based on the belief that financial incentives are instrumental in influencing the behaviour of patients, health care providers and payers when they seek, provide or finance medical care. Medical treatment is considered as a cost in this system which is subject to a capitation of expenses. Primary health care doctors are given a fixed budget per patient and any investigation or referral to a specialist will result in a reduction in the budget. Essentially, primary health care doctors are used as the gatekeepers to specialist treatment in this system.

Proponents of the system say that the main benefits of this system are lower health cost, less investigations and less referrals. They argue that the system will provide an acceptable quality of health care and yet contain health care costs.

Primary health care in Singapore

Our primary health care system is in many ways different from the USA or many of the Western countries. In these countries, the family practitioners are widely dispersed so that there is little competition between family practitioners. In Singapore, the population is densely concentrated in housing estates where General Practitioners abound. The sheer number of clinics within a stone's throw of each other ensures that the medical fees charged are competitive, reasonable and affordable. To many Singaporeans, their family doctors are more than health professionals, they are also counsellors and friends. This doctor-patient relationship profoundly affects compliance, drop-out rates, investigation rates and referral rates. There is no evidence that our family doctors generally tend to overcharge, over-investigate or refer excessively. This is an area where the free market has kept primary health care affordable.

Opposing views

Opponents of the managed health care system question whether the professional services of our health care system should be replaced with a public health care business, a managed health care system. Both professionals and managerial expertise are required for both services but professional skills are more important in service whereas managerial skills are more important in a business. Opponents ask: Is managerial capability and efficiency more important in health care than the dedication of doctors, nurses and other health care workers? The basic motivation in managed care is to provide the least acceptable amount of care. Innovation in such a system focuses on improving administrative processes.

There is a fine balance between the quality of care and the cost of medical services. If family doctors are forced to make health cost reduction their primary priority, they will be limited in the quality of treatment that they can administer.

Opponents of the system offer the following views:

(1) Instead of just paying fees directly to the doctors, the patient will also have to contribute towards two other beneficiaries in this system, that is, the insurance companies and the administrators that manage health care groups.

(2) In a cost-effective system, the managed care system by further reducing costs may result in a compromise in the quality of care.

(3) The system encourages the provision of the least acceptable amount of care and hence also discourages investigations and referrals to specialists. Every consultation, medication, investigation and referral is considered a cost that should be reduced. Worse still, doctors may be forced to collude with the aims of administrative systems whose primary aim is to ration services to a minimum. 3.15 pm

(4) The close doctor-patient relationship may be substituted by contracts. Medical professionals may be forced to become self-serving entrepreneurs. The damage it will do to the doctor-patient relationship may be irreparable.

(5) The end product will be more process, not better health outcomes.

There are merits and demerits of any health care delivery system. In Singapore, we have always managed to glean the best from each system and formulate our own system. Despite the weaknesses in the managed care system, it has its merits. I am glad to say that the administrators, whom I know personally, who are involved in formulating the details of this system have the best of intentions. However, they will have to modify the system considerably to overcome the concerns of those who fear that the eventual outcome of such a system may be worse than the current system.

The important changes in the health care scene such as this will definitely merit the attention of the Minister for Health. Perhaps, the Minister will enlighten us on the Ministry's viewpoint on the Managed Healthcare System.

Mr Loh Meng See: Sir, the restructuring of hospitals is intended to give autonomy to management to run the Government hospitals efficiently. There is a very big difference between autonomy and independence. Our restructured hospitals should remain autonomous and not become independent.

As the medical care sector is a case of market failure, we have to be careful when the restructured hospitals are asked to compete against the private hospitals and even among restructured hospitals. The quality of service may suffer in the process. I wish to see more cooperation and sharing of resources and facilities among restructured hospitals.

We have to examine the possibility of centralising the employment of key medical personnel and in the bulk purchase of commonly used items and equipment to enjoy economies of scale. The centralised pooling of resources, for example, the employment of selected key personnel will allow the ease of redeployment among all restructured hospitals owned by the Health Corporation of Singapore, provide career advancement opportunities and the retention of very good officers in our hospitals.

The restructured hospitals must be given every incentive to reduce wastages and be allowed to retain the savings from increased productivity and efficiency. The accumulated funds can be used in programmes where the hospital board can decide for itself the programmes it wishes to support. May I know from the Minister how the restructured hospitals can improve further in their performance for the benefit of all Singaporeans?

Dr S. Vasoo (Tanjong Pagar GRC): Sir, thank you for allowing me to join in the debate. The tempo of restructuring hospitals has been quick in the last eight years, leaving behind very little time for the consumers to take a breather and also leaving the consumers with little choice. We have restructured almost all Government hospitals. There are only two Government hospitals left and they are Alexandra Hospital and Changi Hospital. These two hospitals are rather antiquated. If you look at these hospitals, they are at the bottom of the heap. I feel that the facilities of these two hospitals are rather limited and they do not have equivalent good facilities, like what you have in the Government restructured hospitals. There are also inadequate specialists in these hospitals. And, therefore, these two hospitals, the remaining last two Mohicans, among the other hospitals, should be given better attention so that the consumers will have a choice. There should be a good Government hospital. I hope that the Eastern General Hospital, which is being planned, would be left as a Government hospital to compete equally with the restructured hospitals so that one would be able to say whether the Government hospitals can compete equally with the restructured hospitals.

Sir, the other concern that consumers have is that a lot of resources have been pumped into the restructured hospitals. You have expensive buildings and, sometimes, many of these buildings are overbearing that the consumers really feel uncomfortable or out of place when using some of these facilities. What I think is important is whether the consumers are paying the cost for this. And would the Minister tell the House whether part of the bill in which the patients are paying bears the cost for all these expenses that are put in? Or are these costs, in terms of building and hardware, written off partly and not imputed in the medical costs? If they are imputed, then I am most concerned about it. We should maintain a sensible balance in terms of expenditure in these areas. I know that Kandang Kerbau Hospital and Tan Tock Seng Hospital have already been restructured and there must have been tremendous building expenses, decor and other things being put in. I hope that a sense of balance is maintained, in terms of expenditure in these areas, so that the consumers, ultimately, need not have to bear the cost for all these expenses that have been put in.

Mr Lau Ping Sum (Ang Mo Kio GRC): Sir, with the completion of the Ang Mo Kio Community Hospital last year, the concept of providing a relatively low cost hospital near the community has come to fruition. Grassroots leaders who were invited to view the hospital came away highly impressed. They were impressed by the beautiful facade of the hospital, the excellent quality of the finish and the interior decor of the hospital.

However, they also expressed a concern that the Community Hospital may not be so low cost after all, and this perception may be brought about by two factors. First, we always emphasise the point that the consumer must pay. The payment must be made at the point of consumption. So ultimately, the consumer, in this case the patient, must pay a certain portion of the cost of running this excellent hospital. The second reason may be that some of them have gone to the private clinics located within the hospital - the Community Hospital has leased out a certain section of the space for use by private clinics - and the fees charged by these private clinics are seen to be rather high.

So I would like to ask the Minister whether, for future planning, greater emphasis would be paid to the basics and the functionality of the community hospital rather than the aesthetics and the beautiful architecture of the building.

The second point is in regard to the shortage of manpower in this community hospital. We know that the Minister for Health is a very persuasive person. I would like to find out whether he has been successful in persuading the Minister for Labour in securing greater manpower to fill the vacant positions of all the hospitals in Singapore, including the community hospitals.

Mr Peter Sung (Buona Vista): Sir, I would like to make two brief points. Firstly, the Government's approach towards medical services for the people. I would like to emphasise that I agree with the Government's policy and philosophy on health care. However, I would like to ask the Government to consider allocating a slightly bigger budget for medical expenses in order to reduce the burden and anxiety of the common people whose fear of the rising costs of medical services is well known. The additional money, however, should be spent in such a way as not to encourage wastage and abuse.

Secondly, MediShield and MediShield Plus do not cover medical expenses when the individual is more than 70 years old. How would those people at this advanced age then pay for their medical expenses? At that advanced age, medical expenses are likely to rise. Why should the Government design schemes which make these elderly people more anxious, particularly at the time when they are short of earnings and their medical needs are the greatest? By making this point, I am not suggesting that the Government gives automatic rights to a series of handouts on medical matters. That can lead to abuse. But I do mean that the Government can be kinder to those people whose economic situation is not that strong.

Sir, the Government's sound financial policy has given us a strong economy. The Government is right in putting emphasis on education, on building up a good infrastructure and in accumulating strong reserves. Yes, we need to provide for our children. But how many future generations should we provide for? Beyond a certain point, we should not build up reserves, just for the sake of the reserves. The people are very concerned about medical expenses. Some of the surpluses should be spent on the present generation to lessen the financial burden and to alleviate the anxiety of the common people. But of course, the system must not encourage abuse, wastage or the dependency mentality.

Mr Loh Meng See: Sir, I am raising this subject of traditional Chinese medicine because I feel that if traditional Chinese medicine is here to stay and the public continues to use the services of Chinese sin seh, acupuncturist and bone-setter for treatment, it is better that the Government face the issue and deal with it. We may be able in the process to get maximum value and benefit out of traditional Chinese medicine. The local bodies, the Chinese Physicians' Training College and the Institute of Chinese Medical Studies, are trying their level best to improve the standards of training and practice of traditional Chinese medicine. With their limited resources, I doubt they can go very far without Government intervention.

I read from press reports on the conferment of professorship and doctorate degrees on prominent alumni of the institutes. I wonder if this will not create confusion among members of the public as to the educational standards and quality of training of the institutes. It is time that we set the proper high standards for those who wish to practise traditional Chinese medicine in Singapore.

The experience of Hong Kong and Taiwan shows that it is possible for traditional Chinese medicine to co-exist with Western medicine. Traditional Chinese medicine and Western medicine can be allowed to play the complementary roles in promoting the health care of Singaporeans. Is it not also to draw the best of the East and West in the field of medicine as well? I hope the Minister can comment on this.

The Chairman: Mr Ling How Doong is not here. General George Yeo. 3.30 pm

The Minister for Health (BG George Yong-Boon Yeo): Sir, since we have only just had a very comprehensive debate on the White Paper on Affordable Health Care, I do not propose to spend too much time discussing the structure of our public health system and our long-term plan to keep it under control so that the total burden on the people of Singapore will not be too crushing.

We know that in America, it is already 14% of the GNP and estimates are that they are on course to hit 17%-18% within a few years. One-third of the value of a car built in America goes to health care. Of course, in a democracy, it is for the people to decide. But in any society, a balance has to be struck on how much to spend on health care without that burden preventing the society as a whole from making progress, because it can be too much as is the case in America.

Our population is aging very rapidly. Right now, the amount of resources we set aside for health care is completely affordable. Right now, less than 1 in 10 of our population is over 60 years old. By the year 2030, over 1 in 4 will be over 60 years old. So even if we do nothing but to have this present level of health care, the proportion of GNP going to health will rise very rapidly. So we have to be mindful. We have to establish a system which is non-inflationary and which has got internal safeguards, so that all the time a sensible approach is adopted. While incentives are necessary for its proper functioning, we must not allow these incentives to result in a mad scramble for advantage.

One big problem in America today is that there is too much greed in the system. It is not just greed of doctors. It is greed of doctors, of lawyers, of health administrators, of pharmaceutical companies. A system where each passes the buck to the other, each demands the most for itself. The doctor-patient relationship becomes a completely money relationship. So over the years, in survey after survey, they found that the social standing of doctors in America has been declining, and I think this is at the core of the problem they face. Something has snapped, a certain loss of responsibility, a certain mad scramble by individuals for individual gain and individual advantage.

These are the kinds of pitfalls we must be very careful to avoid in Singapore. While every measure seems attractive, because so many people benefit from it, we must not forget that the road to hell is paved with good intentions. There must be a sense of what we want to be and then each step we take should lead us there. I am not saying that there should not be detours along the way, but we must be mindful of the dangers of a health system that depends too much on the State, or that depends too much on insurance which causes moral hazards.

Let me now answer some of the questions raised by Members of the House. Mr Loh Meng See asked about Medifund. Can I just give some numbers here? The scheme was started in April 1993 and for the first nine months, 12,200 applications for help were received. Of these, 10,900 cases were approved and about 1,300 are still being processed. And only 36 cases were rejected. The approval rate is 99.6%. This is the ultimate insurance for Singaporeans. If all else fails, if you exhaust your Medisave, if MediShield does not cover you, your immediate family cannot help, then there is Medifund as your ultimate safety net.

Of necessity, Medifund is not something we dish out without control. A careful means test is conducted. It is allocated on a case-by-case basis to ensure that the person who seeks assistance from Medifund is a genuine case. And if they are genuine, they will get it. So no one in Singapore should worry that in the event that he has got no children, no one can help him, his own Medisave is exhausted and he has got no money, that he will be left destitute and without health care. Such a situation obtains in America. It will not obtain here because of this provision.

Dr Wan Soon Bee asked whether there are any plans to shift more burden on to the people of Singapore. In fact, if we think about it, however we shift the burden, it is shifted among Singaporeans, because this is our country. Whether we finance health care from taxes, from MediShield or whatever, it is us shifting the burden among ourselves. And what we want to ensure is that the sum total of all that burden which we should bear collectively is not excessive. And within it, there must be a sense that the burden is shared equally. In the Army, we learn to carry logs as a team. If there are one or two who are lazy, the remaining ones carry a much heavier burden. So we must build a system within which everyone faces pressure to carry his part of the load. Otherwise, we have freeloaders and before you know it, those silly enough to carry the burden will not be able to bear it, and then the whole thing crumbles. And that is what we must ensure. So when Dr Wan Soon Bee asks, do we intend to shift more burden to the old, to the elderly, to the sick, I say let us first remember that however we shift, the burden is borne by ourselves.

He asked about the subsidy level. We are more or less there at the target recovery rates. The cost adjustments that have to be made from year to year should be to cover the normal cost of inflation, rising manpower cost, cost of medical equipment and other consumables. But we are more or less at our targeted restructured levels. That is my specific assurance to him.

He asked whether we could not, for certain diseases which are catastrophic like cancers and kidney illnesses, waive the deductibles. As you know, under MediShield, what is catastrophic is not defined by illness, but defined by bill size. Because the system that we have must be simple to administer. If we start going into the details of an illness and start making fine distinctions between illnesses which are catastrophic and illnesses which are not quite so catastrophic, we will have a system which will become very contentious and will lead to heart burn among many people. So we decided from the start, when we instituted MediShield, that it shall be based on total bill size. On that basis, it is better to keep the system simple. The deductibles are not onerous. They are there to ensure that people do not make recourse to hospitalisation lightly. And if a person cannot afford it, then there is always Medifund to help him.

Dr Arthur Beng made an eloquent case for outpatient capitation limit for civil servants, not to be uniformly fixed at $350, but for it to vary with the age of the patient on the basis that the expected needs of a patient would grow as he grows older. I find it very persuasive and I shall certainly commend it to the Finance Ministry for consideration.

A number of MPs have spoken about the pros and cons of the managed health system - Dr Arthur Beng, Dr John Chen, Dr Michael Lim. In America, there is a trend towards it. It looks attractive because, on the surface, it seems to reduce health expenditure because there is more discipline on doctors. Sometimes patients are not happy because they feel that they are under-treated. So they get around it by establishing treatment protocols which means if you, as an informed patient, suspect that your doctor is under-treating you, then you check up the treatment protocol and you say, "Ah, the doctor didn't give me this test." Then you can either go back to the doctor or you sue him.

It sounds very good on paper. But every time I hear a lawyer getting into the act, I get suspicious. Because at that point, the relationship between the doctor and the patient becomes that of a money, litigious, contractual relationship with all the accompanying pitfalls. While I do not want to dismiss the managed health system being proposed by NTUC, I think we should not be too quickly won over by its apparent seductiveness. Remember, every time we want to manage the market, we require an overseeing agency. Then there must be channels for appeals and legal redress. So there are overheads. While costs may appear to be reduced at the working level, there is a cost of overheads to be borne.

Do we need it in Singapore? I am not sure. All of us from young have had recourse to our family physicians, who, as an MP said, are available everywhere. I think Dr Michael Lim said that. You see a doctor. He looks at your throat. He prescribes this, that and the other. You go back to him if it is necessary. You develop a relationship with him. He has served us well. And I do not think the costs are exorbitant. In fact, what I notice is because Singaporean parents are very concerned for their children, they are prepared to pay a premium if the particular neighbourhood doctor has a specialist degree. My wife brings my children to a paediatrician. She pays $10 more because the paediatrician has got an M.Med, MRCP or some such qualification. I do not quite know. But she tells me, "No, you cannot just send the children to an ordinary GP because he is not good enough. You have to send them to a paediatrician." You want to please your wife, so you agree.

But the system regulates itself. In our case, 25% of primary health services are provided by our polyclinics and other outpatient Government facilities. This is like what NTUC Fairprice supermarket does for our retail industry. It keeps people honest. It breaks up local cartels. If a GP tries to overcharge or goes beyond what the market will bear, then there is the polyclinic there which offers an alternative. And I think 25% Government, 75% private doctors, that is not bad. But at the same time, I do not rule out the possibility that costs will continue to rise and we may have to find new methods to control it. If you belong to a company and you have many employees and you want to control the issue of medical certificates, you may negotiate with the company doctor who then undertakes either on a capitation scheme or on a retainer scheme or on a fee-for-service scheme to look after all your employees. These are private relationships which do not involve Medisave. So I do not really want to interfere in that private market arrangement and I am not convinced that there is market failure. 3.45 pm

But the NTUC scheme, as Dr John Chen describes, is interesting and we should not dismiss it out of hand. They have been discussing with the Health Ministry for some time. I am prepared to have it as an experiment. If Dr John Chen is right, if NTUC is right, and they can provide a better service at lower cost for Singaporeans, then why not? We should go for it. So what we would do is, since they are asking for Medisave to be used, and I think we can allow Medisave to be used in a controlled way, maybe up to 50,000 families, let us have it as an experiment going for three, five, seven years, and at the end of that period, we make an assessment whether the managed health system does in fact provide better health care for Singaporeans. If it does, then we should encourage it, proliferate it. If not, we can go back to what we have been used to all this while.

Dr Toh Keng Kiat asked whether we are still subsidising A class beds. We are not. The reason why A class beds in SGH were not raised the last time round was because they have gone beyond the targeted amount in the previous fee adjustment. So the 1992 Straits Times report that he quoted - I have not seen it - I do not quite know why there was a discrepancy. But my data tell me that they had overcharged the last time round and they decided that there was no need to raise the fees any further.

Dr Toh also asked whether it was in fact right for us to absorb the GST for A class beds in Government and restructured hospitals. We have agreed to. So for the time being, that is the policy. But I think we should progressively take this away because A class patients in restructured hospitals should not be subsidised and those beds should compete on an equal basis with private beds outside.

On the question of control of medical students - 150 from NUS and 30 from overseas - and whether instead of controlling by approving only 28 foreign universities we should not conduct licensing examination, my answer to Dr Toh is that it is better for us to bite the bullet and tell the student after "A" level, "Look, if you cannot get a place at one of the 28 universities, have no illusion that if you go to another university, when you come back to Singapore, you can practise". Otherwise, he will try his luck. He will go to an unapproved university. He comes back, he will sit for the examination repeatedly, hoping to get in. Since we intend to control the number of doctors anyway, large numbers of them will be disappointed and they would have spent six years of their lives going through the medical programme, coming back to Singapore and be frustrated. They will be very angry and, rightly so, and eventually they will migrate. I do not think that is a wise solution. It is better for us, since we have decided that it is necessary to control the supply of doctors, to bite the bullet and say, "Look, after "A" level, you know what the score is. If you can get into one of the 28 universities, which is not easy to get into, and they were chosen precisely because they are not easy to get into, then good luck to you." If, in some years, there are more than the expected numbers, so be it. We admit them all.

On balance billing in private hospitals, the Health Ministry is still looking into the matter. It is not a problem now. We expect that it will become a problem later. So we want to study carefully before we move to control. Sometimes we have to intervene in the market heavily, sometimes we should only intervene in it lightly.

On Dr Toh's query about the bill of over $20,000 for one day at the ICU at NUH, I think that was an exceptional example because the patient came in with multiple injuries at A&E. The doctors thought that this was a young patient and they would do their best to save him. They did not succeed, unfortunately. The bill came up to $20,000. I think the young man would have been covered by MediShield. And that is precisely what MediShield is for.

Dr Michael Lim suggested that we should do much more to educate members of the lay public - have videos, persuade them, frighten them, show them the price list, and swamp them with information. I am not sure if this by itself will solve the problem. The doctor-patient relationship is a very special one. It goes beyond money. If it is only money, I will be very suspicious about the doctor. In our tradition, the doctor is always seen as a senior. I was discussing this with Dr Ker Sin Tze the other day and he told me that he once had a back problem. He saw Dr Kanwaljit Soin. Since then, whenever he answers questions from Dr Soin in Parliament he does so with a certain regard because that is the way you treat your doctor. I think that is the case for most of us. We treat our doctor, who sometimes may be younger than us, in some ways like our teachers. That is a very important part of the relationship. No amount of education can make the patient as knowledgeable as the doctor. The way to control the doctor is not by trying to out-smart him, out-guess him, out-question him or out-quiz him. I think the way to maintain this doctor-patient relationship is to ensure that in Singapore we maintain a high ethical code among our doctors. Strong peer pressure, that those who misbehave, we censure them. Those who issue medical certificates lightly, we embarrass them publicly. So be it. But you take the Hippocratic Oath, you undertake to do certain things, I am not saying that you should not be properly rewarded for your services. But I think doctors cannot be motivated by money alone.

Many of us would have parents or dear ones dying from cancer. Sometimes you ask yourself whether it is better to tell the patient everything. Because if you tell the patient everything, everyday is like a living death, dark clouds hanging over you. In Japan, and they are an information-intensive country, in many cases they do not tell their patients. They tell their family members, a certain pretence is kept up, the patients guess at it. They are not sure, they do not ask. There is a certain hope. In life, hope is absolutely important. In their society, doctors are expected to carry a certain responsibility. They bear some of the burden of making decisions. Left to themselves, they probably make good decisions.

But in America, it is the other way round. You come to see me as a doctor. At the back of my mind, always it is whether you are going to sue me afterwards. So I make sure of what is the treatment protocol, but I add two more tests, just in case, if I have got to go to court. In any case, the insurance company will pay or the HMO will pay. So everyone is busy protecting his backside. We have to think through this very carefully and not glibly say, "Ah, the more education the better." What kind of education? Education on nutrition, preventive medicine, good health habits, all that is fine. But trying to educate the patient to a point where he can out-guess his doctor, I think that is very unwise. And if ever we reach that stage, then it will be a very sorry situation. We will be like the situation in America.

Dr Michael Lim and Dr Vasoo raised the question whether or not we have been too luxurious in building new hospitals. Since taking over the Health Ministry I have gone around to all the hospitals to get an impression. I have been to many of them visiting sick people and sometimes being sick myself, but this time I went there as the Minister for Health, and I saw parts of the hospitals which I never saw as a patient or a visitor. I would not say that they are five-star. For private patients, yes, it is a bit more plush. But in fact the patients pay much more than what they are getting back in luxury. It is like the A class patient. No subsidy. He gets the same medical care for his single room, the toilet, the television and air-conditioner. He is paying very much more. If he wants all these creature comforts, so be it. So for the paying patients, or the private patients, we give them a little bit more luxury such as carpet trimmings and more hand-holding. They feel very happy. So they are prepared to pay much more for it. But for subsidised patients, we keep it clean, airy, functional. Yes, Mr Lau Ping Sum's comment about Ang Mo Kio Community Hospital, it being very welcoming, airy, broad corridors. I think there is nothing wrong with that. The purpose of our community hospitals is to encourage patients who have gone through the acute phase to leave the secondary and tertiary hospitals and go to St Andrew's Mission Hospital or Ang Mo Kio Community Hospital. So it must be pleasant. It is not luxurious, but it should be airy, it should be bright, people should not feel oppressed by it. Old people should not feel that if they walk round the corridors they may crash into a fire extinguisher or crash into someone.

Dr Arthur Beng asks a series of questions about the possibility of private specialists doing work either at outpatients' specialists clinics or for the privilege of seeing patients in restructured hospitals. I think this is a delicate point because there is always some rivalry between doctors in the public sector and doctors in the private sector. There is an implicit bargain that if what you want principally is money, then you go into the private sector, as the public sector cannot compensate you to the same degree. If you are in the public sector, in return for less money, you get more job satisfaction because you see a range of cases. You get to teach, you get to do some research and you have a greater sense of control over a much wider field.

If we allow private doctors to cherry-pick, in other words, to have the best of both worlds, to go out, get all the advantages of being a private doctor and then come back to the public sector hospitals and pick those cases they like, I think I may have a morale problem in the public sector. The only exception we make now is for Visiting Consultants. These doctors come back in, they serve at a high level, they teach, they impart knowledge, they perform a public service. On that basis, a bargain can be struck. But for private doctors who do not do any additional public service, I think it is difficult for them to be admitted into our secondary and tertiary hospitals.

However, at Ang Mo Kio Community Hospital, as you are aware, we have started something different. There are a number of private clinics there. We allow the doctors there to admit their patients into the community hospital. This has just started. Let it carry on for a while and we will make assessments after a period of time to see whether the pros and the cons balance out. If it is overwhelmingly successful, then we may progressively consider it for restructured hospitals. But this is not an area which I think we want to rush into.

On whether patients pay for the cost of buildings, the point has been made repeatedly that subsidised patients do not have to pay for building costs and land cost. For A class patients, I think they should, because they should compete on an equal footing with those in the private sector. We got to sort out all the accounts because, even though they are restructured, not all the accounts have been fully clarified.

Whether there should be more cooperation and sharing among restructured hospitals, the point raised by Mr Loh Meng See, for those under HCS, there is a HCS management and where it makes sense for them to bargain as a group for supply, they would, and they are. But where it is unnecessary, then they should allow the hospitals to be autonomous and to have some limited competition among themselves. 4.00 pm

We have already put in macro controls, as you are aware, as has been discussed in the White Paper. But within those macro controls we want certain free play so that different CEOs, different medical units, different surgical units, can compete among themselves.

As to the concern raised by Dr Michael Lim, I believe, about duplication of facilities, equipment and resources, this is directly controlled by the Health Ministry. In other words, expensive items, big-ticket items, they must be approved by the Health Ministry before we allow duplication. So when it is wasteful to duplicate, we will not duplicate.

Dr Vasoo commented on the poor physical state of Alexandra Hospital and Changi Hospital. Changi Hospital - we do not want to do too much because we will shut it down once the Eastern General Hospital has been opened. Alexandra Hospital - there is a programme now to give it a facelift. If you have been to Tan Tock Seng Hospital recently, you will see what some minor improvements and a fresh coat of paint can do to uplift the whole ambience of the hospital. We are going to do the same thing to Alexandra Hospital.

As to whether or not we should restructure Eastern General Hospital, I think we should, because there is nothing so magical about restructuring. It simply means making the costs explicit so that there is greater incentive to efficiency, people know what things cost when they use them. It is better that way. And even in Alexandra Hospital (AH), even though it is not a restructured hospital, I have told the Health Ministry to ensure that AH has got a good internal cost accounting system so that they know where the costs are.

The only way to keep health cost down in Singapore is for us to take a practical approach and to avoid moral hazards, people asking for more than they need because someone else is bearing the cost, to avoid wastage, and to minimise greed in the system.

Mr Peter Sung asked for a bigger budget for health. Let me say this. That because our population is aging rapidly, just to maintain the same level of subvention, public subsidy on health will grow significantly every year anyhow. So before we lightly vote more amounts for public subsidy, let us be very conscious of the fact that our population is aging. We do not want to be caught in a squeeze in the year 2020, 2030. For many of us then in our dotage, there will be very few young people to tax. And if we vote a lot of health care for ourselves at that time, and we may have enough votes to swing it that way, it will be such a crushing burden on the young. Many of them may decide not to remain in Singapore and this, of course, is a drastic problem faced in America where the tax base in the inner cities has been shrinking. The more you tax, the more they leave; the less the Government has, the more heavily they have to tax, and in the end, you are left with a ghetto. I do not think we have reached that position but when we talk about spending reserves, voting more subsidy for health care, we have to be very mindful that even at the existing level, health care cost to the Government, to the public purse, will grow very significantly over the next 10 to 20 years. In fact, I have asked the Health Ministry now to construct detailed models of what the picture would be 10, 20, 30 years from now, assuming the existing level of health subsidy and variations around the existing level.

Mr Loh Meng See asked what the Health Ministry intends to do about traditional Chinese medicine. I think this is an area which we have to give some attention because it is not static. The position is not static. Because of the opening of China, more and more Chinese physicians are coming here from China, many of them on social visit passes, seeing patients in HDB flats and receiving hongbaos in return. And he is absolutely right that despite westernisation, there is still tremendous regard for traditional Chinese medicine and, personally, I feel that there is nothing for us to be ashamed of. The history of Chinese medicine, Chinese pharmacopoeia, goes back centuries, millennia. So there must be a lot of good in it.

The problem in Singapore is lack of certification, lack of codification, misuse of antibiotics, steroids, and we have our share of quacks and charlatans. But because of the dichotomy between traditional Chinese medicine and western medicine, there is very little knowledge in the Health Ministry of traditional Chinese medicine. So while in previous years MPs, like Dr Ow Chin Hock and Mr Peh Chin Hua, had asked for the registration of Chinese sinsehs, the Health Ministry has been reluctant to, because on what basis do you register? So we asked our two Chinese medical schools here to do more, and they are trying. They cannot do it on their own. They lack funds, they are sometimes rent by internal politicking, and they need access to assistance from China. I think this is one area where I can be of assistance to them, which is open doors for them in China, so that more expertise can flow from China to Singapore. I think we can link them to Chinese institutes, the reputable ones, even NUS, if it is interested and, over a period of time, establish different registers, maybe, firstly, for those who are registered in the two medical schools. If they can combine, so much the better; if they cannot, we will have two separate lists. Later on, we can have a list of all those who are graduates from top quality institutes from China, and then we can progressively clean up and tidy up the situation in Singapore.

But we must be under no illusion that this can be done overnight. This would take at least a generation to sort out. But I believe we should take the initial steps. Remarkable things are happening in China because of a synthesis of western and traditional medicines. Those of us who have been there know. You go to a hospital, it has got wings for Chinese medicine, wings for western medicine, and some wings which combine both. And they will advise the patient, "Look, for this condition, better see a traditional doctor." Or when we see a traditional doctor, he may say, "Well, no, no. We can't do much for this. You better see a western doctor." Because of the synthesis, I think they will make interesting progress in the years to come, and we should latch ourselves onto this bandwagon and exploit the fact that we too are beautifully placed in between the east and the west.

So I have asked Dr Aline Wong to form a small committee, in-house, MOH first, and then map out a preliminary plan of action, and after that we will consult the various groups and then we will visit institutes in China, and then maybe in one, two years, come out with a plan on how we can progressively clean up the situation and make progress.

Mr Loh Meng See: Sir, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The Chairman: Order. I propose to take the break now.

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 4.30 pm.

Sitting accordingly suspended at 4.09 pm to 4.30 pm. Sitting resumed at 4.30 pm

[Mr Speaker in the Chair]

Debate in Committee of Supply resumed.

[Mr Speaker in the Chair]

Head P (cont.) -

Mr Loh Meng See: Sir, I beg to move,

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

Sir, some doctors I spoke to lamented that the Government has been instrumental in commercialising the medical practice. The medical practice is no longer the noble profession it used to be but a trade. They say that doctors have been made to become businessmen. They claim that when doctors received their training in the institutions there was the sense of service but now it has turned into money to beget service rather than service first, rewards later. Frankly, I am not sure whether the Government was the cause of it or the black sheep among the medical profession. We heard from the Minister just now as he spoke about medical ethics, the dangers of greed coming into the picture and how important it is for the medical practitioners to enjoy high status in our society. We have heard the Government say that it has been responding to the reality of the situation of rising expectation, increasing demand for medical services, the ageing of our population, etc.

Sir, the Government is in a dominant position in the provision of medical services. The public sector should set the right direction and the pace of development for the rest in the medical service sector to follow. It is not wise and proper for the Government to compare the public medical sector with the private medical sector only on the income and earnings of specialists and doctors. It may be even more important to compare itself with that of other public sector professionals and how they are paid, for example, the civil servants in the Administrative Service, engineers, lawyers, architects, etc. Then the Minister for Finance need not, in his Budget speech, give notice to students wishing to study medicine that the places would be rationed.

The training of doctors at first degree level should be treated like all other disciplines. It would be a pity that those who have a strong interest are denied the opportunity for training as doctors. We should allow some medical graduates to diversify into other areas of work, whether related to medicine or not. After all, we are interested in using their brains and talents in all fields, and the fact that they have received medical training should not be a handicap. It is the number of specialists that we should watch closely and impose strict limits. I think we should not impose limits on the doctors.

The problem in manpower planning is that often we tend to under-train rather than have enough people being trained, including the training of doctors. The irregular flow of medical graduates in the pipeline is unhelpful and may be even more serious if we are faced with a shortage of medical practitioners. We cannot train them overnight. My suggestion is that it is better to err on the surplus side than be faced with a shortage of doctors and specialists in the future. I hope that the Minister will be generous in the number of doctors to be trained.

Mr Choo Wee Khiang (Jalan Besar GRC): Sir, I have three cuts under this subhead. May I take the three together, please?

The Chairman: No. Please follow the schedule.

Mr Choo Wee Khiang: Thank you. Sir, the large majority of Singaporeans will not be able to afford private medical care. Instead they would continue to look to the Government and restructured hospitals to meet their health care needs. To maintain the high standards of medical care provided in the Government and restructured hospitals, we need to ensure that a serious brain drain of specialists from the Government and the restructured hospitals to the private sector does not occur. Could the Minister inform the House on the attrition trend of doctors, particularly of the senior specialists in the Government and restructured hospitals? How does the Ministry plan to maintain a critical pool of senior and experienced specialists in the Government and restructured hospitals?

Dr Wan Soon Bee (Brickworks GRC): Sir, high-tech medicine has raised the standard of medical care to new heights. It has helped improve and prolong the lives of many by permitting the early detection of diseases. It has also provided better and more effective cures.

However, high-tech medicine is not without its disadvantages. The disadvantage of high-tech medicine is that it tends to cause medical costs to escalate dramatically. Studies have shown that, in many instances, unnecessary demand is created because of the availability of high-tech medicine. Sometimes, unnecessary demand is also created to recover the high costs of high-tech medicine.

I, therefore, feel that the acquisition of high-tech equipment should be more strictly controlled and better coordinated. As an example, I cite the case of the Magnetic Resonance Imaging system, more commonly referred to as MRI. I have been informed that the MRI is a very advanced and sophisticated machine for diagnostic purposes. It is also a very expensive piece of equipment. Each MRI system costs between $6-$8 million. In the United States, the recommendation is for one MRI system per million people. Scotland, with a population of over 5 million people, has only two such machines. Singapore, with a much smaller population of 2.7 million people, has five MRI systems; two in our private hospitals and three in the restructured hospitals. This not only appears excessive but also uncoordinated.

In such a situation, it is likely that unnecessary demand will be generated in order to recover the cost of these machines. The cost of each MRI scan ranges between $500 and $800. This House will, no doubt, appreciate that this is a very expensive procedure.

The MRI system is but a single example. I wonder how many other examples there are of excessive or unnecessary acquisitions of high-tech equipment. The MRI example certainly seems to suggest a lack of coordination between the private and public sectors of the health care industry. A pooling of resources in this case would have better served the country. This example also calls into question the effectiveness of our controls on high-tech medicine. Certainly, we can and should better control and coordinate the introduction and use of such high-tech medicine. What is the Government's position on this point? I hope the Minister will give his comments.

Mr Choo Wee Khiang: Sir, in our pursuit of medical excellence, it is inevitable that we need to continuously upgrade our medical technologies and equipment so as to enable us to pitch the standard of our health care to that of the other developed countries. However, in so doing, we should not lose sight of the primary consideration of containing medical costs, ie, to ensure the continued affordability of health care to the general public.

Would the Minister inform the House on how they intend to strike a balance between cost containment, on the one hand, and the need to introduce more advanced medical technologies and equipment on the other? How much did the Government and restructured hospitals spend on upgrading medical technologies and equipment over the last five years, for example, as what Dr Wan said, MRI and laser equipment? Another question is: how does the Ministry ensure that there is no duplication of resources among its Government and restructured hospitals when acquiring new technologies and expensive medical equipment? My last question is: how does the Ministry monitor the use of these expensive equipment at its hospitals to ensure that they are fully utilised?

Mr Loh Meng See: Sir, MediShield is an excellent scheme to insure against the hefty cost of medical bills when a person succumbs to a catastrophic illness. However, according to statistics, only 90% of all eligible CPF members are covered under MediShield. I am concerned about the remaining 10% who are not covered. Can the Minister tell us whether there are any good reasons for this 10% to opt out from the MediShield scheme? Does this number include those who have withdrawn their CPF monies on retirement?

I would imagine that only a small percentage of hospital patients receive MediShield reimbursements. I deduce this from the CPF Board's Annual Report because we can see that the funds are growing under the MediShield Account. The administrators of MediShield are rightly concerned that they should be prudent and cautious in managing the MediShield funds because the claims can get out of control. But because, as the Minister told us just now, MediShield is really the ultimate safety net, we can afford to be generous to those people who are in need of coverage under MediShield, particularly basic MediShield. If it is possible, we should also consider MediShield Plus. But I think I would give priority to basic MediShield. 4.45 pm

Just now, the Minister told us that the definition of "catastrophic illness" under MediShield would depend on the bill size. But I think the problem is that when a person is down with a catastrophic illness, the true meaning of catastrophic illness, it is a hard case of expecting co-payment or deductibles. Co-payment does not really apply because it would not be a deterrent for frivolous hospitalisation for such cases, ie, people with catastrophic illnesses. I would ask the Minister whether he would go one step further to define those real bad cases of catastrophic illnesses and consider not imposing deductibles for such cases. If it is not possible for practical reasons, whether some adjustments could be made to the deductibles.

The average lifespan of Singaporeans is 76 years old. The bulk of medical expenditure is in the last year of a person's life. There is a 6-year gap that needs to be bridged, because the age limit for basic MediShield is only 70. Can we extend the age limit? Even if we extend, the bulk of the payment is still some time away. Is there any money left when CPF members withdraw their CPF Minimum Sum monies at 60, which is way before the age limit of 70 covered under MediShield? Is there anything that needs to be done to retain these CPF members to be covered under MediShield?

Mr Choo Wee Khiang: Sir, as statistics would show, our general public do lean heavily on the A&E departments in the Government and restructured hospitals, in cases of accidents and emergencies. I would like the Minister to enlighten us on how the quality of A&E care in Singapore compares with that of the other trauma centres or A&E departments in the developed and developing countries. Would it be a misconception that patients in the A&E departments are attended to only by junior doctors? Perhaps the Minister could help to dispel this misconception by informing the House on how the A&E departments in the Government and restructured hospitals are being staffed. What is the ratio of senior doctors to junior doctors in these departments? Do our A&E doctors undergo any specialist training in emergency care or trauma care? What is the Ministry's plan to upgrade the quality of our A&E services, not in terms of the number of cases attended to, but in terms of the standard of care and treatment provided?

BG George Yong-Boon Yeo: Sir, Mr Loh Meng See asked whether the Government was not encouraging the doctor-patient relationship to be a purely commercial one. I explained earlier that if that were to happen, then we will have the American situation where money will be the dominant nexus between doctor and patient. It will lead to legal suits. The system will get out of control and there will be poorer service for the patient. It is very important that doctors retain their high position in our community and that they are motivated more than just by financial incentives.

While saying that, we cannot ignore money, because if the incentives are not right, then all those other things cannot come into operation. Our approach is to get the incentives right, but the incentives themselves are not enough. I mentioned earlier that it is very important not to let greed become the dominant operating element in the system.

We have to control the supply of doctors because the experiences of other countries have shown that there is a tendency for supply here to generate its own demand. So we have decided on 180 doctors; 150 doctors trained locally plus 30 more from established institutions overseas, and then we calibrate around that. If we feel later that the proportion needs to be tweaked either up or down, then we will do so accordingly. I do not think there is a danger that we will suddenly find ourselves with a big shortfall of doctors in Singapore. We are now targeting to have the kind of doctor-population ratio which is found in advanced countries.

Mr Choo Wee Khiang asked whether there is a brain drain of doctors from our public sector to the private sector. For junior doctors, it is not a problem. In fact, we have had to release many of them from their bond because there is an over supply. The problem is among those who are more senior. There, the situation in most of the restructured hospitals is not alarming. The outflow varies from year to year depending on the situation in the market, depending on whether the private hospitals are opening up new wings and having more beds. In the last few years, the market has become more active, so more have been leaving. And it is about 10% a year from the restructured hospitals. It is a situation which is not under control. It is part of the natural flow rate which we want in any case in our hospitals. Some who feel that they are not getting into positions of leadership feel frustrated, they leave. There is no great harm. It is good to have continuous renewal anyhow.

Dr Wan Soon Bee asked whether we are not controlling tightly enough the availability of high-tech equipment. As I said earlier, we have established procedures to vet the cost benefit of expensive equipment and facilities before they are introduced to the public and restructured hospitals. This is an MOH responsibility. Every such investment has to be approved by a board at MOH first before we agree to the purchase of the equipment or the installation of the facilities.

He raised MRI as an example of where it has gone out of control. In fact, this is not true. We have not been excessive in buying MRIs in Singapore. I have got some statistics here to show that we have about three-quarters of a million persons to an MRI which compares with 700,000 in Korea and about 850,000 in Hong Kong. This is comparing among the NIEs. In Japan, it is about 73,000 persons to an MRI. So there are many more MRIs in Japan per million than we have in Singapore. These figures are as of June 1993.

If you look at it around the world, in the US, it is about 100,000 in 1991 per MRI. But then we have all agreed that it is an example we do not want to follow. In Europe, most of the countries there have more MRIs per million than we have. So I do not think we have been excessive and MRI is not a good example of where high-tech equipment has gotten out of control.

Mr Choo Wee Khiang asked whether there is duplication. The same procedure applies. Before we duplicate, we must be convinced of the necessity and if it makes more sense to centralize the facility, we centralize. This was a question raised by Dr Michael Lim earlier.

Mr Loh Meng See asked whether we could not improve MediShield terms since we are accumulating surpluses. He asked whether we could not remove co-payments and deductibles and extend the age limit beyond 70 years of life. Deductibles and co-payments are important because they keep the system under control. If there are no deductibles, there will be a tendency towards moral hazard, towards over consumption, which is the problem in country after country in the West. So we are learning from their mistakes and we are putting these safeguards to ensure that our insurance does not become inflationary.

As to raising MediShield age limit beyond 70, this is a matter we are now studying very carefully, because it involves subsidy across generations. If we do not subsidise across generations, then we have to charge very high premiums for those who are above 70. Some consultants have advised us to allow cross-subsidy for a person within his own lifetime. In other words, he pays more premium when he is younger in order to subsidise himself when he is older. I think this is something which we can consider. But we do not want lightly to subsidise across generations without doing very careful actuarial analysis. Because once you extend, you cannot reduce. Before we extend, let us be very careful. The Ministry of Health is now reviewing terms for MediShield and we hope that we can improve the package somewhat within a few months.

Mr Choo Wee Khiang asked about the way we run our A&E departments, because, as is to be expected, there are many complaints about the services there. The A&E departments are staffed by both junior and senior doctors. There are medical trainees, medical officers, registrars and senior registrars. And the Head of the A&E department is a consultant or senior consultant. In other words, there is a whole hierarchy and there are seniors overseeing the work done by juniors.

Medical officers are required to have at least one year post-housemanship experience before they are posted to the A&E department. They are also required to undergo two weeks intensive course on A&E medicine prior to their posting. The A&E medicine course focuses on the management of the more common medical problems seen at the department.

There are presently 15 medical officers who are trainees in emergency medicine and 7 medical officers trained in emergency medicine. These doctors are then posted to the various A&E departments in MOH Government and restructured hospitals.

Senior doctors are on duty at the department, either in the hospital or in the department throughout the day and night. And they are always on call and available for consultation by junior doctors on the management of problem cases at the A&E department.

The problem with our A&E department is that many people, particularly at night when the neighbourhood clinics are closed, are not sure whether a particular complaint is serious or not. So just to be safe, they go to the A&E. When they go to the A&E, there are other emergency cases and they end up having to wait for a long time and the doctors who are busy would tell them, "Look, your case is not serious, you have to wait." Or maybe come back the following day if they do not want to wait. Then they get upset. This is a problem which all A&E departments face.

MOH is considering the feasibility of having a 24-hour GP-type of clinic, situated in proximity to an A&E department, so that cases which are non-emergency can go and see the GP instead. This will free doctors at the A&E department. And this will also reduce the frustration of those patients who thought they had something serious, but when they arrive, found that the GP can look after them and there is no need for them to pay higher rates anyway at the A&E department. This is an idea which we are considering at the Ministry. We will get one or two of the restructured hospitals to try it. It is a pilot project. If it works and people are happy with the service, we will proliferate it at all our A&E Departments. 5.00 pm

Mr Choo Wee Khiang: Sir, I am happy to note that we are not having a serious brain drain problem. However, I would like to ask the Minister whether he has any contingency plans if we were to have this brain drain problem in future because replenishing a doctor, especially a specialist doctor, takes a long time.

BG Gorge Yong-Boon Yeo: There is no significant brain drain problem among our doctors because in most countries the profession is a highly regulated one. They put all kinds of hurdles before you are admitted to practise as a member of the profession. So this is not something which can happen suddenly overnight and over which we are not able to react gradually over a period of time.

Mr Loh Meng See: Sir, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Mr Tong Kok Yeo (Nominated Member): Sir, I beg to move,

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

Sir, public sector hospitals, polyclinics and outpatient clinics are equipped with their own pharmacies. These pharmacies, I believe, are stand alone in the sense that the dispensing of medicine and drugs for patients is based on their doctors' prescriptions. These Government hospitals and outpatients' clinics, polyclinics and pharmacies are all spread out over the island. In dispensing the drugs to the patients, pharmacies do not have the facility to gain immediate access to the patient's medical history prescription. In this connection, I wish to ask the Minister whether it is feasible to establish a medicine and drug database on-line network to integrate patients' prescription record for all Government pharmacies, perhaps initially for the Government pharmacies, and later private pharmacies can be linked to it. If it is not feasible, whether the existing MediNet system can be expanded to provide such a facility. I believe the establishment of such a network will enable pharmacies to know immediately whether the patient already has a prescription for the same medication or whether it would interact with another drug a patient may be taking. It also can help to prevent prescription drug problems that may lead to hospitalisation.

The Minister of State for Health (Dr Aline K. Wong): Sir, the Ministry of Health and the National Computer Board have already set up a medical network called MediNet which Mr Tong referred to. MediNet provides a wide range of information for all health care professionals. Our Government hospitals as well as health establishments are subscribing to this system. Most of the information which is relevant for pharmacy operations has already been identified for inclusion in MediNet. Some of the information is already on-line, others would be included at a later stage. Already in operation is prescribing and product information which is listed in the Drug Index of Malaysia and Singapore as well as information on poisons which are commonly found in households as well as in industries.

The next step we will take is to facilitate the electronic procurement of pharmaceutical items and medical supplies and so on. Later on, if we want to, we would be looking into the establishment of a register of western drugs and so forth. But Mr Tong's suggestion is to have a computer network to link up the patient's drug profile so that the pharmacist, in dispensing a drug, would have immediate access to whatever drugs the patient has taken before and, therefore, will be able to tell whether there could be drug interaction, adverse effects of new prescriptions and so on. At the moment, the Ministry does not think that such a drug network is necessary for the following reasons:

Presently, most of the prescriptions are dispensed at the clinics or hospitals visited by the patient, as Mr Tong rightly pointed out. The information on previous drugs is actually on the patient's records and it is available to the pharmacist. If a patient goes to an outside retail pharmacy for over-the-counter drugs, the pharmacist can obtain the names of the drugs that he is already taking because now, by law, all drugs which are dispensed must be labelled. So the patient is able to show the pharmacist what drugs he has been taking. On top of that, we have already a drug allergy alert system called the Medik Awas card. So if there are patients who have certain conditions that would render them very susceptible to certain drug reactions, allergies and so forth, they also carry this Medik Awas card with them.

[Mr Deputy Speaker in the Chair]

5.09 pm

The Minister of State for Health (Dr Aline K. Wong): Overall, if we want to computerise the patients' drug profiles, I think the more practical solution is to use the so-called smart card technology so that the patients can carry on their own person a card which gives the medical record with a history of the medicines they have taken and other kinds of data. Unfortunately, this technology is only at some experimental stage, although in some countries it is in a pretty advanced testing stage. For example, there are pilot projects in France, Japan, Canada, USA, UK, Sweden, Italy and Spain. They are still carrying out the evaluations of this kind of technology.

I believe some of the main problems connected with this kind of smart card technology include not just the question of medical and legal implications, confidentiality and data security, but they have found it very difficult to standardise the type of information to put in. So we are watching the development of their experiments. In fact, the National Computer Board is initiating a study to identify a suitable approach to adopt the smart card technology so that we could have in future an electronic medical record system that would include information on drugs and so on. With that, it will be far more convenient for a patient, and wherever he goes he would be able to allow pharmacists or doctors to access his medical record, drug history and so on. But, first of all, we must see whether these cards exist in other countries and whether it is also feasible for us. So, for the moment, we do not find it necessary to have a drug network.

Mr Tong Kok Yeo: Sir, I thank the Minister of State for her comprehensive reply. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Mr Low Thia Khiang (Hougang): Sir, I beg to move,

That the sum to be allocated for Head P of the Main Estimates be reduced by $10 in respect of Code PD 3300.

(In Mandarin): Sir, the Government has stated that the aim of restructuring Government hospitals is to give them more efficiency in determining their expenditure and better use of their manpower resources. The new Minister for Health has also said that restructuring is more cost effective. From the amount of subventions, we can see that since 1991 we have repeatedly exceeded the estimates. In 1991, we have exceeded by $10 million, in 1992, by $16 million, and in 1993, by $50 million. Why is this so? The previous Minister for Health said that after the restructuring of hospitals they can change their operational methods and implement measures to save costs. I would like to know since then, apart from SGH, what kind of cost saving measures have been implemented by other hospitals. Have these measures caused any inconvenience to the patients and has a standard of medical care been lowered?

Finally, I would like to know what is the shortest and the longest time a patient has to wait before he is seen by a doctor in our hospitals.

Dr Aline Wong: Sir, the purpose of restructuring is to allow the hospitals to have more autonomy so that they can respond more readily to patient demand and come out with more innovative programmes to meet the needs of the patients. Among the hospitals, there is some degree of specialisation. So they have differences in their patient base, so to speak. The process of restructuring has gone on for almost 10 years, since 1985. NUH was the first hospital to be restructured. Stage by stage, we have restructured all the major Government hospitals already.

What is the reason for the increase in subvention year after year? This is because health care costs have increased, the demand has increased, labour costs have increased, more modern equipment and facilities have been introduced, and we have better quality medical services in the restructured hospitals. Thus, even after we have decided on the target subsidy rates, the absolute amount of subsidy will rise year after year. There is no question about that.

What kind of cost-cutting measures have we introduced in the restructuring process? For instance, we have utilised space more effectively. In building new hospitals, we are going highrise because land is expensive. In introducing services, we have streamlined the staff line relationships. So we pay more attention to cost effectiveness of doing things. We have been short of nurses. So what do the restructured hospitals do? Under the civil service system, they cannot hire nurses at different kinds of salary scales. So they have gone into pooling resources, such as sponsoring nursing students at the Nanyang Polytechnic. They have also used more ward assistants and more clerks to take care of administrative work which has hitherto been done by nurses. In this way, nurses can be released for more professional work. So they have introduced various cost-cutting measures.

I believe the Member's concern is that the rise in cost should not go beyond the affordability of the population. Now, we have introduced the concept of capping the revenue. With the capping of the revenue and fixing it at CPI plus X, in future we will be able to control the rise in cost and moderate it. The Member was a member of the Cost Review Committee. He knew the mechanics of how the restructured hospitals work, and he has also read the White Paper and we debated it. So all these cost control measures are in place. It is not that he does not know what we are doing.

As for the standard of medical care, he asked for the waiting time. I am afraid I do not have the figures for the shortest and longest waiting time. I only have the figures for the median, and it is not entirely a satisfactory measure of the amount of waiting time at NUH, SGH and so on. For the restructured hospitals as a whole, the median, I emphasise this is a median, ie, 50% of the patients wait less than this length of time for obtaining specialist outpatient appointments, the median patient waiting time in 1993 was eight days for subsidised patients and six days for private patients. For specialist outpatient clinic consultation, that is, actual waiting in the clinic, the median waiting time was 27 minutes for subsidised patients and 29 minutes for private patients. For elective surgical operations, it was 10 days for subsidised patients, and also 10 days for private patients. With restructuring, we have been able to improve the level of services, including waiting time, and you can also see there is not much difference between the time in which the subsidised patients and the private patients are served. 5.15 pm

Mr Low Thia Khiang: Sir, can I seek two clarifications from the Minister of State? Granted the cost increases in medical technology and operating costs, but did the MOH take into account all these higher costs in its budget? And does this lower estimate than the actual expenditure - I think it is a huge variance - indicate that it is the intention of Government to try and reduce medical expenditure by the Government?

Second clarification. It is also stated in the Budget book that due to more patients being received in the restructured hospitals last year - I suppose business was good - there was a back payment amounting to about $40 million by restructured hospitals. Why was it so?

Lastly, would the Minister of State send me the range of the waiting time?

Dr Aline Wong: When the Member talks about the operating costs, he cannot just talk about the absolute amount of operating costs. A better way is to look at the cost per patient, as expressed by the cost per adjusted patient day. Over the last four years, this cost has increased only by about 7%. So the increase is not drastic. The whole subsidy amount has increased significantly because the number of patients has increased significantly in the restructured hospitals. If the Member would like to know the increase in patient load for the restructured hospitals, I would be able to show him the figures another time. As for the $40 million that he referred to, I wonder if he could show me which page it appeared in the Budget book.

Mr Low Thia Khiang: General description.

Dr Aline Wong: Do you have the page reference?

Mr Low Thia Khiang: In fact, I do not have the Budget book here.

Dr Aline Wong: I am afraid I would not be able to answer him outright. Which figure is he referring to? If he wants to, he could submit a written question on clarification of a particular item in the Budget book.

Mr Low Thia Khiang: There is a reason. It is stated in the Budget book that there is a back payment of about $40 million due to more patients being received by restructured hospitals.

Dr Aline Wong: Can I suggest that the Member table a question and I will answer him?

The Chairman: Mr Low, we are running short of time.

Mr Low Thia Khiang: It is in page 385. I quote from the Budget book:

`The apparent low increase [that is by way of GIA] is due to back payments amounting to $37.62 million for operating subventions to restructured hospitals in FY 93 for the increase in patient load.'

Dr Aline Wong: If it is back payments for patients load, it is self-explanatory. Every year, the restructured hospitals receive a lump sum subvention which is based on the previous year's patient load. So if at the end of year, you have more patients, the Government has to pay back.

Mr Low Thia Khiang: Is the Government paying back to the restructured hospitals or the restructured hospitals paying back to the Government?

Dr Aline Wong: Either way.

Mr Low Thia Khiang: Either way?

The Chairman: Mr Low, could you withdraw your amendment?

Mr Low Thia Khiang: Sir, I withdraw my amendment.

Amendment, by leave, withdrawn.

Mr Loh Meng See: Sir, I beg to move,

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

Sir, the Government has provided more money for the development of facilities for the aged from $18.4 million in FY 93 to $32 million in FY 94. Can the Minister tell us what the facilities for the aged are?

I am pleased to note that there has been an increased number of home visits made in providing nursing care for elderly patients. It seems that the number of home visits will taper off at this level. Have we reached the limit of home nursing service that the elderly need? Are we happy with the current situation or is it because of the limitation of manpower resources that do not enable us to have more visits?

I would like to see more outreach programmes in the primary health care of the elderly. Our polyclinics can devote more resources to look after the elderly.

Can the Minister tell us what will be done to cater to the health needs of the elderly in the future?

Sir, can I move on to the next amendment?

The Chairman: Yes.

Mr Loh Meng See: Sir, I move on to the subject of food and nutrition. Singaporeans eat out a lot. As many couples are working, they are dependent on the food centres and hawker stalls for their cooked food. The Ministry of the Environment has done a good job tightening the hygiene standards of food handlers.

I think it is now time for the Ministry of Health to consider taking the next qualitative step to work out programmes to develop further the skills and knowledge of the food caterers, the cooks and the stallholders on the method of preparation and the nutritional value of the food that they serve. The Ministry may give us a stock answer: let the market decide. But, Sir, I am afraid that we need the Government to help organise and cajole the food caterers and stallholders to play their part in contributing to the healthy diet of Singaporeans in line with the objective of developing a healthy nation.

Will the Ministry take on this enviable food tasting role?

Dr Aline Wong: The $38 million that the MOH will be expending is to help mainly the voluntary welfare organisations which run nursing homes, day care centres and community hospitals. Over the years, especially since we have taken over the administration and supervision of nursing homes, the Ministry of Health has been coordinating the work of these voluntary organisations and we have been granting them financial assistance to the tune of 80% of capital cost and 50% of the recurrent cost. So the $38 million is used mainly for the capital cost of upgrading some nursing homes and also to finance the recurrent cost of others. Actually this is only a part of the overall development plan that we have worked out with the voluntary organisations. Between 1993 and 1996, we will be helping in the redevelopment of 10 projects carried out by the VWOs, and the amount the Government will eventually expend will be much more.

As for the polyclinics and more resources for helping the elderly, Mr Loh knows about the work of our Senior Citizens' Health Care Centres in the polyclinics. These are run by the Home Nursing Foundation but with tremendous support from the Ministry. Yes, we have been able to increase the number of home visits by quite a lot over the last three years, from something like 29,000 to about 40,000. But we have somehow reached a plateau. I think we are already reaching the capacity of our resources.

One major constraint is nurses. We need home visiting nurses but we do not have them, even though MOH is able to second 35 or so nurses to the Home Nursing Foundation. Another constraint which we were able to resolve and therefore raise the number of nursing visits was the transport problem. The health care services programmes for the elderly all over the world know that getting the elderly to the places where service are rendered is a difficult thing to do. So we are trying to further improve on this. But the constraint is mainly our manpower resources.

Hygiene for food handlers, cooks and stallholders - yes, they are under the purview of the Ministry of the Environment. The hawkers, whenever they have to renew their licences, are now required to go through a course on hygiene in food handling. And MOH has taken the opportunity to latch on and make them sit through a talk on nutrition and healthy cooking.

But this is only part of the effort to educate food handlers in cooking more nutritious food, more healthy diet, and so forth. We have been trying to reach out to food retailers, food distributors, fast food restaurant outlets, and we even go down to school canteens, workplace canteens, and help them monitor the quality and nutrition value of the food.

Ultimately, I think we have to depend on the population changing their food eating habits towards more nutritious contents. The Minister has just said earlier on that more education is not necessarily a better thing. But as far as food education and nutrition are concerned, I think there should be more education. The problem is that even after educating them, the people do not necessarily follow. I give you an example. As part of my new responsibilities in the Ministry of Education, I have been going around and visiting schools. One programme I am interested in is nutrition, obesity and the TAF programme. Some schools over the last year have been able to raise the physical fitness of the children. But as far as the percentage of obesity is concerned, they have a hard time in reducing it. They say they saw a dip last year, but this year, it goes up again.

What happens is that you can have additional exercise sessions for the children in school, you can control the quality of the food sold in school canteens, but during the school holidays, the parents feed them the usual food. Once they are out from school, they just go across to the corner where they sell fried chicken wings. So the teachers are saying that they need the cooperation of parents and the public. Our approach to healthy food is, more healthy food is better for everybody. I do not mean to say that we should be so conscious and aware of every bit that we are eating that we should abstain from, say, all eggs because of cholesterol, because they will do harm to our heart. I think we should be able to enjoy eating, but eat moderately.

Mr Loh Meng See: Sir, I withdraw my amendment.

Amendment, by leave, withdrawn. 5.30 pm

Dr Kanwaljit Soin (Nominated Member): Sir, I beg to move,

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

A recent study has been done by the Ministry of Health on adults and dental health in Singapore and this has revealed: (1) only five out of 10 people visited the dentists at least once a year, and 10% of people never visited the dentist at all; (2) there is a high incidence of gum disease in Singapore and this is a major cause of tooth loss in adults. And here I would like to quote Dr Aline Wong herself:

`Some patients who come to our dental clinics have advanced dental disease and large tumours of the oral cavity. Clearly, if we had been able to detect these conditions early, or a patient had been aware enough to seek dental treatment at an earlier stage, the treatment would be less prolonged, complicated and costly.'

In view of all this, it seems to me that annual dental checkups should be encouraged for all adult Singaporeans. And if this fee could be paid from Medisave, it would be money well spent and prevent future serious dental problems causing health costs to go up. So I am suggesting that a ceiling of $100 per year be set for routine dental treatment. This scheme will induce Singaporeans to go for their annual dental checkups. Would the Minister please consider this extended use of Medisave for this very important aspect of preventive health care which is often overlooked in adults?

Dr Aline Wong: Yes, I certainly said in a speech, and probably in many more speeches, about dental health and that people should go for regular dental checkups. My position is that dental health is very much a part of the total health of a person and that is why in our public education on healthy lifestyle, and so on, we have never left out dental health. But I do not think Medisave should be used for dental checkups, and for good reasons. Dental checkups are quite cheap and affordable. Even in the private sector, if you go for a consultation, the average charge is only about $15. Should you need dental X-rays, small ones, $10, scaling, $25. This is within the affordability of most people.

Members know that Medisave is meant for hospitalisation expenses. A person should use it wisely and conserve it as far as possible. For some major dental procedures for which a person has to be hospitalised, we have already allowed for Medisave deduction. But if you were to extend Medisave to dental checkups and, for the same reason, regular health checkups, I am afraid the Medisave balance would be used up much faster and some people may not have enough for old age. If you extend it to dental checkup, then what is there to prevent people from asking that Medisave should also be extended to annual health checkups? Health professionals believe that it is not absolutely necessary that everyone should go for an annual health screening. You should go for opportunistic screening. Comprehensive health screening should be done only once every two to three years.

Dental checkup, yes, every year you should go for one. But since it is so affordable, we should bear the cost out of pocket, instead of opening up Medisave for all kinds of requests and, in the end, we find we do not have enough for ourselves, for our family, and for our old age.

Dr Kanwaljit Soin: I am not persuaded by the Minister's argument because she herself said that annual medical checkups are different from annual dental checkups. In an annual dental checkup, you are looking specifically for gum disease and there is something you can do about it. I beg leave to withdraw my amendment, but I would urge the Minister to consult the Singapore Dental Association and look into this matter.

Amendment, by leave, withdrawn.

The sum of $729,481,420 for Head P ordered to stand part of the Main Estimates.

The sum of $334,383,600 for Head P ordered to stand part of the Development Estimates.

Head S -

The Chairman: Head S - Ministry of Labour. Amendment No. (1), Encik Othman.

Encik Othman bin Haron Eusofe (Marine Parade GRC): Sir, I beg to move,

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

Sir, we have enjoyed another year of industrial harmony. Good labour-management relationship lays the foundation for our economic and industrial success. However, we cannot take our harmonious industrial relations for granted. Instead we must continue to work hard to nurture and strengthen this relationship. To be durable, labour-management relations must be based on mutual trust and respect. We now face keen competition from the NIEs and also our neighbours who have more resources than us. To enhance our competitive advantage, it may be necessary for our companies to restructure and strengthen their organisation. In some cases, they will have to go regional as well to seize the opportunities that are available in the region and elsewhere. It is important that in this climate of intense competition and rapid change with the introduction of new technology and ideas in the workplace that there must be more consultation between management and unions to prepare for the challenges ahead. This will enable problems that are faced by the companies as well as the workers in the face of these challenges to be quickly addressed. The Ministry of Labour must always be alert to this development and take quick action to defuse any potential difficulties. I would like to ask the Minister to outline what is his Ministry's programme or strategy to meet this challenge in this important area of the development of healthy and positive labour-management relations.

Sir, to enhance our competitiveness, employers and unions must give due emphasis to workers' training and productivity improvement. Employers must invest generously in training and provide opportunities and motivation for each and every employee to upgrade. It is important that employer's commitment to workers' upgrading and career development be included in the collective agreements. Therefore, there should be a clause on training in all collective agreements and, where possible, targets should be stated.

Sir, on this subject of training, I would like to turn to the suggestion made by Mr Robert Chua, Nominated MP, during the Budget debate dealing with the restoration of the 1.5% employer's CPF contribution. He has suggested that 1% of this should go into a special employee Education Account. Whenever a worker attends a training programme approved by the SDF, an amount equivalent to the course fee be transferred from this account to the employee's CPF. And if at the end of two years, the worker has not used up the money in this account, the balance should go to the SDF for training of other workers.

Sir, I think we should first establish whether it is the worker who does not want to go for training, or it is the employer who is not training. The feedback we have received is that employers, especially smaller and medium-sized companies, are not training. Secondly, does Mr Robert Chua's proposal mean that smaller employers (who are not training enough) will train if the employees bear the cost of training? Again, here the experience suggests otherwise. Smaller employers have been given training vouchers which pay for 100% of the cost fees of approved in-principle courses but the utilisation rate is very low. This suggests, therefore, that smaller employers have not paid sufficient attention to training.

Sir, however, the CPF Training Account is a good and interesting idea and unions would have no objection if the employers contribute the additional percentage to the employee's Education Account. This must be over and above the 20% employer's contribution. The employer can say how this amount is to be spent. However, if the employer does not train, the balance, after two years' accumulation, is for the employee to decide how he should spend the funds in his account for training courses. The employee must also have the right to take the balance with him if he changes jobs.

Sir, may I also suggest that the Government consider topping up the CPF Training Account each year when there are good budget surpluses, much in the same way as Edusave.

Sir, can I go on to the next amendment?

The Chairman: Yes.

Encik Othman bin Haron Eusofe: Sir, on the review of labour legislation, the Ministry of Labour is currently reviewing the provisions of the Employment Act to keep them relevant in the changing business environment. A Tripartite Committee is now meeting to examine the provisions in the Act to remove rigidities caused by outdated provisions. This exercise is important to help us to be more competitive. However, at the same time, we must have adequate safeguards to promote workers' interests and well-being.

Sir, I would like to ask the Minister whether the Ministry is also taking steps to review the other labour legislation to ensure that they are relevant to changing conditions. Here, I would like to deal specifically with the urgent need to review and to amend the Factories Act, to update safety and health provisions as well as to expand the scope of the Act to cover workplaces where there is hazardous work.

Sir, recently, we had a spate of unfortunate accidents in our shipyards. Two Committees of Inquiry, the "Stolt Spur" and the "Indiana" Committees of Inquiry, were established and they had made recommendations to improve safety systems in our shipyards. These include the need to strengthen the existing permit to work systems and also to require shipyards to conduct independent safety audits. I would like to ask when these recommendations will be implemented. There is urgency for the Ministry to introduce more comprehensive safety and health requirements to protect the workers in the shipbuilding and ship-repairing industry as well as in the other hazardous industries.

Dr John Chen Seow Phun (Hong Kah GRC): Sir, the Ministry has formed a Tripartite Committee to review the Employment Act. In doing so, it has recognised that some provisions in our labour legislation enacted and amended some time ago have become irrelevant and do not meet the needs of our fast changing economy and our prevailing social conditions. While a tripartite review of the Employment Act is under way, and I hope the Minister will later give this House a progress report on that, the Ministry has not indicated whether other labour legislation will be reviewed. 5.45 pm

Sir, our economy and society have become more and more complex and sophisticated day by day. Our approach to labour legislation should be to provide more flexibility in order to meet these complexities. In addition to the Employment Act, I believe there are provisions in other Acts which need to be reviewed. Mr Othman has mentioned the Factories Act.

Let me cite two provisions in the Industrial Relations Act. First, section 16(3) of the Industrial Relations Act provides that when the majority of a union's membership comprises rank and file members, then the union cannot represent those in managerial or executive positions. To address the problems of bogus titles, the Ministry has provided a set of guidelines to help weed out those who are genuinely not executives and hence should be allowed to be represented by the rank and file union. The guidelines, however, do not change the legal position under section 16(3). Executives still cannot be represented by rank and file unions even in cases where there is no discipline and control problem and no conflict of interest.

This law hampers the union's organising efforts and deprives it of a potential source of leadership. The irony is that even when companies have recognised the union's representation of executives, the Industrial Arbitration Court cannot certify a collective agreement which covers both categories of workers, because of section 16(3). Should we therefore review the law and remove the restriction?

Second, under section 25, pioneer status companies covered under the Economic Expansion Incentives (Relief from Income Tax) Act and other companies covered under section 25(2) are prohibited from granting terms and conditions of service which are more favourable than those stipulated under Part IV of the Employment Act, such as annual leave, sick leave, etc. In view of Singapore's rapid economic growth and tight labour market, companies that do not provide good benefits cannot attract staff. Hence, many had asked for exemption from this provision. But the irony of this provision is that the minimum terms and conditions of service provided in the Employment Act became the maximum that are allowed under this provision of the Industrial Relations Act. This does not provide the flexibility that we are looking for in today's context. Again, this provision was introduced in 1968 and we need to review whether it has become irrelevant.

Sir, there are other Acts which may also need to be refined. May I know whether the Minister intends to do so?

Mr Robert Chua Teck Chew (Nominated Member): Sir, before I begin, may I refer to Mr Othman's suggestion on the employer education account. I would like to suggest that this matter be deliberated by the National Wages Council where Government, unions and employers are represented.

Sir, the economy grew at 9.9% last year and the manufacturing sector posted a 9.8% gain over 1992. Businessmen are concerned that such growth will once again demand more workers and consequently the labour market will tighten further and increase labour costs. Companies' growth potential will then depend on the availability of workers and they may have to look for more foreign workers to meet their expansion programmes. Firstly, will the Minister please inform Members of the House whether his Ministry intends to revise the foreign worker policy? And, if so, can his Ministry give the private sector advance notice of any proposed changes so as to facilitate the formulation of corporate strategies? Such information will enable the Singapore companies to plan their expansion or investment projects and help them decide whether to locate such projects locally or overseas.

Secondly, whether the Minister is prepared to liberalise the waiver of the foreign workers' levy for those companies which have invested overseas and plan to bring their foreign workers to Singapore for training for a period of up to six months or more. Presently, the number of foreign workers a company can bring back for training is limited to 10% of the company's local workforce. This is too restrictive and not practical as companies investing overseas quite often also try to minimize their workforce in Singapore. Will the Minister consider increasing this 10% limit and adopting a more flexible and pragmatic approach to helping the companies overcome this problem?

Dr Kanwaljit Soin: Sir, from the last official estimate, there are about 65,000 foreign domestic workers in Singapore. These workers work in close proximity with their employers and thus are vulnerable to abuse by their employers. The welfare of these domestic workers is further threatened by the lack of an employment contract that protects their interests. It is not uncommon to hear about cases of abuse of domestic maids. Instances of abuse range from non-provision of meals to cheating and hoarding of salaries, no rest days and inadequate hours of sleep. All these complaints relate to the welfare and well-being of the worker. They are not related to the job content which deals with the various job duties that a maid has to do, eg, child care, housekeeping, marketing, etc. I agree with the Minister that it may be difficult to draw up an employment contract that specifies job duties, but it should be possible to draw up a contract that specifies minimum welfare for the foreign maid.

Sir, work is always a human practice and never just an economic transaction. The Ministry of Labour could set up minimum standards of welfare and these would guide Singaporeans who are employing maids for the first time to ensure that there is adequate enforcement. I would like to forward a suggestion made by a Straits Times journalist, Ms Tan Sai Siong. She said that just like inspectors are sent to factories to ensure that safety regulations are kept, the Ministry of Labour could also send inspectors at random to homes to check on the maid's well-being. No more than a fraction of the homes need to be visited, but the possibility of such visits would be a useful deterrence against ill treatment of the foreign maid. Most of our foreign domestic maids come from our neighbouring countries with whom we have economic ties. And the way we treat their nationals will not only affect our economic relationship but will also reflect on our Asian values of morality and hospitality for our guest workers. Would the Minister, therefore, reconsider his decision and institute a minimum contract of welfare for foreign domestic workers?

Encik Othman bin Haron Eusofe: Sir, the GPC for Labour has already stated our support for the CPF Minimum Sum scheme. I would like to ask the Minister to consider another proposal, ie, whether he will consider the establishment of another authority or board to work on the policy and management of the Minimum Sum and Retirement Account in the CPF. This authority can then focus on the need to ensure our aged will have sufficient funds to meet their old-age requirements, whether it is financial, medical or other needs. The CPF Board can then concentrate on the other aspects of the CPF which is now being liberalised for other uses like housing, investment and education.

As we are a fast-aging population, we need to provide more resources for the needs of the aged. However, unlike the West which is being crippled by the burden of the welfare state system which has to be financed by taxes, we are putting in place a scheme to provide for our old age by our own savings and hard work. Sir, good returns given by the scheme can motivate workers to contribute more to the Minimum Sum scheme. And in this way, they can continue to have a good quality of life in their older years.

This authority or board can also work with the Ministry of Health as well as the Ministry of Community Development on a comprehensive policy to serve the financial, medical, emotional and other needs of the aged.

Mr Chng Hee Kok (Tampines GRC): Sir, I support the Minimum Sum scheme that has been proposed by the Ministry of Labour.

Actually, when we consider the $80,000 set at today's prices it is nominal value. The real increase in the Minimum Sum is really not very substantial, especially if we take into account the fact that inflation this year, as the Minister for Trade and Industry has said, is 5.5% and for subsequent years it may be about 2.5%-3%.

The other factor that will minimise this sum is the fact that the Minister for Finance has already announced that the Retirement Account will attract an additional interest of 1.25%. I will be raising this matter under another amendment later on and will suggest that the 1.25% is, in fact, too little. This sum of money, which is set aside for a very long term and cannot be used for public housing or private housing, should attract even a higher rate of return in view of the fact that the Government is investing this sum of money and making good returns. I will take it up under a separate topic later on.

My main concern on the minimum sum is the raising of the age in which the money can be released from the Retirement Account to correspond with the retirement age. The problem is that as the retirement age is raised, not all Singaporeans will be able to work to the retirement age. In other words, with advancing age, there is a danger that medical and other problems multiply and, as a result, a number of Singaporeans will not be able to work until retirement age. This being the case, there will be a time lapse of several years when the man actually leaves his job and has to wait to collect some money from his Retirement Account. I wonder what is the Minister going to do about this group of people.

The second suggestion I have on the Minimum Sum is about the Minimum Sum Top-Up Scheme. We have, at the moment, for tax purposes, allowed a taxpayer to top up his parent's CPF Minimum Sum, ie, the taxpayer is able to deduct that sum of money which he puts into his parent's account against his taxes. I shall like the Minister to consider a change now that we are also concerned about the spouses as well in view of his recent announcement. Will he also extend this Minimum Sum Top-Up Scheme to include spouses, other than the parents? In other words, a taxpayer should also be allowed or encouraged to top-up the Minimum Sum account of his spouse? 5.59 pm

The Chairman: We have one minute more. Do I have the agreement of Members to adjourn now?

Hon. Members indicated assent.

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

The Minister for Labour (Dr Lee Boon Yang): Sir, I beg to report that the Committee of Supply has made further progress on the Estimates for the financial year 1994/1995, and ask leave to sit again tomorrow.

Mr Deputy Speaker: So be it.