HEAD O - MINISTRY OF HEALTH (cont.)

Head O - Ministry of Health (cont.) -

Resumption of Debate on Question (16th March, 2004),

"That the total sum to be allocated for Head O of the Main Estimates be reduced by $100." - [Dr Lily Neo].

Question again proposed.

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Means Testing

Mr Gan Kim Yong (Holland-Bukit Panjang): **** Sir, the Government has proposed the introduction of means testing in healthcare services. I agree that with the given limited resources, we must refine our subsidy system to ensure that those who need it most will get it. I believe means testing is a workable service. However, the Ministry has not provided sufficient details on the proposed system. It is a bit like watching a mystery movie - you are kept in suspense until the end. Many Singaporeans are confused and concerned. For example, they do not know who will be affected by the change and whether they are in the low income group that will benefit from it, or they are in the high income group that will have to pay more in time to come. They also do not know how much more they have to pay. Sir, this known/unknown is very unsettling, and I hope the Ministry can disclose more details as soon as they are available.

I have received feedback from some of my residents. They think that the Ministry is using this means testing to reduce the overall Government subsidy because of the budget deficit. I think the Ministry should clarify its intention so that there will be no misunderstanding. In working out the details of the means testing, I would like to urge the Ministry to define the qualifying criteria clearly. Income should not be the only factor. Family obligations, such as handicapped family members, mortgage obligations, etc, should also be factored in. As I mentioned earlier, we should adopt a tiered system. I would suggest the Ministry studies similar systems implemented in other countries so that we can develop a comprehensive, fair and transparent system. I hope the Ministry will also leave room for some flexibility to cater for exceptional cases. In the introduction of means testing, the higher income group must expect lower

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subsidies. It would, therefore, be crucial that they be covered by some form of healthcare insurance. Therefore, it would be timely to review the MediShield scheme for this purpose.

Lastly, communication is vital. I would urge the Ministry to conduct extensive public consultation so that the final scheme would take into account feedback from all segments of the population. The Ministry must also take pains to explain the scheme to the people to ensure acceptance. In this regard, I am sure grassroots leaders and MPs like us would be more than happy to help.

Dr Michael Lim Chun Leng (Pasir Ris-Punggol): Sir, means testing is a means of trying to reduce the subsidy to those who are more able to afford healthcare services. However, knowing how the healthcare system works, I really have very bad vibes about means testing for healthcare services at an acute general hospital. I will give you 10 good reasons why we have to think very carefully before considering implementing means testing.

(1) Penalising those who pay the most taxes by increasing their healthcare cost sends the wrong signals. This is not about giving tens of dollars in S&C rebates per household. This is about tens of thousands of dollars in cost per person.

(2) Being hospitalised is not a vacation. It is neither an option nor a choice. You go into the hospital because you have to, and not because you want to.

(3) Using household income or per capita income is not the solution as healthcare cost is personal and we cannot force the person to bear another person's healthcare bill.

(4) As families get smaller, the children have to bear a significantly larger

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burden to support elderly parents, leaving them with little savings and disposable income.

(5) Healthcare costs are unpredictable, and when a complication arises, the cost can escalate significantly. Every percentage point in subsidy can mean a lot to most middle income families.

(6) I believe it is going to be a major public relations disaster. The Ministry stands to lose a lot of goodwill that the Ministry has built over the years.

(7) There are too many variables and I cannot think of any simple formula. What it means is that there will be a lot of unhappy patients.

(8) To do means testing for patients will require an entire bureaucracy that will have to manage a very unhappy public that have failed the means test. It reminds me of Casemix. The Ministry had spent millions of dollars on IT cost, man-hours and employing new staff. Yet, till this day, few believe that it has translated to any real tangible improvements in the healthcare delivered to the man-in-the-street.

(9) Is the Ministry prepared to be totally transparent about their assumptions and methods for means testing?

(10) Is the Ministry able to show significant real cost savings from this exercise?

One comment that has been made is that Singapore is the only country in the world where the public hospitals have better finishes than the private hospitals. There are many areas where we can save cost, and I hope that we are not barking up the wrong tree and being penny-wise and pound-foolish. I would urge caution in rushing into means testing. I would like to suggest that the Minister considers

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setting up a committee to study this matter very carefully before making a decision. If the Minister cannot convince this House, how can the public be convinced?

Mdm Ho Geok Choo (West Coast): Sir, much has been said recently about the need to revise hospital charges so as to better reflect the affordability of patients and their families to pay for the cost of their hospital stay. The main criterion by which affordability is determined appears to be solely that of income. Sir, the ground has raised, through feedback, a number of concerns with respect to the proposal to make changes to the proportion of subsidies, by the income of the patients and/or their families.

Sir, first, is the question of income and affordability. The assumption that both of them are synonymous appears to be an unwarranted one. The high incomes that some patients earn could very well be spread out across very many family members who are dependent on the income of the breadwinner for their maintenance and sustenance. Whatever is done to change the manner by which hospital fees are to be charged will, in my view, have to take into consideration a whole range of factors, other than income by which to gauge the ability or otherwise of patients to pay.

Second, Sir, is the question of fairness. If high income patients are made to pay for the subsidised wards, then the issue of double payment would crop up for high income patients are paying higher taxes, part of which goes to the subsidies that patients staying in Class C and Class B2 get to enjoy. If they are made to pay a higher fee for their wards, then they would effectively be paying twice for the cost that they incurred. Will the Minister reconsider this scheme to ascertain its desirability from the perspective of ensuring the efficient use of our resources and from that of fairness?

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My other question to the Minister is: if we use income as the main criterion for means testing, are there mechanisms in place for individuals to explain why they should be getting Government subsidies, even though their income would require them to pay more for the class of ward that they are staying in? From what I gather, in some countries that had adopted means testing as a way to determine the amount of subsidy that patients enjoy, mechanisms are put in place that permit patients and their families to explain more fully the specifics of their family situation. I think this is only fair because income alone does not indicate the ability of the family to pay for their healthcare cost. And so my question is: would the Minister adopt a more liberal and open approach to the determination of affordability, with income perhaps as one determinant of affordability and not the only determinant? And would the Minister consider putting in place mechanisms that would allow patients or their family members to explain the financial situation they are in?

Mr Steve Chia Kiah Hong (Non-Constituency Member): Sir, there is alarm among many people that means testing is another mechanism for the Government to reduce its expenditure on healthcare over the longer term. Specifically, there is great concern among the middle income group that their healthcare cost is going to rise with this means testing procedure. I hope the Minister can provide some answers to these two questions.

(1) How will MOH determine how best to start means testing? Will the administrative cost for carrying out means testing outweigh whatever savings it could derive?

(2) How will MOH know how much a patient earns? Will it be by personal declaration or will it be through access of the

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IRAS records? If it is by declaration, how does the Ministry intend to verify whatever is declared as genuine? But if it is through the IRAS records, many more people will be even more alarmed as these earning figures are very private details of the citizens and IRAS has no right to disclose such figures. What is the Ministry's assurance on this matter?

Sir, citizens pay taxes for Government to provide certain essential services like healthcare. The Government should see subsidising healthcare as part of the essential services it provides to the citizens. How can the Government ask for double payments from the citizens, once, through taxes and then, again, through selective higher co-payment through means testing? Although I concede that it looks unfair for high income patients to enjoy the same 80% subsidy as poorer patients when staying in a Class C ward, I would like to ask the Minister further. How does he intend to define the rich and the high income group? Is it the top 20% earners of our population? Or is it the top 20% plus the middle 50% of our population, making 70% of our total population? Or is it somewhere in between? I hope the Minister can be more specific about the definition of "high income".

Mr A Nithiah Nandan (Nominated Member): Sir, the last three years' statistics have shown an increase in the number of patients using subsidised wards in Government or restructured hospitals. These developments may have prompted the Government to consider the introduction of means testing. However, it must be noted that these developments have a correlation with the prevailing economic condition. I do agree that subsidised medical treatment should go mainly to the low income, the poor and the needy. I wish to strongly suggest that the current subsidy level and cost should remain as it is so as not to deprive the group of citizens of their medical

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needs. Sir, many Singaporeans have been worried by this term "well off". It has not been clearly defined. Different people may mean different things when you say "well off". So I think the Government has to clearly explain on this point.

Sir, we should also not ignore the plight of the middle income workers in managing healthcare cost for themselves and their dependants. A number of such workers have been affected by the economic downturn. At the same time, we should study the reasons deterring such workers from using non-subsidised wards, besides the high cost of such wards. Take, for instance, the B1 Class wards. Even if one were to use Medisave, he still needs to top it up with cash deposit. For example, if one is going for a Table 1 surgery in SGH, the cash deposit needed is about $1,000. And for Table 7 the cash deposit needed is $3,800.

This clearly shows how much of Medisave one can actually claim. The rest has to be forked out.

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This is not the end, Sir. Once he is discharged and he goes for follow-up treatment at the specialist outpatient clinic, the cash needed could be considerable. It will be much more if one is suffering from a chronic illness.

This need for cash deposit should be reviewed, and the use of Medisave should be considered for expensive outpatient treatment. Another factor to be reviewed is the difficulty one faces if he chooses to downgrade to a subsidised ward later if he faces hardship.

The plight of the middle-income workers with insufficient Medisave accounts to cater to their medical needs and their dependants should also be taken into account.

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Sir, I wish to urge the Minister to consider these factors mentioned earlier when details of means testing are worked out. And, at the same time, the basic medical scheme should be reviewed.

Mr Low Thia Khiang (Hougang): Sir, although I agree with the principle that medical subsidy should be given to those who are really in need, the question is: who is qualified for the so-called "really in need"? Means testing is also a departure from the current principle of Government providing affordable basic healthcare and the patient decides which class of ward is affordable to him or her. With means testing, the affordability of a patient is now dictated by the Government. Although the Government could argue that the patient could still decide which class of ward he or she wishes to be admitted, the patient who is deemed not qualified for the lower class ward will end up paying more.

The Government said that it is unfair for high-income patients to enjoy some 80% subsidy as poorer patients. Can we have some statistical data to show what income level of patients use Class C wards? What is the extent of the problem? Could the scenario be that of people who are deemed rich by the Government, but the healthcare cost is too high, and they are not able to afford to go to a higher class ward? In other words, decreased affordability in health care forces more people to opt for Class C wards.

DPM Lee painted two undesirable scenarios that in order to maintain the current level of healthcare service, either the Government has to spend a lot more, resulting in a tax raise, or the quality of healthcare provided will be lowered. Why must the Government's expenditure on basic healthcare service fall under these two paradigms? Is the self-professed

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highly capable and thus worth to be paid a million dollars and Government unable to continue to provide basic healthcare? May I know how much is the Government expected to save in this healthcare expenditure by implementing means testing? Is it not the Government's fundamental responsibility after collecting taxes to provide an affordable basic healthcare service for the public good, regardless of social and financial status? Here I am referring to Class C wards.

I believe that, eventually, the notion of affordability via means testing will be felt by the bulk of Singaporeans who largely belong to the "not really in need class." I would like to end by quoting a Straits Times reader, Mrs Teo Lai Ching, who was quoted to have said that "she is not rich enough not to be affected, and not poor enough to qualify for help."

Subsidised Wards

Mr Andy Gan Lai Chiang (Marine Parade): Sir, cost issues on healthcare will never go away, as healthcare is a highly skilled and highly personalised service. High standards of medical services never come cheap, especially as new medical equipment and drugs are being introduced regularly. Furthermore, as our population ages, there will be a greater need for more medical services. And with higher expectations, greater costs will be incurred. The minimum level of medical services rises as the population grows to accept a higher level of medical care. Hence, I support subsidised class wards in general, as most people cannot afford modern medical and hospital services.

As affordability differs from one person to another, means testing is necessary to determine the level of subsidy that one is entitled to. Means testing has already been practised in restructured hospitals. It is also carried out for patients who need to be referred

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to community hospitals or who apply for Medifund. Having means testing will ensure that those who are least able to pay have the greatest help from the State.

However, medical care is not just about balancing cost and revenue. It requires finesse to manage people's expectations. The greatest drawback of means testing is that it transfers the power to choose from the individual to the State. Whilst I applaud the Ministry's good intention of making sure that the needy gets the maximum help, the Ministry should also make efforts to reassure the public that their interest will be looked after, no matter which level of income they fall into.

Individuals that fall into the middle income bracket usually end up being squeezed in two ways. They do not qualify for subsidy nor can they afford the high cost. The reasons for Class C wards need to be reiterated and perhaps regularly reviewed to meet changing economic and social norms. It is equally important that at the time of admission, the inbuilt administrative system takes the individual's prevailing circumstances into consideration. Estimated total hospital charges together with hospital fees should be made known to the patient, even if he or she is entitled to a higher subsidy, as the patient's share of cost may be too high even for some to bear. For example, if a patient is out of job and cash poor, this should be reflected when the patient is being considered for subsidy.

We should be careful against creating excessive bureaucracy in carrying out means testing. Processes should be simplified and patient's interest should be placed first. Perhaps the human touch should be reprioritised to a higher plane of importance.

Medical Subsidy

Dr Wang Kai Yuen (Bukit Timah): Sir, within living memory, a free public

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healthcare has always been a safety net provided by the Government. To many Singaporeans, this is being viewed as a right of citizenship. To others, it is being viewed as an entitlement that they have earned after a life-time of paying taxes. Of course, if a person chooses not to be treated in a Class C ward, he does so on his own free will. With means testing, this right to medical subsidies is being taken away from him. This is a big step affecting every Singaporean and a step not to be taken lightly.

In the deliberation of medical subsidies conducted by the Feedback Unit, there emerged a view from the discussions that perhaps the amount of subsidy a patient would have received in a Class C ward should be credited to him whenever he is hospitalised. So, if he so chooses, he could be warded in a better ward in a public hospital or even in a private hospital. Then he could chip in his credit. This is more or less the same concept the Ministry has adopted for some outpatient visits to private clinics. This way, if we adopt it, everyone is happy. There is no need to introduce means testing.

Sir, I think this school of thought is flawed, dangerous and reflects a self-centred view of the individual. I believe healthcare is not a buffet meal. Healthcare subsidy should be targeted at those who really need it. To pursue the viewpoint that healthcare subsidy should be credited would be simply ludicrous because we will be taxing ourselves to pay for our own needs. I think it is important for the Minister to explain clearly and convincingly why introducing means testing is necessary and why it is good for everyone in Singapore.

Mdm Ho Geok Choo: Sir, Singapore currently spends slightly more than 3% of our GDP on healthcare. Contrast this with the 14.7% of GDP spent on healthcare in the US and 6-10% in other developed nations, it would appear that we are

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containing our healthcare costs quite well. However, it is quite evident that the cost of medical treatment in Singapore has been rising to the point that we have priced ourselves out of the regional healthcare market.

The Report of the Health Services Working Group of the Economic Review Committee shows that neighbouring countries like Malaysia and Thailand are attracting more foreign patients to their medical facilities. Even Indonesians, who have traditionally come to Singapore for their medical care, are also going to Malaysia to get cheaper treatment. More importantly and worryingly, Singaporeans are feeling the pinch of having to pay more for healthcare.

Recently, published data on hospital charges show that facilities like Alexandra and Changi Hospitals, generally thought to be cost-effective regional hospitals, are not as cheap as they are perceived to be. In fact, prices for certain procedures at unsubsidised rates may be obtained more competitively at private hospitals. Well, taken in this context and with some reconsideration of determinants, I suppose the advent of means testing to determine the eligibility of patients to get subsidised care can be seen as a timely one.

The Minister for Health has stated that the savings from not subsidising the better off will help put off annual increases in C Class rates. Linking the healthcare subsidy to a needy individual as opposed to a bed category will also allow the subsidy to be portable, as recommended by the Health Services Working Group. Patients who are means tested and receive a subsidy can choose to be treated in public or private hospitals. We should compete on the basis of price and care. The resulting market competition amongst public and private hospitals should lead to more cost-

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effective pricing by the hospital care providers. Therefore, my question to the Minister is: since the recommendations of the Health Services Working Group were accepted in full by the Government, does the Ministry of Health intend to make the healthcare subsidy portable?

Medisave

Dr Chong Weng Chiew (Tanjong Pagar): Sir, I would be talking about the usage of Medisave for home care.

Singapore has a rapidly aging population and, as we all know, with fast rising healthcare cost. Domiciliary medical and nursing care which is commonly known as home care is one of the best ways to help curb costs. This is because home care allows patients to be discharged earlier and yet the medical team can provide monitoring as well as attending to these patients in the comfort of their homes. Also, many admissions to hospitals can be prevented and minimised with the provision of home care.

I propose that the Minister reconsider the current position and allow Medisave to be used to pay for home care services. The reasons are compelling. Firstly, the trends in medical treatment are changing. Technology has made what was impossible previously accessible and convenient today. Secondly, due to the restriction of the use of Medisave, patients who could actually be treated at home currently choose more expensive treatment in hospitals. Why? Obviously, it is because they have limited cash savings and they could use Medisave in hospitals but not for home care currently.

We have placed an additional burden on such elderly patients. And as custodians of their Medisave funds, it would be irresponsible for us to compel them to use them up more quickly than

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what is necessary. The Ministry has indicated that home care is the way to go for an aging population like ours. It is already funding operators of home care services currently. Thus, it is only logical that patients be allowed to use Medisave to pay for home care services.

It was mentioned before that Medisave is for the use of catastrophic diseases. However, if we are going to prevent catastrophic diseases through the provision of home care, should we not allow Medisave to be used for home care?

Mdm Halimah Yacob (Jurong): Sir, currently, there are very limited and strict uses for the Medisave account. Singaporeans can use their Medisave savings to pay for the premiums of MediShield or Medisave-approved insurance schemes. They are also allowed to pay for certain hospital and outpatient fees up to a certain limit.

Contrary to popular belief, Medisave is not an insurance scheme but it is essentially a savings scheme. As we are now in the midst of reviewing some of our healthcare policies, a fundamental change being the idea of means testing for hospital care, I would like to ask the Minister whether the Government will consider allowing greater flexibility in the use of Medisave. I think it is time that the Government allowed Medisave to be used for buying some type of healthcare policies, which CPF members are now using cash to buy, because they cannot use their Medisave. This makes sense because the deductible quantum under the MediShield or any of the approved plan is high. So MediShield does not cover a person from the first dollar of hospitalisation. In fact, MediShield covers catastrophic illnesses. It is designed to cover someone who suffers a prolonged illness or hospitalisation. But if a person is hospitalised for only a few days without any surgery, MediShield may not pay a cent. As healthcare cost is not likely to

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decrease, the burden for Singaporeans who are not adequately insured will get worse. So the Ministry of Health should consider allowing the use of Medisave to purchase some healthcare policies to top up the MediShield, subject to whatever safeguards it deems necessary. I hope the Minster will look into that.

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The second area of review,

which I hope the Minister could look into, is in allowing greater flexibility for the use of Medisave funds for the fourth and subsequent children as well as paying for the in-vitro fertilisation treatment. Currently, Medisave can be used for only up to the third child and there are restrictions when we use our Medisave for IVF. But with the current emphasis on procreation, there is clearly a need to consider relaxing these restrictions. It does not make sense to encourage women to give birth but, at the same time, even when they have money in their Medisave, they cannot use it and will have to use their own cash.

Healthcare Financing/Medical Insurance

Dr Lily Neo (Jalan Besar): Sir, may I beseech the MOH to look into healthcare financing in Singapore to ease the pain of healthcare expense? As I have said before in this House, the present Medisave system where we save and pay as we go financing for healthcare is becoming less adequate to serve our needs. By retirement stage, healthcare costs are expected to be higher. We need to make drastic changes here now for a better tomorrow.

Savings alone for healthcare financing is not ideal anymore and may cost too much for each individual to bear, especially when meeting critical and severe diseases that may wipe out all the savings in no time. Sir, "Risk Pooling in Healthcare Finance" is a good

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consideration. "Risk pooling" is required because of the large uncertainty in the magnitude and timing of an individual's healthcare expenditure needs. It implies the redistributive functions, from the healthy to the sick and from the productive to the unproductive stage of the life cycle. The arguments in favour of "risk pooling" in healthcare reflect equity and efficiency considerations. Fear of over-consumption can be minimised by adopting best practices.

MOH needs to assume this role of "stewardship" of healthcare financing urgently to cater for rising health expenditure, demographic change of an ageing society and technical innovation.

In our health insurance expansion planning, some incentives should be incorporated to rally Singaporeans towards keeping fit and healthy. The other issue in the health insurance expansion is to ensure coverage for Singaporeans when they are in dire need, such as when they are without jobs and between jobs. Another consideration is on our pro-natalist importance where couples are insured for procreation anomalies such as complicated pregnancies, premature babies and infertility.

Two important areas to ensure success of such "risk pooling" policy are, firstly, universal coverage to involve the whole population and, secondly, on the provider payment side, reimbursement should be according to a nationally uniform fee schedule.

Mr Yeo Guat Kwang (Aljunied): Sir, our healthcare system is based on 3Ms - Medisave, MediShield and Medifund. Moving ahead, we have to strengthen our healthcare financing system to deal with the new employment situation and the ageing population. Before implementing means testing, we have to first strengthen our medical healthcare social safety net,

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ie, to put in place a national basic medical insurance scheme. To make our medical benefits portable, the basic infrastructure is again a national basic healthcare insurance scheme.

For the same reason that most states require drivers to carry car insurance, the Government should consider a basic tier medical insurance to cover all Singaporeans. For those who can afford, they can add on to enhance its coverage by paying more premiums. For those who cannot afford, the Government should consider giving some public subsidies. This will facilitate fully portable coverage to all.

Take those who have joined the civil service after 1994, for example. With the additional 1% Medisave contribution as in-patient medical benefit given to them, at the end of 10 years now, the sum comes up to only about one-and-a-half months' salary. Is it enough to cover an in-patient episode? I do not think so.

Facing the challenges of globalisation, the labour movement in Singapore has been strongly advocating portable medical benefits. In a way, the MediShield scheme is a portable scheme. It covers people up to 80 years. We hope the Ministry will consider the several suggestions that the labour movement put forward to the Ministry for consideration to enhance the MediShield Scheme. The Government should reinforce our healthcare financing system through allowing better use of Medisave, through expanding the scope of MediShield and, more importantly, integrate the existing employer-based medical benefit with MediShield to reduce duplication.

I am particularly concerned that due to the duplication with the employer-based medical benefits, about 270,000 workers, in fact, had opted out of MediShield.

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What happens when all these "opt-out" workers are retrenched? He or she will actually end up without any medical coverage.

I also understand that about 26% of our resident population is not covered by MediShield. This is largely the non-working spouses and their children, some of the self-employed and the low income people. When they are struck by catastrophic illnesses, their family with be in hardship. I would like to know whether MOH has any plan to bring all Singaporeans under MediShield coverage. I urge the Ministry to expedite its review on MediShield and basic healthcare insurance to strengthen our healthcare financing framework and to facilitate the effective implementation of PMBS to better protect our workers.

Mr A Nithiah Nandan: Sir, the labour movement has raised the issue of portable medical benefits in the past couple of years. To-date, there has been very little progress in this area. Yes, in 1994, the Government did introduce portable medical benefits for civil servants under the MSO scheme. Like the hon. Member Mr Yeo Guat Kwang mentioned, under the MSO scheme, whatever was contributed in the last 10 years could have been wiped off by one serious episode of medical problem. All this while, the only national medical insurance in place is the MediShield insurance scheme, which is neither comprehensive nor sufficient to replace the current medical benefit provided by employers to workers or cater to the increasing cost and address the needs of an ageing society.

Sir, in the last couple of years, a number of retrenchments or early retirement are taking place in many industries in Singapore. In fact, restructuring, reorganisation and merging have resulted in workers losing their jobs early. Many of the retrenched workers are older workers and amongst them, a

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number of them may have medical problems. Such workers are left stranded without the medical benefits provided by their employers. Yes, they could use their Medisave to pay for the inpatient treatment, if they have sufficient funds, but not for costly expensive outpatient treatment.

Due to the economic downturn, workers who have lost their jobs are not covered by a medical benefit scheme. Even for those who are covered by MediShield, the coverage is not comprehensive or adequate to meet their needs. Hence, it is important that workers be covered by medical insurance not only when they are in employment but, more importantly, in between jobs and after their retirement. Such medical insurance should not only cover inpatient but also some major outpatient treatment.

I would like to know whether the Government has plans to review the MediShield insurance scheme or introduce other insurance schemes in the immediate future to address the problem faced by many Singaporeans. If the Government has decided to introduce medical insurance, it must have sufficient mechanism to check the abuse of insurance companies and medical professionals for their own self-interest. The Government should act as a strong gatekeeper. Sir, at the same time, I would also like to urge the Government to consider giving a one-time reprieve to those who have opted out of the medical insurance scheme to rejoin the scheme. As mentioned by the hon. Member Mr Yeo Guat Kwang, about 270,000 have opted out, and there are many non-working Singaporeans who are also not covered by MediShield. We should treat this as a national agenda and give a one-time reprieve.

The Acting Minister for Health (Mr Khaw Boon Wan): Sir, Dr Lily Neo, Mr Gan Kim Yong and many others spoke on

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healthcare cost. In fact, we had just recently, in this House, a short discussion on the same topic. People, all over the world, worry about rising healthcare cost. They want to be sure that, first, good healthcare services are available should they fall sick, and, second, they will have quick access to these services, whether they are rich or poor.

This is totally understandable. With advances in healthcare, patients have become accustomed to thinking that death can be avoided, if only good medical services are rendered in time.

Just last week, I read some media reports about "doctor bashing" in one Chinese province, I think, near Chengdu. Some doctors there had received death threats from relatives of patients who died. One doctor was slashed by a woman with a chopper! Some doctors have had to engage bodyguards. As one doctor put it, and I quote him, "they think we are gods, that we can cure anything". So when such expectations were not met, the relatives got mad with the doctors.

While this is an extreme example, the global trend is one of rising expectations for the best possible medical care to provide a good outcome, regardless of the nature of the illness. Now, this is especially troublesome when it is not matched by an equal willingness to co-pay for the care. As a result, Health Ministers all over the world are expected to do the impossible: provide the highest standard of medical care but at the lowest fee, even better, free. Many politicians do make such a promise, and some voters believe them, only to be disappointed when the promises are not fulfilled. But, meanwhile, public healthcare services deteriorate.

In Singapore, we make no such promise. Right from the beginning, we persuaded Singaporeans to accept co-payment and shared responsibility in

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healthcare. This philosophy is institutionalised in our 3M framework of Medisave, MediShield and Medifund. Our 3M framework is far from perfect, but it is probably the best healthcare financing model you can find in the world today.

Last week, my Ministry published a paper comparing the utilisation of medical services in Singapore with several developed countries. And we did well. We have lower hospital admissions per capita. Our patients generally do not overstay. I know some media commentaries have pointed out that this may be because healthcare here is so expensive that Singaporeans cannot afford to seek treatment, so they stay away from hospitals, like SARS. The logical extension of that argument is that Singaporeans, so deprived of proper healthcare, must therefore be generally sickly and dying prematurely. But if this was so, our life expectancy would not be one of the highest in the world today, having improved from 76 years in 1994 (10 years ago) to 79 years now. Women live longer, past 80 years. We should certainly not get complacent, but I think we can take heart that we have achieved a high standard of health, with lower resources, as compared to others.

But, of course, there is scope for improvement. I have some ideas on how this can be done and I will use the next few months to discuss them thoroughly with Singaporeans.

Today, let me just highlight the key strategies and in that process, I will try to address all the points raised by Members.

Hospitals: Stretch the budget dollar

First, our hospitals have to stretch their budget dollar. They have to learn to do more with less. Among other things, they have to make better use of IT and

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technology to help cut costs, as suggested by Mayor Zainul Abidin yesterday. They should use generic instead of patented drugs, where possible, without compromising safety.

Last year, when I launched Singapore-Medicine, I spoke about how we should strive to be the Toyota in healthcare: to produce the Corollas in healthcare, at low cost, with high reliability and zero defects, if possible.

So I was pleasantly surprised to read in last month's issue (February 14th) of _Hospitals & Health Networks _ (which is an American healthcare magazine), an article about how some American hospitals are adopting the Toyota Production System in their hospitals. They are going all out to eliminate waste,

the Toyota way. Why is waste seen as the root of all evils? For hospitals, wasteful steps add to cost, increase the time to respond to patients, multiply the opportunities for mistakes. And for patients, waste means long waiting, having to move from pillar to post, unnecessary suffering and additional cost.

11.45 am

The article went on to describe what some of these "Toyota-hospitals" are doing to improve the situation to achieve what they describe as the "lean turnaround". And one key strategy is standardisation. As one Chief of Cardiac Surgery put it, "We are crazy about standardisation. We standardise everything and then we standardise our standardisation."

And the article ended with this vision which is worth quoting: "Imagine our healthcare organisations with errors near zero, where everyone has quick access to diagnosis and treatment, where year by year costs are stable or even decreasing, and where revenues are rising. Sounds like a fantasy? The early pioneers in lean

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manufacturing envisioned a similar "fantasy". Those who were bold enough to embrace the lean revolution early (like Toyota ) have their competitors behind."

So I urge our hospitals to get similarly inspired. It is probably difficult for healthcare to match the automobile industry, for the simple reason that patients, unlike automobiles, are not identical. I think we have a short discussion on that also at the last sitting. But I am sure there are valuable lessons that hospitals can learn from the efficient car manufacturers.

Second, we help Singaporeans stretch their Medisave dollars. One of the best things to have happened to Singapore healthcare is Medisave. Every day we work, we save a few dollars of our income for our future hospital bills.

After 20 years of Medisave, we have collectively saved a total of $30,000 million in our Medisave accounts, ie, $30 billion. And it is growing. Every year, about $2.5 billion of Medisave contributions are collected while $800 million, ie, $0.8 billion, are withdrawn to help pay hospital bills and ElderShield/MediShield premiums. Collections exceed withdrawals because we are still a young society, so we are saving for our future aged needs.

Although $30 billion sounds like a big amount, the individual balances of most accounts are not that big. For example, 17%, one in five, of all Medisave accounts have less than $1,000. One trip or two to a Class B2 or C ward and everything could be wiped out. It is for this reason that MOH is very reluctant to allow Medisave to be used for home care, as suggested by Dr Chong Weng Chiew. These home care services are generally still affordable after Government subsidies, and Singaporeans should really preserve their Medisave for more expensive hospitalisation.

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Even the larger Medisave accounts are not that big. And this is because we cap the Medisave balance per account at a maximum of $30,000, which is based on B2/C rates of needs. But a significant portion of Singaporeans in the upper and middle class prefer private or Class A/B1 type of medical services. And they will find their Medisave balances insufficient for their needs.

I would like to help Singaporeans stretch their Medisave dollars. And one effective way is through insurance. Every year, only one in 10 Singaporeans needs to be hospitalised. The trouble is that we do not know whether we are in that 10%. If we were to individually self-insure, in other words, make provisions for this risk of hospitalisation, the cost to each one of us and, also, to Singapore as a whole, would be quite large. But if we all chip in to pay for insurance to collectively cover the risk of this 10% of our population who need hospitalisation, then our individual burden can be reduced considerably. This is, of course, the concept of risk pooling.

Currently, we do allow some pooling of risk via MediShield. So every year, among the 10% who are hospitalised, a small proportion of the patients develop catastrophic illnesses - cancer, organ failure - which require long hospital care and expensive treatment. And hospital bills for such illnesses, even at B2/C rate can be catastrophic. So 14 years ago, we introduced MediShield to allow Singaporeans to share the risk of catastrophic illnesses. And it has worked generally well.

However, many Singaporeans do not quite understand the concept of catastrophic illness insurance, as pointed out by Mr Nithiah and Mdm Halimah. Some Singaporeans think that MediShield would cover all hospitalisation, including the non-catastrophic illnesses. So when

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they find that their MediShield coverage does not cover their short hospital stay, they get pretty unhappy.

My Ministry is studying how we can extend risk pooling beyond MediShield to cover non-catastrophic illnesses with use of Medisave allowed for such premiums. This is an old idea which several MPs, particularly Dr Lily Neo, have been advocating in this House. If implemented, we can tweak it to make employee medical benefits portable, an issue advocated by Mr Yeo Guat Kwang, also for several years. And I hope to be able to turn this old idea into reality. This will benefit all Singaporeans, upper, middle, lower income groups.

Non-catastrophic medical insurance is not new, of course. It is common in the US, Europe , Australia , Japan and many others. But the experience, as pointed out by Dr Gan See Khem yesterday, has often been catastrophic.

Last year, the former California Governor, Gray Davis, lost his job partly because of medical insurance. In the US, for years, the premiums for medical insurance have been rising, double digit percentage, at 12%, 13%, 14%, per annum. Employers are crying out as it adds to their cost and it affects their competitiveness. So they are passing on some of the increases to the employees. Naturally, the employees are crying out too, and they voted in the "Terminator".

The reason why premiums are increasing is that costs and volumes have run wild, and run wild every year. Because of the way they structure their health insurance system, there is very little incentive for patients or doctors to save. As a result, over-consumption by patients and over-servicing by doctors are very common.

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I am not making this up. In 1995, not too long ago, Taiwan introduced a National Health Insurance, providing comprehensive coverage, including for outpatient care. So Mr Nithiah should listen to this carefully. But the scheme has now run into problems - wastage, over-consumption. Just some data. Outpatient visits per person per year in Taiwan is 15. So every month, at least one trip. This is three times the level in Singapore . Outpatient expenditures alone account for two-thirds, two in three, of the total claim amounts. The programme therefore went into deficit. In 1998, payouts exceeded premiums collected by NT$2 billion. This deficit increased to NT$16 billion in 2002. South Korea implemented a similar programme, a few years earlier than Taiwan , and is also facing perennial funding deficits.

So before we rush into this non-catastrophic medical insurance nation-wide, I think we better debate all these downsides thoroughly, make sure we have good mechanisms in place to reduce such risks. And that is why I need a few more months to carefully study the problem and discuss it with Singaporeans extensively. We should take a leaf from motor car repair insurance, which many of us have personal experience with.

For today, let me just lay down the key principles underlying what, I think, a well-designed non-catastrophic illness insurance plan could look like. First, it must have a deductible component. For motor car repairs, insurance does not cover from the first dollar and we have to fork out the first $1,000 before insurance kicks in. Similarly, we should not allow the first dollar coverage for healthcare insurance. In this way, hopefully, we can cut out frivolous claims.

Second, it must have a co-payment element. Patients must co-pay part of the bill. In this way, we cut out abuses like prolonged hospital stays or demand costly

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implants when cheaper alternatives are available.

Third, the premiums must be affordable. As pointed out by several MPs, large insurance pools are generally cheaper to fund than small insurance pools because of economies of scale. To minimise administrative cost, a compulsory national scheme is the best, as pointed out by Dr Lily Neo. It ensures full coverage with the lowest possible premium. It ensures maximum equity and efficiency, so that insurers cannot cherry pick and leave out all those with preconditions or born congenitally sickly. But if there is no consensus for a national compulsory scheme, then we will have to find compromises, which hopefully do not stray too far away from this ideal.

Fourth, it must be financially viable. Premiums collected must more than cover claims, not just for one or two years, but for the long term. Insurers have to build up reserves and this is especially so for a young society like ours. We have an experienced insurance industry in Singapore and we should see how we can leverage on the industry to formulate and operate the schemes.

Fifth, it must offer choices. Different people have different needs. Some are satisfied with Class C; others prefer private hospitals. While we should have a national basic medical plan to which all Singaporeans subscribe, we should allow enhancement schemes as riders - I think that was pointed out by Mr Yeo Guat Kwang - to the basic medical plan, for Singaporeans with higher needs.

Sixth, it should cover only hospitalisation and the equivalent, such as day surgery. I think we better learn from the experiences of Taiwan , Korea , and avoid an extended framework covering all sorts of minor ailments, coughs and colds which can be easily abused. This would also be consistent with our basic

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approach to Medisave, since the intention is to allow the use of Medisave to cover the premium and Medisave is primarily only for hospitalisation.

I have begun the discussion with the industry. Last week, I met a few players from the insurance industry over lunch. And when I shared these views with them, one senior insurer stressed the need to discourage over-charging and over-servicing by doctors and over-consumption by patients. As pointed out by Dr Lily Neo, there must be a national fee schedule to control prices. He was speaking from experience in motor car insurance, and I value such insights.

I welcome more debate and more discussion on this important subject. Let us settle the larger picture of this national basic medical insurance plan before we address other details, like Mr Yeo Guat Kwang's query on how existing employer-based medical insurance could accommodate the proposed national health insurance plan, without duplication, or Dr Lily Neo's proposed insurance to cover complicated pregnancies, or Mr Chay Wai Chuen's proposed

insurance for home nursing.

12.00 noon

But one thing is clear. We should not leave out the self-employed. If they stay out of the 3M framework, they are storing up problems for themselves and their loved ones. CPF Board will be enforcing Medisave contributions by the self-employed, and I hope Singaporeans can accept this need for strict enforcement. Small regular payments via monthly GIRO have helped many taxpayers pay their taxes. Likewise, the self-employed should use GIRO for their Medisave contributions.

The third strategy is for the Government to stretch our subsidy dollar. As Health Minister, Acting or otherwise, I will do my best to secure the largest

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possible budget allocation from the Ministry of Finance. But, realistically, Government money is not unlimited. So, my Ministry will have to stretch the subsidy dollar. How? Means testing.

Many Members have commented on this. Dr Michael Lim gave us 10 reasons why it should not be implemented. On the other hand, Dr Chong Weng Chiew has expressed support and, in fact, urged me to do it as soon as possible. Dr Michael Lim pointed out that the number of well-off Singaporeans opting for B2 and C class wards should be small, and asked if it makes sense to put in place a system to catch such a small minority. Mdm Halimah also questioned if the social cost of means testing justifies the benefit. Mr Yeo Guat Kwang asked for some details, but all of you advised me to be cautious. So, this is clearly a complicated subject and, like non-catastrophic medical insurance, I would take my time to think through the issue, consult widely and hear all views, so that we can come out with a practical scheme.

Dr Lily Neo and Mr Chay Wai Chuen stressed that medical insurance should be in place before implementing means testing, so as to avoid distressing the affected group. I think that is valid.

Mdm Ho Geok Choo and Mr Gan Kim Yong said that the criteria for determining affordability should be multi-dimensional, ie, a range of factors, and not solely dependent on just income level. Family size should be taken into account. At the same time, however, Dr Lily Neo, Dr Ong Seh Hong and Dr Chong Weng Chiew pointed out that the current formula used in nursing homes seems to penalise small families. Dr Chong has two years of ground experience with means testing. That probably explains his confidence and why he recommended that I move faster. But he too noted that the current scheme

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was not perfect and should be refined.

From the various comments, I have distilled several key principles behind what, I think, could be a practical means test scheme.

First, it must be simple to implement. I agree with Dr Ong Seh Hong and many others that we should not end up with a bureaucratic monster. We will, therefore, need to simplify, but, to simplify, inevitably we will have to use proxies to determine whether it is wealth or income. The scheme should cause minimal inconvenience to patients and not delay their treatment. It should not be costly to administer.

Second, it must provide choices. Mr Andy Gan reminded us that if means test results in taking away freedom of choice from patients, that would not be good, and I agree. So, Class C wards should remain open to all Singaporeans, rich or poor. Patients should continue to have the freedom to choose. In fact, there is nothing wrong about the rich going into Class C. Let us not be judgmental about their decisions. Mr Low Thia Khiang asked just now whether there are data. There are. A few weeks ago, I remember, MOH published an occasional paper and there were quite a lot of data in that paper to show the income profile of patients in the various classes. It is a small minority. I think somebody asked the question: who are well off? So it depends on how you define the "well off". It is, from my point of view, still a small minority. But it is not insignificant. And what we are trying to do is to, hopefully, nip the problem in the bud, to avoid a larger problem in the future. Dr Lily Neo and Dr Chong Weng Chiew reminded us to ensure an adequate supply of Class B2 and C beds, which I agree.

Third, it must be fair. The aim of means testing is not to reduce Government subsidies because of the

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current deficit, as suggested by Mr Gan Kim Yong or some other MPs. The aim is to better target our subsidies to those who need them most. Dr Lily Neo and several MPs, eg, Dr Ong Seh Hong and Mr Nithiah Nandan, have spoken about the potential squeeze on the middle income group. I share their concerns, which we will take into account when devising the means test criteria. We will calibrate subsidy levels appropriately, to ensure that hospital bills remain affordable to all Singaporeans. That must always remain the priority.

Fourth, we will be gentle in implementation. With simple rules, there will inevitably be deserving cases which fall through the cracks. Mr Andy Gan made the point that the patient's circumstances prevailing at the time of admission should be taken into account. We must be able to come in promptly when alerted, to sieve out such deserving cases and free them from unnecessary distress. Let me assure Mayor Zainul Abidin that our means test will not be mean. As Mdm Halimah pointed out yesterday, means testing should not be a demeaning process, but should be handled sensitively.

Fifth, it must be transparent. And you know my view about transparency. Mr Gan Kim Yong and Dr Michael Lim called for transparency in implementation. I fully agree. The scheme must make sense to everyone, such that Singaporeans, if they like, are able to compute their own subsidy status.

As this is a complicated subject, let us continue to discuss and suggest more ideas over the next few months. I have created a special section in the Ministry of Health's website to gather all feedback and suggestions. And I intend to continue to work with the Feedback healthcare group to advance this project.

Mr Steve Chia objected to means testing. He asked several details, such

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as, will we be using IRAS data, therefore, breaching confidentiality. What is the cut-off? What do we mean by "well off"? Obviously, those are details that we will have to discuss through over the next few months. He made a point that if we means test out the rich, they will have to pay more. But the rich are also the ones who pay the most in taxes. Are we double taxing? But we are trying to achieve an outcome whereby, because we have to balance our accounts, subsidy is a zero-sum game. So, if I have more subsidy money because I collect more fees, then I can help the poor, I can stretch the subsidy dollar more. If we do not do this, and all rush to go to Class C when they could afford a lower subsidy, then I will first have to raise fees more frequently for all classes, including Class C, or raise taxes more, in which case, we will be going back to this top whatever percent who are the major taxpayers.

So, let us not kid ourselves. We are not magicians here, and my job is to present the facts out into the marketplace so that people can see for themselves. If we are squeezing everybody, making profits, paying doctors and CEOs unrealistic pay and so on, then obviously we are in the wrong. But my job is to try to provide a good level of healthcare in a sustainable manner, and we all know a good level of healthcare does not come cheap.

Mr Low Thia Khiang objected, I think, to means testing. I was flipping through some Hansard records a few months back, when I was asked to take on this job. I am relying on memory here. I am past 50, memory not perfect. I think I recall him making some comments, objecting to the rich becoming subsidised patients through the polyclinics, because our system is, if you are referred by the polyclinics, you are straightaway a subsidised patient. I remember, I think, he made such a comment that those who

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are rich should not be subsidised. But without means testing, how do I then know whether you are rich or poor? On that score, I thought he would then be supporting means testing. But I agree with him details are what count, and we will spend the next few months debating that.

Dr Michael Lim spoke about exporting our medical expertise to the region, especially China and India, and I agree fully with him. He asked how I intend to change the mindset of my colleagues in the Ministry of Health to support such a development. I have already made one major mindset change to incorporate regional medical hub as an MOH priority. Please allow the Ministry of Health to digest that change first. In any case, as the Minister for Health, my priority is to serve the medical needs of Singaporeans first, followed by foreign patients who come here for treatment. And then if I have some time to spare, I will think about how to serve the medical needs of foreigners in their home countries. Meanwhile, I leave it to experts like Dr Michael Lim, to tap that market, championed by MTI and IE Singapore. I will cheer them on the sidelines.

Dr Michael Lim also urged a greater relaxation of advertising rules to allow our doctors and hospitals to market themselves better in the region. He described our current regulatory regime as conservative and outdated - although he did not use those words. My instinct, honed in MTI for seven years, is always for light regulation, because every regulation has a cost, and should be put in only after careful thought.

But in healthcare, which affects life and death and which has major cost implications, it is better to be slightly conservative. In US magazines, prescription drugs like Viagra and Zoccor are now

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widely advertised to lay public. I am not exactly sure if this is a good thing. Earlier, we heard comments on how we should educate patients to accept generic drugs so as to save on cost. Such advertisements by patented drug manufacturers must surely lead to patients demanding such prescriptions from their doctors.

It is, therefore, better that we move carefully, evaluate the impact, and then take further steps. Meanwhile, rules governing advertisements by hospitals will be loosened. Draft rules are in our MOH website for public consultation, and we will move as soon as we have studied the feedback.

Finally, Sir, let me respond to Dr Tan Cheng Bock's passionate call for a greater role for primary healthcare. He felt that primary healthcare is the key to moderating healthcare cost and that, if we remain too hospital-biased, we are barking up the wrong tree. I share his passionate sentiments. That is why, shortly after I joined the Ministry of Health, I appointed a primary healthcare working group, which is still active, with representatives from both the public and private sectors. Their job is to identify gaps in our current systems and come up with innovative ways to manage disease holistically and also to transform primary healthcare services in Singapore.

Our GPs and polyclinic doctors are the unsung heroes and heroines of our healthcare system. They will always get my personal support. I firmly believe that every Singaporean should have a good family physician, ie, someone who knows you, who knows your family well, who will respond to your night calls when warranted, and who will offer you sound advice on which specialist to see and which hospital to go, if you need secondary or tertiary care. A good family physician can help you save money, besides nagging you on your diet,

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waistline and exercises. If you have yet to have one good family physician, better hurry and look for one. A good family physician can also be a good gatekeeper to the rest of the healthcare delivery system.

12.15 pm

Dr Tan Cheng Bock lamented the erosion of this role. I share his observation but I do not think it is because of cluster formation. In fact, one of the objectives of cluster formation is to bridge primary healthcare with the secondary and tertiary healthcare. One example is that I am pushing lifelong Electronic Medical Record (EMR) for every Singaporean: one patient, one medical record, multiple clinics, multiple hospitals. Cluster formation will help us facilitate this transformation.

The key is to bring together like-minded stakeholders and leverage on technology to achieve an integrated ecosystem of healthcare services from primary to tertiary, and back to step-down care. The concept is easy and simple. But to operationalise it is a huge challenge. I have some ideas and some plans for a pilot project to try this out. Later this afternoon, when I respond to the next group of cuts, I will use that opportunity to elaborate on this idea and I will definitely want to tap on Dr Tan Cheng Bock to help bring primary healthcare to the next level of excellence.

As for Dr Tan Cheng Bock's comment on disease outbreaks like SARS, Ministry of Health, post-SARS, is no longer the same as before. We have learnt a lot fighting SARS, we have many battle scars to show for it. While we must not be complacent, we are now more fighting-fit. But Singaporeans must continue to help us out, by doing the simple things like wash your hands, do not touch your eyes, use serving spoon, stretch your body and exercise your heart.

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Mr Low Thia Khiang: Sir, may I seek clarifications from the Minister? The Minister referred to my previous comment in Parliament about polyclinics. Sir, I wish to clarify that I am not objecting to the basic principle that the subsidies in healthcare should be given to those who are really in need. I am aware of means testing for step-down care in the medical service. I have never complained about it.

But, Sir, we must understand that we are now talking about C Class ward in the hospitals. We have to bear in mind that the cost of hospitalisation can be very high. No one really knows, whether you are relatively rich, or you are poor, and how much it will cost you. When people go for means testing, and some fall within the category of "not eligible for Class C ward subsidies", do they really know that they can afford? But affordability is dictated and determined by the Government that thinks they can afford. Is it fair to them? In my view, C Class ward, as it is now, is the last frontier of our social safety net system. If people are not sure whether they can afford, and they fall sick, they can go to C Class ward, and if they really cannot pay, Medifund will pay. I think people will not have so much anxiety. But the moment we change all this, when people fall within the category of non-eligibility, depending on where we set the benchmark, it will cause them a lot of anxieties and it is not being fair to them.

Mdm Halimah Yacob: Sir, I have asked the Minister whether he would consider allowing Medisave to be used for the fourth and subsequent children as well as greater flexibility for IVF use. I believe the Minister has not answered that question.

Mr Steve Chia Kiah Hong: Sir, I thank the Minister for sharing his thinking on healthcare services. I just want to clarify that I did not object to the idea of means testing as claimed by the Minister. But I

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would like to seek an answer and clarification on which the Minister said he is thinking and studying the matter and will give us an answer in a few months' time. I appreciate that.

Dr Chong Weng Chiew: Can I request the Minister to comment on the use of Medisave for home care?

Dr Tan Cheng Bock (Ayer Rajah): Can I ask the Minister? I cannot reconcile the fact ---

The Chairman: What are you asking, Dr Tan? Make your point, please.

Dr Tan Cheng Bock: Because I do not see much primary healthcare funding in this year's Budget, and the Minister has talked so much about it. I just cannot understand. If the Minister advocates this ---

The Chairman: Dr Tan, I am afraid that you cannot make another speech.

Dr Tan Cheng Bock: I am not making a speech. I am just saying that the Minister should have put more money, at least, in this year's Budget, on the primary healthcare funding, if he advocates so strongly on primary healthcare.

Mr Khaw Boon Wan: Sir, first of all, I thank Mr Steve Chia for clarifying that he has no problem principlely with means testing and that he was seeking details which, I am sure, we will have a few more months to discuss.

Mr Low Thia Khiang also gave his explanation that he has no fundamental objection to the means test philosophy. In fact, he supported means test for polyclinics and nursing homes. But his worry is Class C ward. Because if you are wrongly means tested out or unfairly means tested out, then - to use his

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words - this last frontier of safety net will be taken away. I think I got him right now.

At this stage, I am quite happy that if, on principles, we can agree on the whole conceptualisation of it, whereby if you are better off, you pay more than those who are less well-off, the rest are details. That is why I wanted the next few months to discuss those things. I do not think the last frontier is Class C subsidised ward. I think the last frontier, in the case of healthcare, has always been Medifund. Medifund is there to protect those who dropped through the safety net. So long as we have a good and sound Medifund in place, everybody can sleep tight. That is the reason why I persuaded DPM Lee and Minister for Finance to raise the Medifund allocation this year by another $100 million, to now make it $1 billion. But, never mind, let us hold the horses and await the details. We will have enough opportunities to discuss those details and then we can judge for ourselves whether they fulfill the various principles that I have outlined just now - simple, fair, etc.

Mdm Halimah asked a question on Medisave and IVF. As there is a related question on this later on this afternoon, I will tackle that later.

Dr Chong Weng Chiew asked about home care. I thought I have answered that in my reply. The answer is no - it is a consistent reply of "no."

Dr Tan Cheng Bock spoke about primary healthcare and said I must demonstrate words with dollars. Indeed, a huge amount of money is in primary healthcare, out of the $2 billion budget - I cannot remember the details - for the Ministry of Health, which is a big chunk. If we look at subsidies - I published an occasional paper a few weeks ago - this was a bit outdated, so the figures should be more by now. About two years back, generally, we subsidised more than $1

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billion in healthcare, of which $100 million go to primary healthcare. There is an opportunity to discuss more about this very interesting topic of primary healthcare. Please hold your horses.

Mr Low Thia Khiang: Sir, further clarification. I do not agree to have means testing in hospitals, although I do agree, in principle, that healthcare subsidies should be targeted at those who are really in need. I also wish to clarify though I do not disagree with the means testing, for instance, in step-down healthcare or even polyclinics if we want it, because I think these are services that people could more or less cope with it to a certain extent. Hospitalisation is something which is not that easy to cope with, and nobody really knows. I also wish to clarify that Medifund is not the last frontier. It is the Class C ward, which is the last frontier for many Singaporeans because not many people qualify for help under Medifund. Secondly, there is no need for people because they can calculate for themselves - if they think they cannot afford a higher class ward, they can go to C class ward. This is a comfortable social safety net. It is not something which people have to go and apply for it, beg for it and say, "Please, I am so poor." I think it is demeaning for many people. That is why I am referring to it as the last frontier of our social safety net.

The Chairman: Mr Khaw, do you want to respond?

Mr Khaw Boon Wan: I do not want to prolong this agony other than saying this. Whatever we do, affordability of healthcare to all income groups, rich or poor - that is always an important operating principle in the Ministry of Health. Whatever we design, whatever fees we charge, it must be affordable. How we design means test so that even if we assess that you are clearly in the category who can well afford, the charges

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remain affordable. I do not think I will cut the division of lines so precise that if you miss by a dollar, you are in this or that category. We will go for simple classification. That will be the approach I will take to this exercise.

Mr Low Thia Khiang: One more clarification, please. I would like the Minister to clarify whether he thinks affordability should be determined and dictated by the Government or the Government should provide a range of services, and let people decide what is affordable to them.

The Chairman: Mr Low, is that a clarification or a question? It sounds like a question, I do not think I can allow that. Dr Wang.

Competition in Medical Care

Dr Wang Kai Yuen: Sir, when the Government restricted the enrolment of Singapore medical students into overseas universities, it justified the action on the basis that it would prevent the over-supply of doctors. In so doing, the Government embraced protectionism for the medical profession.

Soon thereafter, Sir, we started to see distortions in the demand and supply of doctors. In fact, the Government hospitals themselves started to recruit overseas-trained doctors. This showed that market manipulation by anyone, including the Singapore Government, is not going to work very well.

In this respect, I am indeed heartened that DPM Lee has announced in his Budget speech a further expansion of the approved overseas training universities to about 70-plus, effectively driving the nails into the coffins of protectionism on the supply of medical doctors. But the effect of the old policy lingers on. By and large, the cost of medical care in Singapore is high, especially the fees of specialists. For

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instance, a cataract operation by a private-sector surgeon would cost close to S$5,000 per eye. I noted that, despite better technology procedures thereby resulting in better productivity, this cost has not come down over the years.

Furthermore, Sir, the issue of branded drugs in Singapore, being more expensive compared to those just across the Causeway, has been brought up in this House before. Then Minister Lim initiated some actions - I cannot remember what - but we heard nothing about it after a while. Sir, it is well-known that drug companies will price their drugs differently in different countries based on the per capita income or their ability to pay. And this is not just happening in the case of Singapore and Johore. There is a BBC radio report comparing the cost of prescription drugs sold in the US and those sold in Canada, which is just across the border in the state of New York. There was indeed a substantial difference. This has led to grassroots activists among US retirees to call for legislation controlling prices of such drugs in the state of New York.

Sir, I am not very sure whether legislation will be very effective. In any event, my questions to the Minister are: how do we allow greater freeplay of market forces in the demand and supply of medical personnel like doctors, nurses and branded medicine like drugs? How do we remove man-made barriers to foster greater competition?

Competition between Medical Clusters

Dr Chong Weng Chiew: Sir, years ago, one of the main objectives of setting up the two health clusters was to inject an element of healthy competition into our public health sector in order to spur us into achieving world-class excellence. It was an inspiring and exciting goal then.

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But since then, many unexpected changes have occurred. As a result, Singapore too, has been affected.

The wind currents have changed and perhaps it is time for us to change our sails as well. A re-consideration of the role of the two health clusters and a restructure of our public health sector may be timely. What was appropriate earlier may not be suitable for our current situations as our priorities have changed. Right now, with a weaker economy and definitely an ageing population, we are more concerned with keeping healthcare cost down and ensuring the availability of solid basic healthcare to all Singaporeans. Therefore, the possible duplication of some resources as a result of the clustering has definitely become a concern. With that background, I have the following points and questions to raise.

12.30 pm

Firstly, I read the National Healthcare Group Annual Report 2002-2003 and understand that the NHG employs about 1,600 staff in pure administration. Can I find out from the Minister the roles and duties of these 1,600 staff? I do not have the exact number for SingHealth, but I believe they would have a figure close to NHG. How much duplication of work is there actually?

Secondly, we have a limited pool of medical personnel in Singapore and the clusters have to compete for talents in order to attract patients, driving up remuneration and adding to cost.

Thirdly, the Acting Minister has said that there is always good and bad competition. But how can we differentiate one from the other? Based on the following knowledge I have, I do know that staff in both clusters are rewarded bonuses based on the revenue and not on the level of service or efficiency. Last year, staff of the clusters were paid a

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group bonus, based on a group profit, on top of their basic pay package. So this motivates revenue-generating behaviour among the staff of the clusters. Thus, with this profit-oriented mentality, how can we ensure good competition to bring down healthcare cost? Things and circumstances, as I have mentioned, have changed and I do hope the Minister will review the situation and, hopefully, reshape our healthcare foundation by abolishing the two groups system in our healthcare system currently.

Efficiency of Hospitals

Dr Ong Seh Hong (Aljunied): Sir, we thank the Minister for the publication of the medical bills on the most common procedures of various hospitals. Now, Singaporeans are more aware of the issue of efficiency in the healthcare sector and the public hospitals are given the task of keeping wastage as well as medical cost down. Sir, I share the sentiments of Dr Chong that clustering does not improve the efficiency. Someone actually lamented to me that with the clustering - with this additional administrative structure put in place - they now have to deal with three MOH headquarters. I would actually suggest that efficiency can be driven through open market competition, not between the clusters, but between public and private hospitals. MOH should consider buying more services from the private sector, whichever can deliver the services at the cheapest. With that, MOH would be better able to set its own benchmark of what is the actual cost of any services. Like Dr Chong, I would like to ask: what is the underlying rationale behind rewarding hospital managers' performance based on profitability? With this orientation, the result would be that only the Government subvention portion of the total bills would be managed better, but the increase in the cost may be simply passed on to the patients. So the Ministry should review the underlying principles and set better yardsticks for

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rewarding public hospital managers.

A more accurate measure of hospital efficiency should consist of comparing the total medical bill, which includes Government subvention and patient co-payment portion, against the total patient's bill of a similar procedure in other hospitals in Singapore, as well as in other regions. This will uncover the misalignment in the perception that our public hospital is cheap. Just a quick illustration. The cost of operation in a private hospital may be $4,000 and the patient pays $4,000. But the cost in a public hospital may actually be $5,000, but the Government pays $3,000 and the patient pays $2,000. To the patient, it is still cheaper to go to a public hospital. So, I hope the Ministry will look into this and enlighten us on some of these issues.

Performance Indicators

Mr Zainul Abidin Rasheed: Sir, I agree with Minister Khaw Boon Wan that doctors are not god, neither bomohs , I suppose. But for those who think of MOH as our godfather, think again. I think we need to do a reality check on that. As for the Toyota system, I have been a Toyota consumer for some time now, not quite Lexus yet, but I am happy with Camry, so I hope the Minister would be kind when they do means testing for me.

Sir, for a country like Singapore, where we have achieved varying top positions in many areas including airport and port, workers' productivity and risk factor, performance indicators are important. I would like to ask the Minister what are MOH's key performance indicators. What is the number of patients served? Quality of service? Is it cut waste? Cut cost? Or affordability? Is it the use of IT or application of technology? But what about relative to managing cost? Is it how we stretch the Medisave dollar, as the Minister was

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talking about just now or, perhaps, more importantly, how will MOH stretch Government's subsidy dollar for medical care?

Mission of National Healthcare Group and SingHealth

Mdm Ho Geok Choo: Sir, like my colleagues before me, I would also like to touch on the two public healthcare clusters. The public health delivery system was reorganised into two vertically integrated networks in 1999. This reorganisation created the National Healthcare Group and the Singapore Health Services. The intention then was to enable more integrated and better quality healthcare services through greater cooperation and collaboration among public sector healthcare providers. It would minimise duplication of services and ensure optimal development of clinical capabilities. But, in reality, the competition between the two clusters has resulted in a mushrooming of services and clinical capabilities. They have business development departments that market and source for overseas patients and bid for hospital projects in foreign countries. They compete with the private sector for local healthcare projects. Perhaps all these explain the reason for the big staff strength in their setup. The point is: is this necessary, in view of our public economy drive? As the two public clusters are significant players, their actions have a major impact on the local healthcare scene. In October last year, the Minister for Health asked the two clusters to stop the silly competition and not to fight for market share. Like my colleagues before me, I would like the Minister to state categorically what is the current mission and role of the two public healthcare clusters and how the mission and role should be changed.

Standard of Medical Service

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Mr Low Thia Khiang: Sir, I appreciate that MOH is finding ways to cut healthcare cost. My concern is whether the cut cost initiative will have the side-effect of cutting corners as well and, therefore, affect the standard of medical services. Sir, I have received feedback that in some hospitals, the diagnostic process is slow and the decision on how to treat patients takes a longer time and causes much anxiety to both patients and family members. Some have even decided to discharge the patient to seek private hospital treatment. I would like to know what are the specific plans MOH has in its cost cutting exercise.

Another area which I am concerned is waiting time. I noted that waiting time at hospital's specialist clinics and polyclinics has been long. In some instance, waiting time in some polyclinics can be as long as two hours. As we put forward budgetary and fiscal cost cutting measures, the Government must beware that certain areas are very sensitive to cost cutting measures. I urge the Government to be mindful of this, especially in the area of healthcare.

Quality of Service

Mr Zainul Abidin Rasheed: Sir, since the Hon. Minister's lucky number 8 approach for his priorities, MOH has shown greater transparency and we welcome that. Cost is important. Yes, but quality of service is also critical. So my question is: how would MOH rate the present rate of quality of service? How is the service mentality at Government hospitals, compared with private hospitals, especially when we are keen to develop Singapore as a medical hub? SARS has shown Singapore's spirit of medical service. But how do you maintain that? Quality of service is different during crisis time compared to peace time or boom time when there is greater mobility. How do you maintain a service when we

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are short of medical manpower, including doctors and nurses? What has Singapore's experience been when it comes to enhancing quality of service, when we have to import nurses from all over Asia - China, Philippines and, I was told now, even Indonesia? In short, will MOH assure us that quality of service will remain credible while medical care cost remains affordable?

Medical Hub

Dr Lily Neo: **** Sir, may I ask the Minister for Health on his plans to enable Singapore to become the regional medical hub? May I ask the Minister to quickly activate measures before we lose the chance completely as our neighbouring countries have been making up grounds in healthcare services by leaps and bounds? These countries have the advantage of lower cost and the marked difference in cost is driving large numbers of cost-conscious patients from the region away from Singapore.

In our endeavour to succeed in this area, may I ask the Minister to consider the following points:

(1) Facilitate a more competitive cost of healthcare to attract foreign patients.

(2) Ensure that healthcare for Singaporeans is not affected by having foreign patients, which he assured us earlier.

(3) There is a need to integrate our healthcare clusters and sectors for better economies of scale and maximising our limited resources to compete globally and not competing between ourselves.

(4) Singapore has a very good reputation as a centre of medical excellence and our healthcare professionals are recognised for their high quality and efficiency. We need to have a more structured aggressive marketing of this fact.

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(5) In order to have the upper edge, there is a need for innovation and we need to develop an ability to predict future trends.

(6) To maintain Singapore's medical excellence, there is a need to pay more attention to the training of our future generation of healthcare providers. Only by continuing to invest heavily on our undergraduate and post-graduate medical education will we ensure that our doctors are competent and conversant with the new developments in medical sciences.

(7) It is worthwhile to include the extension of the service hub to become a training hub as this will boost our aim of being a medical hub in the region. This will have the effect of promoting collaboration with doctors in the neighbouring countries and of gaining their acceptance of us.

(8) Innovative packaging with other products such as insurance, travel arrangements, hotel and shopping needs should be facilitated to make it more attractive for consumers to come here.

Mr Gan Kim Yong: Sir, I am very happy to hear Acting Minister mention that one of his priorities is to develop Singapore into a medical hub. I think it would be an exciting and challenging initiative. It will capitalise on the professional reputation of our medical expertise as well as take advantage of the excellent infrastructure we have already developed, such as transportation, communications, etc. Being centrally located in Asia will also give us an added advantage.

But, Sir, I would like to take this opportunity to share with the Acting Minister some of my concerns and suggestions.

Firstly, we must be focused in our efforts. While our professionalism and

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expertise in medical services are generally well regarded, we must identify certain areas where we have a competitive edge and focus our efforts in developing these areas of excellence. This will ensure that our limited resources are not dissipated.

Secondly, we must adopt a total approach. To become a medical hub, medical excellence alone is not sufficient. We must also ensure that the non-medical supporting system is also tuned up. For example, we must ease the application process for visas and we must provide one-stop services. It may even be necessary to create a new category of visas called "medical visas" to facilitate foreigners who are travelling to Singapore for diagnosis and treatment.

Thirdly, we must ensure that Singaporeans' interests are not compromised. In this regard, I am pleased that the Acting Minister has given his assurance earlier that Singaporeans will always come first.

Sir, I think we have what it takes to transform Singapore into a medical hub for the region. I would like to ask the Acting Minister to elaborate more on his strategy and plans.

12.45 pm

Mr Zainul Abidin Rasheed: Sir, "hub" seems to be the buzzword nowadays, be it in education, transport, training and, of course, medicine. When we go hubbing - and here I do not mean looking for husbands - what is MOH's thinking on Singapore as a medical hub? What are the challenges? What about rising cost of living and medical care here compared to other cities in the region, eg, Bangkok ? What is competition like from Bangkok ? Is there a need to develop strategic alliances with countries in the region and the developed West to make this hubbing

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a success? What is MOH's strategy to make Singapore a medical hub? Is it in general or is it specific to certain areas, eg, cardiac centre, neuro centre, cancer treatment or as an eye centre? Do we have the hinterland necessary to make successful medical or niche hubs?

On a related matter, Sir, what will MOH do to facilitate clearance of patients when it comes to movement of emergency cases? In times of enhanced security post-9-11 and stricter visa requirements, will this be a problem area? Will MOH push for easier clearance for medical visas, even promote medical tourism, eg, provide packages for foreigners to seek treatment here, but also package with other tourism requirements like hotel, shopping and recreation necessities?

Mr Ahmad Khalis Bin Abdul Ghani (Hong Kah): Sir, a number of hospitals in the region, such as those in Malacca, Kuala Lumpur and Bangkok , have been attracting patients from South East Asia , other parts of Asia , and even the Middle East . They are also positioning themselves as medical hubs. I would like to ask the Minister whether we have made studies on these hospitals. What are the lessons we can learn from them and what challenges do they pose in our desire to position ourselves as a medical hub?

Sir, I understand that patients from mainland South East Asia , for instance, from Vietnam , can go to Bumrungrat Hospital in Bangkok with minimal hassle-free visa arrangements - points brought up earlier by my colleagues. Do we have similar medical visa arrangements with other countries? In this regard, can we consider medical visa link-ups with hospitals overseas, so as to facilitate speedy reference and movement of patients? Would the Ministry also consider, I suppose, in collaboration with the Ministry of Home Affairs, visas for patients' family members and accompanying persons?

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The hospitality industry - here, we do not refer to hospitals but hotels and restaurants - would also need to cater to the needs of visitors and family members who come here for medical reasons. Could the Minister say whether our hospitality industry is preparing itself in our efforts to position ourselves as a medical hub?

Dr Gan See Khem (Nominated Member): Sir, I declare my interest in HMI, which is not involved in healthcare activities in Singapore , but is active in the Malaysian healthcare market through its operation and management of Mahkota Medical Centre.

Singapore 's private sector healthcare facilities for foreign patients offer superb outpatient services and subsequent after-care service. However, the development of a world-class centre for medical excellence will require not only the offering of better customer services in a better designed ambience but will include the continuous investment in research and development. I would like to propose that the making of Singapore as a medical hub should not be the prerogative of the private sector, but should be a collaboration between the public and private sectors. The recognition as a medical hub is dependent on the recognition that we achieve for clinical excellence, like the Cleveland Clinic or the Mayo Clinic, which took more than 50 years to evolve. In the US case, there had been a tremendous amount of research and development activities, both in the public and private sectors, over the past decades.

In Singapore , traditionally, the bulk of research and innovative work is done in the public sector where Government funding is included as part of the budget approved in this House. Doctors in the public sector are given recognition for the

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work they have accomplished in research and development. There is no corresponding budget and recognition for doctors in the private sector.

In the US model, research grants are given to both private and public sectors, and they compete for such grants so that they both can contribute to the developments and innovations in clinical practice. I urge the Government to consider giving incentives to encourage the private sector to do research, especially now that so many of Singapore 's top medical brains are already in private practice.

In the Singapore private healthcare model, as Members have said, we function very much like a medical mall where doctors are fiercely independent and they do not work as teams to go out and market our medical capabilities. And, hence, we have not been able to develop a formal referral base like what the renowned Houston Heart Centre had done in the past decades.

In order for us to position as a medical hub, it has to be everyone's business, both the public and private sectors. And with the public sector having made heavy investments in healthcare infrastructure, research and talent, the public sector can set the stage and maintain Singapore 's position as a pre-eminent place for healthcare excellence. It would be good to have the Minister's view on how we can more effectively promote Singapore 's competitive edge in medical science through what we have already invested in research and innovation.

Healthcare Public Education

Mdm Halimah Yacob: Sir, many changes are taking place in the healthcare sector. Some are fundamentals like the proposal to introduce means testing, and others are but refinements to the existing system. In the light of these changes, it

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is important, in my view, that we keep Singaporeans up to speed with these changes so that people understand not just how much different hospitals are charging but also some of the key challenges and issues that the Ministry of Health as well as our hospitals is faced with in maintaining an efficient but affordable healthcare system.

The Minister has mentioned that he intends to put up a discussion paper on the Ministry of Health's website and he intends to use the Feedback Unit channels. I welcome such moves but I believe that they may not be sufficient. There is a need for us to engage Singaporeans on a much broader base to make them understand some of these issues, challenges and constraints. Because I do see that there could be a disconnect and mismatch. Singaporeans see that healthcare costs, particularly hospital fees, somehow defy the law of gravity, but the Ministry of Health and the hospitals obviously have very serious issues and challenges in trying to keep and provide an efficient healthcare system and at the same time making it affordable. So we need to actually engage Singaporeans to make them understand better some of these issues.

The Minister also, at one Parliament sitting, had said that one of his strategies in controlling cost inflation is that he wants to help educate Singaporeans to moderate expectations. I think that is also an important point because I remember there was a resident who came to see me asking me for help in terms of waiving her hospital fees. I did not ask her what class of ward she had stayed in when she went to hospital. I wrote to the hospital subsequently, and was horrified to learn that she had stayed in an A Class ward. To me, that obviously is also an issue that we need to address - how to help Singaporeans moderate expectations

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while we talk about means testing for better-off Singaporeans. There are Singaporeans who obviously cannot afford higher class wards, and we need to educate them on the need to be prudent and careful in spending their health dollars.

Preventive Healthcare

Dr Lily Neo: Sir, my cut is on preventive healthcare. I would beseech that MOH prioritises to maintain our elderly population as fit and healthy for as long as possible. In this regard, I believe in promoting healthy lifestyle amongst our elderly population more aggressively, targeting especially the retirees and housewives.

Would MOH proactively strive to keep our elderly physically, mentally and socially fit and thereby postponing or retarding functional deterioration? This is especially relevant for retirees and housewives who are otherwise too sedentary and home-bound in their retirement. This inactivity and seclusion are definitely not healthy and they are therefore more prone to physical and mental health deterioration. This preventive healthcare can be promoted through purposeful centres for such programmes in the community where they live, such as in the nearby community centres.

I have had success in my constituency with five centres in the last six years, and I hope to see more in other constituencies to cope with the increasing demands of our changing population. Would MOH encourage and facilitate community bodies such as grassroots organisations, VWOs, private organisations and CDCs to set up and run these centres? Such centres can evolve in time to help the frail and semi-dependent elderly live in the community for as long as possible and not depend on institutional care.

Sir, preventive care should remain the hallmark of eldercare. MOH should

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facilitate further in this area with more campaigns through the doctors and healthcare workers, the grassroots organisations and VWOs as well as the media to encourage Singaporeans to go for early health checks and treatment. It will be ideal if more follow-up and reminder facilities are available to keep track of those who have defaulted on treatment or who have neglected check-ups, especially for chronic diseases.

The other two areas worth emphasising by the Health Promotion Board are in stroke prevention in order to reduce the number of patients with long-term disability and in raising the awareness of increased risk of late pregnancies in view of our low birth rates.

Healthy Lifestyle

Mr Ahmad Khalis Bin Abdul Ghani: Sir, people worry about health cost, especially in the case of serious and chronic illnesses and diseases. And one way to reduce health cost is by having a healthy lifestyle. Therefore, healthy lifestyle has a serious cost dimension to it. A healthy lifestyle also enables us to enjoy life more. May I ask the Minister what is the attitude of Singaporeans today on healthy lifestyle compared to, say, three or four years ago? What programmes have there been on promoting healthy lifestyle and how can we improve on them?

Anecdotal evidence suggests that certain segments of our population are more likely to suffer certain types of diseases. I wonder whether there are studies made on the profiles of such patients. For instance, recently, the Berita Harian carried a front-page report of a comment made by a Minister that adult Malays seem to place less emphasis than others to avoid chronic diseases. So more profile information would enable the Ministry to take measures that are more targeted, more focused and more

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effective. For instance, if the target for a certain campaign is for the Malay housewives above the age of 40, then our usual posters and brochures would not work. Probably collaboration with the Malay radio or the brisk walking groups at mosques would be more effective. Similarly, if the problem is smoking among youths in schools, then other more targeted approaches are probably more effective.

Lastly, the underlying principle here about healthy lifestyle is that prevention is better than cure. I wonder what is the Minister's assessment of our present situation. Are we putting this into practical effect or are we still procrastinating on the prevention part until it is too late even to cure?

Elderly Healthcare

Dr Lily Neo: Sir, one of the biggest challenges for MOH now is to ensure that healthcare for the elderly will be efficient and affordable in the years ahead. We should be proactive in planning the financing of elderly care, promoting healthy lifestyles amongst our elderly, enhancing preventive healthcare and catering to the

various imminent healthcare needs of the elderly. We must start laying the foundations for eldercare with urgency and ensure success in this area. I hope that MOH will be proactive in implementing appropriate measures in this area soonest.

1.00 pm

Elderly healthcare has to rely on the existing culture of self-reliance and taking personal responsibility and the premise that early preventive measures are preferable and more effective than later interventions at points of crises. I hope MOH can implement more aggressive measures in assisting our elderly lead healthy lifestyles and providing more

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preventive care for our elderly. An important message for this group will be "disabilities in old age are often due to disease and early treatment of the disease can prevent disabilities." Upon this basis, it is necessary for MOH to ensure that those with diagnosed chronic diseases can get their regular long-term medications. It is, thus, necessary to include chronic diseases care, which is presently not provided for those eligible poor elderly in the Primary Care Partnership Scheme. I would like to declare, Sir, that I am a doctor looking after some patients under PCPS.

A one-stop diagnosis and care-plan centre is essential for elderly care. At this centre, a standardised and holistic assessment can be done according to the patient's needs. Sir, having the correct diagnosis and the choicest management for each illness not only results in better outcome but also saves us money. Referral to the correct doctor and discipline for treatment is essential for reduction in hospital admissions.

Sir, many Singaporeans are concerned about rising medical costs, and this is especially so for the elderly folk in our midst who have no income but increasing medical needs. In time to come, this increasing burden will affect even more people due to our fast ageing population. I would, therefore, like to urge MOH to have good plans, insurance schemes and various safety nets put in place to ensure affordable long-term healthcare for all Singaporeans.

Mr Khaw Boon Wan: Sir, several Members have asked if the corporate missions of our clusters are properly aligned with our objective of keeping healthcare affordable to all. For example, Mdm Ho Geok Choo asked what their mission is: Is it to get more patients? Dr Chong Weng Chiew and Dr Ong Seh Hong

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felt that if doctors and CEOs' income depended on patient volume, then they are bound to compete for more patients and revenue, pushing up healthcare cost. So I put these comments to the two clusters' CEOs.

Dr Lim Suet Wun explained to me that pay and promotion would depend on a number of performance measures. Workload is not the only measure but it could not be ignored. Let me quote him: "Not to consider workload means that those who work hard and those who don't, are paid the same." In his cluster, as an example, his doctors are pushing projects which improve the care for asthma patients so as to reduce their admissions. Their diabetic foot care programme to prevent amputations is another example. As he put it, "less amputations hurt our bottom-line, but we enjoy doing it".

Similarly, Prof. Tan Ser Kiat explained that his cluster doctors are also measured on a number of indicators. Revenue and patient load are not the only criteria.

But, at the end of the day, it is values that count. If a doctor is solely interested in maximising his income, then I think the public healthcare sector is not the right place for him or her. We need to gather around us like-minded people who share a common objective to serve. We have to reward them adequately, and we will, but their passion must be towards their patients. Then they are qualified to join the Fellowship of the Ring. Our job is to expand that Fellowship. I, therefore, spend considerable time sharing my thoughts and values with the staff. That probably explains why I have less time to speak to the public, which is what Mdm Halimah urged me to do, which I will.

My advice to both clusters is simple - put patients at the centre of their focus, not clusters, not hospitals, not doctors, but patients. At the same time, bear in

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mind the need to keep healthcare affordable, which means doing more with less but without compromising clinical quality. So to Mr Low Thia Khiang, let me assure him that, yes, we are cutting cost, but we will not cut corners. At the most fundamental level, these must be the key performance indicators which Mayor Zainul Abidin touched upon.

Let me illustrate with some examples this patient-centric philosophy.

Electronic medical record (EMR)

First, sharing of electronic medical record (EMR). One in four of our patients needs to cross clusters. For example, a patient may begin with a consultation with a doctor at NUH. Subsequently, he may decide to seek another opinion from a doctor in SGH. If we focus on the clusters' benefits, we will probably make it inconvenient for the patients to cross the border. So, duplicate medical reports will have to be created and tests may have to be repeated at unnecessary cost. But if we focus on the patient's benefit, we will quickly realise that the correct decision is to facilitate the transfer and make it seamless. One cluster's gain is not another cluster's loss. It is not a zero-sum game. The patient's care is what counts. And this is the approach I take towards cluster competition and cluster cooperation.

Two weeks ago when DPM Lee reopened Ang Mo Kio Polyclinic, he was shown how IT was being used to allow doctors in the National Health Group (NHG) Cluster to access medical records of the patients once they have had one encounter with the cluster. For example, if an Ang Mo Kio polyclinic's patient was admitted to, say, NUH A&E Department, the NUH doctor would be able to check, real-time, online, the medical records of the patient in the other NHG institutions, even though it is the patient's first visit to NUH. This is the power of electronic

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medical records.

Last week, the other cluster (SingHealth Cluster) also illustrated the capabilities of EMR to the public. The objective is identical, which is to exploit IT to benefit the patients. I am glad that for their pioneering efforts, SingHealth took one of the top five spots in the CIO Asia Awards.

I am moving this initiative up to the next step. We are now working to link up the EMR of both clusters, so that a patient, once served by a member of a cluster, will enjoy the benefits of the EMR in subsequent visits to any member of the cluster. This has powerful applications. For example, patients would no longer need to re-register at counters, a tedious and time-consuming process. They can avoid being sent for repeat tests and x-rays, if these have been carried out recently by doctors in different institutions - I think a point made by Dr Lily Neo yesterday. A&E doctors can access the patient's medical record to look out for drug allergy, or other pertinent clinical information which may influence the treatment to be rendered. We are not there yet in linking up the EMRs of both clusters. But I am determined that the key pieces will be put in place within 12 months. It is complicated business, but it can be done.

Rebuilding of Alexandra Hospital

Second example, the rebuilding of Alexandra Hospital (AH). MOH made a commitment to rebuild Alexandra Hospital . I am seeing through this commitment. There are good reasons why Alexandra Hospital should be rebuilt. It is already 65 years old. The buildings are old and sprawling. Patients have to walk long distances to get different treatment. Although the staff has done a wonderful job in sprucing up the place, it is becoming expensive to maintain.

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The question is, what kind of hospital should replace it? In the last 25 years, we have rebuilt all the public hospitals, except Alexandra. From Changi to Woodbridge , they have all been given a new lease of life. For the new hospital to replace AH, will it be more of the same?

Members are aware of the transformation of our public libraries. From a boring depository of books, they have become "lifestyle destinations". Dr Tan Chin Nam told me that their approach was to treat every new library project as a prototype to test out new ideas, new innovations in library services. As a result, every new library is an enhancement over the previous one.

I posed the challenge to the AH rebuilding team: do to your hospital as what Chin Nam did to public libraries. And I do not mean to turn hospitals into lifestyle destinations! Specifically, build a hospital where patients will be treated as you would wish for yourself or your loved ones. To meet this challenge, the hospital will have to be designed with patients unambiguously at the centre of the focus, with technology fully exploited for the benefit and convenience of patients. It will be a hospital where patients do not get lost or get pushed from pillar to post. It will be a hospital with minimal bureaucracy and paper work. It will be a hospital which is well linked to the polyclincs, GPs and nursing homes in the neighbourhood, and to which the patients can be transferred seamlessly and in a way that makes the most sense to them. It will be a hassle-free hospital.

I know this is a tall order, and I would be pleased if they can achieve half of what I have sketched to them. The hardware aspect is the easy part. We have done it many times before. But it is the software that will determine if they succeed or fail in this mission.

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The AH team is brainstorming these software issues, in collaboration with many partners, including Infocomm Development Authority (IDA). We will not know which ideas will work. But if you do not try, you never know. They will use the next couple of years to try them out at Alexandra Hospital . I will squeeze out some budget to support them in this. And for those ideas that work, we shall adopt them at the new hospital.

I have asked them to consult widely, speak to the patients, ask their relatives, and certainly involve the stakeholders in the neighbourhood, the GPs, the polyclinics, the nursing homes, the MPs and the grassroots leaders. Whoever can bring value to the table, involve them.

I have also told them to avoid building a huge hospital. Every city needs a couple of huge hospitals. We already have them - SGH, NUH and Tan Tock Seng Hospital . I suggest that they limit their new hospital to around 400 beds, big enough to accommodate a range of specialties, and yet small enough to be manageable and be patient-friendly.

Hospital in the North

Third example, the general hospital in the north. During the last general elections, DPM Dr Tony Tan promised a hospital in the north. In fact, he appointed Senior Minister of State Ho Peng Kee to head a committee to identify a site for the hospital. I am seeing through the commitment. Currently, we do not have any hospital in the north. All our hospitals are in the south. I have been studying the ambulance travelling time between Woodlands and our A&E departments. They are still within acceptable limits but, at times, pressing the boundary. There are already a million Singaporeans living in the north and north-east. They can well justify a general hospital. So we shall site the rebuilt

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Alexandra Hospital in the north. My Ministry has been working informally with Assoc. Prof. Ho Peng Kee and we hope to settle the site for this proposed Northern General Hospital very soon.

1.15 pm

Fourth example, integrated healthcare services in the West. I have been discussing with Minister Lim Boon Heng on existing healthcare services in Jurong. There are many players - a tertiary hospital in NUH, a community hospital, several nursing homes, and there is a new polyclinic coming up at Jurong West, and, of course, many GPs. So the residents are adequately served for the moment.

There was a plan to build a new Jurong General Hospital . A site has been reserved. We could proceed with this plan. But I persuaded Minister Lim Boon Heng that it is better to postpone the plan for the time being.

Let us focus instead on the software of delivering healthcare services to see if we can transform existing services to serve the Jurong residents better through greater use of IT, adoption of innovative ideas that link up the various players in a seamless manner. The idea is to put patients at the centre and with services reorganised around the patients. I think such a patient-centric, software-driven project in Jurong is much more meaningful than simply building another general hospital.

We have tentatively codenamed this project: "Jurong health-connect". It is to pilot a new concept of care at our polyclinics with virtual links to day-care facilities, nursing homes and community hospitals, with close cooperation, weekly joint management meetings, single case files for each patient across the continuum of care.

It will attempt what Dr Tan Cheng Bock outlined yesterday: "manage chronic

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diseases, like diabetes and hypertension in a proactive manner, but outside of hospitals", ie, a public and private partnership that not only treats the disease but also prompts the patients to manage their risk factors so as to avoid costly hospitalisation. This will enable us to serve patients better for both acute illnesses as well as chronic diseases. In America , it was reported that quite a large proportion of diagnosis and treatment traditionally carried out in a general hospital could in fact be done in a community setting. This is less traumatic for the patients, besides saving them money. Can the Jurong West Polyclinic be the nerve centre for this new concept of care? If so, it may have to be enhanced physically to provide a wider range of services.

For the elderly requiring long-term care, there is the St. Luke's Community Hospital and several nursing homes and day rehabilitation centres run both privately and by VWOs. But the services are fragmented as they are all facility-centric. Can we bring all these services to a higher level by linking them up through IT and also link them up to NUH and AH so that the care of patients can be centrally coordinated, even as they progress through the various healthcare facilities?

Is it worth doing? I read the Hansard recently and I recall there was at least one sitting during which Dr Lily Neo made several suggestions on how public and private sector healthcare services could be integrated to provide the elderly and the chronic sick with a better level of care. And this morning, she proposed more ideas on this issue, including having holistic treatment for the elderly and one-stop diagnostic centres. The question is how to convert intent into practical ideas which can be executed on the ground. But we know now who to call to help us in this project. So besides Dr Lily Neo, Dr

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Tan Cheng Bock will be invited to join the Fellowship of the Ring. And, perhaps, Dr Tan Cheng Bock shall be Gandalf, our wise counsellor.

Mr Lim Boon Heng was persuaded by my plan and signed on to the Fellowship quite early on. He brought with him his full GRC backing on the ground. So Mdm Halimah is in the Ring too. We will work together to flesh out Jurong Health-connect and make it work for the residents there.

As providers, we will put patients at the centre of our focus. But I hope Singaporeans, in turn, will put their health at the centre of their focus. They can do so by adopting a healthy lifestyle, but not merely chanting the mantra, but actually doing it.

Mr Ahmad Khalis asked how Singaporeans' attitude towards healthy lifestyle has changed over the years. The cup is half-full and half-empty. On the one hand, many more Singaporeans have moved to the right side of the divide. The percentage of Singaporeans doing exercise regularly has gone up, from 14% in 1992, 10 years ago, to 20% now, ie, one in five. The percentage of Singaporean smokers has fallen from 18% to 14%. Tens of thousands of Singaproeans exercise in our public parks, especially during the weekends. Mayor Teo Ho Pin is a champion of healthy lifestyle in his CDC. He started brisk walking clubs and he told me that he was pleased to note the steady increase in both the number of clubs and the number of participants. And occasionally, he told me he organised joint brisk walking among all the clubs and would be able to gather 10,000, 20,000 walkers in one session. Quite impressive!

On the other hand, many are still not exercising regularly. Many are still over-weight. Many with hypertension and

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diabetes still do not know that they have such problems. So we are getting better, but we certainly can do more.

Promotion requires a multi-pronged approach, as pointed out by Mr Ahmad Khalis. This is because young children, working adults, older individuals have different needs. To reach out, we need all the 3P sectors - the people, public, private - to work together.

MOH is grateful to the Ministry of Education for its efforts in getting our kids to acquire a healthy attitude from young. We are also grateful to the Ministry of National Development for their many, many parks. I am especially pleased to read that NParks is expanding and will be adding more park connectors. And, of course, we also thank the Singapore Sports Council for their many sporting activities, including the Annual Singapore Marathon which several MPs and I took part recently, and we thoroughly enjoyed ourselves.

At the workplace where more than half of the population spend a significant amount of their time, we have great opportunity to promote health. Where the company's CEO and management are personally committed, their company will tend to have the right environment for everyone to follow. And that is why it is so important for all of us in this House to set personal examples. I have been in the Ministry of Health for nearly eight months now. I have never used the lifts. When I started, I would not bump into anybody at the staircase. Now, I do, and often.

MOH, unlike my previous offices, does not have an office gym, because there is an excellent one in SGH campus. I use it regularly during lunch time. So compared to my previous office, it is a bit inconvenient because you have to change, expose yourself in shorts and drive there. But after a while, I realise that it actually serves an additional purpose. Hopefully,

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the taxi drivers and patients in the queue will be inspired to follow suit.

Mr Ahmad Khalis asked if there were statistics to prove that healthy lifestyle did reduce sickness rate. There are plenty. They are all in the literature, you can find it on the Internet. But he is certainly correct to say that we need to design programmes that will cater specifically to segments of the population which are more prone to certain diseases.

Dr Lily Neo spoke passionately about elderly healthcare. And she has done so often in this House and has made many good suggestions. We have to work together to get the elderly to stay physically, mentally and socially fit. Being old does not mean frail or disengaged from society. In fact, there are many elderly Singaporeans who remain active.

I was at the 96th birthday party of Venerable Shi Chin Yam of Man Fut Tong recently. She is tireless raising funds for her inmates. At the party, she told us that she is launching a new project to build an orphanage. At the age of 96!

Maintaining a healthy lifestyle from cradle to grave is the key. Managing and controlling the risk factors are important. The cost of screening these risk factors is inexpensive. Unfortunately, many are still not aware of their risk factors. At the grassroots level, many of us are organising such mass screenings, as pointed out by Dr Neo just now. At the workplace, simple health screening for hypertension and diabetes can uncover hidden health problems. I really hope more companies can be enlightened to offer this for their employees.

I am for more opportunistic screening. Let me explain. Every day, 1% of Singaporeans will visit some doctors, public, private, clinic, hospital, somewhere. So while the doctors attend to the patients' immediate needs, there is an

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opportunity for them to also screen the patients for the common risk factors, if this has not already been done recently, and then, more importantly, document the results in the patients' electronic medical record. In this way, we update the Singaporeans' electronic medical record regularly, making it a lifelong medical record, one for each Singaporean. This can potentially transform the whole practice of medicine in Singapore and bring the management of chronic diseases, such as diabetes and hypertension, to a higher plane. Through the proposed Jurong Health-connect, we hope to pilot some of these ideas.

Dr Lily Neo also stressed the greater promotion of preventive healthcare. Yesterday, she pointed to the tiny budget of the Health Promotion Board, not so tiny, about $100 million, and supported a bigger budget for HPB. I must thank her. I always thank MPs who support bigger budget for the Ministry of Health.

MOH has and will continue to support worthy initiatives, especially in the area of health promotion and preventive care. Effective programmes, by the way, need not always be costly. Much can be achieved if we have champions who are passionate and creative. Also, it is how you cleverly leverage other people. Although we said only 90 million or 80-odd million dollars are for Health Promotion Board, this Government actually invests billions every year in health promotion. The entire budget of the Ministry of the Environment is for health promotion. You have clean water, you remove all the rats, as what Minister Lim Swee Say is trying to do, you are improving people's healthcare. You keep the air clean, you improve the healthcare for everybody. Likewise for Ministry of Education, the huge budget in the schools promoting healthy lifestyle, that is health promotion.

We should also bear in mind that, in principle, while nobody can disagree with

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more preventive healthcare, it is also possible to go over-board. There is a recent rather controversial trend in the US where millions of people have been diagnosed with one or, often, several, what they call, "pre-disease", before disease, conditions. The controversial question is what to do with such pre-disease conditions?

Preventive medicine is at its best, if pre-disease diagnosis leads to lifestyle changes: cut out salt, cut out sugar, cut down weight, exercise more. Preventive medicine is at its worst, if pre-disease diagnosis leads to over-treatment, over-medication: often expensive drugs paid for by insurers or the State.

1.30 pm

But nothing is simpler than writing a prescription,

and nothing is harder than achieving a change in behaviour. This is the challenge of managing preventive medicine. I am watching this US trend very closely.

Let me now turn to Members' points about making Singapore a regional medical hub.

Dr Lily Neo spoke about having competitive costs in order to attract foreign patients. I totally agree. As is the case with other sectors of the economy, if we do not have a good handle over our cost-competitiveness, we can forget about trying to maximise our potential as a regional medical hub. An important part of our strategy is to recruit and train many more doctors and nurses. Matching supply of healthcare workers to demand is the key to ensuring that even as we become a regional medical hub, we do not inadvertently push up overall healthcare costs. If foreign patient load grows, without a corresponding increase in doctors and nurses, then healthcare cost

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is bound to rise. I therefore agree with Dr Wang Kai Yuen on the need to review our control of medical school enrolments and have more flexible market-based manpower policies. We certainly should not inadvertently protect a cartel. I am tackling this at various fronts.

First, we have increased the NUS medical intake from 150 to 230. The next increase in intake will be when a new graduate medical school working with Duke University starts in the SGH Campus.

Second, MOH has expanded the list of recognised foreign universities and medical schools to 71. I hope to do more.

Third, we have allowed fast-track entry of foreign-trained specialists already registered in the UK and Australia. As a result, the number of foreign-trained specialists practising in Singapore has grown by an annual rate of 23% per year in recent years. Can we do more? I posed this question to the SMC recently: why can we not allow fast-track accreditation of all US-board certified specialists? They have reviewed, and they have just decided. They will allow this for nine specialties, eg, general surgery, orthopaedics and so on, and they are actively looking into the other specialties, as there are significant differences in the training structure and duration.

Fourth, we are getting our hospitals to redesign jobs and re-engineer their processes to make nursing a desirable profession again. This will improve the students' attitude towards nursing as a profession.

Fifth, we are exploring setting up a local degree course in nursing in our university to provide the next generation of nursing leaders.

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Sixth, we are recruiting foreign nurses from countries like the Philippines and China. There is a global shortage of qualified nurses. Despite our efforts, the clusters still have 200 vacancies. We have to work harder on this front.

Dr Lily Neo pointed out that, in order to sustain advantage in quality, we must always pay attention to medical training and, hopefully, the training of medical doctors as well as nurses can also be part of Singapore's intention to be an education hub. I totally agree with that. Hopefully, the Duke University partnership at the SGH Campus can help stimulate development along that line.

I agree with Dr Gan See Khem that the public sector has a role to play in the regional medical hub. Let us work together. But we need to manage it properly because, by mandate, our public hospital workers must be to serve Singaporeans first, especially the bottom 50%. However, where the hospital has the capacity to do more, having acquired a regional reputation and strong finance, I think they should pro-actively pursue international patients on their own or jointly with private hospitals. In fact, I am trying to work with the Singapore National Eye Centre to see how we can try to meet these two contradictory goals of serving Singaporean needs and, at the same time, serving foreign patient needs. Hopefully, we can learn from that experience.

Mayor Zainul Abidin and Dr Lily Neo talked about marketing Singapore and gave many useful suggestions. Mr Gan Kim Yong suggested that we should focus on niche specialties where we have a competitive edge and adopt a total approach in promoting them. Singapore Medicine has identified a few areas that we will intensively market, and these are likely to be specialties that have large patient populations in the region, and would include areas like opthalmology,

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cancer, heart, etc. Singapore Tourism Board is also in active dialogue with healthcare providers, travel agencies, hotels and other service providers to ensure that the diverse needs and requirements of our foreign patients are catered for. The issue of medical visas, I think raised by Mr Ahmad Khalis and Mr Gan Kim Yong, is also actively being reviewed. The objective is to make it easy for foreign patients to come here for treatment.

Finally, let me respond to Mr Low Thia Khiang's point on medical standards. He reminded us that while we cut cost, let us not cut corners. I do not intend to do so. I think we would have failed in our duty, if medical standards deteriorate as a result of whatever objective that we may be at the same time tackling. The bottomline is this. In healthcare, if you are rich, regardless of what the healthcare system is, you are all right because you can fly to anywhere you want. If you are poor but not too sickly, also never mind, because whether your healthcare is good or bad, you will cure yourself anyway. Our immune system will take care of that. But if you are poor and you are very sick, where would you rather be within, let us say, a 7-hour flying radius of Singapore? I think it is Singapore. Yes, it is easy and politically sweet to promise a 30-baht medicine. But a 30-baht medicine is no use, if you need a bypass or you have serious cancer. I think we have a good system in Singapore. It does not happen by accident. It is an investment that we have done over many years, and my job is to continue to build on that.

Mr Low Thia Khiang: Clarification, Sir. First of all, I do not understand what the Minister meant by "30-baht medicine". Can he clarify?

An hon. Member: Thai bahts.

Mr Low Thia Khiang: Okay, Thai bahts. The Minister assured this House that the

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standard will be all right and there will be no cutting of corners. But could the Minister let us know specifically some examples as the medical standard has not dropped or in fact has increased? I have also in my speech asked for the average waiting time in polyclinics and Government specialist outpatient clinics. Could he tell us what is the average waiting time now? Has it improved?

The Chairman: It is not a clarification. It is a question. Do you want to answer that question, Mr Khaw?

Mr Khaw Boon Wan: There are two questions. One is on data to support why we say the medical standard in Singapore is not bad. However, I do not think this is the occasion, because I do not carry those data. One of these days, I will publish an occasional paper and the Member can see for himself. But, anecdotally, we all know who come here for treatment, like some of the VVIPs that we handle in Singapore. We know where the better healthcare standard is, Singapore vis-a-vis the others.

As to waiting time, many years ago, when I started my career as a hospital CEO in 1984, young and naive, I told my management team at NUH - at that time, it included Dr Jennifer Lee - "Let us run a hospital with zero waiting time." As an engineer, I thought I could bring engineering practice into medicine, so that we can systematically manage the clinic, eg, a new case will require 30 minutes, repeat case maybe 15 or 20 minutes, and then we can schedule things, and so on. But I quickly discover that the reality outside is not like in textbooks. I remember one conversation I had with the former head of orthopaedic surgery. He had a busy practice, with many Indian ladies as his patients. He said: "You know, Khaw Boon Wan, when the Indian ladies come, especially those in sarees,

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they take more time to change". So, he said, "Please give me more time."

But, more importantly, it is because illnesses differ. I think we have had that discussion not too long ago. Yes, we can schedule so many patients and so on, but once you have a complicated case, clinic management goes haywire. Should we, for the sake of efficiency, even though this patient may need one hour to look after, cut corners and just go for the scheduled 20 minutes so that everybody would not have to wait too long? We cannot. So, I have resigned myself to the fact that clinic waiting is a phenomenon which is impossible to eliminate. But what one can do is try to reduce it. And this will require cooperation all round, from the patients especially. There are data to show that "no shows" - "no shows" means I have an appointment but I do not turn up - are, unfortunately, still very common. And the more "no shows" you have, in order to better utilise the resources, the more I have to overbook because, if I do not overbook and there is no show, then the doctor will be shaking legs.

I can run a clinic with zero-waiting. But to run a clinic with zero-waiting means that I must have expensive resources waiting for business. And that is the model in the private hospitals. I charge high because my patients cannot afford to wait too long. But, yes, I see maybe 30 patients a month, instead of 30 patients a day, as in the public hospitals. The economics are completely different. So, if you want to keep healthcare costs low and as affordable as possible, I think we have no choice but to exercise our resources to the maximum, which means I have to work them at high occupancy level, whether it is wards or clinics and, unfortunately, as a result of that, I am afraid some waiting is inevitable. But, of course, the waiting cannot be because the doctors or nurses are having prolonged lunch or meetings and then not turning up

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at the appointed time.

The Chairman: Dr Lily Neo, you have two cuts. Take them together, please.

Dr Tan Cheng Bock: Sir, can I ask the Minister two questions on this?

The Chairman: If you want to clarify, yes, but no questions, Dr Tan. You have had your turn.

Dr Tan Cheng Bock: Can I just clarify then? I think it is important because the Minister mentioned about the electronic medical records. The question of confidentiality of the patient is very important, and I think it is important for the Minister to clarify this point.

Mr Khaw Boon Wan: Indeed, patient confidentiality is one key issue, and it has always been the issue, whether it is paper-based or IT-based. Today, it is not electronic medical records, it is paper medical records, but we also have to preserve patient confidentiality. In fact, with electronic medical records, it is easier to audit and manage. What is the concern? The concern is doctors or nurses may look into medical records of patients whom they have nothing to do with, somewhat being a "busybody". And you can be a busybody today. Doctors can walk into our medical records office and take out medical files. But, with IT, I can now track who are the busybodies, eg, someone who handles, say, 2,000 patients a month but has accessed 3,000 medical records. Something must be wrong, right? Then we can look into it. But whatever it is, the profession has to respect its promise to preserve patient confidentiality. And my intent is that it may be useful every year to remind all our healthcare workers about the need to preserve patient confidentiality.

Doctors

Dr Lily Neo: Sir, doctors in the public hospitals have complained of low morale

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due to various factors such as the uncertainty of their career paths and the frequent change of policies. May I request MOH to look into these issues and to engage the doctors more through better communication with them? Hospital staff have to be roped in for better planning and implementing of new policies.

1.45 pm

May I ask MOH for an update on the problem of shortage of junior doctors in the public sector? Sir, the American Accreditation Council for Graduate Medical Education said that work-weeks of up to 120 hours were harmful to young doctors and could endanger patient care. In America, under the new rules, the normal resident work-week is limited to 80 hours. The standards also imposed mandatory rest periods of up to 10 hours between shifts, one day off a week, restrictions on moonlighting and close faculty supervision. Is there any plan to strive for such standards here? May I ask MOH not to subject our public doctors, especially junior doctors, to 30-hour shifts that may affect their concentration and standard of patient care?

The Minister mentioned earlier that there will be an increase in the annual intake of medical students. May I ask him on this number, please? May I also ask for the percentage of female medical students admitted to the NUS medical faculty last year? Is MOH still practising recruiting junior doctors from our immediate neighbours whose medical schools we never recognised before?

It has been the practice of MOH to limit the training of specialists to no more than 40% of each cohort. In view of our endeavour to become the medical hub of the region, will the Minister rescind this policy and increase the number of training

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posts for specialists in our public sector?

Sir, we need to pay attention to the training of our junior doctors to ensure the competency of future generations of our healthcare providers as we talked about earlier. Only by continuing to invest heavily on our undergraduate and post-graduate medical education, I would like to emphasise again, that we can ensure our doctors' competency in the future. Thus, our investments on the Health Manpower Development Programme (HMDP) should be enhanced. May I ask the Minister what steps have been taken to ensure this? May I also ask him whether our hospital doctors are too preoccupied with daily routines that require them to manage maximal numbers of patients, as the Minister said earlier on maximising their time and effort, and leave the seniors with little or no time to teach the juniors who in turn have no time to be trained?

Nurses

There is a shortage of nurses in Singapore. May I ask what are the steps taken by MOH to address this perennial problem? What is the attrition rate of nurses and are there measures to try to reduce this attrition rate? It is necessary to review ways to make nursing more lucrative in terms of career development and monetary returns as well as family-friendly.

Lately, there has been an increase in the number of admissions of students for nursing courses in ITE. But the increase has not been matched in terms of the training opportunity for clinical exposure due to various factors, one of the reasons being the shortage of clinical instructors. This may result in less-than-satisfactory trained nurses but, more importantly, the enthusiasm and morale of such young and aspiring nurses may be harmed even

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before they start on the job proper. I hope MOH will look into this issue urgently.

There is a need to enhance and uplift the image of nursing to emphasise the noble nature of nursing. Nurses are an important and integral part of our healthcare system. The nursing profession should be given more recognition and its due importance. I hope that MOH can involve and rope in the nursing profession into planning and implementing any healthcare policies as well.

Sir, there is an increasing need to have higher-trained nurses to perform more diverse duties. Within our fast-changing technological advancements in science and healthcare, we do require nurses to master complex information. To this end, will MOH give more upgrading grants for nurses to take up special diploma courses? Could we also have an undergraduate nursing programme for nurses?

Presently, the shortage of nurses is being cushioned by foreign nurses. Many of them are doing good work and it is a pity that there are some acceptability hindrances by both patients and medical managements. Many foreign nurses do not have the sense of permanence here. Could we find novel ways to make their stay here more attractive, more alluring for them to stay here permanently?

Workplace Health

Mr Yeo Guat Kwang: Sir, as a labour movement, the NTUC has been encouraging workers to adopt healthy lifestyle and helping workers to improve their health. We see it as part of our efforts to improve the lives of workers. Lifestyle diseases sometimes strike people in the prime of life.

Today, heart disease, stroke and cancer, in fact, are the top three killers,

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accounting for more than 60% of all deaths in Singapore. Our death rate of 76 per 100,000 population from heart disease is higher than that of 58 and 60 per 100,000 in Canada and Australia respectively.

Therefore, in addition to provision of medical benefits for employees, we would like employers to implement preventive health promotion programmes at the workplace to help workers to stay healthy. Unless we monitor our health-risk factors regularly and adopt a healthy lifestyle, many of us may have to spend the last few years of our lives burdened with ill health and disability.

The NTUC Health Outreach Programme, an on-site basis health screening programme, has already reached 50,000 workers in the last four years. I hope the Ministry will also consider a structured approach to also give incentives to get Singaporeans to monitor their own individual health risk factors regularly.

Based on the recent survey conducted by the Health Promotion Board (HPB), the prevalence of private sector workplaces that have a comprehensive Workplace Health Programme (WHP) has increased, to 45% in 2003. These companies employ 63.5% of the private sector workforce compared to 26% in 1998. This is encouraging.

However, the key challenge now is to improve the effectiveness and the quality of the Workplace Health Programme so as to achieve the benefits of Workplace Health Programme, in terms of more productive and healthier employees and reducing healthcare costs.

I hope to see more support from the employers, and particularly from the Ministry of Health, to see how we can respond to the Minister's call to help all the workers to put their health at the centre of their focus. I would like to

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know whether the Ministry has concrete plans to further strengthen the tripartite collaboration and effectively improve the health profile of all the workers in Singapore.

Patient Siting

* *Dr Chong Weng Chiew: Sir, I am talking about patient siting. When I mention the words "patient siting", I am referring to where patients should be treated and admitted. Should it be in acute hospitals, community hospitals or nursing homes?

Our current system of care placement and referral of our elderly patients can definitely be improved upon. With the implementation of Diagnosis Related Grouping (DRG) in acute hospitals some years ago, funding of the hospitals is based on a fixed budget per disease grouping. While it is an efficient system, it definitely places pressures on hospitals to discharge patients as quickly as possible to be cost-effective, as a result of which, elderly patients are most disadvantaged. Those who are not ready yet to go home are referred to step-down facilities. Particularly, these are patients with social problems.

Sad to say, they would be transferred to the provider who accepts their cases fastest. This is far from ideal if we assess the long-term effects of indiscriminate discharging. For example, an elderly patient who may have rehabilitation enters a nursing home instead, rather than a community hospital, just because the nursing home has no waiting list and a community hospital has.

Thus, may I propose to set up a neutral body comprising independent healthcare personnel, preferably employed by the Ministry of Health, to look into the assessment and the appropriate placements and discharges from hospitals.

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Finally, at the national level, we should definitely promote greater awareness of the various step-down care facilities and their functions. Singaporeans should realise that immobility need not be a natural progression in old age. In fact, in many cases, rehabilitation is the key. This would definitely translate into substantial savings for our entire healthcare system.

Mental Wellness at Work

Mr Yeo Guat Kwang: Sir, we are definitely living in a world where we have to contend with higher stress levels in our jobs as we strive to ensure our employability in such a competitive globalised world.

Workers are facing a higher frequency of job changes and industry restructuring. They may be retrenched. Their companies may merge or split. All these changes are rapid and they may hit the worker when he least expects it.

A little stress is helpful to keep us motivated in our life. However, too much or prolonged stress is unhealthy. What is too much stress? Some months ago, the media reported that a worker killed himself after his appeal for a transfer was rejected. His supervisor did not know that he might be suffering from depression. Stress can be managed. A strategy like this could have been averted had there been better awareness of stress management at work.

The World Health Organisation's World Health Report projected that depression will become the second leading contributor to the global burden of disease by the year 2020. A research by the World Federation for Mental Health revealed that mental disorders are costing businesses in North America about US$80 million in loss of productivity, and

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depression alone accounts for about 75% of that figure. We cannot take the situation in Singapore for granted. Most businesses do not recognise the losses due to mental ill health and take steps to prevent this.

I would like to know whether the Ministry of Health has plans to encourage more companies to take an interest in promoting mental wellness, or consider extending counselling by setting up employee guidance clinics, like the one that has been set up at the Health Promotion Board for children from the schools. The idea is to provide counselling at a centralised place as employees would feel stigmatised or discriminated against if they have consulted a doctor at a mental clinic or at the workplace.

Primary Healthcare

In Singapore, 80% of the primary healthcare is provided through more than 1,200 individual private GP clinics. The polyclinics in Singapore play a relatively minor role. I would like to ask the Ministry whether this is a desirable outcome.

With an ageing population and emphasis on preventive healthcare, would the Ministry consider a thorough review of our primary healthcare provision and policy? Is 80:20 the right ratio?

Primary healthcare is more than just fire-fighting of common infectious diseases like flu virus and provision of antibiotics. I would like the Minister to enlighten the House, moving ahead, how are we going to strengthen the standard and effectiveness of our primary healthcare system to better serve our people and improve their health.

Sir, the Primary Care Partnership Scheme was extended nation-wide in year 2002 to enable all low income elderly to

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receive subsidised outpatient medical and dental healthcare treatments at private clinics near their home. This is a good scheme. I would like to ask the Ministry, to-date, how many elderly have benefited from this scheme and how will the Ministry ensure that more of those who are eligible for this scheme sign up for the programme.

Dr Michael Lim Chun Leng: Sir, Singapore has an excellent primary healthcare system where costs are cheap and accessibility is universal.

Where in the past, the private GPs have been the main providers of primary healthcare after office hours, the economic downturn has seen the Government extending service after office hours through the polyclinics. While this is a very good service welcomed by one and all in the vicinity of the polyclinics, it is unfortunately not available at all polyclinics as a result of lack of manpower resources. I would like the Minister to enlighten us as to what are the plans for night clinics. Where this is not available, as a result of manpower resources, will the Ministry consider subsidising polyclinic patients who see neighbourhood GPs after office hours by pre-approving GPs who want to participate in the PCPS? This will kill two birds with one stone by providing subsidised evening services to polyclinic patients, and also utilising the resources of GPs more efficiently.

While the polyclinic doctors are very busy at their polyclinics, many of the GPs do not have such a heavy workload. Are there any plans for the Ministry to harness this synergy between the polyclinics and the GPs so that we can optimise and improve the utilisation of our primary healthcare resources?

Primary Care Partnership Scheme

Mr Gan Kim Yong: Sir, last year I urged the Ministry to review the Primary Care Partnership Scheme with a view to

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broadening its scope. The then Minister replied that more time was needed to gain experience in the scheme before expanding it. Sir, I would like to ask the Acting Minister whether the time has come for him to reconsider it. Under the PCPS, senior citizens who meet the criteria are allowed to seek treatment at neighbourhood private clinics at subsidised rates instead of having to travel all the way to the Government polyclinics. This has benefited many residents, and save time and travelling costs. The cost to the Government is arguably the same, as they would have enjoyed the same subsidy had they gone to the polyclinics. In view of the benefits of the scheme, I would like to urge the Ministry to consider expanding the scheme to cover at least the following categories:

First, the handicapped people who are less mobile. It would be good to cover them under the PCPS to reduce the need for travelling.

Second, patients requiring long-term medication or treatment. It would be an added burden if they are required to travel to polyclinics to seek treatment or medication on a regular basis. We should consider putting them under PCPS so that they can receive treatment and medication from nearby private clinics.

Third, low income families, particularly families who are receiving financial assistance from the Government, should be covered under the PCPS regardless of their age. It would not make sense to incur additional travelling cost and time when they are already having problem to make ends meet.

Sir, I believe that these groups of people are quite clearly defined. Expanding the PCPS to cover them is unlikely to lead to major abuse. Therefore, I would urge the Government to consider reviewing the qualifying

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criteria of the PCPS so that these people will also benefit from the scheme.

The Chairman: Mr Shanmugam is not here.

Doctors, Nurses and Patients

Ms Braema Mathiaparanam: **** Sir, I have to declare my interest here as I work in the Corporate Communications Department in a restructured hospital.

Sir, with greater transparency, which is something that I applaud, and a population that is better educated, it becomes imperative for doctors and nurses to develop good communication skills and bedside manners. What I am saying here is from my experience as both care-giver and a patient. Currently, both the Certificate in Nursing and the Diploma in Nursing have modules, in some cases, elective, that deal with communication skills. In other cases, bits of it are incorporated in the general course. I hope that in the proposed degree course in nursing, and in all these other courses, communication skills which play an important role be made a compulsory module. Housemen, nurses and trainee nurses whom I spoke to, say that much of it is left as an on-the-job training, and depended on a good mentor to take them through. It is my hope that the Ministry will look into this. As the public gets more and more educated, they would need more information. The way information is given to them becomes very important as it will help them make considered choices in an era of greater transparency.

Lastly, the patient-nurse-doctor relationship is a very delicate one. It means mutual respect for each other. In certain cases, I think doctors need to be more mindful and respectful of the roles that nurses play. I totally endorse what Dr Lily

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Neo brought up about the image of the nurses. It is my hope that mutual respect, or a process towards attaining mutual respect, can be taken on by the Ministry with the help of the Singapore Nurses Association, which I think can play a bigger role in all of these.

Shortage of Manpower

Mdm Halimah Yacob: Sir, the Minister had cited shortage of skilled manpower as one of the three reasons for the increase in healthcare cost in the recent discussion on this subject in Parliament. I would like to ask the Minister how the Ministry proposes to deal with the shortage of skilled manpower. The many developments that we now see will continue to impose considerable strains on our manpower resources, and Singaporeans fear it will cause healthcare cost to go up.

Let us look at the situation in terms of the manning position of our healthcare sector. Currently, about 40-50% of the staff strength at the ward level in our hospitals are already taken up by foreign nurses, and about 25% at the hospital level are also taken up by foreign nurses. There are about 1,500 vacancies in the healthcare services which are not filled. Juxtapose this against the demands that are going to be imposed on the manpower needs as a result of certain developments, one of which is the announcement on the part of the Government last year to develop Singapore into a leading healthcare services hub in Asia by increasing the number of foreign patients in Singapore from 211,000 in 2002 to one million by 2012, and juxtapose that also against a rapidly ageing population that will impose serious demands on healthcare services, the problem is very apparent. And it has been estimated that by 2030, the elderly will make up 43% of total hospital admissions.

Singaporeans are also reminded by the recent exodus of doctors from the public

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hospitals. A recent media report cited that 177 doctors had left the public sector to join the private sector, including 43 specialists. So the question on everybody's mind is whether such an exodus will result in higher wages to attract and retain even more doctors and specialists. Sir, while Singaporeans will not disagree with the objective of building a medical hub, it is good as it will contribute significantly to our GDP. Singaporeans are, however, concerned that a busy medical hub treating many foreign patients, coupled with the other severe resource constraints that I have mentioned, will push up healthcare cost as public hospitals will then have to compete with private hospitals for specialists, doctors and nurses. There is clearly a need to match supply of healthcare workers with demand to ensure that healthcare cost will not escalate.

In this respect, Sir, I would like to ask the Minister how the shortage of skilled manpower will be addressed, and what more can the Ministry do to make the healthcare sector much more attractive to Singaporeans, and what steps will be taken to ensure that turning Singapore into a medical hub will not result in higher medical cost for Singaporeans.

The Minister of State for Health (Dr Balaji Sadasivan): Sir, first, I would like to thank Dr Lily Neo, Ms Braema, Mdm Halimah on their questions on doctors, nurses and the supply of skilled healthcare manpower, Dr Michael Lim and Mr Gan on the question of primary healthcare, Mr Yeo on physical and mental health in the workplace, and Dr Chong on where patients should be appropriately treated.

To begin, I want to point out that the healthcare system in Singapore is a good system, and has improved the health of Singaporeans. On average, our system has increased the life expectancy of Singaporeans by three months every year,

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over the last 20 years. The life expectancy was 73.3 years in 1984. Today, it is 78.9 years. We expect it to exceed 80 years by the end of the decade. Singaporeans enjoy a higher life expectancy than most people in the world. It is higher than even that of the US, the country that is the origin of most of the recent advances in medicine. If we are cutting corners, as suggested by Mr Low Thia Khiang, Singaporeans would not be living to such a ripe old age.

Our challenge is to maintain this high quality system at an affordable cost. To do this, our healthcare delivery must be as efficient as possible. Healthcare is an expensive service. More than half the cost in healthcare service involves paying for the services of skilled people - doctors, nurses and other paramedical professionals. Our healthcare system can be more efficient if we use the services of healthcare professionals in an efficient and appropriate manner. For example, if a patient has caught the flu and has a cough, he could decide to see a lung specialist. He would make an appointment at the specialist clinic, wait a while and see the specialist. The specialist can treat the cough and prescribe a cough mixture. But if the patient says to the lung specialist, "This medicine is for my cough, but my nose is stuffy, do I have a sinus problem?", the lung specialist will refer him to the Ear, Nose and Throat doctor or ENT doctor. He goes to the ENT clinic, waits a little while more, then gets his sinus checked and will be given more medication. As the patient is about to leave the ENT clinic, if he says he feels bloated, then the ENT surgeon will refer him to a doctor looking after the digestive system. If he thinks the problem is at the upper end, the referral is to a gastrologist. If he thinks it is the lower end, the referral is to a colorectal doctor. If the ENT doctor is not sure, the patient gets referred to both. This is an example of expensive and inefficient delivery of healthcare. But if the patient had seen a

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GP, the GP would have treated all the complaints in one consultation. Many patients are seeing specialists when a primary physician can take care of the problem. This is why our specialist clinic attendance is growing at the rate of 6%. It is also driving the cost of healthcare upwards.

This does not mean that patients do not need specialists. At times they do need to see a specialist, but the problem that the public sometimes faces is that they may not know when and which specialist to consult. If every family in Singapore had a family doctor, then by consulting the family doctor or GP, they would know when they need to see a specialist and when the family doctor can take care of their medical problem. The family doctor can serve as a friend and mentor to the patient and as a gatekeeper who directs traffic within our sophisticated healthcare system. GPs and polyclinic doctors are the key to solving the proper matching of health resources in our system to the health needs of the patient.

**** My Ministry has, therefore, instituted measures and programmes to encourage Singaporeans to see their family physicians and general practitioners in the private and public sectors. Singaporeans must also play their part. Where a medical problem can be settled at GP clinics or polyclinics, it should be done so, and when the medical problem has to be referred, it should be directed to the right specialist. Such habits will reduce cost and build a long term doctor-patient relationship where there is commitment to care and trust between the patient and the primary care doctor.

My Ministry has programmes to facilitate primary healthcare for special groups by improving accessibility of subsidised care. For example, there are

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many less well-off elderly who do not live near polyclinics. Getting to polyclinics can be inconvenient for them and for such elderly patients, the Ministry brings affordable healthcare closer to them through the Primary Care Partnership Scheme (PCPS), which was mentioned by Mr Gan. Under this scheme, my Ministry engages private general practitioners and dentists to provide common outpatient medical and dental treatment to needy elderly. These elderly pay polyclinic charges for such services. The number of elderly on the scheme has increased over the last one year, as a result of our outreach efforts, which include road shows at Senior Activity Centres and door-to-door promotion at 1- to 3-room HDB flats. More than 15,000 elderly are now on the scheme, compared to 5,000 elderly one year ago. That is a 300% increase in the number of patients in one year, and we will continue to look at ways of increasing the scope of this programme. This programme is currently served by 570 GPs and 210 dental clinics.

Night clinics were previously set up so that lower income Singaporeans could have the convenience of subsidised medical attention at night instead of having to wait until the following day. Seven night clinics have been set up so far. The polyclinics deploy their own doctors and also engage private GPs to provide the night clinic services. Each clinic employs an average of three doctors and sees about 57 patients a night. The cost per patient of providing polyclinic service at night is much higher than that during the day. So we will review these services to see if this is the most efficient way of providing primary healthcare. As suggested, perhaps GPs in the clinics may be a more efficient way of providing this care at night. The clusters have no plans to expand night clinic services.

In the healthcare cluster, better vertical integration of hospital and primary care services has resulted in shared care

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programmes between hospitals, polyclinics and general practitioners. This enables the coordination and management of diseases across the spectrum of care from primary to secondary to tertiary care to achieve better outcomes.

For example, the Singapore National Asthma Programme to manage severe asthmatics at both hospitals and clinics has helped reduce hospital admissions for asthma.

2.15 pm

Health Education

Health education is important and besides using the various media, it is also conveyed through the polyclinics or by GPs, who can obtain free health education materials from the Health Promotion Board (HPB) either directly or through the Singapore Medical Association and the polyclinics. Doctors and patients can also download health education materials from HPB's website. Patient education tools have also been developed by HPB to help GPs provide education to patients with chronic conditions.

The sick elderly and right placement of care

Dr Chong brought up the issue of the right placement of patients so that they can get the appropriate care. Our elderly utilise more healthcare services because there are more health problems as a person grows older. There are challenges here - to deliver care at the right place at the right time. The community hospitals and nursing homes, whose focus is rehabilitation, provide lower cost and a more holistic care compared to acute hospitals. Elderly patients sent to the appropriate facility have better long term recovery. Wrong placement, on the other hand, results in unnecessary financial and social costs. A patient who should be rehabilitated in a community hospital but instead goes to a nursing home may not receive the optimum care to get back to

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their full rehabilitation potential. On the other hand, the patient who is better taken care of in the community hospital but stays in a more costly acute hospital may be consuming health resources to a greater degree than is needed.

Lack of awareness of healthcare services must be tackled. My Ministry intends to pilot an Aged Care Assessment Programme (ACAP) to promote right placement of care in hospitals, community hospitals, nursing homes, day rehabilitation facilities and the patients' own homes as appropriate. We will train health care professionals in the acute hospital to be familiar with the criteria for step down and rehabilitation services.

Workplace health and mental wellness at work

Prevention is better than cure and getting the public to lead a healthy lifestyle in a healthy environment will reduce the consumption of healthcare services as more people remain healthy. Two-thirds of Singaporeans work and spend a minimum of eight hours in the workplace daily. No company wants poor health amongst its employees. My Ministry is serious about healthy lifestyle amongst working Singaporeans. Workplace health programmes promote healthy lifestyle among employees, such as regular exercise, healthy eating, smoking cessation and mental wellness. To encourage workplace health, my Ministry gives a grant of up to $5,000 to companies to start workplace health promotion programmes. They can also apply to the Skills Development Fund for funding workplace health promotion training. We recognise that a collaborative approach from employer and employee is needed. Mr Yeo Guat Kwang has pointed out that NTUC is actively promoting this. The Health Promotion Board and NTUC will launch a pilot project to reward employees for participating in workplace health activities. Singapore National

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Employers' Federation (SNEF) is also HPB's key partner to promote healthy lifestyle in the workplace.

Mr Yeo raised the issue of mental wellness of workers. Stress is a concern and mental wellness is important to work effectively. HPB conducts public education programmes on stress management and managing depression for workers, students and the elderly. The Institute of Mental Health has plans to implement an Employee Assistance Programme to provide confidential counselling either through the telephone or in person for employees. With this programme, we hope tragedies like that mentioned by Mr Yeo would occur less frequently in future.

Medical and healthcare manpower

A number of questions were also raised on our medical and nursing manpower, the training of doctors, nurses, morale and communication skills of these healthcare workers. One key challenge is to safeguard our medical standards whilst we strive to achieve optimum numbers of skilled and competent healthcare professionals to meet the healthcare needs of Singaporeans, as well as to support our drive to become a regional medical hub. Healthcare manpower is highly skilled and takes many years to train, and you need the right mix of skilled manpower - doctors, nurses, pharmacists, therapists and health science professionals. All must move and work together for smooth progress.

Protracted training required

The protracted training required to develop these professionals poses a major challenge in managing manpower. It takes up to 12 years from entering as a medical student to becoming a medical specialist; and perhaps another 10-12 years to reach

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the pinnacle of excellence in a specialty. Three to four years are required to train entry-level practitioners for the various healthcare professionals like nurses and therapists. But it takes many more years of training and experience to produce highly skilled nursing professionals and therapists. There are no quick-fix solutions, but we are working to enlarge our local base of professionals as well as drawing talent from overseas.

Raising intake of students

We have raised the annual intakes of students. For example, the intake of medical students in NUS has risen from 150 in 1996 to 230 in 2003. We have also lifted the quota on the number of female medical students, and to answer Dr Neo's question, in 2003, the intake of female medical students was 43%.

We have also recognised more overseas medical schools - from 24 to 71 schools in 2003. For the past three years, an average of 100 doctors from recognised overseas medical schools were registered per year. The Singapore Medical Council has also allowed the clusters to employ doctors with non-registrable degrees under temporary registration, provided such doctors are very closely supervised. For the past three years, the total number of such doctors registered averaged 120 per year. We will continue to increase the supply of skilled healthcare manpower without compromising the standard of these personnel.

The 13.9% vacancy in junior doctor positions in the last quarter of 2002 was reduced to 6.2% in the last quarter of 2003. To put in another way, the number of filled positions had risen from 1,470 to 1,656. For medical specialists, although there is a 40% specialist cap, we are still some way from reaching this as specialists presently only comprise 35% of all fully and conditionally registered

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doctors in Singapore. With the development of the regional medical hub, we will require more specialists to provide good quality care, both in the public and private sectors as well as to moderate healthcare cost increases. If there is a need, this cap will be removed.

Nurses

For nurses, the intake of nursing students into the Institute of Technical Education (ITE) had increased from 146 in 2001 to 204 in 2002 and 238 in 2003. The number of new nursing students has to match the number of nursing instructors that can be recruited.

Nanyang Polytechnic had also an increased intake of nursing students from 588 in 2001 to 707 in 2002 and 854 in 2003. More lecturers are being recruited by ITE. Nanyang Polytechnic is also actively recruiting clinical instructors. It has increased the number of lecturers and clinical instructors from 73 in 2001 to 87 in 2004. We are making progress, though there are no quick-fixes to the problem of training new nurses and doctors.

The clusters continue to recruit foreign nurses to supplement locally trained nurses from Nanyang Polytechnic and the ITE. Measures will be implemented to reduce the attrition rate of foreign nurses and to encourage the better ones to commit to a long-term career with us. A new work pass, which will replace the existing Q2 pass, with effect from July 2004 will benefit many foreign nurses by allowing them to bring in their dependants. This may help to retain good nurses. MOH is also looking into reducing the waiting time for good foreign nurses to obtain permanent resident status.

Vacancies for nurses in public sector institutions had been reduced from 4.1% in 2002 to 2.4% in 2003. The number of public sector nurses increased from 8,575 in 2002 to 9,065 nurses in 2003. The

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attrition rate of public sector nurses in 2003 was high - about 14%. The two healthcare clusters have targeted to reduce the attrition rate to 10% by 2005. A multi-pronged approach is being taken to achieve this, including balanced work schedules, job redesign, improving career pathways, training and development programmes and review of nurses' salary to ensure competitiveness.

In developing healthcare manpower, we have heard much about other professionals and retrenched workers who switched vocations to enter healthcare. The Strategic Manpower Conversion Programme (Healthcare) implemented by MOH and the Singapore Workforce Development Agency (WDA) is for mid-career workers who want to take up job opportunities in the healthcare sector. Under this programme, mid-career diploma courses have been launched to train registered nurses and diagnostic radiographers. The trainees are provided with full sponsorship and a training allowance. The first two batches of 109 trainees are undergoing the two-year accelerated diploma in nursing at Nanyang Polytechnic, and the third batch started in July this year - the target is 100 new trainees. Half of the trainees already have university degrees and the feedback on the programme has been positive.

NTUC and the National Heart Centre have also launched the Skills Training and Employability Enhancement for Retrenched Workers (STEER) programme for training of Enrolled Nurses, Healthcare Assistants and Health Attendants. There are a total of 215 trainees for STEER, out of which 114 trainees have graduated from the Healthcare Assistant and Health Attendant programmes, and 101 trainees are currently undergoing the training for Enrolled Nurses, Healthcare Assistants and Health Attendants positions. There are also on-the-job programmes run by ITE together with participating healthcare employers. These include various types of

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ITE Skills Certificate in Healthcare, including outpatient, inpatient, homecare and clinic practice skills, which takes one year to complete as well as a similar Skills Redevelopment Programme which takes nine months to complete. ITE also runs short skills based programmes of three months for health service, housekeeping operations and patient service and a six-month course on rehabilitation therapy.

Morale of doctors

Dr Neo was concerned about the morale of doctors. We believe that the morale of our healthcare workers is good or even excellent. Our regular six-monthly survey of doctors indicated that over 90% of medical officers are satisfied with their work and postings. Doctors have traditionally worked long hours. During my years as a trainee, I routinely worked more than 100 hours a week for many years. Because this was a historical practice, it does not mean that we should carry on making our doctors work such long hours. All over the world, as has been pointed out by Dr Neo, in the US and Europe, steps are being taken to reduce the working hours of junior doctors. We too are gradually reducing their working hours.

In terms of reduction of hours,

in 2003, 18% of our junior doctors in public hospitals performed more than six night calls per month, compared to 26% in 2002. Our medical officers currently work an average of 60-65 hours per week. The clusters are also making efforts to ensure that junior doctors do not work more than 30 hours continuously. We cannot change the working hours dramatically overnight, because it will affect patient care. But as more young doctors graduate from our medical school, the working conditions of our young doctors will continue to improve over the next few years.

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2.30 pm

Training of doctors in the Hospitals

Are senior hospital doctors too preoccupied with daily workload that they have no time to teach the junior doctors? MOH had surveyed medical trainees in 2003 and it showed that over 70% of the trainees gave high ratings on the supervision received from their seniors. The survey showed that trainees have been given time for training and almost 90% of trainees indicated that they participated in various organised learning activities. The workload of the trainees was not onerous as more than 60% of the trainees saw fewer than 20 patients per day in the wards, while about 70% of doctors saw fewer than 60 patients per week at specialist outpatient clinics. We are assured that, on the whole, there is a satisfactory level of supervision and training for our trainee doctors in the hospitals.

Communication skills training for doctors and nurses

Communication skills are important, as pointed out by Ms Braema. The good practice of medicine requires good inter-personal skills. EQ is as important as IQ. Communication skills and the ability to empathise are skills needed for good medical practice. We can teach communication skills, but empathy must come from the heart. Medical students in Singapore undergo a communication skills programme to enable them to communicate effectively with patients and relatives. This comprises many hours of course work, lectures, role-playing and mentored interaction with patients. The programme, administered by the NUS Medical Faculty, together with the Faculty of Business Administration, supplements the students' practical exposure to communicating with patients during their 3-year clinical postings. For practising

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doctors and trainees, programmes on communication skills are organised by the Healthcare clusters, NUS and professional bodies like the Singapore Medical Association (SMA) and College of Family Physicians . Experienced GPs and family physicians are involved in such programmes. Nursing students in the Institute of Technical Education (ITE) and Nanyang Polytechnic (NYP) undergo course modules on communication skills which are also acquired in practice sessions and clinical postings. Good senior clinicians, both in medicine and nursing, serve as role models who teach our young doctors and nurses to understand the human condition and empathise with patients.

Further Nursing Education, sponsorships and the nursing degree programme

To upgrade the skills of nurses, the clusters have a sponsorship programme for Diploma training for nurses. Nurses who are working for VWOs under MOH funding can also apply for training sponsorship from MOH if the training is relevant. MOH provides funds under the HMDP for the upgrading of training of public sector healthcare nurses. This has resulted in an increasing number of nurses doing fellowships in well-known overseas centres - about 50 nurses in 2002 and 60 nurses in 2003. Under the Visiting Experts programme, nursing experts have been invited to teach nurses in specific nursing skills. The Ministry of Health, together with the Ministry of Education, is currently considering a degree course in Nursing at the proposed Outram Campus.

The Health Manpower Development Programme

The continuous training of health professionals is essential to provide high quality healthcare services. The Health Manpower Development Programme has a Fellowship scheme, through which doctors are sent to eminent centres overseas for training, as well as the

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Visiting Experts scheme, where top foreign experts are invited to train local professionals. About 45 visiting experts are invited annually to train our health professionals in the various healthcare disciplines. The budget for the HMDP Fellowship and Visiting Experts programme is about $6.5 million per year.

All of us want Singapore to enjoy the best healthcare in the least expensive way. We want excellent doctors, excellent nurses and excellent allied health professionals like therapists, radiographers, etc. We also want a logical well structured system that can draw out the best of what our healthcare professionals can offer. We want to remain healthy and not see health professionals if we can. But should we need to seek medical care, a family doctor should be our contact point with the healthcare system. We must encourage all Singaporeans to have a primary physician who can advise and guide them on healthcare matters. Healthcare is not just the concern of the Government and healthcare professionals. All Singaporeans have a part to play to ensure that the healthcare system continues to be both efficient as well as of high quality. And the first thing Singaporeans can do is to make sure that they have a family doctor.

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 3.00 pm.

_Sitting accordingly suspended
at 2.35 pm until 3.00 pm. _

Sitting resumed at 3.00 pm

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[Mr Speaker in the Chair]

**** Debate in Committee of Supply resumed.

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[Mr Speaker in the Chair]

Head O (cont.) -

Prescription of Medicines

Dr Chong Weng Chiew: Sir, for most illnesses, besides patented and generic medicine, there would usually be a number of alternative medications that a patient can take. Definitely, of course, he usually relies upon his doctor's prescription without much query. This could be good or bad, depending on how good or how bad the doctor is. Patients usually have no idea about the range and cost of the alternatives, or why one medication is prescribed over the other. It depends almost entirely upon the knowledge and diagnosis of the doctor. Some medications can be very expensive, and subsidised patients may find themselves struggling to afford them on a long-term basis even though the drugs could already be subsidised. The price difference between the prescribed drug and the next best alternative can be substantial. Sometimes, the effectiveness of one drug may be only marginally better than the alternative, although this may not be reflected in the price difference. The financial circumstances of the patient and his family should definitely be taken into consideration.

To give an example, for gastric pain, the cheapest medicine that can cure it could be an antacid that costs only about five cents, while a new medicine being developed, eg, Omeprazole, can cost $2 per tablet. Therefore, I would like to suggest to the Ministry that they should ensure that doctors, particularly the junior doctors in acute hospitals, are aware of the cost of the medicine that they prescribe. This is particularly essential because, many times, junior doctors practising in hospital wards are not too aware of the cost of the medicine they prescribe, since the workflow of the

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hospital is such that they prescribe the medicine in the wards and the patients do not pay until they are discharged. Many times, the doctors are not directly involved in the billing of the patients. As such, many of the junior doctors would not be aware of how much of the medicine, in terms of cost, they are prescribing. Definitely, we know that the latest and the most expensive medicines are not always the best nor the most appropriate. Hence, we should educate our doctors as far as possible, to avoid prescribing expensive medicine for patients, especially those which are beyond their ability to pay for them.

Traditional and Complementary Medicine

Dr Lily Neo: Sir, I would like to seek an update from MOH regarding the registration of Traditional and Complementary Medicine Physicians. May I ask for the number of those who took their TCM Qualifying Examinations, and the number of those who had succeeded and failed? May I ask the Minister whether considerations were given to those who did not make it in the examinations and thus causing them to lose their livelihood? Were they given chances to upgrade themselves to enable them to pass the subsequent examinations? Are the TCM Qualifying Examinations tailored to the various specialties of TCM? Is it better to examine them on the fields of their expertise?

Since many have been in practice for many years, are considerations given to the patients under their care? Are we depriving the continuous care of their patients by not registering them? Is there assistance given to those who have failed the examinations repeatedly in terms of their livelihood?

Dr Chong Weng Chiew: (In Mandarin) : Sir, under the present regulations, all facilities, including hospitals and nursing homes under the charge of the Ministry of Health, do not allow Chinese physicians

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to treat the patients there. Patients who require treatment with Chinese medicine would have to be moved to another room outside the hospital ward or nursing home before treatment could be administered. All Chinese medical treatment procedures, including acupuncture, are affected. This would not only cause inconvenience to the patients and medical and administrative staff but also marginalise the status of traditional Chinese medicine in our healthcare system in Singapore.

In fact, the Ministry of Health recognises the role of traditional Chinese medicine in the medical scene in Singapore. The Ministry of Health itself has a department on traditional medicine and one on Chinese medicine. Over the years, the Ministry of Health has adopted positive actions to regulate and register the Chinese physicians, the Chinese medicine practitioners as well as the Chinese herbal and patent medicines. In order that we could further improve the use of Chinese medicine in Singapore, we should do something to satisfy the needs of our patients in Singapore who require Chinese medicine treatment. So, I would urge the Ministry of Health to allow the Chinese physicians to treat their patients in the hospital wards.

Mr Chay Wai Chuen (Tanjong Pagar): Sir, I believe there can be more that we can incorporate traditional Chinese medicine into our healthcare system. Western medicine and the healthcare system have no doubt made advances beyond the human imagination. However, I am not sure whether the 14% of GDP the Americans spend on healthcare is any more effective than the 8% or less which the Europeans or Singaporeans spend on ours. I believe that traditional Chinese medicine should have its place. Traditional Chinese medical practices have always been incorporated in the social and philosophical framework of human life and well-being. It has existed for thousands

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of years and it has proved to be lasting. So, I hope the Minister can incorporate traditional Chinese medicine into our healthcare system.

I am told Chinese medical care is aimed at the gradual approach to treatment, emphasising the social, mental and the psychological approaches to life, living and well-being. I think these descriptions fit well into modern and even new-age needs and perspectives on living and well-being. One way is to systematise the body of Chinese medicine practitioners, including the training and education of these practitioners, to link them with Chinese medical bodies overseas, such as in China, on a more intensive level, including the exchange of doctors and regular sharing of development knowledge. Once this is done, essentially, one would have taken control of the supply stream of relevant TCM practitioners and of ensuring that they are of a certain international standard. Another way is to identify the area of medicine where TCM is considered sophisticated and effective, such as in the area of acupuncture, which has been mentioned, or these areas can be determined in consultation with other experts. The rest of them should be left to market demand.

The Ministry of Health should also consider allowing choices by people, by allowing TCM practices at prescribed MOH clinics or hospitals. These are currently done privately by many non-private bodies, such as Chung Hwa Clinic and the Kwan Im Hood Cho Huay. The latter has helped my constituents in Queenstown, for example, run a free TCM clinic for more than 10 years. And patients make small donations in a box after their treatment. Believe me, there is a regular queue waiting for treatment, young and old of all races, for the last 10 years. So, it cannot be without use or effect, when the sick keep coming. It must be useful and effective. It must

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have answered to the need when it has lasted more than 10 years, and it is still continuing. So, alternative medicine and TCM can prove to be effective and more cost-effective, and may be more satisfactory than western medical treatment in certain fields.

Subsidy for Providers of Home Therapy

Dr Chong Weng Chiew: Sir, I declare my interest in the following cut.

The Ministry introduced subsidies for home care providers two years ago. This is in recognition of the role home care plays in the healthcare system, and I was glad to hear the Minister reconfirming that point again just now. However, currently, the subsidies do not extend to home therapy providers. I hope the Ministry will reconsider this decision in view of our ageing population. Increasing numbers of elderly in Singapore will require physiotherapy. While there are currently day-care centres which provide physiotherapy, home therapy and day-care centres target at different groups of patients. Day-care centres request patients to be at their doorsteps. However, there is a large group of patients, especially those with severe strokes and who, as a result of which are bed-bound, are unable to go to day-care centres for rehabilitation. Thus, for such groups of patients, home therapy is the only option. Elderly poor patients who currently are unable to move to day-care centres, as a result, would be left stranded thoroughly without much of a subsidy and treatment. If the Ministry is able to fund home therapy services and with the convenient and regular but affordable treatment sessions, many current disabled home-bound elderly would be able to benefit from improvements in their health and quality of life.

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Thus, in conclusion, home care services, definitely including the therapy component, can contribute to a higher standard of health among our elderly patients. In the long run, this would help to bring down our healthcare costs. Hence, I hope the Minister could consider my request.

Pro-family policies

Mrs Yu-Foo Yee Shoon (Jurong): (In Mandarin) : Sir, today, I would like to talk about pro-family policies. Here, when I talk about pro-family policies, it would be very broad-based, not just on procreation. I would like to touch on two aspects.

First, I hope that the Ministry of Health would, through the National Health Promotion Board, spread the message of procreation promotion to all our people In this respect, I would like to thank the Ministry of Health. In fact, the hospitals and the polyclinics are very well structured and fully equipped, and the facilities are very good. The Acting Minister for Health has just announced that he was going to consolidate all the healthcare facilities in the western part of Singapore. This is indeed a piece of good news to us. But the problem is some of our senior citizens with chronic diseases are having difficulty going to the hospitals for treatment. We should train our young people to support these elderly people and find some ways for these old people to receive treatment at home.

In the 1970s, when we were promoting family planning in all our hospitals and clinics, we made every effort to discourage the mothers from having any more babies. But now, when we are reversing the process, have we trained our hospital and polyclinic staff to promote procreation and encourage our young mothers to have more babies? Every year, we have more than 10,000 abortions. In principle, I do not oppose abortions, but I feel we should train our

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hospital and polyclinic staff to give consultation to pregnant mothers who are contemplating abortion. For those who are married and are thinking of going for abortion because of financial difficulties, we should try and help them and see how the babies could be saved.

In our family planning programme, we should also educate our people as to when is the best time to give birth to children, that is, from 18 to 28 years. We should tell them not to delay their marriages. Even after their marriage, we should also encourage them to have babies as soon as they can. For those who are infertile, we should try and help them with IVF, and make it affordable.

Finally, because most of the hospital staff are females, I hope that we could have pro-family policies to help these female medical staff find time to be with their families.

3.15 pm

Mr Khaw Boon Wan: Dr Chong Weng Chiew reminded our hospitals not to prescribe overly expensive medicine to subsidised patients especially chronic patients, as they may not be able to afford them after discharge. I appreciate his timely reminder. One practical way to help patients save money is to go for generic drugs and the savings can be considerable, as the example he gave just now, between $0.50 and $2.

Use of generic drugs should be Standard Operating Procedure (SOP) in all our subsidised clinics and wards. It will help stretch the hospital's budget, patients' savings and Government subsidy - three-in-one. I therefore agree with him and also Dr Wang Kai Yuen, who mentioned this morning about the need for an open competitive market for drugs and to facilitate the entry of generic alternatives.

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About two-thirds of our 7,500 pharmaceutical products registered here in Singapore are generic drugs, from various sources, including India. We would, of course, continue to tap generic drugs where feasible.

This morning I mentioned about DPM Lee reopening Ang Mo Kio Polyclinic and that he was shown the capabilities of IT in the NHG cluster. One of the applications pertains to this, which is, what we call, e-prescription. Instead of handwriting, which very few people can read, through the IT, the doctor can send out his prescription. And the power of IT is, with a computer screen, when the name of the drug is keyed in, alternatives are put up, including their pricing, so that doctors, whether it is the MO or the Senior Consultant, can, with a look, with the patient in front of him, decide what to prescribe. If the patient insists on branded products, we will tell him how much it will cost and we will prescribe accordingly. But if they want to save money, then go for cheaper alternatives, which, as Dr Chong puts it, are as effective. Patients themselves play an important role and should understand that in most cases, the generic medication can do the same job as a branded drug.

The Health Sciences Authority assesses generics for local registration to ensure that they are safe, efficacious and of good quality. My Ministry will step up public education to provide information on drugs to help Singaporeans make better choices.

Home therapy services

Dr Chong also asked my Ministry to consider subsidising the providers of home therapy. By home therapy, I presume it means sending a therapist to a patient's home to provide rehabilitation services. Whether we should subsidise such services will depend on the effectiveness of the service and, of

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course, the financial status of the patients. The problem is: home therapy is not cheap. We should not subsidise just because patients are poor, especially when there are cheaper alternatives in the community. We are already subsidising home medical and home nursing care. I will have to think many times to see whether we should make this further concession.

For patients who need rehabilitation and therapy, there are many day rehabilitation centres providing such services. I do not know about Dr Chong's constitutency, but within Tanjong Pagar GRC, there are several. Many of them are located in HDB void decks and they are definitely very much cheaper than the home therapy.

Traditional Chinese Medicine

Let me now discuss the Traditional Chinese Medicine (TCM). I grew up with TCM. As a child, I probably took more Chinese medicine than Western drugs, and I do not think my experience is unique or unusual. Is there a role for TCM, even in modern Singapore? Of course, there is. Our data suggested that one in 10 outpatient attendances are served by TCM practitioners. Will the demand grow? TCM has been able to retain its market share over many years. In fact, this is not unique to Singapore. Recently, I read a British article which noted the growing popularity of TCM in the West. It made an interesting observation that the TCM clientele, at least in the West, were either the lower-educated or the highly-educated. The author did not explain why.

There are many things about TCM which we have no answers to. That is why all healthcare regulators, whether it is the east or the west, find it very challenging to regulate TCM and other complementary medicine. The reason is

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the basis and approach of TCM and Western medicine are fundamentally different.

Members would know Dr Hong Hai. He was an MP, western trained, English-educated engineer, with a PhD in Economics and a recent serious interest in TCM. He has just graduated from a local TCM school and he is now a fully qualified TCM practitioner. When I met him recently, he commented positively about my health. So I asked him to substantiate his observations. He explained his observations by noting the colour of my face, my complexion and such esoteric stuff. I was very happy with his conclusion - never mind if I could not fully understand his explanation.

And therein lies the challenge of trying to regulate TCM, especially when we want to integrate it into mainstream Western medicine. In Western medicine, the operating principle is evidence-based medicine. If we say that a particular drug or a particular treatment works, it is backed by clinical trials, double-blinded randomised, and research findings which have been subject to international scrutiny.

Although TCM is increasingly subject to evidence-based tests in countries like China, where leading universities teach and conduct research in TCM, the level of rigour has not quite reached that required by Western medicine. The question to regulators is: should we accept lower standard of evidence for TCM or should we apply that evidence-based principle strictly? A strictly conservative approach will make it very difficult for the practice to continue, let alone grow. This will, as Mr Chay put it, deprive consumers of a service which has provided much relief and comfort to generations of Singaporeans, many of which are in his constituency.

So in 1995, then Minister George Yeo appointed a TCM Committee, under Dr

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Aline Wong, to look into this subject. It recommended, and subsequently Ministry of Health agreed, a cautious step-by-step approach to TCM. That same year, 1995, MOH set up an Acupuncture Research Clinic in Ang Mo Kio Community Hospital which is still functioning. A year later, we started to upgrade the training of TCM practitioners. In 1999, we tightened the control of Chinese proprietary medicine. In 2001, we registered acupuncturists. Acupuncture is now a registered practice. Only in 2002, we began to register TCM physicians. I will continue this step-by-step approach.

I will particularly want to learn from the experience of others. In fact, next week, I will be in Nanjing because we are launching the inaugural direct flight of SIA between Singapore and Nanjing. I will take that opportunity to visit the TCM University in Nanjing to discuss the development of TCM. But whatever we do, one thing is clear. This is an area where regulations inevitably will have to be light, for the simple reason that regulators do not know enough. The major focus of regulation is to ensure safety of the TCM products, such as by checking whether there are contaminations of the herbs with heavy metals, and whether there are adulterations of Chinese proprietary medicines with Western pharmaceutical agents. However, regulators are unable to assess such products for efficacy as is done for Western pharmaceutical drugs. Therefore, consumers must not equate TCM with Western medicine. Consumers will have to be sensible and careful. At the same time, it is incumbent on TCM practitioners to regulate themselves, and to do so seriously, they must self-regulate and be prepared to turf out those who are sub-standard or not up to standard. And more importantly, they must continuously upgrade their standards of practice.

Dr Chong and Mr Chay asked about the adoption of TCM treatments within

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our hospitals. Acupuncture, as I have said, is available at Ang Mo Kio Community Hospital and also in NUH, SGH and Tan Tock Seng Hospital for selected medical conditions. However, to make it clear to the patients that this treatment lies outside mainstream Western medicine, TCM therapy is provided in a clinic, separate from the Western clinics and hospital wards.

I met the medical community recently and asked if we could now move beyond acupuncture to consider other forms of TCM therapies. They were unanimous in suggesting to me that the next modality after acupuncture could be " tui na ". My Ministry has therefore formed an expert committee under Prof. Lee Tat Leang of NUH to look into this idea and if viable, to look into the operating details. Prof. Lee is both a professor of anaesthesia and a qualified acupuncturist.

Mr Chay asked about the training of TCM practitioners. The two local TCM training schools have recently upgraded their courses to six-year part time or three-year full-time diploma courses. This is accredited by the TCM Practitioners Board. One of the schools has also linked up with Nanjing TCM University to offer a Bachelor's Degree in TCM while the other offers a Masters degree in TCM, but jointly with Beijing TCM University. As for TCM herbal dispensers, my Ministry has worked with the traders community to conduct a four year part-time training course in TCM herbal dispensing. This course is also accredited by the TCM Practitioners Board.

Dr Neo asked about the qualifying examinations for the practitioners. Any person who wishes to practise as a TCM physician now needs to pass the examinations. This was the decision taken many years ago, with ample notice to the TCM practitioners and with much preparation involving upgrading of TCM

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training at the schools. There are some TCM physicians who did not have the opportunity to receive formal training. The Ministry created a special transitional arrangement to grant them various exemptions based on their individual qualifications and experience. Only those - and that is a small minority - who did not have sufficient qualifications or prior experience, as assessed by TCM Practitioners Board, were required to enrol in the TCM upgrading training course and also to pass the common examinations.

To give all applicants sufficient opportunities to upgrade themselves and to take various examinations, a total of three appraisals,

two examinations and one upgrading training course were conducted over a period of two years, and a vast majority passed. Unfortunately, despite repeated reminders, 61 applicants did not come forward for the appraisals, 37 did not come for their examinations and 27 did not enrol in the upgrading course. But they were really a tiny minority.

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The common examination, from now on, will be conducted every year. So those who failed to be registered under the transitional arrangement can still enrol in either of the two local schools and be registered once they have passed the examination.

Pro-family policies

Finally, let me respond briefly to Mayor Yu-Foo Yee Shoon's various baby and family-friendly comments. Along the way, I will also address Mdm Halimah's comment this morning.

As Members know, baby policies of all Ministries are under scrutiny. MOH will do its part in this review. I am quite sure

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Mr Lim Hng Kiang will leave no stones unturned; no diapers unchanged. But as a parent who knows how to change diapers, we also know not to change the diapers unless they are soiled. We will relook the pricing of IVF, but offhand, I think it is unsoiled. I will be very reluctant to start subsidising IVF. Why? Subsidy is a zero sum game. More subsidies for unborn babies mean fewer subsidies for the sick who are already born. But, of course, if there is extra subsidy coming from Mr Lim Hng Kiang's baby budget, then it is a different story.

As for childbirth subsidy, Medisave has made childbirth expenditure very affordable. And that is the reason why more Singaporeans are born in the private hospitals now, than in public hospitals. Are hospitals family-friendly? I think they are. But, like all things, there is always room for improvement. With Dr Jennifer Lee, who champions family-friendly policies at the office, running KK, I know that KK could be a good benchmark. Along the way, we will pass on best practices to all the other hospitals.

Dr Lily Neo: Sir, I would like to thank the Ministers for their comprehensive replies, especially the Minister for Health, Acting or otherwise, for his clear replies. I would also like to wish him success in his endeavours on his priorities for MOH. I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

The Chairman: Amendment No. (2), Dr Lily Neo.

Dr Lily Neo: Sir, I beg to move,

That the sum to be allocated for Head O of the Main Estimates be reduced by $10 in respect of Code OA 3600.

Fertility

Sir, one in five married couples finds it difficult to conceive. In view of our

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declining Total Fertility Rate, we should further help these couples who yearn to have children. The amount of Medisave withdrawal for each in-vitro fertilisation (IVF) programme should be increased. The Minister said earlier that he will do his part for the baby issue and, therefore, I hope that MOH will also consider subsidising other fertility procedures, like intra-uterine inseminations (IUI), to ease the burden for patients at all fertility clinics in the public hospitals, especially if he should get more funding from Minister Lim Hng Kiang.

In Singapore, one in five women has kids when she is 35 years old or older. This figure far exceeds the developed world average. There is an increased risk of infertility with late pregnancy. Pregnancy in older women also carries increased risks for mums and babes. These include miscarriages, pregnancy complications and complicated deliveries. Would the Minister for Health help promote healthier pregnancies and prevent neonatal abnormalities by publicising and promoting the advantages of earlier childbearing? I feel that we need to better inform the public on the medical disadvantages of pregnancies in older women. MOH can disseminate this message through either the Health Promotion Board or in collaboration with other organisations. Grassroots organisations can be co-opted to hold talks and seminars on such topics in their constituencies.

Sir, complicated deliveries for mother and premature babies can incur financial burdens to young couples. Therefore, I hope, as discussed earlier, that the Minister consider risk-pooling insurance schemes for medical expenses and maternity insurance from our Medisave to insure couples against complications of pregnancies and childbirths.

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Stroke

Sir, stroke is the second leading cause of death worldwide, and it is the fourth leading cause of death in Singapore. Data from MOH shows a rise in the number of admissions to hospitals for cerebrovascular disorders, including stroke and transient ischaemic attacks, from 3,732 in 1986 to 10,250 in 2001. As some patients may prefer to remain at home rather than go to hospital, a notion that has to be corrected through public education, the actual numbers are probably higher. About 63% of all stroke survivors in Singapore are still moderately or severely disabled three months after the event.

Sir, anti-platelet therapy and thrombolytic therapy improve outcome with fewer in-hospital deaths for cerebral infarcts when they are prescribed early; preferably within hours of onset. And, in Singapore, over 74% of stroke cases are due to cerebral infarctions that would benefit from such therapy. The diagnosis is possible and treatment can be started only following early brain scanning which, unfortunately, is expensive. Will the Minister facilitate these tests by allowing patients to use their Medisave to pay for them even as outpatients?

Will the Minister help set up urgent protocols in our public hospitals to facilitate stroke patients to get early investigations and appropriate treatment as soon as possible?

Since about 30% of stroke cases end up with long-term disability, does our healthcare system provide enough assistance in managing such patients, for example, in terms of rehabilitative and other supportive measures? Do we have enough therapists to provide for such care?

Will the Minister enhance further on public education on stroke, especially on advice to seek early treatment and on

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preventive measures for strokes, maybe by the Health Promotion Board?

Does the Minister foresee an increasing need for caring of more sick people with disability due to stroke and other causes in view of our fast ageing population? What action plan is the Minister taking to cope with this trend? Will the Minister also consider an epidemiological study on stroke with the purpose of improving the management of stroke patients and the prevention of stroke?

Homecare

Sir, the challenge for MOH on the care of the dependent elderly will be in assisting them to live in their own homes for as long as possible with appropriate support. We recognise that institutional care is costly and causes loss of independence. We also recognise that the family unit, with adequate support, is the principal way to provide care in the home environment rather than institutional care. Thus, we must accept that homecare will translate into convenience, lower costs and a happier populace.

Such a priority for MOH, in the care of the elderly, will help our nation cushion the awesome effects of a fast ageing population. Careful proactive planning and action now will ensure a successful outcome in this area.

Sir, the aim is to minimise hospital admissions and dependence on long-term care in institutional settings. Homecare with medical care, domiciliary services, daycare with rehabilitation facilities, occupational therapy services as well as equipment and adaptations at home should be made available. Homecare requires the services of personnel, transport and domestic support. Older people often have a variety of inter-related

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needs, including nutrition, nursing medication and mobility management.

The training of caregivers of homecare is important for MOH to develop. And these caregivers can be the professional providers, family members and volunteers. There is a need to involve the communities to facilitate the elderly to stay in the communities and at their own homes for as long as possible by involving community help and community volunteers to deliver the services.

Sir, apart from providing the combination of these services, MOH needs to look into the funding for such long-term healthcare to ensure that it is affordable, equitable to all generations, and sustainable over time.

Dr Balaji Sadasivan: Sir, Dr Neo has brought up three issues. The first is related to fertility in women. I totally agree with her. My Ministry agrees with her that if mothers delay their pregnancies and have children in their old age, the risk to the children is much greater. The only solution to that is to encourage women to have children at a younger age, certainly below 35 years old. This is something the Health Promotion Board, as part of health education, needs to educate mothers on. This will be part of our contribution to the procreation policy of Singapore.

She also asked about Medisave for in-vitro fertilisation. My Ministry would like to help couples who need assisted conception procedures to have children. A treatment cycle costs about $6,000-$8,000. The first cycle has the highest chance of success. With successive cycles, the chance of success decreases. Currently, couples can use their Medisave for assisted conception procedures up to a maximum of three treatment cycles. There is a need for a cap on the number of treatment cycles to prevent premature depletion of Medisave. The Ministry had,

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in June 2001, raised the withdrawal limit from $2,000 per treatment cycle to $4,000 per treatment cycle. This means that up to $12,000 from Medisave can be used for these procedures. This is a significant drain on Medisave resources of couples. I am concerned about the ability of these couples to pay for their medical care should they fall ill. The Ministry will consider reviewing the cap. And, when it reviews the cap, it will try and balance the competing needs - the need to preserve Medisave and the need to help procreation.

The second issue Dr Lily Neo brought up was stroke. All our public hospitals have stroke units and multi-disciplinary stroke teams to provide integrated and holistic care to patients with acute stroke. Clinical care pathways and guidelines are in place to streamline the care of patients with stroke, from the Emergency Department till discharge. More than 95% of all stroke cases admitted to the hospitals would get a brain scan within 24 hours of admission. Most get it within one hour. As part of the clinical protocols in hospitals, rehabilitative care is initiated when the acute medical problems have been stabilised so as to improve outcomes. Patients who require more intensive rehabilitation are either referred to in-hospital rehabilitation departments, or to community hospitals. For those who will benefit from outpatient rehabilitation, they are discharged home with either a referral to community-based therapy centres and/or their care-givers are trained in simple rehabilitation techniques to assist the patient at home. The use of Medisave for outpatient brain scanning does not arise in acute stroke because acute stroke patients should go to the Emergency Department for appropriate treatment by a stroke team.

Brain scans will be done as part of the inpatient evaluation and treatment plan.

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The third issue that Dr Lily Neo brought up was on home care. The Ministry's philosophy on home care is to encourage the elderly to stay in the community for as long as possible and institutionalisation should only be a measure of last resort. As such, the Government has extended subsidy to financially deserving elderly who require home medical and home nursing visits. With subsidy, more severely disabled elderly can continue to stay in their own home with their families, thus avoiding the need to stay in an institution.

Our subsidy scheme for home care services has benefited about 7,000 elderly who meet medical nursing and financial criteria for subsidised home medical and home nursing care. For 2003, over 53,000 home visits were provided by the VWOs, 10 home medical and 13 home nursing providers which altogether cost the Government $3.6 million in subsidies. The norm cost is $122 for home medical and $56 per home nursing visit.

For the elderly to stay at home, care givers need to be trained to reduce burn out. Home carer training courses aim to equip home carers who may be family members or maids. Restructured hospitals, community hospitals, VWOs and private operators provide home carer training. Community Development Councils are also running a number of home carer training programmes in the community. The scope of training provided varies across organisations but, in general, it incorporates information on basic nursing care, activities of daily living, transferring techniques and personal hygiene.

The Health Promotion Board also has a web page specifically designed to provide information on help for the elderly. A free video titled "Home Care for the Elderly" can be downloaded from the HPB website as well.

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We are also looking into improving the knowledge of home carers by providing them with easy access, eg, through the MOH website, to information on home carer training courses available in the community.

Dr Lily Neo: Sir, the Minister of State addressed my earlier question on whether our healthcare system provides enough assistance to about 10,000 stroke patients each year. Does he foresee an increasing need for caring for more sick people with disabilities? And what is the action plan provided for this trend and whether will he agree on an epidemiological study on stroke with the purpose of improving the management and prevention of stroke?

Dr Balaji Sadasivan: Sir, stroke is one of the three major causes of mortality in Singapore. It is also the biggest cause of disability in Singapore. It is a large part of our medical care and a large part of our healthcare subsidy, both to our acute hospitals and community hospitals. In fact, a large portion of the subsidy in the community hospitals is for stroke.

With regard to an epidemiological study, there was an epidemiological study done in the 1990s on the breakdown of stroke in Singapore. Perhaps it is time to review that study to see whether a new one is needed.

Dr Lily Neo: Sir, I am not quite satisfied with the answer. Anyway, I will discuss with him later on.

I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

The sum of $2,056,173,500 for Head O ordered to stand part of the Main Estimates.

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The sum of $1,725,017,350 for Head O ordered to stand part of the Development Estimates.