HEAD O - MINISTRY OF HEALTH

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Head O - Ministry of Health (cont.) -

**** Resumption of Debate on Question [8th March, 2005],

"That the total sum to be allocated for Head O of the Estimates be reduced by $100." - [Mdm Halimah Yacob].

Question again proposed.

Regional Medical Hub

Dr Michael Lim Chun Leng (Pasir Ris-Punggol): Sir, I wish to declare my interest as a medical practitioner.

The gap between Singapore and its regional competitors has narrowed significantly. Top doctors from the region, whether they are from countries like Malaysia, India, Philippines and China, are no less than many of our top doctors. In India and China, procedures are done at a fraction of our cost. Many of their top doctors have been trained in top western foreign medical institutions. Today, the reality is that a large number of nurses, medical technologists and radiographers come from our neighbouring countries.

The Government tells Singaporeans to be entrepreneurial, take risks, grow the economy, create jobs; and on its side, it will provide incentives, regulate lightly and remove bureaucratic hurdles.

I dream of a Singapore Regional Medical Hub where we combine the best of Singapore and the region by drawing upon the talent of some of the brightest and best doctors from the region, including Malaysia, India, Philippines and China. In this sense, where the large majority of the patients are foreigners, these foreign consultant specialist doctors can be allowed to practise independently to service our large foreign private sector pool. They are allowed accreditation to

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perform procedures based on their training and experience. They adopt Singapore standards of medical practice.

We work with the medical MNCs to become regional centres of excellence in various areas of medical advances. As we continue to maintain high standards, we provide cost competitive healthcare services which make us a magnet for foreign patients. When we grow sufficiently big to have a big pool of local and foreign specialists, we will set up outposts where we use Singapore standards but local costs. In a few years, Singapore Regional Medical Hub will compete in the home ground of our ASEAN neighbours and in South Asia and China.

Drawing talent from the region, being reference centres for medical technology, practising the highest standards of medicine and remaining cost competitive, Singapore Regional Medical Hub eventually becomes the medical centre of choice in Asia.

Singaporeans dare to dream, take the risk and raise the standards. We want to lead in the world and are not content to be just followers of other countries. We may run into competition with the public sector but we need not fear if the competition is open and transparent without resorting to bureaucratic hurdles, turf protection measures and harassment through Government agencies.

Singaporeans know what they must do to beat the competition, but the steps ahead require rapid changes in the system. Is the Ministry of Health ready? As one senior healthcare official told me - you are too far ahead of the time, we cannot change fast enough.

I do not know whether all these will continue to remain a dream or whether it will become a reality. But one thing I know for sure is that in India and China,

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their large pool of foreign trained specialists will post a formidable challenge to Singapore. If we do not act fast enough, not only will the number of foreigners coming to Singapore decrease, the number of Singaporeans seeking private healthcare treatment overseas will increase.

Future Development of the Two Hospital Clusters

Mr Alexander Chan Meng Wah (Nominated Member): Sir, our public healthcare delivery system was reorganised into two vertically integrated delivery networks - the National Healthcare Group (NHG) and the Singapore Health Services (SHS). This was to enable more integrated and better quality healthcare services through greater cooperation and collaboration among public sector healthcare providers.

Let me declare that I am a director on the board of the National Healthcare Group, one of the two public healthcare clusters. Having seen the genesis and the early-stage transformation of this cluster, I know that there were numerous challenges to meet, as expected in any new organisation with new management, newly created and reformed competition, the changing patient demand picture and the newly crafted regional segmentation of the restructured hospitals. There was great impact on staff at many levels, leading to movements between hospitals and clusters, due largely to the perceived imbalance of medical disciplines between the two clusters at the start, and the perceived difference in management styles as well.

In any case, five years after the birth, these two hospital clusters have stabilised their respective operations. The entities seem to be driven by well staffed mission oriented management teams supported by their respective boards. There have been critics of the cluster system as well as

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supporters no doubt. The rising development of competing hospital systems in the neighbouring countries as others before me have talked about, plus the continuing public attention on healthcare costs, may have also added some doubt as to whether the original goals and objectives of hospital clustering are being achieved. I would like to ask the Minister how he assesses the situation and whether he views the clusters as fulfilling the original goals and objectives, whether there is a need to change these goals and objectives and therefore whether there is a further change anticipated to the clusters.

The Chairman: Dr Chong Weng Chiew, you have two cuts. Please take them together.

Third Health Cluster for Premium Services

Dr Chong Weng Chiew (Tanjong Pagar): Sir, currently, there are two medical clusters providing a wide and comprehensive range of public health services to Singaporeans. At the same time, they have the objective to pursue medical excellence and thus provide certain premium services. This is definitely an inspiring and exciting goal in line with our desired status to be a centre for medical excellence. However, the availability of premium services in public facilities often leads to very high cost for certain families. For example, whenever a patient is admitted regardless of the class of the ward, the family of the patient would normally request that the medical personnel choose the best available treatment for their loved ones. More often than not, there is little discussion over cheaper alternative treatment, particularly because the filial piety is part of our Asian culture.

There may be some marginal differences in their effectiveness but the cost difference can be substantial. Thus, I would like to recommend that our

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current two clusters focus on providing basic health services only, and if the two medical clusters are to pursue premium services to set up the third cluster, if necessary, for these premium services. The third cluster would have the freedom to pursue excellence for more cutting-edge medicine in our quest to be the world class centre for excellence.

Traditional Chinese Medicine

Sir, my next cut is on traditional Chinese medicine (TCM) and I wish to speak in Mandarin.

(In Mandarin) : Sir, I wish to thank the Minister for Health who has, after listening to my repeated appeals in Parliament, finally decided to allow qualified Chinese physicians to treat patients in the wards of approved public hospitals. This is much welcomed and praised by the traditional Chinese medicine practitioners, as well as patients who prefer TCM treatment.

Such a cooperation plan can help to promote better mutual understanding and recognition between the western-trained doctors and the TCM physicians. I hope that, in the not too distant future, similar cooperation plan may be extended to more Government hospitals and clinics. However, to arrive at such a stage, as pointed out by Minister Khaw Boon Wan, the pre-requisite is that the professional standard of the Chinese physicians must be raised.

At present, we have two colleges providing specialised training for Chinese physicians. There are some 2,000 registered Chinese physicians in Singapore, and another 1,000 or so studying in the two colleges.

May I ask the Minister whether his Ministry is keeping track of the number of

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TCM students and registered practitioners to ensure that there would not be a situation of over-supply of TCM practitioners? At the same time, we must ensure that the TCM bodies in Singapore go for quality rather than quantity.

Dr Tan Sze Wee (Nominated Member): (In Mandarin) : Sir, I would like to ask the Minister for Health whether he could enlighten this House as to how many students are currently studying in each year of the six-year part-time training course in the two TCM colleges.

Whenever we mention primary healthcare service, we would inevitably think of the western-trained family doctors. This is an incomplete perception. In fact, from the patient's point of view, there is a variety of primary healthcare services available, including western-trained doctors, retail pharmacists, natural cure practitioners and Chinese physicians.

At the moment, there are two privately-run TCM colleges recognised by the Government. I understand that the two colleges are actively training a considerable number of Chinese physicians. In recent years, there is an upward trend in both enrolment and number of graduates. Since we do not have any TCM hospital, the number of outlets available to the fresh graduates is limited. Generally speaking, they can only play the role of the primary healthcare providers after graduation.

In the field of western medicine, our only NUS Medical School trains more than 200 western doctors each year. About half of them will eventually become family doctors. The second medical school will start its enrolment soon to train even more western doctors. In other words, there will be some 100-200 western-trained doctors becoming family doctors.

In the situation of an over-supply of western doctors, we may face the following problems:

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First, the crisis of “suppliers inducing demand�? as mentioned in the MOH's 1993 White Paper; and

Second, the TCM practitioners will be first to face the impact. As the Chinese saying goes, “Too many monks with too little porridge to go round�?. After all, under our present healthcare system, the outlets available to the TCM practitioners are more limited than the western doctors.

Can the Minister state categorically that we have unconsciously trained excessive western-trained family doctors and TCM practitioners? I would also like to know whether the Minister is of the view that the Government should directly or indirectly control the number of training places for TCM practitioners, as it did for the western-trained doctors, thereby providing some form of security for basic job opportunity for the newly graduated Chinese physicians.

Chinese Massage Therapist Certification

Mr Ong Ah Heng (Nee Soon Central) (: In Mandarin ): In our daily lives, very often we would fall down and either sprain our ankles or dislocate our joints. More often than not, the ordinary folks would go to the traditional Chinese massage therapists or die da sinsehs for treatment . If the sinseh is known to be effective and well-established, he would be very popular. People may go all the way from one part of Singapore to another part to seek treatment from him.

Most of these massage sinsehs hail from martial arts background and learn their skills from their fathers or masters. They come from all schools of Chinese martial arts, such as the Shaolin “Touch Vital Point�? therapy.

The Chinese Physicians' Certification Examination currently being conducted in Singapore covers a wide range of medical

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subjects such as internal medicine, acupuncture, etc. The traditional die da sinsehs may have been practising all their lives and are very experienced, but this kind of certification examination is just not their cup of tea.

I urge the Government to allow them to take an alternative form of certification more attuned to their specialty so that they could continue to practise their skills for the benefit of the community.

12.15 pm

The Minister for Health (Mr Khaw Boon Wan): Mr Chairman, I thank Dr Michael Lim for his comments on our ambition to become the regional medical hub, an initiative which we have codenamed SingaporeMedicine . I share his dream, not every single detail, but at least the larger plot.

The Economic Review Committee felt that we could succeed in SingaporeMedicine . Years ago, we were a clear leader in the region. But as Dr Lim pointed out, our competitors have quietly narrowed the gap with us. It is not just Parkway in Malaysia, or Bumrungrad in Bangkok. It is now also Apollo, Escorts, Max Healthcare and Fortis in India. If we are not careful, it will soon be Shanghai, Beijing and Dubai.

Dr Lim asked if MOH is ready to make his dream come true. SingaporeMedicine is not strictly an MOH portfolio. But from MTI where I was for seven years, I knew that without MOH's support, SingaporeMedicine will be so much harder to achieve.

To secure our lead, we have many things to do: increase supply, step up training, let in more foreign talent, make our cost more competitive and work more actively with world-class partners.

Ministry of Health's past ambivalence on SingaporeMedicine is not without good

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reasons. As increased demand would have to be supported by more specialists, there were concerns that more specialists, in turn, would lead to higher demand. The assumption is, as what Dr Tan Sze Wee has just noted, that supply could induce demand in healthcare. The end result is higher healthcare cost.

Supply-induced demand is real but is not unique to healthcare. Wherever there is market failure and unequal power between provider and consumer, the potential for supply to induce demand exists. For example, where sellers know more than the buyers, what economists call information asymmetry, an irresponsible seller can creatively induce spurious demand.

Look at motor repair workshops. Most of us know how to drive, but I think very few of us know exactly how engines work, let alone how to fix a car problem. So this is a classic case of information asymmetry between the mechanic and the car owner. So, bad luck, you go to a mechanic who is irresponsible, he will say: fix this or fix that, this is the bill. I think very few of us will be able to argue with him or to even know whether we have been taken for a ride. And if insurance is going to pick up the tab, most car owners may not even care. They are more interested in how soon they can get the car back in good shape.

There are many examples of such market failures. When you go to a strange city where you are not familiar with the roads, you hop into a taxi - information asymmetry - and you say, "I'm here. I want to go there," and the taxi driver took you on a long way, you may not even realise it; hence, the expression "taken for a ride".

The way to address such market failures is not to restrict supply and expect demand to go down. The correct

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response is to make as much information as available to consumers, reduce the information asymmetry so that consumers can make better informed choices. If they cannot digest the information, they can seek third party advice, for instance, from their family physicians or their insurers. That is why it is so important for every Singaporean to have a good family physician. It is crucial - very important. Equally important, we need to put in place a framework which generates incentives for hospitals to provide good basic healthcare with minimum resources.

For some time now, we control the supply of specialists as a policy, on the premise that this would moderate healthcare demand. But from an economic point of view, this logic may not be entirely correct. As I said just now, it is wishful thinking to hope that with fewer specialists, demand for their services will go down. This is particularly so when demand is largely driven by exogenous factors, like in our case, by our ageing population and our aspirations to be a regional medical hub. Over-restricting supply in the face of independently-rising demand will simply drive up healthcare costs, as prices will adjust to the excess demand. This is Economics 101.

That is why I favour taking a more market-based approach to manpower planning. We must be responsive to market demand and we must be flexible in adjusting supply. Yes, there are valid concerns about supply-induced demand. We will watch the situation carefully. But, at the same time, we must take care not to rigidly control numbers and overly-choke supply, creating a severe excess-demand situation. After all, if SingaporeMedicine makes progress and we still restrict the training of specialists, queues will simply lengthen, and prices just go up.

We must also step up training, but not just for ourselves. We must help train our

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neighbours, particularly Malaysia, Indonesia, Thailand, Vietnam and China. Many are very keen to learn from us. Every year, our hospitals play host to thousands of such doctor visitors. We should welcome such trainees, even from countries which we may not have traditionally recruited from. The best amongst them, we hope, will eventually settle down here, and become Singaporeans; the rest will go back and they become very important links for us to their region. Moreover, with a larger patient base, we can train our own doctors better and faster.

Look at India and China, which Dr Michael Lim described. The number of organ transplants, coronary artery bypasses and joint replacements that their doctors get to work on is mind-boggling. What our trainees get in one year, they can get in one month; sometimes two weeks! Coupled with their vast pool of talent and hungry ambition, it is a matter of time their skills will surpass ours.

We should not be afraid that we are training our competitors. The strength of Singapore is our ability to get things to work and maintain operational efficiency over time. We are good at operating complex systems.

Just look at Changi Airport and PSA. Others can buy the same hardware, the same cranes, the same IT equipment and so on. But we stay ahead of competition by operating what we have, effectively and efficiently. Likewise, our regional healthcare competitors can buy the same technology that we have. But I am confident that our hospitals have what it takes to stay ahead of competition.

Dr Michael Lim has painted his dream. Let me share with Members my vision. It is that our hospitals can be the best in Asia and be acknowledged as such by our peers. But let me quickly clarify what “the best�? means. To be the best does not

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mean the tallest, shiniest buildings or the most expensive equipment. "The best�? means we have the best clinical outcomes, the lowest morbidity and mortality, the lowest complication rates, the fastest recovery, the lowest usage of resources. And we come up with new productive devices, new effective techniques, and new processes.

Not all specialties can achieve this. But, hopefully, a handful can produce results within a few years, which will then encourage the other specialties. Can we make it? I know it is a tall order. But we have proven our abilities in other areas before. Yesterday, I spoke about our SMs model of funding healthcare, totally made in Singapore. Our response to SARS was world-class, and again made in Singapore. With some of our best students in medicine, and some of our best talent in healthcare, we must put these top brains to work.

Dr Michael Lim spoke obliquely about “bureaucratic hurdles, turf protection and harassment through Government agencies�?, all of which could turn his dream into a nightmare. He spoke, presumably, from his own experience. I listened carefully; I got his “coded�? message. Let me encourage him not to lose his passion. Changing mindsets overnight is not possible. But there are people within the Ministry who share his dream. Count me as one. Together, let us make it happen.

The medical leadership is keen to work towards this vision, but acknowledging the challenges. If we stay focused and we are prepared to be bold in our approach, with determination, I think, after five to 10 years, we should be able to produce significant results. But we must be prepared to change, re-engineer our processes, and work with the best.

Since Dr Chong Weng Chiew mentioned traditional Chinese medicine

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(TCM), let me use that as an illustration. It is a very difficult subject, given our lack of domain knowledge. There is a certain mystique about it because we do not know what we do not know.

Take the regulatory regime for TCM herbs as an example. We have two options: do nothing, keep them largely unregulated and hope that no accidents happen. Or we can proactively engage the TCM experts and the industry to see whether we can develop a regulatory and certification system which can, in fact, be a global model.

Consumers all over the world always have problems differentiating real herbs from fakes - and there are many. Often, we get conned. I had been conned before too. I bought some cordyceps from somewhere, and once you started boiling it, it became something else! Can we develop the standards and the tests to help certify authentic TCM products? Can we aim to be the certifying body for the world market? Singapore is a trusted brand. I think if it comes with the Singapore chop, most people will trust that and say, "Aw, done by Singapore, certified by SISIR (or now called SPRING), should be reasonable." That will create a whole new industry in Singapore.

Ten years ago, Minister George Yeo planted a seed in Ang Mo Kio Hospital when he started acupuncture there as a pilot. There have been some developments since. Even our Zoo finds application for TCM. Last week, I read Ah Meng somehow benefited from acupuncture!

12.30 pm

I am giving TCM a booster shot. That is why I said “yes�? to Dr Chong Weng Chiew's request to bring the full range of

TCM services into Ang Mo Kio Hospital

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which he runs. My hope is that the local TCM practitioners take this opportunity to climb up the ladder.

Success is likely to come if they actively partner with the best in China. We must acknowledge that our TCM is not as developed as in China, and see how we can bring the best in TCM here, to help us evolve a model which can bridge east and west. We should jointly conduct scientific studies and clinical trials of TCM practices and TCM herbs and then publish the results in international scientific journals, actively contribute to a better understanding of this ancient art of healing.

They should invite the best TCM physicians to come here regularly to conduct clinics, treat patients, teach and give lectures. They can come as experts on temporary registration. To achieve best results, we must not be protectionist or fear that such foreign talent would take away our lunches. They can already do so, operating from China. I think it is far better that they are with us here, even if it is temporary.

At the same time, as Dr Chong pointed out, the local TCM community must upgrade and professionalise.

That is why I am not sure if I can accept Mr Ong Ah Heng's approach of allowing “ die-da �? practitioners to continue with their traditional way of training, often from father to son.

" Die-da " is a branch in TCM dealing with injuries to bones and soft tissues. The correct practice of " die-da ", like the practice of any specialty in TCM, requires full knowledge of TCM. That is why we require those who wish to practise " die-da " to undergo the complete training in TCM and be registered as TCM practitioners. This is also the regulatory regime in China and Hong Kong. You know at the hospital end, we have seen

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some of the damages done by some of these so-called " die-da " practitioners.

However, we are sympathetic to the incumbents who had no opportunity for such training in the past. And that is why we have special provisions allowing them various chances to try to study and pass examinations, and quite a few do. A few dropped out for various reasons. But I think, from now on, for all new practitioners, we have to require them to be fully-trained and fully registered as TCM practitioners. I think let us not compromise on standards here.

Dr Tan Sze Wee asked about the enrolment in our local TCM schools. We have two schools. They offer 6-year part-time course or a 3-year full-time course. And I am quite glad both have tied up separately with TCM universities in China.

Last year, about 100 graduated from both schools. Currently, about 800 are at various stages of studying, another 200 are doing the 3-year full-time course. So there is a total of about 1,000 stretched over several years. I just read today's newspaper that NTU is starting a double degree course with Beijing TCM University. So there will be a few students from there too. I welcome that development.

Dr Tan asked about the impact of TCM training on western primary healthcare. But TCM has always co-existed with western medicine, playing a very useful complementary role. Their market share is about 12%, and I have been looking at those data for several years. It has remained quite stable at 12%.

Dr Chong Weng Chiew expressed a concern that we may be over training. We have now about 1,800 on the TCM register and, as I said, there are 1,000 still in the pipeline. It seems like a very large number. I have no idea whether the

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market will be able to absorb 1,000. As always, as I said so yesterday, let the market work. But the market can only work if you provide useful information. What we would do and what the TCM community ought to do is to publish information, how many are you training, what is the job prospect of graduates. Like NUS and NTU, every year, they systematically publish within so many weeks or months, their graduates get jobs, their starting pay, etc. And I think the students need to know. My fear is that if you have two competing TCM schools and they start competing to produce as many as possible, it is troublesome, you get over-training and the students come out, they cannot find jobs. I do not think that will be fair to the students. I am not saying that the students are finding no jobs. I do not know enough about the industry yet. But I would urge the community to publish more such information into the public domain.

Let me now move west to our hospital clusters. Mr Alex Chan and Dr Chong asked whether cluster formation has achieved the purpose and whether excellence can be better achieved through a third cluster. Frankly speaking, the key to medical excellence is seldom due to organisational structure. I have seen various kinds of organisational structures among the top institutions, from Cleveland to Stanford. Top performance comes from leadership. Are the leaders serious? Are they clear of their goals? Are they able to attract like-minded people to join their cause? Are they ready to drop team members who are distracting or are distracted?

So whether it is one cluster, two clusters, three, or five, the more important question is whether we are clear about our mission and do we have good people who are passionate about our vision. Do we know when to cooperate,

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and when to compete? This is increasingly the key to winning the global competition.

As I see it, the only way SingaporeMedicine can stay ahead of competition, is for all hospitals, public and private, to work together as Singapore Inc. when it comes to professional matters. We fight as one team.

Last year, I advised the two clusters to stop organising competing annual scientific meetings but jointly organise much bigger annual scientific meetings with far greater impact on the region. I am glad that they are taking up my suggestion. They are now planning to upsize the many small local professional meetings to include the professionals from the region. Then you have meetings involving thousands and not just a few hundreds. They will also share and consolidate their databases of conference participants so that we can market our meetings more effectively. They will also try to leverage on the many world-renowned scientists, Nobel Prize Laureates, that A*STAR brought into Singapore, to help project Singapore as a thought leader for all things medical. I am very cheered by this development.

Last year, one of my grassroots leaders had a mild heart attack. He was a former patient of SGH Heart Centre. He had a heart attack at home, called the ambulance and because he lived very near to Tan Tock Seng Hospital, the ambulance brought him there. After stabilising him and discovering that he was a former patient of SGH, Tan Tock Seng Hospital, different cluster, called up SGH, informed them that they were sending him over. They put him into an ambulance and sent him to SGH. SGH was ready to receive and admit the patient. He stayed in hospital for seven days, recovered, he came out. Then only he told me about his experience of a very pleasant encounter

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with the two hospitals. Mind you, he was a subsidised patient.

I was very happy to hear his experience. Obviously, the rivalry between the two clusters must have eased. I dare not say that it has disappeared, but it has eased, at least in this instance, and SGH and TTSH have been able to cooperate for the welfare of their patients.

In short, it is not about how many clusters we have. The key is focus and leadership. What counts is how we take care of our patients at the front line, in the clinics and the wards. If our clusters compete to have the latest equipment, inflating pay to poach staff from each other, and shifting costs to each other, then we are headed for disaster. But I am confident that we have enough sense to know that the competition is not against each other. Competition is against diseases. Our focus must always be on how to improve health, how to reduce illness, how to do better and more with less, for the sake of all Singaporeans.

Our success will depend on whether we have the right leadership at the front line: hospital CEOs who see the larger picture and share the vision, and yet at the operational level, are hands-on at the helm of a tightly-run ship. They serve the doctors, the nurses, the frontline staff, make sure that the right systems are in place, the right people are well-trained and well-deployed, and facilities and equipment are working optimally so that our professionals can care for their patients in the best and least-costly manner.

If we stay focused on the right thing and have the right people in charge, I see no reason why we cannot be the best in the region.

The Chairman: Mdm Halimah, can you take your cut, please?

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Manpower Supply and Development for Healthcare

Mdm Halimah Yacob (Jurong): Sir, I think on the issue of manpower development and supply for the healthcare sector, we all agree that having an effective and adequate supply of manpower for the healthcare is extremely crucial for an effective delivery of healthcare services in Singapore. In this respect, there have been many developments, one of which has already been alluded to by the Minister when he spoke recently about the establishment of the second medical school and focusing on how to create greater specialisation and sub-specialisation for doctors. These developments will contribute towards developing better healthcare service through the doctors.

The other development is, of course, the establishment or allowing nurses to continue to upgrade themselves through a degree in nursing through the second medical school that is being set up. For a long time, this has been the bugbear of nurses that they have no opportunity to do so to improve themselves. This is definitely a step in the right direction. I would like to ask the Ministry also to consider not only on the direct staff providing healthcare services, like nurses and doctors, but also to look at the para-professionals. Because to have an integrated, holistic healthcare delivery system, particularly with an ageing population, we do need para-professionals, ie, podiatrists, psychotherapists, to provide palliative care as well. There is some concern that this group probably has not been receiving enough attention, and there may also be a shortage of this category of para-professionals. So I would like to urge the Ministry to look into the needs of this group of people and also to ensure an adequate supply of such para-professionals in the public health service.

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Health Manpower

Dr Tan Sze Wee: This is relating to health manpower. Can the Minister inform the House what is the exact number of doctors working in the polyclinics of each cluster in each financial year from 2001 to 2004, particularly those doctors who are registered under Temporary Registration with the Singapore Medical Council (SMC). The reason why I ask this is that I understand that the temporary registered doctors in polyclinics are not Singaporeans. Singaporeans are either provisional, conditional or fully registered with SMC. Can the Minister provide the nationalities of these temporary registered doctors in the polyclinics? Also, can we request for this data from the cluster hospitals as well?

The second question is, what are the average salaries of our doctors, say, for a first year medical officer after his housemanship who has graduated from either NUS, or Singaporeans who are trained overseas, either UK, Australia or approved universities, versus the temporary registered doctors who are working and employed in the same service. Third, with the onset of block funding, should there be a difference between those under temporary registration and the other two categories? Would the clusters be, therefore, more inclined to hire more doctors under temporary registration versus locally-trained or overseas-trained Singaporean doctors? Fourth, can the Minister assure the House that, with block funding and possibly increased use of such foreign doctors under temporary registration, quality care to our Singaporeans will not be compromised in the public sector?

Finally, I understand that these doctors are registered under the temporary SMC registration. Having read through the relevant sections of the Medical Registration Act (MRA) on Temporary Registration, which is section

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23, and given the nature that these doctors are purely here to give service with skills that are already commonly available amongst Singaporean doctors, I am uncertain how they can qualify for temporary registration on such a prolonged basis. Temporary registration is for doctors to "engage themselves exclusively in teaching, research and postgraduate studies in medicine". These doctors are here in our polyclinics to give a service primarily. Therefore, would it be better to amend the MRA to create a special class of conditional registration instead?

12.45 pm

In addition, in a reply to my learned colleague,

Dr Lily Neo in 2002, Dr Balaji, SMS for Health, said that there would be many more doctors entering the workforce in 2007. Can MOH confirm now that we will no longer need such temporary registered doctors working in our polyclinics from 2007 onwards?

Preventive Healthcare

Dr Lily Neo (Jalan Besar): Sir, preventive healthcare aims to have those who are healthy to remain well for as long as possible without getting ill from especially the lifestyle-prone diseases. Life expectancy for Singaporeans is about 79 years, and I would like MOH to start paying more attention to the needs of the elderly and ensure that they keep fit and healthy for as long as possible. I am advocating adding life to years.

What are the steps taken by MOH to ensure that the elderly also keep fit and healthy? Will MOH step up health promotion and prevention of diseases for this target group? MOH should partner MCYS in the setting up of centres of activity, especially for those less well-off retirees in the community. There should

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be at least one centre per constituency to keep the mobile elderly physically, mentally and socially fit.

Sir, early preventive measures are preferable and more effective than later interventions at points of crisis. Will MOH promote and reinforce the axiom of "disabilities in old age are often due to disease and early treatment of the disease can prevent disabilities"? Will MOH ensure that those with diagnosed chronic diseases get their regular long-term medications? Chronic diseases, such as hypertension and diabetes, are big problems to the poor, as they have limited resources. By stinging on the required regular long term medication, they end up with diseases, such as stroke, heart diseases and kidney failure that cost them and the society more in the end. Will MOH include chronic diseases care for those eligible poor elderly in the Primary Care Partnership Scheme?

Sir, I want to declare that I am a doctor participating in this scheme.

Chronic Sick Services to Complement Polyclinics

Dr Chong Weng Chiew: Sir, I would like to declare my interest as a health practitioner in a few charity welfare organisations.

In fact, I agree fully with what hon. Member Dr Lily Neo has mentioned.

Currently, only patients who seek treatment for chronic illnesses follow up at polyclinics qualify for Government subsidies. However, there are limitations to the reach of our polyclinics to the needy. Many of the elderly sick have mobility problem and thus have difficulty going to the polyclinics without assistance. As a result, many of the sick, the poor elderly postpone or even to the extent of defaulting on their visits to the polyclinics until, very often, which is the

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case, their conditions are irreversible or untreatable. Such situations lead to unnecessary sufferings and could result in even heavier medical bills for them subsequently and their families, as well as the taxpayers, who would subsidise the more aggressive and usually more costly treatments to help them recover.

To alleviate the situation, may I suggest that the Ministry of Health consider allowing means-tested patients to seek subsidised chronic sick follow-up at private clinics. Our network of private clinics is excellent, at least one within walking distance of almost every HDB block.

Next, besides giving grants to our two current health groups, would the Ministry consider allowing qualified charity welfare organisations who offer chronic sick follow-up medical services to the needy to claim similar grants? This way, voluntary welfare organisations can also assist in serving the poor and sick by offering subsidised services which complement those already offered by our current medical agencies. This would be perfectly in line with the many-helping-hands approach of our Government.

The Chairman: Dr Tan Sze Wee, you have two cuts. Take them together. Five minutes, total.

Polyclinics

Dr Tan Sze Wee: Sir, let me first declare my interest, although very little as a part-time GP on weekends when I do not travel.

On the anecdotal feedback from my medical colleagues that the two cluster polyclinics have very different objectives and modus operandi, one is rather conservative while the other is quite aggressive, and hence the growth rates for the two polyclinic clusters are quite different. This has also been compounded

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by the introduction of night polyclinics back in 2001 which led to further growth. If these growth rates are sustained in the future, will block funding be able to sustain these growth rates? If not, what can we do about it?

Will the Minister kindly furnish us with the following information:

(1) The year-on-year growth in workload and year-on-year growth rate of the polyclinic workloads of each of the two clusters from 2000 to 2004 inclusive;

(2) Give us the possible explanations to account for the differences in growth rates between the two clusters, should the rates be quite different;

(3) Given that the rates obtained in (1) above, does the Minister expect these growth rates to continue to vary very significantly in the next five years; and

(4) Reassure us that the proposed block funding mechanism will be able to continue funding these rates of increase, as given in (1) above of the two clusters' polyclinics in, say, the next five years and, if not, are there any plans to fund the polyclinics along these rates of historical expansion or to curtail demand for polyclinic services.

In developed countries all over the world, it is established wisdom and common practice to "de-market" subsidised primary healthcare. The exceptions being that of immunisation, whereby it is treated as a public good with positive externalities as well as certain disease screening, such as pap smear and mammography. However, from the years 2000 and 2004, it is largely perceived that the polyclinic went on a marketing spree to market its services. Because there is no means test currently in practice in the polyclinics, the capacity to abuse through a "buffet mentality" or "moral hazard" remains pretty large.

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The other issue with block funding of polyclinics is the disproportionate distribution of market share between the two clusters. One cluster has almost two-thirds of the polyclinic cluster while on the other hand, it only has 40% market share on the hospital, ie, secondary and tertiary, level. So, it is not 50-50 down the line vertically integrated. Going forward, is this mal-distribution sustainable? With the advent of block funding, what is there to prevent one cluster from dumping subsidised patients on another cluster by getting polyclinics to refer its patients to the other cluster?

Infectious Diseases

As brought up by Mdm Halimah Yacob yesterday as well, it was mentioned that during the SARS outbreak in 2003, Singapore did not have enough infectious disease specialists and public health specialists. Can the Minister inform the House how many doctors have been recruited for the Basic Specialty Training (BST) and the Advanced Specialty (AST) for the disciplines of infectious disease and public health respectively?

The Senior Minister of State for Health (Dr Balaji Sadasivan): Sir, I would like to thank the hon. Members, Mdm Halimah Yacob, Dr Tan Sze Wee, Dr Chong Weng Chiew and Dr Lily Neo for their comments. Mdm Halimah and Dr Tan asked about the medical manpower situation. Dr Tan made particular reference to the polyclinic.

Sir, manpower planning in healthcare is not an exact science. As we recently announced, there will be a second medical school. This school will take 25 students in its first batch in 2007. They will be housemen in 2011, finish their advanced training around 2017, and become specialist consultants around 2020, ie, about 15 years from now. Likewise, the

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number of doctors and specialists we have today was influenced by the admission policies of the last 30 years. Fortunately, the number of doctors working here is not solely dependent on rigid manpower planning. This is because a significant number of Singaporeans study medicine abroad and a number of them return home to work. We also take in foreign doctors who have augmented our numbers. And we have Singaporean doctors who leave to work abroad in the US, UK and Hong Kong. They reduce the local supply but they are an asset to Singapore because they form a Singapore network around the world that we can tap into. Just as Singapore hospitals recruit foreign doctors, foreign countries try to recruit our doctors. Some time ago, there was a team from the UK which visited Singapore. It was led by a distinguished surgeon and they were trying to recruit surgeons for the NHS. Three years ago, two of my former neurosurgical trainees who became consultant neurosurgeons were offered salaries of US$500,000 each, tax-free, to work in an oil-rich country. They turned down the offer.

Today, there is a global market for skilled medical manpower. Our healthcare system works within this market. The global market helps us import doctors in the areas where there is a shortage and allows our doctors to work abroad if there is a temporary oversupply in any specific area. In the same way, there is a global market for nurses and the health sciences professionals like physiotherapists and radiotherapists. Our nurses are targeted by foreign recruiters. I am told that the recruiters hand out leaflets to nurses at the bus-stops and MRT stations serving the public hospitals. The existence of a global market means that we have to pay globally-competitive wages if we are to hold on to our healthcare workers. But it also means that we can meet shortfalls in our manpower requirements by recruiting foreign-trained workers.

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Of the 7,000 doctors registered by the SMC, about a fifth are foreign-trained. They have been a plus to our healthcare system. Let me give two examples of foreign-born foreign-trained doctors who have contributed to our healthcare system. Prof Abu Rauff and Dr K C Tan are foreign-born and did not graduate from the local university. Prof Rauff was Chief of Surgery at NUS and was teacher to many of the top surgeons in practice today. Dr K C Tan is, of course, Singapore's liver transplant surgeon who saved both Ms Andrea D'Cruz and Mr Suleiman when their livers failed.

By welcoming talented foreign doctors, our healthcare system has been able to deliver better care to the public. There is no reason to discriminate against them. In answer to Dr Tan, there is no difference in the pay structure between foreign-trained and locally-trained doctors. The starting salary for medical officers is around $3,500 a month. Temporarily-registered doctors receive less because they have to be supervised. Those on temporary registration who perform well should eventually be given full registration. In answer to his specific question on the number of temporarily-registered doctors, there are 219. They work in both clusters and about 30 of them are in the polyclinics.

In looking at medical manpower, we need to also consider the distribution of doctors between the various specialties. Specialisation makes it difficult to redeploy medical manpower. The United States, which has a sophisticated training system, has 24 specialties and includes family medicine as one of the 24 specialties. Singapore has 35 specialties, and we exclude family medicine. Specialisation creates silos with walls that prevent the movement of work or doctors across specialties. Even within specialties, doctors sub-specialise further and are reluctant to be deployed elsewhere within the specialty. This can create a relative

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over-supply or under-supply within the specialty. For example, since the number of deliveries in our public hospitals has dropped from an annual peak of about 40,000 to less than 20,000, the number of neonatal beds should be halved. Instead, the neonatal specialists tell me the number of beds remains the same and that they are working at 110%. When there were 40,000 births, the neonatal specialists had the modest goal of reaching a standard equal to that in a good hospital in the UK or Australia. Now, they want to be one of the top three centres in the world. With more than enough skilled manpower, relative to deliveries, they can set themselves this goal. The neonatal specialists are a dedicated and hardworking group, and they may achieve their goal. I am proud of their work. But this is an example of supply-induced demand. Since the supply of neonatal specialists has increased greatly in relation to the number of deliveries,

they have just set higher standards for themselves.

1.00 pm

Mdm Cynthia Phua yesterday expressed concern about the high cost of drugs and diagnostic tests. The clusters buy in bulk and this has reduced the cost of medicines. With regard to radiological tests, there are many new diagnostic machines. In countries like the US, rules have been relaxed so that other specialists are allowed to own and operate these diagnostic machines. This is not yet the case in Singapore. Our regulations reduce the supply of specialists who are allowed to operate the machines to only radiologists. The cost of radiological investigations in Singapore is sometimes twice that of neighbouring countries. This is not a problem restricted to the private hospitals. The MRI and CT scan charges at our restructured hospitals may, in some cases, be higher than the private sector. Patients bear this cost. MOH will study

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how to safely deregulate and introduce more supply and more competition so that the unit cost for radiological tests is brought down. This will benefit patients.

I have given these examples to show that market principles apply in healthcare and, at the same time, to show how supply can create its own demand.

For the market to work, our hospitals must have autonomy in making decisions on how they employ their doctors and what services they wish to provide. So, in answer to Dr Tan on the differences between the clusters, there must be differences because NHG and Singhealth do not have identical practices. They have the autonomy to make their own management decisions and compete with each other. This gives patients choice and the competition between the two will lead to better service and lower costs. They have different manpower recruiting strategies and different plans for future expansion. The CEOs of the clusters, hospitals and polyclinics are on the ground and they are in the best position to make decisions. I believe MOH should not try and micromanage the polyclinics or hospitals. And we should not unnecessarily set restrictions on them on what they should do in 2007. I do not have a crystal ball to look into and say in 2007 what the situation will be and what decisions they should make.

Mdm Halimah wanted to know what the doctor-patient ratio was. She was concerned about the number of doctors we have. In 2000, it was 1:720 population. It is now 1:650 population. So there has been an improvement. The second medical school will increase the supply of new doctors starting seven years from now. At the same time, we are going to need more doctors as our population ages. So looking ahead, I think supply will match demand, but even if the

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two did not match up exactly, any shortfalls or excesses will be evened out by the global market place in healthcare manpower.

Mdm Halimah was also concerned about other health sciences professionals. I agree with her. We must support the training and development of other healthcare professionals like nurses and the allied healthcare workers.

Dr Lily Neo highlighted the problems of chronic diseases in the elderly. Looking after the chronic diseases of the elderly will become the biggest sector in healthcare. With our high healthcare standards, Singaporeans can look forward to living into their 80s and 90s. This is good news. But it also means many will develop one of six chronic diseases in their lifetime, namely, hypertension, diabetes, heart disease, stroke, cancer or dementia. We must therefore be able to manage these diseases better and in a holistic manner.

Unfortunately, many members of the public think that specialist care is better than the care of a GP or a polyclinic doctor. Perhaps, this is because of the word "specialist", which is derived from the word "special". So patients think they get ordinary care from a GP and special care from a specialist. This is not so. The "special" refers not to special care, but to a special part of your body. The part of your body considered special is not really special - it could be your liver, or your lung or your colon or skin. It is considered "special" by the doctor because that is the usual part of the body he treats. So depending on the number of parts your body is divided into, you will need that many specialists to look after you. A specialist is therefore a body-part expert and not a whole-body expert. I have said there are 35 specialties in Singapore. If we exclude pediatrics and obstetrics, which I presume a man will not need, a man may need 33 specialists for his care.

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So that is why many patients in our hospitals end up seeing multiple doctors which costs them a great deal. Even then, sometimes things are missed because there will be gaps between the body parts covered by the specialists looking after the patient.

We need to educate the public that GPs, family physicians and polyclinic doctors are experts in looking after the whole body just as specialists are experts in looking after one part of the body.

The chronic sick often have multiple problems and they need holistic care. The polyclinics will be piloting specialist Family Clinics to look after chronic diseases. They will start with clinics that will look after hypertension and diabetes. They will announce the details when they are ready to roll out the service. If the pilot is successful, then GPs can be brought into the system to provide holistic care. We will study how best to model this scheme, possibly similar to the PCPS scheme, as suggested by Dr Lily Neo. Similarly, we can study how VWOs can be involved in chronic care, as suggested by Dr Chong.

Looking after the elderly requires a "many helping hands" approach. The grassroots can take the lead. And if any technical assistance is needed, my Ministry will help. I agree with Dr Chong that VWOs can play an important part in looking after the chronic sick. Like MOH, VWOs can employ competent doctors to provide primary health care. But there is a difference between MOH and a VWO. The great strength of the VWO is that it is a people-driven organisation, and that means it is an organisation with a heart that beats in tune with the community and that it is closer to the community.

Dr Tan had asked about the adequacy of infectious disease manpower. There are 18 infectious disease specialists, of whom 15 are in the public sector. There are also over 70 trained public health specialists

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and there are about 10 trainees in each speciality. For the exact details on the numbers, we can send it to the Member. Is this enough? Having more specialists is always better but I think our numbers are adequate.

In November, I had forecast that the rate of increase of AIDS was such that, in 2004, we will cross the 300 mark in terms of new cases diagnosed. The final tally is in. Sadly, the total number of new cases for 2004 was 311. In 2003, the number of new cases was 242. This means there was a year-on-year increase of 28%. Currently, 90% of these newly diagnosed patients are males, with one-third being gays. We had a low prevalence rate of HIV in the past, even in the gay community. We do not know the reasons for the sharp increase of HIV in the gay community. An epidemiologist has suggested that this may be linked to the annual predominantly gay party in Sentosa - the Nation Party - which allowed gays from high prevalence societies to fraternise with local gay men, seeding the infection in the local community. However, this is a hypothesis and more research needs to done by the experts. The reported new cases are only the tip of the iceberg. In total, we have more than 2,000 HIV/AIDS patients. But for every AIDS patient we have diagnosed, there are possibly two to four undiagnosed patients with HIV in Singapore. That means there could be anywhere between 4,000 and 8,000 undiagnosed HIV patients in Singapore. Last month, there was an alarming report from the US. The AIDS virus has mutated and the new virus is drug-resistant and kills quickly. Even those who are already HIV-positive can get infected by this strain.

We therefore have to make testing simpler for people at risk. MOH is currently studying the introduction of over-the-counter HIV test kits. These test kits are easy to use because they test the

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saliva. Any member of the public should be able to do it themselves. This will allow those at risk to test themselves. If those with HIV are diagnosed early, they could receive treatment early and hence minimise the development of complications. They could also take precautions so that they do not spread the disease.

Recently, we made testing of HIV in pregnant mothers an opt-out option. This increased the overall screening rate from 37% to 77%. As a result of screening, in the last two months, we have saved at least one child from getting infected. MOH is studying proposals to make testing of pregnant mothers compulsory so that we can achieve 100% screening.

Sir, besides gays, the other major risk group are heterosexual men who have casual sex. In many cases, this puts the wife at risk. In countries where the AIDS epidemic is full-blown, the majority of AIDS patients are women. This is because it is easier for the infection to move from man to woman than from woman to man. Currently, 10% of AIDS patients in Singapore are women.

If we do not act to protect women, many women will get infected and we will have a situation where women form the majority of AIDS patients. Do we want this to happen? There is a need to balance the right to confidentiality of the AIDS patient with the right to protect those at risk. The current legislation appears to be tilted in favour of the patient and exposes the spouse to the risk of catching AIDS. It also prevents the healthcare system from performing its public health duties. This is one reason why the AIDS epidemic is not coming under control. We need to treat AIDS like any other public health problem. We must give public health workers the tools needed to screen for the infection and contact-trace the infection. We need to protect the women of Singapore.

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There has been a reluctance to deal pro-actively with AIDS because of the fear that the AIDS patient will be discriminated. Hence, many measures were put in place which hindered efforts to diagnose HIV. But if the HIV patient is not diagnosed and even the person who is HIV-positive does not know he has HIV, how can we effectively stop the transmission of the disease? We need to de-stigmatise testing and, at the same time, we must prevent discrimination against AIDS patients. A lot of education is going to be needed. And the Health Promotion Board in Singapore will be busy this year working on this. Those who test positive for HIV should be able to lead normal lives in society. MOH will consult with the public and stakeholders before proposing any legislative changes.

Finally, there was some fear expressed by Dr Tan over the block budget system affecting clinical services. Minister Khaw has outlined to this House our approach towards block budgeting. There is no perfect health system. The health administrator has to work in a market-based system and is forced to be as efficient as he can. At the same time, the block budget ensures that the overall growth of the healthcare sector is moderated so that healthcare remains affordable. So, in answer to Dr Tan, the clusters will have to see what their block budget is and then determine what service they should expand. If they think polyclinic services should be expanded more because there is such an overwhelming demand, then that is what they should expand. If they think they should invest more in inpatient services, that is what they should do. I do not think we want to set a rigid guideline for what they should do over the next five years and then guarantee this House that that is what they are going to do and guarantee that the block budget should be used for that. As far as possible, we should let those on the ground decide how best to use the funds available

and match what

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new services they are going to provide with what is needed by the people of Singapore.

1.15 pm

For the doctor, he must do the best for his patients with the means available to him. He should do what is reasonable and correct in the provision of care to the patient. The standard of care we expect is that set by his peers. So, there will always be some tension between the two - the doctor and the administrator. But this is a healthy tension, as long as both realise that the other is also working for the benefit of the patient.

The Chairman: Mr Ahmad Khalis is not here.

Eldercare

Dr Lily Neo: Sir, would MOH endeavour to improve the quality of life for the elderly? I would like to ask MOH for the policy planning on the medical needs of the elderly in the next 10-25 years when the elderly population will increase from 14% to 20% of the population. Such a policy planning should be prioritised by MOH so that the heavy burden in the future will be cushioned.

What progress has MOH achieved to provide for the three-fold increase in the resident population above the age of 65 in 25 years' time? Are there plans to increase the capacity of the various healthcare services such as acute hospital services, nursing homes, day centres, community daycare centres? May I urge MOH to ensure that we do not leave it too late for this provision in the coming years.

Sir, I would like to ask if MOH agrees that homecare in Singapore is at its infancy and if MOH considers homecare as an integral part of healthcare in an ageing population? Does MOH see it as a priority presently and, if so, would MOH

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develop homecare services in professional medical caregivers, domiciliary services, daycare with rehabilitation facilities, occupational therapy services, as well as equipment and adaptations at homes? Would it also look at a variety of inter-related needs such as nutrition, nursing, medication and mobility management and, thus, the services of personnel, transport and domestic support? Should MOH involve the community help and community volunteers to deliver part of the homecare services? Most caregivers in the community are family members and maids. Would MOH help to provide the proper know-how and homecare support?

Sir, MOH should aim to provide seamless integrated care services for all discharged elderly patients from public hospitals to placement of patients to stepdown care facilities that look into their medical, social and psycho-social needs. Would MOH ensure coordination and effective implementation of these services and make them user-friendly as well?

Home Therapy

Dr Chong Weng Chiew: Sir, once again I agree wholeheartedly with hon. Member, Dr Lily Neo. She always has the privilege to mention those points before me.

The Ministry has introduced subsidies for homecare providers three years ago. I think that is in line with the Ministry's objective of promoting homecare or rather home-based or community-based care as compared to institutional care. However, currently, the subsidy does not extend to many other services including home therapy services. Thus, I hope the Ministry will reconsider this decision in view of our growing ageing population.

An increasing number of elderly Singaporeans will require physiotherapy

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and other follow-up care services that are conducted at their homes and in the community. This is because many elderly people are either living alone or are alone in the day, when their children or caregivers are at work. Hence, they are home-bound. Yes, there are daycare centres at various locations island-wide but, even so, elderly with mobility problems will have problem accessing these services. In addition, not every estate has daycare centres. In fact, those people who will benefit maximally from therapy are actually those who are home-bound. If a person has the ability to go to a daycare centre for rehabilitation, probably his disability is not as bad as one who is home-bound. Thus, without MOH's subsidy, the elderly poor will not be able to benefit from treatment and therapy just when they need them most. If the Ministry could subsidise such services, many elderly will benefit from this improvement in their health, as well as their quality of life. Thus, I hope that the Ministry will review its position on this policy.

The Parliamentary Secretary to the Minister for Health (Dr Mohamad Maliki Bin Osman): Sir, I thank Dr Lily Neo and Dr Cheong Weng Chiew for sharing their views and concerns, especially with regard to the elderly population. I agree that there are immense challenges in transforming our healthcare sector, and in ensuring more efficient use of resources, as well as more effective delivery of services. The MPs have highlighted the importance of a multi-pronged and seamless approach for public health policies and programmes, from preventive healthcare to ensuring that the services are delivered to the elderly population.

Today, the healthcare service delivery in both the private and public sectors remains fragmented. Both of them are healthcare practitioners, and they are in a

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better position to understand and to know that. This lack of integration gives rise to disconnects in service delivery and optimal healthcare outcomes. Except within small groupings of providers, there is very little sharing of critical information, when a patient moves from one provider to another. To compound the issue, we continue to be concerned with chronic diseases such as diabetes, hypertension and heart disease, each of which can cause significant health and financial burden.

Tremendous effort lies ahead of us, and to date the progress has been slow. The technology needed to link up different health care providers has existed for many years, yet very few, if any, providers have taken the initiative to come together. Why is this so? Many chronic diseases can be detected early and actions taken to prevent their deterioration. Prevention or delayed onset of such diseases will help individuals achieve a higher quality of life, as well as lower their healthcare costs.

We need to address this more systematically. To have better disease management and proper care for the chronically-ill, it is crucial that we continue to transform our healthcare delivery system innovatively and on various fronts. More of the same certainly is not sustainable. With the advice and wisdom from our MPs who understand the issues on the ground, we are confident that these problems could be overcome.

To facilitate this journey of change, the Health.connect concept that was mentioned in this House last year has now been fleshed out in more detail and piloted in the Jurong area since July 2004. Jurong Health.connect is an initiative that MPs like Mdm Halimah, Dr Tan Cheng Bock, Dr Lily Neo and Mr Ahmad Khalis are actively involved in, with the strong backing by Mr Lim Boon Heng. This is not an easy pioneering effort. Jurong

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Health.connect requires active support to integrate healthcare services across both public and private healthcare sectors, across hospital and step-down care, across carers and patients. When completed, it will deliver holistic care from all providers working as a team, with the Electronic Medical Records as the backbone.

Let me start with the first transformation needed in preventive healthcare. One key to a successful healthcare system is the early detection of diseases. Thus a primary component of Health.connect is health screening. Today, we have many players who reach out to different subsets of the community for health screening, under the Check Your Health programme, NKF screenings and ad-hoc outreach projects conducted by NGOs and religious groups. The GPs and polyclinics also conduct opportunistic screenings for their patients.

Unfortunately, there is no consistent health screening standard that these providers adopt, resulting in disparate datasets that are not effectively managed for useful analysis. Follow-up for those who require further attention is not systematically monitored. Jurong Health.connect is moving forward in this regard, with various providers agreeing on a standard screening approach. There is a call centre. The call centre under the Health.connect framework will reach out to those identified as needing further attention, allowing early intervention to manage the disease. This is part of the seamless process that we want to try to facilitate.

Since the launch of the call centre hotline and website in mid-October 2004, the last four months or so, it has fielded more than 100 calls, with 36 referrals generated, within the community. Cases helped by JHC include, for example, a woman who obtained a referral for a home nursing service for her 100-year-old

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mother who was recently discharged from hospital. Another example is a woman who obtained information on services for her mentally-disadvantaged uncle. These cases were given information and access, referrals to facilities that are within the community. JHC is gradually building up a network, one step at a time, to link up healthcare providers in that area.

Sir, while we applaud the move towards better coordination of early screening, it remains a great challenge. Although the Government keeps the cost of screening affordable, we need more Singaporeans to be forthcoming. For example, a few years ago when a Community Health Screening Programme was launched to detect diabetes, hypertension and high cholesterol, at minimal charge, only a quarter of the target group turned up. The situation has now improved for ad-hoc screening programmes with larger numbers turning up, but not for regular periodic screenings.

The feedback from our healthcare providers and partners is that people do not realise the importance of regular check-ups, or of follow-ups, after an initial diagnosed medical condition. Singaporeans must do their part in preventive healthcare. We have provided the infrastructure, created the opportunities, but they must come forward for the screenings as well as follow-ups.

Sir, on a broader level, preventive healthcare is about healthy living. MOH and the Health Promotion Board actively encourage Singaporeans to lead healthy lifestyles, so that they remain healthy and disease-free for as long as possible. Promoting healthy lifestyle requires a multi-pronged approach to reach out to different segments of our population, such as school children, working adults and the elderly.

With a significant proportion of our population being working adults,

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employers have an important role to play. In 2003, the National Workplace Health Promotion Survey showed that 86% of the Singapore workforce has access to a comprehensive Workplace Health Promotion (WHP) programme. We hope they capitalise on the opportunities that are presented.

Sir, international studies show that adopting a healthy lifestyle could significantly reduce the risk of chronic diseases. It would also significantly reduce the individual's healthcare spending. Research in the US, for example, has found that healthcare spending for obese Americans accounted for 27% of the growth of overall healthcare spending, and healthcare cost incurred by the obese individuals was 37% higher than that of normal weight individuals.

Sir, there is some good news at home. Preliminary results from our latest National Health Survey in 2004 show that Singaporeans are exercising more and smoking less. 24% of adult Singaporeans now exercise regularly, up from 17% during the previous survey. The proportion of smokers has fallen from 15% in 1998 to 13%, although there is a worrying prevalence of young female smokers. Singaporeans with diabetes declined from 9% to 8%, with high blood pressure also falling from 22% to 20%, and with high blood cholesterol falling also from 25% to 19%. This is between 1998 and 2004. The survey is conducted every six years. These figures are indeed very encouraging. But, whether this improvement is sustainable remains to be seen. We will, however, continue our efforts to encourage Singaporeans to remain healthy.

Sir, Dr Lily Neo raised some pertinent concerns with regard to the elderly population. I thank her for being a

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constant voice for our senior citizens, and constantly reminding us of the plight of this group of Singaporeans. We acknowledge that as our society ages, more effort will have to be put in place to meet the health care needs of the population.

We have put in place an active programme of primary prevention and early detection and management of chronic diseases like hypertension and diabetes for Singaporeans at large as well as specifically for the elderly population. I mentioned earlier the HPB's “Check Your Health�? programme and other community health screening programmes, which are being enhanced to encourage more participation by the elderly. The cost is kept very affordable and the screenings are conducted on Sundays in HDB town centres to increase accessibility to the elderly. Where possible, the elderly are personally invited to undergo the screening.

For those elderly who have acute medical conditions, our polyclinics and hospitals are able to provide them with affordable care. We have set up the Integrated Care Services (ICS) in 2001, to ensure the proper discharge and post-hospitalisation handling of elderly patients, and that they are able to access long-term care if required.

To date, there have been 7,000 referrals through the ICS, 70% of which have been referred to nursing homes. The remaining cases either had families which found alternative arrangements or were not suitable for nursing homes, and some subsequently would have passed away.

1.30 pm

The elderly who require step-down care can access a comprehensive range of institutional and community step-down facilities - community hospitals, nursing homes, day rehabilitation services and home medical/nursing services - which

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are subsidised by the Ministry. The ICS has been effective in reducing the waiting time for nursing homes, from three months to two weeks . This is with regard specifically to the concerns that Dr Lily Neo raised to ensure that there is seamless process of ensuring the patients who need step-down care when they are discharged from hospitals are taken care of.

The MOH is also working to improve referrals to day rehabilitation centres and other community facilities through further publicity with public hospitals as well as community referral mechanisms like the Jurong Health.connect. We will continuously review our processes to ensure that the movement of patients from acute hospitals to step-down facilities is quick and smooth for patients and their families.

The provision of health care services in an ageing population will continue to be a challenge for us. MOH is working with its partners, including agencies like MCYS, People's Association, the Singapore Sports Council, VWOs, CDCs and other grassroots organisations, to look after the health of elderly Singaporeans. We will continue to monitor the adequacy and effectiveness of these elderly care facilities.

The above and other inter-agency ageing issues are discussed through the key platform of the Committee on Aging Issues, co-chaired by SMS Balaji and myself. Recognising the multi-faceted nature of aging issues, this committee comprises relevant agencies such as MCYS, MOH, MND, MOT and MOF, as well as the people sector. We recognise and we realise that elderly issues are not the responsibility of only one particular Ministry, but it is a combination of the responsibilities of various different Ministries. So this platform of the Committee on Aging Issues will address those concerns that are relevant and related to the elderly population.

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Sir, to date, a sizable number of ideas are being discussed for testing. The committee is also currently deliberating on the Eldercare Master Plan for the next five years. Dr Neo asked for the next 20-30 years. I think it is reasonable to work towards a five-year plan with a long-term understanding of what the implications are of the elderly population several years down the road.

Healthcare is one main issue affecting the elderly which the committee will monitor closely and provide further recommendations to ensure the healthcare concerns of the elderly population are addressed.

Sir, Dr Chong Weng Chiew raised the issue of home rehabilitation services for home-bound patients, just like Dr Lily Neo also. Indeed, we are keen to ensure that the elderly are placed with their family and within the community as far as possible. This ensures that the primary responsibility of the family is not compromised.

Today, MOH is already subsidising a range of home care and day rehabilitation services for the elderly who live in their own homes. The subsidies cover: (a) home medical and home nursing services by 14 VWOs; and (b) 27 day rehabilitation centres and therapy services, many located in HDB void decks. In addition, the current capacity of existing services for the elderly can be stretched. For example, the day rehabilitation centres can be further utilised, as the current utilisation rate is only 63%.

Our low-income elderly patients today already have access to subsidised rehabilitation, therapy and home care services in the community. We are assessing the availability and cost effectiveness of alternative services in the community, as well as the level of need in the community.

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Dr Lily Neo asked whether the current services are adequate and whether we have any projections in terms of the need. At this point in time, the home care nursing services are very well subscribed. We have over 6,000 users of home nursing services and over 800 users of home medical services. We do not have an existing waiting list. I think we will continue to monitor the extent of need of the elderly population for both home medical and home nursing. And we certainly will look into how best we can further develop the services to ensure the needs are continually met.

Sir, a service like home therapy, as suggested by Dr Chong, requires one-to-one despatch of a therapist to a patient's home to provide rehabilitation services and comes at significant cost. And because of high subsidies required, it is not sustainable if the numbers are not big. So what we try to do now is actually to ensure that the medical and the nursing needs of the elderly who are home-bound are met first, bring them to a level that they may be able to travel with aid to the community rehabilitation facilities and then subsequently ensuring that they get the rehabilitation services that are already available in the community. I think the rehabilitation services in the community are sufficient because, as I mentioned earlier, the utilisation rate is now at 63%. We want to make effective use of those resources that have already been put in place. The principle behind it is to ensure that services are available close to the community such that more can access those services. If access is an issue, then we have to look at access issues.

The Ministry is aware of Dr Chong's point that there are some elderly patients in need of rehabilitation who have problems travelling to day rehabilitation centres. Today, there are a small number of private and non-Government

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organisations, with some private foundation support, which offer home therapy. Some home nurses and therapists help develop home exercise programmes and train family members and caregivers to give simple physiotherapy for these elderly disabled until they can be brought to day rehabilitation centres for therapy. We will monitor the current situation.

Sir, the healthcare system is indeed a complex issue with many dimensions - quality of service, efficiency, cost, to name just a few. The solution is not simply to build more hospitals and clinics or to keep on expanding our existing services.

We believe that making the system work requires the co-operation of all the stakeholders - the Government, healthcare providers, and the people. The Government has put in preventive programmes including screening, and is investing in more public health education programmes which promote a healthy lifestyle. Singaporeans must take ownership for their well-being and go for regular screening and any necessary follow-ups.

Health.connect is an innovative experiment towards achieving seamless health care for our community - the issue that Dr Lily Neo raised. Health screening is an important step under Health.connect , but it is just a first step. Those patients who need acute treatment will enjoy seamless access to an appropriate treatment centre or hospital, accessed within the community as far as possible. Once discharged, Health.connect will facilitate the return and reintegration of these patients into the community through step-down facilities, including home medical and nursing care.

The small steps we take with Jurong today will one day lead us to a new model of healthcare delivery for Singapore. It will not be an easy journey. If successful, we may eventually have one nation-wide

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Health.connect which integrates and delivers healthcare to all Singaporeans who require it. Certainly, for this to materialise, every stakeholder must play his part.

Dr Lily Neo: Sir, three clarifications for Minister Khaw Boon Wan, please.

Earlier on, he mentioned about supply induced demand. Could I ask him whether he has control over such practices in the public sector? Has he identified these practices? And what are the steps taken by his Ministry to stem out such supply driven demand in our public sector?

My second clarification is that the Minister earlier talked about Singapore being the regional medical hub, which I concurred with and which I spoke at length in the past in this House. May I ask him that in order to achieve this, we need to maximise our medical resources; therefore, will he endeavour to try to integrate the public and private sectors as much as possible and not just the clusters? And what are his plans on this?

Lastly, yesterday, he talked about the exodus from MediShield. Could I ask for an explanation from the Minister why he does not favour a national coverage of MediShield, so that the exodus of MediShield which he talked about would not be an issue?

Mr Khaw Boon Wan: Sir, since my name has been mentioned, I have got to respond. I thought I could relax already!

Dr Lily Neo asked about supply induced demand and what are we doing in the public hospitals. If Members had listened to what I said yesterday, what I am trying to evolve is an approach, because the bottom-line is this: we cannot possibly micro manage every department, every operator. My job is to make sure that the framework is as market-friendly

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as possible, to allow operators themselves to have the incentive to do what is right. That is the larger picture. It is easier said than done but I think, progressively, if we eliminate distortions, we make the framework better. So some of the moves that I made in the last 12 months - block budgeting is a good example - where as long as the incentive is to reward volume, as Mdm Halimah pointed out, then, of course, supply induced demand would just grow and grow. But if I now say, "Sorry, this is your budget. It is an increase over last year. This is what I can afford. This is what I can get from the Ministry of Finance. Do the best with this budget. If you make savings, you can keep the savings or you can use those savings to introduce new services, improve on other activities and so on. Or pay your staff better so that you can retain your staff." Then I think CEOs and hospital departments would begin to think and do what is rational. Whereas if we try to micro manage and tell them to do this and do that, I can do that. I spent many years running hospitals but I always remind myself every day, when I walk into the Ministry of Health, not to try to become a hospital CEO or Permanent Secretary. That is the discipline that I always constantly remind myself. So I focus on what is the larger picture, the larger framework.

Her second point is about SingaporeMedicine and integrating the public and private sectors. Certainly. I made a major message in my earlier speech that we fight as one team, if we want SingaporeMedicine to succeed against the rising competition from China, India and so on. If we have civil war inside, treating each other like enemies, then I think the battle is lost. The important thing is that the competition is outside. And within Singapore, the only competition is against diseases and illnesses,

and we are all partners fighting this common enemy. It is like SARS. So

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whether it is SARS, whether it is obesity, diabetes or stroke, that is the enemy. And where we can work together to improve the welfare of Singaporeans through better health, that is what we should do. But in practical terms, I have got to make sure all this starts from the public hospitals first. Then I am on moral high ground when I tell the private GPs or private hospitals to join me in this cause.

1.45 pm

Dr Lily Neo is helping us out in a significant way in the Jurong HealthConnect that Dr Maliki mentioned just now. That is a huge skunk works, pioneering work. Nobody is doing it in the world. We are at least attempting to try to solve this problem. I outlined this concept last year at the Budget debate. I was very happy that Dr Tan Cheng Bock, Dr Lily Neo, now, Mdm Halimah, and others are chipping in because it is a challenge. At the same time, if we can get it fixed, I think we would have made a major contribution to transforming how we deliver healthcare.

What is the end point? The end point is that everybody begins to look at the patient as a person. And we are all partners, as a team, trying to bring about better health for this patient. Instead of I looking at you, when you step into my hospital, then I am interested in you, and the moment you are discharged, goodbye; or the moment you walk into my clinic, I am interested in you, and the moment you leave, sorry, you are another digit, another medical record. But to bring that about, there are huge challenges. Fortunately, technology is beginning to help us.

So yesterday, when I outlined the vision of one Singaporean, one electronic medical record, it is crucial. Because without that infrastructure, how can I

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share information with the GPs? Because, today, you may come and see me; tomorrow, you may walk into another private doctor. But how to share it? You require this infrastructure. From the IT planning point of view, it is no big deal. We only have 4 million people. So it is actually only four million electronic medical records. What is the big deal? In the financial sector, all those multinationals, like CitiCorp, you can go anywhere in the world, there are ATM machines, you have got the right password, and you can access your account. And that is global. Why can we not do it in the tiny little place called Singapore?

Who has done it in the world? Nobody has done it. I have a certain sense of optimism that because we are small, we are compact, we are better organised, and more importantly, the political leaders here enjoy a certain level of goodwill and trust by the people that we can have a better chance of making it happen. And if we do, then I think we will have made a major contribution to the whole practice of healthcare which can be a model for the rest of the world.

The last point is about exodus. I used that word in relation to Mr Low Thia Khiang's comment yesterday. He said, and quite rightly so, that the elderly premiums are high, a few hundred dollars. But at a stage when you are probably on pension, no income, and yet your premium is high. So he says, "Why can't we average it out?" So for MediShield insurance, average it out means everybody pays the same rate, young or old. It means the young subsidise the old. But I reminded him that the premium range is as wide as $30 for the young per year to over $500. So, if we average it out, it means that it may be around $300 to $400. That means we expect everybody to pay $300 to $400, instead of $30 today. That is 10 times more.

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Can he guarantee that there will be no exodus of the young from MediShield? Because if there is, we will be in trouble. Then what is left would be all the old people, and what have we achieved? So that was when I used the word "exodus" in that light.

Since we still have 5 minutes, let me elaborate a little bit about the young and old. This is a very complicated subject - young subsidising the old. There are two aspects to it. Are you talking about today's young, like Miss Penny Low, supporting tomorrow's old when Miss Penny Low becomes older 20-30 years down the road? That is one aspect. The other aspect is today's young, again using Miss Penny Low as an example, subsidising today's Khaw Boon Wan. The first aspect is easier to handle and is probably more equitable. You are talking about the same person. We are just saying, "All right, when you are young and working, you pay more, so that when you grow old, you get these services." I have incorporated that into our MediShield reform. So we have a loyalty programme. The longer you stay with MediShield, when you become 70 years old, you will stand to get discounts as high as 40% off. So that is cross subsidy. That aspect can be settled that way.

The other aspect is more complicated - today's young subsidising today's old. The westerners did that. All the welfare states in the world "pay as you earn". And that is how the pension scheme was developed. It is wonderful when your demographics are in your favour. So for decades, it is the most kind and gentle system that one can evolve. But when they now go into the second half of the demographics curve, when the old are growing while the young are not growing, especially with very low birth rates, they know they are heading into insolvency. So if you read the newspaper reports, all the pension reforms, all the huge debates in

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the US and Europe are all over the same issue.

We are a young society. I think we better learn from these older societies their problems. It is a huge trap that you are creating if you try to follow them. This is not to say that the young should not subsidise the old. But I think we have to subsidise it in a way which is sustainable for the long term. So what is Singapore's solution? What we have evolved over the years is top-ups. So whenever the economy can support, we top up. Whenever there are good budget surpluses, we set aside in endownment funds. And I think that way it is a much more sustainable model. More importantly, we make sure that we do not take away the role played traditionally by families.

It is an Asian tradition that parents sacrifice for the young and when they become old, the young people, when they can earn money, support their parents. But society comes in to supplement. So filial piety, which was mentioned by Dr Chong Weng Chiew just now, is a fundamental value. It is part of our heritage and culture. If you look at the Chinese word "educate", jiao comprises two parts. It is xiao and wen . In other words, education is the art of filial piety. So filial piety forms the crux of Asian education. I think that piece of Asian wisdom we should never forget.

Dr Lily Neo: My question was, why not national coverage of MediShield, which the Minister did not answer?

Mr Khaw Boon Wan: I have explained this before. If I were to design MediShield from day 1, 15 years ago, I would have done so. I would have preferred to make it compulsory. So it applies to all because it benefits everyone. Unfortunately, we started off on an opting-out scheme. Having opted out and to go back to make it compulsory, I think it is a step backward. Will Singaporeans support

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that? I know NTUC heavily supported it. It is also my preference. But when I look at reality, opting out ---

The Chairman: Time is up, Mr Khaw.

Mr Khaw Boon Wan: --- has been able to generate 90% coverage, which is good enough.

Mdm Halimah Yacob: Sir, first, I would like to thank the Minister, Senior Minister of State and Parliamentary Secretary for their extensive and comprehensive replies to this House. We have heard various initiatives and many changes which were introduced to our healthcare system. Many of these changes are good changes, and they will make our system more resilient and robust. In particular, we now have a more transparent system.

The Chairman: Mdm Halimah, I am waiting for you to withdraw the amendment.

Mdm Halimah Yacob: Yes, I am making the points. And we look forward to many more initiatives on the part of the Ministry to put the patient at the centre, as the Minister is saying. I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn .

The sum of $1,689,007,260 for Head O ordered to stand part of the Main Estimates.

The sum of $102,490,200 for Head O ordered to stand part of the Development Estimates.