NURSES AND MIDWIVES (AMENDMENT) BILL

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NURSES AND MIDWIVES (AMENDMENT) BILL: Order for Second Reading read.

The Minister for Health (Mr Khaw Boon Wan): Mr Deputy Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

The purpose of this Bill is to establish a Register for Advanced Practice Nurses, so that we can systematically develop this category of clinical nurses with a "Master in Nursing" degree, to contribute to our healthcare system.

Background

This is not a new idea. In 1999, the Nurses and Midwives Act provided for the setting up of a Nurse Specialist Register. The objective was identical. It was to promote the development of nurse specialists who can, through formal training, acquire the necessary knowledge, skills and competencies to play a greater role than that traditionally performed by nurses. Over the years, some of our nurses have, on their own efforts, acquired such expertise and many more have expressed an interest to pursue such advanced training.

My Ministry encourages this trend. First, it raises the status of the nursing profession. Second, it recognises and maximises the potential for some nurses to take on added responsibilities. With proper training, such nurses can competently perform tasks like: physical assessments of patients; ordering and interpreting diagnostic tests; and initiating treatment according to an approved protocol.

Internationally, such a development is not new. In the US and the UK, such a category of clinical nurses has evolved over 30 years to become an important player in their healthcare systems.

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Increasingly, they have also switched to call such nurses "Advanced Practice Nurses" instead of "Nurse Specialists".

This Bill will essentially update and amplify the existing provisions in the Nurses and Midwives Act, which pertain to the certification and regulation of nurse specialists. In so doing, we shall re-name nurse specialists as "Advanced Practice Nurses (APNs)", in line with international nursing nomenclature.

_Benefits of APNs
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APNs bring benefits to patients, doctors and nurses. International experience suggests that APNs are effective in initiating management of common acute illnesses and injuries. APNs are also valuable in managing stable chronic conditions with particular emphasis on health promotion and disease prevention. They can promote better patient compliance with treatment.

Many studies have been conducted to gauge the quality of care provided by APNs. Early studies found that in an appropriate setting, patient care and outcomes were of equivalent quality to that provided by doctors, and patients were satisfied with their care. More recent studies have shown that APNs' intervention and care contributed to shorter length of stay, fewer hospital admissions, reduced re-admission rates and therefore healthcare costs.

Such outcome studies confirm the positive impact of APNs and establish them as cost-effective caregivers of quality healthcare.

For doctors, the services provide by APNs complement their care. This makes APNs useful partners. APNs' extended scope of practice allows them to take on some of the routine duties of the junior doctors. This frees up the junior doctors

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to spend more time on patients who require their higher level of expertise.

As an example, in primary healthcare setting, APNs can work with family physicians to manage nurse-led follow-up clinics for patients with chronic diseases. They can also conduct patient education and counselling sessions which will include re-enforcement of self-management skills, emphasis on medication compliance and evaluation of treatment.

For the nursing profession, the APN Register opens up an alternative career track to allow experienced and skilled nurses who have the necessary advanced qualifications to remain in clinical setting without compromising their career development. This is one way to retain good nurses in the profession.

To prepare for this development, the National University of Singapore started its "Master in Nursing" programme in 2003. This was a milestone in local nursing education. It launched our APN training programme. The first batch of 14 graduates will complete their one year internship next month. They will then be eligible for appointment as APNs.

_Main features of the Bill
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Let me highlight the key amendments.

_Advanced Practice Nurses
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Part V of the principal Act has been repealed and re-enacted in the Bill. This will amplify the existing provisions relating to the certification and regulation of the practice and conduct of APNs. It covers the use of job titles, qualifications, training, education, standards and scope of practice, professional conduct and ethics of APNs.

The nomenclature of nurse specialist or nurse specialist register has been

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updated to Advanced Practice Nurse or Advanced Practice Nurse Register, wherever it appears in the Act.

_Continuing Professional Development
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The Nursing Board intends to implement mandatory Continuing Professional Development for the renewal of the APN Practising Certificate. This is similar to mandatory Continuing Medical Education for doctors.

As nurses enlarge their roles, it is essential that they uphold the quality of nursing care by keeping abreast of the changes and developments in medical science. Clauses 7 and 22 of the Bill amend sections 18 and 44 of the Act to mandate such a requirement. The new provisions will also allow the Nursing Board to exercise this requirement for other categories of nurses, if and when the need arises in the future.

Other amendments

Sir, let me now move on to the other amendments which will enhance the administration of the Act.

_Establishment and membership of Board
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Currently, the Nursing Board comprises 14 appointed members (including 11 nurses) and three ex-officio members. The ex-officio members are the Director of Medical Services, the Director-General of Education or his representative and the Chief Nursing Officer.

Traditionally, the Board is chaired by the Director of Medical Services. In this House, Dr Lily Neo has previously argued for the Board to be led by a nurse. I support her view on this. Clause 4 of the Bill provides for the Director of Medical Services or his representative to be a member of the Board. This technical

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amendment in clause 4 will facilitate such a development.

_Administrative/civil sanctions
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Clause 8 of the Bill amends section 19 to increase the range of disciplinary actions that the Nursing Board may take. The range of penalties includes issuing of warning, censure, imposing a financial penalty, suspension or cancellation of registration. This would give the Board greater flexibility in administering disciplinary actions.

Clause 21 empowers the Board to prescribe compoundable offences and to compound offences. Clause 6 will enable it to decriminalise minor offences such as the failure to inform the Registrar of a change in address or other particulars. This is in line with the move to promote the greater use of administrative and civil sanctions.

Disclosure of information

Currently there is no explicit provision for the Board to disclose information to Government organisations for policy planning purposes. The new subsection (6) in clause 6 of the Bill will allow the Board to release such information. This is similar to the provision in the Medical Registration Act which allows the Registrar of Singapore Medical Council to disclose the information in the registers as prescribed by regulations made under the Act.

_Power to invest funds
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At present, the Act does not allow the Board

to invest its surpluses. Clause 20 of the Bill amends section 42 to empower the Board, with the approval of the Minister, to invest its funds. This would allow for prudent management of reserves.

Sir, this year, the Singapore nursing profession celebrates its 120th

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Anniversary. Over this long period, the profession has made significant progress.

Our nurses have kept up with the rapid advancement of medical science and technology. Their job scope has grown in breadth and complexity. They have become valuable partners of our doctors and other healthcare professionals. Some of the credit for the high standard of healthcare in Singapore should go to our nurses. The critical role played by our nurses in the battle against SARS is still fresh in our memory.

For the profession to remain valuable partners in our healthcare team, they must continue to upgrade and keep in step with global development. This Bill will help to contribute to this.

Advanced Practice Nurses can potentially become a key player in our drive to keep healthcare cost affordable while maintaining quality. Let us actively embrace them and incorporate their services into our healthcare delivery systems for the benefit of our patients.

Sir, I beg to move.

Question proposed.

Mdm Halimah Yacob: Mr Deputy Speaker, Sir, I rise in support of the Nurses and Midwives (Amendment) Bill.

As a whole, the amendments will elevate the standards of nursing practice in Singapore to that of the developed countries. It will also provide our nurses with greater career advancement opportunities. These opportunities provided to our nurses to upgrade themselves are well appreciated and will help to attract and retain talented nurses in the nursing profession.

Sir, over time, as the APN scheme becomes more established, we hope that it would help to reduce healthcare costs

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as well as also provide greater focus on preventive measures, particularly in the management of chronic illnesses. APNs would be important partners of doctors and collaborate with therapists, home nursing caregivers and medical social workers to improve the quality of healthcare in Singapore.

I am also particularly happy to note that failure on the part of the nurses to update the information is no longer a criminal offence, although the fine has been increased from $1,000 to $2,000. This is a more humane approach, as it is indeed harsh to criminalise our nurses just because they forget to update their particulars within 28 days of a change occurring.

I would however like to seek a few clarifications from the Minister. Firstly, under clause 7(b), the powers are given to the Board to refuse to grant or renew a practising certificate if prescribed conditions are not met. The prescribed conditions are not stated. But the Minister, in his speech, cited mandatory continuing professional development as one likely condition. As practising certificates are crucial to nurses for them to earn a living, it would be better if these prescribed conditions are spelt out, if not in the legislation, at least in the regulations or guidelines, so that it is less arbitrary and nurses are aware of what are the conditions they have to fulfil in order to keep their practising certificates. Also, in prescribing continual professional education as a condition for renewal of the practising certificate, there is a need to exercise some flexibility as nurses too are human beings and do have families and other commitments to meet, unless of course the courses are conducted during working hours.

Secondly, under clause 8 (section 19(2A)), the due process has to be observed when a nurse has violated any of the provisions stipulated under the Bill

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is prescribed. Under the new section 19(2C), it is stated that a nurse who is the subject of the inquiry will be given an opportunity to be heard either personally or by counsel. Sir, I would like to request the Minister to consider amending this part to allow a nurse who is a member of a trade union to be represented by the union. I am not sure whether without an amendment that is also possible. If that is possible without an amendment, I really welcome that. Nurses who face disciplinary inquiry do not have the skills or knowledge to represent themselves and engaging a solicitor can be very expensive and beyond the means of the nurses. In the interest of fairness, nurses who are members of a trade union should therefore be allowed to represent them. This is not something new as the Public Service Division allows their officers facing disciplinary inquiries to be represented by the union.

Thirdly, under clause 14 (section 32(7)), it is provided that the Board may disclose information about the APNs to prescribed persons. There is no definition as to who are the prescribed persons, leaving this to be decided by the Board. There are issues of confidentiality that is involved. For example, if a nurse is facing a disciplinary inquiry, will the inquiry board be given particulars and information about the APN without even her knowledge, let alone her consent?

Fourthly, clause 20 introduces a new section 43A which allows the Board to compound any offence under the Act which is prescribed as a compoundable offence. It is not clear as to what are the compoundable offences. I think a clarification on this would be useful.

Fifthly, although the Act is described as the Nurses and Midwives Act, over the years, the role of midwives has diminished a great deal as everyone now wants her

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child to be delivered by an obstetrician. There is a need to boost the professionalism of midwives and to accord this profession better recognition. By doing this, we will not only increase the pool of real practitioners and skilful midwives, but we can also help to contain healthcare costs, especially the costs related to child birth. In the UK, there are nurses called doctor nurses who have attained the level of GPs and, because of the severe shortage of surgeons, they are performing an expanded role, such as conducting minor surgeries. We should also look at ways of allowing our midwives, in line with this Amendment Bill, to play a more significant role.

Finally, my parliamentary colleague, Dr Chong Weng Chiew, is not present but, on his behalf, I would like to raise two questions for the Minister's response. Firstly, what proportion of the nursing profession the Ministry is targeting to have as APNs? Secondly, would the upgraded nursing professionals be embarking on the path of a generalist or specialist like the current route taken by our doctors?

Mr Chiam See Tong (Potong Pasir): Singapore aims to be a medical hub in the region, and it is only right that it raises its standard of nursing. The introduction of a new layer of highly qualified nurses, namely the Advanced Practice Nurses, is timely. The Minister has said that these nurses shall be of at least Master degree holders.

These days medical practice has become more advanced and complex, both in practice and of medicine as well as the administrative side of it. These Advanced Practice Nurses who are highly qualified can give good aid and support to the system. The papers have reported that our universities shall be offering a degree course to nurses. In fact, in many countries, like America, Great Britain and Canada, they have already post basic or

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bachelor degree programmes for their nurses as early as in 1925. Singapore seems to be far behind those countries in the training of nurses with specialist degrees. In those countries, post basic programmes are offered in the universities. The purpose of the post basic programmes varies and includes the preparation of teachers, supervisors, administrators and/or nurse specialists in various fields, including midwifery, public health and teaching of auxiliaries. Some augment the education received in other programmes. Enrolment is generally small in relation to the need of postgraduates.

Allow me just to make a brief comment on the local nursing scene. There seems to be a shortage of nurses in Singapore. Nurses are recruited from China and the Philippines. Other than the language problems, I hear that there is a high rate of attrition among the foreign nurses. Foreign nurses move to greener pastures once they get the training in Singapore, both in language and professional skills. If there is so much movement of nurses, it is important for Singapore to expand its training school to train more nurses to fill the vacancies.

I should also like to highlight to the Minister some of the concerns of our nurses. Our local nurses say that the public has low esteem of them. They say that they are looked upon not as professionals but rather more like maids. Nurses say that some visiting members of the public at public hospitals tend to order them about to do chores for their mothers or fathers who are patients in the hospitals. Some of the more senior nurses commented that, in the past, the public respected them and were even afraid of them. But these days, they show no respect for the nurses at all and tend to treat them like their own house maids. If these are the problems, the Ministry certainly needs to do something about it to raise the image of our local nurses. If nurses indeed have such low

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status in the eyes of the public, it would make it more difficult for MOH to encourage young girls to join the nursing profession.

I have a specific complaint from some nurses. Apparently, MOH has started a 10-year programme whereby it reorganises mass health screening every Sunday at all community clubs or CCCs throughout the island. Nurses are asked to give their time every Sunday free of charge to these centres. Some nurses say that those Sundays which they sacrifice are their rest days. I do admit that this mass health screening programme is a good public service. But can MOH make sure that nurses are not over-worked without any rest days?

I hear that the Nurses Day is not a public holiday. To give more awareness to the importance of nurses, I wonder whether the Government can allow or make Nurses Day a public holiday.

Mr Andy Gan Lai Chiang: Sir, I agree with the Minister for Health that the status of nursing profession should be raised. However, I would like to make a few observations which I would appreciate it if the Minister could look into it.

Nurses play a big part in patient care and supplement the medical attention called for by the doctors. And in the absence of doctors, nurses sometimes do have to make on-the-spot decisions as time is of the essence in emergency cases. Should the proposal to raise the status of nurses be limited to such a change in job description and title?

The amendments tabled create recognition for senior nurses and midwives in the form of Advanced Practice Nurses. Does it go far enough to attract people to the profession and to accord recognition to the nursing profession? The entry into nursing as a profession in some countries requires a degree. In Singapore, a diploma

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will do. The National University of Singapore does not offer nursing as a Bachelor degree. Neither does the NTU nor SMU, but only the polytechnics. To raise the status of Singapore nurses, opportunities should be afforded to nurses to decide on whether they wish to pursue nursing at the degree or diploma level. Of course, the diploma holders, for example, can assume the title of Assistant Nurses and rise to the limit of Senior Assistant Nurses.

The amendments state that nurse specialists may now be known as Advanced Practice Nurses. However, according to the Faculty of Medicine at NUS, in order to be an Advanced Practice Nurse, one needs to go through a Master of Nursing programme. In the amendments tabled, it seems that one does not require going through that route in order to obtain the title of Advanced Practice Nurse. To quote from the NUS Medical Faculty website, it states that, "The Master of Nursing programme prepares registered nurses to assume a clinical role and use research to improve patient outcome. Students undergo a rigorous programme that aims to provide an academic and clinical foundation for Advanced Practice Nursing. This programme will prepare Advanced Practice Nurses (APNs). The Master of Nursing programme has two specialisations, adult healthcare and mental healthcare."

To overcome this confusion, the Ministry of Health should set out clearly the qualification for a nurse to achieve before being conferred the APN.

There are other healthcare professionals who do not fall within the strict definition of nurses. For example, a physiotherapist who treats injury or dysfunction with exercises and other physical treatment of the disorder. In Singapore, to become a physiotherapist, the entry level is a diploma. Physio

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therapy is a science that is needed in sports and other areas of healthcare. There is only one school of physiotherapy in Singapore which began in 1992. Prior to this, Singaporeans had to go overseas for their PT education, and most of them were trained in countries, such as the United Kingdom, Australia, New Zealand, Taiwan and the USA. The physiotherapy schools in Asia offer various levels of undergraduate education. Countries like Thailand, Taiwan, Philippines, Korea and Hong Kong offer three to four-year programmes leading to a degree qualification. Countries like Singapore and Indonesia offer diplomas, while Malaysia offers certificates in physiotherapy. Yet other countries, such as Japan, offer a mixture of degrees, associate degrees and diplomas. Other countries in the West offer physiotherapy as a degree course.

Given that Singapore is building more sporting facilities and moving the country towards being a sports hub, physiotherapists are needed here. They are healthcare professionals and ought to be treated as such in order to attract them here. The universities should then consider offering degree courses in physiotherapy, and nurses can also be trained in physiotherapy to enhance their career development.

These amendments to the Bill, however, are a step in the right direction and will increase the awareness of the important role nurses play in patient care, and the need to have professionals and trained nurses to assist the doctor is of prime importance to us all.

Sir, I support the amendments in the Bill.

Dr Warren Lee (Sembawang): Mr Deputy Speaker, Sir, thank you for allowing me to speak in support of this Bill.

Sir, the role of nurses has come a long way in history from the days of Florence

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Nightingale, where their role was still to care for the patient but seen very much in support, to the current time when, speaking as a doctor of many years, I really think that nurses are an essential part of the healthcare system and of invaluable help to doctors. Nowadays, our nurses are very important in terms of helping us to maintain clinical standards.

In the MOH hospitals, doctors come in on a rotating system, spend several months in a posting before moving on to be trained. Advanced Practice Nurses and other nurses who have spent time specialising in the care of certain illnesses are able, because of their specialised knowledge and long experience in treating certain conditions, such as asthma and diabetes, to help the principal physician monitor the patient, improve compliance, and translate very well written clinical algorithms into good clinical practice. They are able to provide a continuity of care which otherwise may be difficult to achieve in a cost-effective way.

It is important for good nurses to come into the profession. In order to attract good nurses to come into the profession, one must give them alternative means and routes to rise to the top. In many years past, the only way to rise to the top was through becoming an administrative type of nurse. I am glad that the Ministry of Health has seen fit to amend the legislation to allow and to recognise that nurses may want to really rise to the top in clinical practice. I believe these nurses will help to also improve the standards of medical research in Singapore. Because of their role in the continuity of care and their specialised knowledge in certain aspects of medical practice, they would also be able to help busy clinicians to put into fact research protocols which otherwise may be difficult to achieve, given the workload on public-sector doctors.

As to the question of whether it is important to have our nurses come in with

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a degree or diploma, I think other countries have wrestled with this problem. In most countries where nursing has been a profession for many years, not all have had nurses coming in with degrees. In fact, most jurisdictions have had nurses coming in through certificate or diploma training programmes. It is only in the recent few decades that many countries have moved towards having degrees for their nurses.

Sir, I have worked now for 20 years in Singapore hospitals and I have seen the transition from certificate and diploma nurses to now degree nurses. It is not the title that is most important. It is the quality of the person, their dedication to their work, the personal attitudes towards continuing nursing education, cooperation with the doctors and administration, and cooperation and working with the patients that count. Senior nurses even without these paper qualifications have an important role in mentoring junior nurses who now have such paper qualifications. I think both have their place in our system. Both have their valuable roles.

I would also urge my fellow doctors not to see the development of Advanced Practice Nurses as a threat to their profession but to see their strongly complementary role in moving Singapore towards greater standards of clinical care and its aspiration towards being a medical hub for this part of the world.

Finally, to address the problem that was raised by hon. Member Mr Chiam See Tong who lamented that, in the past, senior nurses were almost feared by their patients, I think it would be important to make a distinction between fear based on authority to order people around versus respect. I think our nursing profession has moved itself so that its members are now able to command a degree of respect, based on their skills, knowledge and ability to interact with patients, rather than on just their ability to order patients

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and visitors in and out of the hospital, as was the case in the long past.

Certainly, if I may quote examples from my own institution, K K Hospital for Women and Children, the specialised nurses who deal with gestational diabetes, the ones who deal with the National Asthma Shared Care Programme, the nurses who help me in my diabetes clinic, these are all clinical nurses who may currently not be able to be called Advanced Practice Nurses within the bounds of the Act, but who nevertheless are playing a very important role in providing good clinical care for our patients. And I hope that as the Ministry of Health moves on in this direction, it would also consider ways and means to recognise many of these nurses who, because of their entry qualifications into the nursing profession, may have difficulty in eventually reaching a master's degree. I hope we will also find ways and means to recognise them for the important role that they play.

Sir, I support the Bill.

Mr Chiam See Tong: rose ---

Mr Deputy Speaker: Mr Chiam, you have spoken.

Mr Chiam See Tong: I just want to clarify, Sir.

Mr Deputy Speaker: Yes, please.

Mr Chiam See Tong: Sir, allow me to clarify why I used the word "fear". This is the exact word of the feedback from a nurse. Actually, if I had used the word "fear", it should have been within inverted commas. "Fear" not as in the sense of a person with authority whom people fear, but rather members of the public's respect for the nurse, that kind of "fear", ie, respect the nurse. I should have used

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the word "respect". "Respect" should be a better word.

Mr Khaw Boon Wan: Mr Deputy Speaker, Sir, I thank Mr Andy Gan, Mdm Halimah, Mr Chiam See Tong and Dr Warren Lee for supporting the Bill. I especially note Dr Warren Lee's personal perspective as a doctor for many years working in public hospitals.

I think we all share a common objective, which is to raise the standard of nursing care, at the same time, creating opportunities for our nurses who want to and can upgrade themselves, and also to acknowledge their immense contributions to our health. Many nurses have worked with me in my many years of running hospitals, and those who have worked with me know that I particularly appreciate this group of our healthcare workers. They work very hard, are very dedicated, and I have always been a strong champion of nurses, besides the other healthcare workers. But for nurses, I always have a soft spot for them, because I know how dedicated many of them are and how much they put in, in terms of working life. Many of them, as Mr Chiam related, were so devoted and passionate for their cause that they stayed single, and you see many of those who are in the senior echelons now, some have retired, after devoting their whole life to nursing.

This Bill is one of several initiatives which will help us realise this objective. Let me respond to the specific comments and feedback and suggestions.

Mdm Halimah felt that clause 7 could be clearer. Clause 7 is the one that amends section 18, to allow the Nursing Board to prescribe the various conditions governing the grant and renewal of practising certificates. In a similar vein, Mr Andy Gan suggested that we spell out the qualifications that are required in order to be an APN. You know me. I agree

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totally on full transparency. Our nurses must be clear how they can become an APN. We do not, however, hard-wire in the qualifying conditions, because circumstances may change. As Dr Warren Lee mentioned, there could be very experienced nurses who, because of previous lack of educational opportunities, may not be able to achieve a master's degree, but are deserving. But let us start with the master's degree criteria first. After a few years' experience, we will see. If we can along the way make some revisions to the criteria, I think we should. But we will definitely gazette the details of the qualifying conditions through regulations, after the Bill has been approved. For the moment, the key prescribed conditions are a Master in Nursing degree and mandatory continuing professional education for renewal of certificate. After the Bill has been passed, my Ministry will conduct briefing sessions for the nurses in our various hospitals on such details.

Mdm Halimah noted that clause 14 would enable the Board to disclose information to certain prescribed persons. She asked who these persons are. These are the Government officials in the Ministry of Health and the Ministry of Manpower who require specific information on nurses in order to do their work, and the key purposes are:

(1) Manpower planning so that we know how many nurses we have of various types, age and so on; and

(2) Mobilising essential personnel during national emergencies.

Mdm Halimah also commented on nurses who are subject to disciplinary enquiry, and she is rightly concerned that such nurses should not be unduly disadvantaged. Although section 19(2C)(a) specifies that a nurse attending a complaints committee hearing can be heard personally or by counsel, the Board

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allows nurses to bring their supervisors or their colleagues to speak on their behalf. In addition, the Board also allows the union to represent the nurse. The Bill does not prevent that from happening. So, there is really no need to amend the Bill in order to make this clear. Essentially, unlike a court of law, the complaints committee hearing is not adversarial.

It enables the nurse to present the facts of the case in a neutral environment.

Mdm Halimah sought clarifications on compoundable offences. I have given an example in my speech, ie, failure to inform the Registrar in writing of any change of name within 28 days. Currently, it is considered an offence. But as it is such a minor offence, we will make it compoundable and remove it from the Act. Again, after the Bill has been passed, we will gazette such compoundable offences through regulations so that everybody knows what it is all about.

Mdm Halimah wondered if there is scope to expand the services of midwives. But this is really for Singaporean women to decide. The evidence, unfortunately, points towards a declining interest, for whatever the reason.

On behalf of Dr Chong Weng Chiew, Mdm Halimah asked if we have a target for APNs forming a certain percentage of all nurses. I do not have a hard target, mainly because we are still new with this. The American experience after 30 years, suggests to me that maybe 5% could be a medium term target, ie, 5% of nurses may become APNs. What does 5% mean? Currently, we have about 8,000 registered nurses in the public sector. 5% means 400 APNs. Even this number will take us many years to build up. Remember, the first intake was only 14 in NUS. But we have made a start. Let us first work steadily to ensure that APNs are well incorporated into our healthcare scene and then we can expand from

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there. We cannot automatically assume so because, as Dr Warren Lee pointed out, it requires the APNs to win their peers' respect and confidence, especially from the doctors. Fortunately, we have a big group of doctors who are very supportive towards these APN practices, and we will start with them, show the evidence that, indeed, they can be very strong and good partners for everybody. Then, we build up from there.

Again, on behalf of Dr Chong, Mdm Halimah asked if APNs here will pursue a specialist or generalist track. I understand Dr Chong's concern because I have occasionally discussed this particular topic with him. His concern is not so much that specialisation is wrong, but rather that there should not be over-specialisation, as over-specialisation can be counter-productive. He was relating from a medical point of view. Whether this also applies to nursing, I do not know, but it is a concern we should bear in mind.

What we have in mind is, in practice, our APNs will work both in hospitals as well as in the primary healthcare setting. In the hospitals, they will have to work in specialties. Some of them, like what Dr Warren Lee described, will include critical care, emergency medicine, oncology, orthopaedics and paediatrics. Whereas in the polyclinics, they can help doctors manage patients with chronic illnesses, like diabetes, hypertension or high cholesterol. There, I think the nurses' value is they will have more time to spend with the chronically ill, advise them about why they should monitor their blood sugar and blood cholesterol, why they should be taking statins regularly, and if not, just to remind or urge them along. In that sense, maybe some fear of nurses (as expressed by Mr Chiam) is not bad if it leads to better patient compliance. APNs will therefore need to be both generalists and specialists, depending on the

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circumstances that they are in. But we should certainly guard against over-specialisation, as advised by Dr Chong Weng Chiew.

I agree with Mr Andy Gan that raising the status of nurses requires more than a mere change in job title. This Bill is one of several efforts which we are undertaking. A local undergraduate nursing degree is an important initiative. Yes, as Mr Chiam pointed out, nothing new, it has been around for many years elsewhere in the West. But it is better late than never. While not all nurses need to be university graduates, and I totally agree with Dr Warren Lee here, a significant percentage of them can benefit from such training. Today, about 10% of nurses on our register have a degree, all acquired overseas. Again, I do not have a hard target. I do not know what is the final number. We will just grow it incrementally and monitor the situation. I am glad therefore that NUS will be offering a Bachelor of Science Nursing Programme from next year.

Mr Chiam gave some feedback on foreign nurses' attrition and urged us to get more Singaporeans to join nursing. Yes, for a long time, we have a big problem persuading the young boys and young girls to join nursing, and it is not for lack of trying. At the polytechnic level and before that, at the School of Nursing level, the capacity to train is a lot higher than the number of applicants. But I am glad that in recent years, somehow, the picture is improving fairly significantly. I just got some 10-year data here about intake into the Nanyang Polytechnic, which is the main polytechnic doing nursing training. In 1994, the intake was 550. Last year, it doubled to 1,026. So it is a huge jump over these 10 years. More importantly for me, among the Singaporeans, the locals, in 1994, it was 458. Last year, it was 752, almost doubled. Obviously, we have been doing something right in recent years, and, of

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course, crisis events like SARS and our nurse tsunami volunteers in Aceh helped to raise the status and the image that Mr Chiam talked about how Singaporeans look at nurses. Personally, at every opportunity, I will always want to profile the dedication and the high quality work of our nurses.

Finally, Mr Andy Gan strays from nurses to comment on other allied health workers, like physiotherapists. But I agree with his general thrust that if we want to maintain a high standard of healthcare, we must not neglect the professional development of the allied health workers. I recall that during the Budget debate this year, Mdm Halimah made a similar point. After doctors and nurses, the allied health workers form a critical professional group. So, as we elevate the standard of doctors and nurses, the other professional groups should move up in tandem. Like Mr Andy Gan, I look forward to the development of local undergraduate training of such allied health workers. The second medical school at the Singapore General Hospital,

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which is in partnership with Duke University, has such an ambition. But let us get the new medical school up and running first.

Question put, and agreed to.

Bill accordingly read a Second time and committed to a Committee of the whole House.

The House immediately resolved itself into a Committee on the Bill. - [Mr Khaw Boon Wan].

Bill considered in Committee; reported without amendment; read a Third time and passed.