HEAD O - MINISTRY OF HEALTH

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** Head O - Ministry of Health **

The Chairman: Head O - Ministry of Health. Mdm Halimah Yacob, you have two cuts. Take them together. Total time is 8 1/2 minutes.

Healthcare

Mdm Halimah Yacob (Jurong): Sir, I beg to move,

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

Sir, many positive changes have taken place in the healthcare sector over the last one year, for which I must credit the Health Minister. We now have a more robust MediShield scheme where more of the bigger hospital bills are covered, providing immense relief to many Singaporeans suffering from ageing illnesses. Another development is the higher daily Medisave withdrawal limit which will benefit 50,000 Singaporeans. These changes have made our healthcare system much more robust and sound. However, we all know that healthcare is not a static subject, but is constantly evolving with new issues emerging all the time.

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I would like to raise three issues. Firstly, Sir, healthcare costs continue to be a concern to Singaporeans. In a 2004 Feedback Unit survey involving 1,064 Singaporeans, 67% were worried that they would not be able to pay for their future healthcare cost, while 60% were worried they would not be able to pay for their dependant's future healthcare cost. These concerns are not without basis. Healthcare costs have been rising as reflected by our medical inflation rate which, at 5.9% in 2004, was the highest in a decade and definitely higher than the general inflation rate of 1.7% in 2004. Households are also spending more on healthcare, with the lowest 20% of the income groups spending the most, about 7% of the household income compared to the highest 20% of the income group, which spends about 4.7% of the household income on healthcare.

Although healthcare is not something that we consume all the time, it is a subject that occupies our mind all the time. Even those who are now healthy worry in case they fall ill one day and are unable to provide for themselves or their families. While I agree that we can contain our own healthcare cost by keeping healthy and cost increase is also due to advancement in diagnostics and medical technologies, I also believe that the Government can do more to control the increase in healthcare costs and to boost the productivity and efficiency of our healthcare providers. Otherwise, I do not see how we can maintain a tight lid on our national health expenditure and Government subsidies without the population suffering a fall in medical care. I believe, Sir, that we can better leverage on economies of scale, a more efficient use of manpower such as the advanced practice nurses and greater control over the use of new medical technologies, just to name a few areas.

I would like to ask the Minister what measures would be taken to control

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medical inflation and ensure that healthcare costs remain affordable to all Singaporeans.

Secondly, Sir, we need to pay greater attention to the long-term healthcare needs of our elderly Singaporeans. Those above 65 years have on average only about $5,300 in their Medisave, barely sufficient to pay for their MediShield and ElderShield premiums as well as the smaller hospital bills of specialist outpatient treatment. As our population is ageing rapidly, I would like to ask the Minister whether our 3M system is sufficient to take care of the long term healthcare needs of our elderly. I would like to suggest that the Ministry undertakes a comprehensive study of the long-term healthcare needs of our elderly and assess whether our 3M system can sustain their needs financially. I am not talking here, Sir, about the ability of our 3M system to pay for the needs of the elderly today,

but rather to assess how demographics, cost increases, advancements in diagnostics and medical technologies and many other factors would impact on the 3M system and its ability to provide for the future healthcare cost of the elderly.

1.45 pm

On another matter, Sir, related to the elderly, I note that the Committee on Ageing Issues had concluded its work, and made many recommendations pertaining to our ageing population. I would also like to ask the Minister when the Ministry will be giving its response to the recommendations of the Committee on Ageing Issues, particularly on those matters related to health. My concern is that sometimes we have a lot of committees making recommendations but the follow-up may not be sustained. On the elderly alone, Sir, there have been many reports and committees, and what we need now is to ensure that there is effective follow-up on these reports.

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My third point is on the need to continuously improve medical standards. Singaporeans are concerned not only with cost but also whether they are provided with a good standard of medical care in Singapore. The quality and standard of healthcare that we receive is important to ensure that we recover quickly, do not stay in the hospital longer than needed or develop serious complications, all of which will add to our cost and agony. Yet, unlike the purchase of other goods and services where the customer can easily make a distinction in the quality of service or goods, it is not so simple for the average patient to do so. While the publication of hospital fees is a laudable move and has ensured that hospitals do not overcharge for the same type of procedure or treatment, much more needs to be done to inject transparency into our healthcare system. For example, if someone wants to have a cataract operation - the price being equal - how is he to decide whether to have it done at SGH or NUH? Yet, this is an important point. An ignorant or ill-informed patient may breed complacency in our healthcare system as he is not in a position to demand high standards.

In March last year, Sir, Prof. Robert Brook of the US think tank, RAND Health, recommended that health institutions here start providing information about the quality of its services as well, so that people can choose a healthcare service based on price and quality. According to him, if the Singapore healthcare system wants to have meaningful competition and be world-class, then it must provide more than just pricing information to patients. I would like to ask the Minister what initiatives are in place to enhance medical standards and to publish quality indicators of our medical services in Singapore. With quality indicators, patients will be better able to make informed choices on where to seek treatment, and this will also provide transparent benchmarks on the

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comparative efficiency of our healthcare providers.

I note, Sir, that the Joint Commission in the National and American Accreditation Agency already accredits some of our public hospitals. Patients treated at accredited hospitals can expect more consistency in hospital processes and treatments. The question is: why have all the hospitals not achieved accreditation from this Agency, and are private hospitals covered? Also, in what way can the Ministry educate the public so that they can better understand the significance of quality indicators and, in this way, help them to seek better quality treatment and therefore further boost standards?

Medisave

Let me come to my next point, Sir, and this is on Medisave. Currently, the use of Medisave is allowed only in limited areas. I urge the Ministry to allow greater flexibility in the use of Medisave. Singaporeans' need for their long-term hospitalisation needs is well understood and cannot be denied. But it is difficult to explain to Singaporeans, who need cash to pay for their immediate medical needs, why they cannot make use of their Medisave savings but instead have to borrow or seek assistance from the CDCs or other places to pay for their medical bills. Those desperately in need of help cannot be expected to worry about future needs. But if they neglect taking medicine regularly or fail to seek regular treatment and fall seriously ill resulting in hospitalisation, that would put a serious strain on the resources of our hospitals. I would like to request for greater flexibility in the use of Medisave, particularly in the following areas - I am sure the Ministry can look into other areas as well - long-term chronic illnesses, such as diabetes and hypertension, purchase of medical

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consumables, purchase of medical equipment, eg, ventilators, payment for medical tests, such as MRI for those already diagnosed with a serious illness, cost of home rehabilitation and step-down care. To prevent over-consumption and ensure prudence, the Ministry can consider imposing an annual withdrawal limit from the Medisave for these purposes or even limits based on each procedure or treatment.

Mr Chiam See Tong (Potong Pasir): Sir, I would like to ask the Ministry of Health and the CPF Board to allow married couples to use their Medisave to pay for IVF and any Assisted Conception Procedure (ACP). Couples who need ACP would like to ask for the following:

(1) to allow Medisave withdrawals for up to five treatment cycles instead of the current three;

(2) to subsidise the cost of drugs required for assisted reproduction;

(3) increase the age limit for women for acceptance into ACP from the current 45 to 50 years but only if they are deemed medically fit;

(4) increase the number of treatment cycles for women who enter the ACP programme at above 40 years of age, from a maximum of five treatment cycles to 10 cycles.

Instead of taking a pragmatic approach, Sir, both the Ministry of Health and the CPF Board should take a more compassionate view in helping childless couples.

The Chairman: Sorry, Mr Chiam, your time is up. Mr Low Thia Khiang.

MediShield

Mr Low Thia Khiang (Hougang): Sir, rising healthcare costs remain a concern

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of most Singaporeans. At the same time, many Singaporeans feel aggrieved by the large number of foreign residents in Singapore competing for jobs. I would like to ask the Minister whether he has thought about expanding the coverage of the basic MediShield scheme to cover foreign employees as well.

During the course of privatisation of MediShield Plus, whilst making basic MediShield compulsory for all insurance plans covering Singaporeans last year, the Minister for Health accepted the principle that the younger you are, the less healthcare you consume, as the basics of healthcare insurance. I would like to ask the Minister to consider requiring all foreign talent - employment pass holders and workers - to be covered by basic MediShield insurance. This would expand the risk pool of basic MediShield. I hope that with the added injection of funds from the expansion and with the relative lower risk of the new pool in which most are in their prime of their working life, MediShield can provide better coverage for all Singaporeans. This will also allow Singaporeans to see that all the foreign talents are, in a manner of speaking, contributing to the health and well-being of Singapore.

Healthcare Policy

Dr Lily Neo (Jalan Besar): Sir, may I first commend the Minister for Health for improving the financial affordability in our healthcare which I support wholeheartedly? May I now request the Minister for Health to look into the following healthcare issues for further improvement?

(1) Homecare enables the semi-dependant to live in their own homes for as long as possible with appropriate support. Homecare translates into convenience and much lower costs for many and hence a happier populace. Our homecare is almost non-existent presently.

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(2) Step-down care allows for seamless integrated care services for all elderly patients discharged from public hospitals. This is necessary to coordinate and to facilitate placement of patients to step-down care facilities that look into the multi-facet medical, social and psycho-social needs of the patients. At any one time, there will be some 8% of the elderly that require step-down care of varying levels of intensity. Currently, there are multiple service providers with minimal coordination. There is a need for better coordination and effective implementation of the various healthcare services.

(3) Sharing of best practices, preventing over-servicing, maximising limited resources, avoiding duplication, better integration and cutting down wasteful practices by public hospitals.

(4) Expediting plan for Singapore to become the regional medical hub, such as integration of our healthcare clusters and sectors for better economies of scale and maximising our limited resources to compete globally and not competing internally, structured aggressive marketing on our high quality and efficiency, innovative packaging with other products, such as insurance, travel arrangements, hotel and shopping needs, to make it more attractive for consumers to come here.

(5) Better management of chronic diseases, such as diabetes and hypertension, to prevent morbidity and mortality from such diseases.

(6) Heart disease is the number one killer of women in Singapore. Women are less likely to survive heart attacks than men. Many women do not seek treatment as early as men, as the symptoms of heart disease are manifested differently in women. Could MOH raise the awareness on heart diseases among healthcare providers and the public?

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Drug Costs

Dr Tan Cheng Bock (Ayer Rajah): Sir, the Government provides outpatient clinics so that Singaporeans can get affordable and good healthcare. So it is the usual practice for general practitioners and hospital doctors to refer patients to the outpatient clinics for more affordable treatment. But if the cost of drugs at the outpatient clinic is higher than the cost of hospital drugs, then it defeats all the Government's purpose of setting up such outpatient clinics, because it is meant to allow Singaporeans to have a cheaper form of treatment.

Recently, I was shown two bills from a patient - one for drugs taken from a hospital and the other bill for drugs taken for an outpatient clinic. The hospital's prescribed drugs cost $48.30. The same prescription from the outpatient clinic costs $85.25. Of course, when I look at the two bills, I was thinking that maybe the difference could be due to the difference in the quantity of drugs prescribed. He could have been given more drugs at the outpatient clinic and less at the hospital. So I studied the unit cost per drug and I found that the unit cost per drug at the hospital side was much lower than the unit cost per drug at the outpatient side.

The Chairman: You are running out of time, Dr Tan.

Dr Tan Cheng Bock: Six out of the nine items were much more expensive.

Sir, I am asking why is there such a difference. Is this a one-off incident or is it going to be a norm? How can doctors in the hospital then refer patients back to the outpatient clinic if the patient is going to pay more?

Mr Low Thia Khiang: Sir, I often hear from patients, especially patients with medical conditions, such as heart problem, Hepatitis B, etc, and those who

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are chronically ill who need long-term medication, complain of high cost of drugs. I would like to ask the Minister for Health whether he foresees an expansion of centralised drug buying by the Ministry of Health from generic to non-generic branding drugs. As medical technology advances and hospital stays and operations are replaced with pills, I urge the Government to move beyond the basic bulk buying of generics, so that Singaporeans can benefit from lower drug cost. I would also like to know whether we have a unit within the Ministry of Health which functions like the National Institute of Health's clinical excellence in the United Kingdom where clinical efficacy and cost-effectiveness of new drugs are evaluated and recommendation made for bulk purchase.

Sir, I would also like to ask how the Ministry of Health decides what types of drugs should be subsidised. Feedback to me seems to suggest that MOH's prime consideration in the selection of the types of drugs for subsidy is primarily based on the price of drugs, rather than whether the drug itself is more beneficial to the patients in terms of its clinical effect or lesser side effects on the patients.

Means Testing

Dr Chong Weng Chiew (Tanjong Pagar): Sir, when I first filed this cut on means testing in polyclinics and public hospitals more than a week ago, I was planning to ask the Minister about the implementation timeframe. Then I came across an article in Sunday's Lianhe Zaobao mentioning that the Minister said that he would not be in a hurry to do so within the next one to two years. This is due to the inherent difficulties of deciding which households qualify for subsidies. So I guess I do have an indication with regard to the timeframe.

However, I would still like to ask the Minister to share with us the Ministry's

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findings and views to date.

Are we still studying it, or is it "no go" for now?

2.00 pm

I do agree with the Minister that means testing in practice is fraught with difficulties. I have some experience myself when I was working in a community hospital. The processes and tools we use for means testing can certainly be improved. We have to find ways to reduce the paperwork and cut down on our long waits for family members to submit their income documents.

Unfortunately, the disparity now between our acute hospitals and step-down facilities does not encourage our patients to move on from acute hospitals to community hospitals and nursing homes. This is because patients in the latter are means tested but those in our public hospitals are not. As a result, we have more crowded C class wards. This is undesirable because it is an inefficient use of our medical resources. Also, a good portion of our subsidies is going to patients who do not need it. Due to the difference, our total healthcare subsidy costs are being elevated.

I understand the Ministry's caution. If we were to proceed to implement means testing, the scheme has to be carefully conceived. It has to be fair and preferably tiered to be as inclusive as possible. It should also be responsive and flexible, easy to administer and not require too much bureaucracy. This is a pretty tall order. Still, we have to find a way to align the disbursement of healthcare subsidies in all our public medical facilities. The longer we wait, the more our resources will be utilised inefficiently.

ElderShield

Mdm Halimah Yacob: Sir, I would like to urge a thorough review of our

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ElderShield Scheme which I think can be better utilised and specifically in the following areas: Firstly, relax its eligibility criteria. The rigid definition of "disability" which requires a person not to be able to do three out of the six daily routines can result in a ridiculous situation, where even someone who is wheelchair-bound is not considered as disabled.

Secondly, I do not see why when a person is certified as disabled by a specialist in a public hospital, he still has to be assessed by a GP appointed by the insurance company. This restriction should be removed as it unnecessarily adds to the patient's cost. If an assessor is used, the fee should also be absorbed by the insurance company, and not the person claiming which causes hardship, as this insurance is different from motorcar or fire accident insurance.

Thirdly, the waiting time of three months is too long and should be shortened.

Fourthly, the restriction to five years of payment causes hardship and should be removed. At a time when a person needs the money the most, he is left stranded.

Fifthly, $300 monthly payment is too little and should be regularly reviewed, taking into account the medical inflation rate.

Finally, 42% of those who opted out of MediShield were low-income earners earning less than $1,500. Can the Government do something so that more of them can be covered under the scheme?

The Minister for Health (Mr Khaw Boon Wan): Sir, I thank Members for their comments and especially their suggestions on how we can improve our healthcare system.

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I will be the first to acknowledge that our system is not perfect. But I think it is not bad. The World Health Organisation (WHO) ranked Singapore number 6 out of 191 countries on overall healthcare system performance. Only two Asian countries made it to the top 10 list: Singapore and Japan. So, obviously, we must be doing something quite right.

Singaporeans acknowledge our high medical standard but many hope that it could be cheaper, or even free, at least for the poor. I will do my best to meet their aspiration, but such heavy subsidy has to be highly targeted for the poor and not something freely available to all in a uniform way. Despite good intentions, cheap healthcare for the masses ends up being of low standard, hurting the poor and needy the most, because unlike the rich, they have no alternative. They cannot turn to the higher standard in the private sector.

There are two ways that a government can render healthcare free or cheap. One, the government pays the bills out of the taxes it collects from the people. Or the insurers pay for them out of the insurance premiums they collect from the people. But either way, it is the people who pay for healthcare. So the so-called free healthcare is actually not free.

But because healthcare in such systems can sometimes appear to be free, it causes two major problems which we are familiar: the buffet lunch syndrome of over-consumption by patients; and the motorcar repair-shop syndrome of over-servicing by providers. As a result, the US spends 16% of their huge Gross Domestic Product (GDP) on healthcare, UK spends half of that - 8% of GDP - but both have very little difference to show in their health status. Instead, there were large-scale disappointments on both sides of the Atlantic. Nearly 50 million low-income

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Americans go without medical insurance. In the UK, long waiting times for surgeries are very common complaints.

In Singapore, our health is not poorer than the Americans or the British. In fact, in some areas, we fare better. We live longer on average than the Americans or the British. Our infant mortality rate is much lower than in the US or UK. And we have achieved this commendable outcome at a lower cost, at only 4% of our GDP. This does not happen by chance.

We have over the years evolved our own model of providing and funding healthcare. We have no ideological bias. On funding, we are neither in love with the British taxation-funded model, nor the American insurance-funded model. On delivery, we neither favour public hospitals run by civil servants, nor prefer private-for-profit models run by people like Dr Loo Choon Yong.

We have forged a middle way, going for a mixed system of public and private sectors. In that way, we tap and incorporate the strengths of each sector and allow both to co-exist and flourish. Such a mixed system offers the best outcome for our people, giving them choices as public and private compete for patients, in that way keeping the medical standard high.

Last month, when I read the New York Times, there was a commentary - a good one - on the Canadian healthcare system. It reported that their publicly-funded health system was "gradually breaking down", with public hospitals sending growing numbers of patients, whom they can no longer cope, to private hospitals which are cropping up despite laws against their existence.

In Canada, it is illegal to have private hospitals because no hospitals are allowed to charge patients for treatment they would otherwise receive free of charge in

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a public hospital. But in response to public demand, private hospitals are openly defying the law. This is how one private hospital medical director lamented about their healthcare system: "This is a country in which dogs can get a hip replacement in under a week and in which humans can wait two to three years."

The Canadians dread the excesses of the private model that they see in their American neighbour. That is why they embrace the public model. But now, they appear to have come to the conclusion that both systems were wrong and a mixed system is more viable.

I know Singaporeans worry about healthcare cost. This is a common worry all over the world. I am afraid healthcare cost will continue to rise. Why? Because new technology and new drugs will continue to come out of the research laboratories, at great cost, even as they bring about some improvements in healthcare.

It is actually quite easy to run a cheap low-cost public healthcare system. There are many such examples in our neighbourhood, just compare our public hospitals with the standard of the public hospitals there. We can keep our hospitals cheap or low cost by denying our patients of medical advancements, thus pushing patients to private hospitals. But who can afford to go there? Only the middle and upper-income group. The poor are stuck with the public hospitals. I would never accept such an approach for Singaporeans, for the simple reason that the poor cannot afford the private hospitals. My job is to ensure that the poor and the very sick get a good standard of healthcare.

I therefore agree with Mdm Halimah that we should not allow medical cost to escalate beyond our ability to pay. Mdm Halimah noted that medical inflation was 5.9% in 2004, higher than general

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inflation rate of 1.7%. When it was published, I noted this figure too. I was personally a bit upset because this is during my watch in year 2004 and, after having made it one of my top priorities on managing medical inflation, I probed and discovered a number of things. Medical inflation is computed based on a basket of medical services that you get. It includes doctor's consultation, hospital charges, dentistry, payment to TCM, Chinese sin seh, tui nai , drugs, both generic as well as vitamins or supplements, perhaps even tongkat ali , and things like that.

When I probed for the year 2004 about this sudden blip of 5.9%, I found the culprit - TCM consultation fees, Chinese physicians. It doubled from an average of $4 in the year 2003 to $8, average, in 2004. So even though TCM is a small part of our total healthcare system and the weightage is low, but because the increase is 100%, it has skewed the total calculation of medical inflation. If you remove TCM from the calculation, our medical inflation would have been 1.3%, lower than the general inflation of 1.7%. Mdm Halimah would be pleased to note that last year, 2005, medical inflation was 0.4%, again lower than the general inflation of 0.5%. I do not think your Health Minister has been sleeping.

But some medical inflation is to be expected as medical and nursing staff, like other workers, receive some wage increases too. I think they deserve it as well. Last year, general wages in Singapore rose by 3.5%. This must, in due course, flow down to impact on medical inflation. In any case, inflation control cannot be decreed by law or achieved through moral suasion. It never works. The most effective way is through the market.

First, we should ensure that wage increases in healthcare sector keep in step

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with general wage increases. Again, this cannot be decreed. This requires us instead to match medical manpower with demand. If demand rises while we restrict the supply of doctors, nurses, pharmacists and therapists, their wages are bound to go up sharply.

That is why we watch over the supply and demand of doctors. At present, we are slightly short in some specialities although the situation is tolerable. But I see significant shortages going forward, if we succeed in our drive to promote Singapore as a regional medical hub.

I noted Dr Lily Neo's comment that we should move faster on SingaporeMedicine. I will, and I believe in that. In fact, our efforts in the last three years have shown very promising results. Foreign patients coming here for treatment in Singapore increased by an average of 20% per annum in the last three years. Wonderful! I am sure Dr Loo Choon Yong can testify to this. We will press on with this.

I know that this will increase staffing pressure on our public hospitals. But we can try to achieve both objectives, raising Singapore as a medical hub and at the same time trying to ensure that medical inflation is acceptable. How? We are ramping up the recruitment and training of medical specialists. The Singapore Medical Council (SMC) will be expanding the schedule of recognised medical degrees.

Currently, we recognise 71 medical degrees, largely from the British Commonwealth.

2.15 pm

I have shared my view before that all the top medical schools ought to be on our schedule, not just from the US and UK, but also from Europe and Japan. We should also include the top medical schools from India, where some of their

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graduates have gone on to head clinical departments in the US, particularly because we have an FTA with India, where one of the commitments is to open up our medical register. We are not opening up yet, because there is still disagreement with India. India wants every medical school in India to be recognised. I cannot accept that, because we all know there is a wide range of standards and we cannot just open the door to every Indian medical graduate. But there are two, three or four very good medical schools. Entry is so competitive that one must be absolutely bright to be able to enter, and their graduates are proving themselves in the US and Europe. I think there is no reason why we should exclude these top medical schools and their graduates from coming here to help us make Singapore a regional medical hub. The SMC is actively reviewing the subject, and will progressively expand the list. I expect to make the first announcement soon.

But medical manpower is not just about doctors. It is also about nurses, pharmacists, radiographers, other health sciences professionals, even patient care assistants. We should make sure that supply keeps up with demand.

Second, I agree with Dr Lily Neo and Mdm Halimah that we should push our hospitals and clinics to be more efficient. There is really no ground for inefficiencies, wastages or duplications. We will continue to encourage innovations and skunk works and share best practices. Last year, in this House, I mentioned a major skunk works in Alexandra Hospital where it partnered with Microsoft to exploit the benefits of IT. Within a year, they successfully computerised the operations of the A&E Department. The software is intuitive and also very flexible, allowing doctors and nurses to easily make continuous process improvements. I want to record here my thanks to Microsoft for their help. I understand that

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Microsoft has decided to extend their skunk works to Changi General Hospital and even enlarge the scope of their work to include the community hospitals and nursing homes that partner Changi General Hospital in providing integrated care.

Hospitals are expensive resources. To keep cost affordable, hospitals need to use their beds efficiently. For example, once a patient is discharged, they have to quickly get the bed cleaned up so that a new patient can get in. But the entire process is complex, involving many groups of staff. But through standardising policies, streamlining processes and using WiFi technology provided by Cisco Systems and Fujitsu, Alexandra Hospital has reduced the processing times by 30%. This means less waiting for the patients in the admission room. Today, half of the patients admitted to Alexandra Hospital are settled into their beds within 30 minutes.

Alexandra Hospital and Cisco Systems are now exploring how WiFi and VOIP (Voice over Internet Protocol) technologies can be used to reduce the time it takes for doctors and nurses to respond to medical emergencies. This can make a real difference in life-and-death situations.

Third, the market works best when consumers are well-informed. That is why, as soon as I went back to the Ministry of Health three years ago, I got them to compile and publish hospital bill sizes. I am very pleased with the outcome. I am now ready to push this initiative further, in two ways.

One, I will extend the exercise to private hospitals. They have so far joined the initiative voluntarily, but the submitted data is often incomplete and sometimes misleading. I am considering getting their fullest participation, to disclose their hospital bills on a fully comparable basis when they submit Medisave claims on

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behalf of their patients. This will be welcome by their patients, I am sure. Such transparency will also help convince their foreign patients that Singapore offers very competitive pricing for healthcare services.

Next, in response to the call by Mdm Halimah, I will expand the initiative to include qualitative outcome data, eg, surgery complication rates, surgery success rates, etc. Like the bill size exercise, I will begin with public hospitals first to gain sufficient experience, before extending it to private hospitals. Last year, I started a study on cataract operations, one of the most common surgeries done in public hospitals, so I wanted them to measure and track down what were the complication rates of cataracts in the various centres in Singapore. We are concluding a study on this, and the data will be released quite soon.

Mdm Halimah asked about quality accreditation. All hospitals must comply with the standards that we set under the Private Hospitals and Medical Clinics Act. JCI accreditation is an added external endorsement that our local hospitals are comparable to international standards. All our public general hospitals are already accredited. The private hospitals are at various stages of this quality journey.

Making the market work better is the best way to help manage healthcare cost. When customers vote with their feet, healthcare providers will sit up and work to fight the competition. That was how Lasik surgery fees dropped from $2,300, on average, in 2003 to below $1,400 now, saving patients almost a thousand dollars per surgery.

At the same time, we must continue to remind Singaporeans to: (a) save up for their healthcare needs; and (b) insure themselves against catastrophic illnesses.

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Mdm Halimah asked if our healthcare model can cope with the ageing of our population. In particular, what about the healthcare needs of our future elderly? Will 3Ms be enough? This is really a very dynamic situation with many unknowns. What are the new technologies that are coming in? At what cost? What are the changing population attitudes towards sickness, health, etc? And, of course, how much can we afford, which is economic growth? That is why I agree with Mdm Halimah that we need to periodically review and update our 3M system. And we do. Last year, we updated MediShield. This year, my focus is on Medisave.

Our healthcare system is unique in the world because of Medisave. Medisave has now entered its 21st year. Every year, the average Medisave balance of Singaporeans just gets bigger. Among working Singaporeans, four out of 10, ie, 40% or nearly half a million Singaporeans, have Medisave balances exceeding $25,000. This happy outcome applies to low-wage workers too. Those nearing retirement have an average of $12,545, enough for many, many hospitalisations.

In their earlier manifestos (1994/1998), the Workers' Party wanted to abolish Medisave. "Phase out the Medisave Scheme as soon as possible", they said. Luckily, they did not succeed. As a result, we now have collectively $35 billion in our Medisave accounts, for many, many rainy days ahead. I am glad that the Workers' Party has since achieved some enlightenment. Their latest manifesto no longer wants to phase out Medisave. But they have replaced the medicine with another. They are now proposing that Medisave be used for "a comprehensive Public Health Insurance scheme".

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We do allow Medisave for medical insurance. I believe in Medisave insurance, because pooling of risks is a very important part of healthcare financing. But Medisave must not unwittingly support comprehensive medical insurance which will only lead to disappointment and very high healthcare costs. This is not a theoretical argument. The argument has already been settled empirically. We only need to see the experiences of those countries with such comprehensive medical insurance schemes. Let us not repeat the mistakes of others. They are now trying to get out of that hole. Let us not walk into that hole.

When I read the manifesto, I was reminded of a very interesting cartoon published by Zaobao a few days ago. President Chen Sui-bian suspended the Reunification Council, so there was this cartoon that shows President Chen leading the way and there was this big manhole, with Taiwan about to walk into the manhole. If we go the Workers' Party's way, I see this cartoon, maybe of Mr Low Thia Khiang waving Singaporeans into this hole. And you will find this hole is crowded. There are many people there trying to get out. So, I think, let us beware.

Mr Low Thia Kiang suggested that we allow MediShield to include foreign workers. I do not think we exclude foreign workers, because MediShield is open to all Singaporeans and PRs. So, if they are PRs, they are included if they want to. But MediShield is not compulsory. So, you will have to make an effort if you want to join in, although it is opting out. But, as far as I know, many foreign workers may have been covered by their employers, so they may not see the need. But it is really up to them. The point about the foreign workers is that if they are non-Singaporeans, basic MediShield is based

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on Class B2, which is heavily subsidised and, therefore, we keep the subsidy for Singaporeans and, in fact, at the moment, also PRs. But non-citizens are not included.

In fact, just last month, there was a specific case. One of my residents, the maid fell down while cleaning windows. So major surgery in Tan Tock Seng. The bill came to $15,000. They forgot to buy insurance for the maid. So they came to my MPS and say, "Please help." But I cannot help because she is a foreigner. How can I use taxpayers' money to subsidise foreigners? I hope there is a lesson there, ie, employers, please make sure you buy insurance both for yourself and your loved ones, including any foreign domestic workers with you.

I am enhancing Medisave. From lst April 2006, the daily withdrawal limit will be raised from $300 to $400. This will particularly benefit the middle-income group and save them hundreds of dollars per admission.

This is the first step. My next step is to allow Medisave to help cover costly outpatient treatments. But this is not straightforward. That is why I am taking some time to think it through carefully. If we are not careful, Medisave accounts will be prematurely depleted, becoming insufficient for hospitalisation. That would be tragic. However, meanwhile, I have noted Mdm Halimah's various suggestions on this subject and will take them into account.

In this exercise, I will give priority to chronic diseases, a subject which I will discuss later, in the second segment of the debate.

Let me now respond to Mr Chiam's comment on the use of Medisave for IVF and various assisted reproductive technologies. It does. Medisave covers them and, in fact, as part of the Baby Bonus scheme last year, we raised the

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quantum. Relying on memory here, I think you can claim up to $6,000 for IVF, which will therefore cover items like drugs, etc. But we made a distinct decision to limit it to three treatment cycles, and the reason is properly and rationally grounded. You can check the data on the success rate. Each time the couples repeat, it is greater and greater disappointment and, after the third cycle, the chance of a success is very, very low, and you are really throwing away a lot of money. Yes, maybe we are a little bit paternalistic here by saying that Medisave ought to be for other uses and therefore we limit it to three cycles. But it is for a very good reason. If we just open it up - imagine $6,000 per treatment - and we have, say, run it to five cycles, that is a lot of thousands of dollars. Medisave, even though it is significant for some middle-income group, there is an upper bound to it. So it is not as if it is a lot of money and you can just waste it to pursue IVF and the various techniques. So I hope Mr Chiam can accept that explanation.

On ElderShield, I thank Mdm Halimah for her various suggestions. I will take note of them. We are bound by the contract governing ElderShield which does not allow changes for five years. The five-year period will run out in September next year. But I will begin the review process this year. I will certainly bear in mind

the various suggestions made by Mdm Halimah.

2.30 pm

Dr Chong Weng Chiew asked about means testing. He has always been a strong supporter of means testing and I appreciate his support. I believe in it and I have always felt that our 3M model would be stronger if we make it 4M and the fourth "M" is actually means testing.

But two years ago, when I started exploring this subject, I remember at that

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time the GPC Chairman was Dr Lily Neo, and she gave me very good advice and a word of caution, because there are a lot of complications, as outlined by Dr Chong. She felt that I should only start working on it after we have fixed a few other things, especially MediShield reform which, at that time, I was exploring with her, and now, Medisave. So that is why when Lianhe Zaobao interviewed me, I said that it is something that we would do next year or the year after. We cannot rush this sort of thing even though it is a good policy.

Dr Tan Cheng Bock and also Mr Low spoke about the cost of drugs. Dr Tan quoted an example of a patient being referred to a polyclinic from NUH, thinking that it would save him money, only to find that his drug bill there cost him more. I have looked at the example which he handed to the Ministry of Health. Of the nine medications in the bill, indeed, as Dr Tan noted, some were cheaper at the polyclinic but some were more expensive. The costlier drugs tend to be cheaper in polyclinics, in other words, the more expensive patented drugs are cheaper. The reason is this. First of all, the polyclinics and hospitals are different entities, so identical items may not attract identical prices. It is just like X-rays. There is a whole range of X-rays, but they do not coordinate - maybe they should - until every item is the same. But, on an overall basis, we should ensure that the total treatment cost in a polyclinic is less than that in an acute hospital for the same treatment. Otherwise, I agree with Dr Tan that there will be no incentive for patients to move out of expensive acute hospitals.

Mr Low talked about our bulk purchase of drugs and whether we would do so not just for generic drugs but also for non-generic drugs, ie, patented drugs. Bulk purchase covers both, in other

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words, so long as there are economies of scale to be exploited, we will go for a major tender and coordinate them. It is not done by the Ministry of Health because there are two clusters and they coordinate. There is a central procurement unit which calls tenders on behalf of both clusters. And, as I have said, it applies to both generic as well as non-generic drugs. In fact, the savings are a lot more in the case of non-generic drugs because generic drugs, by nature, are low cost. So whether you call bulk tenders or you call smaller tenders, the price will be low anyway. But even then, the benefits ought to be exploited.

Mr Low also asked who decides on what is subsidised and not subsidised. Really, the question is who decides on what are standard drugs and what are non-standard drugs. I think we have explained this previously in this House. There is a panel of experts because these are clinical issues. They will review, when new drugs come in, and decide whether to substitute this normal drug with another drug. So it is a purely clinical decision. Of course, they take into account efficacy as well as cost to the patients. But it does not mean anything that is expensive is non-standard; and everything that is cheap is standard. That is not the criterion.

Mr Low mentioned a unit in UK. Yes, there are several such efforts in various countries, because drugs are now so expensive, and for every new drug, before it comes into the market, they will evaluate the cost benefit of it. Should we start such similar units? I do not believe in doing so because our scale is small. Let us leverage. I have always advised our people to leverage, because why reinvent the wheel. The UK and US publish all their analysis and we just go and take a look. We may want to do some local analysis because Singapore's situation might be different. But that is always a good starting point, instead of trying to

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replicate what others are doing and unwittingly push up healthcare cost.

Finally, Dr Lily Neo has made a number of comments on step-down care, homecare and heart diseases affecting women. We will respond to those points later today.

Mr Low Thia Khiang: Sir, I would like to ask the Minister whether he has updated himself with the latest copy of the Workers' Party's manifesto because, in this manifesto, we are proposing a compulsory basic hospitalisation insurance. He says it is a comprehensive insurance scheme.

Secondly, I would like to ask him whether he purposely distorted the Workers' Party's manifesto for political purpose to hoodwink the voters. Sir, what he has said was not what we published in the 1994 manifesto. We highlighted the inadequacy of Medisave, but we did not say that we want to abolish it. We believe more on risk-pooling of insurance schemes rather than the method of direct payment through Medisave, because you never know how much you need to save. That was the basis on which the Workers' Party felt that insurance would be a better solution.

I would like the Minister to clarify why there is a need for him, when he became Minister for Health, to look at the MediShield insurance scheme and to revamp it. That is exactly the same concept which the Workers' Party's manifesto has enshrined in 1994. It is not true when the Minister accused me like what the papers described as Chen Sui-bian as "pulling the people into a hole". I would say that, Sir, without the revamp of an insurance scheme, it will probably be the Ministry of Health that will have a bigger hole for the people to fall inside, and the hole is something which the Minister created for political purpose to pull me in.

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Mr Khaw Boon Wan: Mr Chairman, I do not like to read the Workers' Party's manifesto but, unfortunately, it is my duty, as Health Minister, to also see it because I read all suggestions on healthcare, and I take a personal interest. So I read them. He asked whether I have updated myself. Yes, I have. In fact, I went to great length. I read their latest manifesto and also the previous one. So when I quote, I am a careful person, as you would know by now. When the Member used the words and claimed that I lied - although he did not want to use those words - it was in his Party's own manifesto when he talked about abolition of Medisave and a comprehensive public health insurance.

In our business, maybe he is not familiar, "comprehensive" has a very special meaning in health insurance. "Comprehensive" means comprehensive - everything, first dollar coverage. That is the meaning of comprehensive. He cannot say, as he tried to explain just now, that "comprehensive" means that there is still co-payment. Once you have co-payment, it is no longer comprehensive. So I read it in that light. I take it at face value. That was in their earlier document when they talked about abolishing Medisave and going into comprehensive medical insurance.

So I must object to his use of words that I am trying to hoodwink Singaporeans. Singaporeans would have seen me by now. I have been in public service for many years. I did not enter politics to score political points. I entered politics because I thought that is one way to do some good for Singaporeans, and that is the way I carry my task seriously. I am not one who hoodwinks people.

Healthcare Infrastructure

Mr Andy Gan Lai Chiang (Marine Parade): Mr Chairman, Sir, it is essential that our medical services have the technology and the technical know-how

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to properly diagnose diseases and illnesses as quickly and accurately as possible.

In the past, doctors wanting to know whether a patient's heart is functioning well may resort to angiography, a procedure in which a thin tube is snaked up the heart arteries through a blood vessel in the groin. Now, an alternative is available. Modern technology has made possible for scanning machines to perform a cardiac CT-scan which will show detailed images of the heart in just a few seconds, all these without the expense and risk of any invasive coronary angiography.

As patients demand for more accurate and quicker diagnosis of their illnesses, be it cancer or a stiff neck that lasts for days, doctors will turn to such technologies as a useful tool for their answers. Are we seeing such trends in the medical sector and, if so, what are the plans the Ministry has in mind for such heavy investments? Will MOH be looking at the advent of such technologies and its uses nationally and, if necessary, provide guidelines on its usage so that a uniformed approach will aid patients in making an informed decision before paying for these services?

To have an economical approach to this scenario, pooling of resources may be necessary to lower individual commitments to such investments and, subsequently, spread out the cost to the paying public who are the users. In cases where it is too expensive for the private sector to invest in such machines for some reason or other, will MOH be looking at buying them and allowing the private practitioners to use them on a pay-as-you-use scheme?

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Adequacy of Hospital Services

In 2004, there were 405,306 admissions. If we average that figure over a period of 12 months, this would work out to be about 33,775 admissions a month. Given the overwhelming statistics, it is clear more admissions are to be expected and the need for more healthcare in hospitals should be anticipated.

Is MOH planning to build new hospitals or extensions to hospitals to cater for expected or projected increases in the demand for hospitalisation? Are there plans to increase the number of doctors and hospital beds to cater for possible increase in demand from an aging population?

Nurses form an important part in providing an excellent medical service and their numbers are always lacking. Training new nurses will not only help to fill in the gaps in the shortage of nurses, but will also contribute to having more adequate hospital services. What are the plans by MOH to ensure that there are enough doctors and nurses to cater to and treat the high-level of patients visiting the hospitals?

While increasing the number of intakes for the medical faculty, and in training nurses at technical and degree levels, is there any dependency level that we have for foreign doctors and nurses? Our aging population will certainly put heavy pressure on the demand for hospital services.

Dr Tan Cheng Bock: Sir, I want to pose a question to the Minister with regard to my cut.

The Chairman: But he has already answered the question.

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Dr Tan Cheng Bock: I put up my hand but I did not catch your eye.

The Chairman: All right. I will give you two minutes.

Dr Tan Cheng Bock: Thank you. I accepted the Minister's reply on the different pricing in the outpatient polyclinics and the hospitals. My point is that the patient's problem has still not been solved. Whenever a doctor refers a patient from a hospital to an outpatient clinic, he still has to pay more. That is the question I am asking the Minister: how is he going to solve that problem?

Mr Khaw Boon Wan: My advice to Dr Tan, so that he can in turn help his patients, is to look at the total bill. Do not just look at one single item and say that you want the cheapest of everything possible, like drugs, X-rays, and so on. But you have to look at it on a total basis, ie, is your total bill in a polyclinic cheaper than your total bill in a hospital? At the end of the day, that is what counts to the patient, how much he has to pay. If he goes to SGH, how much will he have to pay, and if he goes to Toa Payoh polyclinic, how much will it cost? At the principle level, I agree with Dr Tan that we should not distort the pricing so that it becomes silly for patients, who want to downgrade, to have difficulties.

2.45 pm

Since I am on the floor, let me just take one minute to explain this. Actually, I know the reason for the discrepancy. Years ago, I helped to formulate the pricing policy for polyclinics. Those of you, like Dr Chong, who had read the Lianhe Zaobao's interview of me, would know that I believe in the Robin Hood's principle in healthcare, because healthcare is so expensive that the only way to ensure healthcare is affordable is you must play Robin Hood. How? One, the rich subsidises the poor

through taxation. Two, the healthy subsidises the

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unhealthy, who is more sickly, through insurance. There is no other way. And, therefore, when I looked at the pricing of drugs at that time in the polyclinics, I suggested to them - which is still the policy today - "Charge patients $1.40 for drugs". The last time it was lesser, maybe $1; now it is $1.40 per week of medication. In other words, regardless of the medication, cheap or expensive, you pay $1.40. In that way, patients who have minor ailments and, therefore, drugs are simpler, they may be actually paying above cost to the polyclinic, but it is still $1.40. Let us say, if one is unlucky and very sick, the drug may cost $20 per week of prescription, but you still pay $1.40. So, in that way, patients who have cheaper drugs subsidise those who have more expensive drugs. Until today, I will defend that policy. I think that is the correct policy.

But, a few years ago, I do not know when, somehow the hospitals decided to go more precise. So they removed this policy and they just said, "Well, let's look at the drug, if it is 20 cents charge 20 cents, 50 cents charge 50 cents and $2 charge $2, and whatever". So you can argue which is the more correct system. I believe in the Robin Hood's principle. I feel that the $1.40 per week, regardless of medication, is a better way for the patients. Maybe I should persuade the hospitals to move back to the polyclinic system.

Primary Healthcare

Dr Tan Sze Wee: Sir, it has been shown time and time again that the most cost-efficient way of managing healthcare costs is to move care away from the hospital setting to the primary healthcare setting, where health promotion and disease prevention take place and where the primary healthcare physician acts as a gatekeeper to the hospital services. To realise this, many governments have shifted consumption of public healthcare from the hospital to the primary

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healthcare setting through apportioning of more financial resources to primary healthcare providers as well as health promotion and prevention efforts.

Can the Ministry of Health inform us how much of MOH's operating expenditure is devoted to primary healthcare and how does this percentage compare with other countries, such as Australia, the United Kingdom, New Zealand and Canada?

I am not asking for the overall MOH operating budget to be increased, but rather to consider shifting more of the operating budget from hospital services to primary healthcare where we can achieve a bigger bang for the buck, especially if you are found to be relatively under-funding primary healthcare when compared to other developed countries due to insufficient apportionment.

Institutions of Public Character

Mr Low Thia Khiang: Sir, the Government has, in recent months, moved to ensure better corporate governance of the voluntary welfare organisations. This, I hope, will stop any future NKF-form of misusing and misrepresenting its activities to the public.

I noted that while the Ministry of Health has made every effort to explain to the public its position on NKF, it has yet to clarify the issues surrounding the Ministry of Health's award of Institution of Public Character (IPC) status to the then NKF. In the interest of greater transparency on the part of MOH, I would like to ask the Minister, under sections 37 and 107 of the Income Tax Act, who was the final approving authority for NKF's IPC status at MOH? In particular, Sir, I would like to know whether the said approving authority was aware of the concerns of the National Council of Social Services

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and why the concerns of NCSS were overwritten by MOH? I would also like to know what is the procedure for application and approval of the IPC status by MOH and whether the decision is subject to review by a higher authority, or the Minister himself is the final approving authority.

Hospitals

Mr Steve Chia Kiah Hong: I want to ask the Minister for Health where exactly is the Northern General Hospital to be sited, when is construction work commencing and when can we expect it to start operation.

Patient Care

Dr Tan Sze Wee: Sir, with block funding already in place for the clusters, there exists the possibility that each cluster is incentivised to see as few subsidised patients as possible, especially at the hospital level where the lion's share of the block funding is consumed, by shifting workload to the other cluster through more referrals.

Can the Minister reassure the House that there is no gaming within the clusters and cross-cluster referral rates have remained relatively constant over the recent years?

Can the Minister also inform the House what percentage of NHG polyclinic and A&E patients is referred to SingHealth hospitals for further care and vice-versa, for each of the years from 2001 to 2005, omitting 2003 due to SARS outbreak?

Pathology Services

During the 2003 SARS outbreak, our pathology, especially our virology diagnostic capabilities and capacities were put under severe strain. The need to boost our capacities and capabilities was clearly felt. It is thus a disappointment to

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note in the Ministry of Health's budget estimates that plan to redevelop the Singapore General Hospital's Pathology Department building has been delayed.

If my memory serves me correct, when SGH was redeveloped in the 1970s, the Pathology Department buildings were omitted. Thus, the buildings are at least 40 years old, if not older. We all know that most HDB flats at 40 years of age have been given extensive upgrades or redeveloped, what more our SGH's Pathology which actually forms the backbone of our nation's pathology and virology services? The small, crammed and old rooms at the SGH's Pathology Department are also not coping with automation, which saves manpower, and it is also where laboratory medicine is heading towards currently.

The redevelopment of SGH's Pathology Department is especially far more pressing now with an H5 Avian flu pandemic, and probably a human flu pandemic, looming over the horizon. Can the Minister explain why the redevelopment of the SGH's Pathology Department, which is the backbone of our nation's virology diagnostic services, has been delayed, and what steps are taken to expedite its redevelopment?

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

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

Mr Speaker: Order. I suspend the Sitting and will take the Chair again at 3.15 pm.

Sitting accordingly suspended

at 2.51 pm until 3.15 pm.

Sitting resumed at 3.15 pm

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[Mr Speaker in the Chair]

**** Debate in Committee of Supply resumed.

[Mr Speaker in the Chair]

**** Head O - Ministry of Health (cont.)

Mr Khaw Boon Wan: Sir, Mr Andy Gan asked whether the supply of our healthcare services is adequate. Frankly speaking, supply of healthcare services will never be fully adequate. This is because in healthcare, supply does create its own demand, particularly if that demand is heavily subsidised.

Among health economists, there is a well-known observation called "Roemer's Law", which states that "a built (hospital) bed is a filled bed". It is, therefore, wise to keep public hospitals slightly under-supplied and run it at high occupancy rates. That is why, last year, I resisted tackling the overcrowding in Tan Tock Seng Hospital by simply allowing them to expand. By forcing the hospital to understand its sources of overcrowding, we then discovered outdated policies, like free treatment for foreign workers infected with chickenpox and cumbersome discharge procedures which kept patients unnecessarily in hospital.

But we cannot sit on the cap forever. Periodically, we need to expand our facilities to meet real rising demand. That is why we are building a general hospital in Yishun. Mr Steve Chia asked for some details. The site has been finalised. It is a good site, near to Yishun MRT and bus interchange. Planning of the hospital has started. In fact, a design competition is ongoing, and I understand that Prof. Ho Peng Kee will soon organise an exhibition of the design proposals that we have received for this hospital, so that we can get some public consultations and opinions on them. We expect to ground-break before the next Chinese New Year

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and, eventually, open the hospital in phases from the year 2009.

Dr Tan Sze Wee asked me about the building of the Pathology Department at SGH. The project was a little bit a victim of the Asian financial crisis in 1997. Actually, the project was approved and funds were allocated. But after the Asian financial crisis, there was a review of all the capital expenditure projects in the public sector, and this was one of the projects that was decided to be delayed. In any case, those years are over, and we will get the project going again. We are going to rebuild it on a new site within the SGH campus. Planning has begun and we hope to open the new facility around 2010. In fact, if Members check the Budget book, they will see an entry on this particular project.

Besides buildings, we will continue to invest in new equipment. Mr Andy Gan has noted a rise in high-tech diagnostic machines. It has been so for many years and, in fact, it is a factor which contributes to rising healthcare cost. But we will pace it appropriately, balancing between inevitable cost increases and enhanced healthcare standards. As a principle, I prefer the public hospitals to be slightly behind the curve, but not too much behind. For example, the current interest in high-tech scanning equipment - the 64-slice CT scanner, which costs a few million dollars. The first unit was brought into Singapore in 2004 by the private sector. But soon after that, others also bought such scanners, including public hospitals.

By being slightly behind the curve, we allow ourselves some time to evaluate each new machine and establish its cost-effectiveness. Ultimately, it is not investment in technology for its own sake, but, really, investment in patient outcomes that matters. Given the high

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cost of such equipment investment, I agree that wherever it is possible to share it with the private sector, public hospitals should do so. But sharing has to be done at the right price, and certainly not at the expense of public patients.

Mr Andy Gan also asked about the adequacy of nurses to serve our patients. For nurses, we will continue to both train locals and recruit foreigners from abroad, and there has been a progressive increase in the nursing population in Singapore. Just last week, NUS announced the launch of Singapore's first local nursing degree course in NUS, for year of admission 2006. This is a milestone event for our nurses. The programme is designed to meet international standards, and the first batch of nurses will graduate in 2009.

Dr Tan Sze Wee is worried that our cluster polyclinics may game on their block budget, and refer subsidised patients from polyclinics to hospital A&E Departments of the other cluster, so as to save on cost. Let us look at the data. First of all, very few percentage of polyclinic patients get referred to hospital A&E Departments - less than 2% each year. The vast majority of such referrals were within each cluster. So this so-called cross-cluster referral is tiny. As far as I can see, there is no evidence for such gaming going on. I am pleased to say that our doctors are largely ethical, and we should be proud of them.

Let me now spend some time on chronic diseases, which Dr Lily Neo raised earlier and was also mentioned by Mdm Halimah and the other Members as well. This is a very big topic, because it affects a large number of patients, and most of them tend to be elderly, and it consumes a large amount of resources. No country has managed it well. There is much scope for transformation and improvement.

It is my personal goal to see how we can cause the transformation of the care

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of chronic diseases, so that patients with chronic diseases can enjoy better care at lower cost and with less hassle.

To achieve this goal, family physicians play a critical role. Recently, I visited one in Toa Payoh and I am impressed with her practice. She has a base of regular clientele - many elderly with chronic diseases. She knows them well, including their family members, and that is really what a good family physician ought to be. When one of her patients suffered a fracture and could not walk, she arranged for a physiotherapist to provide home therapy twice a week, instead of simply referring the patient to the hospital. The patient had so much pain that walking was not possible. After a month of home therapy, the patient was able to walk. In this way, unnecessary hospitalisation and operations were avoided, and the money saved from inpatient charges was used to engage the therapist.

When another patient was diagnosed with terminal cancer, she personally arranged a shared-care programme with the hospital oncologist - cancer specialist. This way, she was able to continue the patient's intravenous antibiotics at home. That was also the patient's strong preference, to spend his last few months in the company of his loved ones, rather than wasting precious time waiting in the queue in hospital clinics. The patient eventually passed away peacefully at home, avoiding unnecessary hospitalisation which would not have made any difference. His family got to spend quality time with him at home. When death came, this family physician was there to sign the death certificate.

This is what good family physicians can do to bring about better care at lower cost and less hassle for their patients, instead of simply referring them to hospital specialists. There are many such good family physicians in Singapore. But we should grow their numbers and profile them to the public, so that such care

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would become standard best practices here.

I asked our hospitals and polyclinics to help facilitate this transformation. The hospitals have an interest to see this succeed. Many of their patients in the specialist clinics can be competently treated by family physicians, at lower cost. They are keen to partner with willing family physicians through shared-care programmes at the community level.

Let us take diabetes as an example of how this can be done. We already know quite a lot about diabetes. It is a common chronic disease, and affects one in 11 Singaporeans. So it is a large number. Diabetes occurs when the body loses its ability to control the blood sugar level. When poorly controlled, doctors can almost predict what will happen to the patient at different stages over the next 20-30 years. Compared to others, diabetic patients have a higher chance of getting heart attacks, stroke, blindness, loss of limbs and kidney failure. In early stages, there are no symptoms, and many patients are unaware. Left untreated, the condition will just deteriorate over the years. Many suffer greatly from multiple organ failures towards the end.

Many diabetic patients start treatment late, ending up going to multiple specialists for treatment of their many problems as and when each problem surfaces. It is not unusual for a diabetic patient to consult a cardiologist for his heart problem, an orthopaedic surgeon for his leg problem, an eye specialist for his eye problem, and a neurologist for his loss of sensation. The suffering, the time spent at each hospital clinic and the cost of treatment can be unbearable.

Yet, that need not be and should not be the case, if their diabetic condition is detected early and managed well. The simple trick is to help the patients control their blood sugar, look out for early signs of complications and treat the

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complications before they become a big problem. Many of the complications of diabetes can be avoided totally or, at least, delayed for many years.

Today, many diabetic patients are middle-aged and are better educated than their parents. They have the ability and motivation to help themselves. We should really re-orientate our healthcare to work with the patients and enable them to lead a long and healthy life. We actually have many success stories right here in Singapore, at helping diabetic patients live a long and healthy life.

For example, SGH and Alexandra Hospital, and likewise other hospitals as well as Kandang Kerbau and NUH, have diabetes centres to run structured disease management programmes for the patients. Their staff work with the community and employers to screen the population. Those with mild diabetes are referred to their family physicians for follow-up.

For those with more severe diabetes, the specialists assess the patients thoroughly at the beginning of the programme, draw up individualised treatment plans. Non-specialists and other team members then take over and work with the patients to control their blood sugar and to screen for complications, at appropriate intervals, under the supervision of specialists. Once the conditions have stabilised, they are referred back to their family physicians for routine follow-up.

The key is to make patients and their family members the main carers of their diabetic condition. Patients are taught individually and in groups, to enable them to help themselves. They adopt healthier eating habits with the help of dieticians. They exercise more and they reduce their weight. Many are even able to adjust their insulin dosage with help from nurses.

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The outcome has been very satisfying. Patients' blood sugar level is better controlled. Complications are detected earlier and treatment to prevent deterioration initiated earlier. Their experience suggests that one of the most feared complications of diabetes, namely, progressive kidney failure, can be stabilised with good management.

We should expand such success stories widely, to benefit many more patients and also others with other chronic diseases, such as high blood pressure and asthma. Both hospital clusters are spearheading a few structured disease management programmes for their chronic patients and they already have good results to show. For example, patients under the NHG cluster's asthma programme are less likely to end up with emergency asthma attacks. The programme must have saved many lives and avoided unnecessary deaths due to asthma.

Another disease management programme is for heart failure patients - patients who have survived a heart attack. Results are also very encouraging.

3.30 pm

I am very cheered by these innovations and their success stories.

Quietly and unglamorously, our polyclinic family physicians, working jointly with the hospital specialists, are helping our chronically-ill live longer and healthier lives.

Let us help push these programmes nationwide. To succeed at the national level, many things will have to happen. Time does not permit me to elaborate, but they include successful implementation of concepts like right-siting of care - a topic that Dr Tan Cheng Bock mentioned just now. In other words, you should be treated at the right place, not in the wrong place, higher cost, more hassle and

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unnecessary "one Singaporean, one family physician": every Singaporean, if you do not have a good family physician, start looking for one and make sure find one that is good, and build up that long-term relationship. One Singaporean, one electronic medical record - this can be done if we fully exploit IT. And we need IT so that electronic medical records can be shared with all the partners in healthcare so that we can then collectively, as a partner, look after these patients as the centrepiece. It also requires effective partnership between GPs and specialists, opportunistic health screening, cooperation and compliance by patients, and many more such concepts.

This is a tall order, and that is why no country has so far done it well. I am counting on our being small and compact and better organised. I think it can be done. I have been in healthcare for many years now and for the rest of my term as Health Minister, I want to focus on this subject. If we can make a significant difference to the way we handle the management of chronically ill, I think we can then make a major contribution to the health of Singaporeans. It is unglamorous, it will not attract headlines, media attention, but it will make the most crucial difference to our health status. We are building a Health Centre at Jurong West to be one focal point to deliver this transformed service for the residents there. If it succeeds, I will replicate it elsewhere. It will be a one-stop health hub, providing a range of services from, say, outpatient specialist, diagnostic and day surgery services to chronic disease management for common chronic illnesses. It will also be a place for health screening and health promotion. If we can tear down barriers between public and private, GPs and specialists, hospitals and step-down care homes, and leverage on technology, I see an opportunity for a transformation of the way we traditionally manage chronic diseases.

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If we do it right, year by year, we will see improvements, not only in service standard, but also in the health status of the patients. Let us start with a couple of the most common chronic diseases, say, diabetes, perhaps hypertension, where there are established clinical guidelines on how such diseases should be managed over time, and let us get more GPs, specialists and patients to join the programme and embrace the new approach.

Earlier, I said that we are studying how Medisave can be liberalised to pay for costly outpatient care. I therefore see an opportunity to leverage on this initiative to help nudge the profession and patients towards this direction.

Dr Tan Sze Wee asked for data on Government spending on primary healthcare. More than 60% of the Government's subsidies goes towards hospital care, 7% is spent on primary healthcare. This is much lower compared to the various countries he mentioned - Canada, UK and New Zealand - where they spend up to 30% of their health budget on primary care. But I must caution here that the figures are not comparable because, in their case, the primary healthcare is 100% public, whereas in our case, 80% of primary healthcare is in the private sector by GPs. So the spending is not captured. Our 6% is only on public healthcare.

Finally, let me respond to Mr Low Thia Khiang's point about NKF and IPC. I remember I had a full discussion with Mr Steve Chia - unfortunately he has left - not too long ago, maybe last month. Perhaps, Mr Low was not in the Chamber, and it fully addressed what are the NCSS' concerns. I clarified them and these concerns were properly addressed. Time does not permit me to go into it. Perhaps, I think Mr Low may want to just read up the Hansard so that we do not waste

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everybody's time here. He did ask a point about who is the final authority on charities. There is a Commissioner of Charities who currently is also the Commissioner of Income Tax. But if you read the consultation paper, which is now in circulation, and MCYS will make a formal response to it in a few days' time, their intent now is to separate the two roles so that there will be a new Commissioner of Charities and he will be supported by the various deputies, because there are so many charities in Singapore, a few thousands of them - some in sports, arts and healthcare. I suppose, in the case of healthcare IPC, there will be a person identified and he will be the Deputy to the Commissioner of Charities.

Mr Low Thia Khiang: Sir, at the point in time, MOH was the approving authority for IPC. My question was: who in MOH approved the IPC status and whether or not NCSS had some reservations about that and how did it miss the person's approval?

Mr Khaw Boon Wan: Please read the Hansard when this was debated with Mr Steve Chia. The concerns were fully addressed. Let us not get the impression as if NCSS was aware that there was hanky-panky going on in all those things that are now discovered by KPMG. There was none of that kind. The concerns raised were totally different and, frankly speaking, minor in nature, and they were addressed. MOH studied it, analysed it and since there were no reasons to reject the IPC, of course, they approved the IPC. It is easy on hindsight to say, "Hey, why didn't you do this? Why didn't you do that?" But, as I explained at that sitting to Mr Steve Chia, when a CEO, helped by a group of people, in this case, the Board of Directors or at least some of them, went all out to mislead the public, they

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will be discovered but it does take some time.

I also made a critical point which was that while KPMG came up with this thick report but only about a year ago, when KPMG was actually commissioned by the Ministry of Health to look into NKF, they discovered some minor things which were all fixed, but they did not uncover the problem that we now read in the report. So let us put this thing in perspective. On hindsight, it is easy to say, "Why didn't we do this? Why didn't we do that?" In many ways, as I told Mr Steve Chia at that time, the former CEO misled all of us, including Mr Steve Chia, myself and Mr Low Thia Khiang, because he was also in this Chamber for several years and, if he had known about all this, he could have raised it too. But I am quite sure he was not aware, we were not aware, all of us were misled. But never mind, now the problem has been uncovered, let us progressively fix them, and we are fixing them.

The Chairman: Dr Chong Weng Chiew, you have two cuts. Six minutes.

Mobile Healthcare Services

Dr Chong Weng Chiew: Sir, I am definitely happy and glad to hear the Minister's description of the Ministry's interest and views on the chronic sick's illnesses. My two cuts actually involve the following up of the chronic sick's illnesses as well.

First, let me declare my interest as I am involved in a couple of VWOs that provide non-institutional clinical services to needy senior citizens - one runs a mobile clinic and the other provides domiciliary homecare services for the elderly. Today, I will be emphasising about mobile clinics.

As our population ages, more and more senior citizens will face mobility

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problems. Although the Government has started working on making our neighbourhood estates barrier-free, this process will take a few years. Meanwhile, a growing number of elderly, especially the chronic sick, face challenges going to nearby polyclinics, or even their GPs, for their follow-up treatments.

The mobile clinic concept offers an easier option for the elderly with chronic illnesses. They encourage them to get their illnesses examined and monitored. In fact, the work of the mobile clinics complements the services of our established polyclinics as well as general practitioners. If there is a way these two services can work together, they should, in the sharing of patient information, updating of patient conditions, treatments, and so forth. I am glad that the Minister's earlier description on IT has addressed these concerns.

Currently, these mobile clinics operate independently and their services are not subsidised by the Government. They are only able to subsidise patients with funds from donors. As a result, they can only cater to a small number of elderly. If the Government would consider subsidising their services or, more importantly, share patient information with respect to patient confidentiality for the elderly poor, such monetary as well as logistic support will help many VWOs to expand its capacity to service more poor chronic sick elderly in more estates. It would also go a long way to help ensure that the service will continue to be provided to needy, senior citizens at very affordable rates. I hope the Minister would consider this suggestion favourably.

Home Therapy

Next, I will move on to my next cut on home therapy. Likewise, the Minister has mentioned examples on home therapy earlier on and I am sure the Minister is fully supportive of the fact that home

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therapy does provide lots of benefits for patients.

My cut on home therapy would actually be particularly angled for the chronically sick, poor and those living alone. As much as we are able to, we should also do our best to help the elderly sick alleviate their sufferings, particularly in the area of therapy. As I have mentioned earlier in my speech on mobile healthcare services, many senior citizens have difficulties travelling even to nearby polyclinics or community rehabilitation centres for subsidised follow-up treatments. The case as mentioned by the Minister earlier on, to a great extent, is a good example of such a case where the patient would have problem travelling to specific centres for treatment.

Hence, I would like to request the Ministry to consider extending Government subsidies to home therapy sessions for the elderly poor. Many of these live alone, with an elderly spouse or as "latch key" grandparents. Mobility is a big problem for them and many cannot afford to pay for unsubsidised home therapy sessions or domestic help and taxi fares to bring them for follow-up appointments. More often than not, they miss their follow-up therapy sessions and their conditions will start deteriorating from there. Then what happens, ironically, is that they will reach such a bad stage that they have to be admitted into an acute hospital where their medical fees would then be subsidised. But does this not lead to higher treatment costs, more given subsidies and greater suffering, all quite unnecessary since it is preventable in the first place?

Sir, I understand that such one-to-one home therapy sessions come at higher costs because they do not enjoy economies of scale, unlike sessions conducted at community rehabilitation facilities. However, I hope that the Ministry would be able to approve a system whereby selected cases, genuine

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cases, with severe problems gaining access to community services, can be given the benefit of subsidies for using home therapy sessions.

Financial Assistance

Mr Ang Mong Seng: ( In Mandarin ): Sir, in recent years, the Government has reformed its healthcare policies to the benefit of many Singaporeans, particularly patients in the middle and lower-income groups. However, very often, when the senior citizens went for treatment in the hospitals, they were not aware of the many financial assistance schemes provided by the Government to help them pay for their hospital bills. Some of them came to see me at my meet-the-people sessions and asked me to write to the hospitals to ask for assistance in the payment of their medical expenses.

As a matter of fact, many are eligible for the assistance schemes provided by the Government. At the time when they sought treatment at the hospital, they could have applied and be granted the assistance on the spot, without having to wait until the hefty hospital bill comes before rushing to their Member of Parliament for help. Perhaps, it was because they are not well-educated, hence are ignorant of how to apply for such assistance.

I hope that the Ministry would set up an effective system whereby a team of designated officers or department would offer the required assistance to these senior citizens on the spot. This is also a way to reward the elderly for their past contribution to our nation building.

3.45 pm

Gerontological Education

Dr Tan Cheng Bock: Mr Chairman, Sir, in 1984, the Howe Yoon Chong

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Report on Ageing was debated in the House, and I remember the report suggested that there should be an education called Gerontological Education, ie, studies on ageing. He said that Singaporeans must be better prepared for the impending ageing population. Now, 20 years have passed and I do not see that this particular education has been supported. I think it is time that we studied this particular subject again.

I think the Howe Yoon Chong Report is actually a very good report. The only problem was that it got hijacked by the issue of the withdrawal of CPF monies at age 55, which spoiled the whole report. But there are many, many good aspects in this report. Let me just quote what he said:

"Ageing is not only a physical process but also a state of mind. Today, large sections of society still deem the elderly to be a group of persons who should be classified with the sick and the disabled who are no longer fit for employment or capable of being retrained or re-educated to fit into the new jobs."

This is a very important statement. And this is what he suggested, ie, that this particular education should be established to encourage the academic staff, scholars and students of the NUS to do research, studies and investigations into the field of gerontology, to include gerontology in the curriculum of sociology or social science students, and to incorporate geriatric medicine as part of the medical curriculum, and also to encourage research, investigations, studies and regular surveys to monitor the social, economic and other changes that affect the aged.

This report, therefore, called for a new look at ageing by calling for the studying of ageing through properly structured courses to better understand this subject. As I said, we have not done much. We must not be captured by our old style of

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managing the old. The new old, as I said before, are better educated and travelled, and are very knowledgeable. So we must quickly explore new ways and methods to meet the expectations of the new old. The setting up of the Gerontological Unit should not be delayed further. It could be in the universities or polytechnics. I think it is up to the Government to decide. It would provide courses for the care-givers and also policymakers so that they can better understand the subject.

There are two aspects of gerontological education. The one that Members are most familiar with is geriatrics. But it is the other aspect, the social aspect, which has not been well studied. And many of us assume we know a lot. But we will be surprised that we really do not know that much. Therefore, I am asking the Government to have a good look at this subject and incorporate it perhaps as a subject or course in the university and, also, maybe in the polytechnic.

Dr Tan Sze Wee: Mr Chairman, Sir, together with Dr Tan before me, I would also like to ask the Minister for Health regarding the promotion of gerontological education in Singapore.

Our Government has addressed the ageing population issue for more than 20 years. During this time, it has focused properly on the healthcare needs of older persons. The health issues of older persons are addressed by medical gerontology or geriatrics. Non-medical issues are addressed by social gerontology. By this, we mean the study of the reciprocal relationship between the older person and health, family, community and society, as well as policymakers in Government whose decisions affect him or her.

Society needs to ensure the following:

(1) There will be sufficient healthcare for our ageing population; and

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(2) There will be policies, practices and understanding to meet the social and economic challenges posed by that population.

This can only be ensured through gerontological education. It is concerned not only with the provision of healthcare for older persons but also with their development, so that they can continue to contribute to society or to find fulfillment and meaning in later life. It includes the promotion of knowledge and understanding about ageing and older persons.

Therefore, may I ask the Minister, in view of the rapidly ageing population, what are the Ministry's plans for the promotion of gerontological education in Singapore?

The Senior Minister of State for Health (Dr Balaji Sadasivan): Mr Chairman, Sir, I thank Dr Chong Weng Chiew, Mr Ang Mong Seng, Dr Tan Cheng Bock and Dr Tan Sze Wee for their questions and comments.

As they have pointed out, we are an ageing population. There are about 300,000 senior citizens in Singapore. They form 9% of our citizens. Singaporeans are living longer and healthier lives than ever before. These improvements in life expectancy and freedom from disease for most of an average person's life are an achievement that our healthcare system can be proud of.

But this has created new challenges. A good proportion of the elderly will develop a chronic illness in the last phase of their lives. 85% of the elderly will have one or more chronic illnesses that require lifelong treatment. Some will develop disabilities that require daily assistance. At any one time, 5%-10% of the elderly population will need help with

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their personal care and the activities of daily living.

The historical focus of healthcare systems, which is to manage episodes of acute illness with intensive treatment, is not well-suited to manage the medical problems of the elderly. The elderly usually need continuous low intensity medical or nursing care to manage their chronic illness and to enable them to live good quality lives even if they have an age-related disability. If this can be provided in an efficient manner away from hospitals and nursing homes, they can enjoy a higher quality of life. So we must focus our health services to bring care as close to the home setting as possible. This needs a mindset change on the part of everyone, ie, healthcare providers, patients and their families.

The Committee on Ageing Issues, in its report, has recommended that the Government adopt a holistic family practitioner approach towards managing the healthcare needs of senior citizens. Over the next decade, our healthcare system will evolve in this direction.

Dr Chong Weng Chiew has quite clearly pointed out the benefits of providing home therapy and mobile healthcare to the elderly, and he has asked for subsidies for mobile healthcare and home therapy. We should consider this. Subsidies that channel the elderly to the hospital should be re-channelled to keep the elderly chronic sick at home, especially if this is a more efficient way of looking after the elderly sick. We have channelled subsidies before from inpatient to outpatient, eg, HIV treatment and chemotherapy for cancer. So we need to look at this again and, if we can provide more efficient care closer to the home, we should do so. Dr Lily Neo also suggested subsidised home therapy for the needy elderly.

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The Ministry of Health has tried out such schemes and launched the Primary Care Partnership Scheme (PCPS) in 2000, to help bring affordable healthcare to the doorstep of the needy elderly. Instead of having needy elderly patients travel to polyclinics, the scheme engages neighbourhood GPs to provide common outpatient treatment conveniently at polyclinic prices. But it was only for acute medical conditions.

This is a start. We will study our experience with the PCPS scheme and expand the programme gradually to manage chronic illness in the elderly. This will be in line with the recommendations of the Committee on Ageing Issues.

To bring therapy and care closer to home, MOH, together with MCYS, intends to partner the private and people sectors to develop a range of community-based nursing services and personal care services. In addition, we will enhance case management services in the community through tighter integration between the acute and step-down care facilities.

Mr Ang Mong Seng related cases where patients come to see him at the MPS to ask for financial help with their medical bills. I, too, have seen such patients in my MPS, and I asked them if they had seen the Medical Social Worker (MSW). Very often, they have not. And this is because the bill often comes after they are discharged, or they look at it only after they are discharged. One reason this happens is that our hospitals look after patients, regardless of whether the patient can afford to pay the bill, because they know that there are Medisave, Medifund and other assistance schemes to help the patient. So they treat the patient first, get the patient well, send the patient home, and then only after he is well, the patient looks at the bill. Very often, when they see the bill, instead of seeing the MSW, they come down to see us at our MPS

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and we write the letters to the hospital, and then the MSW sees them. But, in fact, they can approach the MSW directly in the hospital.

All our public sector hospitals, national centres and polyclinics have medical social workers. An estimated total of 140 MSWs help look after the social and financial needs of patients. They help administer Medifund, the Government's safety net to help those Singaporeans who, despite Government subsidies, MediShield and Medisave coverage, are still unable to pay the balance of their bills.

Besides Medifund, the MSWs work with the people sector and help administer a whole wide range of non-Government assistance. Our MSWs are highly-committed and passionate individuals who do their best to assist needy patients. Since they administer all the systems, they are really one-stop centres. The application process is kept simple to keep the administration cost down.

Dr Tan Cheng Bock and Dr Tan Sze Wee also spoke on the promotion of gerontological education in Singapore. Recently, the Singapore Action Group of Elders (SAGE) also came up with an open letter proposing the promotion of gerontological education. Dr Tan Cheng Bock referred to the Howe Yoon Chong Report which talked about gerontological education and the elderly. Twenty years ago, the problem of looking after the elderly was the tip of the iceberg. Today, the iceberg is upon us.

So I would go one step further. With an ageing population, it may not be appropriate to consider gerontology as a specialised area for a select group of healthcare and welfare workers with a specialised institution to train a few people. Today, the elderly population are

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the major consumers of medical and welfare services. In some developed countries, more than 50% of government healthcare expenditure is directed towards the elderly. With care for the elderly becoming such a major part of medical and welfare services, gerontology, or the holistic study of the elderly, has to be part of the core curriculum and education of a doctor, nurse, social worker or anyone else in the medical and social services field of study.

Sir, I was quite happy to note that there were three university professors who were in the SAGE initiative to promote gerontology. But they were writing in their private capacity, which is a shame. I encourage these professors to don their university caps and, in their professional capacity as professors in the university responsible for the education of our future doctors and social workers, promote gerontology as part of the mainstream university core curriculum in their respective faculties.

MOH, for its part, will be doing more to promote gerontological education. Most geriatricians currently work in acute care hospitals. But if the elderly are to be looked after in the community, then geriatric skills must reside in the doctors looking after patients in the community. That means family practitioners must practise community geriatrics. MOH will facilitate Continuing Medical Education (CME) courses that will equip GPs with the knowledge skills needed to function as community geriatricians.

Ageing issues are complex and must be tackled through an integrated and holistic approach involving Government, community agencies and the private sector. Much progress has been made in the last several years, though more remains to be done. Going forth, the collective will and efforts of all sectors, ie, the public, private and people sectors, will

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contribute towards achieving "Successful Ageing for Singapore".

4.00 pm

Flu Pandemic

Mdm Halimah Yacob: Sir, concerns over a potential bird flu pandemic remain strong, globally as well as in the region. With these concerns in mind, could the Minister please update this House on the measures taken to prepare Singapore for a bird flu pandemic. How prepared are our hospitals to treat bird flu victims? What are we doing to prepare Singaporeans for such a pandemic?

One way of preparing Singaporeans for the possibility of a bird flu outbreak is through drills. Will the Ministry be conducting such a drill? In Parliament, the Minister had mentioned that the Ministry is actively looking at how Singapore can produce our own vaccine as there is a worldwide shortage of such a vaccine. What is the progress of this and do we have enough stockpile of the vaccine?

Sir, in fighting bird flu, maintaining cross-border cooperation is important, particularly, amongst close neighbours. Several Asian countries have reported cases of the H5N1 virus infecting birds. In a few countries, the virus has spread to humans and had caused death. Could the Minister update this House on the status of the pilot project that it is conducting in Indonesia to help our neighbours fight bird flu?

Mr Andy Gan Lai Chiang: Mr Chairman, Sir, it is alarming that the Avian flu in the form of H5N1 strain has spread across from Asia to Europe. It is, however, heartening to know that MOH has set up a comprehensive influenza pandemic readiness and response plan and influenza pandemic contingency plan. These plans

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aim to reduce the impact of an outbreak on our social and economic lives to reduce the spread of Avian flu.

In the influenza pandemic readiness and response plan, it was hypothesised that if a conservative percentage of 25% of Singaporeans fall victim to influenza, most likely, 11,240 people are expected to be hospitalised. I would like to know whether MOH will be receiving sufficient funds to ensure that implementation of the influenza pandemic readiness and response plan be carried out effectively. And if so, what is the expected budget for doing so?

If there is a pandemic, will our quarantine facilities be adequate with sufficient manpower to cope with? Are there further plans to strengthen our protection against bird flu coming to our shores? There now appears, in some countries affected by Avian flu, to be human-to-human transmission of H5N1 virus and with Singapore, being an open society, infected persons may unknowingly bring the virus here and how are we going to cope with such a possibility. If an outbreak occurs, in spite of these measures, will it have the same effect on the country as in SARS?

Genetic Counselling

Dr Chong Weng Chiew: With regard to my cut on genetic counselling, I would like to suggest that the Ministry work with the Registry of Marriages to encourage all couples registering for marriage to go for medical screening and genetic counselling.

Potential couples have the right to know about each other's health status. If they plan to have children, this information will be even more important. For the majority, there will be nothing to worry about, but for the minority, this information could be critical. They could present an opportunity to seek medical

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advice and treatment. Preventive measures could help to reduce potential health risk to the unborn children and avoid unnecessary suffering.

Every child is precious, especially in baby-scarce Singapore. Pre-marital health screening and genetic counselling will help to maximise the potential of each child in our small nation.

Anti-smoking Policy

Mr Arthur Fong (West Coast): Sir, since the inception of a comprehensive anti-smoking campaign in 1986, I have seen the Government undertake a myriad of approaches to curb the prevalence of smoking in Singapore.

Sir, we have tried many things, from banning advertising by tobacco companies, raising duties and tax payable for cigarettes, including health warning on cigarette packaging and have even restricted the places where one can have a smoke. We have made it illegal to sell cigarettes to those below 18 years old. In effect, we have made cigarettes a forbidden fruit and the consequence is that the groups which we are trying to dissuade from smoking are the ones who clamour all the more for it.

I think most smokers, about 90%, according to a survey by HPB on "Youth Attitudes on Smoking" in 2000, know that smoking can have an adverse effect on their health. But, by restricting it so thoroughly, we may have made some groups all the more determined to try it for themselves. While the prevalence of smoking is down to 12.6% as of middle of last year, down from 13.8% in 2001 for some groups, it is on an uptrend, particularly for youths between the ages 16 and 24 and for females between the ages of 18 and 24.

Sir, in Thailand, cigarettes are cheaply and freely available, even though it has a bit less stringent preventive legislation like

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Singapore in place. Yet, while overall youth smoking trends are rising, the group that most resembles the Singapore youth, and that is the average urban school-going middle-class youth, is not clamouring more for cigarettes. In fact, studies showed that youths in Thailand associate smoking with those who drop out of the mainstream education or move into the labour market early. So this mindset has developed despite cigarettes being so readily available.

Sir, perhaps, our public awareness campaign or anti-smoking communications directed at youths may take the tack that smoking is not cool or something along that line. For the image concerned youths today, this alternative tack may bear fruit rather than just making cigarettes a forbidden fruit. This approach may leave a more lasting impression on the youth and young female smokers for which there is an uptrend. This group will, in time, stretch our health dollar that will already be stretched by our greying population and the healthcare needs.

Can the Minister tell us what is in store to combat the uptrend of youth smokers?

National Blood Programme

Dr Chong Weng Chiew: Sir, with regard to my cut on national blood programme, I am very concerned with the recurring shortage in our blood bank, particularly during our year-end festive seasons.

In December 2005 and January 2006, our supply dropped to such low levels at one point that we have only enough to last 24 hours. With only 1.5% of our population donating blood, we have one of the lowest rates amongst developed nations. An adequate supply of blood is crucial. Imagine what could have happened if we had a crisis during that period? Incidents, such as 911 in the US,

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showed how vulnerable any country can be despite security measures.

How we boost our blood bank is no longer just an health issue. It is also a national security issue. I would like to ask the Ministry if we could re-examine our blood donation programme and identify areas for improvement. As we try to increase supply, we should also try to reduce demand. One way is to get suitable patients to use autologous blood. Patients going for elective surgeries, in particular, could be encouraged to do so. Elective surgeries account for one-third of total blood usage but only around 4.5% of such procedures use autologous blood.

Perhaps, we can look at the experience of other countries. An article in the Philadelphia Inquiry on 27th January this year described the success of blood donation drive in the US. Teenagers over the age of 16 are now the fastest growing group of blood donors, contributing up to 16% of the blood supply in some places. I quote: "Blood banks, including the Red Cross, have aggressively marketed to teens through web pages, MTV commercials. Research by the Ad Council shows teens are more willing to engage in community service than many adults."

Teens under the age of 18 have to get permission from their parents and many end up persuading their parents to donate too. Their contribution comes at a time when demand is growing due to the aging American population. I am not suggesting that we focus on getting blood only from our teenagers but, rather, this development in the US could be instructive. There may be elements that we could adopt. We certainly do not want to make the parents of our teenagers nervous.

Due to cultural differences, our attitude towards blood donation needs

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time to change but, sadly, we cannot afford to wait too long. We too have an aging population. The onus for blood donation remains on the adult population.

Dr Balaji Sadasivan: Sir, I thank Mdm Halimah, Mr Andy Gan, Dr Chong Weng Chiew and Mr Arthur Fong for their questions and comments. Many of the medical issues brought up have been with us for a long time but one problem is new - bird flu. Hardly a day goes by without a news report in the media on developments related to bird flu.

Mdm Halimah and Mr Andy Gan have asked about aspects of our bird flu pandemic preparations. We must be prepared to manage three types of bird flu spread: one, bird to bird spread; two, bird to human spread; and three, human to human spread.

I will begin with bird to bird spread. It appears that the H5N1 virus has established itself in wild birds. It has spread relentlessly from Asia to Europe and Africa. Fortunately, our poultry population is limited and is located in farms with good bio-security. You have heard earlier in the House all the measures that AVA and ENV have taken to ensure that there is no bird to bird spread in Singapore. So far, no H5N1 influenza virus has been detected in Singapore.

Next, there are sporadic cases of bird to human spread. This has occurred in our neighbouring countries when humans have had close contact with sick birds. We have advised Singaporeans to avoid chicken farms when travelling to other countries. We have also put our doctors on alert against possible human cases of Avian flu coming into Singapore.

Finally, we should be prepared for a pandemic in case the virus mutates and starts spreading from human to human. Will a pandemic occur? We do not know. Experts differ in their opinion. Looking

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back at the last century provides conflicting examples. In 1978, there was concern about a swine flu pandemic occurring and 24% of the population in the United States was vaccinated. The pandemic never occurred and no one died of swine fever. But the vaccination caused 500 complications and 25 deaths. On the other hand, in 1918, the Spanish flu pandemic spread across the world and caused 25 million deaths.

Managing a pandemic is a national exercise in science-based risk management. Success depends on three factors: a strong effective political leadership, a cooperative public who follows health advisories during the pandemic, and a healthcare system that is well prepared to deal with public health challenges. This is what we learnt from our SARS experience. In Singapore, we have both, an effective leadership and a cooperative public. I want to assure the House that the third factor, the healthcare system, is well-prepared.

We currently have some 700,000 courses of Tamiflu and are on track to build up our national stockpile by the end of the year. We have an assured supply of pandemic vaccine if we think it is necessary to vaccinate the population. Public healthcare institutions have put in place plans to manage the expected surge in outpatients and in-patients in a pandemic.

We have also worked with other Government agencies to ensure that essential services will continue to operate during a pandemic so that there is minimal disruption to the economy and society. Through our outreach, we have given talks to MNCs, SMEs, private organisations and grassroots leaders to help them understand the nature of pandemics and the measures that they can take to be prepared.

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We will conduct exercises in the next few months to test our pandemic preparedness. In the first stage, we will focus on all public and private acute hospitals to ensure that they are ready. The second stage will be a wider system-level exercise and will also involve other agencies such as CAAS and ICA, as well as the public.

As the risk of a bird flu pandemic is a global one, we are working with WHO and the international community to do our part in containing this threat. In January 2006, Singapore pledged $1 million at the International Pledging Conference in Beijing to fight bird flu. This will go towards our laboratory collaboration and capacity building efforts in Indonesia. In addition to this, together with the United States, we are also working with our Indonesian counterparts on a pilot project in Avian flu surveillance and control

at the Tangerang Municipality just outside Jakarta. This is an area with a population of about one and a half million people. The project is expected to commence in April 2006. Singapore will be contributing both funds and technical expertise towards this project.

4.15 pm

Dr Chong Weng Chiew also suggested that couples getting married attend genetic counselling and screening. In fact, this is indeed already happening today. Public education about inherited genetic disorders such as Thalassemia and Hemophilia has been ongoing since the late 1980s.

Thalassemia is the most common inherited genetic disorder in Singapore. Two decades ago, about 15 babies were being born every year with Thalassemia Major. To address this problem, in 1991, the Ministry of Health introduced a Thalassemia prevention and screening programme for couples and pregnant mothers. The programme has been

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effective. The incidence of Thalassemia Major has now declined to one case per year for the last five years.

Mr Arthur Fong proposed that we tackle the issue of smoking amongst the young. Smokers are a diverse group requiring different strategies and educational messages to encourage them to quit smoking. Singapore's smoking prevalence rate has declined. The smoking rate among those aged 18-69 years declined from 15% in 1998 to 12.6% in 2004. This is one of the lowest in the world. I think we also have one of the highest taxes on tobacco in the world. The smoking rate among young people aged 18-29 years has also declined from 26.2% to 12.3%. However, there is an increase in the proportion of young female smokers in the age group between 18-29 years, and the proportion has increased from 5.2% in 1998 to 6.6% in 2004.

To curb this increasing trend in young female smokers, the Health Promotion Board has introduced targeted initiatives which are gender-specific, such as the Fresh Air For Women Programme. HPB is also exploring new outreach channels such as websites, youth blogs and chatrooms which youths frequent and are comfortable with. We will also take in any marketing ideas that Mr Arthur Fong has and will suggest to them on how they can reach out to the young better.

Earlier, Dr Lily Neo has expressed concern about the fact that the mortality rate from heart attack in women was higher as compared to men. That means that if a man gets a heart attack, as compared to a woman, he has a higher chance of recovery, and suggested that we should increase our education effort towards women so that they will be more aware of this risk. I was quite intrigued by the statistics.

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Two days ago, there was a whole host of experts in Singapore for a conference on this very topic of cardiac resuscitation. So I asked them about the statistics. A senior cardiologist there explained to me that the problem was not with women, but with men. Because men have a lower life expectancy than women, they get heart attacks more often and die at a younger age. There are far more women living to an older age and so the average age of women suffering a heart attack is much older than a man, and so this contributes to the higher mortality rate in women.

When dealing with medical statistics, I am reminded of a saying of Mark Twain, "Facts are stubborn, statistics are more pliable." The facts are that Singaporeans have one of the longest life expectancies and women outlive men. But a single statistic like the mortality rate from heart attack is sufficiently pliable so that different experts can draw different conclusions. Nevertheless, the Ministry will consider new initiatives to lower mortality rates from heart attacks in both men and women.

Dr Chong Weng Chiew has expressed concern about the low stocks of blood during the festive period and has made useful suggestions on how to boost donations and increase autologous transfusions.

The number of blood donations collected has been steadily increasing by 7%-18% and the number of donors by 3%-8% every year over the past three years. This is an outstanding achievement by the Transfusion Service. The national blood supply has been able to adequately meet the needs of patients in Singapore hospitals most of the time, but still faces episodic periods of blood shortage during the December to January festive months. The Health Sciences Authority (HSA), with the Singapore Red Cross, will continue with its donor recruitment

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campaigns to increase awareness amongst Singaporeans about the need to donate blood regularly. These include specific programmes to increase blood donation amongst youths aged 16-25 years of age, as suggested by Dr Chong. In an emergency, there are contingency plans to boost blood stocks quickly.

Although autologous blood transfusion is encouraged in appropriate situations, the use of autologous blood for surgery has declined due to shorter waiting times for elective surgeries and an older patient population. This is because to use autologous blood the patient has to donate first and then he has to wait 2-3 weeks before he goes for his surgery. But with patients expecting very short waiting time for their elective surgeries, there are less of them willing to give autologous blood or donate for autologous blood transfusion. The HSA will, nevertheless, continue to work with hospitals in encouraging autologous blood transfusions. And the Health Sciences Authority will take in Dr Chong's feedback in its ongoing review of blood donation adequacy for Singapore.

The Chairman: We have some time left. Mdm Halimah, make it short.

Mdm Halimah Yacob: I just want to ask the Minister two questions. My first question is: when will the review on the flexibility given to the use of Medisave be completed?

My second question is this. The Minister has said that his Ministry will always review the quality of the services. I do note the special focus and emphasis on the elderly and also those suffering from chronic illnesses. But, there is also a need to pay a bit more attention to one area that is somewhat overlooked, ie, those people suffering from mental illness. I would like to ask the Minister if his Ministry would pay closer attention to people suffering from mental illness in

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terms of the quality and level of care provided to them, both at the hospital and the primary care setting, as well as in terms of educating the public about this illness and accepting mental illness sufferers better and helping them to integrate into society.

Mr Khaw Boon Wan: Sir, the liberalisation of Medisave to look after costly outpatients, particularly the chronically ill, as I explained, is not a simple subject. What is my worry? My worry is abuse, because the barrier to access for outpatients is very low. At the hospitals, I can at least control, through the number of beds, and it is very costly to build hospitals. So, therefore, there will always be a limited supply of beds, and access is harder. Whereas, for outpatients, you can just hang up a signboard and you are in business and patients can just walk into clinics. The worry about abuse, overuse and over-servicing at the outpatient level is that Medisave may then run out. Do not forget that 21 years ago when we started Medisave, the reason was because we worried about expensive hospitalisation. So I do not want, in solving one problem, to create a bigger problem of people suddenly finding themselves, when they are really old and need to be hospitalised, do not have enough money in their Medisave. So I am taking my time, carefully thinking it through, but it is something that I am giving priority. I hope I can make major announcements during this year.

Now, on the second topic of the mentally ill. It is tough being a Health Minister because there is a whole range of illnesses, diseases. So, at any one point in time, we can only focus on a handful of things and, as I explained earlier in the House, this year I want to pay particular attention to the chronically ill. But I have not neglected the mentally ill. Globally, good mental health programmes are also very limited. I am not aware of any

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country that has really done it well. Last year, we formed a national Committee on Mental Health and the experts have been studying it. I am awaiting their report in a few months' time and then we will study their proposals. Part of the trigger for the review was because of gambling addiction discussed during the IR debate. That is why we get them to start thinking about addiction to gambling, chemicals and all sorts of other things. But the end result would be the same, which is, if you upgrade the capacity and the expertise within the mental health institutions, the other mentally ill patients will also benefit from it.

Mr Arthur Fong: Sir, I would like to ask the Senior Minister of State for Health if his Ministry would consider spearheading or initiating a programme with MCYS and MOE to arrest the growing trend of youth smokers.

Dr Balaji Sadasivan: The answer is yes. They are working with MCYS and MOE.

The Chairman: Are there any more clarifications? We still have about 15 minutes. If none, Mdm Halimah, would you like to withdraw your amendment?

Mdm Halimah Yacob: Sir, I would like to thank the Minister and also the Senior Minister of State for the very comprehensive and insightful answers that they have given. I am personally very assured by the Minister's assurance that the Government is very mindful of ensuring that medical inflation is controlled and that healthcare costs continue to remain affordable to all Singaporeans.

On that note, Sir, I beg leave to withdraw my amendment.

Amendment, by leave, withdrawn.

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The sum of $1,809,997,570 for Head O ordered to stand part of the Main Estimates.

The sum of $200,371,800 for Head O ordered to stand part of the Development Estimates.