Aline K. Wong
Singapore
“The ENABLE (Encouraging Achievement and Better Learning) programme gives additional support to those who are not achieving their potential. Our curriculum has given more emphasis to critical and creative thinking skills.”
“Can I just take one more second on the waiting list because Mr Ahmad Magad mentioned that the waiting list is long? There are 18 SPED schools now which cater to about 4,000 children. Of the 18 SPED schools, eight have waiting lists.”
“Sir, I am sure the Member in his meet-the-people sessions has also encountered cases where some families pleaded for priority to be admitted on grounds of, say, the child's sickness, or that the mother is working and is unable to bring the child to school, or that the grandparent cannot manage to take care of so many grandchildren.”
“I think he did not hear what I say. For both of these families, someone who lives within one kilometre or next door and someone who lives right on the border of this one kilometre, or of any delineation you choose to draw, my point is that for both of them, this is their nearest school.”
“Principals, as part of their duties, are always alert to what is happening in the school. They have also been given guidelines, in the Principals' Handbook, on discipline and the code of conduct which is expected of the teachers and staff members. But having said that, all these things are not foolproof.”
“It will continue to stagger the rental increase to market levels for assignment of tenancies, subletting cases and for tenants who are renewing their tenancies for the third time. Shop lessees can also apply to convert to shorter leases to reduce the cost of servicing their mortgage loans.”
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“As I explained just now, the subsidies include the land, building, equipment, salaries of the medical staff and also the cost of medicine. As far as hospitals are concerned, it also applies.”
“The 50% concession is based on the current charge of $6 per consultation and the charge for medicine of $1 per item up to $4 per week, i.e. senior citizens are given a 50% discount on top of this. The subsidy policy for the polyclinics includes the development and depreciation costs of polyclinics. These buildings, equipment, etc, are all Government-owned and they are fully covered by Government subventions.”
“Mr Speaker, Sir, as I have mentioned, the regulations will make it mandatory for private hospitals to state in advance the kind of charging practices they will carry out. That would presumably include that if they do have a video tape, they would have to inform the patient they are going to charge for it. CHILDCARE LEAVE FOR FEMALE EMPLOYEES (Introduction of legislation) 10. Mrs Yu-Foo Yee Shoon asked the Minister for Labour whether he will consider introducing legislation to provide childcare leave for female employees to enable them to look after their sick children, similar to the leave presently in existence in the public sector.”
“Mr Speaker, the question is about the charges for sundries and supplies, not about doctors' fees and charges. If the Member is interested in tabling that question another time, I would be pleased to answer.”
“We are talking about hospital bills here. The hospital bills include charges by doctors for the visits to the inpatients on ward rounds, as well as surgical fees, if there is an operation involved.”
“So all indications are that the present kind of medical screening services we give in our schools is adequate. It is better to utilise our scarce services in other programmes. But of course I welcome his support for our programme to be receiving more funds from the Ministry of Finance. But please be rest assured, Sir, in the opinion of medical experts, our School Health Service is doing a good job.”
“Sir, I am glad that Mr Chandra Das supports the Ministry's philosophy that prevention is better than cure and he also supports the objectives of our School Health Service. With regard to the number of doctors in the School Health Service, actually it has increased from 10 in 1988 to 14 this year, and that is in spite of our zero-growth manpower policy. On the number of nurses in the School Health Service, I think he has got the figure wrong. In fact, we have now 104 nurses in the whole School Health Service. The entire staff complement is 186. So it is by no means a small staff complement. Our expenditure has increased from $5.4 million in 1988 to $7.3 million. Whether medical screening should be done by doctors all the time, it is a matter of expert opinion and also a matter of the end result, the outcome. It is true that medical screening carried out in primary one and secondary four is done by doctors, while those at primary six is done by nurses. But our nurses are trained. Besides, our children also get to have visual screening every year. They also get spinal screening intermittently. So it is not just the medical screening at primary one, primary six and secondary four. Our children are actually very healthy, and they are among the healthiest age group in our population. If by the time they enter primary school, they get any severe medical condition, they would have been picked up by our medical services before they enter school. And even during the school years, those who require specialist's attention would have been sent to the Specialist Outpatient Clinic in the Institute of Health. Attendance figures in our polyclinics actually show that the proportion of school children seeking medical treatment at polyclinics is much lower than the other age groups.”
“Yes, we have stated in the House a couple of years back already that the community hospital at Ang Mo Kio will have a whole range of wards, including A and B1 class. But even for those A and B1 class, the charges would be lower than the private wards in the acute hospitals. As I have just stated, the proportion of subsidised beds will be 75%.”
“As to what kind of research the University is carrying out with NUH, perhaps the Member is in a better position to answer this.”
“So with this, I can assure the House that the community hospital will meet the social objectives as well as the medical objectives that we have set them. As for future community hospitals, a reserved site, next to the General Hospital to be built in Simei, has been made. But we would like to monitor the response to the Ang Mo Kio Community Hospital before deciding to build more community hospitals. Meanwhile, voluntary organisations have been receiving assistance from us, such as St. Andrew's Community Hospital, to set up their own community hospitals, perhaps on a smaller scale. We have given them the necessary capital and operating financial assistance. Dr Michael Lim raised a question about research. Yes, we have a department of clinical research within the MOH, which has an operating grant of about a million dollars a year. But actually we spend more on research each year than this because we receive donations from charitable and philanthropical organisations and grateful patients. For the year 1990/91, a total of $30 million was donated from various sources. We have used them mainly on clinical research. I can assure him that the kind of research we have done in the past as well as in the future will focus on the diseases that are the leading causes of ill health in Singapore. They will benefit the patients directly. We will concentrate on clinical research, epidemiological research as well as research on the needs of elderly patients, in view of our ageing population. We will also encourage research to study the outcome and effectiveness of different techniques and procedures of treatment so as to arrive at the most cost-effective method in order to contain our health care cost.”
“Sir, the first community hospital at Ang Mo Kio Avenue 9 would be ready in the middle of this year, and it is expected to be operational by the end of the year. It will have a capacity of 203 beds with subsidised beds comprising more than 75%. As Members of the House have expressed, the community hospital is meant to be an intermediate level hospital, providing a cheaper alternative to patients who do not require the highly specialised care which is given at the acute hospitals. We would like the voluntary welfare organisations or the private sector to run the hospital. This is because they can promote a greater participation of the community in supporting the services of the hospital. As the name implies, a community hospital must have the support of the community. General practitioners are also encouraged to utilise the services for their own patients. They can visit the patients there, they can do their investigations and treatment there. We would like to see community and voluntary groups come forward to assist in giving help, care and companionship to the patients. The Ministry will provide the necessary capital as well as assistance with the operating expenditure. The Ministry of Health will regulate the charges for subsidised patients and will ensure that they are lower than those at the acute hospitals. We have invited proposals from the private sector and we are still examining them because it is a very complicated matter. But I can assure Mr Leong that the criteria considered will include, not just capital investment or capability, but also experience in running this kind of hospital and also the subventions they require from the Government while remaining within the charges that we set for them.”
“The answer is, yes. The restructured hospitals have actually been trying out scheduling of the shift work of nurses, giving out overtime allowances and also providing further training to nurses. We have been doing that.”
“In the public sector, we have 45 psychiatrists compared to 17 in 1980. On psychologists, yes, we also have some vacancies. But there are already nine scholars studying overseas and when they return between 1992 and 1994 we will be able to fill our vacancies. With this kind of planning and monitoring, I can assure Members of the House that the shortage of our health care professionals would be satisfactorily met and, thereby, we can maintain the quality of our care to the patients.”
“As for Mr Choo's concern about the quality of our nursing training, I can also assure him that the School of Health Sciences at the fourth Polytechnic is teaming up with the Cumberland College of Nursing of Sydney University, which is one of the oldest established university in Australia and which has been accredited with WHO commendations. Whether there would be a component on communications skills in the curriculum, I have to check. If we are going to link up with the Cumberland College, it will definitely be up to international standards. As to his suggestion for geriatric training for nurses, this has been done definitely. Last year, when I was the guest of honour at the Nurses' Graduation Day, I congratulated a batch of nurses who had just gone through their geriatric nursing. We will continue to do so and we will take care of this kind of concern. On therapists, yes, we are short of them. We are not up to the standard that Hong Kong has and that is why we are beginning to have local training for therapists, including physiotherapists and occupational therapists at the fourth Polytechnic. Our annual intake is targeted to be 30 per annum and, again, with future batches of graduates, we will be able to meet our local needs. As far as psychiatrists are concerned, we have been giving postgraduate degrees in psychiatry ever since 1985. We are working together with the School of Postgraduate Medical Studies of NUS and ever since then the average number of psychiatrists trained or taken in every year is about five. In fact, the number of psychiatrists in our health services has been increasing since 1980. In 1980, there were only a total of 22 psychiatrists, but now there are 60 already. So there has been a tremendous increase, to the tune of a three-fold increase.”
“I will reply briefly to the questions about the shortage of health care professionals raised by Mr Loh Meng See, Mr Choo Wee Khiang and Mr Yeo Toon Chia, as well as Mr Lau Ping Sum. Let me assure Mr Loh Meng See that by encouraging the private sector to take up a larger share in the provision of health care services, the Ministry will, by no means, be relinquishing its responsibility the training of health care specialists. In fact, the training of specialists is still within the domain of the Ministry of Health. We coordinate and we keep track of what are the areas of shortage, we create traineeship posts, we select the candidates and we post them to the various hospitals. So we are not relinquishing any of these responsibilities at all. As for the shortage of nurses, I am happy to inform the House that, in fact, the situation is much better than a few years ago, especially since our restructured hospitals have been given the flexibility to recruit their own nurses. The situation will be further improved, as we will meet the requirements for nursing manpower once the Nanyang Polytechnic produces its first batches of graduates. In fact, the response received, in terms of applications, has been quite overwhelming. I am pleasantly surprised that for 260 places for 'O' level graduates, we have received 313 applicants. We still have to select the 'A' level graduates and there will be 90 places for them. Allowing for some attrition, the overall intake would be about 320 this year and, next year, we aim to have an intake of 400. We have also been doing a lot to encourage school-leavers to take up nursing as a career, eg, by organising exhibitions, career talks and so on. We are continuously negotiating with the Public Services Division for their salary reviews.”
“These voluntary organisations, if the plans are approved by us, would be eligible for capital funding of up to 80% and recurring funding of up to 50% of the operating expenditures. For the St Andrew's Community Hospital, we have provided them with $1 million capital grant and we are also providing them with the recurrent subsidy. We will do the same for other nursing homes and community hospitals. St Luke's Home for the Elderly Sick has been approved. A site has been reserved for them at Bukit Batok and we are still working on the details of the proposal. As for Kwong Wai Shiu Hospital, they have done a very good job in providing services which are akin to nursing home services at some level and akin to community hospital services at another. We have been providing them with an annual grant of $50,000 per year. They still have some operating surplus, but we are looking into how we can help them further. In short, we would like very much to work with voluntary welfare organisations in providing community health services to our people.”
“Some senior citizens' health care centres have started involving volunteers to help in the work, and we are looking into working with voluntary welfare organisations to provide home help service to the elderly patients. So you can see we are already working in that direction of reaching out to the community from the polyclinics. But let us be very clear in our minds, at the polyclinics we already have a lot of the elements that Dr Tan refers to and, in fact, we have started and we will be giving more effort to reach out to the community. As for Dr Tan's concept of referral centres, I think it is akin to our specialist outpatient clinics. These are located at our hospitals and they provide ambulatory care. So Dr Tan's idea that these referral centres should provide ambulatory care including day surgery, we are already doing that. We have been putting more emphasis on ambulatory care, day surgery, etc, in order to free the hospitals of the space and the facilities that are required for other kinds of conditions. So Dr Tan's suggestion for specialist referral centres in fact already exist. A very quick response to Mr Loh Meng See's suggestion that we should involve more voluntary organisations in the provision of health care services. Yes, indeed, this is my Ministry's policy and intention to involve more voluntary organisations. Because they are able to bring support from the community and in this way, we can foster a society of compassion with many helping hands. We plan to encourage and facilitate greater participation of the VWOs in the setting up of community hospitals, in the building of nursing homes, in providing day care centres and other home support services for the elderly and the chronic sick also.”
“So Dr Tan's suggestion is for some of the services to be decentralised, to be brought down from the polyclinic level to the doorstep of the people, so to speak. There is merit in this proposal, especially where the continuous care of the chronic sick or the elderly sick patients, people with diabetes, are concerned. We have actually thought about this concept, only that we are calling them multi-service day care centres. To do it well, we need more nurses, therapists and volunteers. Right now, we are still short of nurses and therapists, even for existing services. So it will take time. But if it takes Finland 10-15 years to do it, then I think we should be heartened. The cooperation of doctors is highly necessary in community health services and I think Dr Tan will agree. If he has some good ideas about how to encourage GPs to participate, such as in providing domiciliary care, in referring patients from the clinics to go to the community health centres for follow-ups and so on, I will be most happy to hear his ideas. We do not have a system where all the doctors are salaried or are employed by the Government in Singapore. So that is one of the problems. Meanwhile, we have already started to bring primary health care to the community level. For example, the Home Nursing Foundation nurses have been going out to visit patients at home. They use the senior citizens' health care centres at our polyclinics as the base from which to go and visit the patients. We also have stroke rehabilitation, ie, rehabilitative services for stroke patients. We have day care as well as therapy provided at the polyclinics.”
“But if we look at the national level, private individuals also see primary health care doctors, GPs, etc, and they also spend on primary health care. Overall, judging from what we know on the household expenditure and the items people spend on health and within that, the amount spent on hospital care as compared to, say, primary health care, our overall national expenditure on primary health care is quite comparable to Finland, if not surpassing it. Secondly, I want to point out that the Government's 25% share of primary health services actually covers a lot of the health modalities that Dr Tan mentioned, such as health education, immunisation, maternal and child health services and rehabilitation. In other words, we are not doing just curative care. We are not just giving outpatient treatment. We do all these other things that Dr Tan referred to. In recommending the Government to maintain the present share of primary health care, my Review Committee realised that the bulk of the work in health education, health promotion and disease prevention must be done by the Government. GPs do some of it but the bulk of their work is in medical treatment. So the big responsibility falls on the Government and we realise that. All of the elements of primary health care that Dr Tan mentioned from preventive care to curative care to rehabilitative care are already found in our polyclinic system. No doubt, these are large clinics. They serve a large number of patients and their service may not be as personalised as that provided by GP clinics, but this is unavoidable. For those who have chronic illness and require continuous care, perhaps the polyclinics at the moment are not providing the ideal type of continuous care to them also.”
“If they stay healthy and do not fall sick, their Medisave accounts will remain intact. If they manage to stay healthy throughout most parts of their life, then they will have enough Medisave left for the hospitalisation needs during their old age. Therefore, I think there is already a big incentive in the Medisave scheme for people to want to stay healthy. Employers, if they want, may consider giving, say, rebates on the medical benefits given to the employees if such benefits are not used up annually. But this is up to them. With the commitments we have made to promoting healthy lifestyles on a national scale, and we are going to sustain this effort over the entire decade, I should think the message would sink in and people would be motivated enough to make healthy living part of their daily life. Dr Tan gave us some very constructive comments on primary health care. I agree with him that we should emphasise it because this is the first line of defence in medicine. And if we do it well, it will help us to cut down health care costs. This is why over the years, we have upgraded our primary health services through improving our facilities, staffing levels as well as providing better training for our personnel. Let me, first of all, point out that the figure of 30% of the health budget that Finland spends on primary health care refers to the national health expenditure. Because Finland has a national or state funded health system. There is no private sector, so to speak. The national health expenditure is equivalent to the government health expenditure. It is true that in Singapore, we spend 12% of the Government health budget on primary health care.”
“Sir, I will answer the questions and points raised by Dr Vasoo, Dr Tan Cheng Bock and Mr Loh Meng See. I agree with Dr Vasoo that the best strategy to keep health care costs down is to build a healthy nation through health promotion and disease prevention. My Ministry has always placed a great deal of emphasis on this. And now with the recommendations of the Review Committee, we will put even greater efforts and resources into these programmes and promote healthy lifestyles. Dr Vasoo suggested that we should provide some incentives to those aged 40 years and above to encourage them to remain fit and healthy. Specifically, he mentioned the use of IPPT test as a criterion for rebates into Medisave accounts. Fitness testing is actually more than testing for health related fitness. It also tests for things like muscular endurance, power, agility, coordination and speed. We need to be clear what we are testing for. If we are only reviewing to see if a person is free from illness, then this is different from testing for fitness. And when we say that a person is healthy, we usually mean that he is able to carry out daily tasks with vigour and alertness and that he is free from illness. But the most important question we must ask ourselves is this: what are the reasons for us to stay fit and healthy? Should we do it only because of incentives? I should think not. The benefits of a healthy lifestyle are enjoyed directly by the individuals themselves. They stay fit and healthy because they can eat better, sleep better, work better and feel better. In other words, the benefits of healthy life style are to raise the quality of life. Medisave itself already has a strong incentive for people to stay healthy. Medisave is their own money. It is also tax exempt.”
“But look at what has happened to legal costs there, and what a litigious society America has become. Sir, the training of doctors is very expensive. At present, it costs $53,000 per year to train one medical student. It is as costly to train doctors locally as it is for medical students to be trained overseas, because our standards are comparable to that in advanced countries. Out of this $53,000, the student pays $10,000. Thus, the Government is subsidising each medical student $42,000-$43,000 per year. For each student's entire course of study, which takes five years, the Government provides a subsidy of over $210,000, and this is a huge sum. Needless to say, such heavy investments in our doctors must be carefully balanced against the country's need to train lawyers, engineers, accountants, and so on. Besides, we must not forget that, unlike lawyers and engineers, doctors once trained cannot easily change occupations should the demand drop. This would represent a huge loss in taxpayers' money spent on their training. Therefore there is no question that we must carefully plan the supply of doctors and the intake of medical students. As with all projections, if the parameters change in future, such as, if Singaporeans are not returning from medical study overseas, or if foreign doctors are not coming to practise here, then of course we would have to make adjustments, and the NUS intake of doctors would have to be reviewed again. I hope this will help to clarify the Review Committee's recommendation on the intake of medical students and lay the issue to rest, at least for the next few years, Sir.”
“One of the recommendations that the Committee made with regard to the slowing down of the rise in health care costs has attracted much interest and this is our recommendation on the intake of medical students at NUS. Yesterday, Members of the House have engaged the Minister in a brief discussion on the relationship between the supply of doctors and health care costs. There were some articles recently in the Straits Times and also a letter to the Forum page. And even just now during the coffee break Members of the House were asking me to explain this relationship again. If I may put the issue in rather simpler language, it is just that, under a situation of over-supply, doctors can maintain their incomes by driving up the volume of their services through over-investigation and over-treatment. Patients are often not in a position to dispute the doctor's treatment, not only because they do not have the expert knowledge, but also because when they are ill, they require immediate attention and they are also under great emotional stress. Therefore, at that time, they cannot make rational choices. And where the patient mistakenly equates costly treatment to be the best treatment, he would demand it. The doctor would be only too happy to give it, thereby feeding the demand. Health care costs go up as a result, and people's health is not necessarily better. In the case of terminal illness, costly treatment may prolong life somewhat, but the patient's quality of life is often poorer. It may be true that doctors are not the only professionals who can play up an imperfect market. Others can, eg, lawyers and maybe others. But if I am not mistaken, America has the highest lawyer-to-population ratio in the world.”
“First and foremost, we believe that the individual has a personal responsibility to stay healthy and minimise the need for medical care. Hence our emphasis on health education, health promotion and disease prevention. Every person should make healthy living a way of life. A second principle is that the Government should continue to ensure basic medical care is accessible to all citizens. In practice, this means that market forces cannot be allowed a free play. The Government must intervene in such an important area as health care. Hence, the Review Committee's recommendation that the Government should continue to be the major provider of health care and subsidies should still continue to be provided for the lower income groups. Third, there must be a certain amount of cost-sharing at the point of consumption to discourage wasteful and excessive demand for medical services. As for Dr Arthur Beng's question as to how much is affordable, that is of course open to debate and subject to review. We have made our recommendation in this area also. Lastly, to enable Singaporeans to pay for their share of the costs, they must be encouraged to save, especially for their medical needs during their retirement years which, because of a lengthened lifespan now, stretch to about 20 years and more. So the Medisave contribution rate should be progressively raised, and the self-employed brought within the scheme. These principles are important and we believe they are the right principles. The specific measures and programmes should be seen as implementation of these principles.”
“The question of subsidies and use of reserves to lower the cost of living has appeared many times in today's and also yesterday's debate. Sir, I would like to address this issue in the context of health care services and in my capacity as Chairman of the recent Review Committee on National Health Care Policies. Sir, Singaporeans have by and large accepted that a welfare state is not good for us. But in certain areas, like health care, they are still hoping for bigger subsidies from the Government. However, we must not forget that subsidies have to come from the taxpayers' pocket. The burden ultimately falls back on the people. Therefore, the right approach is to control the rise in health care costs and to ensure that basic medical care will remain affordable to the nation. What is basic medical care? Dr Arthur Beng has just raised this question in the House. He also happened to be a member of the Health Review Committee. He probably would remember that we debated this issue at length and found it is very difficult to define. So we have to work with an evolving definition which we have to tackle from time to time. As far as the question of health subsidies is concerned and the right approach to controlling the rise in health care costs, the Review Committee has drawn up a number of recommendations on, first, how to improve the health of Singaporeans, so that the need for medical treatment will be reduced; second, how to improve the efficiency and quality of our medical services, so that they are worth every dollar spent; and, third, how to manage the rise in health care costs. Underlying our recommendations are several important principles. These have guided the development of our health care financing system and they have served us well. What are these principles?”
“I beg your pardon. At our polyclinics, we have had senior citizens' health care centres for quite a while. Within the Ministry, we have the Department of Health Services for the Elderly and we work very closely with the Home Nursing Foundation at the polyclinic level. There, we actually have the premises and all kinds of facilities for them.”
“My apologies to the Member for Telok Blangah, because I could not see that he was sitting behind me. I wrongly assumed he was absent because he did not speak on his amendment on hospital services. I do appreciate the fact that health screening for the elderly is not seen to be reaching to his target yet. But I do hope the Member will have a bit more patience with us. We just started the health screening programme not too long ago. We have to reach out. We would strengthen this arm of the programme.”
“She mentioned about the upgrading of polyclinics. I did not argue with her on that. I only said that it is well and good but the polyclinics will only serve 30% of the population. And if you are talking about preventive health care, you are talking of reaching out to the masses, to the 100% of the masses, if possible. She said just now that for the first year of the health screening programme, the number they could screen was 4,000 and next year they hope to screen 5,000. That is 5,000 out of so many thousands. If we are talking about 8% of the population aged 60 and above, we are talking somewhere in the region of about 200,000. The other point is about Medisave and she said that she would be surprised that GPs would only treat geriatric patients if they can claim from Medisave. I did not say that. What I said was, if you want to encourage the GPs to practise preventive health care, in other words, to change their style of practice, because preventive health care is time consuming and at the moment GPs are not interested in practising preventive health care, we should allow Medisave to be used for preventive health care.”
“With the objective of controlling and ameliorating the situation, my Ministry has a programme of checking the eye-sight of students. In fact, we have had a vision checking service for a long time at certain levels of primary and secondary schools. But since 1989, we have extended this service to annual vision checking and screening for all the school children at all the levels, both in primary and secondary schools. If a student is found to have defective vision, he or she would be referred to the Institute of Health for further eye testing. This is especially at the Primary 1 level. Students at other levels are referred to the optician for spectacles. I do not think we should be self-congratulatory, but, statistically speaking, if you check more and the children are found to have defective vision, then more are referred to the opticians, and, of course, more students would be wearing glasses. That is good for them. They should start wearing glasses early. But this is a problem. We recognise the problem. We have given guidelines to the Ministry of Education on the lighting and furniture requirements for classrooms, the selection of blackboards and the colour of chalk to be used, the print size, the colour of print and paper, and the texture of paper for the textbooks. We will work more closely with the Ministry of Education and the Public Works Department to ensure that the guidelines are followed. With that, I thank the Member for his concern. Dr Koh Lam Son: Point of clarification. Sir, I want to correct the Minister of State when she said I was not here yesterday. I was in fact here all the time yesterday, right behind her, listening to every word she said about preventive health care, and I still disagree with what she said.”
“In fact, health care services for the elderly will be one of the priorities that the Review Committee will be looking into. We would definitely look at the question of health care services for the elderly. 1.45 pm On the question of Medisave as an enabling condition for the general practitioners to see geriatric patients, I am a little bit disappointed. If the general practitioners do not want to see geriatric patients unless they are given the facilities of Medisave, I think this is not right. Medisave is really meant for hospitalisation. It is mainly for the hospitalisation needs of the elderly. Yet for general screening and periodic checkups by the GPs, Medisave is not really used for that purpose. Moving to the question of eye care programme, Mr Peh has spotted a rather common health problem among the Singapore school children. In fact, defective vision is the most common health problem among our school children. Statistics show that as the children progress in school, the prevalence of defective vision seems to get worse. I have some interesting figures here. In 1989, 12% of the Primary 1 students were found to have defective vision, 47% of the Primary 6 students had defective vision, and 54% at the Secondary 4 level had defective vision. The greatest majority of this is short-sightedness. Interestingly, 10% is long-sightedness, and the remainder is said to have "lazy eye". We do not know exactly what is the cause of short-sightedness. So I am not able to answer Mr Peh's point whether it is due to the environment or something in the genetic make-up of a certain proportion of the population. But we do know that myopia can be precipitated by prolonged close vision work such as reading and watching TV.”
“Dr Koh Lam Son unfortunately was not here yesterday when we discussed the health care services for the elderly as well as our discussion on preventive health care and health promotion. I disagree with him a bit about the lack of effort on the part of the Ministry to promote primary health care during the last few years. In fact, I would say that it was during the last few years that we saw the new generation of polyclinics being completed. We can see these very well constructed polyclinics in places like Jurong, Tampines and recently in Hougang. And within the next five years, by the year 1994, five more new polyclinics will be developed. If the 16 polyclinics are not enough, we are prepared to look into other areas where there is a need. We have also done quite a bit by way of health education and health promotion. Our Department of Training and Health Education produces quite a large number of pamphlets and we have also educational materials in the form of video tapes. GPs would be welcome to borrow them. They could be loaned free of charge. The pamphlets are given out free of charge and they could become excellent materials in the waiting rooms for the general practitioners' patients while they are waiting to see the doctors. Health screening for senior citizens has also started in our polyclinics. While the number we screened last year was 4,700, we aim to reach about 5,000 next year. I hope he would also appreciate the fact that health screening for our senior citizens is given completely free. If the senior citizens had gone to GPs, they have to pay a fee. But I do concede that we should try to do more in this area and make it an annual screening exercise to follow up on the elderly patients.”
“But the basic principle is to provide people with a choice. And for those who prefer and who can afford, we want to provide them with a choice.”
“Sir, with regard to Mr Choo's question on the problem of mental health among young children - I also read the article in this morning's papers - I would like to inform him that we also have child psychiatric services in our polyclinics and at the Institute of Health. On the problem of stress among young people and among adults, I think the population has to realise the importance of maintaining a rather balanced outlook on life and a balanced lifestyle. But I like to inform him that many of the parents like to bring their children with mild behavioral problems to see general practitioners. Our Ministry has already taken steps to include in the training of doctors, ie, for those who want to be family doctors, psychological medicine as part of the family medicine degree. So we are working on the situation. As regards Simei Hospital, it will be completed by the year 1995. I would ask the Member for Changi to be a bit more patient. In fact, the plans for the project are more or less finalised. We are waiting for approval of the more detailed plans for building. In 1995, his residents as well as residents in my constituency, which is in the Tampines area, would be enjoying a new hospital. In addition, we are reserving a piece of land next to the hospital for a second community hospital. Mr Lau asked whether more beds would be made available if there are no A class beds in the community hospital as this would free more space for the B2 and C patients. Whether there are enough B2 and C class beds available has to depend on the pattern of utilisation of hospital beds. We are prepared to review the bed complement after we know how the hospital operates. It is a new concept. We are willing to experiment. We are willing to try.”
“What is the Ministry of Health going to do about it? I am sure many parents are very concerned with this problem. And also, how is the Ministry of Health going to educate the parents so that they will not exert too much pressure on their children?”
“To combat this stigmatisation, a lot of public education on the different types of mental illnesses is called for. We have to appeal to people's understanding, sympathy and also their sense of community responsibility towards these mental patients. We do intend to mount a wide publicity exercise next year in connection with the opening of the new Woodbridge Hospital so that we can educate the public on the nature of the problem, and to emphasise specially on the treatability of a lot of the mental ill health problems. Unless people realise that this illness is treatable, they will continue to shun people with mental illness and people with mental illness will also lose hope. So we will emphasise the treatability of this problem. Another strategy to help the community accept mental patients and for mental patients not to feel too ashamed and therefore become late in seeking treatment, we have already instituted a system of community-based psychiatric health services. I am sure Mr Choo knows about the outpatient psychiatric clinics which we have started to run in the polyclinics. We also have community psychiatric nursing, ie, nurses from Woodbridge Hospital have been visiting patients at home and following them up. In fact, we are going to decentralise these psychiatric nursing services to all the polyclinics when we are ready. With this, I hope that he would rest assured that we are taking a close look at the problem and we are doing what we can. In fact, we all share his concern over the problem of mental ill health. Mr Choo Wee Khiang( In Mandarin): I would like to ask the Minister of State whether anything has been done for our children who are suffering from this psychiatric sickness as it is highlighted in the Chinese paper today.”
“The mortuary will be located at the basement level and will be away at the farthest distance from the blocks. We would appreciate it if Mr Teo would let his constituents know and ask them not to worry as we have taken due consideration of their concerns. View Road Hospital. The View Road Hospital has been catering for the rehabilitation of long-stay psychiatric patients. It also provides accommodation but under supervised care for some patients who are considered fit to be released for employment outside the hospital but who do not have any family members to look after them. So they go back to the hospital in the evening where they would sleep under some supervised care. The need for such kind of facilities will always continue. In the new Woodbridge Hospital, this kind of facilities would not be provided to any significant extent. It is likely that the View Road Hospital would be retained for some years. We will continue to upgrade it and enable it to discharge its functions properly. I share Mr Choo's concern over the plight of the mental patients and for the so-called large proportion of the population who suffer from some minor psychiatric illness. The figure that he referred to actually comes from a survey done in 1987 by the Singapore Association for Mental Health. No doubt the survey shows that about 18% of the population is said to be suffering from these minor symptoms but, in fact, only about 1% of the population actually suffers from psychosis, or the more serious mental illnesses. I recognise this problem of stigmatisation. Mental patients are not well-received by the community and sometimes not even understood and well-received by their own family members.”
“Our bed complement for the community hospital is actually not out of line with our general Government hospital bed complements. In fact, the proportion of subsidised wards would be slightly higher at the community hospital than compared to the Government and restructured hospitals. I come to the question of the Eastern General Hospital in Simei which was asked by Mr Teo Chong Tee. The new Eastern General Hospital is going to be a medium-sized hospital with about 800 beds. It will provide specialties of general medicine, general surgery, orthopaedic surgery, geriatric medicine, psychological medicine and rehabilitative medicine. The reason why we choose the site to be where it is for this Eastern General Hospital is its relatively central location and accessibility in relation to the HDB new towns of Tampines, Pasir Ris, Simei and Bedok. It is also very near to the MRT station and the Pan Island Expressway. So it is highly accessible. With the completion of this hospital, it will replace the existing Toa Payoh Hospital and also the Changi Hospital. Let me assure the Member that in planning for the location and the layout of the hospital grounds, we have taken great care not to inconvenience the residents of the nearby HDB blocks. In fact, we have taken more than sufficient care to ensure that there is a wide enough buffer area between the hospital and the nearest HDB blocks. We will be providing in excess of what the Planning Authority has required. The hospital will be facing in the north-south direction so the wards will be looking away from the HDB blocks nearby. We do understand of course that some residents are very concerned about the location of the mortuary.”
“Sir, first, on the question of the community hospital. The community hospital, as Mr Chandra Das pointed out, is indeed a low-cost hospital, catering to those cases which do not require the very intensive and high-powered level medical care. So the majority of the patients would be those who would be convalescing from recent illnesses or those who need only simple treatment, observation, assessment or rehabilitation. On the question of provision of different kinds of wards, you have to look at the profile of the patients who can afford different types of wards. In all the Government and restructured hospitals, we have a full range of wards from A to B1, B2 to C. These are to cater to the different abilities and the different preferences of the patients. It is true that the Ang Mo Kio Community Hospital would be run as a low-cost hospital. All the wards would be charged at cheaper rates than acute hospital wards. But there will always be some patients who would prefer and are able to pay for better accommodation and greater privacy. If we do not provide for this, we may end up with a situation where, for those who prefer and can afford to pay for better wards, they will be forced to stay in less well-furnished wards, in which case they will even be taking beds away from those people who can only afford the cheaper wards and who require Government subsidies to stay in them. The community hospital is a relatively new concept. In fact, it is meant not just for patients to transfer out from the acute hospitals to stay for convalescence. It is also to accept patients directly referred from the private sector who can be managed by their own GPs or specialists. There would always be a proportion of these patients who also would prefer to have a choice of better wards.”
“As I mentioned, within our hospital services, we have orthopaedic surgeons and rehabilitation physicians who can take care of cases of sports injuries. But for the recognition of the degree, I think Mr Choo should direct his inquiry to the relevant department.”
“I will reply very briefly to Mr Choo's concern over sports medicine. Sir, we cannot agree with Mr Choo more on the importance of sports, recreation and exercise as methods to promote healthy lifestyles. In fact, in all our public education programmes, we have stressed that we should keep fit, and therefore stay healthy. We also recognise that sports medicine, as a medical specialty, is a specialty in its own right. However, our Ministry does not have any department specially devoted to sports medicine. We have orthopaedic surgeons and rehabilitation physicians who specialise in the management and rehabilitation of patients with sports injuries. There is no sports medicine specialist in the Ministry. I believe Mr Choo is concerned about the recognition of the postgraduate degree for the purpose of appointment and promotion to a consultant within the civil service. Unfortunately, this is under the purview of the Public Service Division. Since we do not have any sports specialists in our midst, we have not taken this matter up with the PSD so far.”
“Sir, mental health care constitutes another distinct area of the work of the MOH. On the other hand, in our public health education programmes and in our publicity on healthy life-styles, we emphasise that people should have regular recreation, exercise regularly and control stress. So in that way, through public education, we hope the population will come to an awareness of the importance of mental good health. In that way, we will prevent mental ill health.”
“We will be deliberating on and implementing the various programmes to cater to the residential needs of the elderly sick.”
“For example, we are using a new type of surgical dressing material which needs only to be changed once every three to four days instead of every day. We are using a new type of urinary catheter which is changed every third week instead of weekly. But the point is - I ask, and I make sure that this is the case - that whoever calls for home nursing care is not turned away. In fact, the very next day a nurse will go and visit him. In other words, we are meeting the demand that is there in the population. So that is the important point when you look at this set of figures. We will continue to work with the Home Nursing Foundation to strengthen this very important health service for the elderly. The public also knows about the rehabilitation, health screening and health education services available in the Senior Citizens' Health Care Centres. I have touched on the geriatric departments already. Let me just inform the House that we are also trying very hard to train doctors in geriatric medicine. Since 1983, we have sent seven doctors and 10 nurses overseas. We have also introduced post-basic training in geriatric nursing for the nurses. So, Mr Yeo's concern about geriatric medicine and geriatric wards has been addressed in this way. What he may also be concerned about is the problem of the chronic sick. A lot of the elderly are also chronic sick patients. Right now, there is a Chronic Sick Unit with 117 beds at the Woodbridge Hospital. In the new Woodbridge Hospital, there will be about 200 such beds. As for residential care for the elderly sick, my Ministry and the Ministry of Community Development are working very closely together to follow up on the recommendations of the Advisory Council on the Agedand the Family. We are forming a policy committee.”
“We would also be having another such unit in the Eastern General Hospital with about 100 geriatric beds. So when you look at the figures, they may seem a bit small. But my point is that the geriatric patients need not be managed only in geriatric wards. Taking care of the health care needs of the elderly requires a full range of services. My Ministry has in fact put in place the essential elements of all these care facilities. For example, home nursing. Home nursing care has been an on-going programme since 1976 when the Home Nursing Foundation was established. My Ministry contributes heavily towards the services provided by this Foundation. We provide the doctors, we provide 38 nurses and a clerk. We also provide the premises within our Senior Citizens' Health Care Centres in the polyclinics for the Home Nursing Foundation. So, home nursing care has reached out to thousands of patients each year. A couple of years back, I had noted that the number of home visits by our nurses from the Home Nursing Foundation had been declining, and I had raised some questions on this matter during one of the debates. This time it was brought up again by Prof. Maurice Choo. The number of home nursing visits to the elderly peaked in 1985 with about 46,700 home visits. This number of visits has gradually declined to about 29,000 last year. But behind this figure is the fact that the number of patients taken care of by the home nursing service has actually gone up, which means that the number of visits per patient has gone down. This has been made possible, I was told by my Ministry officials, because now, certain new methods of changing dressing for the patients have been adopted.”
“Although at the moment the proportion of the elderly in Singapore is still relatively small as compared to many developed countries: the proportion of the population over 60 is just about 8%, this percentage will increase to about 11% by the year 2000 and by the year 2030 it will increase to 26%. Mr Yeo's plea is for more residential care facilities for the aged. I think he has a point there. Our senior citizens have done their bit, contributing to the economy, taking care of the families and when they reach a ripe old age, there should be enough facilities to take care of their needs. But I would like to clarify one point. The health facilities for the elderly should not just stop at residential care or institutional care. In fact, we should aim at providing a full range of facilities for the elderly. What I think Mr Yeo meant by emphasising geriatric units was probably a bit too narrowly focused. He probably thought that it is only by providing geriatric wards in hospitals that you can take care of the health needs of the elderly. It is not true. Geriatric units in hospitals are highly specialised wards. The management of geriatric patients actually requires a team of specialists. So in hospitals the geriatric ward might be a small specialised ward, but where a multi-disciplinary approach is needed in the treatment of the patients. This does not mean that the elderly sick patients are not taken care of in the other general wards. They may be in the medical wards, they may be in the surgical wards. So, depending on their condition, they need not be taken care of in a geriatric unit in a hospital. For geriatric medicine, we have started a new department of Geriatric Medicine in Tan Tock Seng Hospital with 70 beds.”
“For health promotion, I would like to take this opportunity to clarify one point raised by Prof. Maurice Choo during his speech at the debate on the Budget statement. He quoted some figures on the amount of money we spent on training and health education. He quoted a per capita expenditure of $2.60 in 1990 and this increased only to $2.73 for this financial year 1991. I would like to clarify a bit. Actually the figure that he quoted for 1990 has been revised because now we know how much we have spent. It is revised upwards to $2.81. For 1991, we are now providing for more, $3.65. So the total amount is $9.9 million for financial year 1991. Nobody can say that this amount on health education alone is a small amount. You also have to look at the nataure of health education. Yes, you can spend lots and lots of money on it, but the idea is that you have to keep it up constantly. It is not just spending on big campaigns every year or every other year, but you must maintain the momentum and the message must be put across to the population. For primary health and preventive health care, our message must be that prevention is better than cure. Dr Hong Hai has put it more graphically. He used the analogy of the car and the plumbing system. It is better to maintain existing parts than have spare parts ready. The idea is that prevention is better than cure. So the message is this: we must take our health in our own hands and be responsible for it. Let me turn to health care services for the elderly and Mr Yeo Toon Chia's concern. Mr Yeo is very concerned about the provision of residential care and nursing care for the elderly. I too share his concern. The figures stare us in the face. The proportion of the elderly population is increasing.”
“We have a plan to gradually close down the older ones so that eventually we have a network of 16 polyclinics. As you have seen, some of them are brand new with excellent facilities. These 16 polyclinics will be quite evenly distributed throughout the island. They will be easily accessible to the population and, as I said, they have a full range of primary health services. 3.30 pm I do not agree with Dr Vasoo that the rate of growth of these polyclinics has not kept up with the rate of growth of the population. We must remember that the services provided by the polyclinics are actually complementary to the services provided by the general practitioners in the private sector. In fact, the general practitioners cater to about 70% of the population, whereas our OPDs cater to 30%. So between the two sectors, we have to strike a fine balance. We aim to be accessible and we provide very cheap and sometimes even free services to the lower income groups. Again, I do not entirely agree with Dr Vasoo's point of view that we have not been devoting more resources to our primary health care programme. He quoted the figure that over the last 10 years between 10% and 14% of the MOH recurrent budget has been devoted to primary health care. But if he looks at the figures more carefully, he will see that our expenditure has actually increased tremendously since 1986. In 1986, we spent $40 million on the primary health division, which represented about 11% of the whole Ministry's recurrent budget. But in 1991 this budget has increased to $73 million or 14% of our budget. In other words, it is not spread out evenly throughout the 10 years. In the last five years, we really concentrated on developing our primary health care services.”
“This year we will be conducting a smoking control programme and a campaign to encourage our people to be physically active and to adopt good dietary habits. The other prong of preventive health services is immunisation. I am happy to report that we have achieved a very high successful rate of immunisation, particularly of infants against common childhood infectious diseases. In fact, we have eradicated diphtheria and polio, and the number of children coming down with measles has dropped to less than 200 per year. Immunisation programmes are given free and we have been able to cover more than 90% of the babies born here. We have also introduced health screening programmes. Health screening, as you all realise, will help to detect illnesses and abnormalities early so that early treatment can be given and in the course of it, health care costs, especially to the patient, would be brought down. We have introduced screening of new born babies for congenital abnormalities and also for pre-school children for developmental delays. All the school children in our schools receive a full medical examination in Primary 1, Primary 6 and Secondary 4 levels. For adults, we have also introduced coronary risk screening as well as general health screening. We have special programmes for women and for the elderly. The health screening services for the elderly are provided free. Polyclinics. Polyclinics provide outpatient treatment for illnesses. We realise that some of the polyclinics are getting run down. But I think Dr Vasoo has to view these older polyclinics against the fact that they have been there for a number of years and that they used to serve the rural population areas. Now, with the shifts in population, the older polyclinics have to be closed down.”
“Sir, I would like to address the question on primary health care and preventive health care services. As Dr Hong Hai, Dr Vasoo and Dr Wong Kwei Cheong have pointed out, and I agree completely with them, these services should constitute one of the main thrusts of the work of the Ministry, because primary health care and preventive health care are not only the first line of defence against illness, they are also very effective strategies in fighting the rising health care costs. Let me deal with the question of primary health care and preventive health care by outlining to Members of the House very briefly the whole range of services and programmes that we have in order to impress upon the Members of this House that in fact my Ministry has continued to place a very great emphasis on these two areas of services. What is preventive health care? It constitutes health education, it constitutes immunisation services and also health screening programmes. We have throughout these years placed a great deal of emphasis on health education. We really want to achieve through health education programmes a change in Singaporeans' perception of depending on doctors to deal with the problems of their illness, and to depend on doctors to provide for medical care, to one which is an attitude where each individual realises that his health is in his own hands, and therefore he should be responsible for his own health. So our health education messages have always stressed healthy lifestyles, such as eating nutritious food, exercising regularly, controlling stress and no smoking. For the information of Dr Vasoo, last year, we carried out a four-month programme on prevention and early detection of cancer.”
“Mr Speaker, Sir, at the moment, there are no plans to expand these two wards yet. The occupancy rates for all classes of beds at SGH are quite full. INTRODUCTION OF UNLEADED PETROLS (Statement by the Minister for the Environment) 12.50 pm”