Khaw Boon Wan
Singapore
“Motor vehicle dealerships and showrooms have been closed since the start of the circuit breaker. As COE bidding is done mostly by the motor vehicle dealers on behalf of prospective owners, the Land Transport Authority (LTA) suspended COE bidding for the months of April and May.”
“Though stressed by the financial pain, they press on with the immediate priority of fighting the virus and supporting essential services. Post-pandemic, we will see how public transport evolves. Will demand for public transport services simply return to the pre-pandemic level?”
“Under our rail financing framework, the Government fully pays for the cost of building new rail lines. In other words, we do not recover the cost of building the Cross Island Line (CRL) from commuters through fares. The CRL project is being implemented and the final costs will depend on tender bids.”
“There are around 5,000 private bus operators with a combined fleet of 13,500 private buses. As we do not track the number of private bus trips and passengers, we do not have data on their carbon emissions.”
“There are nursing rooms at 50% of our bus interchanges. We will provide nursing rooms at all new bus interchanges and integrated transport hubs. For the MRT network, we will provide nursing rooms at all new interchange stations. We will also explore providing such facilities when MRT stations undergo upgrading.”
“Over the last three years, Singapore carriers have reported a total of 20 incidents of food allergies on board their flights. None required the use of epinephrine or emergency flight diversions.”
The complete record
Every one of 2,685 lines we hold for Khaw Boon Wan, in date order, each linked to its source. Free to read, in full, without an account. Page 47 of 54.
“The observations by some Japanese doctors have been rather intriguing and global attention is on it now. One of the key tools in our toolbox against a possible flu pandemic is Tamiflu and all of us, like many other countries, are stocking up Tamiflu and if Tamiflu turns out to be a killer, in this case for children, it will be troublesome. The global attention is now on this observation. TheUS FDA has been studying it and will continue its study. Right now, in Singapore, I can only say that we have not received any such adverse reports. As far as I know, for the Tamifluused in Singapore, we have only received two adverse reports and those are the traditional ones, like vomiting, nausea,but not on this particular observation by some Japanese doctors that there were hallucinations leading to suicides by children. Like all things, we have to see what is the cause and effect. If it is correlated because of some other reasons causing those deaths, that may be so. We are watching and in consultation with the US FDA and they have not banned this product or asked that it be withdrawn. We stand by those judgments by the experts. Column No : 1781 AVIAN FLU (Monitoring of migratory birds) 2. Mdm Halimah Yacob asked the Minister for National Development (a) what measures are in place to monitor the migratory birds that land in Singapore, to ensure that they are free from the avian flu; (b) what has been done to prevent these birds from infecting other birds in Singapore; and (c) whether the birds that are commonly found in Singapore, such as crows and mynahs, which live in close proximity to people, are safe.”
“That is the problem of producing vaccines. I have been studying this problem for quite some time because, if indeed there is a flu pandemic, I see as one of our key weaknesses, not only in Singapore but in many countries, a lack of domestic production capability for vaccines. But it is related to the economics of it. Unless it is a viable proposition, who wants to sink hundreds of millions of dollars building vaccine factories. But we may find it strategic to want to support some local production capability. This is one big headache which I am studying very closely now.”
“I have not seen scientific studies of human vaccines being able to protect against a new mutated virus, because how do you prove it. The virus has yet to appear and it remainsa hypothesis that this vaccine will protect againstsomething which you do not know how it will look like andhas yet to be seen. In healthcare, we have to go with evidence. Without any scientific evidence, I cannot make anyassessment one way or the other. There may be speculation for various personal reasons such as wanting to up the sale of vaccines. At the population level, let us stick to the best practice and it is still human influenza vaccine only for the high- risk groups and bear in mind that, even then, it is only protection against the current strain of human influenza and it is not 100% effective. There have been studies which show that for adults taking the human influenza vaccine, protection may, at best, be 70-80%. So there are stillpeople who are down with influenza, let alone an unknown bird flu. Whether we should stock up the vaccines, I think,is related to the first reply. If you are not sure of its efficacy and you stock up, then you may be just holding on to a stock which is useless. In fact, that underlines the great difficulty of vaccine suppliers. I have been studying the economics of vaccine production. Why is it that over the last 10-15 years, the number of vaccine producers has kept on shrinking? There are only a few suppliers in the world left because it is bad business. They have to stock up. They produce certain vaccines and every six months WHO issues new updates and so their vaccines may expire. If they overstock, they lose money, and if they understock, like now, the whole world is against them and asking why they did not stock up more.”
“Sir, there is a temporary global shortage of human influenza vaccines. This is partly because, just like Singaporeans, many people in the West and other countries were mistaken that this vaccination will protect against bird flu which is now endemic among the poultry and birds. So there is a run on the vaccines which caused a temporary shortage. Members will recall that last year there were some production problems of one major vaccine supplier in UK. So several factors have compounded it. For Singapore, our annual demand for human influenza vaccine is not big. I have looked at the data and last year, we consumed something like 200,000-odd doses. This year alone, we have used up 210,000 doses. But additional supplies have been coming in progressively. Another 40,000 doses will be coming in soon and they are coming in by batches. Somebody sent me an email to say that a particular polyclinic ran out of the vaccine but a few days later, after I responded to him, he said that he was able to get it. My message remains the same: it is only for the high risk group. If everybody goes and chases for the vaccine, it will be like a run on a bank. If you belong to the high risk group, by all means, have the vaccination and, if it is recommended by GPs, I am sure they will ration accordingly. For the rest of the people, just stick to basic principles - keep a high standard of personal hygiene and stay away from live birds.”
“For those visiting countries affected by avian influenza, their best protection is to avoid contact with live poultry and avoid handling or eating undercooked poultry and eggs. And of course, keep a high standard of personal hygiene, including frequent and thorough hand-washing. Mdm Phua asked for data on the number of Singaporeans who have received travel-related influenza vaccination. We do not keep track of such data. However, so far this year, our public hospitals have vaccinated some 400 young children and 4,000 elderly. Many more may have done so in the private clinics.”
“Mr Speaker, Sir,first, letme explain that avian influenza is caused by an avian virus, of which H5N1 is one such strain which is currently endemic among birds and poultry in many parts of the world. In Asia, H5N1 has been found to jump from chickens to human in a number of cases, but fortunately transmission remains inefficient. The risk is that H5N1 may mutate to become a human virus with far greater transmission capability among human beings, causing a global influenza pandemic. At any one time, there are several predominant circulating strains of human influenza viruses. These are quite different from avian viruses, like H5N1. Fortunately, human influenza is usually a self-limiting illness. But serious complications may occur in certain high risk groups, like the elderly or those with chronic heart and lung diseases. There are vaccines for human influenza. But because human influenza viruses constantly undergo minor genetic changes, WHO issues regular updates on the prevailing dominant strains in the northern or southern hemispheres. Based on these updates, vaccine producers will formulate influenza vaccines which are deemed to have the best chance of protection against the prevailing strains. These updates are made every six months. Following each WHO update, my Ministry would use the opportunity to issue advisories recommending influenza vaccination for the high-risk groups. Young and healthy persons visiting temperate countries during the winter season are not in the high-risk group, but if they wish, they may receive influenza vaccination to reduce the risk of getting infected. Let me stress that current influenza vaccine does not protect against the avian influenza virus.”
“Emergency Departments are for the seriously ill. All such patients are attended to promptly upon arrival. There is not much waiting for such patients. Other patients should consult their regular Family Physicians. However, if they prefer to visit hospital Emergency Departments, they will have to wait their turns. And when the hospitals are particularly busy, their waiting time may be long. I have previously explained to this House why TTSH Emergency Department was unusually busy. They have since taken various measures to ease the over-crowding and the situation is now better. Mr Steve Chia suggests that we find a way to let patients and emergency ambulance service know real-time the prevailing state of activity level at the emergency departments. Technically, we can provide such information on the hospital websites and have it updated frequently. Presumably, this will help patients and the ambulance crew decide which hospitals to go to. But I doubt this is useful to patients, for in an emergency, nobody is going to have the time to check into a website. Their first thought must be to jump into a car or a taxi to bring them to the nearest hospital. As for the emergency ambulance service, their current dispatch system is based on geographical zone. The patient is sent to the nearest approved hospital with an A&E department as this is in the patient's interest. FOG LIGHTS ON VEHICLES (Policy) 25. Mr Arthur Fong asked the Minister for Transport (a) what is the policy on the use of fog lights fitted at the rear of some passenger vehicles; and (b) are the authorities concerned that the improper use of fog lights in clear weather results in distracting the motorists following behind, causing them to misjudge their braking distances or to brake unnecessarily.”
“Sir, while $5,300 is not insignificant, certainly it is not sufficient. As I said, it is way below the Medisave Minimum Sum of $27,500. But $5,000 is still $5,000. It can buy, in the case of elderly, 17 years of MediShield premiums. But my main point is this. In funding our healthcare system, we go for multiple sources of funds - with the elderly, their own savings in Medisave, their other savings outside of Medisave and, very crucially, I hope they have good children. Their children will support them. Of course, if nothing else, we have the safety net in the form of Medifund. MANUFACTURING OUTPUT AND JOBS 15. Dr Amy Khor Lean Suan asked the Minister for Trade and Industry (a) what specific strategies will his Ministry adopt in order to double its manufacturing output to $300 billion by 2018, and create more than 20,000 new jobs at the same time, while facing stiff competition from China and India; and (b) how many of these jobs are estimated to be filled by locals.”
“Secondly, Sir, is the $5,000 sufficient, in the Minister's assessment, to cover specialist outpatient treatment as well as other treatments where Medisave is allowed to be used?”
“Singaporeans who are above 65 have an average Medisave balance of $5,300, which is also not insignificant. It is enough to cover 17 years of MediShield premiums, or five average Class C hospitalisations for the elderly. But it is way below the Medisave Minimum Sum of $27,500. This is partly because Medisave was introduced only in 1984 and the present cohort of elderly Singaporeans did not have enough time to build up their Medisave balances. I think future generations of such elderly Singaporeans would fare better. Meanwhile, the Government has helped to top up their Medisave accounts whenever the budget allows it. Over the past 10 years, the Government has made six rounds of Medisave top-ups, totalling $1.32 billion. On each occasion, the Government gave the elderly more Medisave top-up than it did the rest. The most recent top-up was made in July this year, specifically to help Singaporeans cope with the increase in MediShield premiums. In any case, elderly Singaporeans are not helpless. Many have means of support, either from their own savings or from their families'. For example, 60% of the elderly have their medical bills paid from their children's Medisave accounts. In addition, we have Medifund to help those who are unable to pay for their hospital bills despite heavy Government subsidies, Medisave and MediShield. As Members are aware, we are progressively building up Medifund to $2 billion. Mdm Halimah Yacob: Sir, the Minister said that for those above 65 years of age, the $5,000 savings that they have in their Medisave accounts will cover 17 years of MediShield premiums. Now that MediShield has been extended to cover up to the age of 85, there is obviously a shortfall.”
“Mdm Halimah asked if the Government could help the self-employed and the low-income Singaporeans build up their Medisave balances. The two groups are not identical, so the approach will have to be different. First, the self-employed. They must first help themselves by contributing regularly to their Medisave Accounts, like all other economically active Singaporeans. Not all do. In fact, less than half (43%) of the self-employed have paid their Medisave contributions in full. As a result, the Medisave balances of the self-employed are less than those of salaried employees. For example, for the 55-59 age group, the self-employed's Medisave balance averaged $12,500, much less than the salaried employees' equivalent of $21,500 - $12,500 versus $21,500. We should all encourage the self-employed to save regularly for their future medical needs. That is why the CPF Board has to strongly remind the self-employed to contribute to their Medisave accounts. As for the low-income Singaporeans, the advantage of our Medisave Scheme is that even low-income workers can, over time, save up sizeable Medisave balances. The data confirms this. For example, for workers earning less than $1,000 a month, their average Medisave balance today is $10,400, which is not a small sum. It could cover more than 10 average Class C hospitalisations. In addition, the Government will continue to top up the Medisave Accounts of Singaporeans, whenever the budget allows for it. Meanwhile, the safety net of Medifund will also be there to help those who are unable to pay for their hospital bills despite heavy Government subsidies, Medisave and MediShield.”
“Experimental treatments are essentially unproven treatments and are usually part of a clinical trial to see if the treatment works. Many of the experimental treatments use drugs that are not on the Standard Drug List. For this reason, non-standard drugs are not automatically subsidised, but are subject to review. The Drug Advisory Committee (DAC) is an expert committee which periodically reviews new drugs and recommends effective drugs for inclusion in the Standard Drug List. The last review was done in 2002 and the next review would be in 2007. However, there may be cases where patients need drugs that are not on the Standard Drug List. MOH has given a budget to the hospitals to help cover the cost of non-standard drugs that are considered necessary in specific cases. The decisions on when to use which drug is left to the oncologist. Cancer is best managed at a level closest to the patient, that is, based on the professional judgement of the attending doctor. The doctor has a responsibility to ensure that the therapy he prescribes is clinically effective in treating the patient and that his care of the patient meets the standards set by his peers. 2005 ADMISSION FOR NTU AND NUS 40. Assoc. Prof. Ong Soh Khim asked the Minister for Education for the 2005 intake for the Nanyang Technological University and National University of Singapore, (i) how many of the 850 students who entered life science courses in 2005, (ii) how many of the 4,400 students who entered engineering courses, and (iii) how many of the students who entered Medicine and Dentistry, are in the top 5% and top 10% of the admission cohort.”
“Mr Chiam has asked why chemotherapy drugs are not subsidised in the C class wards. Let me state at the onset that chemotherapy drugs are subsidised in the C class wards just as they are in the other subsidised wards and that the same chemotherapy drugs are used in the treatment of C class patients as B class patients. Cancer is of concern to Singaporeans. This is not surprising as it is the leading cause of death in Singapore, accounting for 27% of deaths in 2004. The Ministry of Health has been working to alleviate the burden that cancer places on its patients. Our efforts have contributed to a decrease in the number of premature deaths from cancer, from 124 deaths per 100,000 population, aged 35-64 years in 1997, to 119 deaths per 100,000 population in 2004. Our public hospitals provide high quality subsidised treatment for B2 and C class patients. Specifically for chemotherapy, my Ministry subsidises a total of 30 chemotherapy drugs, comprising essential first-line drugs and some alternatives. Most patients can be treated with these first-line drugs with good results. The drugs include Doxorubicin, Cyclophosphamide, Carboplatin and Fluorouracil. These drugs are available to all subsidised patients at heavily subsidised rates. Sometimes cancer recurs after standard treatment has been given. Often experimental treatments are then tried. Within the international community of oncologists, and even within our own domestic community, there are many different opinions on what treatment strategies are "effective" after the standard treatment has been given. For example, the experimental treatment available at the Mayo Clinic, the MD Anderson Cancer Centre at the University of Texas and at our public hospitals may not be the same.”
“The short answer is yes, but we are market-driven too because we can encourage and promote the courses but there must be takers. But, fortunately, for every cohort of three hundred over students, there will be some who have an interest in different areas. In fact, we have just doubled the intake for infectious diseases and hope that the trend will continue. RELATIONS WITH MALAYSIA AND INDONESIA (Update) 5. Dr Tan Cheng Bock asked the Minister for Foreign Affairs whether he can provide an update on bilateral relations with Malaysia. 6. Ms Irene Ng Phek Hoong asked the Minister for Foreign Affairs whether he can provide an update on the status of the discussions with Malaysia on the proposed bridge to replace the Causeway, in the light of reports in the Malaysian media that Malaysia has decided to go ahead with its construction. 7. Dr Warren Lee asked the Minister for Foreign Affairs if he could provide an update on bilateral relations with Malaysia and Indonesia.”
“First, a correction. When I said 25%, I was talking about anti-virals, not vaccine, because there is no vaccine yet because we do not know what kind of creature we will be fighting. So we are talking about anti-virals and, in any case, there is no need for anti-viral for the entire population; vaccine, yes. For vaccine, you must reach out to the entire population but anti-viral is only temporary prophylaxis. But you need to cover a critical mass of population, but it is not feasible nor desirable to have anti-viral for the entire population. In our pandemic flu plan on the website, there is a significant section on business and companies; how they should react, and some simple advisories. But, really, companies among themselves have to think it through, and I read a similar report where they found that many companies are still not geared up. My advice is for them today to check into MOH website, study the few hundred pages on flu pandemic plan and think through what are the steps that you should be preparing yourselves for.”
“Fortunately, when we look at influenza virus, it is still largely droplets-based. It may be more infective than SARS but it is still droplets-based. And being droplets-based, what it means is common public health personal hygiene practices go a long way.”
“On Dr Geh Min's question on Singapore being a regional centre for infectious disease, I presume she meant a regional scientific centre, not an incubator of infectious disease or a treatment centre for infectious disease. Certainly, particularly as we are in the tropics where infectious diseases are common. Do we have special expertise? Yes and no. I think this requires international effort. If you look at SARS when it happened, the whole international scientific community responded to it and therefore within weeks, the whole genome was mapped out. So the same thing is likely to happen for the flu pandemic. Increasingly, this is global business and we certainly should be an active player. Can we be THE player? I doubt it very much because you cannot beat, first, the billions of dollars of NIH funds in US or the number of scientific expertise there. But, in Singapore, we are building up our Biopolis and we have a life science interest and certainly we ought to be a player in this game. What lessons we learned from SARS? Many, many lessons were learned. We did something right, we did many things which, on hindsight, we could have done it better, and we have responded to the deficiencies. Some of the capacities were inadequate, isolation rooms were inadequate which we have built up over the last two to three years, and we continue to build up. But I think a lesson from SARS is to take a commonsensical approach because the next outbreak we can have all kinds of scenario planning, it will turn out quite different from what the scenario planners would like it to be. So there are bound to be surprises, but take a commonsensical approach. We have to understand whether the virus is airborne, droplets-based or what? How infectious is it?”
“Yellow is when the first imported human case appears in Singapore. That will be yellow. And then you have the other colour codes, ending up with a very dark scenario of black. Black is when the outbreak gets out of hand and then there is huge trouble. As for resistance to Tamiflu, these findings are not surprises because viruses are not stupid, just like dengue mosquitoes or dengue virus. They mutate, they change, and they will react and, in due course, there will be resistance to Tamiflu. There are some recent studies where laboratory testings show its resistance. It may or may not be. It will take some time and therefore part of our flu pandemic plan includes testing out other anti-virals like Relenza which Dr Lily Neo mentioned. In fact, the plan is when we stockpile Tamiflu, we will also stockpile some Relenza, so that we have some diversification.”
“Sir, I agree with Dr Lily Neo that prevention is better than cure. So, likewise, with the flu pandemic, if we can prevent it so much the better. In the case of Singapore, because we do not have a significant agricultural sector, the risk of a flu pandemic emerging from here is very small. Therefore, the likelihood of a cluster appearing somewhere will probably be in the region outside of Singapore. If we can have what people call forward defence - push the boundary, push our border as far as possible - so we have some interest in helping our neighbours to, if we can help it, prevent a cluster from happening or when it happens, quickly isolate and ringfence the cluster. At some stage if there were to be a flu pandemic, a human cluster will emerge. So on a theoretical basis, if within the first 36, 48 or 72 hours this cluster is identified, we have a rapid medical team to move in, isolate, inject Tamiflu, cull the animals, and so on, it is possible to prevent this from spreading. But the first 36 or 72 hours are crucial. For that to happen, we need two ingredients: one, the moment suspicious incidents like that happen, somebody will blow the whistle; two, you have a rapid response force - doctors, scientists, together with the anti-virals that can be brought to the cluster zone. Both have to be in place for this to happen and much of the international preventive efforts are driving in that direction. Let us try to create this outcome. It is not easy, but I think we should try. The second point is about what will trigger our reaction within Singapore. As I said, there is a DORS system and in the case of flu pandemic, we have colour coded it. We are right now in colour green, meaning there is no efficient man-to-man transmission yet. The next colour code will be yellow.”
“Along the way, we can teach each other, learn from each other and hopefully we can avoid this, if nothing else can postpone this, for as long as possible.”
“We have a certain target to work towards, which is enough Tamiflu for one quarter of the population, which means one million courses. We are building it up progressively. We started quite early, so that was helpful. As first mover, we have some advantage here. We have built up to quite a significant proportion. Probably by sometime next year, we should build up to this targeted one quarter of the population's requirement. The third point is on international cooperation - this is crucial. I think every country has been developing its internal response plan. My main criticism has always been that while those activities are useful and important, I think not enough attention is being paid upstream. The pandemic will be so disastrous that I think if we can avoid it, so much the better. And to avoid it, one really should go upstream. And, here, international cooperation is key. So I am quite glad President Bush called for an International Partnership when he addressed United Nations recently. Last week, you see his Health Secretary spending a couple of weeks in this region on areas which have such outbreak of H5N1 already happening, and we hope such activities will continue. There are various forums now within ASEAN, within APEC, within ASEM. It reminded me of the Y2K crisis. Remember Y2K? It is not biological, but it is a millennium bug. But I think by thinking about it, and thinking through what are the steps that one can do to cooperate with each other and within limits, we can avoid a calamity and a whole industry of Y2K experts were built up. And now in this case, we hope that a whole industry of flu pandemic experts will also be built up.”
“On flu vaccination, I think let us be clear. There is the usual seasonal winter flu and, of course, there is this dreaded flu pandemic which we will not know yet what exactly will be the virus and what form it will take. For seasonal flu, the advice has always been to apply only for the high-risk group. We are in the tropics and, quite unlike US, when winter comes, the elderly there would be advised to take a flu jab - voluntary, not compulsory - but that is the advisory. They leave it to the people to decide. In the case of Singapore, there is really not much need unless you are in the high-risk group. The high-risk group is defined as those who are doctors or healthcare workers who have to work with patients who are likely to have flu. So this is one category of the flu vaccine which varies with each season. WHO gives advice regularly, twice a year, on what is the latest cocktail of flu jabs to take. But specific to flu pandemic, it depends on what particular virus strain will crop up. It may evolve from the H5N1, nobody knows. But if it does, the effort would be towards that direction. Currently, there is no such vaccine because we do not know yet what exactly this particular mutant will look like, but there are a lot of research efforts going in this direction. We ourselves are helping in some research efforts with our Australian partner and, hopefully, some results can show in due course. As for Tamiflu, there is now a worldwide shortage especially now that the H5N1 has been found in Europe. You can expect a huge demand and it will grow but, unfortunately, there is only one supplier, so there is a global shortage. And every country has been advised to do some stockpile. We do.”
“Briefly, this framework comprises (a) an effective surveillance system and (b) a rapid response system. Our surveillance system has external and internal components. External surveillance continuously scans foreign and international news and health websites and information exchange networks on infectious diseases. Our internal surveillance comprises continuous evaluation of atypical pneumonia cases, laboratory surveillance of influenza viruses and through the implementation of new IT systems to rapidly capture, analyse and monitor cases of infectious diseases of concern. Under this DORS framework, my Ministry will mount a rapid response to major disease outbreaks by mobilising teams to investigate the outbreak, analyse epidemiological findings and then contain the outbreak as quickly as possible through appropriate control measures such as contact tracing and quarantine, treatment or vaccination. Fifth, we regularly exercise our plans. This is important to ensure that the players know what to do if and when a real crisis happens. It also allows us to learn from the exercises to refine our plans. Finally, we must involve all Singaporeans in our preventive and response strategy. What can Singaporeans do? When there is a specific outbreak, we will seek specific actions from the people. But, meanwhile, I think Singaporeans can do a lot on the preventive front: aim for a much higher standard of personal and public hygiene. Let us get back to basics. Do not spread germs: so do not spit, wear masks when unwell, do not touch your face unnecessarily, wash hands thoroughly and often, keep public toilets clean and dry and please do not litter. Simple acts like these can go a long way to minimising the spread of infectious diseases.”
“The Committee is supported by an Executive Group comprising Permanent Secretaries and chiefs of key Government agencies. My Permanent Secretary heads the Crisis Management Group for Health which reports to the Executive Group. This command and control structure is to ensure a coordinated Government response to any major health threat. It was tested during SARS and further refined after that crisis. Second, we have formulated various outbreak scenarios and planned our specific response strategies. This exercise can never be exhaustive but by thinking through them, we develop useful insights into our strengths and our weaknesses. We can then try to enhance our capabilities. The response strategy to each disease outbreak would depend on the nature of the disease - how it is transmitted, availability of diagnostic tests and whether there are treatments or vaccines. Mdm Halimah asked specifically about our flu pandemic preparedness and response plan. We have just recently reviewed and refined it further. It is now published on our website, both to inform as well as to consult. It is based on what we know about past pandemics, nature of the flu virus, and availability of drug treatments and vaccines. We will continue to review and strengthen the pandemic plan. Third, we have learnt extensively from the SARS experience and have significantly strengthened our capabilities and capacity. In particular, we have augmented our surveillance and response systems, operational and emergency preparedness capabilities. This has been done through increasing manpower and other resources such as isolation facilities in hospitals. Fourth, we have constituted our various response strategies into what is called a DORS, Disease Outbreak Response System.”
“Global and regional epidemics are immense challenges. The world had a taste of such challenges during SARS. Past flu pandemics also provided valuable lessons. The current bird flu outbreak may trigger the next global flu pandemic. Mdm Halimah asked about the likelihood of it happening. The World Health Organisation (WHO) has warned repeatedly that it is not a question of whether it will happen but when it will happen. However, no one knows when that time will be. What is certain is that a major disease outbreak such as a flu pandemic will be very costly in terms of human lives as well as economic losses. International cooperation is the key to avoiding such calamities, or when they occur, to minimise the damage. That is why we maintain very strong links with health authorities in other countries and with key international health agencies such as the WHO and the US CDC. This facilitates the rapid exchange of critical information and expertise and will help us better prepare ourselves or deal with any outbreaks. With globalisation and jet travel, we are all vulnerable to global epidemics and must collaborate with one another to manage any outbreak. Domestically, we are progressively gearing up for such major outbreaks. Preparations can never be complete as it is not possible to know the nature or the extent of the next outbreak. With more funds and resources, we can certainly do more. But the major pieces are in place. Let me just briefly outline what those pieces are. First, we have established the organisational structure to deal with such crises. There is a Ministerial Committee chaired by the Deputy Prime Minister and Minister for Home Affairs. I am a member of that Committee.”
“Sir, with your permission, can I take Question Nos. 3 and 4 together, please?”
“As the notification of tuberculosis is compulsory, we no longer have to estimate its prevalence based on community surveys. Instead, we track and report its annual incidence rate. This is more precise in tracking the trend of the disease. In the last 10 years, the incidence rate among our young has continued to decline. See following Table. Table Tuberculosis Incidence Rates Among Singapore Residents Aged 0-19 Years Year Rate per 100,000 population 1995 6.4 1996 7.0 1997 8.9 1998 7.1 1999 7.7 2000 7.5 2001 6.3 2002 5.3 2003 4.7 2004 5.1 APPENDICES”
“This limit was set in 1995 and has been sufficient to cover the annual premiums for the basic MediShield package. Currently, the highest premium rate is $510 per year which is well within the Medisave withdrawal limit. The Medisave withdrawal limit, of course, is not permanent and will have to be raised if and when prevailing premiums exceed it. As I indicated in this House last month, my Ministry is reviewing the MediShield age cap. If we decide to raise it beyond 80, the premiums for the new age band may well exceed the current Medisave withdrawal limit. And, if so, it will be raised at the same time. PARENTHOOD PACKAGE (Assessment of effectiveness of schemes) 11. Dr Amy Khor Lean Suan asked the Minister for Community Development, Youth and Sports (a) whether he will provide an update on the take-up rates of the various schemes under the parenthood package introduced last year; (b) what is his Ministry's assessment of the effectiveness of these schemes; and (c) if any of these schemes will be further refined.”
“Mdm Ho Geok Choo wanted to know how needy Singaporeans could be assisted to remain covered by MediShield. As Members are aware, the MediShield was reformed last month so as to enhance its effectiveness as a catastrophic illness insurance plan. But let me first clarify that the amendment to section 13(1)(b) of the Central Provident Fund Act is not directly related to the MediShield reform. The amendment is merely to regularise an existing administrative practice whereby Singaporeans can withdraw their Medisave savings for medical treatments and approved insurance premiums, without having to first set aside the Medisave Minimum Sum. As for the reformed MediShield, almost all Singaporeans who work would have enough Medisave to pay for the premiums. For those who are not working, either permanently or temporarily, many can rely on their past Medisave savings. Some 150,000 Singaporeans are able to rely on their family members' Medisave savings to pay for their MediShield premiums. They form about 10% of all MediShield policyholders. In addition, from time to time, when the budget position allows it, the Government will top up Singaporeans' Medisave accounts. Just last month, the Government transferred some $320 million into Singaporeans' Medisave accounts. This will help Singaporeans pay their MediShield premiums. The largest top-ups, at $350 per account, went to Singaporeans above the age of 60. For the minority without adequate Medisave savings or family support, the additional safety net is the Medifund. We have, over the years, built up the principal sum to $1.1 billion. We will increase it to $2 billion eventually. Mdm Ho also asked about the rationale for setting the Medisave withdrawal limit at $660 for the annual MediShield premiums.”
“I suppose better coordination is something we can take a look. But having spent many years in healthcare now, a layman's understanding of what is emergency is difficult to explain. You can always try to educate. I think to educate Singaporeans to detect suspicious parcels is a lot easier. Once you are sick with fever, everything is an emergency. That is why you need triage when you come in. To do triage over the telephone is not possible. And for a real emergency, living around Tan Tock Seng Hospital, that is critical, because that is my constituency. You want immediate attention, zoom, go straight to Tan Tock Seng Hospital Emergency Department. And, so far, if you are a true emergency case, you will be attended to immediately. PREMIUM PAYMENT FOR MEDISHIELD PLAN (Assistance to the lower income group) 10. Mdm Ho Geok Choo asked the Minister for Health following the amendment to section 13(1)(b) of the Central Provident Fund Act, (a) what kind of assistance will be rendered to Singaporeans who are financially inadequate such as the aged, the unemployed and the retrenched in the lower income group such that they can continue to pay for their premiums for the MediShield Plan; and (b) if he will clarify the rationale for the limit of $660 per person on the withdrawal from Medisave account for the annual premium payment for the MediShield Plan.”
“It varies from country to country. Last night, I was a bit amused when I read a paper published on the UK NHS, and it was talking about waiting of a different kind. This was not waiting at the Emergency Department, but, just as an illustration, waiting for surgeries, and they were measuring it in terms of months but it actually means years, whereas here we are talking about days and weeks. So, everything, as we said, is relative. But I take his point that, certainly, if it is a true emergency, that patient cannot be waiting for hours. And if it is a true emergency, nobody in Singapore's public Emergency Department waits for hours. He only waits for minutes. And if you are truly on high priority, or what we call P1, immediate treatment is rendered. I do not know how Mr Low got the feedback. Was he a patient in Tan Tock Seng Hospital recently or was he a resident around there?”
“I remember, just a few months back, I published an occasional paper on waiting times in the Emergency Departments. This was maybe about five or six months ago. Regularly, I would look at those data, and I will continue to publish them. If you look at those papers, you will discover that, other than Tan Tock Seng Hospital, all the other Emergency Departments do not fit the description that Mr Low mentioned. Even Mr Low's description of Tan Tock Seng Hospital Emergency Department was exaggerated. So, please take a look at those data. I have to rely on data - unless data are being cooked up - and those are data faithfully taken. The situation was not as what he has described.”
“Sir, the Minister mentioned in his answer that there is a high cost vis-a-vis the non-clinical part of the service, like waiting time. So he is saying that perhaps the patient should tolerate and bear, otherwise the cost will be high. My question is: to what extent and at what expense should the patient pay for a relatively lower medical cost? What is deemed acceptable to the Minister? For instance, waiting time at the A&E Department may be stretched to three to five hours. Is it acceptable? Or is the waiting time for a bed from the Observation Ward of A&E Department to a normal bed of 24 hours acceptable to the Minister? Whilst the Minister says that the medical standard has not been compromised, does he not agree that those who are waiting at the Observation Ward have very little time to rest because they cannot even bathe, they do not have privacy, there are a lot of activities going on there? And does he not further agree that patients, who are kept at the Observation Ward, are attended to by doctors and nurses who are trained in emergency medicines and not so much, I understand, in internal medicines which patients really need in order to recuperate?”
“Certainly, it is the location of Tan Tock Seng Hospital. When I was discussing this with the CEO of Tan Tock Seng Hospital, in a light-hearted manner, he said, "Our feng shui is very good", ie, its location is best and, therefore, all patients flock there. But feng shui aside, we have to solve the problem, and the problem is really to speed up the development of the northern General Hospital. As I explained, for some historical reason, all the hospitals were built in the south, because the history of Singapore started from the south, from the mouth of the Singapore River. But in the last few years, we have not been adding new hospital beds in the other parts, definitely not in the north. It is high time we built one in the north. That was also a political promise made by Prof. Ho Peng Kee, and I shall discharge that on his behalf. Let me illustrate this by looking at SGH. I gave the example just now that, 15 years ago, when I was running SGH, I remember the A&E Department patient load was 500 patients per day. It was the largest A&E Department in Singapore. It has dropped from 500 to 310 today. It is not even the second biggest A&E Department. The second biggest A&E Department is now at Changi General Hospital, which has 320. Tan Tock Seng Hospital - 380. What does it mean? Had we not built Changi General Hospital, SGH today would be an even madder house than Tan Tock Seng Hospital. So the same thing would be resolved in a few years' time. Mr Low Thia Khiang: Sir, I am afraid that the political promise made by Prof. Ho Peng Kee, delivered by the Minister for Health, is a bit too late because the promise was made in the last election. Perhaps, it is not too late because the election is coming, I believe, that is why he is speeding up the northern hospital.”
“If I do that, then problems like chicken pox patients who are kept in Tan Tock Seng Hospital will persist. This came out during the review in the last couple of months. When Singaporeans are down with chicken pox, what do we do? We send them home. But now, our beds are being clogged up by foreign workers, who are being dumped at Tan Tock Seng Hospital, because, for some historical reason, we heavily subsidise these foreign workers with chicken pox, when the right solution for the employer is to vaccinate them. Years ago, when I was running the hospitals, I know many of our beds were clogged up, and SGH too, by NS personnel with chicken pox. Then when we introduced proper transfer pricing to MINDEF, the right decision was made, ie, MINDEF started vaccinating NS personnel. So, today, no more beds are being occupied by NS personnel with chicken pox. But, obviously, we have not applied the lesson to foreign workers, who are being dumped at Tan Tock Seng Hospital, at the expense of patients who genuinely require emergency care and beds. But I want to highlight to Mr Low that no seriously ill patients are being turned away or being sent from hospital to hospital. Those indemnity forms, which I accept were not a clever innovation, only applied to those who should not have been in Tan Tock Seng Hospital, or any hospital's Emergency Department, to begin with. Mr Andy Gan Lai Chiang (Marine Parade): Sir, is it true that one of the reasons for over-crowding in Tan Tock Seng Hospital is that ambulances find it convenient to send their patients there and, since it is the only hospital in the north, that problem is going to be more acute? So, in the meantime, has the Minister thought of any solution to that?”
“And if you ask me, my priorities are in that order - first, high clinical standards; second, keep cost as low as possible; and, third, non-clinical customer service, like waiting, as best and as high as possible. It is not possible to match all three but where we can, we try to do our job as well as we can. So, if you want customer service to be as best as possible - meaning there is no waiting, doctors, nurses and beds waiting for customers to come in - I can do that, but it means very high cost. Our private hospitals can achieve that, but look at their average occupancy rate, it is less than 50%. So, cost is high, but they can easily pass it on to the patients. I can do so in public hospitals too, but I am quite sure Mr Low will be the first one to protest and say, "Why are fees going up?" So this is the magician's act that we have to perform daily. I am not very proud of the non-clinical customer service at Tan Tock Seng Hospital A&E Department today. But we can try to resolve some of these problems, and we will. So, I think building the Yishun General Hospital is a major fundamental step which we will speed it up. But, in the meanwhile, I think we can try to ease the burden as much as we can. Let us bear in mind one point. When we run heavily subsidised public hospitals, sometimes deliberately squeezing supply, keeping occupancy rate high is not something to sniff at. It is an important part of the strategy if we want to keep overall healthcare cost as low as possible. If we have plenty of resources or plenty of money that people are willing to pay or to subsidise, sure, we can open up as many beds. I can actually open up another 150 beds at Tan Tock Seng Hospital tomorrow. I can if I want to. But is that the right solution?”
“Sir, I disagree with the intensity of the criticism. I do not think the situation was acute on a nation-wide basis. I have given a very careful and fairly comprehensive reply to the Member. What is important is that we are a little red dot. You can go anywhere within half an hour or one hour. It is not like the UK. If there are bed shortages in one corner, it means that there is a possibility of emergency patients not getting medical attention in time. We have to look at it on a nation-wide basis. Are we short of public hospital beds? I have given the Member data to show that we are not. But, yes, there are local problems which we have to resolve them locally. So it is not because of Mr Low's parliamentary question that I suddenly wake up and discover this problem in Tan Tock Seng Hospital. Sir, the problem, on a nation-wide basis, is not as acute as what Mr Low has tried to paint it. But I agree that there are difficulties at Tan Tock Seng Hospital. Let me take some time on this matter, if you do not mind, Mr Speaker. Running public hospitals requires trade-offs between three objectives which are often contradictory. First, keep clinical standards as high as possible. This means employing top brains - doctors, nurses, and equipment. Second, keep cost as low as possible, because we want to make sure that people can afford health care. Third, keep what I call "non-clinical customer service" as best as possible and as high as possible, equivalent to a five-star hotel. And we know that all three are very difficult objectives. Any politician who promises you that he can deliver all three is a liar! But I feel that our job of running public hospitals is to try to balance these contradictory objectives.”
“Mr Speaker, Sir, the practice that Mr Low highlighted is a local innovation, purely within Tan Tock Seng Hospital. It is not a Ministry of Health's directive. I have run practically every public hospital in Singapore, except Tan Tock Seng Hospital. And in all those hospitals, we never have such a practice. But, like all innovations, some are good innovations and some are bad innovations. As part of a creative economy, we allow for local innovations to take place. But when it was highlighted, I myself thought that it was quite a silly innovation. So I am quite glad that, upon review, they have terminated it. Mr Low Thia Khiang: Sir, I would like to know from the Minister whether he was aware of the shortage of beds situation prior to the question being filed, and how the Ministry of Health supervised the hospitals since he said that it was a local innovation, bearing in mind that this local innovation, whether creative or not, can cause a lot of suffering and anxiety to patients who seek treatment. My question is: how close is the supervision? Secondly, is the Minister aware of the incident and also the bed shortages? And what has he done prior to the problem, which, I believe, is quite acute now?”
“Therefore, I shall not hold TTSH or any of its employees, servants or agents liable in any way whatsoever for any loss, bodily injury, mishap, accident, loss of life and of property arising directly or indirectly as a result or in connection with my consultation/treatment with TTSH.' Sir, if Tan Tock Seng Hospital is not concerned about its medical standard being compromised because of the situation, why is there a need to get patients to sign an indemnity form? Secondly, is it fair to turn away a patient who goes to a particular hospital, especially near his home, in an emergency and is asked to go away and seek treatment somewhere else? If not, the patient has to sign an indemnity form as though he is selling his life, never mind whether he is dead or not.”
“Those who respond to treatment and get better are discharged. Those who require admission are constantly monitored and provided necessary treatment, and are admitted as soon as a bed becomes available. Mr Low is worried that medical care for patients in the Observation Ward might be compromised. It is not. In fact, in the US and UK, many hospital emergency departments have such "Short Stay Wards" for patients whose conditions can be addressed by short and directed medical treatment. Finally, there are patients whose conditions are not severe at all. They will have to wait their turn while we attend to the more seriously ill. In fact, most of these patients should not be in the hospital's emergency ward. As part of patient relations, Tan Tock Seng Hospital tries to keep them informed of the expected waiting time, which is likely to be long. The purpose is to give them an option of seeking medical attention at other hospitals if they wish. For those who chose to wait, Tan Tock Seng Hospital had previously asked them to acknowledge this decision through signing an indemnity form. However, upon review, Tan Tock Seng Hospital has terminated this practice. Mr Low Thia Khiang (Hougang): Sir, I would like to ask the Minister for the rationale for Tan Tock Seng Hospital to ask people who refuse to go somewhere else to sign an indemnity form, which reads: 'I hereby confirm that I have chosen to seek medical attention at Tan Tock Seng Hospital despite having been informed that TTSH is currently experiencing full house situation.”
“Second, at any point in time, there are some 40 patients (40 beds) in Tan Tock Seng Hospital who are waiting to be transferred to community hospitals or nursing homes due to administrative delays. We are working to shorten this bureaucratic delay, so as to free up more beds for new admissions. Third, some of Tan Tock Seng Hospital's beds are clogged up by foreign workers down with chicken pox. Practically all, if not most, do not need to be hospitalised. So we are fixing this problem. In the medium term, the thorough solution to this problem is to build a new general hospital in the north. That is why I brought forward the construction of the Northern General Hospital. Planning is underway and we hope to open Phase I of the hospital at Yishun before 2010. And if we are lucky, maybe in 2009. Let me now address the services rendered at the Tan Tock Seng Hospital Emergency Department. All emergency patients are triaged upon arrival. This is a standard operating procedure throughout the world. The purpose of triage is to assess the severity of the medical conditions so that medical care can be suitably prioritised. This is largely done by experienced senior nurses. But during peak periods, Tan Tock Seng Hospital would deploy a doctor to help accelerate the screening process. This is to provide swifter preliminary diagnosis and to initiate treatment. Mr Low also commented on the Observation Ward. The purpose of the ward is to cater to patients who are in the intermediate category, between those who clearly can be discharged and those who require immediate admission. At the Observation Ward, the patients will be rendered the necessary tests and preliminary treatment to stabilise their condition. So, they are not simply just "waiting for beds".”
“Sir, Tan Tock Seng Hospital is, at times, over-crowded, apparently with more patients than it can cope. But Tan Tock Seng Hospital already has over 1,100 beds. This is not a small hospital. After the Singapore General Hospital (SGH), it is now the second largest general hospital here. The key issue is whether Singapore is overall short of public hospital beds. Here, the answer is no. Our public hospitals have an average bed occupancy of about 80%; this has been so for quite a few years. If necessary, we can expand the public hospitals by several hundred more beds in the short to medium term. The current congestion at Tan Tock Seng Hospital arises because it is the general hospital nearest to the north. For historical reasons, all public general hospitals are located in the south. With the growing population in the north, Tan Tock Seng Hospital ends up with a patient load larger than expected. Its accident and emergency patient load today exceeds that of the Singapore General Hospital. Traditionally, SGH has the largest emergency patient load, but, nowadays, Tan Tock Seng Hospital saw 21% more attendances than SGH's current patient load. We are monitoring the overcrowding situation carefully. Tan Tock Seng Hospital had been planned with a little more room for expansion, and we can open another 150 beds in stages. However, I want to exhaust other avenues first before doing this, so that our healthcare budget can be stretched to its maximum. First, we should spread out the patient load across the hospitals, to make maximum use of available beds. As with other hospitals, high demand for beds varies from day to day. We can try to spread the load across hospitals, because not all public hospitals experience the same high demand at the same time.”
“Mr Speaker, Sir, with your permission, I would like to take all the three questions by Mr Low Thia Khiang on the over-crowding problem in Tan Tock Seng Hospital together.”
“Most importantly, the NKF must remember that the core of all charity is basic humility and a simple desire to help our fellow human beings. The NKF, and indeed all charities, exist because of the people, and it is the people they must serve, and not the other way round. [Applause.]”
“After all, this must be the basic mission ofNKF: to deliver kidney dialysis services tothe patients at the lowest possible cost, commensurate with a good standard of clinical care. Conclusion Mr Speaker, Sir, we have hadtwo days of fruitful debate in this House.Unfortunate though the entire NKF saga may be, I am cheered by the fact that all Members saw this as an opportunity in the way we collectively handle this crisis, for both the NKF and, in fact, the entire charity sector to emerge stronger and more resilient. More broadly, Ms Irene Ng described thisincident as a "defining moment", an opportunity for Singaporeans to sharpen our collective identity. I agree. And I am not the only one. Members may know of Mr Jack Sim, an active Singaporean volunteer, who is passionate about toilets. He started the WTO: not the one in Geneva, but the World Toilets Organisation based in Singapore. He sent me an email to say that he saw the NKF incident becoming a nation building exercise. Let me quote him:"Now you know we are not Bo Chap Singaporeans. Everyone is a patriot at heart … and maybe a stronger Singaporean identity will emerge, including Singlish." Let us now, therefore, allow the dust to settle, and let the new NKF Board get on with the necessary restoration work.The old NKF has great strengths but also weaknesses. Let us build on the strengths and correct the flaws.The new NKF must remain creative, innovative and professional. Being the largest charity in Singapore, it must take on a pace-setter role, and be a shining example of good governance, transparency and accountability. To achieve this, it must fix all its inadequacies and root out bad practices.”
“I see values in some competition between charities, provided competitionis properly applied. Already, there have been suggestions that we mergeNKF withKDF. I am not sure if this is awise move. Currently, dialysis patients have some choices:NKF, KDF, public hospitals, private hospitals, private dialysis centres, a certain range of prices that they can go to, depending on their needs anddifferent levels of service - some have aquariumsand some do not, some are very basic. But if they all compete to deliver the best value at the lowest possible cost, what is wrong with that? Dr Lily Neo asked for the criteria used byNKF on assessing patients for admission to their dialysis programme. She asked if too many were rejected, and whether KDF was started precisely because of the need to look after the rejects fromNKF. Honestly, I do not know.Please bear in mind that NKF is a private non-governmental VWO. It is not a department of the Ministry of Health.I am beginning to know a little bit more about the operation. I will know more as I get involved. But since I am on this point, I hope that, at the end of the day, let us keep NKF non-governmental and it should not become, for example, a Ministry of Health's department, orentity. I think that would be walking backwards. Cost effectiveness Dr Wang Kai Yuen, and I think Dr Geh Min, also questioned the cost-effectiveness ofNKF in kidney dialysis and some data were produced to show the comparison with KDF.We will bear this observation in mind. We need to dive into the cost details in due course. I share Dr Wang’s objective thatNKF should try to be as lean and slim as possible, so that the savings could be passed on to the patients.”
“We decide how much we want to raise and seta target. Betweenthe two of us, we are quite resourceful. We can raise large amounts of donations if we want to. But once we hit our limit, we stop and say, "Enough. Thank you very much." That should be the way fund raisers conduct themselves. This is why we need a review on the NKF’s reserves policy. We need to piece together their strategic intent on reserves and projected needs. Dr Tan Sze Wee mentionedhis view on this. He knows - he is a medical doctor -the need for chronic care and the funds required depend on your assumption. Do youprovide for 10 years of liabilities, or three years, or 20 years? Intuitively, I agree with him that unlikelythe so-called 30 years of reserves is the case. Dr Geh Min askedsomequestions. What is the life expectancy of dialysis patients? If I am not mistaken, the first patient on dialysis in Singapore is still alive.How many cases are therein Singapore today? I think we have something like 3,500 dialysis patients. NKF's market share is about half, 1,800 or so, and every year about200 patients are added, and this is cumulative. One observation I want to make is that NKF's recent major donation drives were not for kidney patients, but for cancer patients, which is a new programme. So intuitively, I am quite sure there is not enough money for this new programme.However, as I said, I have suspended the fund-raising activities in NKF. So Prof. Ong's worry about wheelchairs being pushed out and more TV shows being occupied by NKF,for the next few months,she would not be seeing all those. However, Dr Wang raised a more fundamental questionabout whetherNKF should not just stick to kidney dialysis, and not wander to other areas. I keep an open mind on this issue for the moment.”
“As noted by Dr Warren Lee, under such a model, it may not be wrong to incentivise performance of fund-raisers based on funds raised. But it must be a basis that a sound Board of Directors is willing to publicly defend. Also, as any of our many listed and professionally run businesses will tell you, the human resource management practices of organisations must, ultimately, be anchored by the organisation’s core values and code of ethics. These values must be lived by the Board, the management and the staff and be coherent across all dimensions of the organisation, be it in the way they serve their customers, the way they do business with partners and the way they run the organisation internally. VWOs can be run by paid professionals but they must be underpinned by strong ethics and guided by a moral compass. As Jack Welch, formerly of GE, noted, the most difficult type of managers he had to decide on were the type that "does not share the value, but delivers the numbers". His conclusion was "we have to remove these managers because they have the power, by themselves, to destroy the open trust-based culture that we need to win today and tomorrow". He was talking about the needs of a for-profit multinational, let alone a charity. I challenge the new NKF Board to put this right in the NKF, and I am confident it can be done. Reserves policy For example, it is a basic ethical rule of fund-raising that we do not mislead donors and potential donors. We do not coerce and exploit beneficiaries in order to arouse donor sympathy. And when we have collected enough, we suspend fund-raising. Asan aside forthe PAPCommunity Foundation (PCF), every year we do fund-raising for charity.Dr Ng Eng Hen and myself are responsible fororganising the PCF fund-raising for this year.”
“Until the review of the NKF’s processes is concluded, I would not like to speculate as to whether staff bonuses were indeed based on funds raised and, therefore, led to perverse incentives. We need to understand their HR policy and the remuneration system. This is an aspect which the review will uncover. We should bear in mind, however, that there are two separate functions inNKF. One is the provision of medical services at subsidised rates. This must be done by competent professionals, as lives are at stake. These professionals must be paid a market wage for their services. The other component is fund-raising to pay for the subsidies. This can be done by volunteers or paid staff. Where small sums are required by a charity, using volunteers would be adequate and probably the best way. But where huge sums are required on a continuing basis, like the NKF, the charity may have to fall back on professional fund-raisers like some big American foundations. The question is then how to remunerate these paid fund-raisers. Mr Speaker, Sir, structuring an appropriate performance remuneration system is an important part of HRmanagement in any organisation. If we want the professionals to do their best, they need to be properly incentivised. Some are self-motivated, like Mr Gerard Ee and Dr Robert Loh. They work out of basic kindness, or Mr Gerard Ee puts it, just "coffee and cakes". Although as Iinteract with him morein the next few months, I am going to advise him to cut down on coffee and cakes. I worry about his waist line. But some charities do need professional fund-raisers to help in their charity work, so that they are free from the burden of fund-raising and can concentrate on providing services to their targeted beneficiaries.”
“TV shows come under MICA, but I did the Question yesterday because originally we were not sure that there would be a Ministerial Statement. So, may I suggest that the Member file a proper Question to the right Minister. I am sure he will giveher a full reply, including from the Ministerfor Home Affairs. But I have noted her proposed new priority for the Board. I have suggested six priorities for the Board, andshe said quite rightly that there ought to be a priority too on how NKF ought to deal withits patients. I heard and I am worriedabout some of the comments and feedback by Dr Warren Lee that, apparently, patients are being coerced to do certain things, otherwise the line may be pulled.Let me repeat myself here. I find it completely and totally unacceptable and unethical to do so. But I think with the new leadership, I am sure if, indeed, that was the case, the matter would change overnight. Once I have settled down- I still got the Ministry of Health to run -Iplan to visit the dialysis centres again, talk to the patients, and hopefully in a candid way,let me gather some of the feedbackdirectly from them. But let me caution on one point. Some of the feedback might be motivated by wanting NKF to provide services for free, a point which I have addressed yesterday. I do not think that is the right approach.The need for co-payment is there, provided the criteria are open and objectively applied, and not unduly stringent,I am sure Singaporeans can accept. Several MPs speculated that the NKF incentive structure might have fuelled the management’s drive to collect donations at the expense of everything else. I do not know at this point.”