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.”
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“Mr Speaker, Sir, my Ministry encourages all healthcare institutions to be transparent with their charges. This will enable their patients to have a better idea of what to expect. However, merely publishing the fee schedule is often of little practical use to patients. To be meaningful, information on charges has to be properly compiled, tabulated and suitably organised by disease conditions. SINGAPOREANS GOING OVERSEAS FOR SEX WITH MINORS 9. Ms Eunice Elizabeth Olsen asked the Minister for Home Affairs if the Government is aware of Singaporeans who go overseas to engage in sex with minors and, if so, how many cases have come to the attention of the authorities.”
“Sir, I have read from the Hansard a similar debate in this House between Dr Neo and my predecessor precisely on these two points. I suppose I could rehash, repeat or re-broadcast Minister Lim Hng Kiang's reply. But let me take a second look at it again. It is clearly on my workplan for next year - the review of ElderShield. I took my time on this because partly I felt that the MediShield reform is much more urgent. And, really, I am already losing sleep over MediShield, and I cannot afford to lose further sleep over ElderShield. It is something that I will study carefully next year. I remember Minister Lim Hng Kiang's reply to both questions, which is, not in so many words, that "there is no free lunch". If you want better payouts, the premiums will be larger. If you want less premiums, then the payouts will have to be shrunk. Anyway, let us take a look, now that we have two-and-a-half years of claim data and another 12 months, three-and-a-half years of claim data, we can better judge whether the policy has been over-priced, in which case it will be a nice problem, as it is a matter of extending the benefits or reducing the premium. If the review were to come to a conclusion that the premiums are not enough, we will have a bigger problem. But I think I will rather keep my options open at this stage. PRIVATE CLINICS (Publication of fees) 8. Mdm Halimah Yacob asked the Minister for Health what is the Ministry's policy on private clinics publicising their fees to the public considering that the Ministry is now encouraging public sector hospitals to be more transparent by publicising their fees as part of the overall policy to contain healthcare costs.”
“Sir, honestly, I have no idea yet whether 1,200 out of 700,000 by year two is small. In due course, when I have gone into the details of this scheme, and particularly after taken into account experience overseas, I will be able to make a better judgement by then. The problem is this. This is a long-term disability insurance scheme and it started off by taking in only people without pre-existing disabilities. So the number of successful claims will build up. Once you are disabled, you add to the number cumulatively. Those who were already disabled at the time of the launch of the scheme were automatically excluded. So I am not surprised that the numbers will be small at the initial stage. But whether this is actuarially too small or too big, I will be able to make a better judgement after I have gone into the details of the review. As to the question on the three months' claim process and also the assessment fee, as I said, these are fairly standard industry procedures. I have looked at other similar insurance plans overseas - Japan, US, UK - they set an even longer claim period, some as long as six months. So I thought three months seem reasonable, but we will certainly take the comments into account when we review this. As to whether the fee is affordable, it is only $25, which I think ought to be fairly affordable for most claimants, if not all.”
“Sir, I think my predecessor, Minister Lim Hng Kiang, took care of that. When he introduced ElderShield, he also introduced IDAPE, which is precisely to look after Singaporeans who are excluded from ElderShield because they have pre-existing disabilities or because of lack of financial means or being outside of the age group. As to the general question about how do we take care of the poor and the elderly in nursing homes or in the acute hospitals, all the Health Ministers before me, and myself and future Ministers, address this problem by making sure that we have proper safety nets in place. And I have on previous occasions elaborated on that. There are multiple layers to those safety nets, and provided everyone plays their part, nobody needs to worry that they will be excluded, whether it is from acute care or nursing care, if they are poor.”
“Sir, ElderShield was launched in June 2002, three years ago. Currently, there are more than 700,000 policyholders. So far, 1,200 policyholders have benefited from ElderShield. Processing of claims takes about three months. This is referred to as the deferment period, a standard feature practised by the industry, to help sieve out claims which may be due to a short-term injury. ElderShield requires claimants to pay for the medical assessment. This is another common industry feature to cut out frivolous claims. As it is important to have objective criteria to ensure fairness and consistency in the claims process, ElderShield claimants need an independent assessment from a doctor who is trained to assess disabilities. Mdm Halimah asked if I would be reviewing the ElderShield scheme. I remember Mr Gan Kim Yong asked me a similar question a year ago. The current ElderShield scheme comes with a binding five-year contract with the two insurers. The contract will end in 2007. Once the implementation of the MediShield reforms is well underway, I will start to review the ElderShield scheme.”
“Sir, with your permission, I will take Question Nos. 6 and 7 together.”
“Adjourned accordingly at Twenty-five minutes past Seven o'clock pm to a date to be fixed. APPENDICES”
“More importantly for me, among the Singaporeans, the locals, in 1994, it was 458. Last year, it was 752, almost doubled. Obviously, we have been doing something right in recent years, and, of course, crisis events like SARS and our nurse tsunami volunteers in Aceh helped to raise the status and the image that Mr Chiam talked about how Singaporeans look at nurses. Personally, at every opportunity, I will always want to profile the dedication and the high quality work of our nurses. Finally, Mr Andy Gan strays from nurses to comment on other allied health workers, like physiotherapists. But I agree with his general thrust that if we want to maintain a high standard of healthcare, we must not neglect the professional development of the allied health workers. I recall that during the Budget debate this year, Mdm Halimah made a similar point. After doctors and nurses, the allied health workers form a critical professional group. So, as we elevate the standard of doctors and nurses, the other professional groups should move up in tandem. Like Mr Andy Gan, I look forward to the development of local undergraduate training of such allied health workers. The second medical school at the Singapore General Hospital, which is in partnership with Duke University, has such an ambition. But let us get the new medical school up and running first. Question put, and agreed to. Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Khaw Boon Wan]. Bill considered in Committee; reported without amendment; read a Third time and passed. ADJOURNMENT Resolved, "That Parliament do now adjourn to a date to be fixed." - [Mr Lim Swee Say].”
“APNs will therefore need to be both generalists and specialists, depending on the circumstances that they are in. But we should certainly guard against over-specialisation, as advised by Dr Chong Weng Chiew. I agree with Mr Andy Gan that raising the status of nurses requires more than a mere change in job title. This Bill is one of several efforts which we are undertaking. A local undergraduate nursing degree is an important initiative. Yes, as Mr Chiam pointed out, nothing new, it has been around for many years elsewhere in the West. But it is better late than never. While not all nurses need to be university graduates, and I totally agree with Dr Warren Lee here, a significant percentage of them can benefit from such training. Today, about 10% of nurses on our register have a degree, all acquired overseas. Again, I do not have a hard target. I do not know what is the final number. We will just grow it incrementally and monitor the situation. I am glad therefore that NUS will be offering a Bachelor of Science Nursing Programme from next year. Mr Chiam gave some feedback on foreign nurses' attrition and urged us to get more Singaporeans to join nursing. Yes, for a long time, we have a big problem persuading the young boys and young girls to join nursing, and it is not for lack of trying. At the polytechnic level and before that, at the School of Nursing level, the capacity to train is a lot higher than the number of applicants. But I am glad that in recent years, somehow, the picture is improving fairly significantly. I just got some 10-year data here about intake into the Nanyang Polytechnic, which is the main polytechnic doing nursing training. In 1994, the intake was 550. Last year, it doubled to 1,026. So it is a huge jump over these 10 years.”
“We cannot automatically assume so because, as Dr Warren Lee pointed out, it requires the APNs to win their peers' respect and confidence, especially from the doctors. Fortunately, we have a big group of doctors who are very supportive towards these APN practices, and we will start with them, show the evidence that, indeed, they can be very strong and good partners for everybody. Then, we build up from there. Again, on behalf of Dr Chong, Mdm Halimah asked if APNs here will pursue a specialist or generalist track. I understand Dr Chong's concern because I have occasionally discussed this particular topic with him. His concern is not so much that specialisation is wrong, but rather that there should not be over-specialisation, as over-specialisation can be counter-productive. He was relating from a medical point of view. Whether this also applies to nursing, I do not know, but it is a concern we should bear in mind. What we have in mind is, in practice, our APNs will work both in hospitals as well as in the primary healthcare setting. In the hospitals, they will have to work in specialties. Some of them, like what Dr Warren Lee described, will include critical care, emergency medicine, oncology, orthopaedics and paediatrics. Whereas in the polyclinics, they can help doctors manage patients with chronic illnesses, like diabetes, hypertension or high cholesterol. There, I think the nurses' value is they will have more time to spend with the chronically ill, advise them about why they should monitor their blood sugar and blood cholesterol, why they should be taking statins regularly, and if not, just to remind or urge them along. In that sense, maybe some fear of nurses (as expressed by Mr Chiam) is not bad if it leads to better patient compliance.”
“In addition, the Board also allows the union to represent the nurse. The Bill does not prevent that from happening. So, there is really no need to amend the Bill in order to make this clear. Essentially, unlike a court of law, the complaints committee hearing is not adversarial. It enables the nurse to present the facts of the case in a neutral environment. Mdm Halimah sought clarifications on compoundable offences. I have given an example in my speech, ie, failure to inform the Registrar in writing of any change of name within 28 days. Currently, it is considered an offence. But as it is such a minor offence, we will make it compoundable and remove it from the Act. Again, after the Bill has been passed, we will gazette such compoundable offences through regulations so that everybody knows what it is all about. Mdm Halimah wondered if there is scope to expand the services of midwives. But this is really for Singaporean women to decide. The evidence, unfortunately, points towards a declining interest, for whatever the reason. On behalf of Dr Chong Weng Chiew, Mdm Halimah asked if we have a target for APNs forming a certain percentage of all nurses. I do not have a hard target, mainly because we are still new with this. The American experience after 30 years, suggests to me that maybe 5% could be a medium term target, ie, 5% of nurses may become APNs. What does 5% mean? Currently, we have about 8,000 registered nurses in the public sector. 5% means 400 APNs. Even this number will take us many years to build up. Remember, the first intake was only 14 in NUS. But we have made a start. Let us first work steadily to ensure that APNs are well incorporated into our healthcare scene and then we can expand from there.”
“We do not, however, hard-wire in the qualifying conditions, because circumstances may change. As Dr Warren Lee mentioned, there could be very experienced nurses who, because of previous lack of educational opportunities, may not be able to achieve a master's degree, but are deserving. But let us start with the master's degree criteria first. After a few years' experience, we will see. If we can along the way make some revisions to the criteria, I think we should. But we will definitely gazette the details of the qualifying conditions through regulations, after the Bill has been approved. For the moment, the key prescribed conditions are a Master in Nursing degree and mandatory continuing professional education for renewal of certificate. After the Bill has been passed, my Ministry will conduct briefing sessions for the nurses in our various hospitals on such details. Mdm Halimah noted that clause 14 would enable the Board to disclose information to certain prescribed persons. She asked who these persons are. These are the Government officials in the Ministry of Health and the Ministry of Manpower who require specific information on nurses in order to do their work, and the key purposes are: (1) Manpower planning so that we know how many nurses we have of various types, age and so on; and (2) Mobilising essential personnel during national emergencies. Mdm Halimah also commented on nurses who are subject to disciplinary enquiry, and she is rightly concerned that such nurses should not be unduly disadvantaged. Although section 19(2C)(a) specifies that a nurse attending a complaints committee hearing can be heard personally or by counsel, the Board allows nurses to bring their supervisors or their colleagues to speak on their behalf.”
“Mr Deputy Speaker, Sir, I thank Mr Andy Gan, Mdm Halimah, Mr Chiam See Tong and Dr Warren Lee for supporting the Bill. I especially note Dr Warren Lee's personal perspective as a doctor for many years working in public hospitals. I think we all share a common objective, which is to raise the standard of nursing care, at the same time, creating opportunities for our nurses who want to and can upgrade themselves, and also to acknowledge their immense contributions to our health. Many nurses have worked with me in my many years of running hospitals, and those who have worked with me know that I particularly appreciate this group of our healthcare workers. They work very hard, are very dedicated, and I have always been a strong champion of nurses, besides the other healthcare workers. But for nurses, I always have a soft spot for them, because I know how dedicated many of them are and how much they put in, in terms of working life. Many of them, as Mr Chiam related, were so devoted and passionate for their cause that they stayed single, and you see many of those who are in the senior echelons now, some have retired, after devoting their whole life to nursing. This Bill is one of several initiatives which will help us realise this objective. Let me respond to the specific comments and feedback and suggestions. Mdm Halimah felt that clause 7 could be clearer. Clause 7 is the one that amends section 18, to allow the Nursing Board to prescribe the various conditions governing the grant and renewal of practising certificates. In a similar vein, Mr Andy Gan suggested that we spell out the qualifications that are required in order to be an APN. You know me. I agree totally on full transparency. Our nurses must be clear how they can become an APN.”
“Disclosure of information Currently there is no explicit provision for the Board to disclose information to Government organisations for policy planning purposes. The new subsection (6) in clause 6 of the Bill will allow the Board to release such information. This is similar to the provision in the Medical Registration Act which allows the Registrar of Singapore Medical Council to disclose the information in the registers as prescribed by regulations made under the Act. Power to invest funds At present, the Act does not allow the Board to invest its surpluses. Clause 20 of the Bill amends section 42 to empower the Board, with the approval of the Minister, to invest its funds. This would allow for prudent management of reserves. Sir, this year, the Singapore nursing profession celebrates its 120th Anniversary. Over this long period, the profession has made significant progress. Our nurses have kept up with the rapid advancement of medical science and technology. Their job scope has grown in breadth and complexity. They have become valuable partners of our doctors and other healthcare professionals. Some of the credit for the high standard of healthcare in Singapore should go to our nurses. The critical role played by our nurses in the battle against SARS is still fresh in our memory. For the profession to remain valuable partners in our healthcare team, they must continue to upgrade and keep in step with global development. This Bill will help to contribute to this. Advanced Practice Nurses can potentially become a key player in our drive to keep healthcare cost affordable while maintaining quality. Let us actively embrace them and incorporate their services into our healthcare delivery systems for the benefit of our patients. Sir, I beg to move. Question proposed.”
“The new provisions will also allow the Nursing Board to exercise this requirement for other categories of nurses, if and when the need arises in the future. Other amendments Sir, let me now move on to the other amendments which will enhance the administration of the Act. Establishment and membership of Board Currently, the Nursing Board comprises 14 appointed members (including 11 nurses) and three ex-officio members. The ex-officio members are the Director of Medical Services, the Director-General of Education or his representative and the Chief Nursing Officer. Traditionally, the Board is chaired by the Director of Medical Services. In this House, Dr Lily Neo has previously argued for the Board to be led by a nurse. I support her view on this. Clause 4 of the Bill provides for the Director of Medical Services or his representative to be a member of the Board. This technical amendment in clause 4 will facilitate such a development. Administrative/civil sanctions Clause 8 of the Bill amends section 19 to increase the range of disciplinary actions that the Nursing Board may take. The range of penalties includes issuing of warning, censure, imposing a financial penalty, suspension or cancellation of registration. This would give the Board greater flexibility in administering disciplinary actions. Clause 21 empowers the Board to prescribe compoundable offences and to compound offences. Clause 6 will enable it to decriminalise minor offences such as the failure to inform the Registrar of a change in address or other particulars. This is in line with the move to promote the greater use of administrative and civil sanctions.”
“For the nursing profession, the APN Register opens up an alternative career track to allow experienced and skilled nurses who have the necessary advanced qualifications to remain in clinical setting without compromising their career development. This is one way to retain good nurses in the profession. To prepare for this development, the National University of Singapore started its "Master in Nursing" programme in 2003. This was a milestone in local nursing education. It launched our APN training programme. The first batch of 14 graduates will complete their one year internship next month. They will then be eligible for appointment as APNs. Main features of the Bill Let me highlight the key amendments. Advanced Practice Nurses Part V of the principal Act has been repealed and re-enacted in the Bill. This will amplify the existing provisions relating to the certification and regulation of the practice and conduct of APNs. It covers the use of job titles, qualifications, training, education, standards and scope of practice, professional conduct and ethics of APNs. The nomenclature of nurse specialist or nurse specialist register has been updated to Advanced Practice Nurse or Advanced Practice Nurse Register, wherever it appears in the Act. Continuing Professional Development The Nursing Board intends to implement mandatory Continuing Professional Development for the renewal of the APN Practising Certificate. This is similar to mandatory Continuing Medical Education for doctors. As nurses enlarge their roles, it is essential that they uphold the quality of nursing care by keeping abreast of the changes and developments in medical science. Clauses 7 and 22 of the Bill amend sections 18 and 44 of the Act to mandate such a requirement.”
“In so doing, we shall re-name nurse specialists as "Advanced Practice Nurses (APNs)", in line with international nursing nomenclature. Benefits of APNs APNs bring benefits to patients, doctors and nurses. International experience suggests that APNs are effective in initiating management of common acute illnesses and injuries. APNs are also valuable in managing stable chronic conditions with particular emphasis on health promotion and disease prevention. They can promote better patient compliance with treatment. Many studies have been conducted to gauge the quality of care provided by APNs. Early studies found that in an appropriate setting, patient care and outcomes were of equivalent quality to that provided by doctors, and patients were satisfied with their care. More recent studies have shown that APNs' intervention and care contributed to shorter length of stay, fewer hospital admissions, reduced re-admission rates and therefore healthcare costs. Such outcome studies confirm the positive impact of APNs and establish them as cost-effective caregivers of quality healthcare. For doctors, the services provide by APNs complement their care. This makes APNs useful partners. APNs' extended scope of practice allows them to take on some of the routine duties of the junior doctors. This frees up the junior doctors to spend more time on patients who require their higher level of expertise. As an example, in primary healthcare setting, APNs can work with family physicians to manage nurse-led follow-up clinics for patients with chronic diseases. They can also conduct patient education and counselling sessions which will include re-enforcement of self-management skills, emphasis on medication compliance and evaluation of treatment.”
“Mr Deputy Speaker, Sir, I beg to move, "That the Bill be now read a Second time." The purpose of this Bill is to establish a Register for Advanced Practice Nurses, so that we can systematically develop this category of clinical nurses with a "Master in Nursing" degree, to contribute to our healthcare system. Background This is not a new idea. In 1999, the Nurses and Midwives Act provided for the setting up of a Nurse Specialist Register. The objective was identical. It was to promote the development of nurse specialists who can, through formal training, acquire the necessary knowledge, skills and competencies to play a greater role than that traditionally performed by nurses. Over the years, some of our nurses have, on their own efforts, acquired such expertise and many more have expressed an interest to pursue such advanced training. My Ministry encourages this trend. First, it raises the status of the nursing profession. Second, it recognises and maximises the potential for some nurses to take on added responsibilities. With proper training, such nurses can competently perform tasks like: physical assessments of patients; ordering and interpreting diagnostic tests; and initiating treatment according to an approved protocol. Internationally, such a development is not new. In the US and the UK, such a category of clinical nurses has evolved over 30 years to become an important player in their healthcare systems. Increasingly, they have also switched to call such nurses "Advanced Practice Nurses" instead of "Nurse Specialists". This Bill will essentially update and amplify the existing provisions in the Nurses and Midwives Act, which pertain to the certification and regulation of nurse specialists.”
“In the past three years, the average weekly notifications of hand, foot and mouth disease (HFMD) among children aged six years and below have varied from 273 cases in 2002, to 92 cases in 2003 and 106 cases in 2004. This year, the weekly average has gone from 163 cases in January to 180 cases in February and 382 cases in March. For the first week of April, the number has declined slightly to 347. HFMD is generally a mild and self-limiting childhood disease. Most of the cases reported so far had mild illness, requiring only outpatient treatment. The virus that caused the HFMD-related deaths in 2000 and 2001, Enterovirus 71 (EV 71), has not been detected in the HFMD cases this year. MOH works closely with MCYS, MOE and NEA in the prevention and control of HFMD in childcare centres, preschools and kindergartens. The measures undertaken include the enforcement of high standards of personal and environmental hygiene, and the early identification and isolation of infected children. In the affected childcare centres, notices of HFMD outbreaks will be posted and parents would be informed via letters. MOH also provides weekly epidemiological updates to the public on its website at: http://www.moh.gov.sg/corp/publications/idbulletin. APPENDICES”
“One emphasis is in early detection and intervention, so that gambling addiction can be nipped in the bud. We will work with MCYS to raise public awareness on unhealthy gambling behaviour. Third, we will invest in research and training. Training programmes for family service centres, teachers and other outreach partners on screening and intervention skills will be expanded. Research will be conducted on best treatment practices, taking into account the factors that are unique to Asians. Fourth, the Centre will work closely with our community partners, such as VWOs, and strengthen community action against problem gambling. To encourage such community involvement, we will provide convenient access for addicted individuals and their families to seek help and to continue treatment. Mr Speaker, Sir, I am against gambling. I do not encourage gambling. But there will always be gamblers, and there are millions of them here in our region. When the integrated resorts are set up, Singaporeans may visit them. But my advice is for them to stay away from the 5% gambling spots. By all means go and watch the giant whale that Minister Lim Hng Kiang talked about yesterday. But do not get near any of the "whales" that Chia Teck Leng wrote about, or imitate them. Remember Chia Teck Leng's advice: you can never win against casinos. Casinos always win. That is why a tiny 5% can cross-subsidise the rest of the integrated resort and still yield fat margins for the investors. We hope not too many Singaporeans succumb to pathological gambling. By regulating casinos here, it is my hope that we can then have a better handle over this undesirable activity. Meanwhile, my Ministry will step up our efforts in managing gambling addictions and raise this to a higher level of competence.”
“If the casino operators are correct about the huge appetite for casino gambling among Asians, it would mean a need for several major treatment centres in this part of the world to serve the huge number of addicts. We have a modest set-up in CAMP. So, I told IMH, "Step up your capabilities. Acquire new expertise and let us not be half-hearted about it." I asked them to benchmark itself against the best in the world. In the US, the state of Oregon is recognised as a leader in the field of problem gambling services. Its strategy incorporates prevention, outreach and a comprehensive network of local treatment programmes. In Canada, the Centre for Addiction and Mental Health in Toronto is its leading addiction and mental health hospital, with community locations throughout the province of Ontario. It combines cutting-edge treatment with strong community support, education and prevention programmes. These are world-class benchmarks which we should strive towards. In particular, we should study the peculiarity of the Asian addicts. Let us aim to be among the top treatment centres in Asia. CAMP will be enhanced to develop such capabilities. We cannot achieve this overnight, but we should progressively work towards this target. Tentatively, we will focus on four key priority areas. First, a strong focus on multi-disciplinary treatment, with clinical practices based on evidence-based research. As a one-stop tertiary treatment centre, we will provide the full range of services, including screening, assessment, individual and group therapy, structured relapse prevention, family therapy services, as well as legal, credit and financial counselling, and even employment advisory services. Second, a strong focus on prevention programmes to avoid or reduce the problems of gambling.”
“" Another one: "I can't understand why I keep on gambling. I always lose. But once I pay my creditors back, I return to gambling ... I just can't understand it." We have all read the tragic path of Mr Chia Teck Leng, whose pathological gambling led him to criminal acts and, finally, into Changi Prison. While his is an extreme case, there are many other cases, of lesser degree, but with equally devastating consequences to themselves and their families. In most countries, some 2%-4% of the people develop gambling problems, while between 1% and 2.5% may become pathological gamblers. The latest MCYS study suggests a similar extent of incidence here. To deal with this, the Institute of Mental Health runs a Community Addictions Management Programme (CAMP). It is the main centre for addiction treatment, training and public education in Singapore. CAMP is not narrowly focused on gambling addiction. It also treats addiction to substances, such as alcohol and drugs. But many addictions pertain to gambling addictions. It offers a range of clinical services, treatment, counselling, support for recovery. Last year, we saw about 100 patients for gambling addiction. They receive treatment under the care of a multi-disciplinary team that includes psychiatrists, psychologists, counsellors, social workers and nurses. Twelve of their professional staff are trained and certified as Gambling Addiction Counsellors, in accordance with international standards. CAMP also has a distinguished panel of international expert advisers. Asia has lagged behind North America in the treatment and research of problem gambling. Somehow, this has traditionally been neglected or ignored, despite the general observation that Asians seem particularly predisposed to gambling.”
“If casino gambling by Singaporeans and the associated social ills cannot be avoided, then better that we have some influence over the operators than to leave the situation completely to the mercy of the casinos in other countries. And we can exert influence only if the casinos are in Singapore within our jurisdiction. By legalising casino gaming in Singapore, we can impose the necessary social safeguards on the casino operators. Yesterday, we have heard Minister Vivian Balakrishnan outlined the social safeguards. They are more stringent than in other jurisdictions. This is reassuring to me. Now that the Government has decided to lift the ban on casinos, on my part, my Ministry will step up our programme that deals with problem gambling, especially pathological gambling. Pathological gambling, more commonly known as gambling addiction, is a serious mental health disorder. Patients become increasingly preoccupied with gambling. They need to bet more frequently and with larger stakes. They become restless, irritable when attempts are made to stop them from gambling, some sort of withdrawal symptoms. The result is a progressive increase in gambling activity over time, in spite of the harm caused to himself or herself and their family members. It may be difficult for non-gamblers to understand this affliction, so let me relate a few descriptions which some addicts and their relatives have shared with our psychiatrists: "I feel as though I am hypnotised when playing jackpot. It helps me to relieve my stress. Also, I have a group of friends at the gaming room and we are very supportive of each other." Another one: "My father used to gamble away the children's milk money. So our family used to eat one egg broken into broth, and served with rice.”
“They are not demanding any casino monopoly. They are confident that the rising Asian market is so huge that it can support more than one casino here. It is not possible for two multi-billion dollar casinos to survive in our tiny domestic market. It means that they are confident of drawing in a large number of foreign gamblers to make their huge investments viable. What does this mean? It means that while they are keen to set up in Singapore, they are likely to set up elsewhere in our neighbourhood if we say "no" to them. So whatever our decision, they are going to be here, in our backyard. It means that world-class casino resorts in Phuket, Bangkok and perhaps even Johor, springing up in the near future are a distinct possibility. So even if we do not allow casinos here, the social problems brought about by casinos will be with us. I would have still gone for the status quo, if we can be certain that our neighbours will also maintain the status quo. But I will not bet on that. Alternatively, if we can effectively isolate ourselves from the emerging regional casinos, then I will still go for the status quo. Unfortunately, with easy and inexpensive access to these popular tourist destinations of Singaporeans, saying "no" to casinos here cannot isolate us from the social ills of gambling. Hundreds of Singaporeans are already travelling to Genting, Batam and cruising to nowhere every day. In reality, the casinos are already available here today. Except now, we have absolutely no control over these casinos. It is this realisation which changed my mind about casinos.”
“Mr Speaker, Sir, for many days, I agonised over this issue whether to allow casinos or to maintain the ban. This is not the first time I have had to face this question. For seven years as Permanent Secretary of MTI, I had taken a clear stand against casinos. The Singapore Tourism Board pushed for this proposal periodically. Each time, I would object to it. I told them not to go for "easy options", but think hard about how we could be special and still bring in the tourists without a casino. They tried: Haw Par Villa, Volcano Land, remaking Sentosa, further remaking of Sentosa when it did not work, and meanwhile, our market share in tourism continued to shrink. After I left MTI, I had to face this issue again during the Economic Review Committee's deliberations. I chaired the Services Sub-Committee. Mr Wee Ee-chao, as Chairman of STB, and the Tourism Working Group strongly recommended that we allow casinos in Singapore. This time round, he was backed by a strong chorus of private entrepreneurs, both local and international. I discouraged him. When his Working Group finally submitted his recommendations to my Sub-Committee, I was quietly pleased that casinos did not feature in his report. My reasons for objecting to casinos are similar to those already put up by many Singaporeans who had spoken against it. So I would not repeat them. What finally changed my mind was the response to MTI's Request for Concept. I was struck by the quality of the proposals, the strong interest expressed by these prospective investors and their multi-billion dollar bids. The economic benefit is huge and we cannot ignore the many, much needed, jobs that will be created for Singaporeans. I particularly noted that they were prepared for more than one casino in Singapore.”
“The short answer is, yes, because the more people are insured under any of these catastrophic plans, it is better, both for the individual as well as the society. The question is how to reach out, and we will do our best. It is always this half-empty half-full sort of phenomenon. We can certainly do better, and I intend to do more aggressively on this front. We are now trying to see where I can locate suitable points to remind. The younger people, it is easy because, upon registration of marriages, that gives me a useful milestone to remind the couples. But for the elderly, I probably have to work with the People's Association and the various community efforts to try to reach out to them. RAJA IZZUWIN (Charge for parking offences) The following Question stood in the name of Ms Indranee Rajah - 11. To ask the Minister for Home Affairs, with reference to the case of Raja Izzuwin reported in the Straits Times on 30th March 2005, (a) why it is that the Police did not realise, prior to charging him with the parking offences committed by another person, that the I/C and residential particulars given by him were false, and (b) whether as a matter of general procedure the police checks the photos and thumbprints on the identity cards of suspects against the physical appearance and thumbprints of the suspects in custody.”
“In principle, I like those features, because I am a great champion on healthy lifestyle. And if we can shape and influence behaviour that way, we should. The practical problem, of course, is how do we verify. Some of those data may be genetic. For example, I am genetically predisposed to high cholesterol. To say that just because of high cholesterol, you have a higher premium to pay, many Singaporeans may not find that acceptable. But if you say, "All right, if you do regular exercises, then I will give you a discount", how do you verify? Everybody would put up their hands and say, "I do regular exercise." But when you ask, "What exactly do you do?", you find that self-declaration is very difficult to verify. But I have been encouraging our private insurers to think deeply into this, because they have much more global experiences. Some of them are apparently thinking about incorporating some of these features and I am anxiously looking forward to their products.”
“Dr Amy Khor asked me for some MediShield opt-out data. I have earlier clarified with her that she is actually interested in the number of Singaporeans who have completely opted out of catastrophic medical insurance, and not just MediShield. Besides MediShield, Singaporeans can choose from among 15 private catastrophic medical insurance plans. We encourage Singaporeans to subscribe to catastrophic medical insurance. Failure to do so may render one in financial difficulty in the event of a major illness resulting in a huge hospital bill. That is why we operate MediShield on an opt-out basis. Its auto-cover feature kicks in as soon as an individual starts working and contributing to the CPF, unless he or she opts out. Singaporeans appreciate the need for catastrophic medical insurance. Nine in ten working Singaporeans are insured under MediShield or its equivalent private insurance products. At present, about 400,000 adult Singaporeans are not covered by any Medisave-approved catastrophic medical insurance. Of these, nearly 60% or 227,000 are women. Among these women, about 40% are above 60 years old. CPF does not have readily available information on their marital or employment status. Presumably, some opted out of MediShield after they stopped working. But the majority remain insured as they and their spouses see the benefits of continuing coverage. Singaporeans who have opted out have the opportunity to join MediShield anytime. However, to be fair to those who have stayed loyal to MediShield, CPF would have to subject these applicants to medical underwriting and, hence, medical examinations. Therefore, we strongly advise those who are uninsured to opt in while they are healthy, to avoid future regrets.”
“I think, for new hospital design, our Class C wards are now much smaller. Alexandra Hospital, which I talked about just now, has as large as 40 beds. But those are I think Florence Nightingale days. Nowadays, if we keep it to 10, 15 and sufficiently "cubicalised", I think we can minimise the problem. MEDISHIELD SCHEME 10. Dr Amy Khor Lean Suan asked the Minister for Health (a) how many Singaporeans have opted out of the MediShield scheme to date; (b) of these, how many are women; (c) what is the profile of these women in terms of their age, marital and employment status; (d) whether the Ministry will consider allowing those who have opted out of MediShield one last opportunity to opt in; and (e) if so, what conditions are likely to be imposed for the opt in.”
“Dr Tan Sze Wee suggested that we limit the number of beds to four per room in our public hospitals in order to better control the spread of communicable diseases. While I appreciate his good intention, this would unfortunately mean that such hospitals would have to go without Class B2 and C wards. I know that Dr Tan is a strong supporter of means-testing and it is possible to have all patients in private wards but enjoying different subsidy level in accordance with their income. But this would require a much more intensive form of means-testing than what I have in mind and what Singaporeans, I think, are prepared to accept. The key point is whether good infection control can be achieved in an open ward. While large open wards pose a greater challenge, a high standard of infection control is still achievable if there is rigorous adherence to infection control practices and work processes, such as hand-washing, barrier nursing and prompt isolation of infectious patients. During the SARS crisis, Members may recall that Alexandra Hospital, with large open wards, remained SARS-free.”
“Dr Tan Sze Wee suggested that we disperse the immuno-compromised patients, such as hematology, oncology and renal failure patients, among the various public hospitals, instead of concentrating them in the Singapore General Hospital. This is to minimise the risk of a major communicable disease outbreak causing havoc among these patients. We do spread out such patients. In addition to SGH, these patients are treated in the National University Hospital, KK Hospital and Tan Tock Seng Hospital. However to distribute these tertiary specialties to all hospitals as a policy would not be practical. A tertiary specialty does require a critical mass of expertise, supported by a minimum volume of patient load. Otherwise, there will be wastages of duplication and inadequate opportunity for our clinicians to sharpen their skills. In any case, there is no excuse for poor standard of infection control practices. This is ultimately the most effective means to minimise such disease outbreak. NEW PUBLIC SECTOR HOSPITALS (Limiting size of rooms) 9. Dr Tan Sze Wee asked the Minister for Health whether he will consider limiting the size of all rooms in new public hospitals to at most four beds per room, with an attached toilet and bathroom, as a means of achieving better prevention and control of the spread of communicable diseases in public hospitals.”
“And if we find that a particular hospital has an excessively high infection rate, then, as regulator, I think I would need to step in to perhaps, in extremis, even suspend the operation of that department until they clean up the operation. IMMUNO-COMPROMISED INPATIENTS (Measures to disperse among public hospitals) 8. Dr Tan Sze Wee asked the Minister for Health, in order to achieve better risk management against communicable disease outbreaks, will he consider having measures to 'disperse' the risk of large numbers of immuno-compromised inpatients, namely hematology, oncology and renal failure patients, from the Singapore General Hospital by increasing the availability of immuno-compromised clinical specialities in the other public sector hospitals.”
“I think the reply to the second question is, yes, we are checking what actually caused this cluster. As I said, although VRE is rare in Singapore, it does not mean we have none. All these years, looking at some of the data, each hospital may report one or two cases. It is a handful of cases. The trouble is, this phenomenon has been around for 20 years now and we are so well connected to the rest of the world, one, two or even a handful of cases a year should be considered as a fairly good outcome. As to her first question, hospital-acquired infections are now very much acknowledged as one of the complications of being hospitalised in a hospital, not just here but worldwide. Therefore, the practice worldwide, in fact, is not for hospitals to take responsibility for picking up the bills, for the simple reason that the cause of infection is very hard to establish. Is it the fault of the doctor, nurse or the patients themselves? So, instead, the global hospital practice is to look at what is the infection rate. Even in the best-run hospitals, it cannot be zero. It is almost impossible. Instead, what we do is that we benchmark ourselves against others to compare with our incidence rate. I look at those rates occasionally and, by and large, Singapore's situation is not bad. But I wanted to take the next step, which I think I have expressed before. I will be starting to publish some of our infection rates post-surgery, and we go by types of major surgeries, eg, hip replacement, what is the infection rate in Singapore among the various hospitals, and then we can benchmark against the other hospitals.”
“Mr Speaker, Sir, I am not personally aware whether such studies were done. There may be. I would have to check. But it is traditionally very difficult to compare practices between two hospitals, unless they have identical patient profiles. SGH, being our major tertiary institution with multiple specialties, their patients' needs for vancomycin may be higher than the others, everything being equal. But what I can say safely is that we in Singapore, compared to many developed countries in terms of usage of antibiotics, are a lot more careful. And, as I said just now, it is not a result of good luck or whatever. Pricing has to do with it too. Vancomycin, for example, is a non-standard drug and, in countries where they subsidise until everything is free, the tendency to over-prescribe may be greater.”
“I honestly do not see a compelling need to do so because VRE is not like VD or HIV where there is a stigma associated with it. It is one of those "bad luck" illness, if you get it. Even with HIV, confidentiality is always preserved by hospital workers, in the sense that when we take a particular decision - in this case, circulate the list - it was purely on a need-to-know basis because, what is the alternative? The alternative is not to inform. Then we are exposing the patients, say, in the private hospitals to a potential spread. So, on this score, our conscience is quite clear, ie, there is nothing wrong in sharing the list for the greater good of society. Dr Lily Neo (Jalan Besar): May I ask the Minister whether there will be more liberal use of Vancomycin in SGH compared to other hospitals that caused the VRE outbreak in SGH? Has there been a review done on the prescription habits of doctors in SGH, especially on the prophylactic use of strong antibiotics? Should there be better guidelines on such prescription to prevent future recurrences?”
“Sir, this is one hypothesis. It is not just the size of the hospital but it is also the range of specialties although the two tend to be linked. When you have a large hospital you will also have multiple disciplines, especially tertiary disciplines, with greater mixing of patients. One observation that some doctors made during the SARS period was why is it that SARS became such a problem in those major centres with modern hospitals whereas in the third world, in the villages, somehow it was not a problem. One hypothesis was that it was because of concentrating the multi-specialty patients together. Because of specialisation, the same patient is being handled by different departments and the patient has to go through several departments instead of just going to one place. Therefore, if there is a carrier of the bacteria, you expose the various patients in different parts of the hospital. I think it is a fairly reasonable hypothesis. Like all things, such as casinos, you open the window and all sorts of things will fly in. So we have to decide whether or not we want to shut the window and if we do so, of course, we will be secluded. But how do we stay secluded in a modern world?”
“Sir, the answer to both queries is yes. In the US, UK and parts of Europe, VRE is now entrenched and the US' experience has been going on for about 20 years. We have been fairly lucky but I doubt that it has a lot to do with luck. It has to do with the practices. And careful usage of antibiotics and making sure that they are not used indiscriminately is one of the key measures besides the usual infection control procedures. We had SARS and that was a period when we reminded everybody about the importance of infection control. Now, we have the bird flu and VRE and potentially it could be a major risk for us. I think it will be extremely difficult to eradicate VRE to make sure that it is not part and parcel of our eco-system because we are such an open economy. Just like the NUH case that I mentioned in my reply, it was a foreigner who came in for treatment. We look around the region and we know that antibiotic usage is almost rampant and that is a major risk.”
“Dr Tan asked whether VRE should be gazetted under the Infectious Diseases Act. We see no need as VRE is not a community-based infectious disease like tuberculosis or SARS. However, it poses a risk to immune-compromised patients in hospitals. We have therefore included VRE as a target in their infection control programmes.”
“Mass screening of all the inpatients in SGH has so far identified 93 patients with VRE. Of these, only three were found to be infected, with clinical symptoms. They were patients with multiple chronic medical conditions. To minimise the spread of VRE to other hospitals, we have also reminded them to step up infection control procedures. At the same time, SGH shares with the other hospitals the list of their recently discharged patients so that they can be isolated and screened for VRE if they are admitted there. So far, one such patient has been admitted to NUH. NUH has since identified another case of VRE in a foreign patient, but this patient was not related to the SGH cases. Mdm Halimah and Dr Amy Khor asked what precautions have been or will be taken to reduce the risk of future occurrences of VRE cases in hospitals. This is best done through a combination of measures. First, there must be a rational usage of Vancomycin. Second, there must be good surveillance for hospital-acquired infections. Third, there must be strict adherence to sound infection control principles such as prompt isolation of patients with infectious diseases, barrier nursing and hand washing. These are good hospital practices which all hospitals should adopt. Like penicillin resistant bacteria and MRSA, VRE may eventually become part of our bacterial landscape. If this happens, infections now treated with Vancomycin will have to be treated by other antibiotics. The greatest danger is bacteria that becomes resistant to multiple antibiotics. To minimise this risk, antibiotics must not be used indiscriminately. Doctors should use antibiotics only when indicated and patients should complete their course of antibiotics when it is prescribed to them.”
“The enterococci infection is then treated with an antibiotic other than Vancomycin. Mdm Halimah and Dr Amy Khor asked for the source of the VRE cases in SGH. It is still being investigated. We may never know for sure. The bacteria could be bacteria that mutated locally or it could be bacteria brought into Singapore by healthy carriers who carried the bacteria in their large intestines. The vast majority of patients with VRE are healthy carriers of the bacteria without any symptom. There are no effective treatments for healthy carriers since these bacteria are normal to the large intestines. Hospitals use many antibiotics within the hospital premises and the bacteria that survive and lurk in the hospital setting tend to be those that have antibiotic resistance. Outside of hospitals, the bacteria there tend to be the non-resistant type. So very often a VRE carrier in the hospital setting becomes VRE negative after being discharged. However, as this process may take some time, carriers can continue to shed VRE in their stools for many months. Hospitals have an interest to identify them early so that while in the hospital they can be isolated. This will reduce the risk of VRE spread. In the current episode, VRE was first identified by SGH on 9th March 2005 in a 75-year-old patient with multiple medical conditions. Through screening his close contacts, SGH identified five other patients with VRE. At that point, SGH decided to screen all its inpatients with a view to identify the carriers so that they can be properly isolated. In parallel, SGH staff were reminded to step up good infection control practices such as mandatory hand washing in between patients and stricter compliance of the 2-visitor rule in the hospital.”
“Sir, several Members have asked about the VRE cases in the Singapore General Hospital. Let me assure Members that VRE is not like SARS. All perfectly healthy people have billions of bacteria in their large intestines. Enterococci are examples of such bacteria. Normal healthy people also carry bacteria in their nose, mouth and skin. These usually harmless bacteria may occasionally cause infections like pneumonia (lung infection) or septicemia (infection in the blood). Such patients are then treated with antibiotics. Enterococci used to be always sensitive to the antibiotic, Vancomycin. But bacteria mutate and can develop resistance to a specific antibiotic. When bacteria become resistant to an antibiotic, a different antibiotic has to be used to treat infections caused by the bacteria. The first antibiotic to be used in the world was penicillin. After many years of penicillin use, penicillin-resistant bacteria emerged. The same happened after years of use of Ampicillin and, more recently, Methicillin. Staphlycoccus aureaus - bacteria normally found on the skin which become resistant to methicillin is called MRSA. Not surprisingly, after many years of Vancomycin use, we now have enterococci bacteria that are resistant to Vancomycin - VRE. VRE was first reported in England in 1986, nearly 20 years ago, and hospital-acquired outbreaks have subsequently been reported in USA and Europe. In Singapore, fortunately, VRE is still rare, with only a handful of cases reported in recent years. Very few patients actually fall sick because of VRE. Those who do tend to be patients with low immunity because of multiple medical problems such as renal failure, diabetes and cancer. In these patients the VRE may infect sites such as a wound or urinary tract.”
“--- has been able to generate 90% coverage, which is good enough.”
“I have explained this before. If I were to design MediShield from day 1, 15 years ago, I would have done so. I would have preferred to make it compulsory. So it applies to all because it benefits everyone. Unfortunately, we started off on an opting-out scheme. Having opted out and to go back to make it compulsory, I think it is a step backward. Will Singaporeans support that? I know NTUC heavily supported it. It is also my preference. But when I look at reality, opting out ---”
“It is xiao and wen. In other words, education is the art of filial piety. So filial piety forms the crux of Asian education. I think that piece of Asian wisdom we should never forget.”
“That aspect can be settled that way. The other aspect is more complicated - today's young subsidising today's old. The westerners did that. All the welfare states in the world "pay as you earn". And that is how the pension scheme was developed. It is wonderful when your demographics are in your favour. So for decades, it is the most kind and gentle system that one can evolve. But when they now go into the second half of the demographics curve, when the old are growing while the young are not growing, especially with very low birth rates, they know they are heading into insolvency. So if you read the newspaper reports, all the pension reforms, all the huge debates in the US and Europe are all over the same issue. We are a young society. I think we better learn from these older societies their problems. It is a huge trap that you are creating if you try to follow them. This is not to say that the young should not subsidise the old. But I think we have to subsidise it in a way which is sustainable for the long term. So what is Singapore's solution? What we have evolved over the years is top-ups. So whenever the economy can support, we top up. Whenever there are good budget surpluses, we set aside in endownment funds. And I think that way it is a much more sustainable model. More importantly, we make sure that we do not take away the role played traditionally by families. It is an Asian tradition that parents sacrifice for the young and when they become old, the young people, when they can earn money, support their parents. But society comes in to supplement. So filial piety, which was mentioned by Dr Chong Weng Chiew just now, is a fundamental value. It is part of our heritage and culture. If you look at the Chinese word "educate", jiao comprises two parts.”
“He said, and quite rightly so, that the elderly premiums are high, a few hundred dollars. But at a stage when you are probably on pension, no income, and yet your premium is high. So he says, "Why can't we average it out?" So for MediShield insurance, average it out means everybody pays the same rate, young or old. It means the young subsidise the old. But I reminded him that the premium range is as wide as $30 for the young per year to over $500. So, if we average it out, it means that it may be around $300 to $400. That means we expect everybody to pay $300 to $400, instead of $30 today. That is 10 times more. Can he guarantee that there will be no exodus of the young from MediShield? Because if there is, we will be in trouble. Then what is left would be all the old people, and what have we achieved? So that was when I used the word "exodus" in that light. Since we still have 5 minutes, let me elaborate a little bit about the young and old. This is a very complicated subject - young subsidising the old. There are two aspects to it. Are you talking about today's young, like Miss Penny Low, supporting tomorrow's old when Miss Penny Low becomes older 20-30 years down the road? That is one aspect. The other aspect is today's young, again using Miss Penny Low as an example, subsidising today's Khaw Boon Wan. The first aspect is easier to handle and is probably more equitable. You are talking about the same person. We are just saying, "All right, when you are young and working, you pay more, so that when you grow old, you get these services." I have incorporated that into our MediShield reform. So we have a loyalty programme. The longer you stay with MediShield, when you become 70 years old, you will stand to get discounts as high as 40% off. So that is cross subsidy.”
“Instead of I looking at you, when you step into my hospital, then I am interested in you, and the moment you are discharged, goodbye; or the moment you walk into my clinic, I am interested in you, and the moment you leave, sorry, you are another digit, another medical record. But to bring that about, there are huge challenges. Fortunately, technology is beginning to help us. So yesterday, when I outlined the vision of one Singaporean, one electronic medical record, it is crucial. Because without that infrastructure, how can I share information with the GPs? Because, today, you may come and see me; tomorrow, you may walk into another private doctor. But how to share it? You require this infrastructure. From the IT planning point of view, it is no big deal. We only have 4 million people. So it is actually only four million electronic medical records. What is the big deal? In the financial sector, all those multinationals, like CitiCorp, you can go anywhere in the world, there are ATM machines, you have got the right password, and you can access your account. And that is global. Why can we not do it in the tiny little place called Singapore? Who has done it in the world? Nobody has done it. I have a certain sense of optimism that because we are small, we are compact, we are better organised, and more importantly, the political leaders here enjoy a certain level of goodwill and trust by the people that we can have a better chance of making it happen. And if we do, then I think we will have made a major contribution to the whole practice of healthcare which can be a model for the rest of the world. The last point is about exodus. I used that word in relation to Mr Low Thia Khiang's comment yesterday.”
“Her second point is about SingaporeMedicine and integrating the public and private sectors. Certainly. I made a major message in my earlier speech that we fight as one team, if we want SingaporeMedicine to succeed against the rising competition from China, India and so on. If we have civil war inside, treating each other like enemies, then I think the battle is lost. The important thing is that the competition is outside. And within Singapore, the only competition is against diseases and illnesses, and we are all partners fighting this common enemy. It is like SARS. So whether it is SARS, whether it is obesity, diabetes or stroke, that is the enemy. And where we can work together to improve the welfare of Singaporeans through better health, that is what we should do. But in practical terms, I have got to make sure all this starts from the public hospitals first. Then I am on moral high ground when I tell the private GPs or private hospitals to join me in this cause. 1.45 pm Dr Lily Neo is helping us out in a significant way in the Jurong HealthConnect that Dr Maliki mentioned just now. That is a huge skunk works, pioneering work. Nobody is doing it in the world. We are at least attempting to try to solve this problem. I outlined this concept last year at the Budget debate. I was very happy that Dr Tan Cheng Bock, Dr Lily Neo, now, Mdm Halimah, and others are chipping in because it is a challenge. At the same time, if we can get it fixed, I think we would have made a major contribution to transforming how we deliver healthcare. What is the end point? The end point is that everybody begins to look at the patient as a person. And we are all partners, as a team, trying to bring about better health for this patient.”
“Sir, since my name has been mentioned, I have got to respond. I thought I could relax already! Dr Lily Neo asked about supply induced demand and what are we doing in the public hospitals. If Members had listened to what I said yesterday, what I am trying to evolve is an approach, because the bottom-line is this: we cannot possibly micro manage every department, every operator. My job is to make sure that the framework is as market-friendly as possible, to allow operators themselves to have the incentive to do what is right. That is the larger picture. It is easier said than done but I think, progressively, if we eliminate distortions, we make the framework better. So some of the moves that I made in the last 12 months - block budgeting is a good example - where as long as the incentive is to reward volume, as Mdm Halimah pointed out, then, of course, supply induced demand would just grow and grow. But if I now say, "Sorry, this is your budget. It is an increase over last year. This is what I can afford. This is what I can get from the Ministry of Finance. Do the best with this budget. If you make savings, you can keep the savings or you can use those savings to introduce new services, improve on other activities and so on. Or pay your staff better so that you can retain your staff." Then I think CEOs and hospital departments would begin to think and do what is rational. Whereas if we try to micro manage and tell them to do this and do that, I can do that. I spent many years running hospitals but I always remind myself every day, when I walk into the Ministry of Health, not to try to become a hospital CEO or Permanent Secretary. That is the discipline that I always constantly remind myself. So I focus on what is the larger picture, the larger framework.”
“But I am confident that we have enough sense to know that the competition is not against each other. Competition is against diseases. Our focus must always be on how to improve health, how to reduce illness, how to do better and more with less, for the sake of all Singaporeans. Our success will depend on whether we have the right leadership at the front line: hospital CEOs who see the larger picture and share the vision, and yet at the operational level, are hands-on at the helm of a tightly-run ship. They serve the doctors, the nurses, the frontline staff, make sure that the right systems are in place, the right people are well-trained and well-deployed, and facilities and equipment are working optimally so that our professionals can care for their patients in the best and least-costly manner. If we stay focused on the right thing and have the right people in charge, I see no reason why we cannot be the best in the region.”