Lily Neo
Singapore
“Thank you, Mr Speaker. May I ask Minister for Health on MOH's capacity in coping with serious cases of COVID-19 in terms of adequacy in respirators and in our ICU beds. Am I correct to say that already half of NCID's ICUs are taken up? What will happen when it reaches its full capacity?”
“But even so, with the right measures of social and medical assistance in place to assist them with their daily living, they can still age gracefully in the comfort of their own homes.”
“Thank you, Mr Chairman. Yes, I will keep it short. Minister earlier said that MSF will proactively reach out to families in HDB rental homes to assist them, to possibly buy their own HDB flats. Many of these families lamented that they cannot afford it. How does the Minister plan to do it?”
“Thank you, Mr Chairman. May I ask the Minister whether there is a possibility of more widespread community spread of COVID-19? And will MOH be able to cope with this? And whether does our Government have more specific measures in place to cope with this scenario?”
“Thank you, Mr Chairman. Earlier in my speech, I asked whether there are assessments by HDB for applicants of Joint Singles Scheme (JSS) to ensure that they are free from mental illnesses and medical conditions before compelling them to stay together.”
“Many of them have lived in rental housing for more than six years and some more than 10 years. Thus, there are signs of entrenchment. What are the schemes in place and the success rate of such schemes, to assist them in looking for better options in their housing needs and to help them get out of their predicaments?”
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“Sir, there is even an instance of three en bloc redevelopments with buildings to go as high as 30 storeys approved on sites with buildings of 10 storeys on a short narrow road with definite constraints to road widening. Under the Planning Act, it is a requirement for the Development Guide Plan to be exhibited so as to obtain feedback from the residents and the general public. Sir, as the notice is usually placed in an advertisement, it is not satisfactory because many people may not have read or paid attention to such notices. We may perhaps improve in this area by sending letters to the residents and allow them an opportunity to raise objections, when necessary. Sir, I would like to urge the Minister for National Development to look into the abovementioned issues.”
“Sir, ongoing is a spate of en bloc sales which will bring with it a whole new set of potential problems. Kim Seng, being Districts 9 and 10, has its fair share of en bloc sales and some residents there have voiced their concerns and their "headaches" on the matter. The most frequent complaint is about the noise and dust from the redevelopment projects. Other inconveniences, such as obstructions, traffic snarls and increased numbers of non-residents all add up to the stressful environment. Worse still, are situations where several projects are going on in the same area simultaneously. Since these areas are all densely populated, the number of people inconvenienced is considerable. The ill effects on these people can become intolerable. Sir, what can the Ministry of National Development do to lessen the pain of these residents in their predicament? There is usually an increased plot ratio granted in most of these en bloc sales. Many new redevelopments can therefore have buildings as high as 30 storeys or more. I know the Government is allowing this plot ratio change to optimise the land use in Singapore. The Minister for National Development has, earlier in his reply, touched on this subject with some assurance on the plot ratio change. My concern however is whether we have indeed allowed this increased plot ratio even though there are physical constraints. For example, is it right to grant a plot ratio change when the site area is small and the access roads are tight and heavy with traffic? Will we have a situation where residents have to queue just to get out of their own gates?”
“If the third party were a subsidiary of the supplier, section 47 of their Trade Practices Act would not prohibit the supplier from forcing the customer to purchase products from itself and its subsidiary. Will the Minister for Trade and Industry consider introducing a similar Fair Trading Act in Singapore?”
“Sir, I would like to urge the Minister for Trade and Industry to look into the issue of "third line forcing" as an unfair trading practice in Singapore. In "third line forcing", the supplier's goods or services will not provide the goods or services unless the customer agrees to purchase from a third party chosen by the supplier. The supplier is thereby "forcing" the customer to purchase from a third party as a pre-condition to supplying the goods and services to the customer. Sir, the most common type of "third line forcing" can be found in lending arrangements. Take this for example. Before lending money for the purchase of a new home, a bank requires the borrower to take out home insurance. Unless the borrower insures his home with the insurance companies stipulated by the bank, the bank will not approve the loan to the borrower. The effect of this arrangement limits the choices to the borrower. This type of arrangement is illegal in Australia, a country advanced in terms of its statutes, legislation and court processes. Sir, we have adopted much of Australian legislation, such as the Land Titles Act, the Companies Act and also their mediation and dispute resolution processes. The rationale of making "third line forcing" illegal under their Trade Practices Act is that it snuffs out competition, which can only be beneficial for the citizens. There is, however, a slight inadequacy in the Australian Trade Practices Act which we may further improve on. Their law only stops arrangements between the supplier of goods or services and a third party. Their law does not prohibit a supplier requiring the customer to purchase another product or service of the supplier.”
“Will the Minister be able to get better postulation on our medical staff requirement, considering that medical training takes many years to complete and that many years of advance planning is necessary?”
“May I ask the Minister whether it is likely that we will be requiring many more doctors for multi-factorial reasons, one of which will be the ageing population that will need more medical care. And will a shortage of doctors in fact be perpetual in the coming years, especially if we have to depend mainly on our own university for the supply of our medical personnel?”
“May I ask the Minister if we are in fact short of doctors here again and, if it is so, why are we adhering with the policy of restricting the number of recognised universities for medical students?”
“Before the Legal Aid Bureau takes on a case, the Director will assess the facts to see whether such a case is worth defending or litigating in. It does not appear equitable to punish the aided person who relies on the legal advice and judgement of the Director and Legal Aid Bureau's solicitors. There are many people who are unable to afford lawyers and who are not qualified for legal aid. Sir, this is unfortunate and the situation can be redressed if the means test is made less stringent. In countries like the United States, people are not prejudiced because the legal mechanism works on a contingency-based system. In other words, the lawyers get a percentage of the "winnings" and expect nothing if they lose. We do not have such a system here or it is illegal. Sir, I hope the Minister for Law will address this issue.”
“Sir, I would like to highlight an aspect of legal aid in Singapore today and urge the Minister for Law to look into it. The Legal Aid and Advice Act is essentially an Act which seeks to render aid to Singaporeans and permanent residents in financial need. Applicants for legal aid have to qualify under a means test which, in my opinion, is stringent and does not truly reflect cost of living and salary scales in this present time. Under section 8 of the Act, legal aid may be granted where the Director is satisfied that the criteria, as set out in the Second Schedule, are met. The applicant must not have a disposable income of $7,000 per year and disposable capital of $7,000. "Disposable income" for the purposes of the Act includes that of the applicant's spouse. Thus, an applicant must not earn more than $583 a month and this excludes the spouse's income. Sir, this is totally unrealistic, as even certain lowly jobs easily pay more than that. It is too stringent a means test because a family with two children and a combined income of, say, $1,000 will not be able to cope financially when even a simple case in the Magistrate's court can easily cost $10,000 in terms of legal fees. In fact, the Director has an unfettered discretion to refuse legal aid even if the applicant qualifies under the means test. This is reflected in section 8(3) of the Legal Aid and Advice Act. Section 14(3) enables the Court to direct the applicant to pay the costs of the Director, the solicitor and the other party's solicitor if the Court feels that the aided person has acted improperly in bringing or defending any legal proceedings or in the conduct of them. My view is that this is unfair and punitive.”
“Without this basic shift in mindset, even all the favourable areas in our present healthcare system will sadly go to waste. (4) Many schemes must be structured properly by the Ministry of Health. For example, the visiting consultant scheme must be structured by an objective panel so as to optimise the benefits. Prime Minister Goh did suggest previously that this scheme should be enhanced and called on more private specialists to contribute their services to Government hospitals as visiting consultants. At the moment, this scheme cannot be enhanced because it lacks the directive from the Ministry of Health. Private doctors have to depend on friendship and courtesy of their colleagues in public hospitals to be invited as visiting consultants. Some feel redundant and unwelcome even after being offered visiting consultant posts. To succeed, this scheme must be structured, with the appointments made by a panel from the Ministry, and a clear programme drawn up to optimise the visiting consultants' time in public hospitals. (5) Fuller cooperation by the private sector must be forthcoming, for example, to accredit Government specialists as consultants to private hospitals. Government doctors could be allowed to work in primary healthcare set-ups such as general practice clinics. In other words, let us evolve a system where the cross-borders between public and private sectors are less distinct. Mr Deputy Speaker, Sir, this new directive, if adopted, will bring medical healthcare in Singapore to even greater heights. This opportunity to maximise our present medical healthcare system should be harnessed quickly and fully. I therefore beseech our Government to proceed immediately for greater integration of the public and private medical sectors in Singapore. 7.15 pm”
“Super-specialists will then get more patients to hone and improve their skills. Patients, whether local or foreign, will benefit because they will get to be treated by the best in each field and from a wider base of doctors and specialists. (10) Our talent pool is unnecessarily segregated and restricted in their respective positions in the two sectors. Many doctors will have the chance for research work and teaching as well as to have a private practice if their more dispensable roles can be shared out amongst more colleagues. The private practitioners, in the present system, can lighten the workload of Government doctors if allowed to work in the public sector as visiting consultants, treat subsidised patients and impart their skills to the younger doctors. Mr Deputy Speaker, Sir, we should look at some of the basic steps that must be adopted to bring about integration as follows: (1) Unless the Government is serious about integration of the public and private sectors and actively promote it, all efforts in this ideology will not come about. The Government, therefore, must be even handed in all aspects of its handling of the private and the public sectors. It should be concerned about the well-being of the private sector also. (2) Government must be seen to be committed towards bringing about this change. The appropriate funding and incentives provided by the Finance Ministry will be a good start. The correct directives must also come down from the Ministry of Health to all public medical sector and private medical sector. (3) There must be a paradigm shift of mindset of all doctors in Singapore to work as one in synergism and not in competition, to aim to become a regional medical hub for the good of the country and the people.”
“(5) Both private and public sectors could work together to develop Singapore into a Regional Medical Hub. Mr Deputy Speaker, Sir, the two sectors should not be in conflict but should be in synergism, or Singapore will lose the leading edge over the neighbouring countries. As it is, many overseas patients are now finding Penang to be a very good alternative place to seek medical treatment in lieu of Singapore. (6) Integration will restrain the exodus of specialists from the public to the private sectors, especially during good economic times. This will prevent uneven spread of talent. This will also bring earnings of doctors in both sectors more comparable with one another and stem one of the major reasons for the outflow of doctors to the private sector. (7) Training of young doctors will get a boost from the active participation of private doctors, both general practitioners and specialists. Sir, there are many private practitioners who love teaching and are, indeed, very good at it. Training young doctors should therefore be seen as a national concern, involving doctors from both sectors, as it is a "very specialised, time-consuming and expensive" exercise. (8) Doctors can learn from each other when more collaborative work becomes possible through integration. They will learn when they work together and get to see and treat more complicated cases that they may not otherwise meet individually. This will further fine-tune the skills of our doctors, and thus get closer towards our aim of being a regional medical hub. (9) With the healthcare system integrated, both doctors and patients will benefit. Specialists from both sectors can be called in to treat local and foreign patients, especially in areas of super-specialisation.”
“We must look at things globally and we are doing in so many aspects of our forward planning. Our healthcare plans should be included in this overture and I am suggesting that we quickly do away with the divide between the public and private sectors of our healthcare system. Mr Deputy Speaker, Sir, I would like to give ten reasons to emphasise the importance of integrating the public and private medical sectors in Singapore. I am sorry I have to hold you back, my colleagues. (1) Singapore is a small country; an integrated system will lead to maximisation of potential in the medical arena. (2) The public and private sectors should work together to plan facilities more efficiently. Integration will reduce duplication of facilities, in terms of expensive equipment such as the gamma knife, etc, in the two sectors. Sir, there is certainly no necessity for duplication of facilities in certain highly specialised fields of medicine where the patient pool in the country is limited. (3) It is more sensible to maximise the use of our healthcare personnel. For instance, the experts in the very specialised fields like liver transplants should be allowed to operate in both sectors because there is really not a sufficient pool of patients from our population of three million to support these areas in the divide of the two sectors. Another example is to make the private practitioners look after a portion of the "subsidy patients" and ease the load in the polyclinics and specialist outpatient clinics. (4) Patients will stand to benefit from integration of the two sectors because there will be more equitable availability of quality care. The costs will be better contained and the wait times will be less lengthy.”
“BG George Yeo, when he was Minister for Health, supported the notion for greater integration of the public and private sectors. Integrate these two sectors and we may even achieve global recognition as being one of the best. Staying on with BG George Yeo, he mentioned that he had visited the Mayo Clinic at Rochester in Minnesota. He noted that Rochester was a small town of less than 100,000 inhabitants, in the middle of nowhere and has beastly cold winter four to five months a year. But it has the most wonderful medical facilities in the whole world. And because it serves the rich and famous from around the world, the people and Rochester enjoy a quality of healthcare not possible for any other prairie town of 100,000 in America or in the world. He said that in the same way, if we were able to establish Singapore as a "Mayo Clinic in South East Asia", then all of us who happen to live in Singapore will enjoy a quality of medical care far surpassing what a population of three million would otherwise deserve. Singapore will be a "Mayo Clinic in South East Asia", Mr Deputy Speaker, Sir, and the way towards achieving this is through the integration of our public and private medical sectors. There must be a change of direction towards integration rather than maintaining division. Singapore is a small country with a small population; we must derive our strength through unity. We must remove the unnecessary waste of energy on competing and bickering amongst ourselves. Our energy should be used to put all our resources to maximal use. In the past, the Government's policy has been to rely on competition and market forces to keep health cost down. Sir, we need a mindset change now; these are different times.”
“Mr Deputy Speaker, Sir, I stand to urge the Ministry of Finance help chart the future work of the Ministry of Health in a new direction and for the better of healthcare in Singapore. It is a known fact that the right allocation of funds will determine the advancement of certain desired outcome. Sir, the new direction I would like the Ministry of Health to go in this new millennium calls for a greater integration of the public and private medical sectors in Singapore. This is far removed from the type of integration that we have been stressing on - the vertical integration between primary through to tertiary services and facilities all within the public sector only. What we need to look into is the lateral integration, say, between the polyclinics and the private general practices, between specialists in restructured hospitals and those in private practice and between restructured and private hospitals, etc. I do contend that there is already a little integration in our health system at the moment. The Health Ministry allows private doctors to come back as visiting consultants to teach and to impart experiences to the younger doctors. A set of scheme under the Ministry of Health has specialists providing services in hospital departments that are short in such expertise. The Health Ministry taps expertise from private sectors with the setting up of specialist centres. Among doctors, collaboration for complicated procedures, such as open heart surgery or liver transplant, is common and fairly routine. There is, however, a distinct and disturbing divide between the private and public medical sectors in Singapore. And, Sir, this divide is and will always be a dilemma for healthcare here.”
“Sir, I beg to move, In page 12, line 32, to delete the words "without assigning any reason,". Sir, my reason for proposing the deletion is that it sounds too harsh, as it gives an absolute discretion to the Minister to reject any application without assigning any reason. Secondly, the deletion will, in a way, leave a room for the Minister to give reason if any applicant attempts to appeal or ask for a reason for the rejection. Without the deletion, the Minister may conveniently refuse to entertain any such request.”
“Sir, the Minister said earlier that the ElderCare Fund will also go towards the recipients of home care. I want to ask him how would this work and who will be eligible for this ElderCare Fund. Will the recipient be the beneficiary or the carer of the recipient?”
“Would the Government also encourage donations with an incentive of three-to-one matching grant, similar to that given to the CDCs? I would like to suggest that the Ministry of Health devise a plan for the approval and disbursement of the Medifund and ElderCare Fund via "local councils". Such "local councils" could be the CDCs. The authority to assess eligibility and to approve the use of these Funds can then be devolved. The Ministry will, hence, need less administrative manpower. Each CDC could be made to raise some of the money so that it will have more authority to disburse the funds. It is likely that the CDC, through its closer rapport with the constituents and with the liberty to decide whom to help in its ward, will allow for more effective disbursement of the funds. The CDC will also become more relevant to the people. Sir, as Members of Parliament have closer contact with their residents and also have the help of the grassroots workers, they would know the needs of the residents better. They could be advisers to these "local councils". Mr Speaker, Sir, I would like now to comment on the following clauses of the Medical and Elderly Care Endowment Schemes Bill. Clause 6 The Act to be repealed specifies that the Advisory Council should contain not less than five and not more than nine members. The Bill does not provide for any minimum or maximum number and is left to the discretion of the Minister. Is there any reason for this? Clause 25(6) Where there is any suspension, the approved provider shall not be regarded as one. What happens to its patients in the interim? I hope the Minister for Health could enlighten me on these points. Mr Speaker, Sir, I support the Bill although I would like to propose an amendment to one clause of the Bill at the Committee stage.”
“Mr Speaker, Sir, I would like to support the Medical and Elderly Care Endowment Schemes Bill. In fact, I am very glad that the Government has come up with yet another provision to cope with our fast-increasing population of elderly and an ever-increasing ratio of non-working to working individuals in the near future. It is good that there is now a scheme that gives Singaporeans further peace of mind in their golden years. I would, however, like to add that this Government must continue to promote and encourage some of the very basic values that have served us well all these years. Sir, the need for self-sufficiency and looking after one's own kin and families in our Asian values should be emphasised. Otherwise, the two endowment funds which are to serve only as safety nets for those really in dire need, will be found lacking through callous and overwhelming demand. The ElderCare Fund, like the Medifund, will be for the nursing care of our needy elderly in future. As announced by the Minister for Health in his introductory speech, the Government will build up the ElderCare Fund with an initial capital injection of $200 million. Further capital injections will be made when budget surpluses are available. Only the interest income of the ElderCare Fund will be used to fund the operating subsidies to VWO nursing homes and extension to other kinds of step-down care services will be considered when the ElderCare Fund has more resources. Sir, in order to build up the ElderCare Fund faster so as to extend the other services sooner, would the Government consider accepting donations from private organisations, philanthropists or even grassroots organisations?”
“Sir, will the Minister consider a more pro-active approach regarding giving information to our public whenever the Ministry detects an imminent epidemic, especially to inform the susceptibles to go for either vaccination or even immunicable injection?”
“May I ask the Minister whether he would consider mandatory reporting to the Ministry of Health by doctors on all medical errors including near misses, with the assurance from the Minister that this is a matter of investigation so that certain improvements could be made to correct any individual or system deficiency, and not for litigious proceedings?”
“Sir, may I ask the Minister how many deaths were there in Singapore in the past 10 years due to medical errors, and how many doctors were implicated as negligent?”
“May I ask the Minister whether we have a regulation that compels the employers to inform employees to stop work as soon as they are pregnant because we cannot depend on designated factory doctors. A lot of time, the designated factory doctors do not know who are the patients that are involved with such hazardous materials.”
“Further, section 47A (4) states that a written description of the safe work procedures shall be kept by the occupier or the employer. As such, I feel that section 47A (5) should provide that the occupier of the factory or the employer is required to ensure that every person in the factory will observe and comply with the procedures. Sir, the proposed section 47A (5) does not seem to impose such a duty on the occupier or employer. Also I wonder whether the word "inspector" appearing on the last line of section 47A (4) refers to the Chief Inspector. If it is, why not state "Chief Inspector"? Amendment of section 88 - Mr Speaker, Sir, may I ask the Minister for Manpower if the new section 88(14) is really necessary. I ask because the law on partnership is clear, and we have a Partnership Act (Chapter 391) covering this situation. Amendment of section 89 - as the explanatory note states, this new section 89(6) is to enhance the penalty for second or subsequent conviction. However, one may note that all other subsections have provided that additional fine per day could be imposed for further offence if contravention continues after the conviction. As such, I wonder whether the enhanced penalty, that is, the amount of fine in the new subsection 6, includes the additional fine. Sir, I stand to support the Factories (Amendment) Bill.”
“Sir, what are the measures taken by the Ministry concerning the protection of expectant mothers in the handling of materials that may cause abnormality to developing foetuses? Do we compel our factories to inform our female workers on the dangers to their newborns in certain hazardous factory jobs? This is to ensure that expectant mothers cease holding such jobs from early pregnancy, that these teratogenic effects take place during their early weeks of pregnancy must be highlighted to these workers. I hope the Minister can enlighten me on the queries I have posed. I would like now, Mr Speaker, Sir, to comment on some of the amendments in the Factories (Amendment) Bill as follows. Amendment of section 6 - I believe that the word "liquified" appearing in section 6(2)(m) also needs to be amended to read as "liquefied" similar to section 6(2)(t). Amendment of section 9 - I feel that some flexibility has to be given for the fixed period of one month. Perhaps the substitution should read as "one month or such extended period as the Chief Inspector may approve in writing". New section 27A - I feel that these words "if so required by the Chief Inspector in writing" should be inserted immediately after these words, "The occupier of a factory shall", appearing on line 31. It is difficult for the occupier of a factory to know whether his employees fall into that class or description, unless some form of notice is sent to him by the Chief Inspector indicating that his employees do fall within that category requiring safety training courses. New section 47A - I note that section 47A(1) (d) and (3)(b) require employees to be made familiar and to be informed on the safe work procedures and means.”
“Sir, I have encountered factories sending all their staff, including their managers, who do not deal with hazardous substances, for regular check-ups for such substances, and thereby adding unnecessary costs to their healthcare expenditure. How does the Ministry decide on the interval on the compulsory medical check-ups required by the workers for each hazardous substance? How does the Ministry balance the safety aspect of each hazardous substance with the cost for the factories? Furthermore, is the Ministry providing designated factory doctors the necessary continuous updates and education on new hazardous materials approved by the Ministry so as to ensure adequate check-ups through appropriate blood tests and other investigations on their factory patients? More importantly, Sir, how does the Ministry help to educate both the management and the workers on the side effects of the hazardous materials? Here, the age-old adage "prevention is better than cure" is most apt. If the management were aware of the harmful effects of certain substances, they would be more inclined to provide the necessary protection for their workers. If the workers know about the adverse effects of certain substances that they handle each day, they will certainly be more prepared to comply with the safety measures that are prescribed and provided. Take, for example, the use of earmuffs at noisy factories to prevent noise-induced deafness. Most workers complain of discomfort or inconvenience in their use and often ignore the advice given. They will probably be more compliant if they realise how easily they may suffer the debilitating effects of noise-induced deafness.”
“Mr Speaker, Sir, I stand to support the Factories (Amendment) Bill. I wholeheartedly support especially the part of the Bill that further ensures the safety of factory workers. I would like, however, to seek clarifications on certain aspects regarding the safety of workers in factories and comment on some of the amendments to the Bill. Sir, how does the Ministry monitor and ensure that all the factories using hazardous materials comply with the safety precautions required in the use of such materials, especially of new chemicals? There are new advances in technology all the time and as such, new chemicals and other substances are constantly being churned out for use in our factories. Section 60A in the Factories Act provides regulatory control on the use of toxic, corrosive and inflammable substance under the Material Safety Data Sheet. How does the Ministry enforce this regulation, especially with regard to new materials used? Indeed, Mr Speaker, Sir, how does the Ministry keep track and recognise adverse side effects that these materials may possess? Under section 60A(3), the fine for contravening the aforesaid regulation has not been changed from $5,000. Is this an oversight, in view of the increasing relevance in this area with more newer, possibly toxic, substances being available due to improved technology? There is a provision in the Factories Act (section 69) requiring all factory workers that are exposed to hazardous materials to go for regular medical check-ups. How does the Ministry ensure that the exposed workers go for the check-ups? Furthermore, how does the Ministry help the factories determine "at risk workers" that should go for regular check-ups?”
“I would like to thank the Minister for his vision that best practices will be maintained in the implementation provisions of this Bill. May I ask the Minister whether he will appoint several lay persons to be in the Singapore Nursing Board so as to allow broader views, perspectives and objectivity?”
“I am of the opinion, Sir, that there should be specifications like holding a Masters degree or equivalent qualification, in a specialised branch of nursing, and a minimum of five years of experience in that branch of nursing. Under clause 32(4)(e) and (4)(f), there should be a statutory recourse, same as in clauses 17, 18 and 19 as in the case of nurses and midwives, instead of leaving these to the discretion of the Board to make regulations. Clause 39 provides for the appointment of a legal assessor and a medical assessor. Here, Mr Speaker, Sir, whilst the role of the legal assessor is broadly defined, there is nothing mentioned about the role of the medical assessor. There is also no mention made about the requirements of a medical assessor as in the case of a legal assessor who needs to be an advocate and solicitor of at least 10 years' standing. In order for a legal assessor to make a meaningful contribution, his role should not be restricted to questions of law. Indeed, there is very little question of law involved in determining the requirements of the approval, cancellation and suspension process, and it deals a lot with the facts and arguments of facts to which contributions from a suitable legal assessor with an appropriate background will undoubtedly be immense. For instance, questions of whether the conduct or negligence of an applicant or a nurse or midwife would render him unfit to be registered or enrolled. Sir, I support the Nurses and Midwives Bill.”
“Since this affects livelihood, it is not unreasonable that an applicant be given more than a chance. Clause 22 deals with conviction final and conclusive. Under this clause, it appears to mean that anyone convicted of a criminal offence cannot be registered or enrolled, or whose registration or enrolment will necessarily be cancelled. There is no definition in this Bill of "criminal offence". Taken broadly, it simply applies to all offences (and this extends beyond the Penal Code) which lead to conviction. Sir, the offence, which a person is convicted of, may not be relevant in determining whether he or she is fit to be a nurse or midwife. Clause 23 concerns application for re-registration or re-enrolment. In clause 23(3), the restriction on re-application seems harsh, as three years is a considerably long period since this concerns a person's livelihood. Clauses 28 and 29 deal with the appointment of unqualified persons to practise nursing or midwifery and with the nurse's agents. Here, under clause 28(5)(b), clause 29(3)(b) and clause 29(4)(b), the words "due diligence" connote a higher level of care than "reasonable diligence". Sir, is it then sufficient if the nurse or midwife produces a copy of a current practising certificate and a prospective employer accepts this? This would be deemed a reasonable effort on the part of the employer, but to show "due diligence" would infer that he should investigate further, like seeking confirmation from the Board as to its authenticity. Clause 32 is about nurse specialists, etc. Clause 32(2)(a) (b) and (c) deal with registration of nurse specialists and the issue of nurse specialist certificates. Here, there is a vague definition on the type of specialist's qualifications.”
“For the purposes of the Act, professional misconduct, in relation to an accredited nurse, means unsatisfactory professional misconduct of a sufficiently serious nature to justify the removal of the nurse's name from the Register. For the purposes of the Act, unsatisfactory professional conduct includes any of the following:- (i) any conduct that demonstrates a lack of adequate knowledge, experience, skill, judgement or care by the nurse in the practice of nursing; (ii) the nurse contravening (whether by act or omission) a provision of this Act or the regulations; (iii) the nurse's failure to comply with an order or condition of registration; (iv) any other improper or unethical conduct relating to the practice of nursing. It is noteworthy that the aforementioned grounds are all relevant and the words "conduct relevant to the practice of nursing" are significant. This qualification, Mr Speaker, Sir, is strikingly absent from our aforesaid Bill. Under clause 17(6)(a), the Board needs to consider the reasons why the registration or enrolment in another country has been cancelled or suspended. This may be due to mere technicalities as, for example, when the applicant had failed to pay the prescribed fee on time or when the applicant was no longer practising in that country. The provision in its current form does not impose such an obligation on the Board. Under clause 17(7), the Board should not only inform an applicant by written notice of such refusal pursuant to the section, it should also furnish its reasons for the applicant to lodge a meaningful appeal to the Minister. Sir, the rules of natural justice also suggest that there should be a procedure whereby an applicant can appear before the Board to submit his case, prior to the final avenue of appeal to the Minister.”
“In the past, the majority of the members are from the public sector. As there are about 30% of nurses or about 3,827 nurses in the private sector, it would be reasonable that this clause caters for at least four members from the private sector. Clause 6(1) provides for the appointment of the Chairman of the Board and it states that the Minister shall appoint one of the members as the Chairman of the Board. In my opinion, the Minister should appoint a registered nurse as the Chairman of the Board. In the past, this has not been the case with the Singapore Nursing Board, as the Directors of Medical Services have been the Chairmen. The appointment of a registered nurse as Chairman in the Nursing Board is adopted in countries like Australia, New Zealand, England and America. This is logical and would be in line with practice in the other professional bodies. Clause 17 deals with the general provisions for registration and enrolment. Clause 17(5)(b) states that the Board may refuse registration or enrolment where the applicant is, in its opinion, not of good reputation and character. This subclause is too brief and open to subjective opinions, as there is no relevant yardstick. A test of relevancy should be applied, as for instance, "not of good reputation and character which renders him unfit to be practising as a nurse or midwife." Sir, in this area we may find some useful provisions from the equivalent Australian Nurses Act 1991. Now, the Australian Act defines "professional misconduct" and "unsatisfactory professional misconduct" as being two instances where there can be a cancellation.”
“Mr Speaker, Sir, I stand to support the Nurses and Midwives Bill. This new Bill is much more comprehensive in comparison to the old revised Nurses and Midwives Act of 1985. This new Bill will more aptly address the new and changing trends in many areas of the nursing field. Sir, I would like, however, to raise a few of my concerns in this Bill. Clause 3 provides for the establishment of the Singapore Nursing Board as a body corporate and constitution of the Board. Clause 3(2)(a), (b) and (c) spells out the members of the Singapore Nursing Board. Sir, I feel that here we should include as a member the President of the Singapore Nurses Association. It is more appropriate to have the representative of the voices of the nursing profession to be in the Board. This will give weightage to the Singapore Nursing Associations, to recognise them and to acknowledge their contribution. Clause 3(2)(d) specifies that 14 members are to be appointed by the Minister. Under this action, I have three points to make. (1) I feel that we should have a provision for the recommendations from the Chief Nursing Officer, public and private health care institutions and the Singapore Nurses Association. (2) The Nurses Registration Board in New South Wales has 13 members, most of whom are nurses but three are lay persons, out of which one is a lawyer nominated by the Minister and two are nominated by the Minister as representatives of consumers. Sir, the benefit of having people outside the profession is that it allows a wider spectrum of views, perspectives and objectivity. I think this is a good idea and should be considered by the Government. (3) There is no specification on the number of members from the public and private sectors.”
“(5) Establish better distribution of subsidy. Directive on funding should be towards better distribution of the subsidy to those that are really in need. We must make sure that there is no loophole in our system that may lead to abuse, misuse or "buffet syndrome". Singaporeans are pragmatic and will usually not "waste" any windows of opportunity that comes to hand. Our present subsidy guidelines are not the most rational because anyone can get the maximum subsidy if he so chooses. The Ministry of Health does not apply any "means test" as compared to the Ministry of Community Development or the Ministry of National Development. New funding for the chronic sick for long-term healthcare should be worked out as soon as possible. Perhaps, we should look at utilising a Medisave-type of funding here. A lot of work will be needed to establish the criteria on the use of funds for long-term healthcare as in, say, how primary healthcare providers could be remunerated in a reasonable and controlled manner to ensure affordability. Mr Speaker, Sir, we are fortunate here in Singapore. We have the means to afford world-class medical care for our people. We have the personnel and premises to dispense the medical excellence to our people. We also have an abundance of ideas and means to turn this country into a regional medical hub we allude to not infrequently. So let us make sure we get the best mileage from what we have. Sir, I support the motion of thanks on the President's Address.”
“Sir, I have brought up and discussed this important issue at an Adjournment motion earlier. (4) Plan for an ageing population. It is important for us to adopt correct and effective policies in this area right now so that we may cater for the diverse and varied needs of an ageing population. Done the right way, we will also be cushioned against increasing demands in future. I am glad that the President, in his Presidential Address, referred to the recommendations of the Inter-Ministerial Committee on Ageing Population and said, "We must start now to implement policies and programmes to address these future needs." Mr Speaker, Sir, bear in mind that the ageing people will be the main users of our medical healthcare, I would suggest that we consider the following points: (a) Plan for more "cheaper to run" community hospitals for the chronic sick. We do not need more acute hospitals as we do have more than enough of them at the moment. (b) We need to better postulate the needs of an ageing population, especially in terms of the number of nursing homes, dementia homes, geriatric departments and geriatricians. (c) We seriously consider the most effective way to cater for the chronic sick in the future and that would be to get the primary healthcare doctors to share the workload. Sir, I would like to declare, at this juncture, that I am a primary healthcare doctor. Shared care and step-down care to the primary practitioners will certainly reduce the use of acute hospitals and community hospitals. Moreover, patients will also benefit through staying at home and close to their own families. (d) We increase the teaching of gerontology for all medical personnel and establish geriatrics as a worthy specialty for younger doctors to pursue.”
“It would be better if there is no excessive re-duplication of specialty and especially super specialty services. It would also be better to allow for the free flow of medical personnel, where applicable, to maximise the results of service. At the moment, even public hospitals compete with each other. Terms like 'double standards', 'competition', 'level playing fields', 'limited use of Medisave' and the like are frequently used nowadays. Many restructured hospitals are under pressure to perform well, especially in monetary "bottom-line" at the end of each year. If that becomes the dominant factor, the ensuing policies that the hospitals make will invariably take on pecuniary inclinations. Consider, for instance, the situation when hospitals remunerate doctors for the number of patients they see. Theoretically, the doctors might hold on to a few more of those patients that could be discharged and thereby increase their patient-load. The resultant effect would be insufficient time being allocated to each patient. The patients would be at a disadvantage because the excessive numbers of patients would diminish the quality of care. This is another example of market failure at work. Mr Speaker, Sir, the Ministry of Health must have directives that ensure our public hospitals are there to treat our sick and not to make money with Government subvention. (3) Prioritise preventive healthcare. The directive on preventive healthcare should be put firmly in place. The various Ministries involved should work in concert and view this as a matter of priority. The successful implementation of preventive healthcare will translate into quality life for our people and with enormous savings for the people and the nation on healthcare cost.”
“The Ministry should change its commonly perceived mindset of looking at the doctors in public and private sectors as two different and opposing camps. Sir, I would have thought that it would be better for all doctors to work together as one continuum. They would all be better trying at all times to exchange new information and experience, to share the workload of looking after subsidised patients, to help train junior doctors, and to save on heavy expenditure by maximising joint usage of those expensive technology and equipment. The mindset must be to function as one force to further excel in medicine, to work as a team steering ourselves to better heights for the better of all patients and to develop Singapore into a "regional medical hub". Sir, the stumbling block here is the Government's directive, as set out in the 1993 White Paper, to rely on competition and market forces to improve service and raise efficiency. This mindset has been entrenched in our medical sector for years, although it is a known fact that healthcare is an instance of market failure. It is not good when the public sector starts having to compete with the private sector and it is worse when the Ministry of Health is becoming more and more synonymous with the public sector. Sir, cooperation rather than competition should reap us better results here and there is a need for all parties to modify or change the existing philosophy. The details on how to go about getting better use of all the medical doctors in Singapore are another topic by itself. (2) Make full use of our resources. Mr Speaker, Sir, all our hospitals should complement rather than compete with each other. Better cooperation between hospitals would enable us to maximise our own resources.”
“This may involve fundamental changes in philosophy and will require the Government to be open-minded and willing to do the right thing when the right thing comes along. The Ministry of Health has done well in keeping our healthcare cost at about 3% of our GDP for the past 10 years. Considering that Government's expenditure was 0.9% of GDP last year, it would be seen that the national healthcare expenditure here has remained relatively low compared with other major industrialised countries. It is remarkable that, this notwithstanding, the Government can still affirm that no Singaporean will be denied of any medical treatment due to the lack of means. Singapore has engineered and given sound foundations to the Medisave, MediShield and Medifund schemes as means of ensuring affordable medical healthcare. By improving primary healthcare affordability, controlling public hospital funding and regulating private hospital charges for Medisave users through a "casemix" system, we expect to further enhance quality affordable healthcare. Mr Speaker, Sir, we do have the broad picture of what we need to ensure "good and cheap" healthcare. What we do have is also the work ahead and the need for caution and care in our approach. In this respect, Sir, I would be well pleased when the Ministry of Health could consider the suggestions I have on the following: (1) Capitalise fully on our "talent" pool of doctors. There should be a directive calling for better use of our medical doctors and specialists. Every year, many of our best brains in Singapore take up medicine. We should have a lot of talent amongst our medical doctors. The maximum potentials of many, especially those in the private practice, have not been harnessed.”
“Mr Speaker, Sir, the President, in his Address to Parliament, has outlined several new and significant directives for the various Ministries. These directives will put Singapore in good stead for the new millennium and I therefore would like to support the motion of thanks to the President for his Address. There is a sense of urgency amongst the many healthcare providers who wish to see our healthcare system make even more adequate and affordable and even more effective in terms of both cost and quality. Ironically, it is not the lack of activity and anxiety that bothers many. It is the very vibrant and tremendous pace of change happening to the whole system that is worrying. Sir, now is the time for us to look at our future needs and I seek indulgence of this House to deliberate on this today. I would like to suggest that unless we adopt a new mindset, there would not be any scope for further significant improvements to our system when the new millennium unfolds. Are we planning adequately in accordance with the requirements of the present and future population trends? Have we enough safeguards against the very fast changing trends in medicine and medical technology? Are we bold enough to discard any remaining illogical philosophy and historical baggage? Are we utilising and coordinating our resources to the fullest? I fear we do not have a resounding "yes" to all these questions just yet. Although our healthcare system is in a healthy state and the Government has done a very good job thus far, we are in no position to rest on our laurels. We have many good policies in place and we would do well to keep them. We also have some policies that require re-evaluation so as to be either improved upon or removed from our forward planning.”
“May I seek a clarification? Autism is a difficult condition. Does the Senior Parliamentary Secretary think that we should leave all this to the grassroots organisations or does she think we should rope in the Ministry of Health so that we can get their experts from the medical doctors to help these children?”
“May I ask whether we know the number of such children in Singapore and whether we have done any study to ascertain the future trends and how do we cope with it?”
“Sir, we are fortunate here in Singapore as we have the means to afford a world-class home for our people. Nevertheless, we must always try to strive for the better and desire to improve upon what we have. This Government has always been discerning and knows what is best for Singaporeans and Singapore. I am sure the Government knows that promoting preventive healthcare is one of those items that should be top on the list of what is best for us. My concern, Mr Deputy Speaker, Sir, is that we do not hasten and act on getting what we need as a matter of urgency. We do have an abundance of ideas and a fair measure of means to get what the world can offer, let us go for the quality life that we want all Singaporeans to have in their world-class home.”
“It would be good if the Government could put forth a scheme that harnesses this primary healthcare sector for preventive medicine. Not only will this be cost effective and efficient, this will also give patients the advantage of increased accessibility and convenience to this type of care. (9) The Ministry of Health should also prioritise preventive healthcare in terms of more public education. It is necessary for the public to be reminded that they should and can maintain good health. We must accept that it will be through continuous education and considerable patience before we can hope for a change of mindset amongst our people. We must impress upon the people that they should not be seeking healthcare only when they have become sick. They should be encouraged to have routine medical check-ups to detect early stage diseases. To provide for more scope in public education, we need to provide for the training of "facilitators" who promote preventive healthcare. These "facilitators" may be polyclinic nurses, neighbourhood doctors, community centre grassroots leaders or various company personnel officers. A more integrated and a more consistent approach island-wide to promote different aspects of preventive healthcare could be initiated. The Community Development Councils (CDCs) or even the community centres can be involved in this area with the guidance of the Ministry of Health. Mr Deputy Speaker, Sir, the need to prioritise preventive healthcare must not be underscored and should definitely be an important directive for the Ministry of Health. In order to further improve the health of the people and enhance the healthcare in this country in the next millennium, we ought to push for a prompt and serious effort on the implementation of preventive healthcare.”
“We should pay more attention to the more prevalent and devastating of the cancers. The Ministry of Health must carry out comprehensive studies and elucidate the necessary course of action. Thus, preventive care in terms of breast cancer should be prioritised since breast cancer is, in fact, the leading cancer amongst women in Singapore. Three new cases of breast cancer are detected daily in Singapore. The incidence of breast cancer is expected to increase from 32.9 per 100,000 women in 1985 to 55.1 per 100,000 in year 2000. By then, we are expecting more than 1,000 new cases to be diagnosed every year. Preventive healthcare is important because early detection is the single most important factor for survival of patients. 25% of patients who presented with breast cancers of 3 cm in size would have died from the disease five years after diagnosis and this would be in spite of their having received all forms of treatment. (8) This next pointer involves acceptance of a new mindset and a radical approach. The Ministry of Health should involve the primary healthcare doctors in preventive healthcare because they are already looking after 80% of patients at the level of primary healthcare. I must, at this juncture, declare that I am a doctor in private practice. Preventive care often involves giving a lot of advice and persuasion to the people directly. General practitioners, as family physicians, have better rapport and more time with the patients, are eminently suited for this function. It is known that we have efficient and affordable primary healthcare in Singapore very much because we have a good spread of GP clinics, enough competent doctors and relatively inexpensive fees for primary-care services throughout the island.”
“Immediate and successful implementation of preventive healthcare now is necessary as many of these people may lapse into chronic ill health very soon indeed. (5) Mr Deputy Speaker, Sir, there cannot be successful implementation of anything unless the monetary issues are addressed. I would like to urge the Finance Ministry and Health Ministry to facilitate the people who seek preventive healthcare. Perhaps, as a first step, tax incentives could be given to employers who provide preventive healthcare for their workers. In addition, individuals should be allowed to use their Medisave and MediShield accounts to fund their expenses for basic preventive healthcare. I might venture to say that allowing use of CPF funds for this purpose might even be superior to allowing use of CPF funds for life insurance. Thirdly, we should endorse the use of Medifund for the extremely needy as these people would probably be those who are most in need of preventive healthcare but who are most deprived of it, either due to ignorance or lack of funds. (6) The Ministry of Health should be proactive and remain savvy in keeping up with the changing and pressing problems that arise from time to time and be ever ready to alter course where necessary. Being willing and prepared to re-evaluate and scrap existing unsuccessful methods would be a good virtue to have. Consider the pap smear screening test in its present form. It has been available in Singapore since 1964 and yet the incidence rate for cervical cancer has not declined. We should not have to wait 30 years to re-evaluate this failed method, and should have implemented better methods long before now. (7) Sir, whilst it would be ideal for us to handle all cancers on an equal basis, we have to be realistic and practical.”
“Perhaps, the Ministry of Health would consider what I have in mind in nine areas as follows: (1) To take off in this area of healthcare, the Ministry must first want to revamp the existing model of healthcare and put up a bold and comprehensive new method of implementation of preventive healthcare. More funding and allocation of personnel in preventive medicine have to be put in place. The very crux of the issue is to reach out to the people and efforts in this matter must be expanded. (2) The Government, as the largest single employer in the country, must take the initiative and provide free and basic medical healthcare for all civil servants on a regular basis. Spending in this area now will be worthwhile in the longer term. We will be rewarded in time with a healthier workforce. The quality of life for the workers will be enhanced because they will be less prone to chronic debilitating diseases in the future. (3) Expanding on the previous point, the Government should work with more companies to facilitate and promote preventive medicine. As an example, more doctors and nurses can be made available to help companies conduct preventive check-ups and to give talks on various topics of preventive healthcare. When Prime Minister Goh launched the "Healthy Lifestyle Campaign" this year, he said that the experience in many countries around the world has shown that health programmes do help control medical costs, improve productivity, reduce absenteeism and heighten staff morale. (4) There is a projected increase to about 800,000 aged citizens by the year 2030 and it is obvious that those born in the 1950s and 1960s will make up a majority of the elderly of tomorrow. It is therefore urgent that we target preventive medicine on these citizens who are now in their 40s and 50s.”
“The Ministry of Health allocates only 13%, or thereabouts, of its budget towards primary and preventive healthcare at the moment. Sir, this clearly shows that the emphasis on preventive medicine by the Ministry of Health is dismal. The 1998 National Health Survey has revealed that more Singaporeans have hypertension, high blood cholesterol, diabetes and obesity now when compared to the situation in 1992. The incidence rate of cervical cancer had declined only very slightly despite the availability of pap-smear screening tests for women in Singapore in the past 30 years. The four leading causes of death in Singapore are cancers, heart diseases, pneumonia and cerebro-vascular diseases, in that order. Deaths from these diseases are largely preventable and many potential cases can be averted through preventive healthcare. The resultant effect will be reduced illnesses and increased quality life for Singaporeans. The Ministry of Health must have a new mindset and approach in terms of preventive medicine if we want to do much more than we have so far. Why should the Ministry take on this job single-handedly when we can tap all our resources to give effective and positive results? Sir, I would like to suggest that the Ministry of Health harness our doctors in both the private and public sectors and have an integrated effort towards enhancement of preventive healthcare. We have already in place qualified and competent doctors that can promote preventive healthcare efficiently. We can have a good go at it and I urge the Minister for Health to implement directives in this important area of healthcare.”
“Mr Deputy Speaker, Sir, today I would like to entreat the Ministry of Health to prioritise preventive healthcare as the paramount directive for the next few years. The adage "prevention is better than cure" succinctly defines a fact that everyone would accept wholeheartedly. In terms of maintaining the best state of health for any population, preventive medicine, rather than an excess of healthcare facilities and services to cure the sick, is in line with the adage and is a fact that each one of us here would also accept wholeheartedly. Sir, we must pursue all avenues to help the healthy maintain their well-being for as long as possible. In the long run, it will be the continuous and concerted efforts in promoting preventive medicine that provides the best quality life and contains the escalating cost of healthcare for the people and the nation. It is proven that if we can succeed in preventing the development of diseases in the first place, we would have achieved the ideal. Classic examples of this would be in the management of hypertension, diabetes and hyper-cholesterolaemia, which predispose patients to cerebro-vascular diseases. Well-informed patients generally have better outcome and better compliance with their treatment and do lead quality life for much longer. They are spared the incapacitating and results of strokes, heart attacks or renal failure. They are spared the agony of having to suffer and the nation is spared the burden of having to pay for the enormous costs of treatment. Sir, the rewards from preventive medicine will be immense if it is done swiftly and if it is targeted towards the population as a whole. The expenses now will yield abundant savings in the future.”
“May I ask the Minister if there is a need for psycho-analytical assessments for pilots on a regular basis as part of their routine medical check-ups?”
“Sir, may I ask the Minister whether the Johns Hopkins Hospital is under the jurisdiction of the Ministry of Health, as it may have come under the Foreign Direct Investment Scheme? Are the Hospital and its medical staff subjected to the same laws and practice guidelines as for local hospitals and local medical personnel?”