Lim Hng Kiang
Singapore
“The company has made commitments to recycle the ash, and as for renewable energy, the gasification project is not an energy project, it is not a generation company (genco). It is to produce hydrogen and carbon monoxide or, essentially, carbon. Because as feedstock to the petrochemical sector, you need more C and more H2.”
“The Government will continue to recover the IIA awarded if the company fails any conditions or breaches the legislative amendments. I would like to highlight that there are no errant cases in the last five years for IIA and the current amendments are, therefore, not reactionary in nature, but are being made for legislative clarity.”
“In addition, the IIA scheme will be extended till 31 December 2022. Clauses 10 to 13 give legislative effect to this change. The remaining legislative changes arising from our periodic review of the income tax system are either administrative or technical in nature.”
“Data on household and individual savings rates by income groups are not available. However, data on the aggregate level of household financial assets can be obtained from the Household Sector balance sheet compiled by the Department of Statistics.”
“The aggregate level of financial assets owned by Singapore’s household sector6 in each of the past five years is provided in Table 1 below. Data on the amount of financial assets owned by households and individuals in the different income percentiles is not available.”
“The Second Review of the Comprehensive Economic Cooperation Agreement (Second CECA Review) is ongoing. The review is taking some time as both countries have our respective interests to work through, such as in the area of labour mobility. Our agencies regularly engage Indian counterparts to work through issues collaboratively.”
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Every one of 2,677 lines we hold for Lim Hng Kiang, in date order, each linked to its source. Free to read, in full, without an account. Page 23 of 54.
“Isolation area Let me now turn to the second area which is the isolation area. Clause 7 of the Bill will give my Ministry new powers to quarantine any premises for the purposes of controlling or preventing the spread of an infectious disease. This will be accompanied by necessary powers to make specific orders in relation to the restriction of persons or goods within the quarantined premises as well as powers to authorise the destruction, disposal or treatment of goods, structures, water supply, drainage, sewerage system or any other matter known or suspected to be a source of infection. This section is included in the Act as a contingency to cater for a scenario like that of the Amoy Gardens in Hong Kong. Civic responsibility The third area that I would like to talk about is civic responsibility. Mr Speaker Sir, to prevent persons from behaving irresponsibly and endangering the health of others, the Bill proposes a new section to be added to the Infectious Diseases Act to prohibit certain acts which are liable to expose others to the risk of infection. Under this new provision, a person who knows or suspects that he is suffering an infectious disease must not expose others to the risk of the infection by his presence in a public place. The only exception to this is when he is seeking medical treatment. However, if the Director of Medical Services has designated a specific place for the medical treatment of the infectious disease concerned, then the person must seek treatment in the place specified. This provision only applies to infectious diseases which are specified in a new Fifth Schedule. SARS will be the first infectious disease listed in the Fifth Schedule.”
“Clearly, this endangers the public health and we must not allow this to happen. To begin with, the amended Act will make the legal process of issuing Home Quarantine Orders clearer. Currently, Home Quarantine Orders are issued under section 15(1) of the Infectious Diseases Act which allows any person who is or who is suspected to be a case, carrier or contact of an infectious disease to be detained and isolated in a hospital or any suitable place. Section 15(2) of the current Act that deals with the issue of home quarantine can only be applied to persons who are suffering from an infectious disease. Furthermore, we cannot compound a fine if a person breaks home quarantine. Clause 5 of the Bill will amend the Act to allow a person who is, or who is suspected to be a case, carrier or contact of an infectious disease or has recently recovered from an infectious disease or has been treated for an infectious disease to be quarantined in his home. He will also have to follow the conditions which are applied to him with respect to his quarantine. One of these conditions will be to wear an electronic wrist tag if he breaks his quarantine. To tighten the control on persons who are put on home quarantine, the amendment will make it an offence for persons to break home quarantine or to refuse to comply with any condition applied to the quarantine. The offence will then be compounded by my Ministry. Persons who break their quarantine may also be arrested by the police or authorised Health Officers and be detained in a hospital or other appropriate place and be required to undergo necessary medical examinations and treatment. Repeat offenders can also be referred to the courts and the courts will take his previous offences under the Act into account in sentencing.”
“If a patient admitted to a hospital does not tell the truth about his contact or travel history, he may not be categorised as a suspect case and may not be isolated quickly. As a result, the infection can spread throughout the hospital. If a person with a fever sees a general practitioner and lies about his contact or travel history, he may not be referred to Tan Tock Seng Hospital and he goes on to infect others in the community. The Infectious Diseases Act provides for the control and prevention of infectious diseases in Singapore. Today, I propose new amendments to the Act, to give additional and necessary powers to the Ministry of Health to control the outbreak of SARS in Singapore. The main specific provisions cover five key areas: Home Quarantine Orders, the quarantine of premises, the prevention of persons from acting irresponsibly which cause the infectious disease to spread, compliance with disease control measures and the handling of bodies of deceased persons who are suspected to have SARS. Home Quarantine Let me turn to the first area which is home quarantine. It is important that all persons with SARS are identified early and isolated for treatment at the Tan Tock Seng Hospital. This will minimise transmission of the disease to other people. We also impose Home Quarantine Orders on contacts of patients with SARS. Although asymptomatic contacts of SARS patients are well, the imposition of home quarantine allows us to pick up cases of SARS much earlier and prevents them from infecting others in the community. Home quarantine is therefore a key measure to prevent community transmission of SARS in Singapore. If people placed under home quarantine disregard their quarantine, they risk infecting others in the community.”
“Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time." We are faced today with an unprecedented public health crisis. This crisis has been caused by the outbreak of Severe Acute Respiratory Syndrome or SARS. Several senior doctors told me that they have not experienced anything like this in the last 40-50 years. The SARS outbreak can destroy the capability of our national healthcare system if it is not contained. It can have wide and severe repercussions on many sectors of our economy. The SARS outbreak can be very pernicious because SARS is likely to be more infectious when the patient is more ill. And the patient is likely to be most ill when he is in the hospital. Once a group of healthcare workers is infected by SARS in the hospital, it can spread quickly within the hospital. In Hanoi and Beijing, they have had to take the very drastic step of closing down the affected hospital, keeping everybody within the hospital, in order to stop the transmission into the community. Even when SARS is contained, it will take a heavy toll on the healthcare system. SARS will place a disproportionate demand on ICU facilities and isolation rooms. The Government is doing its utmost to control the SARS outbreak in Singapore. However, we need the cooperation of all Singaporeans in this battle. Until we have reliable and effective diagnostic tests, our doctors have to depend on two main criteria to assess whether a person has SARS. First, the clinical symptoms, like fever, cough, muscle aches and chills, which can be very non-specific. Second, the contact or travel history. With global travel and the complex web of interactions in a modern bustling city, establishing contact history is not an easy task unless the patient is truthful and forthcoming.”
“Yes, Sir. [Copies of the Bill distributed to hon. Members.] COMPANIES (AMENDMENT) BILL Order for Second Reading read.”
“Tomorrow, Sir. Certificate of Urgency signed by the President in respect of the Bill, laid upon the Table by the Minister.”
“Mr Speaker, Sir, I beg to introduce a Bill intituled "An Act to amend the Infectious Diseases Act (Chapter 137 of the 1999 Revised Edition)". Bill read the First time.”
“The Courage Fund offers up to $70 per day for people who come forward for screening and who are then held for observation. Because we felt that for some of these people in the Pasir Panjang Wholesale Centre, especially the casual workers, if they are served with a Home Quarantine Order, then what DPM announced today will kick in, and they will be given the financial support. But even just to come forward for screening, and you have a temperature and you are held in Tan Tock Seng Hospital for observation for a few days, there may be a loss of income for these people. So the Courage Fund has come forward to say that for screening and observation, they will also provide the financial support for up to $70 per day. So there is no double payment for the Home Quarantine Order people.”
“Mr Steve Chia asked whether we can have a different facility as intermediate care. In fact, that is possible by going to the polyclinic. But, of course, if you know that you have contact with a SARS patient, then I think you should go directly to TTSH. Dr Warren Lee asked whether we can have alternative home arrangements. As I have tried to explain painstakingly, the person who is on home quarantine is well and is not infectious until he has the symptoms. So he can continue renting a room or staying at home. It would be very difficult for us to make alternative arrangements for accommodation for all people serving HQOs. Dr Lily Neo asked about the epidemiological study. I am no expert. I will get my staff to give her whatever they have found out. For the staff who are in direct contact with unknown or potential SARS patients, like people in the A&E, ICU and emergency departments where they have to deal with potential SARS patients, then they put on the full suit, together with the goggles. For those who have to do actual interventions, then they put on the hoods. That is how I have explained in my statement. There is no cure for SARS. In the early stages, Hong Kong thought that Ribavirin would be useful. The clinicians in Singapore are not as aggressive in their approach as the Hongkongers. I think we are closer to the American clinicians and, therefore, we have used Ribavirin very, very conservatively, because we realise the toxic side effects of this anti-viral regime. Public directives - we are building up the contact tracing setup, organisation, data collection, as Mr Wong Kan Seng explained. And when these things are more systematic, of course, we will then be able to issue these out in proper public directives. There is some confusion on the Courage Fund.”
“Similarly, for NUH Wards 55 and 68, we had been tracking the situation, and it is a combination of staff and patients having fever. Some days the fever is up, on other days the fever is down. The patients there are diabetic and kidney patients and, according to what the doctors tell me, fevers in such situations are not uncommon. But, at the same time, we are always on very high alert, and we have to make a professional decision when a combination of red flags comes up. Do we just ringfence them in NUH or do we physically move them across to Tan Tock Seng Hospital? So the Director of Medical Services and the Chairman of the Medical Board in each hospital are confronted with such professional decisions every time they are faced with situations like this. I think I have answered most of the questions. I am sure there will be many other questions which I have not answered, in which case, I will respond later on. I do not want to hold up the others.”
“From MINDEF, we have used the medics; we have people from the People's Association to help us in contact tracing; we have used detectives from the CID to help us in contact tracing; we have used all resources in the Government to tackle this problem. And as you would have heard from the responses of the various Ministers, all the Ministries are gearing up to tackle the different aspects of how to deal with SARS. Some Members asked about the treatment regime. When we started off, as I said, there is no specific treatment regime. The Hong Kong experience, they tried to use Ribavirin, the anti-viral regime. But as we all know, it has toxic side effects and so we have to use it very carefully. The American clinicians are more conservative, and they prefer not to use this very aggressive approach. So, our clinicians have to make professional judgments, ie, when to use the full array of antibiotics and anti-viral regimes. Dr Lily Neo asked about the situation in NUH Wards 55 and 68. These are the kinds of problem that we are confronted with nowadays, because our threshold of alert is now set very, very low. When you have two staff with high fever and patients with high fever, everybody gets very excited. So, in SGH, on Good Friday, we transferred Ward 74 to TTSH because of this combination of staff and patients having fever. It was a precautionary measure. We transferred lock, stock and barrel, ie, one whole ward across - a lot of resources and effort. As it turned out, it was, thankfully, a false alarm. The fever of the staff came down, and the patients in that ward, because of their other medical problems, were showing this fever. But we would rather be safe than sorry.”
“If we need an accelerated contact tracing because the way we go about it through detective work takes 24 or 48 hours and that takes too long and the risk is too high, then, of course, we will publish the names in the media. But for recalcitrants and defaulters, I think we should publish their names and shame them because, otherwise, such Singaporeans will continue not to do what is necessary of them. So, although we try to preserve medical confidentiality, people who default and wantonly break the rules, we will definitely name them so that we can shame them. On the supply of equipment, eg, masks, gowns, goggles, thermometers, etc, there is a shortage of masks worldwide. But we are using all our resources that we have in Singapore, eg, from MINDEF, MTI, IE Singapore, ST Logistics, to get ourselves the necessary supplies to keep our healthcare workers protected. So, our commitment to our healthcare workers is that we will leave no stones unturned to get this equipment for them. Thermometers are less of a problem. We have ordered more than a million. I think these will be available over the next few months. Mdm Cynthia Phua asked whether there is a difference in the minimum number of days in the Home Quarantine Orders. We have used 10 days because that is the incubation period. But some employers, for example, impose a voluntary quarantine of 14 days to make it even safer. I think there is nothing to lose if you want to extend it to 14 days. But, for us, we use a minimum of 10 days because that is the incubation period. Next is the sort of resources that we have. As you have heard from the DPM, the full resources of the Government are behind the Ministry of Health to combat this problem. We have used resources from every agency.”
“So, people can stay in the ICU, intubated, ventilated, and then the body will have a chance to fight the virus. So, the earlier Singaporeans who are down with SARS present themselves for treatment and for this full medical support to help them fight the SARS, the higher the chances of survival. If you track the kind of cases that come to our hospitals, when they come in very, very sick and very, very late, and they have to go to ICU almost immediately, then I think the chances are all very, very slim. If you have been following stories, those who come very late and very sick and go to ICU straightaway, they have much lower chances of recovery. Overall, our recovery rate is still very good. 85% fully recover. Those who go to ICU, more than half recover too. So, again, I urge Singaporeans to come forward if you have SARS. Seek early treatment and you will have better chances of recovery, you do not infect your family, and you do not cause infection in the community. Dr Warren Lee asked whether we need special accommodation for the people on Home Quarantine Orders. As I explained, it is not necessary, because these people are not infectious. We just want them to be isolated in their own homes and, if they have a fever or other symptoms, then they present themselves immediately for treatment. The next set of issues is really the level of information that we give out, ie, whether we should publicise the names of patients and people on Home Quarantine Orders. Generally, we are reluctant to do so, because I think we should try to preserve medical confidentiality as much as possible. But where there is a public health need, then we will do it.”
“The third group of questions which I thought is important for me to elaborate on is the situation in Tan Tock Seng Hospital and why Singaporeans fear going there. We have come out several times to explain the very high level of infection control in Tan Tock Seng Hospital and that it has been screening hundreds of people since the beginning of the SARS outbreak, and people have been discharged, they go on with life as usual. So, cross-infection in Tan Tock Seng Hospital has not taken place. If, after screening, the Tan Tock Seng clinicians feel that you should be warded for further observation, then you are kept in an isolation room. You will not infect others and others will not infect you. And the healthcare workers who come to look after you will all be fully gowned and fully protected. So, again, a very high level of infection control. If you are down with SARS, as I explained in my statement, the main treatment is to give you medical support and allow your body's immune system to combat the virus itself. The problem is when you have other complications. Then you need the full medical support system to address these medical complications. But the actual combating of the SARS virus would really be done by the person's own immune system. Of course, if you ask yourself, logically the earlier you come forward for treatment, the better your chances of recovery, because if you do not have the full medical support, especially in the ICU, when you have congestion in your lungs and you cannot breathe, then no oxygen gets into your blood stream and your chances of survival are very low. But if you are in the ICU, then they can intubate you, they can force oxygen into your lungs and cause your body to continue to absorb the oxygen, and so you have a fighting chance.”
“But we do have a situation where the entire family is served with the Home Quarantine Order. Then of course we will come in to provide support to them, in case they need grocery, etc. But if they can make their own arrangements, ie, if their relatives can bring the food to them and leave it outside their door, it is all right. This is just to be extra safe because, if they follow the rules that we set for them, they are not infectious until they exhibit the symptoms. So the workman can go to their house and do the repair as long as these people are responsible. If they do not exhibit any symptoms, they are not infectious and life goes on. But the minute they have a fever and they have symptoms, then they will call us and we will bring them to TTSH for screening. When we serve the Home Quarantine Order on a person, the CISCO police who serves the order will set up the camera and give the instructions. I accept Mr Tan Soo Khoon's point that we should give it in four languages. We will do that. But the CISCO police will explain to the person, who is served with the Home Quarantine Order, what he has to do and how he reports through the camera whenever we call him up. At the same time, we will send a nurse to visit the person under Home Quarantine Order and the nurse will have a kit with a thermometer, a face mask and also instructions, so that he knows how to take his temperature on his own and, if he is sick, then he puts on the surgical mask and wait for the ambulance to come. So, this is the way we explain to the person what he has to do and, of course, it would help if we put it in four languages, and we will do so.”
“But we insist that he stays at home so that, whenever he has a fever or he shows symptoms and becomes infectious, we will pull him out to TTSH. The adult family members will not get infected until the contact gets infected. Then they themselves will take another incubation period of three to 10 days before they become infectious. So the other family members can continue with their work and their life, because they are not infectious and they will not be infectious until the contact becomes infectious himself. Why do we not do the same for children? Medically, we should do the same for children. But knowing the sensitivity of parents over the children in the schools, we decided that, for children of a contact, we will be extra kiasu and we also issue a Home Quarantine Order on them. When we started, of course, we stipulated it as a requirement in the Home Quarantine Order, as Mr Tan Soo Khoon raised. This has caused some confusion in the public's mind. Recently, we decided that we would actually issue an individual Home Quarantine Order on each of these children. There is another situation where a family member is a probable or a suspect SARS case, in which case all the family members are contacts and all the family members would be issued Home Quarantine Orders, including the children. So to minimise this confusion, nowadays, when a child is asked to stay at home, we will issue a Home Quarantine Order and there would not be any confusion among the public. Some Members asked what about financial support for this group. If the contact is given a Home Quarantine Order and the other family members are not at risk until the contact becomes infectious, then the other family members can go about with their life as usual, go and buy grocery, etc.”
“When we detect a probable SARS or a high suspect SARS case, we start contact tracing and the people whom we determine to have contact with this patient, a probable SARS or a high suspect SARS, we will then issue the Home Quarantine Order. As far as this contact is concerned, he is still healthy, he is still well, but because of his contact history with a probable SARS or a suspect SARS case, he is given a Home Quarantine Order. And the reason why we do so is that we want him to stay at home, monitor his health constantly and the minute he has a high fever or other symptoms, he will call us and we will dispatch an ambulance to fetch him to Tan Tock Seng Hospital straightaway. So in that way, we minimise the likelihood of him infecting other people in his family as well as in the community. But the other family members are not contacts of a probable SARS or a suspect SARS patient. So if they are not contacts, they will not be issued a Home Quarantine Order. But if the other family members are contacts, they will also be issued a Home Quarantine Order accordingly. Then how do we treat the children? Because we felt that as schools are very sensitive institutions, we took the extra care of asking the children to also be quarantined even though the children will not be infected until the adult is infected. Let me go through this again. If we detect a probable or a suspect SARS case, we determine the contacts. Let us say, there are 20 contacts. Then we issue a Home Quarantine Order on each of these 20 contacts. These 20 contacts will have an incubation period before they become infectious. The incubation period is between three and 10 days.”
“As a result, the public goes there and they are now feeling the strain because Alexandra Hospital is a very small hospital and it is not used to this load. So a lot of the load that used to go to TTSH and SGH now goes to Alexandra Hospital. Changi Hospital, after their episode in end-March, has not had another episode. So they are again gearing up. So, today, I would say TTSH, KK, Changi and AH are bearing up well. We have the problems in SGH. They were doing okay until the recent episode with Dr Alex Chao. And in NUH, we still have the cluster that was started by the brother of the index case in SGH which created a cluster there. That one, we are still trying to keep it under control. So we have the Ministerial Combat Team under SMS Khaw Boon Wan. He and his team have gone down to the hospitals to button down the protection guidelines, the execution of those protection guidelines, to raise the standards and the morale and the capabilities of the hospitals. I think they are doing a great job and we should be able to see the situation improving day by day. Sir, our hospitals are coping fairly well with the public services. As to hospital charges, we have explained this before. Screening is free. So if you come forward for screening in Tan Tock Seng Hospital, it is free. If you are kept for observation, then you are charged C class rates. So it is heavily subsidised. And if you have financial problems, then our medical social worker would apply Medifund for you. So I do not think Singaporeans should be concerned about the medical costs of coming forward for screening or treatment. The other group of questions which Members raised and which I thought it is worthwhile for me to go through, in some detail, is the Home Quarantine Order.”
“It has to be very tight-fitting, so it is hard to breathe and if it is not tight-fitting, then it does not work. So it requires a lot of vigilance and a lot of discipline. Day in and day out, keeping this protection on because you know that if you make a slip-up, it will be a very costly slip-up. So for the healthcare workers, it is a lot of stress, and they are over-stretched in the wards. But the situation varies. When we have a big cluster like in SGH and in the Pasir Panjang Wholesale Centre, then of course the workload increases. But if you look at the situation across the public hospitals today, Tan Tock Seng Hospital is well protected. As we mentioned in our statements, we have not had any of our healthcare worker being infected for the last six weeks. So the morale is high. They know that if they are diligent and they take good care of themselves through the protection, they will continue to be protected. But once there is a slip-up, it will be a real setback. The resources in Tan Tock Seng Hospital are bearing up. Our critical resources are the ICU and the isolation rooms. In the ICU, we are doing okay because we have nearly 40 ICU rooms and we are using about 20 each time. So we still have some capacity. Our isolation rooms are now very stretched because, with the Pasir Panjang Wholesale Centre cluster, we encourage people to come forward for screening. Because we do not have a diagnostic kit, we have to keep them in individual isolation suites to watch over them for some time. And therefore the isolation rooms are filling up very quickly. The other hospitals are bearing up reasonably well. As I have said, KK Hospital is also clean of SARS and I think they are managing very well. Alexandra Hospital has not had an episode of SARS.”
“Our rule is 14 days' home quarantine, that means, not just 10 days' medical leave at home, but we insist that the person stays at home for 14 days on Home Quarantine Order, and he has to come back to TTSH regularly through the ambulance for his blood tests and chest X-ray. So we follow WHO guidelines, in terms of reporting of statistics, otherwise, there would not be sensible comparisons across the countries. When it comes to clinical guidelines, our staff here always try to be more conservative, as I have illustrated on the criteria for recovery. Dr Lily Neo asked about epidemiological study group. We are doing this constantly, trying to piece this together and trying to get a picture of the disease pattern. We also have two WHO consultants with us and one consultant from US CDC helping us to track this pattern. They of course provide the link to their parent organisations, and whatever we do is completely transparent to them and audited by them. And so they have high confidence in their parent headquarters that whatever we report is the truth and not something which we are doctoring to give a different picture to the world. Dr Lily Neo also asked about the healthcare workers. Are they adequately protected? We try to have as stringent a level of protection as possible. But a lot depends on correct usage of this protection. For example, if any of you have used the N95 mask, you will find that it is very, very uncomfortable. It is very hard to breathe. When I put it on, I find that I was being suffocated. And I cannot imagine how I could ever be a nurse. But the nurse has it on for eight hours, 10 hours, 12 hours. And it is very uncomfortable. In the open wards, it is very warm with the gown and the mask. These are not easy conditions.”
“5oC, which is not a very high grade fever. So, everybody is on very high alert. And contact tracing is not 100% foolproof. We need people to be very truthful about their contact history. Otherwise, if they give us half a story, we miss out some of the contacts and we cannot ringfence these people. So I would like to say that this SARS challenge is a tremendous challenge for us. We are flying blind. We only have two instruments which are the clinical symptoms - fever, chills, cough, muscle aches - and then only much later, ie, three days, five days, or seven days later, you get the chest manifestations. The second instrument we have is contact history so that we know that, even if you have got fever and cough, but, because of your contact history, we must suspect that you have SARS. And that is why I said in my statement that we have to depend on people taking temperature, and we have to depend on people being truthful to us in their contact history. Dr Lily Neo asked about WHO guidelines, why we have to follow them and why do we not set our own guidelines. We have to follow a certain set of international guidelines because we have to report to WHO. This is a global problem. We cannot have a different set of guidelines. Then WHO would not have a true picture of our situation. But for the clinical guidelines set by WHO where we can be more conservative, we have done so, for example, WHO guidelines on what is deemed a recovery. When a person is deemed to have recovered from SARS, WHO says he must have no fever for 48 hours. In Singapore, we set it at 72 hours. Then they insist on a series of blood tests to see the white blood count. We do that too. They insist on X-rays. We do that. They say you need 10 days' medical leave at home.”
“By the time we detected his brother who had visited him in SGH, that was already 8th April, one day later. By then, his brother who caused this cluster of problems in Pasir Panjang had onset of fever on 4th April. He still went to work at Pasir Panjang Wholesale Centre on 5th April. He was unwell on 6th April; so he did not work on 6th April. But he went back on 7th April, and again on the 8th. By the 8th of April, he was quite unwell; he was sent to NUH. So by the time we realised he was a contact of his brother in SGH, he had already been admitted to NUH on the 8th. So this illustrates the difficulties we face. When a patient is presented with all kinds of chronic problems, it masks the typical symptoms that we associate with SARS - high fever and all the other symptoms, plus pneumonia and chest problem. In this case, they did three X-rays, they did a blood test, and this did not manifest itself till much later. We have to do contact tracing very quickly, but it still takes us 24 hours. We set a target of completing contact tracing within 48 hours. So in this case, even if we meet the limit of 48 hours, by that time the onset was on the 5th of April, he was very sick, and on the 8th he was already in NUH. On hindsight, could we have done better? The problem is a significant one. Obviously we could have done better. I think SGH management could be on greater alert when it comes to staff coming down unwell, which is now the new standard that we impose. Any two healthcare workers having fever in the same department now sends out a red flag. But having set the standard of two healthcare workers having fever sending out a red flag, I hope Members realise now a lot of red flags are showing because it is not unusual to have fever. And we set our fever threshold now at 37.”
“Because of the symptoms he presented, SGH did not consider him to be a suspect SARS case, and treated him for his problems and put him in an open general ward (Ward 57). On the 5th day of admission, on 28th March, he developed high fever. So SGH took note and gave him a repeat chest X-ray. The repeat chest X-ray was normal again. He was treated with antibiotics on 29th March and the temperature came down, indicating that this could be a bacterial infection and not a viral infection. A blood culture showed that he had infection of the blood by a bacteria, E. Coli. A third chest X-ray was done on 30th March, and this was again normal. He was given a stronger antibiotic on 4th April, and he did not have fever anymore. But his chest X-ray on 4th April showed signs of pneumonia, and SGH did the right thing, which was to send him to TTSH, because with a chest manifestation, he was considered as a suspect SARS case. At that time, SGH management also began to notice a group of their staff and healthcare workers coming down with fever, and they went into alert. A cluster of potential problems was growing. So on 5th April, they decided to transfer Wards 57 and 58 to Tan Tock Seng Hospital. The process took some time and the transfer was completed. The transfer started on 6th April, and it was completed on 7th April. In transferring two wards, we had to move all the patients, many of whom were fairly sick, and the staff together with them. We initiated contact tracing, involving 120 people - the patients and the staff - to find out whom they were in contact with. Because if they were infected, we did not know who else could be infected in the two wards. So the contact traced everybody. From the 120, we have to contact trace a few hundreds to see who they are.”
“Mr Speaker, Sir, I would like to start off by responding to Dr Lily Neo's question about how the SGH outbreak started and whether it could have been averted, and also how did that lead to the outbreak in the Pasir Panjang Wholesale Centre. I hope in explaining how these got started, Members can appreciate the difficulties that we are dealing with. We do not have a reliable and quick diagnostic test system now. We have to depend on clinical symptoms and we have to depend on very rapid contact tracing in order to ringfence the contacts to prevent the spread from widening, which is also the second question which Dr Lily Neo presented. This index case in SGH that caused this cluster was an ex-patient in Tan Tock Seng Hospital. He had a multitude of problems and he was discharged from Tan Tock Seng Hospital on 20th March. He recovered from some of his problems, and this was a regular discharge on 20th March. On 22nd March, we decided that Tan Tock Seng Hospital would be a hospital dedicated for SARS. So this was in the middle of the problems that we were having in Tan Tock Seng Hospital. He was discharged on a regular basis because he recovered. Because of that decision to make Tan Tock Seng Hospital the dedicated hospital for SARS, when this man had gastrointestinal bleeding on 24th March, he had to go to SGH because Tan Tock Seng Hospital was only admitting patients for SARS. He went to SGH. SGH took all the necessary precautions - screened the person. He had gastrointestinal bleeding. He also had a foot ulcer and a low grade fever. SGH took a chest X-ray, which was done on the date of admission on 24th March. The chest X-ray was clear.”
“If you are sick and you seek medical treatment immediately, your chances of recovery are better. You are less likely to infect your family. If everyone who has fever and is unwell stays at home and away from crowds, then Singaporeans will have greater confidence that the likelihood of meeting a very infectious person in a crowd will be much reduced. In this way, we prevent the Battle against SARS from becoming a Crisis of Fear. In the Battle against SARS, if all Singaporeans work together, with our healthcare workers in the frontline in the hospitals, with all the Government resources backing them, and all Singaporeans playing their part with higher social discipline and social responsibility, then I am confident that we can contain the disease.”
“Right now, we only have two weapons to work with. First, the clinical symptoms, of which the onset of high fever is an important indicator. Second, the contact history which points to the possibility of being infected by a SARS patient. To win the battle against SARS, we need a change in mindset, a much higher level of social discipline and social responsibility. To make full use of the first weapon, we must encourage everyone to take their temperature daily. If you detect that you have fever and are unwell, do not go to work. If your child has a fever, do not send your child to school. See a doctor and stay at home until you are well. When you go to the doctor's clinic, wear a face mask so as to reduce the risk of spreading infection to others. If you cough, cover your mouth and nose with tissue paper or a handkerchief. Do not spit on the floor or in the open. Practise good personal hygiene and wash your hands frequently. During this difficult period, Singaporeans should also look out for one another. If your family member or colleague or neighbour is sick, advise him to see a doctor and stay at home. Next, we must be truthful about our contact history. If we suppress information about our travel history, our likely contacts with probable or suspect SARS patients, our visits to the hospitals or other venues where we may have contact with SARS patients, then we are giving false information and giving up a very important weapon in our fight against SARS. To the GP, for example, without knowing your contact history, he may arrive at the wrong diagnosis and think that your fever and cough are just the symptoms of a cold or a flu. Singaporeans must recognise that it is in their interest to work together with the Government to prevent and control SARS in our community.”
“My answer is that they should follow the advice given by the local health authorities where they live. They should also check on the information provided by MOH through our website on how they can reduce the risk of catching the infection. Mr Gan Kim Yong, Dr Michael Lim and Dr Chong Weng Chiew asked how we are recognising the professionalism and contributions by our healthcare workers. Let me put on record that we are proud of them and we commend them highly for their dedication and professionalism. I am pleased to inform the House that the two healthcare clusters, as employers of these healthcare workers, have already implemented a policy of covering the complete medical bills of their staff and their families should they fall ill with SARS in the line of duty. For these staff, the medical expenses and medical leave will not be deducted from their yearly entitlement. A Courage Fund has been set up by the two healthcare clusters, the Singapore Medical Association, Singapore Nurses Association and Singapore Press Holdings, to help the families of needy patients in honour of all healthcare workers in Singapore. The clusters have in place a mechanism to review the salary of our nurses and other healthcare workers regularly. Apart from the salary review, we will look into other ways to honour and recognise the exceptional contributions made by all our healthcare workers at an appropriate time. Let me now turn to what we can do. My Ministry has put in place all the measures to minimise the risk of new clusters of infection from unrecognised cases of SARS in our hospitals and from imported cases. However, I would like to caution Members that in the absence of a definitive diagnostic test, it is very difficult to identify and isolate such cases early.”
“This complements the checks that airlines have put in place at check-in counters. Flight crews are also on the lookout for ill passengers on board aircraft. All visitors to Singapore have been required to complete a Health Declaration Card from 9th April this year. All travellers who enter Singapore from affected countries are also given a Health Alert Notice to explain the symptoms of SARS and how they can get help if they fall ill with suspected SARS. We will continue with these measures for the long term. About 120,000 people enter Singapore from Malaysia each day and half of those travel daily. My Ministry is working closely with our Malaysian counterparts on measures to prevent and control SARS in our respective countries. A delegation of MOH and MHA officials met with their Malaysian counterparts to discuss joint measures and the regular exchange of health information. But we have to be realistic. Global travel means that new imported cases will occur in the future. Screening of travellers is limited in its effectiveness as it will not pick up persons during the incubation period. Persons can therefore be well as they pass through the screening procedures and develop SARS later. A single imported case can trigger off an outbreak involving many cases, especially if he or she is a super-spreader, even though we quickly institute the control measures to isolate and ring-fence ill persons and their contacts so as to limit disease transmission. Hence, we must all be prepared to accept that we are in this for the long haul. Let me now turn to some of the specific questions raised by Members. Dr Amy Khor asked about measures taken for Singaporeans living in SARS affected areas.”
“In response to Mdm Ho Geok Choo's questions, selective closure of affected areas of SGH has been carried out instead of closing SGH completely. For example, the patients and staff in wards 57 and 58 were all transferred to Tan Tock Seng Hospital en-bloc. At the same time, staff who may have been exposed to SARS patients have all been quarantined. SGH has also changed its work practices so that teams of doctors work in only one physical site, hence limiting the potential of cross-infection. All public hospitals are closely monitoring their capacity so that they can take the necessary measures to match the need against their capacity. As for using private hospitals to supplement the public hospitals, this is being explored. One option is to refer some subsidised patients for selected treatment in private hospitals. The outbreak in SGH in early April also led to a cluster of SARS cases at the Pasir Panjang Wholesale Centre. We shut down the Centre for 10 days and imposed Home Quarantine Orders on all the stallholders and their workers in the Centre. The aim is to keep them isolated at home and prevent the infection from spreading. The regular buyers at the Wholesale Centre are closely monitored through telephone surveillance. This is a massive effort to systematically isolate and contain the spread. We have harnessed all the Government resources to this end. We need the cooperation of all those involved, in order to break the chain of infection. We have also put in place a number of measures to ensure that clusters of infection do not develop from new imported cases of SARS. To reduce the number of imported cases, we are carrying out health screening through temperature checks on incoming air and sea passengers from the SARS affected areas.”
“The lack of a rapid diagnostic test that can be applied early, the non-specific nature of SARS symptoms, ie, just fever and cough, and the possibility of the co-existence of multiple illnesses masking the presence of SARS in the same patient have made it very difficult to identify SARS patients early and reliably. The outbreak in SGH that started in early April involved a single super-spreader with multiple illnesses. The outbreak in SGH led to a cluster of SARS cases in NUH. We are still mopping up the consequences of that setback. My Ministry has implemented additional measures to contain the outbreaks in hospitals and other healthcare institutions, including nursing homes. Firstly, all healthcare workers in all hospitals are now required to wear N95 masks, gloves and gowns and to practise frequent handwashing after every patient contact. In isolation facilities, Emergency departments and ICUs, they are also required to wear goggles and hoods if there are any interventions. This is to ensure that they do not get infected by patients who have SARS but have not been diagnosed to have the disease. Secondly, all healthcare institutions are now required to monitor their staff closely through twice-daily temperature monitoring. Strict instructions have been given to disallow any staff member who has fever or is unwell to start or continue working. Thirdly, all healthcare institutions have set up special teams to prevent and control SARS. The Ministry is carrying out audits on health care institutions to ensure compliance with the infection control practices. The Ministerial SARS Combat Unit, headed by SMS Khaw Boon Wan, will give leadership and political weight to the hospital audit teams.”
“Many laboratories, including those in Singapore, are working to achieve this. There is, as yet, no specific treatment for SARS. WHO has stated that no treatment beyond good intensive and supportive care has been shown to improve the outcome in patients with SARS. About 8-9% of our cases have died compared to the global average of 6%. The case fatality rate in Hong Kong has been about 7% but that in Canada has been about 9%. A likely reason for the slightly higher fatality rate in Singapore compared to Hong Kong is that the daily occurrence of new cases here has been much lower than that in Hong Kong. In Canada, most of the fatalities have occurred among elderly patients with co-existing chronic illnesses. Let me now touch on the current situation of SARS in Singapore. I had previously explained our strategy to contain SARS in Singapore. The main components of this strategy are to identify and isolate symptomatic cases early, to quarantine contacts who have been exposed to patients with SARS and to minimise the number of new imported cases. My Ministry decided early on to concentrate all SARS cases in TTSH and CDC. Enhanced infection controls were put in place. No TTSH staff looking after known SARS patients have caught the disease for the last six weeks. An important characteristic of SARS is that it is more infectious when the patient is sicker. Hence, it tends to be transmitted quickly among healthcare workers who are not appropriately protected when they take care of SARS patients.”
“This may also have been due to the fact that their SARS illness had not been picked up earlier and they had infected a large number of persons in close contact with them by the time they were diagnosed with SARS. Hence, in Singapore, four SARS patients have been responsible for the transmission of the infection to the vast majority of the 182 non-imported patients that we have seen so far in Singapore. However, there may be situations where SARS may have been transmitted through other routes. For example, the outbreak involving a large number of residents in an apartment block in Hong Kong suggests that SARS may be transmitted perhaps through some common environmental route. Transmission through contaminated surfaces also cannot be ruled out. That is why we emphasise the need for a higher standard of personal and environmental hygiene. So far, three diagnostic tests have been developed for SARS. However, all the tests have limitations. There is a test for antibodies to SARS in the blood. However, this is present only from about 20 days after the onset of clinical symptoms. It therefore cannot be used to detect cases at an early stage. The second test, an immunofluorescence assay (IFA), detects antibodies reliably as of day 10 of infection, but this is a comparatively slow test that requires the growth of virus in cell culture. The third test is a molecular test for detection of the SARS virus genetic material. This is useful in the early stages of infection but at this stage of development, the test method fails to pick up many patients with SARS. WHO has stated that more work is needed to produce a robust test that is capable of rapidly and reliably detecting cases at an early stage of infection.”
“The majority of patients who succumb to the disease are older persons above the age of 40 years. But we have had three deaths from patients below 40 years old. We have observed a number of cases where the symptoms have not been typical. This has made the disease even more difficult to combat. This has occurred in patients with many pre-existing chronic medical conditions, such as heart disease and bacterial infections that mask the symptoms and signs of SARS. In such cases, the fever may be low-grade at the beginning and signs of lung infection occur very late in the course of illness. Such cases are very difficult to recognise early and pose a major challenge for our healthcare professionals. How is SARS transmitted? Both WHO and the US CDC believe that the main way SARS spreads is through transmission of infectious droplets, for example, when a SARS patient coughs or sneezes droplets into the air and someone else close by breathes these droplets in. Our own experience in Singapore supports this view since most of our cases have occurred either among healthcare workers caring for SARS patients in hospital, or family members and friends of the patients who had visited and come into close contact with them. Based on our experience, patients appear to be most infectious when they are ill. Most of the SARS patients in Singapore have passed on their infection to a small number of people only, and through close contact. However, we have also noted that there is a small number of SARS patients who appear to be highly infectious, infecting a large number of people. These people have been called the "super-spreaders".”
“The World Health Organisation (WHO) has stated that SARS is a serious threat to international health and could become the first severe new disease of the 21st century with global epidemic potential. So this is a very serious problem confronting Singapore and the rest of the world. Let me start by summarising what we know and what we do not know at the moment. It is now six weeks since WHO first issued its global health alert on 12th March on cases of atypical pneumonia. For the Healthcare Workers (HCW) at the frontline combating SARS, this has been a long and demanding six weeks. But six weeks is a relatively short period for a completely new disease. The WHO announced on 16th April that a newly discovered virus from the coronavirus family is the cause of SARS. Identification and characterisation of the exact causative virus will allow development of better diagnostic tests and treatment protocols. A significant step towards this was the recent sequencing of the viral genome by scientists in the US, Canada, Hong Kong and Singapore. We are learning more about the spectrum of clinical presentations. Most patients present with typical features with a sudden onset of high fever with or without muscle aches. Some patients may also have chills, shivering, cough and headache. After 3 to 7 days, patients may start to have shortness of breath, and X-ray changes to their chest reflecting pneumonia. In about 80-90% of cases, the patient gradually recovers. However, in 10-15% of cases, after about seven days, the pneumonia progresses and the patient needs treatment in the intensive care unit with most requiring a ventilator to help them breathe. About 6% of cases die despite intensive care.”
“Yes, that is right. Can I begin, Sir? Mr Speaker: Yes.”
“Mr Speaker, Sir, can I have your permission to take all the Questions relating to SARS in a Ministerial Statement?”
“It is indeed correct that the two charges have been brought against Dr Ramachandran. He has left the country and we have put up a warrant of arrest and are seeking his extradition back to Singapore. As for Prof. Shorvon, he has accepted the findings of the Report and we are taking the findings up with the professional Medical Council to take professional action against him. REVIEW OF INTERPRETERS AND TRANSLATORS SERVICES (Recommendations of sub-committees) 6. Mr Seng Han Thong asked the Prime Minister (a) what are the recommendations of the two sub-committees formed to review the interpreters' and translators' services; and (b) whether the Government has accepted all or part of the recommendations and, if so, will the new scheme be competitive to attract talents to join the service.”
“As I said, the tests that were conducted on the patients were done without the knowledge of their supervising doctors. So, that is a clear breach of ethics. The impact of the tests on them varies and the patients are now being watched over by their doctors.”
“There has to be strong leadership with a deft touch, so that the freedom to do proper research is not curbed by bureaucracy while, at the same time, errant researchers are pulled up quickly. We will look into this seriously. The Ministry will also look into the education of patients and the general public about their role in medical research.”
“The problem was that we had two doctors in the project who very deliberately circumvented the rules. It is not easy to legislate against such conduct. Everyday research is being carried out ethically. Most people are honest. Drs Shorvon and Ramachandran are the exception. Their conduct was exposed when the human subjects and their doctors complained. We have to look carefully at what we can do. To prevent any errant researcher from attempting to beat the system by seeking out loopholes, we will look at how we can further strengthen the existing systems. The Ministry appointed a Committee of Inquiry to look into the system and procedures relating to the ethics approval and conduct of the study in question. The Committee made several recommendations to strengthen the ethics approval process in hospitals for clinical research, ensure the medical confidentiality of patient information in hospitals, and improve the standards for the conduct of clinical research. My Ministry will study the NNI Panel's report as well as its Committee of Inquiry's Report, and will do what is necessary to strengthen the components of the existing research oversight system. The hospital ethics committees and research monitoring process would be strengthened, so that any deviations from the approved stated protocols are detected and remedied early. But we do not want to put in so many rules to counter dishonesty that we end up seriously affecting honest researchers. Experience shows that such rules will not always deter dishonesty anyway. What is really needed, in addition to strengthening the existing systems, is strong leadership in the various institutions that deal with research, and a strong culture of ethics.”
“The conduct of research on human subjects in Singapore has to be carried out in accordance with rules which are internationally accepted and which are based on the Helsinki Declaration. Under these rules, the welfare of the human subjects is paramount. The research procedure must also be approved by independent Ethics Committees of Hospitals from where the research is to be conducted. In the NNI project, investigations show that Prof Shorvon and his assistant, Dr Ramachandran (who was the Project Manager), deliberately subverted the rules. They did not tell the Hospital Ethics Committees the exact tests that were going to be conducted on the human subjects. They misled the Ethics Committees into thinking that they were only going to extract blood. In fact, they carried out other tests which had not been approved. These tests were not conducted with proper safeguards and exposed the human subjects to unacceptable risks. The two doctors also did not tell the human subjects the whole truth about the tests. There was a clear and deliberate breach of the Helsinki Declaration and our own national guidelines. The unapproved testing started in May 2002. Most of the human subjects were, however, tested in the period November to December 2002. By January 2003, the unethical actions came to light and the project was suspended. There was thus a period of about 5 to 6 months where the unapproved testing was carried out. Such conduct is serious and unacceptable. We will not tolerate this. Research is important. But it has to be carried out ethically. That has to be the foundation on which we build our biomedical research capability. There is nothing seriously deficient about the systems and procedures that we had put in place.”
“Mr Deputy Speaker, Sir, I beg to report that the Committee of Supply has made further progress on the Estimates of Expenditure for the financial year 2003/2004, and ask leave to sit again tomorrow.”
“And I believe that all our doctors discharge that responsibility professionally. They do not discharge a patient if they, in their opinion, think that the patient is not ready. And our system is such that if the patient is not ready, the patient continues to be funded by us.”
“Sir, as I have explained in my answer, first of all, casemix is not the culprit in discharging patients. We have to trust the doctor. If the doctor says that the patient is ready to be discharged, that is his professional opinion. I think we have to trust him. The casemix system does not incentivise the doctor or the hospital to discharge the patient, because, under casemix, we are subventing both the funding per episode, and if the patient needs to stay longer in the hospital, we will continue to fund on a per diem basis. That has been my assurance and that is what is happening on the ground. When Dr Lily Neo quoted this study done on St Luke's Hospital which showed a very high unscheduled discharge, the sub-acute capabilities of our community hospitals are still not there yet, and I readily admit to it. And that is the reason why we are building the capabilities. We have a regional general hospital with a geriatric department supporting each community hospital, so that the hospital does not just discharge the patient and shed its responsibility. The regional general hospitals continue to provide the professional support to the nursing homes within the regional catchment. We are providing the funding for the community hospitals to develop their capability, particularly in the sub-acute areas, as I mentioned. And as a result, our survey showed that the situation has improved and my Ministry will continue to monitor this and make sure that the situation gets better and better. 5.00 pm So I want to assure Dr Tan Cheng Bock that casemix is not the cause for premature discharge. He and I must agree that, in the end, we have to depend on the professional judgement of the doctors in signing off the discharge.”
“On the definition of disability, we chose three ADLs, because that is the market standard. This is the current insurance standard. We are working with the GPs very actively to make sure that their assessment of what constitutes three ADLs is consistent and sensible across the board. With experience, I am sure we can sit down with the College of Family Physicians and the SMA to make sure that the criteria can meet the needs of the insurance companies and can serve the needs of Government without causing a huge pay-out if we change the criteria too drastically. I think there is scope for us to fine-tune the criteria of what constitutes three ADLs as we go along. As to whether we can increase the allowance, this is something that we have go back to the Ministry of Finance. The fact that we have over budgeted does not mean that we can increase the allowance. We have to go back to MOF and make out a sensible case why the allowance of $100 or $150 ought to be increased further to help these people. Sir, I believe I have addressed most of the issues.”
“We cannot have low premiums, high pay-out and low qualifying criteria. Something has to give. So we will look at the system when we get better claims history. But I would like to assure him that we do have a clause in our contract with the two private sector insurers, that if the pay-out is less than what they anticipated in their calculation of the premiums, there will be a rebate. It is in the contract. Ms Fang Ai Lian asked about the IDAPE pay-outs. To date, more than 3,600 Singaporeans are benefiting from the monthly IDAPE pay-outs. I agree with her that the budgetary provision for the IDAPE has been set very generously, because we expected a higher pay-out pattern. As it turned out, the people who qualify are fewer than budgeted. But we have to work this system for a few more months to be confident that this pattern is indeed the level of disabilities in our senior citizens. Let me also qualify that for those who are already handicapped or severely disabled, there is no age criterion. Age criterion above 70 years old is only for those who are currently not disabled. And if they become disabled subsequently, then they qualify under IDAPE. For those who are already handicapped and below 70 years old, they already qualify. I will take into account her suggestions, but let me respond quickly. First, to reduce the age limit. The reason why we set the age limit at 70 is to encourage those below 70 to opt into ElderShield. What we are saying is that if we put those above 70 in the risk pool of the ElderShield, it will cause a very high burden on the rest of the people in the risk pool. The Government undertakes to fund the risk of those above 70 years old, so that the premiums of those in the ElderShield risk pool is lower. So the age limit is determined on that basis.”
“Mr Andy Gan wants to know the plan for the number of community hospitals. Our intention is to have one community hospital co-located with each regional general hospital. So, for the next general hospital that we are building in Jurong, we will have a community hospital there too. Through this plan, we are confident that we will have enough community hospitals to serve the needs of Singaporeans. Our intention is to increase the proportion of private nursing homes from the current 25% to 40% by 2010, so that the private sector can contribute actively in this step-down care sector. We have tendered out several sites. The development is on schedule. So the provision of the private nursing homes is coming on stream as we planned. And by extending the subsidy to the private nursing homes, we are, in fact, creating a level playing field between the VWOs and the private sector. In so doing, we think this will incentivise the private sector to participate more actively in this sector. As Members know, my Ministry runs annual dialogues with the key providers in the step-down care sector. To this end, we will welcome any new initiatives from the private sector to develop the step-down care sector further. Finally, on ElderShield and IDAPE. I commend Mr Gan Kim Yong for his patience and his perseverance. I hope he will continue to be patient, because the claims pattern cannot be determined in a matter of months. It must be clear after a matter of years. So I think we need time for the claims pattern to settle. With that claims pattern data, we will be able to make a sensible review of ElderShield. Mr Gan Kim Yong is an extremely sensible person and he knows that there is this trilateral relationship between premiums, pay-outs and qualifying criteria.”
“As I said, our attention now is to focus on quality, and we do so through our licensing mechanism and through several clinical quality assurance initiatives as well as a fairly stringent clinical audit. It is our intention to develop this clinic audit so that every nursing home will be inspected and audited for quality every year. We have also produced guidelines to help providers enhance the standard of care. So I agree with Members totally that quality will be the focus from here on. Dr Jennifer Lee also wants to know whether we can involve more GPs in the Primary Care Partnership Scheme (PCPS). Today, we have 600 GPs in the scheme, and I am sure all Members know of the clinics participating in the scheme in their constituencies. In Telok Blangah, for example, for each of the estate that I look after, whether it is Telok Blangah, Dover Road or Depot Road, there are at least two clinics participating in the scheme. And we do that systematically for all the constituencies to make sure that there are enough clinics for the elderly to have access to the GPs. Sir, I do not think accessibility to the clinics is a problem. But we will continue to encourage more GPs to sign up. Right now, we have 600 and we will try harder to get more to sign up. As regards norm cost, we will continue to review it. This is very important. If we set norm cost too generously, then, of course, we are encouraging inflation and higher cost. We want to set a sensible norm cost and try to persuade the providers to try and meet this norm cost. Of course, if we set it too low, then Members are concerned that this will be at the expense of quality. So we will have to review it regularly and make sure that the norm cost is sensible and, at the same time, it does not lead to cost escalation.”
“45 pm I would like to assure Members that casemix does not incentivise or encourage the doctors to prematurely discharge patients from the acute hospitals. This is because, over and above the funding based on the episode, if a doctor says that the patient is not ready to be discharged and the patient is an outlier, the additional days that the patient needs to stay in the hospital will be funded by the Ministry of Health on a per diem basis. So, under DRG, we fund based on the norm cost per episode as well as on a per diem basis if it is an outlier. This is to remove the concerns by Members that if we just only fund per episode, then there may be a wrong incentive to discharge patients early. I have assured the House earlier that we also fund outliers on a per diem basis. Sir, in the end, we are counting on the doctors to be professional and to make the professional determination when a patient is ready to be discharged. And if the patient is not ready to be discharged, we will continue to fund that case as an outlier. The development of the step-down care has been progressing reasonably well. Today, we have 51 nursing homes with about 6,700 beds. 75% of the nursing home beds are run by the VWOs, for which our Ministry provides 90% of the capital cost as well as the operating subsidies, depending on the means-testing of the patients. We have encouraged the private players to come into the nursing home sector by making land sites available. The means-testing allows us to channel subsidies to those who are financially deserving, and such patients can either be managed at the VWO homes or in the accredited private nursing homes.”
“If we have a centrally-run bureaucracy for means-testing, some Members earlier preferred variable criteria and variable means-testing to tailor it to the different needs, whether it is in-patient, SOC or step-down care. We have to be quite realistic. The subsidy levels are quite different. What is suitable for step-down care, because the person goes in, spends weeks, maybe months, may not be suitable for in-patient where the episode may be 4-5 days and you want a very quick way of doing means-testing. But we are prepared to look at the various possibilities. Whether or not we should have the same system with MCDS, this is something that we are studying. Dr Lily Neo pointed to some statistics about the high unscheduled discharge rate and the premature transfers from acute hospitals to community hospitals. I agree that this is not entirely satisfactory. Our community hospitals are not fully functioning as a step-down community hospital because they have not quite built up their sub-acute capabilities. I have to be candid. Some of our community hospitals are just a little bit better than nursing homes and, therefore, over the last few years, we have aggressively moved to upgrade their capabilities. Having said so, we are not slowly upgrading, particularly the sub-acute capabilities of our community hospitals, and so as we progress in this area, I am confident that this unscheduled discharge rate would drop. In fact, a survey by MOH for the last quarter of last year showed that the average unscheduled discharge rate was 3.7% overall, and St Luke's Hospital achieved a rate of 5.4%. So there is some improvement. But I agree with Members that we have to move aggressively so that the community hospitals are able to receive the patients and take care of them. 4.”