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.”
The complete record
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 32 of 54.
“It is a question of definition. Our processes, as I have explained in my answer, cover investigation of all the tissues which are taken out during an operation, it also covers any severe adverse drug reactions. These are the key areas where medical errors can occur, and all these are followed up. As regards "near misses", it is a question of how one defines a "near miss". Medicine is not pure science. It is both science as well as art. You act based on the information available at that time. Post-operation, you may discover that there were other information which were not available. So hindsight is always 20 upon 20. Sir, I think we have in place a comprehensive system. If the Member has any further suggestions of how we can improve, we will be very happy to look at these suggestions. EPIDEMICS (Preventive measures) 8. Mr Noris Ong Chin Guan asked the Minister for Health (a) what are the precautionary measures taken by his Ministry to prevent the spread of epidemics, such as the influenza outbreak, to our much-travelled and much-visited Singaporeans, and (b) whether steps are being put into place to ensure that an adequate supply of vaccinations is always available in hospitals.”
“Sir, as I have explained in my answer, there is a comprehensive system for reporting and follow-up investigation. We do this in a very comprehensive way under the medical audit programme. So this is already in place and any medical errors are reported and investigated. Dr Lily Neo: Sir, with due respect, we do not have any system that requires all doctors to report medical errors, especially near misses.”
“Sir, I am sorry I do not have the numbers here. I will send the numbers to the Member.”
“Inquiries held by the Coroner are open to the next-of-kin of the deceased. Any person found criminally negligent for the death will be liable for criminal prosecution. The hospitals are required to conduct a Committee of Inquiry to investigate any adverse event arising from the management of a patient, eg, severe adverse drug reactions. The objective of the Inquiry is to determine if the patient had been managed correctly, and to recommend measures to prevent the recurrence of any deficiency detected. My Ministry will appoint external audit committees from its panel of medical expert advisors to investigate and review deaths and serious incidents due to medical errors. This will ensure that we learn from our mistakes and prevent a recurrence. Where there is professional misconduct associated with a medical error, the disciplinary process is undertaken by the Singapore Medical Council. The process is retransparent, thorough and objective. To summarise, the current standards of medical practice in Singapore are comparable to reputable centres overseas. Medical errors resulting in deaths and serious injuries here are rare, but when they occur there is an effective and objective system to ensure that such errors are adequately investigated and steps are taken to prevent future occurrence.”
“Mr Speaker, Sir, Singapore has achieved a high standard of medical practice by: (a) providing a comprehensive network of well-equipped and accessible health care facilities; (b) ensuring our health care professionals are well-trained and qualified through a well-established system of statutory registration and accreditation; (c) ensuring that clinical practice is evidence-based and benchmarked with current best practices; and (d) enforcing compliance with standards through the licensing of all health care establishments. The high standard of medical practice in Singapore is well reflected in the good outcomes of medical care we have achieved which are comparable to the best medical centres in the world. We track benchmark performance indicators regularly. For example, our mortality rate for cardiac bypass surgery is 0.8% which is comparable to the rate of 1% in major cardiac centres in the US. A key component of the tracking and regulatory system is the National Medical Audit Programme (NMAP) implemented since July 1998 for all acute hospitals. The NMAP is the framework for comprehensive monitoring and evaluation of clinical outcomes. From the NMAP, we can obtain a comparative assessment of the clinical performance indicators of our acute hospitals. The NMAP also monitors critical quality assurance processes in the hospitals such as infection control, review of tissues removed at operation, review of complications of interventional treatment, in-patient deaths, adverse drug reactions, audit of post-operative complications, and the audit of ICU care, Through these quality assurance processes, potential medical errors are detected and investigated. Any death resulting from medical treatment is reported to the Coroner for thorough investigation.”
“Singaporeans can rest assured that the standard of ICU care in public sector acute hospitals in Singapore is comparable to reputable medical centres overseas. INCIDENTS OF RAGE 15. Mr S Iswaran asked the Minister for Home Affairs whether there has been an increase in the number of incidents of rage, such as those that occurred recently in a cinema and a fast food outlet, and whether there are adequate provisions in the law against such misbehaviour.”
“The annual rate of pneumonia deaths in the ICUs of NUH, SGH, TTSH and AH from 1995 to 1998 is low and ranges from 0.7% to 5.3% of all ICU admissions. Excluding the data for 1999 which is not yet available, the total number of deaths from pneumonia in the ICUs of the four hospitals annually from 1995 to 1998 is 63, 104, 88 and 125 respectively. The incidence of deaths from pneumonia per se is not appropriate as a meaningful indicator of infection control in the ICU. Patients in the ICU are severely ill and more susceptible to complications such as lung infections. A significant number of patients are also admitted into the ICU for the management of severe infections. A more appropriate and internationally accepted indicator of infection control in the ICU which is monitored by our acute hospitals is the "ventilator-associated pneumonia rate". This rate measures the incidence of pneumonia associated with the use of ventilators. The ventilator-associated pneumonia rates in our major acute public sector hospitals range from 7.6 to 33.2 per 1,000 ventilator-days, which is comparable to the rates of US hospitals which range from 12.7 to 26.1 per 1,000 ventilator-days. The evaluation of quality of care in the ICU is a complex process. In addition to monitoring infection control, hospitals regularly set and review ICU care protocols and guidelines. They are required to investigate into any serious deficiency detected, identify areas for improvement and report their recommendations to my Ministry. Since the licensing of hospitals in 1993, there has been no serious deficiency related to outcome of care in the ICU that required investigation by my Ministry.”
“I do not want to belabour the point. Basically, the main criteria for appointment to the Singapore Nursing Board must be the qualifications of the person himself rather than who he or she represents. But as I said, in making sure that the composition of the Board represents a wide section of the nursing profession, we will, of course, draw members from the public and private sectors, the Singapore Nursing Association, different types of nursing profession, etc, and we will send the right signals to the nursing profession that the Board would represent and be the appropriate Board which is competent enough to regulate them. On the specifics, the President of the Singapore Nursing Association was a member from 1993-1996. She is not a member in this current Board, but we will consider the qualifications of the President on its own merits. For Deputy Chairman, that is another flexibility which the Minister has. If the Minister thinks that there is a need for the appointment of a Deputy Chairman to increase the effectiveness of the Board, I am sure that the present Minister and future Ministers will take that into consideration. Question put, and agreed to. Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Lim Hng Kiang]. Bill considered in Committee; reported without amendment; read a Third time and passed. Mr Speaker: Order. I suspend the Sitting and will take the Chair again at 3.30 pm. Sitting accordingly suspended at 3.06 pm until 3.30 pm. Sitting resumed at 3.30 pm [Mr Speaker in the Chair] RULE OF LAW”
“My apologies. The Bill does provide for three members of the Board to be non-nurses and it is our intention that that three persons will represent the lay public.”
“But we will review the whole scheme of where and how our nurses ought to be trained and putting the details of the accreditation to the Specialists Register.”
“What this Bill intends to do is only to set out the criteria for registering and enrolling nurses. So this Bill does not cover the other areas of health care personnel, such as care givers, health care assistants, etc. The Bill is strictly defined to cater for the registration of nurses. In the Bill itself, the definition of who constitutes or who will qualify as a nurse is clearly spelt out. For the other para-professionals who are involved in caring for the elderly, we will have to deal with that separately. Finally, on the topic of continuing education and upgrading, I agree with the sentiments that nurses should keep up with what is going on in their profession. It is our intention to make the avenues for continuing education and upgrading as accessible and easily available as possible, so as to encourage all our nurses to continue to upgrade. We will assess whether this needs to be mandatory in due course, in the same way as the Singapore Medical Council is putting in place a mechanism for continuing medical education. We will do the same for the Nursing Board, and whether to make it mandatory, we will cross the bridge in due course. A final comment on correspondence courses. Although I am in favour of everybody upgrading, in the field of nursing where really a lot of the skills are hands-on, I would have some reservations in liberally accrediting correspondence courses. I think correspondence courses make sense for nurses who want to upgrade themselves in terms of care management and nursing administration. But for purposes of being a clinical specialist, I would have some reservations on correspondence courses.”
“If the offences are not so severe, then of course the Board can impose a period of suspension and the maximum period of suspension is two years. And therefore anything more severe than that which requires de-registration must obviously be above two years. So the minimum period for de-registration is stipulated as three years. Dr Lily Neo also questioned whether the term "due diligence" requires a higher level of care than reasonable diligence. My understanding is that both have similar connotations and, that is, that somebody must take proper and due care in making sure that whoever is practising as a nurse or who purports to practise as a nurse is duly qualified. Let me now turn to the whole issue of nursing specialist. I agree with both Members' comments that with advances in medical technology, there will be a greater role for nursing specialist within our system. The provision in the Bill provides for the setting up of a nurse specialist register. We intend that the details of that register to be set out in subsidiary regulations and not put in the main Act itself. Because it is still in its early stages. We have to decide how we want to set out the criteria for determining the different categories of nursing specialists, whether they require Masters degree or years of practice or different post-graduate qualifications. All this will be stipulated in the subsidiary regulations. The next area which is critical and very important is the whole idea of registration and how to prevent people who do not have the qualifications from practising as nurses. I agree with Mdm Claire Chiang that, with an ageing population, we need a wider range of health care and nursing care people to look after the different levels of care.”
“Secondly, Dr Lily Neo also asked whether in not registering a nurse because of overseas regulatory practices, would we make an effort to find out the reason why an equivalent overseas regulatory body did not register the same nurse. I think this is the current practice. If the Singapore Nursing Board decides not to register somebody because that somebody did not receive registration overseas, we would find out the reasons. In not registering the nurse, we would also give the reasons to the applicant why her registration is not approved. It is not possible to outline all these in specific details in the Bill. The Bill is intended to set out the general provisions and the details would be in the subsidiary regulations. Members can be assured that the best practices will be maintained. Clause 22 deals with the term that the conviction is final and conclusive. Let me clarify that this is to be seen in conjunction with clause 19. We have this clause 22 which says that any conviction for a criminal offence is final and conclusive. If somebody is convicted by the courts, we will take that as a starting point and treat that as final and conclusive. But then the Board itself, when deciding whether the application is to be registered, will take this conviction and consider whether the nurse is fit to be registered as a nurse. So the criminal offence is just taken to be final and conclusive and then starting from that point, we will assess whether that offence has any relevance to the registration of the nurse. The final criterion really is whether the nurse is fit to be registered. Clause 23 is regarding the three-year de-registration period. This is to make a distinction between suspension and de-registration. The Bill provides for a range of penalties.”
“Personally, I do see great advantages in having the Director of Medical Services as Chairman of the Singapore Nursing Board as opposed to insisting that the Chairman must be a registered nurse. But in this Bill, we have broadened the scope and therefore it is entirely possible that the future Chairman can be a registered nurse or he can continue to be the Director of Medical Services or indeed any other person who can lead the Board effectively. Let me also clarify that the function of the Board is essentially to regulate the registration and enrolment of nurses. So we are not setting up the Board as a representative to look out for the salaries, conditions, practices, etc. So we want to appoint people who have the qualifications to regulate the registration and enrolment and the practice of nursing. Therefore, although we want fair representation, this is not a trade union committee which must have representatives from every group to make sure their interests are taken care of. Let me next deal with clause 17 where Dr Lily Neo commented about the definition of what is good reputation or good conduct. This provision is a fairly standard provision in all the professional Acts, whether it is the legal profession, engineers, etc. There is always this clause which says persons must be of good reputation and character. I think we do have a fairly good understanding of what that means. In the case of the nursing profession, in fact, this is outlined in the Code of Ethics and Professional Conduct which is issued by the Singapore Nursing Board in March this year. And the definition which Dr Lily Neo pointed out is very much included in this code. So I think basically we are talking about the same thing.”
“Mr Speaker, Sir, I would like to thank both Dr Lily Neo and Mdm Claire Chiang for their support and their very comprehensive comments on the Bill. Let me take their comments on the various clauses in turn. First, on clause 3 on the composition of the Singapore Nursing Board. There are two approaches that we can go by defining the composition. One is a general approach as we have done, and the other is to define in specifics who should or who should not be a member of the Board. We have decided to go for a general approach. But I can assure Members that in nominating or appointing the members of the Board, we will consider a wide representation of views. For example, the President of the Singapore Nurses Association may not be defined as a member of the Board in the Bill, but traditionally that person has been appointed as a Board member. So it is a question of whether you want to define it or leave it in the appointment process to make sure that there is this wide representation of views and the people who are appointed come from both the public sector as well as the private sector and from the different fields of nursing, whether they are nursing midwives or psychiatric nurses, so that it is broad enough to make sure that the Board can discharge its duties effectively, ie, to set the standards and to regulate the registration and enrolment of nurses. Similar comment on the Chairman of the Board. I agree that there are some pros and cons in defining whether the Chairman should be a registered nurse and that is the reason why we have made it broader. Previously, the Director of Medical Services has traditionally been the Chairman of the Singapore Nursing Board.”
“My Ministry has actively sought the views and support of the Singapore Nursing Board, the Singapore Nurses Association, and the senior nurses from all hospitals and institutions during the preparation of the Bill. They have made some suggestions on the operational procedures which my Ministry will take into consideration when preparing the Regulations. Sir, I beg to move. Question proposed.”
“The Bill will provide for the formation of Complaints Committees that will investigate into complaints and report the findings and recommendations to the Board instead. New Offences I had mentioned earlier about preventing persons from indulging in unqualified practices and the employment of unqualified persons as nurses. In order to maintain nursing standards and to protect public interest, such unqualified practices will be considered as offences. However, as the intent is not to penalise innocent acts, exceptions are made for persons such as doctors, other healthcare professionals, persons rendering emergency help or home carers who render nursing care. The present penalty for each offence under the Act is a fine not exceeding $1,000, except for failure to surrender the registration certificate, where the fine is a sum not exceeding $500. The Bill increases the present penalties from $500 to $1,000 and from $1,000 to $10,000. Consequential and other minor amendments The Bill also proposes consequential changes as a result of the amendments I have earlier described, other minor amendments to delete obsolete terminology and to update the existing provisions. Mr Speaker, Sir, the nursing profession has undergone significant changes over the years. The role of nurses has grown in scope and complexity with the advancement of medical science and technology. As the standards of any profession are dependent upon the quality of its practitioners, the profession must ensure that nurses are properly trained and highly competent, and that their professional development is promoted. This Bill will help to achieve these objectives by empowering the Nursing Board to safeguard both the high standards of nursing practice and the interests of our patients and the public.”
“Register of Nurse Specialists With the advancement of medical science, there is a corresponding move towards specialisation in clinical nursing practice. It is necessary to monitor the development of advanced nursing practice and accredit "nurse specialists". Part 5 provides for the formation of a nurse specialist register and the issuance of nurse specialist certificates. Cancellation of registration or enrolment The existing Act allows the Nursing Board to cancel the registration or enrolment of nurses who, for example, have been found guilty of professional misconduct or are deceased. In addition, the Bill provides clauses to allow the Nursing Board to cancel the registration or enrolment of nurses who failed to comply with the conditions as stated in their registration or who failed to renew their practising certificates for a continuous period of time. The Bill also contains provisions for the Nursing Board to restrict the practice of a nurse whose fitness to practise is impaired due to health problems. Appeal The existing Act only allows for a nurse who is aggrieved by the Board's decision to de-register her to appeal to the High Court. Clause 21 will allow for a person who is aggrieved by the Board's decision to impose any of the prescribed disciplinary penalties to appeal to the courts. Restoration of name Clause 23 provides for a nurse whose registration or enrolment has been cancelled by the Nursing Board, to only apply for restoration of name onto the register or roll after a minimum period of three years. Disciplinary procedures Presently, the Board is required to consider complaint letters and decide whether they should be further investigated. This is cumbersome as it slows down the investigation of complaints.”
“Functions of the Nursing Board Let me now turn to the functions of the Nursing Board. In devolving the training of nurses to educational institutions, the existing functions of the Nursing Board to determine and provide for the training and examination of student nurses are no longer relevant. Hence, these functions are deleted. Additional functions are included in clause 8 to enhance the role of the Nursing Board in: (a) accreditation of formal nursing courses; (b) regulation of training and continuing education for nurses and midwives; and (c) regulation of the scope of nursing practice. This is to ensure that nurses continue to receive appropriate training, keep abreast of advances and developments, and provide safe and competent nursing care to patients. Registration of nurses and midwives Sir, let me now move on to matters concerning registration. Currently, a nurse who has stopped working for more than 10 years is required to successfully complete a retraining and competency assessment programme before the nurse could be registered or enrolled to practise again. This is to ensure that the nurses and midwives are updated in practice. Clause 15 allows the Nursing Board to provisionally register or enrol such nurses to undergo the retraining and competency assessment programme. Another new provision in the Bill is the issuance of Practising Certificates. This is to enable nurses to show proof of current registration, including the type of conditions imposed on registration whenever required. With the issuance of practising certificates, the existing provisions for removal of name if the nurse fails to pay the annual fee or has ceased practice will be deleted. The Bill also provides for a person who is refused registration by the Board to appeal to the Minister.”
“Hence, there is a need to guide the development of advanced nursing practice and to ensure the proper use of the title "nurse specialist". Despite the gradual increase in the number of nurses in Singapore, it is still not sufficient to meet the needs of our expanding healthcare service. To protect public safety, measures are needed to prevent persons making use of the situation to indulge in unqualified nursing practice or to employ unqualified persons as nurses. My Ministry aims to prevent such occurrences by empowering the regulatory role of the Nursing Board. Provisions in the Nurses and Midwives Bill Let me now highlight the major new provisions that are being introduced in this Bill. Constitution of the Nursing Board The present Nursing Board consists of 17 members, of whom six are ex-officio members and another 11 are appointed by the Minister for Health. The size of the Board is about right. However, to widen the representation and to change some of the titles and terms that have become obsolete with time, clause 3 establishes a Nursing Board with three ex-officio members and 14 appointed members. The ex-officio members are the Director of Medical Services, the Chief Nursing Officer and the Director-General of Education or his representative. Of the 14 appointed members, 11 must be nurses and the remaining three need not be nurses. Clauses 6 and 12 allow the Minister to appoint the Chairman and the Registrar of the Board. Clause 4 provides for the removal of an appointed member from office if the member, for example, is found guilty of infamous conduct or is absent without leave from three consecutive meetings of the Board or its committees. This is similar to the provisions in the Medical Registration Act (MRA) and the Legal Profession Act.”
“Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time." This Bill seeks to provide for the registration and enrolment of nurses, the registration of midwives and for matters connected therewith, and to repeal the Nurses and Midwives Act (Chapter 209 of the 1985 Revised Edition). It will enhance the regulatory role of the Singapore Nursing Board to allow it to discharge its functions more effectively and to ensure higher professional standards of conduct and practice. There have been major changes in the last 25 years in the training of nurses, the practice of nursing and the types of nursing services in Singapore. To maintain a high standard of nursing, there is a need to update the Nurses and Midwives Act. Let me briefly describe some of the major changes. Traditionally, nurse training in Singapore was hospital-based under an apprenticeship scheme. The Singapore Nursing Board's role then was to set the training curriculum and to conduct the examinations. Today, the training of nurses and midwives is part of the mainstream educational system with registered nurses and midwives trained in the Nanyang Polytechnic. The enrolled nurses will soon be trained in the Institute of Technical Education. The Nursing Board's role will therefore have to be changed accordingly to ensure that nursing standards are maintained and that nurses have the skills to meet the changing healthcare needs in Singapore. Over the years, the role of nurses has evolved in tandem with the advances in medical science and technology. Many nurses today are highly skilled, with more than a quarter possessing advanced qualifications in various clinical specialties. As at December 1998, 42 nurses are already designated as "nurse specialists" in their hospitals.”
“Mr Speaker, Sir, in 1994, the total number of nurses and midwives registered with the Singapore Nursing Board (SNB) was 12,230, of which 2,022, or 16.5%, were foreign nurses. The number of foreign nurses registered in 1995, 1996, 1997 were 1,844, 2,160 and 2,767 respectively. In 1998, of the total number of 15,568 nurses registered with SNB, 3,239, or 20.8%, were foreign nurses. 1.30 pm”
“As I have mentioned, we do consider this on a case-by-case basis. But we need very good evidence that the transaction is aborted beyond the control of the purchaser. If the purchaser aborts the transaction, you cannot say that that is beyond his control, because he himself aborted the transaction. So he must pay the stamp duty. PRIVATE CONDOMINIUMS AND HDB FLATS (Increase in sale prices and impact on affordability) 3. Mrs Lim Hwee Hua asked the Minister for National Development whether the average compounded increase in (a) private condominium, (b) HDB direct purchase and (c) HDB resale prices over the last (i) 5 years and (ii) 10 years has outstripped the increase in wages over the same periods, and if so, whether the resultant impact on affordability is addressed by the planned land sales. The Minister of State for National Development (Dr John Chen Seow Phun) (for the Minister for National Development): Mr Speaker, Sir, as at the second quarter of 1999, the increase in monthly wages of workers compared with the price increase for the various categories of housing types over the last 5 and 10 years are in the table (Cols. 397-398) which I shall now ask the Clerk of Parliament to circulate to Members. My staff told me that they have given the table to Parliament. Table - Trends of Wages vs Property Prices (Cols. 397-398)”
“Sir, I have already explained the reason for bringing forward the payment. Yes, of course, the Government thought through the whole issue before announcing the package in 1996. If the transaction did not go through because of circumstances beyond the purchaser's control, as I have explained earlier of the seven circumstances, due to reason of the purchaser not being able to get the necessary approval to complete the transaction, then the stamp duty will be refunded. If the transaction fails to go through because the seller aborts the transaction, then the purchaser is entirely within his rights to enforce the contract. If the purchaser himself aborts the transaction, then it is part and parcel of the cost. He knows, before he enters into a transaction, that if he fails to go through with the transaction and he aborts the transaction, then this is part and parcel of the cost involved in aborting the transaction.”
“Sir, if the Member can remember, we brought forward the payment of the stamp duty in 1996, as part of the anti-speculation measures. That was the whole idea - to bring forward the payment of the stamp duty so that only bona fide purchasers, who have real intent to buy property, will go into a transaction and they pay the cost. This is to deter speculation. In the past, when stamp duty was paid at the end of the transaction, it did not cost very much for somebody to take out an option, speculate on a property, and if the market takes a downturn, abort the transaction. So this measure of bringing it forward is part and parcel of the anti-speculation package in 1996.”
“My Ministry is also working with the grassroots organisations and CDCs to help encourage women to go for pap-smear screening for cancer of the cervix and mammography screening for breast cancer. We are piloting a pap-smear screening programme in Toa Payoh next year with the view to extending this programme on a nation wide basis later so that we can have an effective outreach programme to prevent cancer of the cervix. The next area that we want to target at is the senior citizens and to address this issue of affordability, we are having a geriatric screening programme with the College of Family Physicians so as to draw in the GPs, and the funding would be made through the Singapore Totalisator Board which had agreed to subsidise 75% of the cost. So an elderly person would co-pay only 25% of the cost, ie, only $5. We would embark this geriatric screening programme together with the College of Family Physicians and the Singapore Totalisator Board. The Question having been proposed at Fourteen minutes past Five o'clock pm and the Debate having continued for half an hour, Mr Deputy Speaker adjourned the House without Question put, pursuant to the Standing Order. Adjourned accordingly at Sixteen Minutes to Six o'clock pm.”
“For the fifth area, Dr Neo suggested tax incentives for employers who provide preventive healthcare. I will pass this on to the Ministry of Finance but preventive healthcare programme, as I say, is not very expensive and therefore, I am not sure how effective this would be. Dr Neo also suggested the use of Medisave for preventive healthcare cost. There are no clear-cut arguments for or against the use of Medisave. We must realise that Medisave savings can only meet a certain portion of our lifetime healthcare cost. If you spend it on preventive healthcare, and you are unfortunate enough to have an episode in hospital, then you have to dig into your pocket, and that can be a very expensive episode. Alternatively, if people spend this small amount needed to keep their health in good shape, like going to the GP which costs $20 or $30, where people pay out of their pocket, then they keep their Medisave for the more costly episodes in the hospital. So it does not really matter as long as everybody saves and that saving goes towards paying part of the lifelong healthcare cost that all of us will probably end up having to incur. On pap-smear screening, I agree that our track record has not been such a sterling performance and that is because we have not made it universal. We have encouraged and exhorted the women to go for pap-smear screening but it has not been universally made available. We would look at this programme because I think there are medical merits in running pap-smear screening and we would see how this can be taken up together with mammography. We have encouraged the Breast Cancer Foundation and in the three years since it has started, it has done good work to promote awareness of breast cancer and the effectiveness of early detection through mammography.”
“For healthcare financing, the minimum that we would want is cost-sharing so that people value the services provided for them. I do not think we should walk away with the idea that anything that is free would solve the problem. I was told that we implemented a mammography screening project from 1994 to 1997, but only half of the women turned up for screening, even though the screening was provided free of charge. In other words, it was not the cost of the screening that deterred the women, but rather the lack of awareness of the need of the screening, the fear of the screening procedure and sometimes, the fear of knowing the result that made half of the women not to turn up for the screening, even though the screening was provided entirely free. My point is that money cannot solve all problems. I think the more difficult part of the problem is to educate the population, to get them to understand the need and also to target at the groups that are most vulnerable. For example, if you have free mammography screening, the better educated women who can best afford the fees would take this up. But the less educated women, maybe the 50% who did not turn up for the screening, are the ones who are more vulnerable. I would think that the greater effort should be at targetting the groups which are most vulnerable. The third area is to work with companies to conduct check-ups, etc. I think this is one of the areas that we are embarking on, that is, to take preventive healthcare into the companies, into the workplace. The fourth area is to target at people in their 40s and 50s. I agree entirely with Dr Lily Neo. I think we must try and address these age groups early rather than deal with them when they turn 60s. By then, the problem is already there.”
“By and large, if people maintain a healthy lifestyle and take simple tests like these, we should be able to screen out those who are more vulnerable. And I think more can be done to target those groups which are vulnerable. Some of the suggestions have been brought up by Dr Lily Neo and I would go to them in detail. The fourth component is what we call preventive healthcare. That means having detected people who are vulnerable, for example, people who are diabetic, how do you get them to manage their situation so that their situation does not get worse and, in so doing, present more expensive healthcare issues for us. So that is the fourth category. I would say that most of the suggestions that Dr Lily Neo brought up deal with the third and fourth categories, that is, how do we target the groups for screening, those who are more vulnerable, and also how do we better manage the groups which are diabetic or the older groups and that we can manage their health situations well enough so that they do not lapse into more difficult problems for us. Let me address the nine areas now. First, more funding and more people. I think I have done that. If a measure is worthy of implementation, I can assure the House that the Ministry of Health will find the funds to implement it. So funding is never a big problem with us. But it does not mean that we will throw good money and that we feel proud that we have increased the amount of money we spent. It really depends on the usefulness of the programme. Second, the Government should take the initiative as the biggest employer to provide free and basic medicare to all civil servants. Members know that is not our approach.”
“Our approach to promoting a healthy lifestyle now takes on more than just a general exhortation of Singaporeans but also targetting at different groups, ie, those groups which are more vulnerable to a more sedentary lifestyle and to poorer healthy lifestyle habits. We have taken the campaign to the workplace. We are targetting at people in their 30s and 40s because as Dr Neo herself mentioned, it is this group that would bring along their health problems later on when they grow older. But promoting and maintaining healthy lifestyle is one of the most difficult tasks in our preventive healthcare programme. The third component of our preventive healthcare programme is screening. We take a very targetted approach to look at those groups who are most vulnerable and try and detect these groups early so that we can prevent the disease from starting or from getting worse. There is a lot in the medical literature on the efficacy of the different health screening procedure. The Ministry of Health here takes a very pragmatic approach. We do not advocate widespread universal medical screening. We screen the population and we encourage screening where it is effective. If somebody maintains his health and has a healthy lifestyle, there is very little that he needs to do in terms of medical screening. If you do not smoke, maintain your weight within a certain recommended range, every time you see your GP, he takes your blood pressure to make sure that it is within the recommended range and if it is high you try to take measures to bring it down. If every year you take a simple blood test to check your cholesterol level and blood sugar, that would give an indication whether you are diabetic or not.”
“We are consistently looking out for new ways to improve and how we should approach this issue, and therefore, we are grateful to Dr Neo for bringing up some suggestions. Let me deal with the nine areas which she has brought up. But for Members to understand these suggestions and put them into context, let me first explain how we approach preventive healthcare in the Ministry. We divide preventive healthcare into four areas. The first component is to make sure we have the foundation for a healthy population and that means very sound pre-natal/post-natal care and a very sound school health and school dental programme. This makes sure that our population is given the best level of care in the early stages of their lives and, therefore, they have the foundation to keep their health sound. Members know our immunisation programme for our young children is among the best in the world. Our infant mortality rate ranks among the lowest among the developed countries. Our track record is excellent. Our school health and dental programme has done extremely well. We are, of course, on the lookout to see how we can improve this better. So I would say that for the first component on making sure that our population starts off healthy, I think we have achieved that to a large extent. The second component is how to keep the adult Singaporeans healthy, how to encourage them to maintain a healthy lifestyle, ie, having given them a sound foundation, how to maintain a healthy lifestyle throughout their lives. We have started this campaign on Healthy Lifestyle many, many years ago. We have had some limited successes but we are fighting against strong odds. Singaporeans are getting richer, their food gets richer and their lifestyle is more sedentary.”
“Mr Deputy Speaker, first let me thank the Member, Dr Lily Neo, for bringing up this issue. Let me address two broad principles first before I take on the nine specific suggestions that she put up. First of all, the Ministry of Health agrees wholeheartedly with Dr Lily Neo that prevention is better and indeed cheaper than cure. That philosophy is what is driving the Ministry of Health. Second, on the question of more money and more resources, by and large, I would agree that the spending priorities of a Ministry reflect the priorities of the Ministry but one should be careful in not taking that statistic too far. Dr Lily Neo mentioned that preventive healthcare takes up only 13% of MOH's budget and that the emphasis is therefore dismal. As Dr Lily Neo herself mentioned, preventive healthcare is not that expensive compared to hospitalisation. So, 13% does not mean that we do not put enough priority on preventive healthcare. The reason why preventive healthcare is such a small percentage is that hospitalisation is very expensive and the Government subsidises hospitalisation costs to a very large extent, to the tune of 80% for our Class C wards, 65% for Class B wards, and so on. If the Government had subsidised our Class C wards at 50% rather than 80%, and the other wards are subsidised correspondingly, then overnight, the percentage of budget on preventive healthcare would more than double, to more than 25%. I am sure Dr Lily Neo would not say that this is a good statistic. But 13% amounts to $130 million which is being spent every year on preventive healthcare and that is not a small sum. We do lay emphasis on preventive healthcare.”
“Sir, the Member's understanding of the binding agreement is correct. But whatever principles you may not agree with in the White Paper, the fact remains that the Constitution says that the President protects past reserves. And what constitutes past reserves? They are net financial assets and State land and buildings. And if the Government says, "No, that past reserve is defined as the value at the time of the change over of government," and the President says, "No, it must be at the point of transaction.", the President will say, "This is my view supported by the Council of Presidential Advisers. I will veto it." The Government will have to either challenge it, if it can. It will be under scrutiny by the public. In that very simple example, the public will quite clearly be on the side of the President to say, "You sell a piece of state land, it must be at the market value at at the point of sale." I do not think there is any confusion to the public who is right in that scenario that she painted.”
“Sir, the principles will be binding for future Presidents and future governments. And there is, as the Member has described it, an escape clause, that if either the President or future government does not want to follow the principles, they are allowed to say that it is no longer binding. But that does not deviate from the requirement and the spirit of the Constitution, which is protection of our financial assets and protection of our land and buildings, which are deemed as past reserves. State land is deemed as past reserves, and if you sell State land at anything less than market value, you are running down on past reserves, and the elected President will veto that transaction.”
“Mr Speaker, Sir, I guess the Member is referring to the recent press report about a petition by 50 medical practitioners regarding the advertisement put up by Johns Hopkins. Let me say that there are two elements in that complaint. One is whether we use the same rules for the people practising in Johns Hopkins Hospital. There is this allegation that it is an uneven playing field. SMC has replied to the complainants on 3rd August 1999 to say that the same rules were applied to the registration of doctors. To-date, SMC has only registered two John Hopkins specialists. Both of them have the American Board certification in internal medicine and medical oncology, which are recognised specialist qualifications. So the two specialists in Johns Hopkins Hospital have been duly registered based on the same rules that we apply for Singaporean specialists. As to the allegation about the advertisement, this matter is still under investigation by my Ministry's Medical Audit and Accreditation Unit. STAMP DUTIES (AMENDMENT) BILL Order for Second Reading read. 1.17 pm”
“Mr Speaker, Sir, the answer is yes. The practitioners in Johns Hopkins Hospital will be required to be registered by the SMC, just like any other medical professional who wants to practise in Singapore. Similarly, the Johns Hopkins clinic itself will have to undergo registration by the Medical Audit and Accreditation Unit of my Ministry. So Johns Hopkins will have to follow the same rules, as any other practitioner and any other clinic in Singapore. Assoc. Prof. Toh See Kiat (Aljunied): Sir, I would like to ask the Minister if he is aware of any practices by the practitioners in Johns Hopkins Clinic to solicit business in a way that other doctors in Singapore are not allowed to?”
“Mr Speaker, Sir, all doctors, whether Singaporeans or foreigners, are subject to the same regulations and medical ethics. The Singapore Medical Council (SMC) will only register doctors who have met the required standards before they are allowed to practise in Singapore. Medical registration is granted to overseas trained doctors, Singaporeans or foreigners, if the applicant - (a) holds a basic medical degree awarded by one of the medical schools listed in the Schedule of the Medical Registration Act; or (b) holds a recognised specialist qualification, and possesses special knowledge and skills in a field of medicine that are needed by Singapore. The SMC has drawn up an "Ethical Code" to be observed by all doctors. Since 1995, all newly registered doctors, Singaporeans and foreigners, are required to take the Physician's Pledge of the SMC, which serves as a formal affirmation of their commitment to follow the code of professional conduct and ethics. Disciplinary action will be taken against doctors who breach the Code. The SMC will act on all complaints received concerning doctors' professional conduct and fitness to practise. The penalties that can be imposed on doctors include censure, fine, suspension or even removal from the register. Complaints are usually received from members of the public. My Ministry's Medical Audit and Accreditation Unit regularly inspect health care establishments and will report any lapses in professional practice by doctors to the SMC for follow up action.”
“Sir, we recognise that Singapore's population is aging. That is why we have set up the three geriatric departments at the three regional hospitals, and we are building up the geriatricians as well as geriatric-trained nurses to meet the needs of the community. We are confident that we can provide the necessary support to the aged in Singapore. TAX EXEMPTION FOR ANNUITY 6. Dr Lily Neo asked the Minister for Finance whether he will consider complete tax exemption for annuity to encourage people to be self-sufficient for old age.”
“We have three regional hospitals - Alexandra Hospital for the western area, Tan Tock Seng Hospital for the central area and Changi General Hospital for the eastern area - to serve the geriatric needs of the people living in these areas. So far, the level and the extent of the services seem to meet the needs of the community, including the various community outreach programmes.”
“Mr Speaker, Sir, geriatric services have been developed at Alexandra Hospital. The Department of Geriatrics, set up in 1994, provides comprehensive specialised outpatient and inpatient medical care to the elderly. The Geriatric Day Hospital also provides outpatient geriatric assessment and rehabilitation for those who need not be hospitalised. Special focus is given to the more common disabling medical conditions in the elderly, such as stroke management, bone and joint problems, dementia and other mental problems, and continence management. The Department in Alexandra Hospital is also the focal point for various community support services for the elderly in the western sector.”
“The Ministry will be building a polyclinic in Pasir Ris at the junction of Pasir Ris Drive 1 and Pasir Ris Street 51. The proposed Pasir Ris Polyclinic will be co-located with a Voluntary Welfare Organisation, namely Care of the Elderly Foundation (CEF) Nursing Home. The construction of the proposed Pasir Ris Polyclinic and Nursing Home will commence in early 2000 and is expected to be completed in 2002. SECONDARY SCHOOL IN BUKIT GOMBAK CONSTITUENCY 35. Mr Ang Mong Seng asked the Minister for Education whether his Ministry has any plan to build a secondary school in the Bukit Gombak Constituency and if so, when and at which location. RAdm Teo Chee Hean: The Ministry of Education's review of the requirements for secondary schools in the Bukit Batok DGP has shown the need to build one new secondary school in the DGP. I am happy to inform the Member that MOE, together with URA, has identified a suitable site next to the existing Lianhua Primary School at Bukit Batok Street 52, which is within the Bukit Gombak Constituency. The school will be built by the end of 2001. PLAN TO PROMOTE IDEAL OF ACTIVE CITIZENS 36. Mr Harun A Ghani asked the Minister for Community Development if the People's Association has any plan to promote the ideal of active citizens as outlined in the report by the Singapore 21 Committee.”
“Mr Tay Beng Chuan asked the Minister for Manpower what initiatives are proposed by his Ministry in preparing and training our workforce to face the challenges of the transformation of Singapore into a knowledge-based economy.”
“Presently, there are sufficient safeguards to enable doctors and complainants to challenge the decision of the Medical Council prior to the commencement of a formal inquiry. The Medical Registration Act requires that all complaints lodged with the Medical Council concerning doctors' professional conduct and fitness to practise to be processed by a Complaints Committee of the Medical Council. The Committee comprises four members - two Council members, one other doctor and a lay person. It will obtain a written explanation from the doctor concerned and other relevant documents such as medical records. After examining all the facts and evidence available, the Complaints Committee will either dismiss the complaint, issue a letter of advice or warning to the doctor concerned, or refer the complaint for a formal inquiry. The doctor and the complainant will be notified of the decision of the Complaints Committee. For any decision made by a Complaints Committee that does not involve referring the complaint for a formal inquiry, such as issuing a letter of warning, the doctor and complainant can appeal to the Minister within 30 days from the date of the notice. When the Minister receives an appeal, he will review the proceedings of the Complaints Committee, after which, he could uphold or reverse the order made by the Complaints Committee, or make other orders as he deems fit. For any complaint that is referred for formal inquiry by a Disciplinary Committee appointed by the Medical Council, if the doctor believes that the Complaints Committee has acted unfairly or unreasonably, he could apply for a judicial review. The proceedings and decision of the Complaints Committee would then be examined by the High Court. TRAINING OF WORKFORCE FOR KNOWLEDGE-BASED ECONOMY 16.”
“I am pleased to inform the hon. Member that my Ministry has already reviewed and increased the Medisave withdrawal limits for outpatient chemotherapy. From January 1998, these limits have been raised from $250 to $400 for each treatment cycle lasting between 21 and 28 days. The withdrawal limit is $100 for a weekly treatment cycle. The yearly withdrawal limit now stands at $3,000, up from $2,000. With the raising of the limits, about 80% of subsidised patients and 60% of private patients would be able to pay their entire chemotherapy bills using Medisave alone. This does not take into account MediShield claims which can also be used to offset part of the bill, hence making the chemotherapy treatment even more affordable. The hon. Member may be assured that my Ministry reviews Medisave withdrawal limits regularly to ensure that they are adequate for most patients. SPOUSES ON DEPENDANT'S PASS 23. Dr Ker Sin Tze asked the Minister for Manpower if he will consider allowing spouses of citizens and permanent residents who stay here on Dependant's Pass to work.”
“Let me explain that the Complaints Committee is intended as a screening process before a complaint is taken up by the Disciplinary Committee. We want a process by which a complaint by the public or by other professionals is assessed to see whether that complaint is bona fide and, in fact, should be taken up by the Disciplinary Committee. There is no need for the dentist who is complained against to appear before the Complaints Committee. If he is required to show cause, he will have plenty of chances in front of the Disciplinary Committee. Both Mr Rai and Dr Lily Neo also referred to a recent case where a dentist who advertised his services was penalised by the Dental Board. He appealed to the High Court and the High Court felt that the penalty was too severe, and part of this Bill is in response to that case to give a different gradation of penalties. It also illustrates that the mechanism that we have set out in the current Bill is the right one and that there is a due process through the Complaints Committee and the Disciplinary Council, and if the dentist feels that he is aggrieved, he can still appeal to the High Court. And in the High Court, we get the chance to hear the appeal and the judgement can then be taken. I think the process works well and that is in fact proposed in the Bill. Question put, and agreed to. Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Lim Hng Kiang]. Bill considered in Committee; reported without amendment; read a Third time and passed. VACANCY IN PARLIAMENT (Motion)”
“My apologies. So it is also in the Legal Profession Act. In that case, there should not be any objection to having this clause of good reputation and character. Clause 17(6) and (7) talks about the premises for a dentist to practise. The requirement is for practising in the premises. It is not laid out in the Dentists Bill. In fact, it is laid out in the Private Hospitals and Medical Clinics Act. In that Act, the criteria for premises to be registered for such practices are quite clearly laid out and also if the premises are not registered, the licensing authority is required to give reasons why the criteria are not met. So the applicant can make good the shortfalls and allow their premises to be registered. Clause 21(1) talks about bond breaking. We have gone through this debate the last time when we discussed the Medical Registration Act. Basically, the number of applicants to both the medical and dentistry faculties in Singapore is very large. We have to restrict the numbers. The courses are conducted at great expense to the public. The courses are very heavily subsidised and therefore we require students entering these two faculties to give an undertaking that they serve the community after their graduation. If they break the bond, we will require them to pay up the liquidated damages for breaking the bond. If they do not pay the liquidated damages, of course they run the risk of being de-registered as a dentist. I think that is fair because they are educated at great expense by the community and it is not unfair of the community to expect them to serve the community in return. Dr Lily Neo also asked about the way the Complaints Committee is conducted.”
“I do not know about lawyers. Maybe lawyers do not need to be of good reputation and character to be registered.”
“Mr Speaker, Sir, I would like to thank the two Members for their support of the Bill and their comments. Let me take the detailed comments in turn. Dr Lily Neo made the comment that in clause 4, applications may be made in such form or manner and that she hopes that in administering the practising certificates, the Dental Council would not be too restrictive. I assure the House that the purpose of the Dentists Bill is to register and make sure that all dentists have the qualifications, that they are physically and mentally fit to practise and that they are of sound character and reputation. Both Members questioned the need for clause 15 that practising dentists must be of good reputation and character. As I said, all dentists, and indeed all professions, must not only have the qualifications to practise. I think society requires that all professions have certain set standards and one of the standards is that they be of good reputation and character. I think that is quite well defined. The Bill allows for any person who is not registered because of that clause to have an avenue of appeal. This requirement incidentally appears in many professional Acts. Dr Lee tells me it also applies to veterinarians. An hon. Member: Lawyers.”
“These enhanced penalties very clearly signal that the Government is determined to stamp out such cases of illegal practice. Consequential and other minor amendments The Bill also proposes consequential changes as a result of the proposed amendments that I have just described, and other minor amendments to delete obsolete terminology and to update the existing provisions. Mr Speaker, Sir, we have come a long way in the provision of dental care. The general state of dental health in Singapore is good. It is that way because we have well trained and highly competent dentists. The challenges facing the dental profession and the entire healthcare sector will be greater in the years ahead. We will continue to see the development of new materials to treat dental decay, new techniques and new methods to replace missing teeth. The dental profession must ensure that its members are properly qualified before they are allowed to use the new materials and technology. At the same time, we must deter dentists from advising their patients to undergo unnecessary high-tech procedures for financial or other reasons. This Bill will help to achieve these objectives. It will enhance the role of the Dental Council, and empower it to safeguard the high professional and ethical standards of dental practice, and to uphold the integrity of the profession. Sir, I beg to move. Question proposed.”
“The Council shall also be empowered to order the suspension or removal of name to take effect immediately, instead of after 30 days, if it is deemed necessary in the public interest or in the best interest of the dental practitioner concerned. Restoration to the Register If a dentist has his name removed from the Register pursuant to a disciplinary inquiry, it does not mean that he cannot practise his profession anymore. There is provision for the dentist to apply for his name to be restored after a minimum period of three years. Health Committee At present, a dentist who is unfit to practise because of psychiatric condition, drug or alcohol dependency or any other physical or mental condition, cannot be removed from the Register. Clauses 48 and 49 provide for the setting up of a Health Committee to review any dentist whose fitness to practise is impaired by reason of his physical or mental condition. It will be empowered to restrict or suspend the dentist's practice, or recommend that his name be removed from the Register. The Medical Registration Act and the Dentists Act of the United Kingdom also provide for the establishment of a Health Committee with similar functions. Proposed increase in penalty for unauthorised persons acting as dentists Another problem, which we face from time to time, is the illegal conduct of dental procedures by unqualified persons, eg, the making of dentures. Often these are done improperly or under non-hygienic conditions. Clause 28 increases the maximum penalty for a first offender from the present $2,000 to $25,000. For subsequent offences, the penalties will be increased to $50,000 or imprisonment of up to six months or both.”