Michael Lim Chun Leng
Singapore
“Mr Speaker, Sir, I would like to ask the Minister, in the light of scientific evidence to show that as many as half of the people who are presented with a heart attack at a hospital do not have any critical stenosis or narrowing in the heart artery, but actually only have a very minor narrowing in the heart artery, and as a result of tear…”
“My question is: in the light of things evolving, whether for specific high-risk individuals, we should actually look at other means of identifying them. On the second point about AED, if we reach the A&E for a sudden cardiac death, of course, your mortality is more than 90% because it takes a long time to reach it.”
“Clinical practice guidelines help doctors to manage patients in the most optimal way. They do not help doctors manage patients in a most cost-effective manner. Ultimately, most Singaporeans want to have the cake and eat it. Let us not raise the expectations too high. Let us keep healthcare bills in the public sector affordable.”
“The Ministry had spent millions of dollars on IT cost, man-hours and employing new staff. Yet, till this day, few believe that it has translated to any real tangible improvements in the healthcare delivered to the man-in-the-street.”
“Mr Speaker, Sir, I am getting a bit confused here. I am trying to understand the process. Can I check with the Minister? Does it mean that an operator can seek approval from PTC and PTC, based on a certain set of criteria, has approved the routes or what they are supposed to do, and then the operator can decide not to follow what PTC has…”
“Sir, I would like to ask the Minister how can there be more predictability if one took an express bus from point A and reach point B on the same express bus vis-a-vis someone who has to take a bus to the MRT station, drop off at another MRT station and then take another bus to his destination. How can there be more time predictability?”
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“My question is: in the light of things evolving, whether for specific high-risk individuals, we should actually look at other means of identifying them. On the second point about AED, if we reach the A&E for a sudden cardiac death, of course, your mortality is more than 90% because it takes a long time to reach it. But if you have an AED accessible to the person within one, two or three minutes, the outcome is surely very different. So my point is whether the Minister wants to review this need to make AED very accessible to the training areas where there are medics so that they can use it within minutes, rather than waiting to go to the medical centre which will probably take 10-20 minutes, by which time the person may be brain-dead.”
“Mr Speaker, Sir, I would like to ask the Minister, in the light of scientific evidence to show that as many as half of the people who are presented with a heart attack at a hospital do not have any critical stenosis or narrowing in the heart artery, but actually only have a very minor narrowing in the heart artery, and as a result of tear at that segment, they form a clot and block the artery, resulting in a heart attack, this often occurs during exercise. Perhaps, we should consider the possibility of identifying those who go through very vigorous exercise during the NS period, ie, high-risk individuals who would be, in all likelihood, have a high risk of having a narrowing in the artery, which cannot be picked up by traditional means like treadmill testing. We know today that there are technologies available where this can be picked up non-invasively without any risk to the patient. Of course, we want to take guidelines like ESC guidelines or IOC guidelines ---”
“Compared to medical technologists from overseas, our graduates are armed with theoretical knowledge but have very little practical skills. More often than not, we have to get our foreign-trained technologists to give further practical training to our local technologists. The main reason is that when they are posted to the public hospitals for their practical attachment, the technologists there are too busy to teach them to allow them hands-on training. Examinations do not tell everything. Performance in the real world does. (3) Learning Malay. Sir, I remember that, as a primary school child, I had to attend Malay classes for the first four years. Most of us thought that it was a waste of time as it was a non-examination subject. However, in the course of work, the basic foundation I had in Malay became important. Today, I converse in Malay with many of my foreign patients, and it has made a difference. With Malaysia and Indonesia as our neighbours, it will certainly be useful to foster better relations with our neighbours by being able to communicate with them in Malay. We need to allow an avenue for our school children to be exposed to basic conversational Malay. However, learning has to be made interesting. As one student put it, "No one will pay attention to non-examination subjects." Therefore, the onus is on the Ministry to come up with better creative teaching tools.”
“Sir, three major points. (1) Certainty in syllabi. While Singaporeans often complain that the school system is stressful, the question is often whether the stress is from the school or whether it is from outside the school, namely, the parents. My children tell me that their schoolmates from China find it more relaxed and less stressful when they study in Singapore as compared to their schools in China. The Ministry may take measures to reduce workload on children to reduce stress. It has initiatives, such as "Teach Less, Learn More". When there is an announcement on syllabi reduction, instead of being happy, parents get frantic. When you tell parents that examinations will not be based on the standard textbooks, they panic. Parents will tap into their intelligence network to find out the right tutor who had helped a friend's child get solid grades for the last year's PSLE. It is the element of uncertainty that drives parents bananas in their endeavour to over-compensate for that void created in the reduction in school work. What the Ministry and the schools must do is to communicate to the parents as to what is required and spell out clearly what is in the syllabi at the beginning of each year. Nothing causes more stress and drives up the level of kiasu-ness than uncertainty. (2) Outcomes of education. As the education system evolves and we churn out more diploma and degree graduates, the Ministry will need to assess the quality of graduates that come into the workforce. Employers' feedback provide an excellent source of feedback. Only then can we assess the outcomes of our education system. I would like to take the case of medical technologists who graduate from Singapore Polytechnic.”
“In a few years, Singapore Regional Medical Hub will compete in the home ground of our ASEAN neighbours and in South Asia and China. Drawing talent from the region, being reference centres for medical technology, practising the highest standards of medicine and remaining cost competitive, Singapore Regional Medical Hub eventually becomes the medical centre of choice in Asia. Singaporeans dare to dream, take the risk and raise the standards. We want to lead in the world and are not content to be just followers of other countries. We may run into competition with the public sector but we need not fear if the competition is open and transparent without resorting to bureaucratic hurdles, turf protection measures and harassment through Government agencies. Singaporeans know what they must do to beat the competition, but the steps ahead require rapid changes in the system. Is the Ministry of Health ready? As one senior healthcare official told me - you are too far ahead of the time, we cannot change fast enough. I do not know whether all these will continue to remain a dream or whether it will become a reality. But one thing I know for sure is that in India and China, their large pool of foreign trained specialists will post a formidable challenge to Singapore. If we do not act fast enough, not only will the number of foreigners coming to Singapore decrease, the number of Singaporeans seeking private healthcare treatment overseas will increase. Future Development of the Two Hospital Clusters”
“Sir, I wish to declare my interest as a medical practitioner. The gap between Singapore and its regional competitors has narrowed significantly. Top doctors from the region, whether they are from countries like Malaysia, India, Philippines and China, are no less than many of our top doctors. In India and China, procedures are done at a fraction of our cost. Many of their top doctors have been trained in top western foreign medical institutions. Today, the reality is that a large number of nurses, medical technologists and radiographers come from our neighbouring countries. The Government tells Singaporeans to be entrepreneurial, take risks, grow the economy, create jobs; and on its side, it will provide incentives, regulate lightly and remove bureaucratic hurdles. I dream of a Singapore Regional Medical Hub where we combine the best of Singapore and the region by drawing upon the talent of some of the brightest and best doctors from the region, including Malaysia, India, Philippines and China. In this sense, where the large majority of the patients are foreigners, these foreign consultant specialist doctors can be allowed to practise independently to service our large foreign private sector pool. They are allowed accreditation to perform procedures based on their training and experience. They adopt Singapore standards of medical practice. We work with the medical MNCs to become regional centres of excellence in various areas of medical advances. As we continue to maintain high standards, we provide cost competitive healthcare services which make us a magnet for foreign patients. When we grow sufficiently big to have a big pool of local and foreign specialists, we will set up outposts where we use Singapore standards but local costs.”
“Then we will not be able to fulfill our responsibilities to the very poor who really require some of those basic hospitalisations. 6.15 pm Dr Michael Lim gave vivid examples of how technology can postpone death and bankrupt the whole society along with it, often with little quality of life for the patients. He wisely advised our medical community to ensure that our clinical practice guidelines incorporate cost-effective care. I cannot agree more. Politicians have a role to play here. So as Mr Gan Kim Yong quite wisely advised us, we must help to moderate the expectations of Singaporeans. Certainly, we must not fan unnecessary expectations. We just cannot afford it. Meanwhile, let us try to make the market work better for us. The healthcare market will never be perfectly competitive. But it is so imperfect that any incremental improvement will mean big progress. If each year we make it less imperfect than before, we would have made a meaningful contribution. Singaporeans can then continue to enjoy a high standard of healthcare services, a world-class health status, at a cost which our society can afford. Mr Chairman, I would be happy to take any clarifications from the Members.”
“" But healthcare is a partnership between the carer and the patient. There is no such thing as "a pill for every ill". To stay healthy and to recover from an illness, the patient has to play an active part. Let me give you my personal example. I am genetically predisposed to high cholesterol, higher than normal. Years ago, my doctor spelt out the protocol for me: diet, exercise, statins and periodic assessments. And my friends know that I am strict on my diet, consistent with my exercises, and totally compliant with my statins. Without this personal involvement, there is a limit to what my doctor can do to effect a change in my health status. Without this consistent exercise regime, I would not be able to take the punches from Ms Indranee Rajah! I am optimistic that more and more patients will be proactive. Doctors are increasingly being challenged by their patients, who come with printouts of articles that they read on the Internet. I welcome this development. However, let me caution that being proactive does not mean trying to play doctor and demanding every new drug advertised on the Internet. Your doctor will have to assess your needs and prescribe accordingly. That is their job. As always, there are trade-offs to be made. There are now so many new drugs - very expensive, marginal benefits. For subsidised patients, we have to make the choice on behalf of them. That is why we have standard versus non-standard drugs, which Mdm Halimah and Mdm Cynthia Phua brought up. As trustees of limited public funds, it is our job to spend it in a way that brings maximum benefits to all. If we merrily incorporate all new drugs into our standard drug list, we will quickly run out of money.”
“Mr Low Thia Khiang is worried that electronic medical records may cause big problems if they are wrongly recorded and then the damage is magnified. He mentioned the case of his constituent who was wrongly recorded as HIV-positive. I need specific details to find out what caused the error. But there is no excuse for human errors. All hospitals have a duty to keep medical records accurate, current, complete and confidential. That said however, let us not throw out the baby with the bath water. In fact, the change from paper-based systems to electronic ones has improved the accuracy of medical records. For example, in most emergency departments, recent records are no longer handwritten, with all its problems, and laboratory test results are now transmitted directly in electronic forms to the doctors. We have safeguards in place to ensure accuracy and integrity and for sensitive information, like HIV, there are additional safeguards. My message is this. We should not be afraid of IT. In fact, healthcare is inefficient partly because it is such a laggard in the exploitation of IT. I am determined to change that. Our pilot skunk works can potentially transform the way we run hospitals, bringing new benefits to patients. We do not underestimate the challenges but, if we are creative and determined, some of these skunk works may succeed. Finally, let me touch on the other important aspect in any healthcare system, and that is the role played by patients. This has traditionally been neglected. We all say that people value good health. But how many really take this to heart, and proactively work with their doctors to preserve their health? Many patients are passive. When well, they take their health for granted. When sick, they ask their doctors: "Doctor, what can you do for me?”
“I suggested to Steve Ballmer that the current system of running hospitals, whether in the US or anywhere in the world, is not sustainable. But if we can transform the current system, I think we would have made a major contribution to the world. He was excited by the prospect and the opportunity. We decided to use Alexandra Hospital - the entire hospital - as the test site for such a major experiment, or what the Americans call "skunk works". We are involving other partners, including Nanyang Polytechnic. Principal Lin Cheng Tong offered to help. His academic staff and students came forward, worked very closely with Alexandra Hospital, Microsoft, IDA and others. They wrote most of the computer software on trial at the A&E Department that allowed the staff to change and modify their processes, which enabled them to bring down the waiting time from 25 minutes to 14 minutes. This has been a most productive engagement. Students got to work on cutting-edge projects in a real environment, while hospital patients benefit from faster improvement. Microsoft has a work discipline which demands progress every 90 days. Our Nanyang Polytechnic students do not disappoint. Many worked past midnight and through the Chinese New Year holidays to deliver within 90 days. I have no doubt the outstanding ones will find jobs with Microsoft. As I said, we are extending these skunk works to other parts of AH. Let me share with you my IT vision for healthcare. It is "One Singaporean, One Electronic Medical Record (EMR)" which is constantly updated, real-time and shared, privacy protected by all the healthcare providers. This vision will take time to realise, but initial steps have already been taken, benefiting patients in our emergency departments.”
“Over the last 12 months, the Alexandra Hospital team has been learning from Toyota, visiting their Toyota factory in Japan, visiting Toyota workshops in Singapore, talking to the Toyota managers. I know, like Mdm Halimah, cars are not human beings. But there are important lessons to be learnt from Toyota. In fact, the Toyota Production System (TPS) is now a closely studied subject in many management schools. Prior to introducing TPS, AH's median waiting time at A&E was 25 minutes, not unlike the other hospitals. Their waiting time is now half, ie, 14 minutes, despite treating many more patients than before. Let me quote Dr Francis Lee, their A&E Head. He said, "The key is to engage every staff to focus on delivering value and eliminating waste every day. Patients come to us for diagnosis, treatment and advice. We focus on doing just that and removing all the unnecessary work. No magic bullet. Just a culture of continuous experimentation, daily grind work to simplify processes, standardise work and remove bottlenecks. It is step by step, minute by minute." He is sounding like Mr Toyota! They are now going to extend TPS to other departments. The intent is to re-engineer the entire hospital operation, so that when they move to Northern General Hospital by 2010, it will be a new hospital with a completely new operating system. I am watching the Toyota experiment in AH with great expectations. As we learn from Toyota, we are also learning from Microsoft. Last year, Microsoft's CEO, Steve Ballmer, visited us in Singapore. I spent quite some time with him, sharing with him my vision of a hassle-free hospital, with IT fully exploited to make the lives of patients easier. Members may recall that I raised this topic during the Budget debate last year.”
“Good family physicians can provide better care for the chronically-ill than a team of specialists in the hospitals. There is a role for "kueh lapis", if I may use Dr Michael Lim's jargon. He himself provides an excellent layer of our Singapore "kueh lapis". I agree with him that, for chronic illnesses, over-specialisation may not be good. And for chronic illnesses, care is often better given in family physician clinics. But this cannot happen overnight. We will start some experiments, pilot some Family Physician Clinics at the polyclinics, and then we will make progress from there. But no amount of tinkering with subvention or preaching by MOH can work as effectively as the power of market competition in driving productivity and innovation. That is why we will continue to monitor quality indicators and publish them. This will provide the comparative benchmarks for all to drive for greater efficiency gains. When we compare with other globally-competitive activities like manufacturing, we know that healthcare is rather inefficient. There are wastes, duplication, and delays. Decades of protection and market distortions have caused this. But it means opportunities for us to do what is right and to clean up the inefficiencies. But we have to make the effort and learn from world-class organisations, especially those outside of the healthcare sector. Let me just give two examples to illustrate the possibilities. Members may note that last week I published the waiting times at our A&E Departments. Alexandra Hospital (AH) came up tops. It is easy to dismiss this finding by saying that, "Oh, it is the least busy hospital; so, of course, waiting time has to be low". But that would be very unfair to the hospital staff.”
“I agree with him that it is not a meaningful deployment of very expensive and limited resources. But subventing hospitals at a fixed block is also not the panacea. Hospitals may pocket the block budget and do the minimum, pushing patients to one another to shift their costs, resulting in longer queues and under-treatment. In my younger days, public hospitals were all on block budget. So, the Ministry of Health changed to piece-rates, not without good reasons. Actually, I am not completely discarding piece-rates for block budget. I go for both. As always, I go for the middle path. Where outcomes are well-defined, it would make sense to continue with piece-rate subvention. We have identified 70 medical conditions which form the bulk of our patient-load, our bread-and-butter work. We should now go more deeply into the costing of these 70 medical conditions and subvent hospitals based on their volumes for these 70 conditions. As for the rest of the medical conditions, subvention will come under a block budget. I think this is a better way to align our interests. The clusters can then seek to coordinate care more effectively. They will hopefully then "right-site" their patients by treating them at the most appropriate and lowest cost setting. On right-siting, Mdm Halimah reminded me not to "put the cart before the horse". Let me assure her that I am no "bull in a china shop". All my current initiatives, ie, right-siting, disease management, healthy lifestyle, transforming primary healthcare, are long-term strategic initiatives. They will take many years to complete, as mindset change is a crucial part of this transformation. We have to be patient. But if we stay focused, then, step by step, we will make progress. GPs and polyclinic doctors have to upgrade themselves.”
“Healthcare is subject to the law of economics too. But for economics and markets to work, we must make sure that the conditions for market competition exist. That is why I published the bill sizes for the common medical treatments. My objective is for more of these medical treatments to be more like obstetrics, more like Lasik surgery, where patients can make informed choices. When competition is brought to bear on these services, we will then have the right incentives for the healthcare providers to do the right thing all the time, to raise standards even as they reduce cost. I will continue to push out more relevant information on prices and outcomes to the public. Just last month, a friend of mine emailed me to say that she discovered that our Magnetic Resonance Imaging (MRI) fees in the public hospitals seem to be more expensive than the rates she found in Orchard Road. So I sniffed around and discovered that, indeed, there is a wide price range. For comparable products, the MRI fees range from about $500 to $900, almost double. And the public hospitals' MRI fees are not the cheapest. I wonder why. So I am continuing my market research. And when I am ready, maybe a couple of months' time, I will publish them. Since we are in the debate on casino, I bet that it would have an impact on MRI fees in Singapore. 6.00 pm Likewise, if hospitals have the wrong incentives, they may pursue wrong objectives. That is why I am refining our subvention formula to include some elements of block budgeting. As Mdm Halimah pointed out, if hospitals are given piece-rate incentives, of course they would pursue volume, leading to over-servicing and higher healthcare cost. And as Dr Michael Lim noted, night polyclinics are a reflection of this.”
“Market competition has worked in almost every sector of the economy. It has improved the airlines, banking, telecommunications, computer and other industries. Products and services improve, while costs come down. Yet, the conventional wisdom is that for healthcare, there is "market failure". My view is that although healthcare has certain intrinsic differences with other industries, the market does not necessarily fail. It fails only if we allow it to fail. It fails when we create distortions in pricing, reimbursement, and remuneration systems. It fails when we create the wrong incentives, leading to wrong behaviour. It fails when we limit the supply of critical resources, like specialists, creating long queues of patients and, yet, somehow we expect the doctors to charge less out of the kindness of their hearts. It fails when we keep cost and outcome information away from patients and their referring GPs, thereby further worsening the "unequal powers" of providers and patients. I believe we can make markets work better in healthcare. I am optimistic because we know there are some healthcare activities where the market does not fail. Our obstetrics market is highly competitive. Obstetricians compete robustly. As a result, one obstetrician, a friend of mine, lamented to me once, that over the last 10 years, his antenatal charges remain stagnant. And as there is a physical limit to how many babies he can deliver, that means, over the last 10 years, his income in real terms has been going down. Quietly, I felt happy for our pregnant mothers. The Lasik surgery market does not fail. Members may recall that few months ago, when I published the Lasik surgery fees, the prices in some centres dropped by a big margin. So what is the lesson here?”
“But over the same period, Government has topped up Medisave, Medifund and Eldershield by a total of $1.8 billion. This sum will provide our future healthcare consumption. It is our way of collectively saving for future needs. Better make hay while there is sunshine, for we cannot be certain of budget surpluses in the future. But it is not just how much we spend that counts, but how we spend it. As Mdm Halimah and Dr Michael Lim noted, healthcare is more than about financing. Money is not everything. A strong healthcare system has to deal with two other important aspects: the healthcare delivery system itself and the role played by patients. First, the healthcare delivery system. In other words, how are services delivered? Do providers have the incentives to optimise their services, to do more with less? Sadly, there is no perfect healthcare system in the world. We all say that prevention is better than cure, that early intervention can reduce more costly treatment in the future. But how many doctors, clinics and hospitals in the world are proactively and consistently practising this regime? We all say that chronically-ill patients are better-off being treated by GPs, community hospitals, or nursing homes, instead of expensive acute hospitals. Again, how many of the chronically-ill are actually so treated? We all say that healthcare providers should treat patients holistically as a team, share information about the patients, partner one another to bring care to the patients, without duplicating efforts and repeating the tests. But, again, how many patients in the world consistently receive medical care in this manner? Question: why is it so difficult to get all doctors, patients, insurers to do the right things, all the time?”
“Ong Soh Khim, although she has left, was worried that the tender could lead to more healthy lives leaving the Basic MediShield Scheme. Let me assure her that it would not be so. In fact, the key part of my reform is to precisely remove cherry picking. From 1st July, all private Shields will include the Basic MediShield. Their policyholders will all be covered by MediShield at the basic level. Prof. Ong stressed that we should protect the interest of existing MediShield Plus policyholders. I totally agree. So the tender terms will require the successful tenderer to fulfil certain obligations, for example, the insurer cannot unilaterally withdraw coverage on grounds of pre-existing illness. Any downgrading to the Basic MediShield scheme will remain possible. We will also require the successful insurer to guarantee premiums for, at least, three years. Mdm Halimah asked if we would regulate the premiums of the private insurers. I think we should not. We do not regulate the price of rice. But we make sure that the prices of rice are transparent. We also have NTUC FairPrice to help make sure the market play fair. So, likewise, we should make sure that the insurance market is transparent. Hence, my great interest to raise the whole level of transparency, so that consumers can make better choices. Of course, I am very comforted by the presence of NTUC Income. Mdm Halimah shared a perception that "the Government is trying to reduce its share of the healthcare cost". How could it be? In fact, with progressive ageing, we know that we have to do more. Our healthcare subsidies have been increasing steadily, from $850 million in financial year 2000 to $1.26 billion last year, and now, this year, $1.32 billion. And this covers immediate consumption each year.”
“Experience elsewhere has shown that an NCB, no-claim bonus, could lead to perverse outcomes. At the end of the insurance period, say, usually year end, the NCB may lead to some patients who have not been claiming during the year to postpone medical treatment in order to cross over to the next calendar year so as not to lose their NCB for that year. Unlike motorcar insurance, postponing motorcar repairs may not cause irreparable damage. But, sometimes, for some patients, if you postpone even by a few days, it may prove detrimental. So I am persuaded by the insurers. On the other hand, there may be a case to load a higher premium on policyholders who insist on continuing with unhealthy habits, like smokers. In life insurance, smokers attract a higher premium. So I think a case can be made for higher insurance premiums for chain smokers or heavy drinkers. But implementation may not be straightforward. How would insurers verify the extent of smoking or drinking? It is therefore better that we keep MediShield simple, as plain vanilla, with the lowest administrative cost at the lowest premiums. But I would welcome it if some private insurers decide to offer niche products with NCB features, or enhanced insurance plans with premium discounts for those with proven healthy lifestyle. In this way, we have a Basic MediShield to meet the essential needs of all Singaporeans, and then a very dynamic private insurance market on top, offering a wide range of choices for Singaporeans who want and can afford better coverage. To speed up the development of this private insurance market, CPF Board will tender off this MediShield Plus portfolio to a private insurer. Prof.”
“So I do not think it is a very workable solution. Mdm Halimah and Dr Chong asked for greater publicity and explanations on MediShield reforms. I totally agree. As one insurer put it, insurance is a complicated subject. But medical insurance is among the most complicated insurance products, and we will continue to engage the public, right through the July implementation and, also, after 1st July. Dr Chong suggested that we work with CDCs to reach out to those who have difficulties paying their MediShield premiums. I think we should. And I certainly hope that the Mayors and community leaders will help us in this effort to get all Singaporeans "Shielded". Mr Andy Gan asked for MediShield to cover long-term cosmetic dental care. The differentiation is not between medical or dental. The issue is inpatient versus outpatient treatment. MediShield, and for that matter Medisave, is primarily for inpatient care. So it does cover some dental treatment which requires hospitalisation. But I personally would advise against MediShield covering cosmetic dentistry, expensive orthodontics, for the simple reason that greater coverage must mean higher premium. For the Basic MediShield policy, my preference is to keep it really basic and essential so that the premiums can be as low as possible. Mdm Halimah asked that we use MediShield to encourage healthy lifestyles among Singaporeans. I support it in spirit. Specifically, she asked that we incorporate a no-claim bonus (NCB) in MediShield. Dr John Chen first raised this suggestion to me when I did my walkabout in Dr Amy Khor's constituency. And I thought it was a brilliant idea. But when I discussed it with the experts in the insurance industry, they all voiced concerns.”
“Of course, if he is talking about the self-employed who choose not to contribute to Medisave, then they would need to use cash. We should put the pressure on the self-employed to contribute to Medisave. For the sake of your family, contribute to Medisave. Mr Steve Chia is a self-employed, I think. I hope he contributes regularly to Medisave for the sake of his family. 5.45 pm Mr Low Thia Khiang supported, I think, the catastrophic medical insurance. He saw value in it. He asked for greater transparency. I totally agree. In fact, later on, as I mentioned, we will be tendering out the MediShield Plus and we are working out the tender documents. I intend to put as much information into the tender documents as possible so that the tenderers do not have to second guess. Then they can bid according to fairly certain information. And my intent, in fact, part of the objective of this MediShield reform is to raise the level of transparency and disclosure so that when consumers want to shop around for the various "Shields", they can make better informed choices. Mr Low was wondering whether we could have an average premium rate that applies to all age groups so that you do not have the young paying less, and the old paying higher. It is a possible option. But, then, the premiums for the young will have to go up very high. Currently, premiums range from about $30 to over $500 per year. So the average may be about $300-$400, which means the premium of the young will have to go up by more than 10 times. I do not know whether the young would be happy to do so. What if there is an exodus of the young from MediShield, then there will be very few left to carry the cross subsidy, and then the premiums will have to go up further. It may trigger another round of exodus.”
“Such cases of major illness and large hospital bills are not common, but they do occur. I want to help these poor patients cope with very large hospital bills, and MediShield reform is the answer. I cannot think of any better solution. That is why I am baffled by Mr Steve Chia's observation. The increase in deductible is necessary. Why? Because MediShield is a catastrophic medical insurance. What is MediShield for? It is to protect against large hospital bills, not small bills. If the deductible stays unchanged, then MediShield must end up covering more and more small bills, leaving patients with very large bills, like Mdm Cynthia Phua's former classmate, insufficiently protected. Then it is no longer a catastrophic medical insurance. When MediShield started 15 years ago, it covered only about 5% of hospital admissions, the very large bills. Today it covers 50% - one in two! If you want MediShield to cover both small and large bills, then it is no longer a catastrophic medical insurance, it is a comprehensive medical insurance, and the premiums will have to be very much higher. Actually, my preference is for an even higher deductible so that I can reduce the effective co-payment for large bills from the current 60% to about 20%. This will then give greater payouts to such patients who need help. But unionists talked me out of it. I have therefore settled on the current package as the most optimal trade-off that we can achieve. The key question is whether Medisave is sufficient to cover the increased deductible. Here, the answer is a definitive yes. Mr Steve Chia talked about out-of-pocket cash to pay the deductible. Why should it be so? If you contribute to Medisave, Medisave will cover that extra $500.”
“Dr Chong Weng Chiew wanted it done as soon as possible, but Mr Andy Gan and Dr Michael Lim had their reservations. The purpose of means testing is to better target our subsidies at those who need them most. The principle is simple, the implementation not so. If we are clumsy, as Mdm Halimah put it, we can cause "a lot of angst without achieving our objective". I am not in a hurry to implement means testing. So Dr Tan Cheng Bock was quite wrong to say that it will be implemented soon. I have taken the advice of Dr Lily Neo when she spoke on this last year to do means testing after the MediShield reform. She explained that the impact of the MediShield reform ought to be assessed first, before we introduce means testing. Meanwhile, I have noted the many suggestions made, especially the very detailed ones by Dr Tan Cheng Bock, Mdm Halimah and Dr Chong Weng Chiew. We will consider them at the appropriate time. Let me now turn to MediShield. Mr Steve Chia - unfortunately, he has left - claimed that Singaporeans are worse-off with the MediShield reform. Really? He believes that? Does he subscribe to MediShield? Is he planning to opt out? He has either misunderstood the facts or chosen to disregard the benefits of the reform. I think it would be very unfair to mislead Singaporeans. The reform is not cost-free, yes. But I have minimised the cost to Singaporeans. The fact is that with only a modest increase in premiums, policyholders will enjoy substantially higher payouts if confronted with large hospital bills. I am sorry to hear of the death of Mdm Cynthia Phua's former classmate. Her family is now left with a very large hospital bill, nearly $90,000, despite our subsidy. Her classmate had MediShield but the payout was not as much as the family had hoped for.”
“The World Healthcare Congress, an international forum for global best practices in healthcare financing, is holding a meeting next month in France. They have invited us to share our Medisave experience with them. The US studied our Medisave and MediShield. Last year, President Bush established tax-free Health Saving Accounts (HSA) for individuals. Their HSA is very similar to our Medisave, except that it is not compulsory, and neither is it nation-wide. Our SMs model actually comprises two parts: SM and MM. Sorry, I do not mean our two political leaders. Government provides "S" and "M": subsidy and Medifund. Singaporeans must deliver "M" and "M": contribute to Medisave and join MediShield. If we both play our parts, nobody should have to worry about basic hospitalisation cost being unaffordable. The more we have in Medisave, the stronger our system becomes. That is why I support Mdm Halimah's suggestion that we lift the Medisave contribution ceiling, instead of letting the excess overflow to the Ordinary Account. But some CPF members may prefer the current system as it allows them to use the excess monies for housing, investment, or education needs. In any case, the CPF Board will, on a case-by-case basis, allow members to reverse the Medisave overflow, when they incur very large hospital bills. Mdm Halimah argued for Medisave to cover outpatient treatment. But Medisave is intended primarily for inpatient care. Nevertheless, we have allowed Medisave for day surgeries, as pointed out by Mr Andy Gan, and certain expensive outpatient treatments, like chemotherapy, dialysis and many others. We review the list of approved outpatient treatments regularly, and we will add new treatments when appropriate. Several Members have commented on means testing.”
“Our health status is among the best in the world. It is not that I said it but WHO said so. Our fees are not low but, for the vast majority of Singaporeans, they are affordable. Medical treatment is not cheap, especially in the hospitals. But most people do not require frequent admissions. If we contribute regularly to our Medisave, we should have enough to pay for at least class B2/C hospital bills. The average Medisave balance now exceeds $11,000, and this is an average of both active and inactive accounts, because many are housewives who have stopped work. When I look at the active accounts, the average exceeds $17,000. But even at $11,000, it is enough for more than a dozen class C hospitalisations. And this average is growing year by year. I have read the Feedback Report which Dr Wang Kai Yuen mentioned in a previous sitting. The self-employed are significantly represented among those who have expressed concern about healthcare cost. If a self-employed person does not contribute regularly to Medisave, he ought to be concerned. Without Medisave, any hospital bill size may be unaffordable. I think we must get our self-employed to contribute regularly to their Medisave. This is very important. Because without Medisave, we cannot help Singaporeans deal with the issue of healthcare costs. With Medisave, and after we have fixed MediShield, practically all Singaporeans should have no problems with hospital bills. Medifund will take care of those who drop through the Medisave/MediShield net. This model, which I call SMs (Subsidy, Medisave, MediShield, Medifund), of funding hospital cost delivers better results with less abuses. Our unique model has been noted by others.”
“I will try to respond to all the cuts right now, except for five which I intend to do so tomorrow together with similar cuts which are already listed - one of them from Mdm Halimah about clusters which Mr Gan Kim Yong also raised, which I will answer tomorrow - one on preventive infectious diseases, another on HIV and another about holistic care for the chronically ill, which if Members do not object, I will answer tomorrow. Mdm Halimah Yacob and many others voiced their concerns about healthcare cost. If there is any consolation, public concern over healthcare cost is global, from China to the United States. Last month, Harvard University published a study which estimated that medical bills forced two million Americans into bankruptcy every year. The study leader had this to say: "Our study is frightening. Unless you are Bill Gates [that means the whole US population, less one], you are just one serious illness away from bankruptcy." Last month, an East Asian Institute's report on healthcare in urban China drew these conclusions: "health care costs are soaring", "health care providers are concerned with making money", and "the inaccessibility to health care for the poor is widespread". I met an American scientist last week who is familiar with China's healthcare scene. He made a shrewd observation. He said that China now carries out more Lasik surgery than cataract surgery. In other words, the doctors there, at least in the cities, are carrying out more elective surgeries for those who can afford it, neglecting the basic medical needs of the masses. In Singapore, our healthcare system is not perfect, and I will be the first one to acknowledge that, but I think, objectively, it is not bad. Singaporeans enjoy a high standard of healthcare.”
“Sir, the pitfalls of means testing are just too numerous. I fail to be convinced that it is a necessity at this point in time. MOH has said that it will implement means testing. Will the cost of setting up such a system end up being more than the potential savings of implementing such a system? What model of means testing will the Ministry be using that is both practical and yet will not lead to higher manpower cost and higher infrastructure cost? What criteria will be used for means testing? Criteria used must be both transparent and simple. When we implement means testing, will it be implemented only for C class wards? My view is that the Ministry should consider starting with baby steps and perhaps start only with potential C class patients, instead of having a system that cuts across all the different spectra of the healthcare services. And what does it mean when a patient fails the means test? Does it mean that he will remain in the same class of ward but he will be given lower subsidies? Or does it mean that he will have to upgrade to the next higher grade of ward? And if he is allowed to remain in the same class of ward, will it be a fixed reduction in subsidies or will it be tiered towards his level of income or whatever criterion is used in terms of assessing it? Finally, perhaps the Ministry could also let us know when it intends to implement means testing. The Minister for Health (Mr Khaw Boon Wan): Sir, I felt mutilated by so many cuts! Fortunately, I got a soothing one from Mdm Cynthia Phua that helped.”
“Clinical practice guidelines help doctors to manage patients in the most optimal way. They do not help doctors manage patients in a most cost-effective manner. Ultimately, most Singaporeans want to have the cake and eat it. Let us not raise the expectations too high. Let us keep healthcare bills in the public sector affordable.”
“If you think that doctors are going to let your heart stop beating, you are wrong again. Some doctors are suggesting that if there is suggestion that your heart rhythm is abnormal and there is risk of a life-threatening abnormal heart rhythm occurring, you should carry a $40,000 device under your skin that will give your heart an electrical shock whenever needed. Armed with an entire range of drugs and devices, doctors are not going to allow your heart to stop working. Cancer today is no more the dreaded word it used to be. New chemotherapy agents will set you back a few thousand dollars a week or a month. The latest radiation techniques and an entire range of scanning machines ensure that it adds several thousands to your health bill. Your cancer specialist is not going to give up easily. He has access to new therapies, such as bone marrow transplant and stem cell therapies that will cost tens of thousands of dollars. For Singaporeans, the good news is that it is going to be difficult to die. The bad news is that it is going to be even more difficult to live. The disease may not kill you, but the healthcare bill may. 00 pm We will need to address the rising cost of managing chronic illnesses. Clinical practice guidelines ask doctors to follow what is optimal in treatment without consideration for the real cost of healthcare. The biggest dilemma for our public hospitals is to decide where to draw the line between optimal treatment and affordable healthcare. To fix healthcare cost, the Ministry of Health will need to go beyond just raising the premiums for insurance schemes. It will need not adjust clinical practice guidelines for doctors to follow, it will also need affordable healthcare guidelines.”
“Sir, I wish to declare my interest as a medical practitioner. When I reviewed the eight key priorities of the Ministry of Health, it was difficult to find any major flaw with the policies stated. After trying really hard, I have managed a few points. (1) Managing patients holistically. It is not uncommon today for patients to be managed by multiple specialists. Today's medicine is very much like "kueh lapis" medicine, where the patient's body is segmented into different segments and managed by different specialists. This can only increase healthcare cost. Part of the problem is the way the public sector has organised itself into super-specialities. How can the Ministry re-organise its services to reduce this "kueh lapis" medicine? (2) Manpower planning. One of the things I never understood was why the Ministry had night clinics in our polyclinics. It is certainly not a meaningful deployment of valuable manpower resources. It just does not make sense to compete with the general practitioners in the neighbourhoods. Is the average number of sick patients seen nightly in a town so overwhelming for the GPs that it justifies the additional deployment of medical manpower to meet the demand? Feedback from the GPs does not appear to be so. It is time to review it. (3) Affordable healthcare. Better healthcare means a longer life. Advances in medical therapy will make it difficult for people to die of two major chronic illnesses of old age, namely, heart disease and cancer. If you think that blocked heart arteries will kill a person easily, think again. Drug eluting or coated stents keep your heart arteries open for longer periods of time at an average cost of more than $10,000 to more than $20,000 per procedure.”
“Sir, Singapore has an excellent primary healthcare system where costs are cheap and accessibility is universal. Where in the past, the private GPs have been the main providers of primary healthcare after office hours, the economic downturn has seen the Government extending service after office hours through the polyclinics. While this is a very good service welcomed by one and all in the vicinity of the polyclinics, it is unfortunately not available at all polyclinics as a result of lack of manpower resources. I would like the Minister to enlighten us as to what are the plans for night clinics. Where this is not available, as a result of manpower resources, will the Ministry consider subsidising polyclinic patients who see neighbourhood GPs after office hours by pre-approving GPs who want to participate in the PCPS? This will kill two birds with one stone by providing subsidised evening services to polyclinic patients, and also utilising the resources of GPs more efficiently. While the polyclinic doctors are very busy at their polyclinics, many of the GPs do not have such a heavy workload. Are there any plans for the Ministry to harness this synergy between the polyclinics and the GPs so that we can optimise and improve the utilisation of our primary healthcare resources? Primary Care Partnership Scheme”
“The Ministry had spent millions of dollars on IT cost, man-hours and employing new staff. Yet, till this day, few believe that it has translated to any real tangible improvements in the healthcare delivered to the man-in-the-street. (9) Is the Ministry prepared to be totally transparent about their assumptions and methods for means testing? (10) Is the Ministry able to show significant real cost savings from this exercise? One comment that has been made is that Singapore is the only country in the world where the public hospitals have better finishes than the private hospitals. There are many areas where we can save cost, and I hope that we are not barking up the wrong tree and being penny-wise and pound-foolish. I would urge caution in rushing into means testing. I would like to suggest that the Minister considers setting up a committee to study this matter very carefully before making a decision. If the Minister cannot convince this House, how can the public be convinced?”
“Sir, means testing is a means of trying to reduce the subsidy to those who are more able to afford healthcare services. However, knowing how the healthcare system works, I really have very bad vibes about means testing for healthcare services at an acute general hospital. I will give you 10 good reasons why we have to think very carefully before considering implementing means testing. (1) Penalising those who pay the most taxes by increasing their healthcare cost sends the wrong signals. This is not about giving tens of dollars in S&C rebates per household. This is about tens of thousands of dollars in cost per person. (2) Being hospitalised is not a vacation. It is neither an option nor a choice. You go into the hospital because you have to, and not because you want to. (3) Using household income or per capita income is not the solution as healthcare cost is personal and we cannot force the person to bear another person's healthcare bill. (4) As families get smaller, the children have to bear a significantly larger burden to support elderly parents, leaving them with little savings and disposable income. (5) Healthcare costs are unpredictable, and when a complication arises, the cost can escalate significantly. Every percentage point in subsidy can mean a lot to most middle income families. (6) I believe it is going to be a major public relations disaster. The Ministry stands to lose a lot of goodwill that the Ministry has built over the years. (7) There are too many variables and I cannot think of any simple formula. What it means is that there will be a lot of unhappy patients. (8) To do means testing for patients will require an entire bureaucracy that will have to manage a very unhappy public that have failed the means test. It reminds me of Casemix.”
“While they play an important role in regulating the healthcare profession, they can play an even more important role in helping the healthcare sector grow. They must not act like traffic wardens trying to issue a summons at the first possible opportunity. They must facilitate to show the way as to what the healthcare profession can do to create awareness of the services and expertise available. I remember years ago when my clinic was opened in Mount Elizabeth Hospital, the Theng Hai Association had, without my knowledge, taken an advertisement in a Chinese newspaper to congratulate me as I was their adviser and, can you believe it, a complaint was made against me! Yet, it is not uncommon for public healthcare institutions to have press interviews to advertise their services. If the Ministry is serious about making Singapore a healthcare hub, it must allow healthcare professionals to make known their expertise and services to the lay public and to foreign patients. This will increase transparency and allow patients to know what services their doctors are accredited to perform. The Ministry and the Singapore Medical Council should also facilitate the entry of specialist doctors into Singapore in both our public and private healthcare institutions to strengthen our professional healthcare expertise. I would like to ask the Minister when the Ministry can provide clear guidelines for healthcare professionals, and wheredoctors can seek clarification, if they have queries. I would also like to ask the Minister how the Ministry can facilitate the entry of foreign healthcare talent into Singapore to strengthen our pool of healthcare professionals. Means Testing”
“If we do not enterinto the Chinese market in three to five years, when the market is liberalised and there are largeAmerican and Europeanhealthcare institutions there, Singapore will become irrelevant to them. By then, with a lower cost base, China and India will become our competitors in the healthcare sector. We must rise to these challenges. If Singapore succeeds in being a major healthcare provider in China and India, we will not only be able to grow our GNP, but we will be able to grow a huge healthcare talent pool that would not haveotherwise been possible. This will strengthen our depth in healthcare expertise and make us a leading healthcare provider in Asia. I would like to know how the Ministry of Health can change the mindset of the civil service to be more pro-enterprise orientated, and what role the Ministry can play in helping Singapore Inc grow in the region. Ministry programmes Madam, I turn now to my next cut. The Ministry of Health has evolved from being a healthcare provider to being a regulator. Over the years, the Ministry is regulating more and more areas in medicine, making Singapore one of the most highly regulated healthcare markets in Asia. They regulate just about everything, including what doctors can put on the signage in the clinics, what the doctor can say in public, and almost everything that the doctor does, except sleeping and eating. In this era, where the Singapore Government wants to grow healthcare as an economic driver, the Ministry must loosen its iron-fist grip, avoid adding more regulations and redraw the boundary lines for the medical profession. The Ministry of Health and the Singapore Medical Council must change their mindset.”
“Madam, I wish to declare my interest as a doctor with a regional medical practice. The SingaporeGovernment is growing the healthcare sector as an economic driver. Public and private healthcare institutions are banding together to market Singapore as a healthcare hub. While that is a move in the right direction, the larger potential market for Singapore healthcare institutions is to be where the market is, especially for countries which are large and have a demand for high quality healthcare and are yet less likely to come to Singapore because of the distance. India and China are two large neighbouring countries where there is a large demand for high quality healthcare services. Yet, it is highly unlikely that Indian and Chinese nationals would come here for healthcare services in large numbers. Firstly, we cannot compete with our counterparts in Malaysia and Thailand on cost. We can only compete on quality. Secondly, the standard of healthcare there is improving by leaps and bounds. I visited a hospital in Shanghai recently which did paediatric heart surgeries. They do more than 200 such surgeries a year with no mortality. These are certainly very, very impressive figures. China is growing very rapidly, and renowned US healthcare institutions are now trying to get into the healthcare market in China where there is a large pent-up demand for world-class healthcare services. Our strength is that we have a very good system of healthcare that can produce consistently good results, and we are constantly at the cutting edge of technology. To grow healthcare as a driver of our GNP, we will need to be present in large markets like China.”
“I think the Government should review its income ceiling on hiring domestic maids for young couples who have just had babies, and make it easier for them to hire maids to look after their babies. I would even go further to suggest that for young couples who have babies and want to hire a maid to help them look after their babies, the Government should also consider waiving the foreign maid levy for the first three years when the couple have a baby. We also need to review some of our manpower policies. A patient of mine was rather concerned because she said that when her children brought their children, in other words her grandchildren, to her house, they would usually bring their maids along because they could not cope with all these little children running around. So the maids would come together with her children to her house. But I understand, and I checked with the Ministry of Manpower, that apparently this was not something that was considered right. It was something that was not according to our manpower policy and, in fact, they could actually get into trouble with the law. I think we need to review this as to how we can allow young couples, when they bring their children to the homes of their parents, to bring their maids across without any fear that they may run afoul of the law. Finally, to ensure that Singapore couples do not cease at two children, Government must then make making babies a breeze and put their minds at ease. 55 pm”
“These are young couples who are so busy with their careers that they spend whatever precious time they have between themselves. They have no time for babies. I think we should look at incentives for them. In addition to tax rebates, it was mooted that the Government wants to consider giving paid maternity leave of four to six months. Well, it may be good for those in the civil service. It may not be the best option in the private sector, especially if the person is very career-driven. The reality is that if this person holds an important post in a company, being away for four to six months can have a major impact on the company, and it is unlikely that in a job market like this that a career-minded woman would like to take this option. Of course, there is no one size that fits all. The sum that the Government wants to pay for the extra paid maternity leave can also go into another scheme, perhaps what I would call "infant care centre fees" for maybe six months to one year. This will give these mothers who want to opt for other choices to opt for this option as well. I think Government should consider giving adequate subsidies and incentives for infant care centres to be started up. Starting an infant care centre is not the same as starting a childcare centre. It is a totally different ball game. Perhaps a preferential rental charge, increased subsidies, assistance in employment of trained staff will encourage more to set up infant care centres. If both parents work, they will also need to hire a domestic maid, if their parents are not willing to assist or unable to assist them in looking after the baby.”
“Again, what measures should be considered, I think these we will leave it to the different Ministries. But, certainly, we should look seriously at encouraging people to donate their eggs and sperms. Currently, we do not allow egg donation if the donor is more than 35 years of age. This would be about the time when they have completed their family and probably that will be a good time for them to donate their eggs too. So we should also review the age limit for egg donation as well. The second big group is those who are able to have babies medically but do not want to have babies. I think here there are two sub-groups - those who are still single and those who are married. The first group would be what I call the SBC (or Single, Busy and Career-minded) Singaporeans. They are very concerned about their career, they want to climb up in their career path, they are concerned about the cost of housing and financial independence. These factors have led many to live life as singles. Government should look at incentives to encourage young couples to get married earlier. Because if they get married late, which is a trend that is being seen now, at the age of 35, the risk of an abnormal pregnancy can be as high as one in 300 pregnancies and continues to increase as the age increases. So, I was a bit concerned when I saw in the news that the school had reacted with alarm at a 15-year old school boy who had boy-girl relationship. I am not sure whether that is the right signal that we are sending to our young that they should not have any boy-girl relationship until perhaps they have finished their university days. The other group is what I call those who are MBA (Married, Busy and Alone).”
“With the lack of incentives, not many were willing to donate their eggs or sperms. A colleague of mine told me that in the past, people were quite happy to do so, if you just reimbursed their transport cost. But currently, this is not sufficient to incentivise anybody to donate their eggs or their sperms. Just in case you think that it is all the ladies' fault, this is not the case. In the sub-fertile cohort, male factor problems account for about 40-45% of the problem. It could be because of insufficient numbers, poor motility or the shape of the head of the sperm is not right. Government should consider paying or co-paying for ART treatment. I was pleasantly surprised to read in the papers just in the weekend that the United Kingdom government has considered moving in this step. We should also consider increasing the Medisave deduction for ART. Sub-fertility is a true disease. It is not plastic surgery where you are there to improve your external facade. Many young couples do not have much disposable income, but have money in their CPF. They have to pay for their housing loan, their car loan, their monthly bills, and they have to give money to their parents. Therefore, they are not left with very much money. The cost of an ART cycle can be up to $10,000, depending on the type of drugs used and the media used. Maximum Medisave deduction is about $4,000. Therefore, there is quite a substantial amount of money that the couple have to come up with for them to go through this cycle. After three cycles of failure, they are usually advised to consider egg donation. I think we should put in measures to incentivise those who have it in abundance to donate their eggs and their sperms.”
“Mr Speaker, Sir, thank you for allowing me to join in supporting the motion. Singapore faces a major problem with a low birth rate and current measures seem to have lost their attraction. Issues that affect a low birth rate will require changes in policies across many Ministries. The first most important step in this whole exercise of procreation is being able to produce babies without medical hindrances. There are two groups of people that we should target. Firstly, those who want to have babies but, because of medical reasons, they have difficulties in having babies. This is what I call the sub-fertile group. This is the group that is motivated to having babies, and they need support for them to be able to get babies. Sub-fertile couples need to be subjected to ART - not as in drawing, colouring or painting. ART is a new acronym for Assisted Reproductive Technology. It encompasses various types of methods such as superovulation where women are given hormones to increase the chances of producing eggs, in-vitro fertilisation where the egg is assailed by thousands and thousands of sperms, or intracytoplasmic sperm injection (ICSI), which is a more elegant method of fertilising the egg, blastocyst transfer, pre-implantation genetic diagnosis, and a host of other techniques. The numbers are not small. As many as one in five couples, after one year of marriage, are not able to have children. And the success rate of assisted reproductive technology is about 45% success rate of pregnancy. However, the take-home baby rate is about half of that. The ravages of the economic turmoil the last few years did not only strain our financial institutions but also left our egg bank and our sperm bank broke.”
“Mr Speaker, Sir, I am getting a bit confused here. I am trying to understand the process. Can I check with the Minister? Does it mean that an operator can seek approval from PTC and PTC, based on a certain set of criteria, has approved the routes or what they are supposed to do, and then the operator can decide not to follow what PTC has agreed upon? Then, I am a bit confused about the whole decision process. Does it mean that the operator can seek PTC's approval of routes and then after that disregard PTC's decision? If that is so, under what circumstances can they do that?”
“Can the Minister clarify the process so that we will be a bit more enlightened? I would have thought that when SBS was given the commercial right to operate the NEL and they had gone before PTC to get approval for the set of fares, those fares were approved on the basis that the NEL operator would only close the Woodleigh Station. So, I am just wondering, in terms of the principle, whether it is proper, having had the set of fares approved on the basis of the closure of one station, to close subsequent stations. That is my first question. The second question is this. The MPs had heard some rumours about the closure of Buangkok Station and we had written to SBS to seek confirmation in late March only to get a reply that Buangkok Station would be opened. And to our aghast and horror, we were informed that Buangkok Station was not going to be opened just a few days before the opening. Was there any reason why SBS could not have informed the MPs earlier that the station was not going to be opened? Obviously, if there were rumours on the ground that this was not going to be so, they might have known even at the point of time when they called the MPs down for a briefing on the NEL stations. So, why did they not let us know at that point in time?”
“Sir, I would like to ask the Minister how can there be more predictability if one took an express bus from point A and reach point B on the same express bus vis-a-vis someone who has to take a bus to the MRT station, drop off at another MRT station and then take another bus to his destination. How can there be more time predictability? I do not quite understand him. Maybe he could enlighten me.”
“Sir, the purpose of the NEL and the integration of the bus services is supposed to either reduce cost of public transport or to perhaps make it easier for people to travel. I would like to ask the Minister whether he considers this as integration or disintegration of services because they have removed some of the bus services like Service 501 which provides an express service from Sengkang Town to Orchard Road where a single bus service would have taken a person there. Now, with these changes, they have to take a bus to the MRT station, drop off at another MRT station, and then take another bus again. So they end up not saving but spending more time travelling. Therefore, in this whole exercise, I am not sure whether it has actually caused integration or disintegration of services. Could the Minister ask SBS to try to restore some of these services? Sir, I disagree with what the Minister said just now about certain bus routes duplicating the SMRT line and they preserved certain routes because there were some additional benefits. If he had the time to look at the bus routes more carefully, he would have noticed that a route like 501, which is an express service, the distance between the NEL and the bus route that is operating is much further than what this so-called Service 502 duplication of the SMRT line. This is really not a very convincing argument. I think the real reason is because the NEL and SBS are operating the same line, and SMRT and SBS are competitors and that is why they retained the second half and omitted the first half.”
“By taking draconian but rational measures, the Singapore Government, with the full support of its people, will be able to accomplish the aim of making Singapore the safest place to live and work in in this era of SARS. 2.33 pm”
“On the first day when he was back and he watched the news, the American news broadcast focused on SARS and Singapore. When he watched it on the second day, again, it was SARS and Singapore. When he watched it on the third day, it was SARS and Singapore and, by the way, Hong Kong also has some SARS cases. So, the impression given to viewers then was that the SARS problem appears to be mainly in Singapore and that Singapore was the source for SARS. This is certainly not the case. In fact, other relatives from the US have called their relatives here to tell them the same thing as well and, of course, fortunately, their relatives here have told them that this is not the case. I think that the media can play an extremely important role in dispelling irrational fear and also focusing on the positive aspects of SARS, on how people have recovered successfully. And I think the media can also focus on public education messages, such us using a mask when one is sick, how to put a mask on properly and how to take temperature. You may laugh at some of these measures, but let me just tell you what one of my MP colleagues told me. At the screening at a hawker centre, he asked to look at the temperatures recorded for those who were taken at the hawker centre. The temperatures were about 33-34 degrees centigrade. If we were to believe those temperatures, all these people would be dead! So, while we want to encourage people to take temperature, it is important that we educate them as to how to take it properly so that the exercise is useful. I believe that the media can certainly play an extremely important role in this public education exercise. SARS will become a disease that will be found in many countries throughout the world.”
“The current quarantine allows people to visit those who are home quarantined, and there is a risk of spread of the disease if the person eventually turns out to have SARS. We should seriously consider having designated quarantine facilities. Perhaps even one of our off-shore islands, such as Pulau Ubin, may be made a quarantine centre. This will ensure that there will not be any visitors for those who are quarantined, and the likelihood of the disease spreading will be significantly reduced. We may even consider mandating that those on quarantine put on a mask at all times, perhaps except during meals, to reduce the likelihood of spread during the quarantine period. Singaporeans must understand the seriousness of the impact of SARS on Singapore. If we do not take draconian measures to inconvenience a few, the economic fall-out will be so severe that all Singaporeans will have to suffer both financially and medically. I do not think we should be quibbling about how much compensation to give, but we should pull together to make Singapore a safe place. Only then can the economy improve. Last but not least, the media plays an important role, as it has given extensive coverage on SARS, which is a step in the right direction. However, the coverage is so extensive that it appears to others that the whole country is paralysed by SARS, and that the only thing that is newsworthy and occupies the time of most Singaporeans is SARS. A friend of mine who came back from the US recently told me that when he was back in the US and he watched the American news broadcasts, it would appear to those watching that Singapore was very seriously affected by SARS and that Singapore appeared to be the main source of SARS.”
“They took them off to show them to each other and, subsequently, tried on each other's masks. In this instance, the masks would not only not prevent disease but would certainly help to spread infection. A friend of mine also told me about sitting next to a gentleman at the airport who was diligently wearing his mask. But, whenever he wanted to cough, he would lift up his mask and cough into other people's face. This defeats the purpose of wearing a mask in public. The main aim is actually to prevent infection to others. Another very important public measure is screening at all entry and exit points in Singapore. Currently, those from SARS-affected countries are screened. However, if a SARS-affected person enters through a non-SARS country, he would not be screened at the entry point. One must understand that thermal screening is a very useful tool. Nevertheless, even if you have a fever and you are in an air-conditioned environment, you may not be picked up on the thermal screen and, of course, most airplanes are air-conditioned and most airports are air-conditioned too. A patient of mine gave me another example. He attended a conference where there were delegates from Hong Kong, and this conference was held in Indonesia. The delegate from Hong Kong flew to Indonesia, and then to Singapore. The Hong Kong attendees who flew to Singapore were not screened. So he asked me whether it would defeat the whole purpose of trying to screen those from the high-incidence countries, if we did not close this loophole. I think we should protect this as well. On quarantine, those who break their quarantine orders are irresponsible and they endanger the lives of fellow citizens. I support the Government's measures on quarantine. In fact, I am in favour of more draconian measures.”
“I also welcome the move by the Ministry to ask healthcare workers from overseas, especially nurses, to avoid staying together with healthcare workers from other hospitals. However, some of them are bound by tenancy agreements. It is a right move. But I think the Ministry and the hospitals may want to consider offering assistance in helping them with a relocation exercise. Secondly, in addition to healthcare measures taken in healthcare facilities, I think health education is of utmost importance in helping Singapore contain SARS. SARS is a serious disease, but I think we must not over-react. The likelihood of dying from a heart attack is much higher than the likelihood of dying from SARS when you have a heart attack and, therefore, one must put these fears in the right perspective. I think the public should adopt preventive measures, which I would like to call the 3Hs. The first H is health. We have a responsibility to keep ourselves in good health. The second H is hygiene. We must adopt good hygiene practices like washing hands, keeping the environment clean, and avoiding indiscriminate disposal of tissues or other types of waste that may contain germs. The third H is habit. We must adopt good habits. It is time Singaporeans adopted the habit of wearing masks whenever they feel unwell, or are down with fever or cough. This is to minimise the spreading of infection to others. It is also a good habit to check one's temperature when one is unwell, so that the fever can be detected early. However, whether it is masks, thermometers or hand washes, one must use them appropriately. A friend of mine told me that she had observed a school bus carrying pre-school children who were probably five or six years old. A few of these children in the school bus were wearing masks.”
“Mr Speaker, Sir, SARS has grown from a medical problem to become an economic problem. It has also grown from a regional problem to a global problem. Like most viral diseases, an effective cure for SARS is not likely to be imminent. Preventive and supportive treatment are key measures in the fight against SARS. For us to combat this SARS epidemic, the key to success is prevention and containment. Since the SARS outbreak, the Government has put in place many precautionary measures. In the healthcare sector, several measures have been imposed, and these measures have become increasingly stringent. Many of the healthcare workers who are in the forefront of fighting SARS are people whom I have known, not just in terms of work but many of them have been doctor friends for decades or several years. And I can tell you that all these people really deserve our respect and admiration because of all the risks that they take. It hurts the healthcare workers even more when they have to manage their own, especially those who are in the pink of health. When I was told that an ex-colleague of mine, Dr Lee in NUH, was admitted for SARS, my friends in Tan Tock Seng Hospital told me that he had difficulty breathing, and he actually requested for intubation. I was glad to hear yesterday, when I met another colleague of mine, that he had been extubated. The problem of SARS has taken a heavy toll on the healthcare workers. Despite the strain on our healthcare workers, I wish to assure the Government that the healthcare personnel are in full support of the Government's measures. In fact, we will welcome even more draconian measures to break this cycle of the spread of infection.”