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?”
The complete record
Every one of 361 lines we hold for Michael Lim Chun Leng, in date order, each linked to its source. Free to read, in full, without an account. Page 7 of 8.
“Sir, can I make a point of clarification?”
“My point was that if you employ a system where you want to try to give increased importance to subsidised patients, are you implying that, in the first place, they are under-serviced? Because if you say that they are under-serviced, do you try to tell the doctors that they should service them better? And if they service them better, definitely the cost will increase. I think the point is that there is a misconception that patients in the subsidised wards are being under-serviced. And it is more important to clear this misconception rather than to put in a system which will actually further strengthen this misconception that there actually is a difference in the quality of service administered to paying and non-paying patients.”
“Sir, can I just make a point of clarification?”
“However, just as there are those discoveries that have an unequivocal benefit, there are many expensive modern therapies that have yet to be proven to be better than current treatment. It will be prudent to ensure that such modern therapies be confined in a research environment and not in the clinical setting. Otherwise, patients may see it as their right to be given these expensive treatment modalities. In the end, they may pay more but may not be better off. In fact, they may sometimes be worse off. What measures is the Ministry taking to ensure that in our zeal to keep up with advancement in medicine, we are not unwittingly raising the cost of health care unnecessarily by using treatment modalities that have yet to be proven to have an unequivocal benefit? 3.15 pm At the end of the day, the Ministry has the unenviable task of providing good quality health care at affordable rates. The Ministry has done well but I am certain that more can be done.”
“Still on the same principle about cost. I will develop it into a theme about increasing health care cost. This point system will result in increased costs and not decreased costs. It is implicit in the system that it wants to ensure that subsidised patients get as much care as the paying patients. However, does it imply that subsidised patients have been under-serviced and, therefore, the system has been put in place to correct this? Most doctors have expressed their concern that in trying to correct this misconception of subsidised patients being under-serviced, the level of servicing may be increased, thereby increasing costs. This system rewards those with the most points. I cannot see how a system such as this will not result in higher health costs for the category of patients whom we are trying to restrain costs, ie, the subsidised patients. The complexity of the system will also require more administrative costs to administer the system. However, the greatest harm in the system lies in the value that it will inculcate. It links patient care with points. My fear is that younger doctors being brought up in such an environment will think of patients as points. Surely, this will serve to do our health system harm. I will next go on to pharmaceutical costs. Most patients in the health care system are outpatients. The drug bill often forms the lion share of the outpatient costs. Many of these drugs are expensive and there are no cheaper equivalents locally. What measures is the Ministry taking to control pharmaceutical costs? Advancement in medicine has contributed to a significant reduction in morbidity and mortality from diseases and has resulted in increase in life expectancy.”
“In the days of old, doctors depended mainly on clinical skills and a limited variety of drugs. They were unable to do much for patients with heart attacks, cancer, serious infections and other medical illnesses. With the rapid advancement in medicine, we now have better tools to treat these illnesses. If we adopt the stand that we shall avoid high technology and modern medicine, the cost of health care will be substantially lower. However, when you get a serious illness, the well-off can always go overseas to obtain their treatment but the less well-off will not be able to do so. Hence, a high quality of health care will benefit all Singaporeans. But Singaporeans must learn to accept that a good quality of health care does not come cheap. I will next go on to the consultation fee system. There is a move to implement a point system in the Government and restructured hospitals to give equal points to both subsidised and paying patients for the same procedures. The total fees obtained from paying patients will then be put into a pool which will be divided according to the points obtained.”
“Sir, the issue of health care costs is a major issue of concern presently and will continue to be so in the years to come. It is inevitable that health care costs will rise. It is very important not to equate subsidised patients with the low income group. We should be careful about giving health care subsidies liberally, rather we should be liberal in referring those who have difficulty affording health care to the medical social worker for downgrading or waivers. Otherwise, there will be no appreciation of the true cost of health care and there will be over-consumption of subsidised health care services. Recently, a nursing officer in the hospital outpatient clinic was commenting that she was concerned that patients who were being seen as subsidised patients by specialists were paying with Gold credit cards and, being the better educated patients, they knew the system well enough to get themselves referred to several specialists and yet remain subsidised. Unfortunately, she said that there were many instances where there were those who were less well off and were the ones who did not know the system well enough, and ended up being paying patients. Therefore, one must be careful not to equate subsidised patients as synonymous with the low income group. Hence, the reason that I said that we should be careful about giving health care subsidies liberally, but rather we should be liberal in referring those who have difficulty affording health care to the medical social worker. Experience from other countries has shown that over-subsidy of health care services results in over-consumption of services and a deterioration of services. The Government should help the public understand the true cost of health care and the reasons for increasing costs.”
“How has the primary health care service been upgraded to meet the challenges of these new medical entities? With a greying population, the diseases that will affect the population will often result in the need for home nursing care. How has the Home Nursing Foundation been upgraded to meet these increasing demands? I will appreciate the Minister's viewpoints on these issues.”
“Sir, I would like to declare that I am a doctor working in the National University Hospital. A good primary health care system is the foundation of good health in a country. We have a good system of primary health care services. We are building more polyclinics to cater to the health needs of the people. Before we give ourselves a pat on the back, we should ask the question, "Has the quality of primary health care improved?" The quality of primary health care at the polyclinics should be further examined to ensure that we not only improve the hardware but we also improve the software. At the polyclinics, there is a problem of insufficient time for proper assessment of patients with more complicated illnesses, eg, like diabetes mellitus. Certainly, there is no time to take a very detailed clinical history and to do a detailed physical examination even for the first visit. Perhaps there should be a clinic or clinics set aside within a polyclinic itself that should see all patients that are being seen at the polyclinic for the first time. These new patient clinics should be allotted more time per patient to ensure that there will be enough time for a detailed history and physical examination. This will make it easier to assess the patients in subsequent visits. There is also a lack of continuity of treatment as the patient sees different doctors at different visits. The frequent rotation of doctors further exacerbates this problem. Perhaps the Ministry may devise measures to ensure that this problem is alleviated at least for those with chronic illnesses. The disease trends are changing with coronary artery diseases, diabetes mellitus, cancer, hypertension and strokes becoming more important causes of morbidity and mortality.”
“However, the NMP is also a person who is established and well-respected in his profession and is able to use his wealth of experience to offer views that may provide an insight to areas which he is well-qualified in. Being established in his own profession, the public office as an NMP will not do much to enhance his image further. Hence, we must not assume that people selected to assume the office of an NMP are looking for an easy route to Parliament but rather we must be positive and look upon it as an avenue where capable people can also be inducted to play a positive role for the nation and the highest body of the nation, the Parliament. Sir, I support the motion.”
“Until the day comes when the Opposition Members can throw aside emotions and offer constructive viable alternative views and policies, I see NMPs as playing a complementary role in espousing alternative views. Secondly, although I believe that, as a rule, political office should only be held by those who have undergone the electoral process, there may be exceptional circumstances when it may be beneficial for the Government and the country to appoint an NMP to high political office. Although some Members may feel strongly about this, I believe that this would give us another safeguard. One cannot predict when such a need may arise. It is better to be safe than sorry. Thirdly, NMPs can also represent the interests of majority groups. In this respect, I refer to the under-representation of women in this Parliament. Certainly, women are not the minority interest group. No matter how well men try to understand issues regarding women, I doubt that they will ever do it as well as women themselves. I believe that if capable women are selected to be NMPs, the interest of the fairer sex will be better represented. The other fundamental question is: is the NMP avenue an easy way out for those who aspire to be in Parliament? To put this in perspective, we must cast aside emotions. Not all of us are made in the same mould. Those who have stood for elections have the temperament and the disposition to weather the political elections, devote a large part of their time to the community and seek to reflect the views of the average Singaporeans in Parliament. True, this is our strength to know what an average Singaporean needs and how he feels. The NMP may not be cast in a similar mould and he may never be able to fulfil this role.”
“Mr Deputy Speaker, Sir, the issue of Nominated MPs has been put through a mental sieve by many Members when it was first debated in 1989. The records in the Hansard are testament to the thoroughness in which the issue was debated. I do not intend to quote or reiterate the views that had been stated but rather I will state my personal views. I think there are two main fundamental points to address. Firstly, is there a role for NMPs? My view is that there is. I think NMPs can provide alternative non-partisan views. There is a wealth of talent in Singapore. Members in this House are a microcosm of this wealth of talent. However, there are people who are highly capable and well respected in their fields but fight shy of politics. If inducted into Parliament, they can provide non-partisan views. They will not be handicapped by the need to oppose good policies for the sake of opposition. The NMPs are members who do not belong to the ruling Party and, yet, they provide credible, constructive, alternative views. I refer to the statement made by the Member for Hougang just now. He said that the scenario may arise where you may only have ten elected Members and 70 nominated Members. I think this is an unlikely scenario. He has missed the point. There is no need for the ruling Party to get Nominated MPs to push Bills through. We have more than enough to make up the votes. The point is that we want non-partisan people to be able to provide constructive viewpoints. He said that he did not know what were the reasons for NMPs. I suggest that, perhaps, he goes through the records in the Hansard and the reasons are quite clearly stated there.”
“Sir, I thank the Minister for her reply and I beg leave to withdraw my amendment. Amendment, by leave, withdrawn. The sum of $640,521,120 for Head P ordered to stand part of the Main Estimates. The sum of $299,441,300 for Head P ordered to stand part of the Development Estimates. Head I -”
“Sir, just one last point. The reason why laboratory facilities in polyclinics are not well-utilised is not just the convenience but the cost as well. In fact, it may be more costly to do a laboratory test in the polyclinic than at a private laboratory.”
“Dr Aline Wong: Sir, all our large polyclinics have a laboratory on site. These laboratories are also open to the general practitioners. However, the general practitioners' utilisation of our polyclinics' laboratories has been poor, comprising less than 2% of the laboratory workload. This is because some private laboratories are providing a special service to the GPs, collecting specimens from them at no additional charge and so GPs find it not necessary to send the patients to the polyclinics' laboratories. Currently, only one polyclinic at Tampines has an X-ray service which is also open to GPs but, again, its utilisation by GPs is very low, comprising less than 5% of the X-rays taken. Patients, CSC card holders or other people, who are discharged from Government or restructured hospitals can obtain non-standard drugs at the polyclinics if they are patients of the polyclinics. The idea is that they should be followed up in the polyclinics and if the use of non-standard drugs is warranted, then an application would be made for the drugs to be supplied at the polyclinics. On the lack of continuous care, we have covered this subject quite well when I responded to Dr Tan Cheng Bock's proposal about the community health care system.”
“As a result, CSC card holders do not want to be discharged from specialist clinics, as they are unable to get the medication required. I propose that the Ministry allow polyclinic doctors to make an inventory for non-standard drugs for CSC card holders who require medication currently not available in the polyclinic pharmacy. These requests should only be allowed if the patients are sent to the polyclinics from specialists in Government and restructured hospitals. This will make it unnecessary for such patients to be seen at the specialist clinic in hospitals just for the sake of being able to obtain the required medication. (4) Quality of medical care. At this point, I would like to agree with Dr Tan Cheng Bock who said that there were certain problems about the primary health care system. One of the weaknesses, and a very important weakness, of our current system in the polyclinics is the lack of continuity of medical care. Patients with chronic medical conditions like diabetes mellitus are often attended to by different doctors at different visits. At each visit, the harassed doctor scours the medical notes and makes a hurried assessment as he has a large pool of patients waiting in line to see him. Fighting against the problems of unfamiliarity, limited time and a large patient turnover, he can only do his humanly best and would not be able to give optimal care. For the diabetic patient, he can only try to adjust the medication to control the blood sugar level; there is no time to look for eye complications, kidney complications, vascular complications and there is definitely no time to give proper counselling. How does the Ministry intend to improve the situation? I would like the Minister's views on these points?”
“Sir, I beg to move, That the sum to be allocated for Head P be reduced by $10 in respect of Code PE 5100 of the Development Estimates. Primary health care is currently considered a poor cousin to hospital services, but I believe that it is as important, if not more important, as secondary and tertiary health care. A good primary health care service will result in early detection of diseases and prevention of complications. In developing new polyclinics, we must not only continue to make it affordable but we must strive to improve the level of primary health care. I have certain proposals which I would like the Minister to consider. 3.15 pm (1) Install X-ray facilities in all new polyclinics. The Ministry should consider installing X-ray facilities not only to improve the diagnostic capabilities but also by allowing general practitioners to use the X-ray facilities, the level of primary health care in that area will be enhanced. Furthermore, with a higher throughput, it will result in more cost-effective usage of the facility. (2) Set up rehabilitation facilities at all polyclinics. This will allow patients with stroke, orthopaedic injuries and other physical disabilities to have easy access to such facilities. Otherwise, the physical disabilities alone will discourage them from travelling to the hospitals for rehabilitation. Early rehabilitation will allow the patient to integrate back into society and will relieve the social burden on family members. (3) Medication. Patients seen at hospitals are discharged to polyclinics for follow-up when they are stable. However, in certain instances, these drugs are not available at the polyclinics; and there is no alternative drug within the same class of action available in the polyclinics.”
“Sir, I thank the Minister for his reply and beg leave to withdraw my amendment. Amendment, by leave, withdrawn.”
“I am concerned about the development of National Medical Centres. In Singapore, the pool of specialists within each field is limited. We should be careful about spending large sums of money so that doctors can practise in a large building designated as a National Medical Centre and yet continue to practise in their own hospitals. This does not result in optimal utilisation of time and resources. Furthermore, many patients have multiple medical problems which often require a multi-disciplinary approach. It may be better to build on existing infrastructure within a general hospital which is designated to develop a chosen speciality. This will also prevent duplication of expensive medical equipment. Sir, the Ministry has always been wise and prudent in health expenditure. In spending large sums of money in the redevelopment of hospitals, we must not only exercise prudence but we must also explore avenues to restrain cost escalation. What we need are not the frills of classy lobbies or the thrills of latest medical technology, but really what we need is to cure the ills with affordable pills. With this, I seek the Minister's comments on these suggestions and concerns.”
“Often, one nurse may be assigned to each cubicle. Hence, the less beds you have per cubicle, the more nurses you will require. Hence, in class B2 ward, you may have a six-bed cubicle in an acute ward, whereas in an elective ward, perhaps a 10 to 12-bed semi-enclosed cubicle will suffice. (3) Outpatient clinics. We should expand the outpatient specialist clinics in the hospitals to allow walk-in referrals from the Emergency Department. Hence, if the Emergency Department doctor is uncertain, he can refer the patient directly to the specialist clinic for an assessment, instead of admitting the patient. This will reduce the number of admissions to the hospitals where the indication for admission is uncertain and eventually also reduce the pressure for beds. (4) Expensive new equipment. In redeveloping hospitals, one must temper the zeal to acquire all the latest available expensive new equipment with the reality of what is required for the hospital to function as a secondary or tertiary hospital. For example, if a new MRI machine is acquired, there will be a tendency to use this instead of a CT scan or other imaging modalities. Worse still, a patient with stroke may end up with both MRI, which is magnetic resonance imaging, and CT scan, which is computerised tomographic scan. Singapore is a small country and we already have three MRI machines. In the end, my fear is that more patients may be put through the test on the basis that it is good to know, rather than on the basis that it will affect the eventual outcome of the patient. The appetite for new technology is insatiable and therefore it is necessary that the Ministry institutes safeguards to ensure that there is optimal utilisation of expensive new equipment. (5) National Medical Centres.”
“Sir, I beg to move, That the sum to be allocated for Head P be reduced by $10 in respect of Code PD 5100 of the Development Estimates. Hospitals are being redeveloped. We should learn from the lessons of existing hospitals. We must cut down on unnecessary fixtures and minimise staff requirements. We must differentiate what is needed from what is good to have. We must veer away from conventional thinking. I will cover five areas briefly. (1) Ward categorisation. In building new hospitals, we should consider dividing the hospitals into three main wings housing acute care, elective and convalescence wards. Patients with acute illness or acute exacerbation of chronic illness which requires substantial medical and nursing care should be managed in acute care wards which have more wall fittings for suction, oxygen delivery and power points for auxiliary medical devices, and these wards will also have a higher staff to patient ratio. Patients who are admitted for day care procedures, short stay elective surgery and diagnostic or therapeutic procedures, such as tissue biopsies, angiograms, endoscopic procedures should be admitted to elective wards which should be open concept wards. The staffing situation and physical installations in such wards should be minimal. Convalescent patients such as those recuperating from uncomplicated surgery, undergoing rehabilitation for mild stroke or undergoing stabilisation for diabetic control do not require much medical or nursing care. The cost of building, maintaining and staffing such a ward will be intermediate between that of the acute care and elective wards. (2) Beds per cubicle. In deciding on the number of beds per ward cubicle, we must also consider the practical staffing situation.”
“Sir, as I understand that the matter at hand has been resolved, I will not move this amendment.”
“This will definitely result in more cost effective running of the hospital. In certain situations where large capital expenditure is required for common user equipment, this can be costed differently. Sir, if restructured hospitals were to be the main provider of hospital services, the Ministry must constantly strive to make our restructured hospitals more cost-effective. With these proposals, I hope that I would have contributed to the Ministry's effort. I will appreciate the Minister's views in these areas. On research, the main Report of the Review Committee stated that the Ministry will spearhead medical research. To do good medical research, we need large financial resources, full-time research scientists and many research laboratories. I want to ask the Minister: (1) as the sum allocated is not large, how will funding be done? Will there be private funding? (2) How does the Ministry ensure that the emphasis on research does not translate into increased cost for patients? Sir, I would like the Minister's views on these two points.”
“This has resulted in patients with severe stroke, terminally ill patients with end stage multiple organ failure and patients who have suffered severe irreversible anoxic brain damage being admitted into ICU. The usual course for such patients is to have their life prolonged in a comatose state only to reach their expected outcome of death in weeks and, in certain cases, months. When the bill comes, they will seek assistance from the MP. Sir, this scenario is often repeated in our hospitals. Hospitals should help to bear the social pressure and have strict guidelines for admission into ICU so that doctors can exercise good clinical judgment without having to write long explanation letters for not bowing to social pressure. If the beds are limited to the projected patient load, doctors will have to exercise careful clinical judgment and prioritise the needs. We must guard against providing more ICU beds without good medical grounds. Otherwise, ICU admissions will not only be dictated by medical indications but also social indications. (3) Accountability of cost centres A percentage of the surplus made by departments in hospitals must be ploughed back to the department. Departments must then be made to manage their cost centres. This will encourage productivity and reduce unnecessary demand for more staff and equipment. Departments should be made to pay for clinic time and operating theatre time to ensure that those limited resources are utilised efficiently. Subsidised patients who are managed will be offset against the cost imposed by the hospital for utilising the facilities. In this way, departments that want to acquire more staff, more clinic time, more operating theatre time and more equipment must be able to cost for them and show that they can balance accounts.”
“Sir, I want to declare that I am a medical doctor working in the National University Hospital. Sir, restructured hospitals are often misconstrued as costly. In reality, the quality of medical care provided in the subsidised wards is of good quality and at an affordable cost. We must, however, be constantly vigilant and curb the escalating cost in restructured hospitals. We must decrease the pressure for beds, optimise utilisation of manpower, increase productivity and efficiency, and reduce operating deficits. The end result will be more cost effective health care. Towards achieving this end, I propose the following three measures: 2.15 pm (1) Development and expansion of ambulatory day services The Ministry must encourage the development of ambulatory procedures in addition to the current day care procedures. With the development and improvement of technology, procedures such as laparascopic surgery, endoscopic procedures and angiograms may perhaps be performed on an ambulatory day care basis on certain patients. I would like to ask the Minister if these ambulatory procedures were found to be safe on a routine basis, either presently or in the near future, will he allow deduction of Medisave for these procedures? This will encourage patients to opt for such ambulatory services and it will also result in a decrease in bed requirement and lower cost for patients. (2) Optimise utilisation of ICU beds We must control the number of ICU beds available in each hospital. The cost to the patient and to the hospital is enormous. Unfortunately, relatives often put a tremendous amount of social pressure on doctors despite being told of the poor prognosis and doctors have to do all they can for the patients.”
“Sir, can I take this cut and my next one together?”
“Sir, I beg leave to withdraw my amendment. Amendment, by leave, withdrawn.”
“Sir, can I just add one last statement? It appears that my 29-year old housewife with three children will not find solace in the Minister's answer. Perhaps the Minister, before he ends, would like to make a comment about the proposal I made with regard to the widow with children.”
“Sir, can I just clarify? My point is that they have actually applied and they have been interviewed and accepted for the scheme. But following the interview, they felt that it was as if they were begging and therefore they declined the assistance. They came to us for assistance, but our assistance was limited.”
“The centre will maintain the registry, coordinate the activities of all Government and voluntary associations providing for the disabled, and plan for future infrastructural needs. 3.15 pm Lastly, activities of daily living. To facilitate the disabled in their integration, I am heartened that in many places the buildings have been designed to cater for the needs of those who are disabled. We can do more, for example, MCD should coordinate with HDB to help disabled persons who apply for HDB flats to obtain flats that are at the ground floor or at the same level as the lift. We must do more for fellow Singaporeans who are disabled. What plans do the Ministry have in facilitating the disabled in their activities of daily living? Sir, I would like to know the Minister's views in these areas.”
“Sir, in Singapore we do not really know the extent of the population that have disabilities. Using an estimate of 3.8% used by Asian countries such as Hong Kong and Japan, there are about 97,000 disabled people in Singapore. The services for disabled people provided by the voluntary welfare organisations cater only for about 8,000 disabled people. The question is: are we doing enough? There are four areas which I would like to touch on. Firstly, a National Registry of Disabled Persons. Despite the shortcomings of the previous Central Registry of Disabled Persons, I believe that the Ministry should set up a National Registry of Disabled Persons. For this registry to succeed, the referral process must be made simple and the referral sources identified. Sources of referrals should include hospitals, school health services, maternal and child health clinics, polyclinics and schools. Without a proper database, it will be difficult to project manpower needs and plan for infrastructural needs. By making the referral process easy and by increasing public awareness of the registry, the Government will be able to get a better approximation of the incidence of disabled persons and the different disabilities involved. This will be extremely useful for future planning. Secondly, educational and training programmes. Currently, there are insufficient special schools, the vocational training and sheltered workshop programmes are limited, and there is a shortage of trained staff. What plans do the Ministry have in overcoming these shortcomings? Thirdly, National Coordinating Centre for the Disabled. The Ministry should work with the Singapore Council of Social Services in setting up a coordinating centre for the disabled which will employ full-time staff.”
“A common example is a single man, the only son, who earns about $800 a month and his mother gets a stroke. He cannot give up his job to look after his mother, yet he is unable to afford a nursing home for his mother. The situation will become more acute in the future as families become smaller and the elderly population increases. How will the Ministry deal with this growing social dilemma? I will appreciate the Minister's comments on these two areas.”
“Sir, the next topic will be on aging matters. Sir, the problem of an aging population is a real one. The dependency ratio of 8.1 elderly per 100 persons of working age in 1990 has been projected to increase to 31.9 per 100 in 2030. With improving health care standards and a higher standard of living, it is likely that people will live longer and hence there will be more elderly people. I would like to make some proposals. Firstly, Senior Citizens' Corner. Elderly people have simple needs. Recently, I asked a group of about 60 senior citizens in the Punggol area, with ages ranging from 58 to 90 years, whether they were satisfied with the facilities in the constituency and what were their needs. They said that they were happy with the facilities in the Punggol area; their needs were very simple. They wanted a better Senior Citizens' Corner in the void deck. I said that I will look into it. Today, I will take this opportunity to ask the Minister whether MCD will consider the construction of more Senior Citizens' Corners in the void decks, not just simply a few more chairs or a table but rather a semi-enclosed area with simple amenities like a power point and a water point, so that they can enjoy a cup of tea while they enjoy each other's fellowship. Perhaps, MCD may even consider the possibility of setting up an exercise centre for the elderly so that the senior citizens can keep a healthy lifestyle. Secondly, institutional care facilities. The three main diseases that affect the elderly are cardiovascular diseases, neurological diseases and cancer. Some of these diseases, especially neurological diseases, result in significant disabilities which will put a tremendous amount of strain on the family.”
“Before the Minister dismisses my proposals by saying that we should not encourage a crutch mentality, and we should encourage a "many helping hands" approach, and not a subsidy mentality, I want to assure him that I share his views. However, when I cast my mind back to my meet-the-people session in the Punggol ward of Cheng San GRC last Thursday, I am reminded of the recently widowed 29-year old housewife who came to me for assistance. She had to worry about bringing up her three children, a two-month old child, one child attending kindergarten and the third child attending primary school. If that was not enough, she also had to worry about having a roof over their heads, seeing that her family had only paid up one year of their 25 years mortgage on their HDB flat, and her family had not taken up a home protection scheme. We cannot solve her problem by simply helping her to find a job. Who will give the necessary love to the little baby? Who will guide her young children? Only the Minister can answer these questions. Sir, the Minister has a big heart. I pray that he will empathise with my widowed women and their young children from the Punggol area and share in our sincere belief that the Government is one who cares not only in words but also in deeds. Therefore, in considering my proposals, I urge the Minister to overcome the bureaucratic inertia with a generous dose of sympathy and empathy.”
“We should consider this as a means to forge a link between those who need help and those who are able to help within the community. Secondly, enhancement of the public assistance grant. The number of abandoned or widowed women with children receiving assistance in 1991 was 121. I am particularly concerned for this group because I believe that we must do our best to ensure that the non-school going children are put in day care centres and to assist those school-going children to achieve their maximum educational potential. The limited social and physical environment in those homes will impede the children's cognitive development and educational attainment. Hence, we should consider adding an educational enhancement package to allow the child to buy books, to attend tuition schemes organised by community organisations and other activities that will improve the child's educational status. I also believe that the food component in the public assistance scheme should be increased. Looking at the amount given, it appears that the food must have been bought at NTUC Fairprice supermarkets during a discount period. I wonder whether those who calculated the food requirements have ever tried buying food at those prices and eating the way they proposed. School-going children are in their growing age. We should enhance the grant to improve the nutritional component of the grant. Sir, we can have budget surpluses in billions and not just millions. Surely, I would not be asking too much to ask the Minister to consider enhancing the current scheme to help those abandoned and widowed women with children. The primary aim is to ensure that the children have a chance to succeed in life. We are not talking about thousands; as I stated, there were only 121 such cases last year.”
“Sir, I am one who does not believe in encouraging a subsidy mentality. Certainly, if subsidies result in a comfortable lifestyle, there will be no motivation to work or to improve the socio-economic status. However, I believe that we can go some way in improving our Public Assistance Scheme. I would like to propose some changes to the current scheme. Firstly, disbursement of public assistance through community organisations, like the Citizens' Consultative Committee. Asians often want to have face, ie, dignity and, contrary to MCD's concern that Singaporeans will be clamouring for public assistance, there are those who would rather not accept MCD's assistance, as they consider it to be a loss of face. Hence, they may end up in severe financial and social distress before they seek assistance. However, they may be willing to accept assistance from the community organisations. Within the last three months, three of my residents from the Punggol ward of Cheng San GRC were unfortunate in that their husbands died leaving them with young children. All of them sought help from the Residents' Committee, and subsequently saw me for assistance. One of the women was only earning $150 from part-time work; in addition she had school-going children to look after. However, she declined MCD's help because it was like a loss of face after the interview she went through. Eventually, we assisted her and she accepted our offer of assistance. As our assistance is limited, she will require MCD's assistance in the near future. My point is that if public assistance disbursement is made through the community organisations, the subject seeking assistance will not view it as begging from strangers in a Government institution, but rather helping hands from members of the community.”
“Sir, I have three amendments. Can I take them together?”
“One example is the Buddhist Lodge which gives scholarships and bursaries to Malay and Indian students as well. So the Ministry of Finance can perhaps consider granting tax exemption or concession on property tax to those associations which have also contributed to social development, according to the quantum and degree of contributions. Tax exemption or concession should also be given to Malay and Indian associations to make sure that they will not be forced to move out from their original locations because they cannot afford to pay the higher property taxes. This, I think, is good for encouraging healthy social activities and the preservation of our heritage and traditions. Although, Mr Speaker, Sir, I have raised two matters, namely, the need for more flexible fiscal policies to maintain our prosperity and to grant property tax concession to associations, I would say that this year's Budget is still one that we should welcome. Mr Speaker, Sir, I support the 1992 Budget of the Government.”
“But in Neil Road, Bukit Pasoh and Cantonment Road, there are many old houses occupied by Chinese clan-associations. Some of these clan associations are very small, and they depend on the subscriptions, which are also very small, to survive. So if they have to pay for a substantial increase in their property taxes, then they will find it difficult to make ends meet. In the end, they may have to sell the properties and move to some remote places. But in the traditional concept of the Chinese, it is only as a last resort that they sell the properties passed down by their ancestors. Furthermore, members of these associations live in the neighbourhood. If the associations are moved to other places, they will lose their existing members and their activities may be shrunk. Some of these associations may even be dissolved. This is not in keeping with our efforts to preserve our traditions and our community characteristics. Mr Speaker, Sir, under section 3, item 6(5) of the Property Tax Act, if the whole property or part of the property is used for charity purposes, or is conducive to the social development of Singapore, then tax exemption may be granted. Chinese associations also contribute to the social development but they are not granted tax exemption. The explanation is that they are only servicing the Chinese community. This is not in keeping with the intention of the Act. The Chinese associations look after the Chinese community, while the Malay and Indian associations look after their respective communities. This is a form of division of labour. They should all be given equal treatment for tax exemption. Furthermore, some of these associations cater not only to their own community, but also other communities.”
“Our economy will be affected and we can only expect to achieve 4% to 6% economic growth. If during this period, the Minister for Finance can increase the development expenditure or cut down certain taxes to stimulate economic activities, then I am sure the people will have more confidence in our economy. During an economic slowdown, any measure that increases production cost will add on to the burden of the private sector. Traditionally, Sir, the people look up to the Government as their protectors like parents. They expect the parents to protect them as they would protect their children. So during the cold weather, the government should provide more warm clothing and blankets to the people. But the general impression given by the Government is that it is only after you have caught a cold that the Government will give you the medicine and care. This has already affected the physique of the people and the medical cost is certainly more than the cost to prevent the illness from developing. But this perception, of course, is not entirely correct, although it is a very popular one. This does not mean, however, that the Government should implement a deficit budget. What I am saying is that the Government should use flexible fiscal policies to reduce the surplus, when necessary, to maintain the stability in our economy and our development, and this is a good measure of flexibility that we can adopt. Over the past two years, we see slower economic growth and the property market is rather quiet. The exception is that the prices of many old rent-controlled premises in the conservation area have gone up after the rent-control has been repealed. Property taxes go up with the increase in annual values of the properties.”
“Looking carefully at the budget presented by the Finance Minister over the past few years, we can see clearly that Dr Hu has always been very prudent and cautious, always keeping expenditure within the limit of income, and to spend according to what the revenue is. The idea is to ensure that there is more income than expenditure and leave a surplus, if possible. This is the best way of doing business, running a country and a family. To a family if there is a surpl-us, then you will always be ready to meet with any unforeseen circumstances. To the society and the country, if the coffers are rich with budget surpluses, then we will have enough means and resources to meet any recession. But we can see also that the budget of a country is much more complicated than that of a family. The budget of a government is a means that can be used by the Government to lead and regulate economic activities. During recession, or bad times, the Government can increase development expenditure to support and sustain economic activities and to prevent the deterioration of the economic situation. When the economy is under inflationary pressure, then the Government can cut expenditure to prevent overheating of the economy. Therefore, a deficit budget has the effect of stimulating the economy, whereas a surplus budget will have contracting effect on the economy. Even if it is a balanced budget, the effect is still inflationary. In 1991, there was the Gulf War in the early part of the year which made the people very pessimistic about the economy. But at the end of the war, the economy turned out to be much better than expected. We achieved 6.7% of our economic growth. But this year, the economic prospects of the United States and other advanced countries are bleak.”
“We may never experience the effect of such policies on our quality of life, but in the inner sanctum of our hearts we must be able to feel what these people feel and in the innermost niches of our minds, we must learn to understand their perceptions. Just as I do not believe in encouraging welfarism, I also believe that those in the lower-income group must be encouraged to work hard knowing that their just rewards are for them to keep. Therefore, I beseech the Government to add a drop of empathy here and to add a drop of flexibility there when concocting policies, so that the final potion may not be too overwhelming for my dear friends in the lower-income group, on the contrary it should be invigorating. With this passionate plea, I support the Budget. The Minister of State for Information and the Arts and Education (Dr Ker Sin Tze)( In Mandarin): Mr Speaker, Sir, this year's Budget, like those presented by Dr Hu in the past, is solid and realistic. Apart from changes in the tax rate on futures trading and financial services, there are no other major tax changes. In the personal income tax, the 5% rebate was started last year. To the Singapore residents who live in 1-room, 2-room and 3-room flats, the payment by the Government for their service and conservancy charges for December is good news for them. In addition to this, the tax relief for the reservists, the increase in cess and the restriction on the purchase of duty-free liquors are measures that affect only a small segment of the population. The only measure that affects the whole population, in general, is the increase of 5% on the water conservation tax. On the whole, the Budget of this year has no substantial difference from that of last year's. Basically, it is an extension of last year's budget.”
“Though the budget is painless, the pain inflicted in between budgets may sometimes be bruising. An example of this is the recent increase in levy charges for foreign workers. Though the intentions are good, we must tailor the policy to ensure that the added financial burden does not make it economically non-viable for someone to continue working. This is more so when we have a tight labour market. The time-based telephone charges is another case in point. This together with the water conservation tax are forms of consumption tax. The recent announcement on the introduction of a White Paper on Consumption Tax for goods and services in the near future has further raised the spectre of fear. I fear not for myself but for the economic crunch that the lower-income group may face. The principle of consumption tax must be tempered by the need to avoid unnecessary burden on the lower-income group. We must remind ourselves that each policy by itself may not cause a significant dent in the finances of each family but the cumulative effect may tip the scales to economic hardship for those in the low income group. We must realise that those in the low income group may not dare to wear a smile on their face on budget days for it is like the calm before the storm; they have to brace themselves for the winds of taxation that blow in between budget days. Indeed, none in this House will ever feel a chill down their spine whenever a policy which increases the cost of living sweeps through this House. We must, however, not lose the quality of empathy.”
“On this note, I am heartened that the Minister for Finance has taken pains to ensure that the lower income group has also something to look forward to. For citizen householders staying in rented and owner-occupied HDB flats of 3-room size or smaller, the gesture of a one month rebate of the service and conservancy charges is certainly a rainbow in the sky. Though there is no pot of gold at the end of this rainbow, more gestures in a similar vein will help to bring cheer to this group of Singaporeans who have little to look forward to during the Budget period. Though many in this group may not benefit from the 5% personal income tax rebate, as they may not earn sufficient income to pay tax, some will still benefit. The tax relief for reservists is also a step in the right direction. Not only does it give recognition to the contributions of reservists but it will benefit a large segment of Singaporeans, especially those in the lower-income group. I stand firmly behind the Government's decision to achieve a CPF rate of 40% with equal contribution by both employer and employee. The increase of the employer's CPF contribution from 17.5% to 18% and a reduction of the employee's contribution from 22.5% to 22% will bring cheer to many in the lower-income group. The allocation of $1 billion to the Edusave programme will help to ensure that children from low income families will not be deprived of educational opportunities as a result of financial constraints. I am also heartened by the proposal to allocate funds to the Medifund programme in the near future when the proposals are more concrete. Despite these silver linings in the cloud of an economic slowdown, my heart is heavily weighed down with concerns for the lower middle and the low income group.”
“Mr Speaker, Sir, though not a clairvoyant, the 1992 Budget with its characteristic prudent fiscal policies was predictably cast in the image of its predecessor. Despite its similarity to previous budgets, it was a breath of fresh air considering the looming clouds of an economic slowdown. Our fiscal prudence has stood us well. Despite the difficult economic conditions throughout the world last year, our economy had achieved a creditable 6.7% growth rate. Compared to the trend of government spending in other countries, we have been allocating an inordinate amount of the expenditure to the key areas of education and housing. This is essential as Singapore, being a small nation whose only resource is its people, must invest in its people. To protect its people and the country, the allocation for military defence has also been justifiably significant. Together, the total allocation to these three areas of education, housing and defence accounts for 47.9% of the expenditure. Unlike many countries whose expenditure on social and health services hangs like a sword of Damocles over their stretched financial resources, Singapore has managed to keep our allocation to health to 5.6% and community development to 1.4%. Wisely, we have also discouraged a subsidy mentality. Nevertheless, we must always be mindful of the needs of those who are economically less able. While my esteemed colleagues deliberate on free market policies and expound on the solutions to a widening gap between earnings and productivity, the rise in Singapore's unit labour cost and the declining export growth rates, I will focus my attention on the lower income group.”
“Sir, arising from the detailed analysis of the bus services by the grassroots leaders in my constituency and, in the interim, while awaiting for a new bus interchange, can the Minister kindly improve the seven trunk services and four feeder services in my area? I will give the detailed proposals to him later.”
“Sir, though my ardent and earnest plea on behalf of my residents in Punggol could not bring about an early solution to my request for an MRT line, in the interim, can the Minister kindly consider my humble request to increase the frequency of public transport services, such as bus services, to the nearest MRT station in Ang Mo Kio; this being a reasonable request and being in line with the Government's policy to encourage the use of public transport?”
“Sir, may I ask the Minister for Communications whether, since the Ministry has had some technical plans available for the extension of the MRT line, can he, in his wisdom, enlighten me as to what is the most likely date that I can look forward to for a line to my constituency at the north eastern area?”
“Yes, I shall shorten it. Can the Minister kindly clarify whether the extension of the MRT line to Woodlands New Town is aimed primarily at encouraging Singaporeans to relocate there where there are about 70 blocks of unoccupied flats and hence priority was not given to the Punggol area and the rest of the north-eastern corridor?”
“Mr Speaker, Sir, may I ask the Minister for Communications, in view of the population of the north-eastern sector being substantially more than twice that of Woodlands New Town and yet a line has been laid to Woodlands New Town, this being a question that has been bothering a lot of the residents in my constituency and the detailed statistics having been brought up -”