Tan Cheng Bock
Singapore
“As I said, we have not done much. We must not be captured by our old style of managing the old. The new old, as I said before, are better educated and travelled, and are very knowledgeable. So we must quickly explore new ways and methods to meet the expectations of the new old.”
“If we only have such a small pool of talents in Singapore because of our population size, we should spare no effort in seeking every such talent.”
“Thank you. I accepted the Minister's reply on the different pricing in the outpatient polyclinics and the hospitals. My point is that the patient's problem has still not been solved. Whenever a doctor refers a patient from a hospital to an outpatient clinic, he still has to pay more.”
“Six out of the nine items were much more expensive. Sir, I am asking why is there such a difference. Is this a one-off incident or is it going to be a norm? How can doctors in the hospital then refer patients back to the outpatient clinic if the patient is going to pay more?”
“I move this amendment to ask the Minister what is the Ministry's stand on seat belts to be made compulsory for primary and kindergarten buses. I heard over the radio that the Ministry is reviewing the case. There are two issues here, question of cost and question of safety. I think safety has a higher weightage over cost.”
“I also want to commend the NTUC for working with the Government to put this package together. I believe that without the NTUC's representation in putting forward the workers' case, the workers would not be able to benefit so substantially this year from this package.”
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“(10) That the sum to be allocated for Head J be reduced by $10 in respect of Subhead JC-03 Object Group 1210 of the Main Estimates.”
“Would HDB allow them to register for a purchase or rent an HDB flat after they have sold the house? Would HDB relax any restrictions that are currently in force? Finally, I would like to appeal to the Minister to give some thought to allowing free parking on Sundays and holidays in HDB estates. Now, let us allow such days to be used by Singaporeans to visit friends and relatives, without having to worry about car parking coupons running out on them. I am sure it will be a start to more fun living in Singapore.”
“When one partner of a childless couple residing in an HDB flat dies, the Board requires that the surviving member finds a flat-mate, or gives up the flat. Is this fair or necessary? The person, having lived in this house for some time, has developed a certain attachment for the house. Moreover, it is not easy for him or for her to find alternative accommodation. Must he or she give up her privacy by renting out the room? Moreover, with the HDB fulfilling their building programme, it is no longer easy to find suitable tenants. Would the Board like to review this policy? We have a policy that only applicants with a family income of $1,500 and below are eligible to register and buy a 3-room flat. I am aware of the good intentions behind this policy. But I am wondering if we have not inadvertently encouraged our Singaporeans to own bigger flats than necessary. Is this good, and is this correct? Some of my residents tell me at my Meet-the-People sessions that they do not want such big flats because they honestly do not see the need for it. Yet they have no choice but to buy a bigger flat because they have got a big sum of money in the CPF. Saving for housing, I know, is good and it is a sensible investment. But a restrictive policy like this may lead many into buying a flat bigger than required, at more cost and at the expense of other priorities, and perhaps unduly influence their lifestyles. Would the Minister like to review this also? The Minister should also take note that elderly couples who own private homes find it difficult to look after it or maintain it as all their children have grown up and are living on their own. They want to sell their house so that they can live in a smaller flat, especially an HDB flat.”
“I agree it is good to break the monotony of our HDB flats by building elevations here and there, but to build elevations in front of shophouses and to build elevations between two high-rise flats, I think that is a bit too much. I find that even the children do not find those hills a very pleasant place to play in. Talking about landscaping, I would advise HDB and PWD to fill up all the gaps between the slabs in the footpaths. I am sure we are all prepared to sacrifice a little greenery in the footpath for the safety of our pedestrians. I am sure the Minister must have seen many mothers pushing their prams on the road, and old people walking on the road instead of making use of these footpaths. Because these gaps in the footpaths are obstructions. I would also like to draw the Minister's attention to the drink-stalls. I am sure all of us at our Meet-the-People sessions must have received complaints from the drink-stall holders that they get summonses because they stacked their drinks at the side of the stalls in a rather precarious position. I agree it is dangerous, But what do you expect these stallholders to do, when you only provide them with a 6 ft by 6 ft stall? Surely, after so many years of experience, I would expect HDB to have taken this into consideration and make provision for these stallholders to store their drinks. The Minister should also take note of the positioning of air-conditioners in shops and flats. This has to be looked into. Air-conditioners should be placed on top and not below windows. But HDB has designed a position below the window level for all its shops and flats. They are very inflexible when they implement this ruling. I think it goes against all the physical laws of convection current.”
“He will be amazed at the way HDB car parks are built. To get to the car park of the block in front of you, you have to travel about half a mile, then go through a maze of roads, carefully negotiating all the bends before you finally get there, and that is if you are not lost by then. I think some thought should be given to the accessibility into the car parks. Next, I feel very sorry for our lorry drivers. They are being penalized because HDB has not made adequate provisions for them to park their lorries. They are told to park miles away in special designated areas. This is not practical as many of the drivers need to find ways and means of getting into these lorry centres before getting home. Moreover, with the increased taxi fares, I am sure they are going to find it more difficult. Can you imagine them parking their lorries three or four miles away, getting a taxi or bus to go home, and next morning doing the same routine? I am not saying that the lorries be allowed to park in our usual car parks. What I am asking the Minister is to make provisions for them to park at the periphery of the estate or at a reasonable distance from their homes. I am asking that in future planning, please take this into consideration, because you must remember that flat dwellers do own other types of vehicles, apart from cars. When shopowners tender high prices for shops, they do it because of good frontage and good locality. It must be a shock to a lot of them when they find that the HDB landscape artist has decided to build a hill in front of their shops. I think any businessman will tell you that this is bad for business. They would prefer the hill to be built behind rather than in front. It is bad fengshui!”
“Mr Speaker, Sir, many outsiders have expressed their admiration for the Board's achievements. And Singaporeans, by and large, are thankful to the HDB for providing them with decent housing. However, there is always room for improvement and this amendment that I have moved is to draw the Minister's attention to the flat designs and to certain HDB policies which I believe need to be reviewed. 3.00 pm Sir, eight years ago when I visited a friend living in a 4-room HDB flat in Clementi, I was informed that he had to relocate the kitchen sink to a position above the rubbish bin. "It was more convenient," he said. Recently when I visited a friend in Jurong East, I noticed that the sink was similarly relocated. I checked this with a number of residents and I found that most of them did relocate their sink to this particular position. My question is, why is it that HDB continues to locate the sink in a position that is not acceptable to most HDB dwellers? Why let the flat owners incur unnecessary cost? If so many approvals had been given to relocate the sink, surely HDB should have incorporated this into its design. Our HDB lifts are too small, and I have been asking the Minister in this House to consider building bigger lifts. I shall remind him again, and I give him two reasons: (1) To move the sick and the old in and out more comfortably, especially if the person is wheel-chair bound or if a stretcher is required to move the sick, and (2) to move big articles like cupboards, beds and other furniture. It is not only unsightly, but I am sure it is very uncomfortable for a sick person to be wrapped up in a blanket and carried down many flights of stairs. I would like to invite the Minister to visit one of the new housing estates in Jurong.”
“The young, being primarily English educated, tend to look to the West for guidance on how life should be and how society should be run. But is this correct? I agree with our Prime Minister. We must be careful of this. We should not accept nor should we regard Western norms as a standard by which our society should be built, or should be run. We are the products of three great civilizations. We should set our own standards based on our culture, on our tradition, our way of life, and based on the principles of democracy, sincerity, honesty and integrity. We should be proud of what we are as a people. We should be proud of what we have achieved, and we should not be apologetic about the way modern Singapore has evolved under the able leadership of our Prime Minister and the old guards. Finally, Mr Speaker, Sir, over the past five days, there has been a lot of talk, there has been a lot of accusations, insinuations, truths, half-truths, whole-truths spoken in this House. Now that the debate is over and the sound and fury has subsided, we must ask ourselves one question: is your conscience clear? Thank you, Mr Speaker, for your patience and your guidance in this debate. [Applause] Question put, and agreed to. Resolved, That the following Address in reply to the Speech of the President be agreed to:- "We, the Parliament of the Republic of Singapore, express our thanks to the President for the Speech which he delivered on behalf of the Government at the Opening of the First Session of this Parliament." FIRST SUPPLEMENTARY MAIN ESTIMATES OF EXPENDITURE FOR THE FINANCIAL YEAR 1ST APRIL, 1984 TO 31ST MARCH, 1985 (Paper Cmd 3 of 1985) Order read for consideration in Committee of Supply (Allotted Day). [Mr Speaker in the Chair] 12.27 pm”
“All that they want the Government to do is to help them during this period, and they are asking that the Government temporarily lift the SDF and the payroll tax. I hope this will be the rabbit that the Minister for Finance is going to draw out from his bag. The question of future CPF usage and management was taken up by the First Deputy Prime Minister. I shall not go into this except to say that the second account, which is the money to be left for old age, seems to have all but disappeared. It has been reduced to a very insignificant sum. I hope we will look into this. The First Deputy Prime Minister also lamented the lack of response to his call to throw out ideas on how Singapore should be like in the 1990s. There was not much discussion on this, even in this House. And Singaporeans are not generally excited or thrilled by this, as expressed by the Member for Changkat. I think she should not worry too much when ideas are not forthcoming just yet, because it is a longterm objective and people are more concerned with what is happening today. Moreover, people's emotions, their feeIings and their pockets are not hurt like the CPF issue. It is something that the people know that the Government can do and expect us to do it well. It would be a gross omission on my part if I do not comment on the Prime Minister's message to our young. Some of our young complained that the Prime Minister is lecturing to them too much. They want me to pass this message to him, that he need not worry so much about them, that they can take care of themselves when the time comes, and that they are thankful for what he has done for Singapore. However, the young must realize that the Prime Minister's worries go beyond just providing them with material needs.”
“We might end up creating unrealistic demands, unrealistic expectations that we cannot fulfil, and this will spell disaster for all. It is easy to make promises but we must have the means and also the ability to carry out these promises. I think all these talk and promises will go to nought if there is no wealth, as pointed out by the Member for Teck Ghee. Because with wealth, there will be jobs for all, and this we must ensure if this place is to remain healthy for investors. Mr Speaker, Sir, if you were a foreigner listening to these debates, you might have thought that the Government has created two monsters - the HDB and the CPF. And it is ironical that these two, once raved about, are now subjected to constant attacks by the Opposition, by the Back-benchers and by many Singaporeans. Some Backbenchers want to clip the wings of the HDB, calling them to just build flats and leave the administration and the maintenance to others, like town councils. If I were the HDB, I would want to surrender this because maintenance and administration, are the most difficult as seen in private housing and condominiums for example. These are the most problematic issues. However, if MPs are keen and residents are also keen, do not be discouraged by what I said. There are other good points in having town councils. Mr Speaker, Sir, many PAP MPs spoke on the CPF, on the Skills Development Fund and on the payroll tax. They link these to the high overheads that our businessmen have to face. They argue that Singapore business has this added disadvantage in labour costs over our neighbouring countries. They are not arguing that the Government should do away with SDF or the payroll tax.”
“Any responsible government should not allow this to happen, or the people of Singapore will be moved to believe that all these untruths after being repeated a couple of times, are truths; for example, that the HDB makes money from selling flats and that the Government cannot pay back the CPF in cash. I hope the hon. Member for Anson will move away from his obsession on human rights and fundamental freedom which is already entrenched in our Constitution, and to tackle the Government on specific issues. With regard to the Member for Potong Pasir, I can only sympathize with him. He is going to have three busy months ahead of him to come out with a plan to build cheap houses. Mr Speaker, Sir, I think the topic that caught the attention of many MPs is, without doubt, the 15-20% lower income group, and this is understandable because we really want to do something for them. But let me caution the new leaders not to promise too much too fast, as no amount of assistance rendered can improve their lot if the will is not there. And this point was brought up by the Member for Bukit Merah. We must motivate this group to understand, to know that there is hope, and assistance is available if they are willing to sincerely want to improve themselves. There was no lack of ideas from the PAP Backbenchers on how to help them. Some think that education is the answer, others think that education and home-ownership is the answer. Many have put up suggestions ranging from interest-free loans to total waiver of the 20% deposit that the poor of Singapore need to pay if they want to buy HDB flats. However, all agreed that there should be no hand-outs. We are also reminded that while we want to champion the plight of the poor, we must not go overboard in trying to over-provide for them.”
“Yes, I forgot that for the first time women MPs are also in this House. My apologies to my woman colleagues. Many issues, Mr Speaker, Sir, were raised by Government Backbenchers and by the two Opposition Members. Some of the issues raised by the Opposition and Government Backbenchers sparked off strong rebuttals by the Prime Minister and by the Ministers. Not only did the Opposition Members receive a walloping but my Backbench colleagues were not spared. We were shown the cut and thrust of debate by two giants in our political arena - the Prime Minister and the Senior Minister - and they and the Ministers had to rebut false allegations and insinuations and clarified points made by Opposition Members and even some Backbenchers. However, some home-viewers think that we have been too hard on the Opposition Members. But, as expressed by the Minister for Home Affairs in yesterday's sitting, and it is worth repeating, that to let untruths go unchallenged without rebuttal, without explanation, is tantamount to agreeing to what has been said. Some hon. Members: Hear, hear!”
“Mr Speaker, Sir, after listening to our First Deputy Prime Minister and the other Ministers in yesterday's debate, I find my role somewhat redundant. However, I cannot forgo this honour to speak. In summing up the five days' debate, I asked myself whether I have managed to stir up the imagination of my parliamentary colleagues to speak up frankly and honestly. Judging from the sentiments expressed in this House, I am inclined to believe that I have succeeded to a large extent, though a few have not been truthful and honest. If I have led the Minister of State for Health up the garden path, I can assure him that this was furthest from my mind. I hope Members in this House will not be dampened by the Senior Minister's performance two days ago. This is part of politics. We get wounded in this House, but the Frontbench must not be defensive nor should we Backbenchers be irresponsible. Many of the old MPs must agree that this has been a very interesting debate. And this debate is historical because for the first time Singaporeans are watching our performance in this House, and also for the first time we have two Opposition Members elected at a general election in this House after 16 years. Thirdly, for the first time, Parliament meets in the morning. Many issues were raised. An hon. Member: And woman MPs.”
“Mr Speaker, Sir, I am greatly honoured to be given this rare opportunity to move this Motion of Thanks to the President. Mr Speaker, Sir, I beg to move, That the following Address in reply to the Speech of the President be agreed to:- 'We, the Parliament of the Republic of Singapore, express our thanks to the President for the Speech which he delivered on behalf of the Government at the Opening of the First Session of this Parliament.".”
“Their views represent the angry feelings and sentiments of most Singaporeans. The Committee cannot ignore this. It will be wrong of me not to add to their protest. I will be very brief. Mr Speaker, Sir, it would appear logical, with the raising of the retirement age to 60 or 65, to expect the CPF to be withdrawn at 60 or 65 years. But is this right? What is logical may not necessarily be right. If you have given a man to believe that he will be receiving a sum of money after his life-time of work and then withhold it for whatever good reasons, you are courting trouble. You have created a crisis in him in that his hopes, his aspirations, his expectations are shattered. Is this Government acting like an over-anxious parent trying to anticipate his son's every need, and being overly protective? Will Singaporeans lose their fore-father's adventurous and entrepreneurial spirit that has made Singapore what she is today? If at the age of 55, we still have to take such protective care of him, we cannot have been very good parents. Mr Speaker, Sir, I propose that the CPF be withdrawn at the age of 55 years. Whatever CPF money accumulated from working after 55 years be withdrawn at whatever retirement age proposed, i.e. 60 or 65 years. Sir, on the whole, the Committee has produced a fairly good Report. I hope they will consider changing the stand on CPF and thus give the impending old with one less anxiety. 4.03 pm”
“It will link your social and recreational services to the home and, above all, it will link the working family to the elderly at home. It is a practical approach to this issue. If the Minister for Health is prepared to support me, I am prepared to organize such a team in my constituency. In fact, Mr Speaker, Sir, I have already laid the groundwork. Mr Speaker, Sir, one of the most important organizations that has and will con- tinue to play a pivotal role in the caring of the old is the Home Nursing Foundation. It is vital that top priority be given to develop and expand this. I, therefore, regret that the Report on the Role of the Home Nursing Foundation was cursory. The Home Nursing Foundation must be provided with funds to expand and upgrade its services. They could be involved in the training of nurses to man the Domiciliary Nursing Services, Day Care Centres and even Respite Homes. The Ministry of Health must train nurses to be community nurses and not pinch nurses from the hospitals to do the job. If need be, and we are terribly short of girls going into this field. We must seriously look into the possibility of drafting girls into National Service to provide the necessary manpower for the care of not only the old and chronic sick but also as nursing aids in our Civil Defence organisations. Such girls could be trained to go to the homes for the chronic ill or old people to give nursing care and perform minor medical duties. I would, therefore, like to ask the Committee to discourage the employment of foreign nurses to look after our old. It is just not right. I am sure our girls will not let us down, if called upon. Mr Speaker, Sir, for the past two days, my fellow MPs have argued about the withdrawal of the CPF.”
“Therefore, it is easier said than done that we must keep the old at home. But at what price? We want our women-folk to work. We want them to have babies. We want them to look after the family. I honestly feel sorry for them. It is not uncommon, Mr Speaker, Sir, in my many years of practice, to find many middleaged couples in a very stressful position of coping, on the one hand, with increasing demands of an elderly relative and, on the other hand, with the problems of a difficult and at times a rebellious teenager. Mr Speaker, Sir, this reminds us that the management of the old must not be treated as an isolated issue. It is tied up with the problems of our small family pattern. It is tied up with the problems of the working family, and it is tied up with the physical constraints of our HDB flats. Mr Speaker, Sir, how then does the community respond to this situation? How do we build this bridge, this link to give the family the support they need? Mr Speaker, Sir, this link between home and the community at large is the Commu- nity Health Team concept I proposed in Parliament during the debate on Medisave. The Second Minister for Health called me an idealist when I made the proposal. I hope the First Minister for Health will not, In fact, I am pleased that in his Report, a proposal to set up health and recreational committees at key community centres strikes a similar note. Perhaps this will one day evolve into the Community Health Team. Mr Speaker, Sir, it is my firm belief and conviction that the crucial issue in the delivery of care for the old and chronic sick lies in the provision of good support for the home via the establishment of this team. It will be a link between the hospital and the home. It will link the Outpatient Department to the home.”
“This loneliness is further aggravated by members of the family going to work or school. This vicious cycle must be broken, or whatever support services we provide will end up under-utilized and later abandoned. To break this cycle, we must persuade the HDB to develop a barrier-free environment in the new towns and to make the necessary adjustments in the old towns. I am serious about this, Mr Speaker, Sir. The Ministry of National Development must not only build flats and shopping complexes but must relate these with our ageing population and its accompanying social implications. The estate must be planned to be as barrier-free as possible so that the old feel free to move about. There must be suitable areas left for old age activities, either incorporated in the blocks or elsewhere. There should be at least two lifts, one for the active, and one service lift for transporting goods and to accommodate the old, the disabled, especially those who are wheel-chair bound. We must remember that by the turn of the century, there will be many more than 70 years old and this is the age where disability sets in. Next, we must not allow the various support services, that is, the Domiciliary Nursing Care, the Day Care Centres, the Respite Homes and the Meals on Wheels Services to develop in isolation. They must be coordinated by a single body. This is important because in our enthusiasm to provide, we may be over-providing in one area and under-providing in other areas. Thirdly, we must evolve a link between the home and the community. Let me go into some detail. Our small family is faced with a dilemma. To leave the old unattended is to be accused of not being filial. Not to leave the home and work means less money to pay for the home needs.”
“Moreover, legislation to ensure minimUm standards of care and stringent rules of admission must be laid down so that the Government's efforts to encourage aged parents to live within their family and the community will continue to be the cornerstone of caring for the old. Let me now turn to the social and recreational support services. Going through the proposal on page 34 and page 35 of the Report, I must admit that these are important support services but, Mr Speaker, Sir, at the end of the day the old must want to come down to make use and enjoy the services provided. The question is, can he, and will he? Let me explain this in the light of the environment he lives in - the HDB environment, where more than 80% of our population lives. Is the HDB environment, once comfortable and pleasant, slowly becoming hostile to him as he ages? The HDB flats and environment are designed for the active and the healthy, The loss of resources, which ageing by itself or in combination with ill-health, imposes on the individual, will mean that sooner or later he or she will encounter difficulties in the environment he lives in. For example, he will have difficulty in climbing the stairs as our HDB lifts do not stop at each floor. He will have difficulty getting into lifts which are too small and at times close too fast, especially if he is disabled and need a walking stick for support or, worse still, if he is wheel-chair bound. Then again he will find many obstacles and many barriers in his way when he tries to shop at our markets or shops. All these, together with the Asian attitude that when you are old and disabled, you must stay at home, makes him reluctant to go out and he becomes house-bound. When he becomes house-bound, he develops a sense of helplessness and loneliness.”
“With the high cost of home rehabilitation equipment, this incentive would be of help to make it easier for the old. Mr Speaker, Sir, I would like to refer to the Committee's Report in Chapters 4 and 5. It covers a series of support services, including health and recreational needs, social services and institutional care. With regard to institutional care, the Paper proposes two types of Homes for the Aged, namely, Homes for the Aged Sick and Homes for the Destitutes. The Report wants the Ministry of Social Affairs to run the Homes for the Destitutes and commercial and voluntary organizations to run Homes for the Aged Sick. I would like the Committee to re-examine this section on the dependence on commercial and voluntary organizations to run Homes for the Aged Sick. Mr Speaker, Sir, we expect the family to look after the aged healthy. We must not also expect them to look after the aged sick because of reasons beyond their control. I have watched from many years of practice how children slowly lose their cool, their patience, their love for the old, especially the chronic sick, who just lingers on and on. The Hokkien saying, "Wu hao pi ga bu hao" is an appropriate description of this situation. When I asked the children why are they not sending their old sick to the Homes for Aged Sick, their answer is that either there are no places or they are too expensive. I think, Mr Speaker, Sir, it is obligatory for the Government to run Homes for the Aged Sick for at least three reasons: (1) to provide for those who cannot afford the commercial rates; (2) to relieve the burdened families; and (3) to set standards for such homes.”
“Mr Speaker, Sir, let me start by reminding some Members of this House, and especially the Member for Anson, that they have been citing the wrong reason for legislation to look after the old. The Report has stated very clearly and in no uncertain terms that legislation is to ensure financial support for the old and not for filial piety. I refer, Mr Speaker, Sir, to page 43, paragraph 6.4, where the heading of the paragraph states: Legislation for the Support of Aged Parents. It goes on, later in the page, to say, and I quote: 'It should be emphasized that the objective of the legislation is not to legislate filial piety, but to codify an obligation which all sections of the community already recognise and which the vest majority of adult children gladly discharge. it is not meant to be an instrument for use against any but the most blatantly unfilial children. Neither is it meant to be a means for invading the privacy of normal family relationships.' I agree, Mr Speaker, Sir, that we cannot legislate for love, care and filial piety. Filial piety must come from the heart - taught, trained and nurtured at home and in schools. Legislation for financial support for the parents should, therefore, be seriously considered. However, there must be provision in the legislation to exempt those who are neglected by their parents when the children were young and in need of parental care. Moreover, such legislation should only be enforced in the extreme circumstances, as some who cannot support their parents are in no position to support their own family. Perhaps, as an incentive to encourage parental care, the law should allow certain of the children's expenditure for supporting their elderly sick tax deductible items.”
“I am just trying to ask the First Deputy Prime Minister that he must realize that a child takes six years to grow up, so that having first introduced that policy six years ago, he will only see the fruit of that policy this year.”
“Mr Speaker, Sir, the First Deputy Prime Minister is just trying to avoid the issue. With regard to sterilization, the First Deputy Prime Minister must realize that a child takes six years -”
“Is the First Deputy Prime Minister aware that his policy of priority of admission to schools for children of graduate mothers is discriminatory? It discriminates against children of non-graduates. It discriminates against children of graduate fathers and non-graduate mothers. It discriminates against children of mothers who complied with our sterilization policy by ligating after having two children. And in view of this unfairness to most but 200 Singaporeans, would the First Deputy Prime Minister like to review this policy?”
“Mr Speaker, Sir, I am sure the First Deputy Prime Minister must agree that this policy is discriminatory. It discriminates against children.”
“It is relevant. It is related to the Minister's report. Of course, he did not give a very good and satisfactory report. So I am trying to dig it out from him.”
“No. That is on the particular aspect of the Normal course.”
“All these supplementaries are related to the second Question.”
“I will not be around. That is why I am asking all the questions today. Well, I can take it up at the next Budget. Is the Minister also aware that principals are unhappy because the salary of a principal is the same in many instances as a senior staff? And is he aware that some teachers do not want to become principals or vice-principals because of this salary structure?”
“The Minister mentioned about Normal course. Is he aware that his Ministry is trying to think for those parents whose children are in the Normal course, and whether it is wise to interfere too much with the aspirations of these people? And is he aware (i) that his perception of the expectations of the students and of the parents is not what the students and parents perceive, (ii) that their expectation is to do the GCE in five years, and (iii) that the Ministry just prepares them for the examination? And that is what is provided in the Report in 1979. Would the Minister like to comment on this?”
“Mr Speaker, Sir, supplementary questions. Obviously the Minister is very comfortable with his reply. But I am sure Members of his House are not comfortable with his reply. Is the Minister happy that his Ministry has brought remarkable changes to our Education system and has added more anxiety and uncertainty to many students, teachers and parents? Is he aware that his now education system has put labels on our society - Monolingual, Normal, Express, Special, and now Gifted? Is he aware of the consequences of labelling our population in future? Is he aware that Normal course students are unhappy that their chances of doing the GCE are very slim, and that the parents are even more worried when they learn of this fine-tuning of the streaming of the Normal course? Is he worried that the double-weightage given to Languages distorts streaming? Are there only slow-learners in the Normal stream? How many are there because of the double-weightage given to Languages? What has the Minister done to ensure that the child who does badly in Second Language but has good results in other subjects are not wrongly streamed? Is he aware that Monolingual classes are facing a disciplinary problem? Is he also aware that some schools are bogged down with too many pilot projects, that teachers are busy sorting out these pilot projects rather than sorting out the problems of students?”
“Mr Speaker, Sir, allow me to make a very small comment. I am in full agreement with the Minister on most of the clauses that he has mentioned except on clause 16. I would just like to caution him to weigh very carefully whether only a special category of doctors should be allowed to do this statutory medical examination. This examination, with proper guidance, is relatively simple and any MBBS doctor should be able to do it. Therefore, we must not allow only one group of doctors to do this examination or else we might create a cartel.”
“Lastly, Medisave will have many problems during its initial stages and I am glad that the Minister recommends that, I quote him, "there be periodic reviews in the implementation of the scheme and that adjustments be made when experience shows this to be desirable". In a nutshell, the Ministry must be flexible. Don't quarrel or haggle over whether a person has enough Medisave or not when he is in pain. Treat him first and ask him to pay later. If Medisave starts off on the wrong footing, then all this PR work will be wasted and the Ministry will be in trouble. Thank you, Mr Speaker, for your patience in listening to my fairly long discourse. 5.30 p.m.”
“Therefore they must be thoroughly screened. Our number one major cause of hospitalization is accidents, poisonings and violence. This is followed by diseases of the digestive system, diseases of the circulatory system (including the heart and blood diseases), diseases of the lungs and infective and parasitic diseases. These illnesses are to a large extent environmental and socio-economic in origin. It follows, therefore, that our water supply and sanitation must always be of a high standard, our hawkers must be clean. Singaporeans must be advised to live an easier and less stressful lifestyle: smoke less, eat properly and keep away from too much alcohol. Pumping more money from our Medisave to an expensive area of care like hospitals and sophisticated programmes must, therefore, be weighed carefully. On the other hand, community based projects like Community Health Team working with a better equipped and planned Outpatient dispensaries may be better in the long run. My fellow MPs, you must remember that this country is free of small pox, polio, cholera, diphtheria and malaria, because these diseases were eradicated by basic primary health care team of doctors, nurses and community leaders. Mr Speaker, Sir, I support the National Health Plan and Medisave with some modifications. I agree with the Second Minister for Health on the dangers of third party payment like insurances. I concur with the Minister the need for sharing health costs and that Medisave will to a certain extent provide for this. However, I fear that Medisave may not be enough for the chronic sick and some form of insurance coverage may be necessary. We could either allow a percentage of a person's Medisave for this insurance, similar to the home insurance scheme we have for our HDB flat owners.”
“The relationship between the patient and the doctor is sacrosanct and cannot be interfered with. The doctor is concerned that his patient receives the treatment appropriate to need, regardless of cost, and from his point of view it is not in his interest to become involved in the issues of resource allocation, financial stringency and priorities. Provided he receives what he needs to care for his patients, that is his only concern. Doctors, therefore, are the prime users of resources in the Health Services and, as such, must be involved in the management of these resources. The University of Singapore Medical School should, therefore, teach medical students the concepts of cost-effective practice. I am serious about this. Medical students are often asked by their professors, "Why didn't you order these tests?" rather than "Why did you?" I remember an incident in my houseman days when a fellow houseman ordered so many X-rays for a person who was involved in a road traffic accident. That person only suffered simple abrasions and cuts. When I asked him why, he said this was to make sure that our superior did not ask him why he did not do this or that. Of course, you could say that this particular doctor is inexperienced and was working under pressure. But the point I am making is that, unless the provider of the health system is involved, all our attempts to cut down costs will be negated by their non-involvement. Mr Speaker, Sir, we must realize that Singapore is an international city. Ships call at our harbour, planes land on our international airport, cars come in from the causeway. We are vulnerable. Diseases from these countries can easily be spread to us. Constant vigilance in these areas must continue to be top priority. We import workers from other countries.”
“Many top politicians in the United States have a bypass done for their ailing heart. It is a costly medical technology put into widespread use before its efficacy was established. This operation was first introduced in the late 1960s. By 1977, its annual volume exceeded 70,000 at a cost of roughly US$l billion. The Veterans' Administration started a randomized clinical trial in the early 1970s with more than 1,000 patients, roughly half of whom were treated medically, the other half with this operation. The results were published in 1977 by Murphy et al. Surgical treatment was found to prolong life for the 11% of patients having diseased left main coronary arteries. In the rest, there was no statistically significant difference in survival between the two treatment groups at follow-ups, 21 and 36 months after entry into the trial. There has been considerable debate over the significance of these results. Some have argued that surgical technique has improved considerably since the trial was conducted, and that there are important quality-of-life benefits not measured by survival rates. Be that as it may, the point remains that a great deal of spending took place in the absence of any scientific evidence that this use of resources produced better health. Nevertheless, we may proceed with the hypothesis that it is possible to reduce the utilization of some hospital services with- out harm to the health of the population served. Doctors, the providers of our health care, have therefore a crucial role to play. They can create demand, as I said, by unnecessary admissions to hospitals, unnecessary procedures, both medical and surgical. This is due in part to the training he receives as a student. He has been taught to cherish clinical freedom.”
“"Inducing providers to curtail the rendering of those services which yield very low or no marginal health value may be a far more effective and acceptable way to limit spending than attempts to reduce the price or unit cost of services, or to make consumers pay a larger fraction of the price". Let me give you evidence of what I mean by low marginal health benefits. Hutter and his colleagues at the Massachusetts General Hospital, in 1973, reported a study of early hospital discharge from myocardial infarction, that is, heart attack. Uncomplicated patients were randomly assigned to either a 2 or 3-week hospital stay. During the 6-month follow-up period, there was no difference between the 2-week or 3-week patients in frequency of return to work, anxiety or depression, heart condition or survival. A more recent study tried sending half the uncomplicated patients home on the 7th day, with similar results. Later two British groups, Mather et al in 1976, and Hill, Hampton and Mitchell, in 1978, did randomized studies by comparing home and hospital care for acute heart attacks and found no discernible benefit from hospital as compared to home care for most patients. This and many other studies have shown that there is a substantial body of evidence that suggests that, at least in many cases, higher utilization rates yield zero, or possibly negative health benefits. In other cases, higher utilization rates yield marginal benefits that are too small or too elusive to be measured. In still other cases, it appears that utilization of costly services has been expanded in the absence of evidence of efficacy. Allow me to explain. You must have heard of coronary artery bypass graft surgery now in vogue.”
“It is a sheer waste of medical talent and expertise to find top surgeons doing bread and butter surgery when they were once doing renal transplants and complicated surgery. Similarly, it is disappointing to find top Obstetrics and Gynaecology consultants doing abortions mainly, when once they were teachers of our medical school imparting their skills to medical students. Our National Health Plan must examine how we can maximize this potential source of valuable manpower by inducing them back to teach and train our medical students on a part-time basis. I know that there are at present some private consul- tants in the hospitals but I ask them: How do they fit into the hospitals? Many feel that their expertise is not fully utilized. Why is this so? Hospital Doctors and Medisave I would now like to draw your attention to how hospital doctors' behaviour can affect Medisave. While doctors' services account for less than one-fifth of the grand total health expenditure in many United States Hospitals (I do not have the Singapore Figures), doctors control or exert very strong influence over most of the rest of the health care spending, especially hospital spending. Physicians recommend hospitalization and admit patients. They recommend and perform surgery. They order and perform other diagnostic and therapeutic procedures. They prescribe drugs and they decide when to discharge patients. Blumberg, in 1979, has estimated that physicians control 70% of total health spending. Thus, physicians' propensities to prescribe costly services are of particular interest from the point of view of total health care spending and medisave. I quote from page 173, paragraph 2 of THE HEALTH, ECONOMICS AND HEALTH ECONOMICS.”
“They have set aside approximately one-half of the 6.2% of GNP spent on health care in the country on primary health care and health education. They have the lowest infant mortality rate in the world. I refer you to Appendix III (Cols. 117 - 118). Appendix III - Expenditure on hospitals and primary health care, Number of new posts in primary care (P) and hospital services (H) between 1975 and 1979 (Cols. 117 - 118) Private Practice & NHP Then there is much talk about involving the private sector in our future medical care. This is well and good, but I wonder if the Ministry has examined whether the private sector can discharge such a role effectively. At present the care provided by General Practitioners is basic. It is effective but not efficient. Unless the Government is prepared to open its facilities at the Outpatient Clinics to these doctors, their contribution will not change much from the present in the Year 2000. Moreover, HDB encourages individual practitioner, by its present method of tendering, and solo practitioner will not be able to contribute much because of the very nature of his work. The Ministry of Health in the 20-Year Plan has realized this and will be working with HDB to solve this. May I suggest that HDB build clinic complexes to encourage group practice? If it is the Government's intention to encourage private practice, then in line with this trend, the University of Singapore Medical School must include a Department of Community Medicine to train medical students to be community doctors. Only then can GPs in private practice be able to participate in your programme. There are a lot of expertise in the private sector.”
“We have this basic infrastructure of Outpatient dispensaries spanning across our country covering practically every corner of the island. Let us build on it to provide a higher standard of care with doctors, nurses, physiotherapists, X-ray services and proper laboratory services. I know the Ministry is doing up some Outpatient dispensaries into poly-clinics and even building new ones but you must be bold enough to provide more facilities in these to include, amongst others, physiotherapy, psychiatric, geriatric and day-surgery with operating theatre to do simple surgery like the lumps, bumps, cysts, cuts, fractures and even ligation and abortions (with apologies to the Member for Whampoa). Even beds for the elderly could be provided who might otherwise have been forced into hospitals. We could invite doctors to join your set-up by renting out spaces to them. We must look into the better use of our outpatient clinics rather than building community hospitals. Hospital care as the Minister has pointed out, costs more than primary health care. This cost will be ultimately passed on to the taxpayer. Our Second Minister for Health who is also the Minister of Defence and the present Minister who was the former Minister of Defence must be aware that the front-line soldiers play an important role in our defense system. I am asking them to apply this strategy to our health system. Beef up our primary health care and the Community will be better off in the long run. In Finland, for example, the Finns realised that hospital-centred care was simply incapable of meeting the challenge posed by the high-adult mortality and chronic morbidity and that more money had to be spent in the community where some of the aggravating circumstances of the illnesses were created.”
“Community Hospitals I am not quite sure that we should set up community hospitals of the kind the Ministry wants. Firstly, setting up hospitals, community or otherwise, is an expensive affair. Then the running and maintenance of these hospitals is going to be a problem. The Ministry hopes that GPs will run these hospitals. I do not see how the busy general practitioner, working from 8.00 a.m. to 9.00 p.m., can run these hospitals. This is an important practical point. The specialist doctors are mainly concentrated in the city area where private hospitals are nearby. I therefore do not think they will want to use these hospitals with such limited facilities. Moreover, patients' preference for well-equipped, better hospitals must be taken into consideration. Patients prefer to go to the Singapore General Hospital instead of Alexandra Hospital or Toa Payoh Hospital or Tan Tock Seng Hospital. What more with Community hospitals which cannot match up to these hospitals in terms of equipment or reputation? Moreover, our size, the smallness of our republic makes travelling to our hospitals not a big problem, unlike countries like Britain where community hospitals are needed to serve communities in far-away areas. Lastly, our National Health Plan has provision to build hospitals in Bedok, Woodlands and Zhong Bang, when the need arises. I therefore question the need for building community hospitals. Upgrade our Outpatient Services If it is the intention of the Ministry to build community hospitals to take care of the simple surgical cases and less serious medical ailments, I would suggest that we reorganize the present Outpatient clinics to meet such needs.”
“If I were a lonely old man with little home support, living in a 3-room HDB flat, I will be most happy to know that the community geriatric services will be knocking at my door to see to my basic needs. I would just refer Members to Appendix I (Cols. 115 - 116). The details are all there, so I will not talk more on that. Appendix I - Community Geriatric Services (Cols. 115 - 116) I know the next question that the Minister will be asking is "At what cost?" Of course, the initial sum to set up such an organization will be high because you have to train doctors to be community doctors, nurses to be community nurses. Here again, I refer Members to Appendix II (Cols. 115 - 116) on community nurses. Of course, you need the supporting staff and a place to operate. In the long run, (we are talking about a 20-year Plan) this well-organized Team working in close association with our improved outpatient dispensaries, general practitioners, volunteer organizations, religious bodies, and community leaders will set a high standard of care for our chronic sick, the aged, the aged infirm, disabled people and the recent hospital-discharged patients. We would have shifted from an expensive area of health care, i.e. hospital care, to a non-expensive area with no loss in quality of care. But most important of all, it will provide the link between the hospital, the outpatient clinic, the voluntary organizations, the general practitioner and the patient. Appendix II - Community Nurses (Cols. 115 - 116) I believe that the future of our health care in the community will depend largely on this total concept of community nursing. This is because of our aging population and its related problems.”
“Today if you are ill and you have to see a doctor at our outpatient clinics, you will have to wait for a few hours to be seen by a harassed doctor. Investigations are minimal and patients have to go to a few designated centres or even hospitals for further investigations. This is not quality. If you are discharged from hospital after a stroke and sent home, what home support have you if your children are working, and what community support have we? None, except our Home Nursing Foundation. This is again not quality care. Community Health Team - An Essential Link If you want to discharge patients to their home environment for further care, you must have a team at the other end to take over. I see no provision in the National Health Plan except that the Ministry of Health will play a catalytic role. This is vague. I think the Ministry of Health must not merely be a catalyst but must be directly involved in starting a "chemical" reaction. Direct involvement of the Ministry is vital in the provision of better health care. To this end, I would like to suggest the formation of the Community Health Team. This Team would be part of our Outpatient dispensary set-up, or by itself. It can consist of doctors, nurses, social workers, health educators and volunteers from the community. This Team will be responsible for providing support to the discharged patient, the chronic sick, the aged, and the aged infirm. If I were half-paralysed, I would be happy to know that the community has a unit for the continuation of home treatment waiting to look after me when I am discharged from hospital.”
“Is it because of increased demand, or is it because of abuse of our system, or is it because our system is inefficient, or is it because of increased services, building new hospitals, new technology like ultrasound, brain scan or expensive programmes like test-tube babies? We must address ourselves these questions because all these and many more will increase cost which the consumers will ultimately have to pay either through higher taxation or higher Medisave payment. It is in this context that I want this House to know, before approving the Medisave Scheme, so that the Ministry of Health will always be on their toes to check areas of medical programmes and care that cost a lot more but has little benefit to society, and also, whether Medisave money, if spent on other programmes would be more profitable to society. I would therefore leave the detailed discussion on Medisave to my other colleagues while I examine the many areas in our Health Services which will directly or indirectly affect Medisave. Quality of Care Going through the first part of our National Health Plan, i.e. the Health Development strategies, I am impressed by the statistics showing how many hospital beds we need, how many nurses, doctors, dentists, pharmacists we require. by the year 2000. How many outpatient dispensaries will be closed down and how many new polyclinics and hospitals will be built. Little mention is made, however, on the quality of future medical care. Quality of medical care is not necessarily related to cost. It involves more than that. It involves careful planning and training of the appropriate personnel to look into the needs of the patient.”
“Thank you, Mr Speaker, for allowing me to speak first. Being the first speaker to open this debate on the National Health Plan (NHP), I thought I would have the advantage of being able to cover a lot of ground on this subject. But going through the 17 letters submitted to the Ministry of Health plus the numerous letters written in the press on this subject and this morning's centre page on Medisave in the Straits Times, I found no advantage, as nearly every aspect on the Health Plan that I would like to comment has been covered. While I would like to think that this is a deliberate attempt by the Ministry of Health to diffuse the issue by the time it reaches Parliament, I must admit that this has been a good PR exercise and I join my colleague from Alexandra in saying, "if we can do it with Medisave, why not with all major Government policies?" The Second Minister for Health has said that the heart of the National Health Plan is the Medisave. I beg to disagree. Over-emphasis on Medisave The Ministry of Health has asked this House to approve in principle the Medisave Scheme after having "Noted the National Health Plan". This is an assumption that this House has already accepted the first part of the National Health Plan i.e. the Health Development Strategies. There is an over-emphasis on Medisave, little realising that this part is equally important, if not, more so, because this is where the money from the Medisave will be spent. Too much attention has been paid to the funding of our health care system, and less attention has been paid to the Health Care Delivery Planning. I think before we expect the people to share in the funding, it is only right that we ask ourselves why is the cost of medical care going up?”
“Sir, I thank the Minister for a fairly good answer. I beg leave to withdraw this amendment. Amendment, by leave, withdrawn. The following amendment stood in the name of Dr Augustine H.H. Tan - (4) That the sum to be allocated for Head W be reduced by $10 in respect of Subhead WB-01 of the Development Estimates.”
“Sir, I beg to move, That the sum to be allocated for Head W be reduced by $10 in respect of Subhead WB-01 Project 8202 of the Development Estimates. Sir, I am moving this amendment to find out from the Minister whether there are any plans to beautify Pandan Reservoir. I hope Members have heard of Pandan Reservoir. The other reservoirs in Singapore enjoy the pampering of his Ministry with beautiful landscaping of the surroundings. Pandan Reservoir seems to have been overlooked. I wonder why. This reservoir is so little known that it nearly became a racing track, not for horses but for human beings and bets are placed to pick the winners. I am wondering what is the reason for not beautifying this reservoir, which can turn out to be a pleasant recreational ground for residents not only of Ayer Rajah but, I am sure, of West Coast, Clementi, Bukit Timah, Boon Lay and even Jurong.”
“I hope that the use of industrial water in all future HDB flats will be carefully considered, in particular, consideration of the proper choice of pipes and proper pumps. However, from the experience of my two estates, I would advise against it.”
“Yes, Toa Payoh too. Between the period late May 1982 and early March 1983, there were 19 disruptions of industrial water supply, an average of two times per month. Each time it breaks down, it takes quite some time to repair, sometimes a few days. While I agree with our national policy of conservation of water, I question the wisdom of those who support this view without taking into consideration the cost effectiveness of the whole exercise. Take Teban and Pandan, for example. You have two systems - industrial and potable. Both require maintenance, and therefore they cost more, more labour, and more breakdowns. Moreover, the water is smelly. If left for some time, it stains the toilet bowls and even allows mosquitoes to breed. What is more important and shocking is that many residents use potable water to lush down the industrial water. Therefore, where is the saving of water? On top of all this, the ceiling where this system passes through, usually leaks because industrial water is more corrosive. Since the Board took over, they have spent about $620,500 on repairing and maintaining these two systems. This too excludes labour costs, as the repairs and maintenance were carried out by the Board's own staff. The industrial system maintenance and repair alone cost approximately $80,000, excluding labour costs. It might seem odd that I am bringing this question of industrial water to the Minister for National Development when I should have referred this to the Minister for the Environment. But I want to bring up this matter with the Minister for National Development because I want to lobby for his support so that my case will be more effective and strong when I do meet the Minister for the Environment.”
“Sir, last year in this House the Housing and Development (Amendment) Bill was passed to allow the HDB to take over the JTC housing estates. I told this House that HDB was not going to receive a healthy baby. Now, one year since taking over, I am sure they have realized that I was being kind in my choice of words then. I know HDB tried hard. It is not an easy problem and I would like to express my thanks to the HDB Area Office for doing their best. But how best can they do when the infrastructure is bad. I am referring to the constant disruption of industrial water supply to the residents of Pandan and Teban. I hope the Minister will not give my residents a lecture on why industrial water is needed to conserve potable water because I have already done that for him on many occasions. The question I am asking is, at what cost? Sir, toilet-ceiling leaks in practically every flat in Teban is a common thing. Some residents have to use umbrellas to shield off the constant dripping from the ceiling. I saw it with my own eyes. The Minister for Labour and Communications has also seen it in his Walkabout. Of course, it could be argued that the blame is not due to industrial water but it seems odd that Teban and Pandan, which are under JTC, have this peculiar problem. The other areas of my constituency hardly complain of ceiling leaks in the toilet.”
“Sir, I would like to ask the Minister two simple questions, Since golf courses have been developed on these reclaimed lands, will it not be proper for public funds to be recouped from the membership fees to at least defray part of the high cost of reclaiming the land? HDB levies a fee on the sale of HDB flats. Just as there are transfer fees for flats, I wonder if a case can be made out to impose a similar levy on sale of transferable membership of these golf clubs, since the land is leased from the HDB?”