Yeo Cheow Tong
Singapore
“Mdm Ho Geok Choo asked the Minister for Health in light of the recent report on fungal corneal infections (a) whether those who contracted the contact lens related fungal corneal infections will suffer permanent damage to their eyes; and (b) how long will his Ministry take to conclude its investigations into the causes of these contact le…”
“My Ministry performs a regulatory role and what we do is that we try to ensure that we have a conducive regulatory environment for the growth of this industry in Singapore. Let me tell him what we are doing in some areas.”
“Sir, on her two questions, whether we are satisfied that the school buses are collecting fares during the school holidays, as I mentioned just now, the school bus service is a contractual service between the parents and the service provider. It is therefore up to them to work out the terms and to abide by the terms.”
“Sir, on the first question, whether there is any abuse by owners of buses while using the 50% rebate, the answer is no, because LTA monitors very closely.”
“Sir, I have to repeat my answer. We are not responsible for regulating school buses and therefore will not be involved. SCHOOL BUSES (Installation of seat belts) 5. Assoc. Prof.”
“Ong Soh Khim asked the Minister for Community Development, Youth and Sports (a) if his Ministry will increase the cap of $10,000 per disabled person over their lifetime for the Assistive Technology Fund scheme; and (b) if not, whether there will be a flexibility to adjust the funding cap for this scheme based on the applicant's need, as j…”
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“For those who are working outdoors, Mr Chiam was saying, "Well, because the particles are so fine, we need to wear a war time gas mask." I am glad to inform Mr Chiam that technology has actually gone a lot further than that, and that respirator masks are now available. They are very light but still effective enough to filter out most of the fine sub-micron particles. They are not very comfortable and this is why we have been advising the public that for those with chronic cardio-respiratory illnesses, it may be advisable for them to wear one, but they should only do so with the advice of their own doctors. For those who are working outdoors, if the PSI does get up above 200, it may be useful for them to also wear a respiratory mask if they have to work outdoors for a very long period. Sir, we will continue to publicise the different measures. As suggested by Mr Kenneth Chen, we will also continue to give talks to the schools as well as give talks over the mass media. I think I have answered all the points.”
“But studies are not available in the context of what we are facing or what we had last year, 12 days where PSI was between 100-150. 3.00 pm In fact, we have been in contact with the World Health Organisation and the WHO has informed us, not just Singapore but also Malaysia and the other countries, that they will be very keen to do a long-term health impact study from the haze. We have informed WHO that Singapore would be very keen to work with them. When the results are out, I will definitely keep the Members informed. Mr Kenneth Chen has said that Singaporeans are still at a loss as to what to do when the haze hits and whether we can have a larger publicity programme. This year, realising that the likelihood of a haze is very high, in fact my Ministry has already embarked on a public education programme. Members will probably have read in the papers a few weeks ago about the information that we have released on the use of air cleaners and filters. We cannot clean the entire atmosphere in Singapore. There is no way for us to go out and have a giant vacuum cleaner. But we can reduce the personal space to be protected to either the home or the office, because that is where many people spend much of their time. In the office, office owners can install filters in the air-conditioning systems because most of the offices in Singapore are air-conditioned. We have written to most of the building owners and we hope that they will be doing something. At home, those families whose homes are air-conditioned can install filters. For others, whose homes are not air-conditioned, they can purchase air cleaners, and the price of the air cleaners would vary from about $300 to $900 and above. So there is a broad range and there are products that will fit into each person's budget.”
“And today, the fires are still raging, and this is only a small part of Sarawak, which is again a small part of the whole of Kalimantan. From Singapore, we look at fires and we say that we should put out that fire. After all, whenever there is a fire, fire engines go there and within a few hours, the fire is put out. In the context of Kalimantan, if we put Singapore on the map of Kalimantan, it is just a dot in Kalimantan. The fires in Kalimantan are huge. Some of the fires there would probably engulf the whole of Toa Payoh, including Potong Pasir. That is how huge it is. To expect Indonesia to have the resources, I think it is expecting a little bit too much, which is why we have to bring it to the international level, bring in international expertise and know-how and, more important, put in place a long-term mechanism which will help the Indonesians to solve it on a continuing basis, rather than every year trying to fight the fires, and this is what we are trying to achieve. Dr Lily Neo has asked whether there are long-term studies on the impact of the haze. At the moment, we are using the PSI as a measurement of the haze level. PSI which stands for pollutants standard index, is a system that was devised by the US Environmental Protection Agency, and the system has been derived after many years of extensive study on the impact on health when people live in environments of a certain level of pollution. They have a system where if you measure and find that the level of pollution there is within the PSI of 50, this is a healthy environment. Between 50 and 100, it is moderate. Between 100 and 200, it is unhealthy. This study is based on long-term observations.”
“I can assure Mr Tay that when UNEP finally comes up with a package of needed assistance, Singapore will be amongst the countries to review the assistance required and we will do our part in helping to push the assistance programme and effort forward. Mr Chiam has spoken very strongly and I appreciate his concern which many of us share as well. It is just that we are a little bit more circumspect but, nonetheless, we too are very concerned about the impact of the haze on not just the health of Singaporeans but also the overall regional economy. Sir, in trying to resolve the problem, I think one must also analyse and see what is the most effective approach. Will shouting be counter productive or will shouting help to resolve the problem? If it is counter productive, then I think we should not shout too loudly but use better persuasive tools. Let me give Members an example about Miri. Miri is in Malaysia, if Mr Chiam does not know. It is in the west of Kalimantan, northern part of Sarawak. Miri recently was totally blanketed by smoke haze from fires within Sarawak itself, so much so that the airport had to be closed and the PSI level was 300-400. You cannot even see beyond 50 metres. And this is Malaysia. This is not Indonesia. At first, the Malaysians had to despatch 500 people from peninsular Malaysia to Miri to help fight the fire, supplement whatever resources Sarawak had for fighting the fires. And when that was not enough, they had to further send another batch of 500, and I think there are a total of 1,000 fire fighters now, from peninsular Malaysia supplementing the resources that Sarawak has. So even for Malaysia with all the resources, when the fires broke out in Miri, they had so much trouble trying to control it.”
“Sir, I believe that, as the environmental awareness increases, Singaporeans will become more discerning consumers of products and that we should not be using incentives to influence Singaporeans on what to buy, because it is not just in terms of electric vehicles or solar heaters, but there are so many products available, whose manufacturers claim that their products are more environmentally friendly and are more energy efficient. And for Government to get involved in vetting them and then giving incentives for each of them, I think would really distort the market. It is better that these products are sold based on the values they give to the people, and let us not intervene too much by giving incentives. But we should continue educating our people so that they are more discerning in terms of what they buy. And, hopefully, over time, they will be buying things which are also more environmentally friendly. Mr Simon Tay has asked that I reassure the House about Government's policy in terms of joining in the regional and international efforts on the haze problem. Sir, Singapore was very forthcoming on a bilateral basis, because we realise that the haze problem is one which cannot be tackled by Indonesia alone. The problem is much too big for the country and especially in today's context of the economic turmoil, their ability to tackle the haze at source is a lot more diminished, which is why at the last Ministerial meeting in February, the Indonesians were very willing to straightaway join us in issuing a call for international assistance. And I am glad also that UNEP was there at the meeting and UNEP has assured us that the UN itself would be very interested in getting involved in resolving this problem.”
“Sir, first, let me thank all the Members who have spoken up and have made very useful suggestions. I shall reply in the order of the Members who have spoken. First, I am glad that Mr Heng Chiang Meng is happy with the fact that the Finance Ministry has now also extended tax incentives for companies which have introduced more energy efficient equipment. But I would like to point out to him that the state of the environment in Singapore has been of high international standards, even though much of the actions have been taken without tax incentives. I think this points to the fact that, firstly, our regulations have been very well structured and, secondly, that we have been able to impress on companies the need to be good corporate citizens and to take the necessary steps to reduce pollution voluntarily. In fact, I am happy to say that most companies have introduced measures which reduce their pollution levels far below what is stipulated. It shows that the awareness is there. Therefore, while incentives are useful, incentives are not everything. If we have to depend on incentives for each and every action, I think our companies would not really be reacting at all on their own. Sir, I also agree with him that individuals can play a useful part in enhancing environmental compliance, and this is what we are doing. We are educating the public through various mechanisms at the school level, through grassroots organisations and by working with the NGOs.”
“Of course, we have patients who should be discharged but whose families refuse to bring them home. These are things that we have to grapple with and we will have to be more stringent in terms of discharging those who are well enough to be discharged regardless of whether the family is ready to take them or not. Otherwise, patients will suffer by having to wait even longer in the A&E departments. We are now reviewing the occupancy levels in the restructured hospitals and, if need be, after ensuring that the patients are being discharged properly, after helping them to be admitted into nursing homes and all that. If the demand is still there, if the occupancy is still that high, I think we have no choice but to make available more B2 and Class C beds. The situation in nursing homes and community hospitals should improve because in the next three years, we will be increasing the nursing home beds by over 2,000, ie, an increase of 45% and we will be increasing the community hospital beds by 74. I think in the next two years or so, we should be seeing a significant improvement in the occupancy rates as well. 6.15 pm”
“For such cases, quite often, the A&E doctors would even ask the ward doctors to come down to help in providing that preliminary treatment before they are transferred to the wards. 70-80% of those requiring admissions from the A&E department do have to wait, but most have only to wait a short while. This is because, since the subsidised wards are all very heavily occupied, the bed management can be a bit of a problem, ie, they have to maybe move patients around, or sometimes ensure that patients who are being earmarked for discharge that day are actually being discharged, even though the family members may be hesitant to take them home. I am sure Dr Lim is familiar with this problem since he has worked in the public hospitals before. In any case, we are looking into that. In terms of the facilities, he brought up the problem of high occupancy rate in the B2 and C wards and asked what are we doing about that. Sir, the occupancy rates of the B2 and Class C wards have been going up steadily over the years. For example, for Class C, in 1992, the occupancy rate was only 75%. But last year, the occupancy rate has crept up to 93%, and 93% means that it is full house. Class B2 is still manageable. It is very high but still manageable, at about 87%. The demand for Class B2 has increased because, as I have stated just now, we are doing financial counselling. So more patients are now opting for B2 and C than they would have otherwise. Secondly, we are also having significant numbers of long-stay elderly patients. They should actually be transferred to a nursing home or to a community hospital, just like that step-down care capacity is not adequate at the present moment. So they are being lodged by their families in the hospitals.”
“The in-house training will also include orientation, in terms of use of the sort of equipment that are available in the department that they are being sent to. The hospitals also closely supervise and monitor their performance to ensure that nursing standards are being maintained The feedback is that, from time to time, some nurses cannot fit in, and the hospitals have had no choice but to come to some mutual agreement on how to terminate their service. This is also being done. He has asked about lost records. We do have lost medical records and I think it is inevitable with the large number of patients that our system is coping with. Fortunately, improvements have been made. The number of lost records in 1990, for example, amounted to 1.7% of all patient load. As at the end of last year, they have dropped to 0.0003% in SGH, ie, almost no lost records, to a high of 0.4% in Tan Tock Seng Hospital. So improvements have been made but I think more can be done in the other hospitals. What they are looking at now is a programme to computerise record keeping. This has already been looked into for X-rays and the ordering of medical tests. It has already been introduced in some of the hospitals and they will move on to the taking of clinical notes and patient diagnosis. Lastly, Dr Michael Lim has talked about the clinical outcome studies. I will let Dr Aline Wong answer that. He has talked about the A&E long waits. Sir, I agree with him that some patients have had to wait at least 4-5 hours before being transferred to the relevant wards during the peak hours. But I want to assure him that the hospitals have in place a rigorous triage system where patients with serious and emergency conditions are transferred, immediately after they have been stabilised, to the wards.”
“As regards the number of foreign nurses, we have a total of 1,800 foreign nurses in Singapore. Of these 1,800 nurses, 83% are working in the public sector. The vast majority are in the public sector and they comprise about 17% of the total public sector nurses. Therefore, considering that today we have an 8% shortage, if we did not have the foreign nurses, can Members imagine the hospitals running with a 25% shortfall of nurses. Some services may be even decimated because of that. There will be long queues for operations and for admissions. So foreign nurses have helped to relieve the shortage. Yes, we do face certain problems. Some of them do not speak proper English and therefore they have problems communicating with some sector of the population. It is a problem which, I think, the hospitals are familiar with. Because even in Singapore, being a multi-racial society, we also have nurses who can speak English but may not be able to speak another of the national languages, or dialects. Then what the hospitals try to do is to ensure that there is a good mix so that there is some mutual help that takes place in terms of helping to communicate with the patients. He was also concerned about the nurses not being exposed to the sort of high-tech equipment that we have. The hospitals are aware that the foreign nurses come from societies with different cultural backgrounds, different languages and perhaps even different clinical practice. Therefore, what the hospitals have done is to set up orientation and in-house training programmes for the new foreign nurses whenever they join the hospitals. And because the foreign nurses are recruited in batches, it is quite easy for the hospitals to conduct such training programmes.”
“Mr Choo Wee Khiang also spoke about Medifund. He was saying that he hoped that the citizens of Singapore had better not fall sick or they may die. Sir, the first part is correct. I think all Singaporeans should always say, "I better not fall sick." But it cannot be a prayer, because keeping yourself fit and healthy is something which requires an active effort on the part of each and every one of us. This is the message and the intent of our Healthy Lifestyle programme. This is to encourage Singaporeans to have a healthy lifestyle, to invest in their own health so that they do not fall sick. But if they do fall sick, first of all, we have a health care system which will continue to give them a high standard of care, even though our economic growth may have slowed down this year. The health budget, I am happy to inform him, has gone up, despite the tight budgetary constraints. Our health budget actually went up by 7.7%, in terms of our operating budget. With this increase, we would be more than able to retain the current subsidies of 80% subsidy for a Class C patient, 65% subsidy for B2, 50% for B2-plus, and 20% for Class B1. For the polyclinics, we will be able to retain the current subsidy target of 50%. I can assure Mr Choo that the support programmes are being maintained and will be in no way affected by the downturn. Mr David Lim has asked about the standard of nursing. He is concerned about the impact of foreign nurses, but he recognises that they are an important factor; in fact, they are indispensable in our current context. He has asked about the current numbers. What are the measures to ensure standards are maintained? Do we have an on-going system of monitoring standards? And, lastly, lost records. Let me answer them one by one.”
“There are people who remain very healthy right to the very end and then they die within a very short period of time. Studies have also shown that only 2% to 3% of the elderly will require institutional long-term care, such as nursing homes or community hospitals. Unfortunately, any institutional care is costly. Even for VWO homes that are able to offer subsidised charges, the average charges of between $600-$800 a month would mean a very heavy burden to many families. 6.00 pm Sir, the point is that even if we extend Medisave to long-term care, whatever Medisave funds they have will be quickly depleted. A person who now retires at the age of 55, if he has a lot of Medisave balances, he still needs to retain $15,000 in his Medisave account. If he goes into a nursing home and pays, say, $600 per month charges, that $15,000 would not last him very long. So that is not the solution. We have to think of a different approach and it is towards this end that I am also chairing an inter-Ministryerial committee on health care for the elderly. One of the things that we are looking at is how to come up with an alternative funding mechanism for the minority who require long-term institutional care. How do we, in the first place, help to avoid long-term institutional care? How do we keep the sick elderly at home where his medical outlays will be minimised? That is really our focus, keep them at home, support them with a lot of home-based services, so that we limit those who require expensive long-term institutional care to the minimum. If we are able to do that, the scheme we come out with for financing will also be easier to resolve. The committee is looking at that now and I will announce the details when the study is completed in the coming months.”
“If they do not think they can afford that bill size, then they can seek to downgrade to either a B2 or C class ward. So the Medisave limit of $20,000 is adequate and the MediShield limit of $80,000, that is, the basic MediShield coverage, is more than adequate for a patient who uses B2 and C class services even with a catastrophic illness. It is more than adequate. But, again, of course, for those who tend to use higher class wards, the MediShield limit will not be adequate. In which case, I will encourage such patients to upgrade themselves to a higher level of coverage by either going for MediShield Plus which is available and should cover A and B1, or seek private sector coverage. You have the NTUC Income which provides a very comprehensive range of catastrophic insurance packages as well as other insurance companies. So if you get the appropriate coverage, it would be enough. But if you use a lower coverage to cover a higher cost service like in the private hospitals, then of course it would not be adequate. Medicare. Sir, as I have explained, the higher level coverage is already available, and I would hesitate to set up another system under the Government when the private sector is already providing the higher coverage for those who prefer a higher level of service. Dr Neo is also very concerned about the elderly who require long-term care or those who require long-term care. I agree with her that this is a real problem for the future, especially with the increasing number of elderly and the larger proportion of the elderly amongst our population. Sir, whilst there are some elderly who do require long-term care, fortunately, the vast majority of elderly are well elderly and do not require long-term care even till their last few days.”
“Now that the CDCs are involved, we will work with the CDCs on how to further publicise the fact that Medifund is available and if they face any problems, they can either go to their own MP or grassroots organisations for support. Dr Lily Neo talked about Medisave and the ability of patients to afford the healthcare charges even with Medifund, MediShield and Medisave. Sir, I will take her two questions together. First, whether Medisave is adequate and, second, whether we can extend Medisave to nursing homes and other long-term care services. Sir, Medisave has been a very well thought- out scheme, not just in terms of helping Singaporeans to have a savings fund, but also the contribution rate and the maximum limit for Medisave account. Studies have shown that the average adult aged 21 will require approximately 55 days of hospitalisation from the age of 21 to the end of his life. Of course, that is an average. You are going to get the outliers. In any case, based on the 95th percentile of B2 hospital bills, we have computed that the life-time expenditure in today's dollars would amount to only $27,000 if he uses B2 class facilities. If he uses A, B1 or private sector services, I think the figure would be much, much greater. So the key to affordability is that patients should use the type of service that they can best afford. If they are in the lower income group with low Medisave contributions, please use B2 or C class ward. It is for that reason that we have implemented a very rigorous financial counselling programme at the hospitals so that patients who are going for A or B1 class ward are told of what to expect in terms of the bill size and are asked to rethink again.”
“Secondly, the patient must be either a B2 or class C inpatient, or if an outpatient, similarly, he must be a subsidised patient or someone who is using the polyclinic services. Thirdly, he has to show that he cannot afford to pay for the hospital bills that have been levied on him. Very simple criteria. If he meets those criteria, he is then referred to the Hospital Medifund Committee for assessment. The last point is the one which I think may sometimes pose a problem. Can they afford to pay the hospital bills? What the medical social workers would do then is to review the Medisave balances. If there is enough Medisave balance, the point is that they should then use their Medisave balance first before appealing for Medifund. In any case, the Hospital Medifund Committees are made up of grassroots leaders and being grassroots leaders, and having very close connection to the people on the ground, the members tend to err on the side of generosity which is why we have such a high success rate. Now that the CDCs are also involved, I think the outreach would be even better. How can we help to publicise the avenues of appeal? Sir, as pointed out by Mr Goh Choon Kang, one common avenue of appeal is really the MPs. And I have from time to time enquired of my MP colleagues as to whether their residents are facing any problems in getting Medifund help. I am quite happy to report that no MP, including Mr Low Thia Khiang, has told me that his residents have had problems getting Medifund support. Usually, if they face any problems, they will go to the MP and the MP will make an appeal. So far, the Committees have been very supportive of the MP's' appeal. In terms of publicising the avenues, we will continue to do that at the hospital level.”
“Sir, first, let me address the questions raised by Mr Goh Choon Kang. Mr Goh Choon Kang has expressed his happiness with the work and outreach of Medifund but he is concerned that there are no additional top-up grants to the endowment fund this year. He would like the Ministry to ensure that when the economy recovers in future years, there will be top-ups to the endowment fund. Sir, the decision not to top up the endowment fund this year was actually taken after very serious consideration. If the need had arisen for top-ups, I think we would have scrounged around and argued very strongly for top-up. The fact is that Medifund is actually quite well endowed now. We have $600 million and this gives us an annual income of about $21 million and, as pointed out, the outlay of Medifund a year comes to about $10 million. So that means we currently have enough revenue flows to more than meet the needs of the poor in Singapore. And even with the economic downturn, I think we have enough of a cushion there. But I would like to assure Mr Goh Choon Kang that once the economy improves, we will of course put in our bid for Medifund to be further topped up. Mr Sin Boon Ann asked two questions. First, whether the medical social workers actually do brisk screening of Medifund applicants and, if they did, would the success rate (he mentioned 99.4%) still be correct, or would the figure be actually lower? And secondly, he asked the Ministry to publicise more widely to the public what are the avenues of appeal for those people who have applied for Medifund support but have been turned down. Sir, let me answer the first point. Do medical social workers screen potential applicants? To qualify for Medifund, there are some simple criteria. Firstly, the patient must be a Singaporean.”
“Sir, let me respond to the two points. Dr Tan was speaking on behalf of Mr David Lim. I do not know whether I should reply to Dr Tan or Mr Lim. Let me assure Dr Tan that all emergency cases are stabilised in the receiving hospital before they are transferred to the hospital with the relevant expertise, whether it is paediatrics, a head injury or a heart condition. As I have mentioned to Mr David Lim, this will be done in due course. Give KK Hospital a chance to consolidate what it is doing. I am sure that the CEO and the doctors of KK Hospital will be very happy to spread their wings.”
“Has the large number of foreign nurses here jeopardised our service standards? I would like to assure Mr Choo Wee Khiang that the Singapore Nursing Board takes a very cautious approach. Before we embarked on a recruitment of foreign nurses, we consulted the professionals oin the Board and they came out with their conditions and standards. Not only that, they also went to the key countries of recruitment to get acquainted with the key teaching institutions so that they understand what are the methodologies, the curriculum and, more importantly, the actual practice of teaching what is claimed in that nice little booklet which all institutions give out. So we have gone through the quality audits. Not only that, when the nurses come to Singapore, we counsel them. The Singapore Nursing Board also conducts a test on their competency and, quite often, this takes the form of a written test. So there are a lot of stringent requirements in place already to ensure that our high standard of medical care is not in any way compromised.”
“Sir, Mr David Lim asked whether we could consider allowing NCH to have a department of paediatrics. As I mentioned just now, Singapore is an extremely compact country. On the PIE, from one end of Singapore to the other, it takes about 45 minutes. I think now with the road expansion works that are going on, once they are completed, the travel time may be even shorter. The concern here is that, as I have stated, how do we make sure that we do not end up dissipating our limited resources with a balance? When NCH was planned, it was very clearly pointed out to the hospital that the existing Toa Payoh Hospital departments will be transferred to the New Changi Hospital, and that the development of new departments there, especially departments of specialties, will have to be approved by the Ministry. This is because if, left to themselves, every hospital will want to have the whole complete range of specialties plus, if you have that piece of equipment, they will say, "I better have one too." That is the surest formula to a high cost type of healthcare system. We have learnt from the other countries how to avoid that and how to ensure that there is enough central control on development while giving each hospital maximum flexibility and autonomy to operate efficiently within their areas of purview. 5.15 pm Sir, in terms of paediatrics, it is an on-going request from NCH. Our reply to NCH is, "Let the consolidation of paediatrics in the new KK Hospital be completed first." If need be, once KK Hospital has settled down, I am sure KK Hospital will be very happy to provide a satellite operation in NCH. So in due course that will be done. As for nurses, because of the large number of foreign nurses here, as I have stated just now, 12% are foreign nurses.”
“Sir, as I explained last year, since the list was drawn up on certain assumptions that, on the average, we are enrolling about 50 Singapore students under that list of approved institutions, we should spend some time observing what is the actual outcome. Our preliminary findings are that, in the first two years alone, since the new schedule took effect, the approved medical schools have already been taking in about 50 students a year. Our expectation would be that in the coming years, the enrolment of Singapore students in those schools is likely to pick up. And, therefore, the enrolment will actually exceed what we have projected in our manpower planning. At the same time, we have already proceeded to increase the intake in NUS; the 180 this year which will be increased to 200 this year. And if the need arises, we will be quite happy to discuss with NUS on the possibility of increasing the intake further. But let us spend some time to watch the trend before deciding what to do again.”
“Sir, in response to Dr Lily Neo's question, whether our senior doctors are given adequate R&D time, unfortunately, since R&D has not been a major focus in previous years, we were unable to give protected time to many of those who were interested in research. Our plan now is to recognise that research is an important pillar of institutional practice and therefore we would ensure that funds are available to enable those who are really interested in research to have enough protected time to conduct research and enough funding to employ supporting staff to help him or her in the research project. Dr Tan Cheng Bock asked whether the 160 doctors recruited last year are from the recognised medical schools. The new schedule was effective end-1993. So anyone who enrolled in those medical schools before end-1993 will still qualify. Since this is 1998, and they were recruited in 1997, I assume that they had enrolled in the medical schools under the old schedule, before the new deadline took effect. [Mr Deputy Speaker in the Chair] 5.10 pm”
“That means 120 are Singaporeans. As regards whether we know how many of them were trained abroad because they could not get into NUS, unfortunately, I do not have the information.”
“But we are prepared to let the National Heart Centre (NHC) provide some supporting services in NCH and allow NCH also to develop some service up to a certain level of complexity, ie, check-ups, perhaps even some interventional work, but definitely not by-pass operation. So we have to balance, on one hand, the aspirations of the doctors and hospitals; and, on the other hand, we have to balance against the national interest, which is how to make sure that we do not unnecessarily duplicate both expertise and equipment which are very expensive. So it is a continuing balancing game that we have to play. Mr Choo Wee Khiang asked about the brain drain, whether we have a contractual agreement and are we seeing a lot of foreign doctors leaving. Is he talking of bond-breakers? As regards contractual agreements, I believe most of the doctors are recruited here and offered contracts over a certain number of years. So there are normally contractual agreements binding them. Should we worry about the brain drain? I think it is a toss up. If we are worried about the brain drain and we do not go out to recruit foreign doctors, then we end up with an ever bigger shortage here, which must impact on the quality of care and result in long waiting queues of patients. Our experience has been that most of the foreign-trained doctors do sink their roots here after a few years, because the practice of medicine is a very personal thing. After practising here for a few years, they develop close links with a certain group of patients and it does not make sense to give up that goodwill which they have built up over the years. So many of them do sink roots and settle down here. Mr Sin Boon Ann has asked about the 160 doctors that we recruited last year. Three-quarters of them are Singaporeans.”
“Sir, first, on the point brought up by Mr Bernard Chen that some of the hospitals are concerned that their traditional specialist areas may be jeopardised. There are two different types of acute hospitals. One is the tertiary hospitals which would be mainly SGH and NUH, where we have a significant number of specialties available in those hospitals plus super specialisation. And we also have the regional hospitals which reach out to the broad general public. The aim, as has been spelt out in the 1993 White Paper on Health Care, is that in view of our compact size and in view of our small manpower and patient pool, it is important for us to ensure that, on the one hand, we do not over provide; and, on the other hand, have such a dispersion of specialties that each of the departments now ends up with a sub-optimal patient load. Therefore, the regional hospitals, like New Changi Hospital, Tan Tock Seng Hospital and, Alexandra Hospital, will continue to have general departments of medicine and surgery, and they will also continue to have an ability to focus on one, two or three specialties. It does not mean that they are going to stagnate there, because the population profile would change over time and, together with that, the change in the medical condition and the demand for medical care. For example, heart. New Changi Hospital (NCH), at the moment, does not have a heart department, because in terms of the present supply of service, both SGH and NUH, together with the private sector hospitals, are adequate.”
“It would also enable us to come out with, what you call clinical pathways, ie, for certain complex conditions as well as other commonly encountered medical conditions, a guideline on how that condition should be best treated. In this way, the patients will get the best possible treatment and hopefully the most cost effective as well. Will the centres result in more costly treatment? Sir, the answer is no, because already at the present moment, the fees charged in these centres are exactly the same as those charged in the other restructured hospitals. But of course sometimes the perception could be that the patient goes in and the bill size is a lot bigger. But that is because patients going to the nationalmedical centres tend to be patients with more complicated conditions and therefore they are subjected to more tests and the result is a higher bill size. But the point is that if they had gone to an existing department, the same tests would probably have had to be conducted. So in terms of costs, the answer is no. If you are able to now consolidate the pool of expertise and come out with more cost effective treatment protocols, over the long term, we should be able to see a better control on our healthcare costs. Sir, I would now like to ask my Senior Minister of State to reply to the last part.”
“In the meantime, the paramedics would be able to stabilise the patient. And if the patient decides to go to, let us say, New Changi Hospital which should be the nearest, the hospital staff there would be able to stabilise him and get ready for a bypass operation, if need be, in the Singapore General Hospital or NUH. So the centres will coexist. But more importantly, the centres will allow us to optimise the use of our limited resources. Singapore, having a small population, also implies that the rarer and more complex cases would be fewer. Rather than having these rarer and complex cases split over several centres and each centre not having enough of the critical mass to develop the expertise, what we will do is we will now be able to coordinate and ensure that these more complex and rarer cases are centralised in one centre so that the chances of developing in-depth skills will be better improved. What we are also doing is that we are reaching out to the private sector practitioners as well as practitioners in other hospitals and encouraging them to come forward and be dual- appointed. This means they can have their appointments where they are but also receive another appointment at the national centre so that those who are interested and have some expertise in treating those more complex cases can also now come to the national centre and have the advantage of a bigger patient load. So it is a win-win situation for both the specialists involved as well as the patients who have such conditions. Also, it will help the profession greatly. Because by having the leading specialists being affiliated to the centre, we will also be able to upgrade the standing of the profession as well as better facilitate and coordinate the development programmes for that specialty.”
“We need to recruit progressively. And last year, in 1997, we had one of our biggest recruitment drives. We managed to recruit 800 nurses from abroad. They mostly come from the Philippines, India and, to a small extent, China. 4.45 pm Sir, over the longer term, we are also looking at the fundamentals. To achieve that, we are now carrying out a strategic review of the nursing profession. The objective is how to make the profession, as a whole, more attractive, more challenging, more satisfying. We have set up a task force in November 1997 to look into this and we expect the task force to complete its work by the end of May. Sir, let me now move on to the next cut by Mr Bernard Chen. He asked how do we reconcile the treatment in the national centres versus other hospitals and his concern as to whether the medical centres will in fact result in higher costs and therefore higher fees for patients. Sir, in order to discuss the first point on how we reconcile the treatment, let me first explain that the national centres are not meant to replace the existing departments in each of the hospitals, for example, the National Heart Centre. The National Heart Centre will coexist with the Heart Department in NUH and in fact will provide support to the other hospitals, in terms of providing expertise and working with them on their patients who have heart problems. For most cases, because Singapore is very compact, the existence of a national centre will not impact on the safety of the patient. Let us say a patient has a very serious heart attack and requires a bypass. Because Singapore is so small, even if a person is staying in the eastern part of Singapore, it will only take about 20 minutes to go by the highway.”
“Because at the end of the day, this is what distinguishes institutional practice from private sector practice - the teaching and the research. In terms of research, we are now making available more funding for research and we are asking the hospitals to set aside protected time to enable those doctors who are interested in doing research to actually conduct the research work. I believe that with all this, we would be able to better retain an adequate number of specialists to serve in the public institutions. Sir, nurses - the shortfall is still very significant, unfortunately. Last year, we managed to increase our nursing manpower by 400. But, unfortunately, the shortfall has increased from 6% to 8%. And this is because the opening of the Kandang Kerbau (KK) Women and Children's Hospital and the New Changi Hospital have resulted in an increased demand for nurses. We have opened more wards and therefore the two hospitals have had to recruit more nurses. The national shortfall in nurses is expected to be about 1,300 between now and the year 2000. What are we doing to resolve this problem which has been with us for a long time? Sir, first, we are intensifying efforts to promote nursing as a career of choice. As you all know, there are tremendous career opportunities available now to our young girls and boys, and nursing will have to make a strong bid for their attention and a strong bid for their decision. So we are doing career talks and exhibitions. And I think the results over the past two years, in terms of enrolment in the diploma course in the polytechnic, had been encouraging. We are also recruiting from abroad for the time being. It is very essential. Because it takes three years to train a nurse. Shortage is with us now. Service is being affected.”
“The public sector, as at the end of 1997, is still short of 70 specialists. The figure is an improvement over the year before. At the end of 1996, we had a shortage of 84 specialists. We were short of 84 specialists. So it is an improvement. And, again, the existing shortage is mainly in two areas - anesthesia and diagnostic radiology. As a short-term measure, we are asking the restructured hospitals to continue recruiting from abroad to make up for the shortfall. And we are also reaching out very actively to the private sector to encourage those who are practising in the private sector to devote some time in the public sector institutions, do some service, conduct some teaching, and if they are interested in research, we are also very happy to involve them in our research activities. In terms of retention, it is not possible for the public sector to pay the same amount as what private sector specialists can earn. In fact, we have not paid close to what they are able to earn in the private sector. But because of the need to ensure that the better ones are retained, it is important for our payment system to ensure that our leading lights are able to earn more and that the gap between what they can earn versus what they can potentially earn, if they went out to the private sector, will be closed or reduced. This is something that we are looking at very actively now and I think we should be seeing some change in the coming months. As for the overall environment, it is something that we are also looking at actively - how to make sure that the teaching is more meaningful, more satisfying, and also how to ensure that we have adequate research funds for them.”
“What is also interesting is that one-quarter of the 160 are non-Singaporeans. So, in fact, we have been able to widen our talent pool. And as a result, we have managed to reduce the shortfall in the medical officers. The shortfall now is a very manageable 61. We will continue to encourage Singaporean doctors to return. We will continue to have regular dialogues with our medical officers to understand what interests them and help them to do their career planning. And I believe that with this concerted effort, we will be able to continue holding on to more MOs and therefore reduce the shortfall in the coming years. Once we are able to do that, then I think the problem that Mr Goh Choon Kang brought up just now, that in the polyclinics that he visited, with a planned manpower of 12 doctors, we were only able to supply seven - . I think if we are able to hold on to more MOs, we would be able to ensure that the polyclinics will be fully manned in the next few years. Specialists - this is a very crucial group, because specialists do not only provide service but, as pointed out by Dr Lily Neo, the senior specialists are also teachers of our future generation of doctors. Therefore, it is important that we try to retain the better ones of the senior specialists. But having said that, I want to also ask the House to remember that there will always be a turnover of doctors and specialists in the hospitals because if we have, let us say, 200 doctors graduating each year, and we train half of them as specialists, it is not possible for our public sector to retain all the 100. So it is good, in fact, to have some turnover to ensure that the public sector is not bloated and also to ensure that the private sector is not stifled.”
“Last year, I mentioned about the night calls being very onerous. We have reduced the number of night calls from between eight and 10, to six now. So it is a significant reduction. Furthermore, we have also tried to match the postings of the medical officers with their interests. So if a person would prefers to work normal office hours, then we try to make sure that the person is posted to a polyclinic which operates during the normal office hours. If a person has a certain interest in, let us say, the elderly, then we also try to make sure that we are able to give the postings that fit in with that particular doctor's interest. And I believe that if we can do this better, it is not always possible to match perfectly, but if we can improve on the matching, then I think the long-term ability to make the job more interesting for the MOs concerned would be there, and therefore the long-term ability to retain them would also be there. Of course, we are recruiting talent from abroad. The healthcare sector in that respect is following what the other sectors of the economy have had to do - recruit talent from abroad. And I must say that the recruitment results have been encouraging. We embarked on that last year. I am happy to inform the House that last year alone we managed to bring back and recruit a total of 160 medical officers and housemen. In previous years, we were only able to get about 50 a year. So last year, with the concerted efforts, we have tripled the results. I do not think we can maintain this level, because what we did was in reaching out. We are also able to reach out to Singaporeans who were already working abroad and therefore we brought them back. That pool will dwindle in years to come.”
“But, unfortunately, it is also very time-consuming and therefore it will increase the need for doctors in the years to come. Secondly, aging population. With the number of elderly increasing, the demand for doctors from the elderly population will also increase. Thirdly, medical research. This is also related to what Dr Lily Neo has said. It is important that we focus also on medical research in our medical institutions. This will allow us to remain at the forefront of medical development as well as to ensure that we are able to maintain a high standard of medical care. The fourth is, of course, foreign patient load. It has gone down now. But I think once the regional economies recover, the foreign patient load will also rebound. Sir, the first three factors are definitely not affected by the downturn and, therefore, we should continue with our present programme to increase the supply of doctors. The impact of the economic turmoil, in fact, in terms of the Ministry's manpower supply, has in fact been positive. The resignations of specialists from the Government hospitals has, in fact, declined slightly. For example, last year, in February and March, the two months, we lost a total of 14 specialists. This year, for the first two months, that loss has been reduced to eight. So I think the trend is quite encouraging. In terms of actual plans to address the shortfall, whichat Mr Goh Choon Kang has asked for, I would like to break this into three different categories which are very important: the medical officers (MOs), the specialists, and the nurses. For MOs, last year, I announced the improvement in terms of service. We have implemented that. We have adjusted their salaries, we have adjusted their pay scales. We have also improved the work environment.”
“Sir, first, I would like to thank the MPs who have spoken. On the first cut, four MPs have spoken on manpower supply of doctors and nurses. Mr Bernard Chen has asked for a report on the progress that we have made in meeting the manpower targets, in terms of supply of doctors and nurses. And he is also wondering what is theits impact of from the current downturn in foreign patient load. Mr Goh Choon Kang has asked what are the plans for solving the manpower shortages that we are facing in both doctors and nurses. Dr Lily Neo is also worried about the exodus of doctors and wants to know what we are planning to do, whilst Mr Choo Wee Khiang is also concerned about the downturn in the economy and impact on the private sector, and what we are doing to reduce the intake of foreign doctors and nurses. Sir, these are different perceptions from different angles. I would like to assure Mr Bernard Chen that the steps that I mentioned last year in this House for increasing the manpower supply are being taken. The first step, of course, is very important - increasing the intake of medical students from 150 a year to 180 in the 1997 intake. But I think it will be also useful for me to briefly recap the four key factors underpinning medium to long-term health manpower projections, because, unless we keep these in mind, we will not be able to appreciate what the Ministry is doing. Sir, first, is that patients' expectations will continue to increase. Singaporeans are better educated, and they are better informed. Increasingly, doctors tell the Ministry that patients and their families insist on being told exactly what is the diagnosis, what is the treatment being rendered to them, and what are the implications of the treatment. This communication programme is a very good one.”
“Sir, if he had been listening carefully, he would have heard that I said that the ASEAN Ministers, realising that there is a big crisis looming, have already asked for international help, very early in the game, and that UNEP has responded quite positively, and we look forward to the international efforts coming with the active help of UNEP. With the international help, I think we have a better chance of solving the problem, rather than leaving it just to Indonesia and Malaysia. SCHOLARS AND SCHOLARSHIP BONDS (Statement by the Deputy Prime Minister BG Lee Hsien Loong) 12.38 pm”
“Sir, I can assure Mr Jeyaretnam that we are in regular contact with our Indonesian counterparts as well as with our Malaysian counterparts who are also equally concerned as we are. The Indonesian Minister has told us, as I have reported in my main answer, that in view of the fact that the fires have now spread over such a big area, they can only hope to solve the problem with the help of nature, ie, hope for the rains to come and for the drought to end.”
“Perhaps Mr Chiam may like to go to Jakarta and put his message across.”
“Yes, Mr Chiam, the Indonesians have relevant laws against illegal burning, and we have been urging them to ensure that those laws are being enforced as best as possible.”
“Yes, there is a government there, as I am sure Mr Chiam knows. However, the fires have now spread to a huge area, and the situation has been made worse by the long drought that Kalimantan has been facing because of the El Nino effect. I think Mr Chiam would realise, if he has been watching TV on fighting big bush fires, that once the fires are raging, it is very difficult to put them out. In fact, the fire that we had recently in Singapore involving a pile of waste wood took us about 3-4 days to put out. With over 50 people working and with a lot of equipment being put on the job, it still took us quite a few days to put out what is relatively a small fire, in the context of the big fires that are raging in Kalimantan. That is why we have to mobilise international support and assistance, because in the current economic situation that Indonesia is in, I think it would be difficult to expect them to deploy a lot of resources. So we must supplement whatever resources they have through international efforts. Mr Chiam See Tong: Sir, I agree that this is an international problem. But is there not a law, in the first place, to stop people from starting the fires there? I think this message should be put across to the Indonesians.”
“Singapore will also actively participate in any international effort to help put out the fires.”
“Sir, unless heavy rains fall over East Kalimantan over the next few months, the chances of preventing the haze from affecting Singapore are slim. Over the past few weeks, satellite pictures have shown a dramatic increase in the number of fires in Kalimantan. A dense cloud of smoke, haze many times the size of Singapore, has built up over Kalimantan. The situation is of grave concern to us. Singapore is currently cooperating with and assisting Indonesia within the framework of the Regional Haze Action Plan. While Indonesia has so far not approached us for any assistance beyond what we are providing today, I have informed my Indonesian counterpart that Singapore will be prepared to assist where we have the necessary technical expertise. During the ASEAN Ministerial Meeting on Haze held in Kuching on 25th February, the Indonesian Environment Minister stated that only the onset of rains could put the Kalimantan fires out, and current fire-fighting efforts by Indonesia would only mitigate the situation. In view of this assessment, the ASEAN Environment Ministers attending the Meeting proposed that Malaysia and Indonesia immediately activate their bilateral MOU on joint disaster management and relief efforts, and that personnel of the two countries proceed to identify the additional resources that are needed to fight the fires. Singapore and the other ASEAN countries can then help to provide some of the needed resources. The Ministers also called for immediate international help to meet the looming crisis. Singapore will work alongside international organisations such as the United Nations Environment Programme (UNEP) to mobilise international assistance. We have met up with UNEP in Kuching and are in touch with them.”
“In 1996 the total number of patient attendances in the specialist outpatient clinics (SOCs) of government acute hospitals, including restructured hospitals, was 2,092,751, of which 459,438 were new cases. In 1997, the numbers rose to 2,197,280 and 489,891 respectively. On average, the number of patients seen by doctors on duty at SOC clinics of the larger restructured hospitals is between 130 and 200 cases per day per clinic. RESPONSIBILITY FOR FOREIGN WORKERS 4. Dr Teo Ho Pin asked the Minister for Labour whether his Ministry will consider making sub-contractors solely responsible for the foreign workers whom they employ instead of the current practice of making main contractors jointly responsible for these foreign workers who are beyond the control of the main contractors.”
“Sir, last October, I had indicated that the control measures in terms of size, number of giant joss sticks, and the distance from buildings could be put in place, and this was widely reported in the media. My officers then proceeded to work very closely with the various bodies in preparation for these control measures. They held discussions with 7th moon festival operators, temple management and grassroots organisations. My officials also met with members of the Singapore Religious Goods Merchant Association last October to inform them of the Government's plan to impose restrictions on the burning of giant joss sticks. These bodies have therefore been given adequate notice. The new control measures took effect from 1st March 1998, as announced. ANNUAL BUDGET STATEMENT Resumption of Debate on Question (27th February, 1998) [Allotted Day], "That Parliament approves the financial policy of the Government for the financial year 1st April, 1998 to 31st March, 1999. ". - [Minister for Finance]. Question again proposed. 1.10 pm”
“Dr Toh See Kiat asked the Minister for Finance what progress has been made on his proposals to pass laws regulating timeshares and soft commodity brokers.”
“During the current Northeast Monsoon season, there is little likelihood of Singapore being affected by smoke haze. At worst, there may be the odd day when a change in wind direction may bring in some smoke haze, causing our sky to be slightly hazy. The probability of this happening is however quite low. Although there is little threat from smoke haze during this time of the year, my Ministry has continued to work closely with the Meteorological Service in monitoring the region's hot spot situation through satellite pictures. In the past few weeks, satellite pictures have started to show some hot spots in eastern Kalimantan, and more recently in central Sumatra. My Ministry has forwarded the satellite information to the Indonesian authorities to assist them in locating and putting out the fires. The winds will become more variable in April, when the inter-monsoon period sets in. If there are still fires and smoke haze in Kalimantan and Sumatra during this period, some of the smoke haze may be blown over to Singapore. Singapore's assistance to Indonesia is within the framework of the Regional Haze Action Plan which Asean Environment Ministers have agreed to. We will install the intranet system by March 1998 which will allow Indonesia immediate access to our satellite-based fire monitoring system. The Asean Environment Ministers and senior officials will meet again on 24th and 25th February in Kuching, Malaysia, to discuss the progress in the implementation of the Regional Haze Action Plan, and we will find out if Singapore can be of further assistance within the context of this Plan. LAWS REGULATING TIMESHARES AND SOFT COMMODITY BROKERS 24.”
“There will be two Tamil language modules to meet the needs of those wishing to keep up with the language at the tertiary level. However, as the purpose of the programme is not language training in Tamil or in other Indian languages, the language component in this South Asian Studies Programme will be optional courses.”
“First, we will have to await word from the Indonesian Government as to which are the companies that are guilty. After that, it is left to the public to decide what they want to do. But as the Government, we would not want to engage in any precedent setting approach which may be used in a very detrimental way against economies around the world. SOUTH ASIAN STUDIES DEPARTMENT 8. Mr R. Sinnakaruppan asked the Minister for Education if he will inform the House on the progress concerning the proposal to set up a South Asian Studies Department at the National University of Singapore. The Senior Minister of State for Education (Dr Aline K. Wong) (for the Minister for Education): Sir, during the Committee of Supply debate in July last year, Minister Teo said that MOE and NUS would study the proposal to set up a South Asian Studies programme at the NUS. MOE and NUS have now completed the study and have concluded that it is indeed feasible to start a South Asian Studies Programme at NUS from the Academic Year 1999/2000. The programme will enrich the university curriculum and give our under-graduates exposure to South Asia. The programme will also complement the academic activities at the East Asian Institute as well as the Southeast Asian Studies Programme at NUS. The South Asian Studies Programme will be structured to allow students to either take modules as non-major electives or take South Asian Studies at the General Degree level as a Double Subject Major, without the Honours component. It will initially consist of 10 modules, with eight South Asian Studies modules conducted in English, including political, social, economic and cultural aspects of South Asia.”
“Sir, the Green Labelling Scheme or eco-labelling schemes that have been adopted internationally do contain certain criteria. We will also abide by those criteria. I think it is not wise to mix up all these criteria with a specific incident, which is the use of fires to clear land. It is better that that problem be resolved in a proper way, ie, if those methods for clearing land are illegal, then the country involved takes the necessary actions to enforce their laws against those companies. This is what the Regional Haze Action Plan sets out to do.”
“Sir, the differences are huge. One is the scheme encourages a positive effort and it poses no threat to the other companies that have not received the green label. The approach that is being proposed by Mr Tay has very adverse implications. In fact, one of the great concerns expressed by many countries, especially developing countries, is that some countries, especially the developed countries, may resort to using environmental measures as a disguise for protectionistic measures, and the approach that has been proposed by Mr Tay would set a very uncomfortable precedent.”
“Sir, the objective of the Green Labelling Scheme is very specific. It is to recognise selected consumer products which are more environmentally friendly. The scheme encourages companies to be environmentally friendly in a positive way rather than discriminate against particular products or companies. This is in line with similar eco-labelling schemes introduced in other countries, and we should not depart from international practice by broadening it.”
“The Indonesian Minister has assured us that the Government is actively investigating. In fact, they have already taken steps to prosecute one company. I understand that they are now at the stage of finalising investigations on several other companies in order to take legal action against them. GREEN LABEL SCHEME 7. Mr Simon S C Tay asked the Minister for the Environment if he will consider broadening the Green Labelling Scheme to advise consumers against products connected with companies causing or contributing to the haze pollution.”