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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“Mr Deputy Speaker, Sir, I beg to report that the Committee of Supply has made further progress on the Estimates for the financial year 1993/1994, and ask leave to sit again tomorrow.”
“We do not have a means test. Sir, I think I have answered all the questions posed by Members. I will now ask Dr Aline Wong to answer the remaining questions.”
“Sir, time is running out. Let me finish first. He has asked about control of drug cost. Sir, the cost of drugs in our Government hospitals varies for Class A patients from about 8% to 10% of the bill, and for Class B2 and C from about 10% to 18%. How big a portion drug makes up the total bill depends very much on the disease condition. I think the more complicated an illness you have, the more drugs you are likely to be prescribed and, therefore, the higher the drug cost. What also influences the size of the drug bill are the prescribing habits of the doctors in the institution. We have the Standard Drug List which we subsidise heavily. Doctors who prescribe drugs that are not on the Standard Drug List, therefore, subject their patients to a higher drug cost, because we do not subsidise that heavily those drugs for patients. Unfortunately, there is no central control at the present moment on the drug list in each hospital. In Alexandra Hospital, we have the lowest number of non-standard drugs. SGH has about 550 and NUH has over 700 non-standard drugs. The longer the list of non-standard drugs, the higher the likelihood of doctors prescribing such non-standard drugs. We are now in the process of seeing how we can influence the number of non-standard drugs that each hospital has. 4.45 pm Mr Low Thia Khiang has asked whether we have any regulation that prevents patients from being admitted into Class C wards. Sir, we have no restriction. The only thing is that if a patient wants to specify that he wants to be treated by a particular doctor, then he must get admitted as a Class A or B1 patient. But if he is prepared to be treated by a doctor that is rostered, or allocated to him by the hospital, then there is no restriction at all. So anyone can go into Class C ward.”
“So whatever the payment system, the hospital management and the Medical Board must still discharge their responsibility by monitoring the performance of doctors in their respective institutions to ensure that they are working efficiently and productively. And, more importantly, to ensure that they are working professionally, ie, they give treatment where treatment is warranted and, if they are over-prescribing or over-treating, the Medical Board must be under no fear, under no reluctance, to come forward and give the doctor a proper reprimand and proper disciplinary action. If they do not do that, I think they are letting the institution down. Sir, the hospitals are now required to have medical audit programmes, as I have stated just now. I have confidence that the Board will continue to discharge their responsibility fully, and with the help of these audit schemes, they will be able to ensure that whatever black sheep existing in their institutions, they are identified and they are either told to behave or told to leave the institutions. And I am sure the good name of our institutions will continue to be maintained.”
“Sir, whichever way we look at it, the question is: are the patients concerned that they are presently being neglected? I think much as we have tried to explain, the perception has been, yes, they have been neglected. Perhaps Dr Michael Lim can do a better job in NUH at convincing his patients that they are not being neglected. But, nonetheless, I think the concern is there. And whilst we can debate as to whether the concern should be there, the fact of the day is that there is a concern, and we better address it. Whatever the system, I think we have to accept that no remuneration scheme can be perfect. We want our doctors to do certain things, we want them to be professional. It is very important that they must be professional. They must not do things in order to generate income. I think if they do that, the whole profession will suffer. Singaporeans will suffer too if our doctors are unscrupulous. We also want our doctors to be efficient and productive. You can either pay them a fixed salary each month and pay them competitively, whatever amount we think they should be paid in order to retain them, and be paid in relation to what their peers outside are earning. Yes, we can do that. How to ensure that doctors will be productive? How to ensure that they will turn up early each day and leave late in the day? If we pay them purely on a piece rate basis, we treat them like textile workers. It is not ideal either. Our system is that we have a combination of a fixed salary plus a variable component based on certain work that they do. No remuneration scheme is perfect and neither is any remuneration scheme a substitute for good management.”
“This has led to a fair bit of unease and unhappiness amongst the public, who fear that if they are in Class B2 and C wards, they will not be treated by specialists. Dr Michael Lim said that that is not true. I agree that the perception is not very well-founded. But it is a fear, nonetheless, and I think we should ensure that the system helps patients rather than make patients worried. We have therefore gone ahead to instruct the Government hospitals and restructured hospitals to delink payment from treatment to patients in A and B1 wards. That means, any payment should be delinked from the class of ward. Whether the patient is a Class C patient or Class A patient, the doctor should be paid the same amount. We do not dictate to the hospitals how that payment should be made or how much should be paid. We believe that the hospitals are autonomous, they have a bottom line to look after, and they must evolve their own system on how much to pay and how to pay. The Government hospital (Alexandra Hospital), together with Kandang Kerbau Hospital, Toa Payoh Hospital, and the National Skin Centre, has already implemented the new system with effect from March 1993. And the rest of the hospitals (Singapore General Hospital, Tan Tock Seng Hospital, Eye Centre, and NUH) would be implementing the new system once they have finalised it over the next few months. Sir, he has raised some concerns as to whether by paying doctors for treating subsidised patients, it will actually cause the doctors now to over-treat subsidised patients. If that is true, are we to say that for A and B1 patients, doctors are already over-treating or over-servicing them? If that is true, I think it does not speak well of our doctors at all. Sir, I would like to be a little bit kinder ---”
“Not only that, we also have the same waiver scheme for those patients who go to the polyclinics and they cannot afford to pay, because, maybe, they have got a chronic condition. And we have waived, for the last few years, 100% of those who came forward to apply for waivers. So the safeguards are there. It is important that we do not artificially keep fees low. When costs go up, salaries and income levels of Singaporeans go up, we must also ensure that the percentage of co-payment by our patients is maintained. So as costs go up, it is better that we, if need be, make small increases every year, rather than freeze everything for five years and have a big jump subsequently. I think that would be very disruptive. So we will keep costs low. We will try to control costs. But if costs go up, it is better that we recover part of the costs in small jumps, rather than delay and have a big jump later on. Sir, Dr Michael Lim said that good health care is not cheap. I agree with him. That is why we need to be very careful about what we spend on in the hospitals, what we do in the hospitals, and ensure that we have a level of health care that we can afford. I do not think we can afford to keep on improving our health care indefinitely. It will only bankrupt us. So we will have to be very careful about the sort of improvements that we make, because every improvement means added expenses. He has also talked about the Consultancy Fee Scheme (CFS). Perhaps I will touch on that now because Dr Wan Soon Bee has also asked me about the CFS. Sir, the original Consultancy Fee Scheme only paid doctors who provided services to patients in Class A and B1 wards.”
“30 pm That is why we focus so much on primary care, contrary to what Dr Tan Cheng Bock feels. Of course, primary health care has been low key and therefore it does not get covered that often in the newspapers and it appears to be out of favour. But that is not so. This realisation has, in fact, brought a change in the thinking of many of the medical schools in the US and UK. In fact now, in the USA, the leading medical schools - Johns Hopkins, Harvard - require their doctors to spend time not in the high-tech research centres and hospitals, but to spend time in primary care facilities. So it is wise for us to also take note, and I am glad to say that NUS is also in the process of revamping its medical undergraduate curriculum to place greater emphasis on primary health care and to increase the duration of time students spend in primary health care clinics. Sir, this makes sense because we must not forget that 60% of every graduating cohort of medical students will go on through life to work as family practitioners. So it is better for us to give these doctors a proper foundation in the undergraduate days so that they can perform properly and professionally as family practitioners. Sir, Dr Wan went on to request that the polyclinics keep their fees at $6 per consultation and keep our B2 and C Class charges at the present level for the next five years. At the polyclinic level, the fees are actually very affordable. Not only are they already heavily subsidised at $6 per consultation, but children (up to junior college level) and the elderly get a 50% discount. So for children and the elderly, they only pay $3 per consultation - very, very affordable.”
“And because there is still capacity, there is no need for any other hospital within the Government group to set up its own department. So every hospital sends their patients to SGH for radiotherapy treatment. Similarly, with MRI. In fact, we only allowed NUH to purchase the first MRI machine for the Government hospitals in 1990/91, ten years after such machines were available in the USA. The reason why we waited so long was that we wanted to be sure that this equipment was well proven and that it was needed in Singapore. And only when the equipment in NUH was fairly well utilised, did we allow Singapore General Hospital to purchase a second machine. So there is coordination. Dr Wan has also stressed the need to train our doctors to have a stronger foundation in primary health practice. Sir, he is absolutely correct in that area. Primary health care is able to treat the vast majority of illnesses. In fact, the Boston University School of Public Health, Prof. Anthony Robins, wrote a very interesting article, and I would like to quote a couple of sections. He said, and I quote: `The number and kind of surgical procedures performed in an area correlate better with the number of surgeons and their specialties than with the variety of diseases. Where there are GPs and primary care services, there are fewew operations and fewer hospitalisations.' I think Dr Tan Cheng Bock has been saying that for quite some time. I agree with him. Prof. Robins also said that: `Primary care is front line medicine, the point at which people who need medical services enter the system by consulting an internist, a family practitioner or a general practitioner. Primary care alone can provide more than 90% of the services people need.' 4.”
“Yes, Sir. The Intensive Care Units are what we call common user wards. Patients from Class C will go into the same ICU units as patients from Class A, but they are charged differently. Class A patients will be charged at class A rates. The Class C patient who is in the next bed, in exactly the same conditions, will be charged at Class C rates. So actually our system is very fair and very beneficial to the low income groups. Dr Wan Soon Bee has talked about the need to control health care cost and asked how we ensure that competition between the hospitals does not result in escalating cost. He has named a few areas. Firstly, specialisation. How do we prevent every hospital from wanting to have the same specialist department because maybe some people think that those departments are more glamorous. Sir, the Ministry of Health coordinates the setting up of departments of specialisation. We ensure that only when the patient-load is large enough to justify the setting up of another unit do we allow such a unit to be set up. So we make sure that there is no unnecessary duplication. Of course, it means that certain units are available in all hospitals. For example, general medicine, general surgery, there is enough patient load in every hospital. Therefore, we have them. Similarly, with orthopaedics. The patient-load in orthopaedics is very high nation-wide and, therefore, we have this specialty unit in many of our hospitals. He has also asked how we control and ensure that high-tech equipment do not proliferate. Sir, I agree with him that there is a need to coordinate and, in fact, that is being done. For example, the purchase of radiotherapy equipment. SGH has now the only radiotherapy department in Singapore.”
“Sir, many of the specialties in the Singapore General Hospital are not unique to the Singapore General Hospital. They are actually available in Tan Tock Seng Hospital, Toa Payoh Hospital and Alexandra Hospital. Therefore, rather than duplicate unnecessarily, and especially where the other hospitals already have spare capacity, SGH therefore does not have class C wards in some of these similar specialties. For example, in paediatrics, Tan Tock Seng and Alexandra hospitals have paediatrics. The Class C wards in these two hospitals have the capacity and therefore there is really no need for SGH to also duplicate it. But there are certain specialties where these are unique only to SGH. For example, the Burns Unit is available only in SGH. These are also mainly high cost specialties, and are available only in B2 wards. This way the heavy subsidies that are needed are given out very carefully, in line with what Dr Michael Lim has said. We should be very careful about giving out subsidies, especially in those heavily subsidised areas. But where the patients are from the low income groups and they find that the B2 bill sizes are not affordable, SGH will very readily reduce the bill size to an equivalent Class C bill. So actually this is to the benefit of the low income group because they pay Class C bill, but they are actually being kept in B2 comfort. At the same time, it allows the hospital to optimise on the use of their facilities and manpower. Because, rather than have them spread out over many wards, they are now spread out over fewer wards and, therefore, it keeps the operating cost down as well.”
“As I have mentioned just now, the restructured hospitals have actually been able to make improvements over the past few years through changing and streamlining the systems, adding automation tools where these are available, automating processes, and so on. And through job enlargement and job substitution, we have managed to make better use of the people. So all these measures have resulted in some savings. I would like to inform the House that between 1990 and 1992 the four restructured hospitals, namely, Singapore General Hospital, Kandang Kerbau, Toa Payoh and NUH hospitals, had an operating cost that increased by only 12% over the two years. Their total operating cost only increased by 12% but their patient-load increased by 6%. So the actual increase per patient day was only 6% over that period of two years, or about 3% a year. I think this has been the lowest that we have achieved so far and it is due to the ability of the hospitals to be flexible, to innovate and to make improvements without being faced with bureaucratic obstacles. Mr Othman Haron Eusofe has asked how we price drugs. For class B2 and C patients, the drugs are provided based on a fixed quantum under the daily treatment fee. For non-standard drugs, they are provided at subsidised prices. So the hospitals do not even recover full cost from such patients. For the A and B1 patients, they are charged at the purchase price plus a small handling fee. So in comparison to the price of these drugs outside, I can say that the prices in the restructured hospitals would still be a fair bit lower. Together with Mr Low, he has also asked why in the Singapore General Hospital certain specialties do not have class C wards.”
“The item Mr Peh has mentioned, Huang Liang is the only herb that my Ministry has banned so far, and so are the preparations which contain the active ingredients in Huang Liang, as mentioned by him. I would like to explain why we have done so. This is because the active ingredients in Huang Liang destroy the red blood cells in people that lack a particular enzyme. That happens with fatal results. So my Ministry cannot allow its indiscriminate use and sale in Singapore. However, since the future batches of Chinese physicians would be better trained, I am prepared to ask my Ministry to study whether Huang Liang and its preparations can be made available to these new physicians down the road for controlled sale. Sir, Mr Othman Haron Eusofe has asked about B2 and C classes and stated his fears that many of these patients are in fact unable to afford the fees. Sir, I have just quoted the bill sizes. They are very affordable. But that does not mean that every Singaporean can afford to pay those bill sizes. There are, of course, the indigent and those who, for various reasons, cannot afford. I would like to assure Members of the House that these numbers are actually very small. In 1991, only about 2,800 patients in B2 and C Class wards applied for waivers out of a total of 160,000 patients in B2 and C wards. So they made up only less than 2%. I am happy to say that 98% of those who applied were granted waivers. In 1992, we had about 3,800 who made up about 2.2% of the class B2 and C patients who applied for waivers, and 99% of those who applied were granted waivers. So again, we have been very sympathetic and very helpful. Sir, he has asked how we are helping to ensure that costs are under control.”
“My Ministry would be very happy to help the two associations to get in touch with the leading TCM institutions in China and Taiwan, if necessary. Sir, my Ministry will also be prepared, at the appropriate time, to assist the two associations to keep the public informed about the new generation of Chinese physicians when they are ready to practise. 4.15 pm On the issue of registration, I think the question is to what extent the Government can be involved in their registration when we are not involved in their training, nor do we have the expertise to vet the course or to ensure quality. The problem is further magnified by the fact that at the moment there are over 1,800 Chinese physicians, practising full-time or part-time, most of whom have not been through a formal training programme and they have only picked up their skills through an apprenticeship programme. What do we do with them? The two associations may wish to examine how this large number of existing TCM practitioners, with no formal qualifications, can be accommodated or upgraded or, as Mr Peh has mentioned, perhaps even be prohibited from practising in the future. With regard to TCM in the USA, Japan and other countries, I am unable to comment, as we do not have any information on what these countries are doing. I will ask my officers to investigate and to study what these countries are doing. Sir, on the subject of banning of certain Chinese medication, I would like to clarify that in deciding whether to allow certain medicinal products to be sold in Singapore, my Ministry's over-riding interest is to ensure that the health and safety of Singaporeans are protected. So far, the main items banned are those containing toxic substances, like arsenic.”
“He has also asked about GP's referral, whether the present practice of patients who are referred by GPs having to be treated as A and B1 patients can perhaps be changed to allow low-income patients who are seeing family practitioners to be seen as B2 or C Class patients. Sir, I would like to assure him that it is already being done. We implemented this since May 1991 whereby GPs, family practitioners, who are referring their patients whom they know belong to the low-income group and who would have problems paying A and B1 size bills, would let the hospital know in the referral letter that this patient is facing financial hardship and would need to be seen as a B2 or C Class patient. In fact, last year, 1,360 patients referred by GPs were reclassified as subsidised patients. Dr Vasoo has talked about polyclinics. I will let Dr Aline Wong answer that. Mr Peh Chin Hua has, for the third time, as he said, brought up the issue of Chinese physicians. Sir, my Ministry welcomes the establishment of the joint training syllabus and the joint examination by the two Chinese physicians' associations. In fact, I urged them to do so last year and I am glad that they have acted very quickly. Their action will help to improve the standard and practice of traditional Chinese medicine (TCM) in Singapore. Over time, a new generation of formally trained Chinese physicians will then be available to ensure the survival of this traditional practice in Singapore. I would like to urge the two associations to ensure that the standards are properly defined and also properly upheld through this new course, by bringing in renowned TCM practitioners from China and Taiwan to not only lecture and supervise the curriculum, but also to act as external examiners.”
“Sir, the level of service in our public hospitals has actually improved over the years, especially in those hospitals that have been restructured, mainly because restructuring has allowed the hospital managements the autonomy, the flexibility, to rethink their procedures, to introduce new work methods, streamline processes, and therefore make better use of their people. As a result, the median waiting time for patients, eg, in the Singapore General Hospital, has been reduced from 38 minutes in 1990 to 32 minutes in 1992. And the number of patients who have to wait more than 60 minutes has been reduced from 27% in 1990 to only 18% last year. So the waiting times have been very much reduced. I would like to ask the public and Members here to understand that it is very difficult really to reduce waiting times much further. Because in a hospital environment, quite often doctors have to be called away on emergencies. And when they are required to do so, I think they have to give priority to the patients who are in the wards who are suffering an emergency condition and who require their attention straight away. Quite often, they have to leave for a limited period of time to look after those emergency cases. And that is when the waiting times get longer than an hour. He has also said that we should perhaps run a hospital like a manufacturing concern, ie, just in time (JIT). Unfortunately, people are not machines! As for machines, cycle times are very predictable, but the medical condition varies from patient to patient. I am sure the doctors would love it if every patient comes in with exactly the same ailment, but that is not so. So JIT, whilst we welcome it, I think it is quite difficult to apply in the medical environment.”
“We have found that it is a highly complicated system. In the USA, reportedly it contributes to about 15% of their total health care cost. We are now looking to see how we can simplify and then in due course apply that to Singapore. On the need to control private sector and public sector charges, we already have in many ways been influencing the public sector charges. For example, doctors in the Government hospitals and restructured hospitals are at no liberty to charge what they like. They can only charge fees that are set by the hospital boards. These fees are reviewed very carefully and any changes are also introduced after much thought has been put into them. With regard to private sector charges, I agree with him that we cannot continue to keep health care cost low in Singapore if we do not have some means of influencing the private sector charges. Because if private sector charges keep on increasing and that the earnings of doctors and paramedical staff increase in the private sector, they must have a "pull" effect on the public sector. We must increase salaries in the public sector to keep our staff. So it will have an impact on health care cost and we are now looking actively into how this can be done. The Green Paper, when it is released in the middle of the year, would have something to say about it. Dr Michael Lim has talked about primary health care. I will leave that to my colleague, Dr Aline Wong. Mr Robert Chua has talked about the quality of health care in Government hospitals and the need to upgrade services. He has asked about how we can perhaps shorten the waiting times for outpatient treatment.”
“So we would rather fund, and the operator, if he is more ingenious and more innovative, can perhaps stretch those dollars a lot further than if we had to pay our own staff and send them there and force the operator to make use of them whether or not he likes them. I think our approach is better. If Dr Tan or anybody else is interested in opening up a community hospital, we will be very happy to carry out discussions with him. Dr Arthur Beng has asked for Medisave to be extended to outpatient use. Medisave is, in fact, available now for outpatient use on a very limited scale and these are only for those outpatient treatments which are more expensive. That is really the role of Medisave, to ensure that where medical expenditures are higher, Medisave comes in to reduce the burden placed on the patient. Most outpatient treatments are actually quite inexpensive. If a patient goes to a polyclinic, he pays $6 consultation fee, a few dollars for medicine. It amounts to $8 or $9, which is very affordable. If you go to a GP, I think the fee probably ranges between $15 and $18, which is quite affordable. We should not turn Medisave into a programme with very high administrative overheads. To do that, I think, would undermine the whole basis of Medisave. So I would like to urge caution in this area. [Mr Deputy Speaker (Mr Abdullah Tarmugi) in the Chair] 4.07 pm Dr John Chen has talked about DRG and the need to control private sector charges, not just private sector charges but also for the Government and restructured hospitals. Sir, the Ministry has been studying the health care systems of all the other countries, the UK, Germany, USA and Japan. We have, in fact, been looking at DRG for the past two years to see how applicable that system is to Singapore.”
“For 1992, in the Government hospitals, namely, Alexandra Hospital and Tan Tock Seng Hospital before it was restructured, 75% of Class C patients paid bills of less than $265. This meant that for the patients using them, they only required 3.3 months of Medisave contributions. So we have kept it very affordable. At the higher end, we have Singapore General Hospital and there 75% of the Class C patients paid bills which were either $445 or cheaper. This was less than 5.6 months of Medisave contributions. For B2, last year, the bill size for 75% of the patients in Government hospitals was less than $585, and that came to about 4.4 months of Medisave contributions. For SGH, the bill size came to $695, which meant 75% of all inpatients used less than 5.3 months of Medisave contributions. So for these two classes, I would like to reassure the House that we are very conscious of the need to keep costs low and that they do in fact remain highly affordable. Dr Tan Cheng Bock has talked about primary health and community hospitals. I would like my colleague, Dr Aline Wong, to reply to him on primary health. With regard to community hospitals, we have an open mind with regard to funding of community hospitals. We are prepared to fund 80% of the cost of community hospitals, which I think is a lot more generous than what we have to pay for a Community Centre. The advantage is that we are prepared to fund the hospital in terms of operating cost and let the operator manage it the way he thinks it should be managed. I think to have the Ministry send people there - doctors, staff and other personnel - does not allow the operator to really maximise on the flexibility and benefits of being autonomous.”
“So we ensure that all these bio-hazardous wastes are discharged off safely. We have guidelines which were drawn up between MOH, PWD and Environment, and these were firmed up in October 1989. I would like to inform the House that we have reviewed our experience since and we are now in the process of reviewing these guidelines to see how we can simplify them and lower the costs for those hospitals that have such bio-hazardous wastes. The cost for last year came to about $1 million. Although it is only about 0.2% of total operating cost, we should try to reduce such costs wherever possible. 4.00 pm For nursing homes, I am glad to say that since nursing homes generate a relatively small quantity of bio-hazardous wastes, they can actually disinfect them at much lower cost and have them disposed of as general waste. For nursing homes, it is actually quite low cost and not a problem. Dr Vasoo has asked about medical audits - to what extent have medical audits been implemented in hospitals and how do we ensure that B2 and C Class wards remain affordable? Since 1st January this year, when we implemented the Private Hospitals and Medical Clinics Act, we now require every hospital to have an inhouse medical audit committee to audit the procedures that are being carried out in the hospitals. We require the hospitals to submit these audits to us and we will then spot check. In the case of Government and restructured hospitals, I am happy to say that such procedures have actually been in place for several years already. With regard to B2 and C Class wards, I would like to assure the House that we are quite conscious of the need to keep the cost low and to keep the fees affordable, because the bulk of our low-income group Singaporeans use such wards.”
“That may seem big but in the context of the total drug sales of $200 million in Singapore last year, the cost of registration only came to 0.2% of total costs. So by no stretch of the imagination, can we say that because of DR, the costs of drugs have gone up significantly. In terms of the sale of generic drugs, I am glad to report that the majority of the drugs sold in Singapore are actually generic drugs. Let me give you an example. For the Ministry of Health, when we purchase drugs, we will stipulate certain key active ingredients. We do not stipulate the brand name. What has happened is that for certain antibiotics, for example, tetracycline, there are actually 25 generic drugs available compared to the original patented drug. And for most of the tenders that we have managed to invite and give out, the costs of the drugs that we buy come to between 20% and 60% of the price of the patented drugs. And for many of these drugs, there are, on the average, about 15 to 25 generic drugs available for each patented item. The same experience would be available for those who purchase such drugs in the private sector. So the fear that DR has driven up the cost of drugs and make generic drugs not available in Singapore, I think, is unfounded. Mr Loh has also asked about bio-hazardous wastes. Sir, medical treatment generates a fair bit of bio-hazardous wastes, for example, needles, sharp instruments, materials used in bacteria culture and tissues or materials from highly infectious diseases. So we need to ensure that such materials are disposed of safely. I am sure many of you have read reports of needles being found on beaches, defective materials and organs being found in land fills, etc. We surely cannot allow such things to happen in Singapore.”
“In fact, quite often, equipment are purchased by the Government hospitals because the patient-load in Government hospitals justifies the purchase of such equipment. For example, radiotherapy equipment. SGH, for many years, had the only radiotherapy equipment in Singapore. All private sector patients were, in fact, treated in SGH. Where the equipment is only available in Government hospitals, they will definitely allow the private sector to send their patients there in order to save on medical costs. Mr Loh has also brought up the point about drugs. He has asked whether the process of drug registration has resulted in significant increases in drug costs, and whether it is true that, because of this, vendors are, in fact, profiteering by bringing in only the more expensive drugs and not the cheaper drugs. Sir, I wish to clarify that much of that perception is unfounded. In fact, if we take one step back as to why we needed to register drugs, it is to ensure that whatever drugs are being sold in Singapore, they are safe and efficacious. We implemented Drug Registration (DR) in June 1991. Prior to DR, there were about 8,500 drugs available in Singapore. After DR, we now have 7,500 drugs, a reduction of 1,000. What happens is that 600 of the applications were rejected by the Medicine Advisory Committee because they were not of proven value, or they contained undesirable combinations of ingredients, or they have prohibited substances in them. So those 600 were not registered. The rest, where the importers had applied, were all registered. So, in fact, much of what was available is still available. Sir, the cost of registration has also been kept very low. For example, in 1992, the total costs of registration came to $360,000.”
“First, I would like to thank all my colleagues who have spoken on this cut. They have raised many issues. I will answer the speakers, one by one. Mr Loh Meng See has talked about the CFS scheme together with Dr Wan Soon Bee and Dr Michael Lim. I will address that later. Sir, Mr Loh has also talked about the need for Singapore not to follow the way the US has developed, in terms of malpractice suits. In the US, malpractice has resulted in escalating health care costs. In Singapore, we are in a very happy position in that, each year, there are less than a handful of malpractice suits being brought to court. I think this reflects the fact that doctors in Singapore are practising medicine very carefully and properly and, as such, very few of them do indulge in malpractice. Sir, we are, however, not leaving matters remain as they are. We are now looking into how to ensure that complaints which are brought to the Singapore Medical Council can be dealt with expeditiously so that any complaints that are brought forward can be investigated quickly and disciplinary action taken quickly, where necessary. We are now looking into amending the Medical Registration Act and bringing in lay people into the disciplinary hearings. This would ensure that there is more openness in the hearings with regard to disciplinary matters and also complaints which are brought forward will be dealt with within stipulated periods of time. Mr Loh has also asked that we maximise the use of expensive equipment by letting the public and private sector hospitals share the use of such equipment. Sir, that has always been the case. The Government and restructured hospitals are very well equipped.”
“Mr Cheo Chai Chen asked the Minister for National Development whether the open field opposite Blk 602, Yishun Central/Yishun Street 61 is reserved for a branch library.”
“The Ministry had originally planned to build a polyclinic in Yishun Central. However, this plan has been changed arising from one of the recommendations of the Review Committee on National Health Policies. The Review Committee recommended that the Government should consider some alternative approaches to primary care provision, such as building multi-purpose clinics for leasing out to GPs. Such multi-purpose clinics or "medical centres", besides providing clinic suites for doctors, would also provide support services like laboratory, X-ray, pharmacy and health related retail shops, thus serving as a "one-stop" medical centre for the convenience of patients. In addition, GPs working in the medical centre could pool their resources and offer a wider range of services, for example, opening not only evening clinics, but perhaps, even 24-hour clinics, and providing house-call services, etc. By pooling resources, individual GPs would also have more time to upgrade themselves through attending continuing medical education programmes. Another aspect of this purpose-built medical centre is that, by leasing it out only to doctors and related services, they need not compete for the tender with suppliers of non-medical services. Since the building in Yishun Central was already under construction, it offered the earliest opportunity for a pilot project to be carried out. We expect the Yishun Central medical centre to be operational in January 1994. My Ministry will continue to provide primary health services for Yishun residents in the existing Sembawang Outpatient Dispensary and Sembawang and Mandai Maternal and Child Health Clinics. OPEN FIELD OPPOSITE BLOCK 602, YISHUN CENTRAL/YISHUN STREET 61 2.”
“As I mentioned just now, our main focus is on counselling. For first time offenders, we will bring them in for counselling and we will also require the schools to counsel them too. We intend to bring in the parents to ensure that the parents also give us their support because they will be acting in the best interest of their children. As part of the counselling process, the attendance centre order which she has mentioned is a good idea. That can be another avenue of counselling for the offenders who have been caught. So we will look into the feasibility of implementing that. Sir, I have answered all the questions raised. Question put, and agreed to. Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Yeo Cheow Tong]. Bill considered in Committee; reported without amendment; read a Third time and passed. LAND ACQUISITION (AMENDMENT) BILL Order for Second Reading read. 2.37 pm”
“We are now looking into reducing that threshold quantity to 5,000, and are now in the process of looking into the implications. Mr Loh also asked, under clause 11(3), whether public parks and recreational places are included under "public place". Sir, the clause reads: '"public place' means the premises of a school within the meaning of the Education Act or any place, premises or building or part thereof ...".'. So under the definition of "public place", parks and recreational areas are also included. He has also asked about the licensing of tobacco retailers, ie, firstly, whether we will control the number of licences that will be issued and, secondly, how will the existing vendors be affected. Sir, as I explained in my Second Reading speech, we do not intend to implement this provision for the time being and we will only do it if required. The circumstances under which we will put this clause into operation will be if we find that the retailers are not observing the ban and they are blatantly flouting the ban because the chances of getting caught may actually be very slim. If that is the case, then we will resort to licensing of all the existing retailers. Any new retailer that opens up for business will be issued a licence quite freely. This will allow us to have a further deterrent for the retailers to ensure that they are actually complying with this new Bill. Dr Soin has said that the $50 fine is not appropriate because the sum is either too small to be meaningful. Sir, the question here is how do we have a penalty which allows us to impress on the young offenders that smoking is actually a very serious and damaging habit and they should not smoke. The $50 is meant to be a deterrent. But the $50 fine is not the be-all and end-all of what we intend to do.”
“Sir, first I would like to thank my two Parliamentary colleagues for their support of the Bill. Sir, Mr Loh Meng See has asked a few questions. His first question is on clause 6 and he wants to know if a person accumulates some magazine or journal for a period of a year and, therefore, he has more than ten copies, will he fall foul of the law and be deemed to have committed an offence. Sir, clause 6 should be read as having accumulated 10 or more copies of the same journal. So if he has accumulated 12 copies of different months' journals, he has not fallen foul of the clause. Sir, the intention of this clause is to allow us to prevent persons from, firstly, producing cigarette posters and, secondly, putting them up in the quiet of the night. What happened was that whilst we had a ban on the advertisement of cigarettes in the past, Members would recall having seen many posters being put up on construction hoardings by the roadside. It was not possible for us to stop this because we had to catch the culprits in the act of putting up those posters, which is extremely difficult. With this provision, whereby we prevent people from not only just printing but also having possession of more than 10 copies of those posters or advertisements, we have effectively solved the problem. And that is why over the past few years, we have not had any posters being put up on hoardings at all. He also asked, under clause 7, whether we would also impose similar restrictions on publications which are printed externally. Sir, we have already implemented that. Publications which have more than a circulation of 10,000 copies a month are now subject to a ban on cigarette advertisement.”
“The WHO has therefore recommended banning the manufacture, import and sale of smokeless tobacco products. Several countries, for example, New Zealand, Australia, Hong Kong, Ireland and Israel have already banned the import and sale of smokeless tobacco products. Clause 15 prohibits the sale of imitation tobacco products. These are now available in the form of toys or confectionery products. Such imitation tobacco items give the young the impression that smoking is fun and enjoyable, and encourages them to give smoking a try when they are older. Clause 17 empowers my Ministry to introduce regulations to license cigarette retailers. Sir, we do not intend to introduce such regulations for the time being. My Ministry will closely monitor the compliance with the new provisions, and will only introduce such regulations if the need arises. Sir, we need to arrest the recent upward trend in the rate of smoking. The main increase has been amongst younger Singaporeans, many of whom take up smoking even before the age of 18. The provisions in this Bill will allow us to make it more difficult for those below 18 to gain access to tobacco products, and deter them from taking up this very harmful habit. Sir, I beg to move. Question proposed.”
“The penalty for this offence is a fine of not more than $50 for the first conviction and $100 in the case of subsequent convictions. Sir, with the passing of this Bill, my Ministry will embark on an intensive publicity and public education programme to inform Singaporeans about its new provisions. We plan to bring the Act into operation in late May, to coincide with this year's "Smoke Free Week". My Ministry will allow a grace period of three months for youth under 18 caught smoking in public places. After that, we will continue to counsel those caught infringing the provisions in clause 11, especially first-time offenders. We will also inform their schools and parents for further counselling to be carried out. I am indeed glad that the Ministry of Education has agreed that the schools will also participate in this counselling programme. Clause 13 prohibits the sale of tobacco products through vending machines. This ensures that cigarettes will not be easily available to young Singaporeans. Clause 14 prohibits the sale of smokeless tobacco products. In recent years, the number of smokers in the USA and Europe has declined. To counter this trend, some cigarette manufacturers have introduced new forms of smokeless tobacco and tobacco substitutes targeted mainly at the young. These tobacco substitutes are items with a non-tobacco base but which contain nicotine which is highly addictive. In the USA and Sweden, such products are already being actively promoted to teenagers. We can expect this to also occur in Singapore in the future, unless we institute preventive measures now. In fact, the World Health Organisation is also concerned with this new approach taken by tobacco companies.”
“The stricter legislative measures we are considering today will reduce access to tobacco products by young persons below the age of 18. At the same time, my Ministry will strengthen the public health education programme and other measures to persuade existing smokers to give up their habit, as well as to encourage non-smokers to remain so. With fewer smokers in the coming years, Singaporeans, the majority of whom are non-smokers, would be able to enjoy a cleaner and healthier environment. Sir, let me now give Members some background information on the Bill. My Ministry presently administers three pieces of legislation relating to smoking. These are: (a) the Smoking (Prohibition on Advertisements) Act which controls cigarette advertisements. (b) the Consumer Protection (Labelling of Tobacco Product Containers) Regulations which spell out the health warning requirements; and (c) the Poisons (Amendment) (No. 2) Rules 1989, which control the tar and nicotine limits of cigarettes. In preparing this Bill, we took the opportunity to merge these three pieces of legislation with the proposed new provisions to reduce access to tobacco products by the young. The result is a comprehensive piece of legislation governing the sale of tobacco products. I will now touch on the major new provisions in the Bill. Clause 10 of the Bill prohibits the sale or giving of any tobacco product to persons below the age of 18. There are now 22 other countries, including the UK, the USA, Canada, Australia, New Zealand and Japan, which have similar legislations, with the age limit varying generally from 16 to 19 years. Clause 11 prohibits any person below the age of 18 years from smoking, chewing, buying or possessing any tobacco product in a public place.”
“What is alarming is that the decline in the number and rate of older smokers has been more than offset by the rise in the number and rate of younger smokers. Smoking rates among those aged 18-19 have tripled from 5% in 1987 to 15% in 1991, while that for those aged 20-29 also rose from 15% to 19% in the same period. Sir, about half of all the present smokers took up the habit before the age of 18 years. We therefore clearly need further measures to prevent those below 18 from being enticed into the smoking habit. At this tender young age, they are easily impressionable and are less able to resist peer pressure encouraging them to smoke. Surveys show that many smokers are aware of the harmful effects of smoking. However, some take up smoking as they think it makes them look more sophisticated. Also, as the adverse effects will only show up very much later, many feel that there is no need to worry about the ill effects of smoking today. Unfortunately, they do not appreciate that the damage to their health is irreversible. When the actual illness is manifested, it may be too late for them to do anything. They will then be a burden to not only themselves and their loved ones, but also to society as a whole. The question we need to ask ourselves is: "As a responsible society, should we continue to allow Singaporeans of a tender age to be enticed into smoking, to knowingly or unwittingly do themselves harm?". This question has been the topic of much public discussion in recent months. Many members of the public, parents, civic and grassroots organisations, the medical and related professional organisations have all come out in favour of a ban on smoking in public places by persons below 18, as well as a ban on the sale of tobacco products to them.”
“Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time." Smoking harms the health of not only smokers, but also non-smokers who breathe in side-stream cigarette smoke. It causes diseases such as lung cancer, coronary heart diseases and chronic lung diseases. My Ministry estimates that cigarette smoking contributed to the deaths of more than 2,800 Singaporeans in 1991. Recognising the dangers of smoking, the Government introduced measures in 1970 to inform the public of the harmful effects of smoking and to encourage smokers to give up this undesirable habit. These measures included public education on the dangers of smoking, legislation to prohibit smoking in certain places, and heavier taxes on tobacco products in order to discourage as well as reduce smoking. In 1986, we strengthened our efforts by launching a multi-pronged National Smoking Control Programme. One of the key objectives in this programme is to reach out to younger Singaporeans and encourage them not to become smokers. Sir, these measures over the years have helped to create a social climate in Singapore that discourages smoking. They have resulted in Singapore having one of the lowest rates of smoking in the world. Our smoking rate declined from about 23% in 1977, to a low of 14% in 1987. However, it has been increasing since then, rising to 17% in 1991, and 18% in 1992. This overall figure, however, hides the fact that the rate for male smokers is 33%, compared to only 3% for females. Analysis of the data also shows that the increase in smoking rate has not been uniform across the various age groups. In fact, there are fewer older Singaporeans who are now smoking. Today, only 17% of those between 40 and 64 years of age smoke, compared to 27% in 1984.”
“Sir, currently, Medisave has a contribution limit of $15,000. Contributions in excess of $15,000 are automatically transferred to the Ordinary Account to avoid excessive accumulation of Medisave. A member who has had excess contributions transferred to the Ordinary Account can apply to have the amount transferred back to his Medisave Account, if he has exhausted his Medisave. However, if there had not been any such previous transfer, the member will not be allowed to transfer any savings from the Ordinary Account to his Medisave Account. But the member may be allowed to pay for his medical expenses with future Medisave contributions provided he receives treatment in a Class C or B2 ward of a Government or restructured hospital. GOVERNMENT COMPANIES (Breakdown of total losses) 6. Mr Low Thia Khiang asked the Minister for Finance if he will provide the breakdown of total losses suffered by Government companies from 1988 to 1992. GOVERNMENT-OWNED COMPANIES (Profits and losses) 7. Encik Harun bin A. Ghani asked the Minister for Finance, since 1988, (i) what is the number of government-owned companies which have been making profits, (ii) whether that number exceeds the number of companies which have incurred losses and (iii) what is the excess of profits over losses of these companies.”
“Sir, I would like to thank all Members for their strong support for the amendments. Both Mr Chandra Das and Mr Sinnakaruppan have expressed concerns about the dangers of life-long membership for certain key people and they stressed the need that new talent should continue to be brought in. Sir, that is the intention. We must strike a balance between maximising the use of talent of the people that we have now as well as, at the same time, identifying new talent outside to bring in. So this process will continue. As to the joint venture partner, the Board comprises very competent, experienced people of good integrity. I am sure they will be very careful in the selection of a joint venture partner. We should allow them to maximise the benefits to the Hindu Endowments Board as well as to benefit the Hindus in Singapore. I will keep in mind the points raised by Mr Sinnakaruppan about the possibility of buying back the shares that are being given out to the joint venture partner in the coming years. Question put, and agreed to. Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Yeo Cheow Tong]. Bill considered in Committee. [Mr Deputy Speaker in the Chair] Clause 1 -”
“The Bill will remove this restriction, except for the appointment of the Finance Member. The Bill also incorporates several minor or consequential amendments. These amendments will enable the Hindu Endowments Board to play a more active and effective role for the benefit of the Hindu community. Sir, I beg to move. Question proposed.”
“Mr Deputy Speaker, Sir, I beg to move, "That the Bill be now read a Second time." The Hindu Endowments Act (Chapter 364) was enacted in May 1969. The Act provides for a Board, appointed by the Minister, to administer Hindu religious and charitable endowments. Since its enactment in 1969, the Act has been amended only once, in 1973. This was a minor amendment to change the year of business from calendar year to financial year. The Hindu Endowments Board currently manages four temples and owns a property at Serangoon Road in "Little India". Following the lifting of rent control in "Little India", the Hindu Endowments Board intends to redevelop the Serangoon Road property to generate funds for the benefit of the endowments. To ensure the success of this project, the Board will be jointly redeveloping the property with a property development company. However, the Hindu Endowments Act, as it now stands, does not empower the Board to mortgage any property or to enter into any joint-venture arrangements. We therefore need to amend the Act to enable the Board to do so. Sir, over the last two decades the activities of the Board and the temples it administers have grown significantly. The procedures and working arrangements of the Board need to be strengthened and updated. We have therefore taken this opportunity to amend several other sections of the Act to enable the Board to operate more effectively. The Bill will enlarge the composition of the Board and enable it to form various Committees as and when required. Currently, appointments to the Board are limited to only two consecutive terms. With our limited talent pool, this restriction often leads to the Board not being able to continue tapping the experience and expertise of key members.”
“He has also asked for further protection for children against people who use them for immoral purposes. Sir, there are adequate provisions in the Bill here as well as in the Penal Code against adults who take advantage of children for immoral purposes. I think these provisions are, as they stand now, quite adequate. Question put, and agreed to. Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Yeo Cheow Tong]. Bill considered in Committee. [Mr Speaker in the Chair] Clause 1 -”
“The understanding at the present moment between MCD and MOH is that if the doctors in the public medical system come across cases which indicate that some form of child abuse has taken place, they will investigate further and if there are good grounds for suspicion that child abuse has actually taken place, they will then bring it up to MCD's attention. So far, I think it has worked very well. We will continue with that. Mrs Yu-Foo has asked whether we can reorientate the training programmes in our approved schools so that those who are academically inclined can then be assisted to take academic courses rather than proceed on to vocational or technical education. Sir, the approved schools do have both academic as well as technical and vocational training. As to which course a detainee is put into, it depends very much on the detainee's interest. So in cases where they are academically inclined, the schools have arranged for them to take up BEST courses as well as WISE, before proceeding on to take their 'N' level examinations. So those two streams (academic and technical) are presently available. Sir, Mr Umar has proposed that the penalties in clause 6 be further enhanced. This is a new clause which we have introduced in anticipation of future problems. Our assessment is that the penalties should be adequate. But I think the key thing is we should be prepared to monitor the situation and if, as Mr Umar feels, the penalties are proven to be not adequate, we will then be prepared to come back to the House and ask for the penalties to be enhanced. Sir, the penalties of $5,000 fine or imprisonment of two years or both are, in our view, quite adequate at the present moment. But we will review and enhance them in future if need be.”
“Mr Speaker, Sir, first, I would like to thank the three speakers for speaking in favour of the Bill. Sir, Mr Tarmugi has raised his concerns about two points. First, what sort of measures we have for reducing abuse in the future and, second, how do we make sure that these measures are effective. Sir, the key to any measure is education of the public. We will continue to educate the public through the support of various voluntary organisations as well as through MCD, and the newly implemented programmes that we have for newly-weds will also make sure that they are prepared for family formation. So education is one of the key platforms that we have and have been stressing, and which we will be further enhancing in the coming years. With education, comes the question of how we ensure that we are aware of cases where abuses have happened and how we are able to intervene before those abuses progress to a stage where fatalities occur? We have to really depend on a few sources. One is concerned neighbours; second, concerned relatives and, of course, third, concerned teachers in the case of children who are in schools. Sir, these three sources have proven to be very useful and most of the abuse cases that have come to light have been brought up through these avenues. We will have to continue educating Singaporeans, making Singaporeans more aware that if and when they come across cases of child abuse, they should not hesitate to report to MCD where an investigation can then be carried out. Sir, in the case of doctors, we need to draw a balance between mandatory reporting and the fear that because there is mandatory reporting, parents would then be reluctant to bring their children for treatment.”
“The provision ensures that the Juvenile Court maintains its distinct forum as a Court which deals with persons of a tender age, ie, offenders between the age of 7 and 16 and even lower, in circumstances where a child requires care and protection either because of abuse, neglect or ill-treatment. The regime and programme of our approved schools and homes are designed to meet the special needs of such children and young persons. These institutions are not geared to deal with young adult offenders, for example, as old as 20 years of age. The Bill will provide the Juvenile Court with additional powers to order a person who has been found guilty, where it deems fit, to be brought before a district court for sentencing for reformative training. Under the present Act, juvenile offenders found guilty are sent by the Juvenile Court to an approved school for a minimum of three years to a maximum of five years. In practice, an offender normally spends about 18 months in an approved school with the unexpired portion of his approved school order on licence, under supervision. This is because the institutional rehabilitation programme in the approved school is geared to a minimum period of one year. The Bill therefore reduces the prescribed period of a sentence to an approved school to a period of not less than two years and not more than three years. Sir, the various amendments incorporated in this Bill will make the measures for protecting children and young persons more effective and more relevant to today's society. Sir, I beg to move. Question proposed.”
“The Bill repeals the existing provisions on transferred children. These provisions exist because of historical reasons. After the Second World War, many displaced children were taken care of by relatives and friends and by persons whose interest in the children was questionable. Many of the children were consequently neglected, ill-treated or abused. The transferred children clause served to protect the children. Such a situation no longer exists today, and therefore we are repealing the provisions. The present Act requires children and young persons taking part in public entertainment to be licensed by the Ministry of Labour. These provisions reflect social problems faced by children and young persons in the immediate post-war period. In those days, children were often employed by wayang operators to perform on stage, or were used by street musicians to collect money. We do not face such problems today. Children and young people who are in employment are now adequately protected under the Employment Act. The existing provisions on licensing have, therefore, been deleted and a new provision enacted in the Bill. It ensures that no child or young person is allowed to take part in any public entertainment of an immoral nature, or which is dangerous to life or prejudicial to his health and physical fitness. Mr Speaker, Sir, another important area is the jurisdiction of the Juvenile Court. The Bill seeks to make it clear that the Juvenile Court shall not try an offender who has already attained the age of 16 years at the commencement of the hearing of the charge. Where an offender attains the age of 16 during the trial, the Juvenile Court will have the jurisdiction to proceed with the trial if it thinks fit.”
“In Singapore, we are fortunate that we are not overwhelmed by offences of cruelty to children and young persons. Indeed, the figures over the last five years show that there has been a downward trend in the number of complaints of child abuse. For example, in 1986, there were about 280 complaints, dropping to 112 in 1991. For the first six months of last year, there were only 47 complaints, of which 18 had evidence of child abuse. Mr Speaker, Sir, whilst the incidence of child abuse is low, what is worrying are the instances where child abuse has resulted in the death of the abused child. Between 1985 and 1988, there was an average of one death from child abuse each year. This increased to an average of two deaths a year for the past three years. The present penalty for both fatal and non-fatal cases of child abuse is a fine not exceeding $1,000 or to imprisonment for a term not exceeding two years, or to both. These penalties are manifestly inadequate. The Bill proposes to enhance the penalties to strongly discourage such abuses of defenceless children. In fatal cases, the Bill will increase the penalty to a fine not exceeding $20,000 or to imprisonment for a term not exceeding seven years, or to both. In non-fatal cases, the penalty will now be a fine not exceeding $4,000 or to imprisonment for a term not exceeding four years, or to both. Mr Speaker, Sir, another area of concern is that there is no express provision in the present Children and Young Persons Act to protect children and young persons against adults who exploit them for their sexual gratification. With video cameras now widely available, the risk of children and young persons being exploited for pornography is higher. The Bill provides a new provision to deal with such mischief.”
“Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time." The Children and Young Persons (CYP) Act was enacted in 1949. It is a comprehensive piece of legislation for the rescue, care, protection and rehabilitation of children and young persons. It strikes a balance between parental authority and responsibility for the care and supervision of children, and the protection of children by the State. Many of the provisions of the present Act are as socially relevant as they were in the 1950s. However, some amendments are necessary as certain social problems that were prevalent in the late 1940s and 1950s no longer exist today. The Children and Young Persons Bill 1993, while retaining most of the provisions of the existing CYP Act, will incorporate several major changes to give the State wider powers to protect children at risk and to make the Act more relevant to present day needs. Penalties are also being increased to a more appropriate level. As there are several major amendments as well as numerous drafting amendments to the existing Act, the Bill proposes to repeal the existing Act and to re-enact it with amendments. The main changes are as follows: First, increased penalties. Mr Speaker, Sir, the quantum of fines and penalties has not been changed since the Act was enacted in 1949. For example, any person who causes a child to beg is liable on conviction to a fine of up to $250 or to imprisonment of three months, or to both. The penalties for offences against children in the existing CYP Act are now too low to be a deterrent. Under the Bill, penalties for offences have been greatly enhanced, especially for offences like child abuse and exploitation and contribution to the delinquency of children and young persons.”
“Yes, patients in B2 and class C wards will be eligible to apply for Medifund. As for B1 and A class, if they are poor they should not be going to A and B1. As regards the criteria, I would expect the Hospital Medifund committees as well as the Advisory Council to publicise the criteria when these are finalised. As regards hospitals lacking funds, Sir, as I explained earlier on, some funds will always be available. But as in everything, the funds are finite. The hospitals must ensure that they utilise the funds in the right way. And if they do that, I think the funds would be adequate. This means that they must stick to the criteria and not deviate from them. But if there are some exceptional reasons, I am sure the Advisory Council will be prepared to consider. Mr Tong has asked about outpatient treatment. For patients who are receiving outpatient treatment in the hospitals and they cannot afford to pay their bills, yes, they are also eligible to apply for Medifund. Question put, and agreed to. Bill accordingly read a Second time and committed to a Committee of the whole House. The House immediately resolved itself into a Committee on the Bill. - [Mr Yeo Cheow Tong]. Bill considered in Committee. [Mr Speaker in the Chair] Clause 1 -”
“Sir, in the class C wards, most operations are available. Yes, there are some tertiary operations that may not be available in class C but they are available in class B2. Patients who go there and who cannot afford to pay the B2 bills will still get waivers. There is no reason for them not to use the subsidised wards in the hospitals. Sir, Dr Vasoo is worried that the Medifund procedures will be so complicated and so time consuming that patients may not get treatment in time. As I have explained earlier on, the treatment and the billing procedures are two different things. They will first get treated regardless of whether they are Medifund applicants and then they will be billed later. Dr Vasoo asked who are the Medifund committee members. They should not be hospital administrators. Sir, I explained in my Second Reading speech that they will comprise mainly members who are community and social workers. In fact, the intention is not to put any hospital administrator on the Medifund committees. Sir, I believe I have answered all the questions.”
“He has expressed the view that, although the 80% subsidy for class C is very generous, some people still cannot afford the 20% co-payment and, therefore, they fear that health care is not accessible. Sir, the fear, if any, is without basis because we have always been treating Singaporeans regardless of income level and regardless of their ability to pay upon arrival at the hospital. The waiver system has been in existence all the while, and it is not a new thing. It has been in existence for decades and that system has ensured that no one is ever deprived of health care. Mr Tong and others fear that in lean years, there will be no Medifund income and that medical illnesses are recession-proof. Sir, the investment of Medifund will be in long-term bonds and the interest income will continue to be available regardless of whether there is a recession. Mr Walter Woon has asked how do we help children who are not Singapore citizens. I have answered that. But I also want to put it in perspective. Medifund is not the only safety net available. The fact that they are non-Singaporeans does not preclude hospitals from reviewing and considering the appeals of their Singaporean parents. The hospitals are at liberty to waive fees using their own financial resources, but of course not from Medifund. So that does not preclude other forms of assistance. The hospitals will review. They will consider carefully and if there are good reasons, good justifications, I am sure the hospitals will proceed to give them assistance. The last speaker, Mr Chia Shi Teck, also mentioned that class C ward, based on feedback received by him, is not popular because some operations are not available and therefore the patients are not being given equal treatment.”
“I assure him that we will provide free treatment to those very poor Singaporeans who cannot afford to pay their bills. There has been some concern about clause 13(1) on applications for Medifund by citizens of Singapore only. Sir, that is the basic objective of Medifund. Medifund is meant as a privilege to be extended to Singaporeans, and Singaporeans only. And that is why clause 13(1)(a) is very specific. Some Members have expressed concern about children and parents who are non-Singaporeans. Dependants of Singaporeans, either the children or parents, who are permanent residents, already get subsidised services because they are free to go into class C wards and be subsidised 80%, even though they are non-Singaporeans. We have to look at this, not just in the context of Medifund, but in the overall perspective of how do we discriminate positively in favour of Singaporeans. At the moment, non-Singaporean children of Singaporean parents do not pay the same fees as Singaporean children when they go to school .It cannot be. We must discriminate in favour of Singaporean children. Similarly, with Edusave and Medifund. That is the privilege of being a Singaporean and we should be proud of that. Dr Soin has suggested that we should consider allowing Medisave account holders to opt in and donate their Medisave funds to Medifund when they die. It is a good suggestion. Unfortunately, this is not currently provided for. We will take a look. But there is nothing to prevent any Singaporean from willing his assets, whether it is Medisave or otherwise, to Medifund, and we would be very glad to accept that. Dr Toh Keng Kiat expressed some fears.”
“For the hospitals, we expect them to continue processing claims for waivers as part of their service to patients and, therefore, not levy a charge to Medifund. Mr Low Thia Khiang again opened up with a quote from other people, which he did also in the last Budget debate, that one can afford to die but cannot afford to get sick. Sir, I hope that when he does come across such people, and being more aware of the health care system, he would act responsibly by explaining to them that that is not true in Singapore. It may be true in other countries, including the US, where 37 million people are without medical insurance and, therefore, cannot get access to medical care. But in Singapore, no one is ever deprived of medical care. A person who is very poor, who does not have any Medisave, is provided treatment the moment he arrives at the hospital, and billed later. The medical treatment and the billing are two entirely different things. Priority is given to treatment. If they cannot pay, they will be sent to class B2 or class C ward where there is vacancy. But treatment is given first and then the hospital worries about billing. I am glad that in the eight years that I have been in Parliament, I have not come across any case of a Singaporean being driven away from any Government hospital because he could not pay the bill. There has never been any case of that nature, and we are very proud of that. Sir, our aim is to make sure that the poor and the indigent get treatment. And Mr Low has asked whether we can give an assurance. Sir, that is an assurance. Every Singaporean, no matter how poor he is, will be given medical treatment and, later when his bills are sent to him, if he applies, we will waive them.”
“And we must make sure that we vet carefully so that the sum that is available, which must always be limited, is used carefully and wisely. Mr Loh Meng See asked which would be the approved hospitals. He asked whether community hospitals would be included. Mr Low now says that he is asking for clarification as to whether Mount Elizabeth and the private hospitals would be included. Sir, we must get back again to the objective of Medifund. Medifund is to help poor, indigent Singaporeans who need medical care in the hospitals. So we must only make sure that those hospitals that are catering for this group of patients will be approved. Obviously, Mount Elizabeth and the other private hospitals would not be catering for these people, unless they have a welfare or charity section of their own. Mount Elizabeth and the other private hospitals will therefore not qualify. Yes, we will also be considering the community hospitals and we will be in favour of approving them because they too perform a very vital role in our health care system. How would the grants be allocated? We will be waiting for the advice of the Advisory Council when it is formed. But I would expect them to take into consideration the historical waivers being given by the hospitals as well as the composition of the wards - what percentage of the beds are in class B2 and class C, because the poorer patients would be using this sort of beds, and the absolute number of beds in each of these hospitals. Mr Loh has asked that the audit and administrative costs be kept low. The main secretariat support will be provided by my Ministry and there will be no charge to Medifund.”