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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“Measures for the control of AIDS must now be targeted at all sectors of the population. Sir, my Ministry firmly believes that education is the key to preventing the spread of AIDS. This is because anyone can easily avoid being infected by the HIV. All he has to do is to be sensible, and avoid high-risk activities. The HIV is normally transmitted through two main ways: either sexual intercourse with an infected person or through the blood, for example, sharing injection needles with an infected person. We will therefore step up our educational efforts to remind Singaporeans about the danger of AIDS, and how the disease is transmitted. Our health education programme is conducted through talks, exhibitions, pamphlets, posters and the mass media. An AIDS telephone Helpline has been in operation since 1988 to provide anonymous counselling for members2 of the public. Personal counselling is also provided to persons with high-risk behaviour. We will continue to follow up on HIV-infected persons. Specially trained doctors and staff will continue to counsel and encourage them to take the necessary precautions so that they will not infect others. Contact tracing is also carried out so as to prevent the further spread of the disease. We will also continue to protect our national blood supply. In 1989, we incorporated a declaration in the questionnaire which all potential blood donors have to answer before they are allowed to donate their blood. It requires potential blood donors to declare the truth about their HIV status and risk behaviour. Donors who made a false declaration are liable for prosecution under the Penal Code. This helps to ensure that persons engaging in high-risk activities are excluded from donating blood.”
“Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time." The Infectious Diseases Act was enacted in 1976 to prevent the introduction and spread of infectious diseases into Singapore. In the late seventies, doctors in the USA encountered a new and deadly infectious disease amongst their patients. In 1981, the disease was identified, and given the name "Acquired Immunodeficiency Syndrome", or AIDS. Scientists also discovered that AIDS was caused by the Human Immunodeficiency Virus, or HIV. AIDS has spread very rapidly since then. In the short period of 10 years, it has become a pandemic, affecting millions of men, women and children on all continents. The World Health Organisation (WHO) estimates that about 12 million adults and children are today infected with HIV. What is frightening is that WHO projects that this number will increase further to 30 to 40 million by the year 2000. What about the AIDS situation in Singapore? In Singapore, we found our first HIV-infected person in 1985. Following this discovery, my Ministry gazetted HIV infection and AIDS as notifiable diseases. Up to the end of January this year, 111 Singaporeans were found to be infected with HIV. What is worrying is that the rate of infection is increasing. We had 10 new HIV-positive cases in 1989, increasing to 17 in 1990. Last year, the number of new cases shot up to 42. We expect the number of infected persons this year to be even higher. The pattern of infection has also changed. Initially, homosexuals and intravenous drug addicts were the main groups at risk. Now heterosexuals form the majority of those newly infected. This change has significant importance and implications for all Singaporeans.”
“Sir, there is always room for improvement in any hospital. The question is to what extent. Normally, the doctors will vet all patients carefully and ensure that they are suitable for discharge. Of course, patients may prefer to stay longer in the hospital, especially in the Class C wards where the charges are very low, rather than be discharged home or into a nursing home where they may have to pay even more. They will then consider themselves to be prematurely discharged, but actually they are well enough and do not require to be kept in an acute hospital which is really meant to cater for people with acute illnesses. ROAD TAX AND DIESEL TAX (Change in basis of computation) The following question stood in the name of Mr Lew Syn Pau -- 6. To ask the Minister for Communications whether he will consider changing the basis of computation of road tax for cars and diesel tax for taxis from a monthly to a daily one.”
“The median waiting period for patients requesting for an appointment to see a specialist has been reduced from 11 days in 1990 to 3-6 days in 1991. In the other hospitals, the median waiting period varies from 7 to 14 days, which is much longer. Patients are now happier with the medical and nursing care, meals and ward accommodation provided by Alexandra Hospital. Patient surveys show that 74-94% of patients rate these services as excellent or good, compared to only 60-88% in 1987. As a result, more patients are now using Alexandra Hospital. In 1991, the number of hospital admissions increased by 4% to 19,700, while the Specialist Outpatient Clinic attendances increased by 8% to 64,100. Sir, my Ministry is continuing to upgrade Alexandra Hospital. We are now undertaking major physical upgrading works in Alexandra Hospital costing $18.2 million. This will enable us to provide more B2 wards, and better ward facilities. We will upgrade the operating theatres, add a day surgery suite, and expand the Intensive Care Unit. There will also be facilities for geriatric patients. All these will help to improve the level of service to patients in Alexandra Hospital even further.”
“Mr Speaker, Sir, Alexandra Hospital (AH) is a medium sized 400-bedded acute general hospital. It has departments of general medicine, general surgery, orthopaedics and paediatrics. It also has a 24-hour accident and emergency service. Alexandra Hospital has been able to improve its facilities and level of service in recent years. It is now comparable to the other Government hospitals. Let me list out some of the improvements. Alexandra Hospital now has 89 doctors, compared to only 66 doctors five years ago. This is an increase of over 35%. Patients, especially those with complex medical problems, can now obtain a much higher level of medical care. Alexandra Hospital has a total staff strength of 882, giving a staffing ratio of 2.2 per bed. This is comparable to the other general hospitals as well. The hospital has also been upgrading its equipment and operating systems. It recently installed new X-ray equipment costing $0.5 million. This has resulted in a shorter waiting time for patients. Alexandra Hospital has computerised its patient registration, billing and appointment scheduling. It has also improved its Accident & Emergency and Specialist Outpatient Departments. Sir, all these improvements have enabled Alexandra Hospital to provide a more efficient and faster service to patients. For example, at the A&E Department, 75% of all patients were seen within 53 minutes in 1989. In 1991, this was shortened to only 27 minutes. A&E patients have to generally wait longer in the other hospitals. Similarly, in the Specialist Outpatient Clinics, 75% of all patients are now seen within 40 minutes, compared to 50 minutes in 1989. In the other hospitals, the waiting time varies from 40 to 70 minutes.”
“Sir, they will in no way be involved in determining whether medical treatment should be given because they are in no position to make such decisions. So I hope that the Member for Bukit Gombak will take the discussions of issues in this House very seriously and do his basic research before coming here and making such simplistic statements.”
“Sir, if the private hospitals are indeed cheaper than SGH, I can assure you that Singaporeans, being very, very careful about value for money, would be flocking to the private hospitals and SGH would have a dearth of patients for the B1 wards. Unfortunately, the contrary is the truth, ie, in SGH, patients who want to go into the B1 wards, unfortunately, have to wait today for their beds because they are so popular. Surely, Singaporeans are no fools. If it is so much more expensive to go to SGH, they will speak with their wallets and with their feet. Sir, he has also mentioned about Medifund. He asked: how can we allow community leaders to determine who should receive subsidies from Medifund and allow the community leaders to make decisions on medical matters? Again, he has talked in a knee-jerked manner without first determining exactly what is the proposal. Again, a very simplistic approach to the discussion of the issue. Sir, the concept of Medifund is that the patients who find that they are unable to pay the fees for medical treatment can make a request for additional subsidies to be given through Medifund. The Government can take the easy way out by referring all these requests to the Ministry of Health. But we feel that by allowing community leaders to take part in this approval process, we will be able to bring the decision-making to a lower level and to a group of people who are likely to be more compassionate and who have a better feel of what is happening on the ground. So therefore the proposal to bring in community leaders into this process of determining who should be receiving the additional support from Medifund.”
“Sir, I would like to respond to some of the remarks made by the Member for Bukit Gombak. Sir, firstly, I am glad he applauds the Government for continuing the subsidy for B2 and class C wards. I am also glad that he agrees that we should charge at least the running costs for the class A and B1 wards, being unsubsidised wards. As stated in the Presidential Address, we will continue to gradually increase the recovery rates for A and B1 wards, because at the present moment they are still being subsidised. So we will be doing that. I am glad that Mr Ling fully agrees with us. Sir, he has made some very simplistic statements about the pricing of the B1 beds in SGH versus the beds in the private hospitals. I agree with him that private hospitals are doing business and therefore they must make a profit. But obviously, although he is in the private sector, he does not understand the mechanism of pricing. Sir, there are such things as loss leaders in business; if not loss leaders, at least attractive packages to get people in through the front door. The pricing of hospital beds in private hospitals, unfortunately, is a very classical case of pricing low to get people in through the front door. Patients who go in to a private hospital pay between $150 and $170 only for the bed. That, unfortunately, is not what the patient actually ends up paying. If Mr Ling had taken the trouble to find out from his friends about the actual bill sizes for patients in private hospitals, he will find that the cost to the patient is not $170 but that the final bill size in private hospitals is routinely in excess of $600. This is only for the hospital portion of the service. It does not include the services of the doctors or the anaesthetists. Those are over and above what is payable.”
“Sir, the average bill size per day for SGH is $59 and in the other restructured and Government hospitals, it is about $52 per day. HDB VOID DECKS (Removal of payphones) 14. Dr Koh Lam Son asked the Acting Minister for Communications why payphones are being removed from Housing and Development Board void decks. The Acting Minister for Communications (Mr Mah Bow Tan): Mr Speaker, Sir, Singapore Telecom constantly reviews the deployment of public telephones in Housing and Development Board estates. If a public telephone is found to be poorly utilised, it is redeployed to a more convenient location. Conversely, in areas where payphones are well utilised, more public telephones are installed. In addition, desk-top coinaphones are installed when there is demand for coin-operated telephones. The total number of payphones, including desk-top coinaphones installed mainly in shops and hawker centres, has increased by 10% in the past four years. There are now some 26,000 payphones compared to 23,500 in 1987.”
“Mr Speaker, Sir, currently the daily ward charge for Class B2 in the Singapore General Hospital (SGH) is $40 compared to $38 in the National University Hospital (NUH) and $28 in the Government hospitals. The daily ward charge in the other restructured hos- pitals, namely Toa Payoh Hospital and Kandang Kerbau Hospital, is also $28. The Class C ward charge in SGH is $22 per day, and in the other Government and restructured hospitals, it is $17 per day. Sir, manpower costs make up over 70% of the operating costs of a hospital. The hospitals must pay competitive salaries in order to attract new staff and to retain existing staff, otherwise the level of service will suffer. It is inevitable that as wages go up, fees must also increase. However, over 80% of Class C and 70% of Class B2 cost increases are absorbed by the Government, ie, patients pay less than 20% and 30% of the cost increases respectively. SGH had made some minor fee adjustments in January this year, and has no plans for a general fee revision at the present moment.”
“Mr Speaker, Sir, Class C wards in the Singapore General Hospital have been fully operational since December last year with a total of 157 beds. From January to May 1991, there were a monthly average of 622 admissions into the Class C wards and this came to about 9% of the total SGH monthly admissions. A survey covering 450 patients was conducted in February to ascertain the socio-economic background of the Class C patients. The survey showed that: 59% of the patients were aged 55 or above; 60% live in 3-room or smaller HDB flats (the remaining 40% were living in 4-room or better flats); the patients were hospitalised for an average of 7 days; and the bill size averaged $277 or about $40 per day. The Class C wards enjoyed an average occupancy rate of 80%, which is similar to the overall hospital occupancy rate of 77%. A separate survey in February also revealed that about 23% of the patients in Class C wards were actually awaiting transfer to Class B2 or better wards. Sir, the feedback from patients so far has been satisfactory. All patients in Class C wards of SGH as well as the other Government and restructured hospitals are under the charge of specialists. Their management is supervised by the specialists and other medical staff of the ward and thestandard of medical care is comparable to that of patients in other wards. CREDIT CARDHOLDERS (Amount utilised) 9. Mr Heng Chiang Meng asked the Minister for Finance if he will give the number of credit cardholders and the dollar amount of credit utilised via credit cards for the years 1988, 1989 and 1990.”
“Yes, we will also be looking into the existing ones.”
“Sir, I will first deal with Mr Choo Wee Khiang's question on dialysis centres. At the present moment, we have no means to control them, but we intend to control them this year through the Private Hospitals and Medical Clinics Act which will be brought into operation later in the year. The Accreditation Unit which I announced yesterday will then publish the guidelines setting out the necessary standards that would have to be achieved in terms of staffing, in terms of having trained renal physicians on hand and all the other items. They will make sure that there is full compliance. The guidelines will also ensure that the operations will pose no medical hazards or health hazards to the people who are living in the vicinity. My Minister of State will answer the other questions.”
“Sir, yes, definitely, I will ask the hospital management to let their staff know that when patients are being prescribed non-standard drugs, they should be told about the prices. This way they will not be stranded.”
“Dr Wong Kwei Cheong has also asked whether we can help the B2 and C Class patients who are facing problems. Sir, we will definitely help them. Those who request to pay by instalments, we will definitely allow them to pay by instalments. And for those who cannot afford, we will waive the fee.”
“With restructuring, we have been able to give the job to the restructured hospitals and then they recruit to make sure that they have the required expertise to undertake the rebuilding programme. So it has also allowed us now to proceed with all three hospitals, instead of having to stagger them over maybe 10 to 15 years, which would have been the case if we have to do it at the HQ. Sir, to sum up, improvements have been made, but I think there is still more work to be done. The hospitals will have to explore more cost-effective ways to achieve these improvements. But since these services are provided by people, inevitably, more manpower will have to be found. All these mean higher costs. We hope patients will bear with us and be prepared to pay for the much better services that they request for and which they will be receiving.”
“Some of the records are with the doctors, others are still in the wards, especially for patients who have just been discharged a few days earlier. Their records may still be in the wards while the doctors work on updating the records. Sir, the problem I foresee will get tougher to solve in the years to come. Because as the service quality improves, I think those hospitals that are improving faster tend to also draw in more patients. So it is going to be a spiral - you improve, more patients, your service gets back to square one, make improvements again. So that problem will have to be faced. And the answer to that is to upgrade the other hospitals and give them more flexibility to respond to problems. This is best done through the restructuring programme, and we will extend it to Tan Tock Seng Hospital early next year. We also find that patients tend to go to newer hospitals, for example, SGH, NUH, which are highly in demand. The older hospitals are not so preferred by the patients. As Dr Hong Hai pointed out yesterday, our hospitals are fairly old, especially Woodbridge Hospital. And that is why in planning the rebuilding programme, we have to prioritise. Since Woodbridge Hospital is the oldest and hardest to renovate on a short-term basis, we decided to rebuild Woodbridge Hospital. Now we are planning to rebuild the three hospitals - Tan Tock Seng, Kandang Kerbau and Toa Payoh Hospitals. The fact that we are able to undertake the rebuilding of all three hospitals at the same time is also due to the fact that the hospitals are now able to handle these projects on their own. In the past, all hospital projects were handled at the HQ.”
“All these patients were channelled to the pharmacy for their medication and the pharmacy was not able to respond to that significant increase in throughput. Secondly, they were facing some staff shortages as well. It is a common story among many companies in Singapore. SGH faces the same problem. They have some staff shortage in the pharmacy. I think most companies find that January is an easy time to recruit staff. So they were able to make up for the staff shortages. And by late January this year, I am happy to inform Mr Yeo and Members of the House that the waiting time in the pharmacy in the Singapore General Hospital has again been reduced to 28 minutes. This is an improvement, but I think much work still has to be done. Mr Yeo also brought up the situation of medical records not being available. Sir, this has been a perennial problem in all our hospitals. With restructuring, I think we have managed to make much headway. For example, in Kandang Kerbau Hospital, before restructuring, 9% of the patients found that when they arrived at the clinic their medical records were not there. By the end of 1990, that number had fallen to 0.1%, ie, from 9% dropping to 0.1%. That again is a remarkable achievement. For the Singapore General Hospital, in 1989, they had 4 1/2% of missing records. By the end of last year, that figure had dropped to 1.4%. Again, some improvements, but work is still needed in this area. 1.00 pm The problem is many patients in SGH tend to turn up without appointments. Therefore, when they turn up without appointments, the records understandably will not be there, and so they have to wait for their records to be located.”
“Secondly, for those cases where the doctors have to be called away on emergencies or other reasons, to keep the patients informed as to why the doctor is not there, and to give the patient an estimation of how much time he has to wait and to provide the patient with an alternative doctor. For example, "Dr XYZ has to be called away. He is likely to be away for an hour in the operating theatre. In the meantime so and so is available. Would you like to be seen by that doctor?" This would give the patient a choice of waiting for his own doctor or to be seen by another doctor a little bit earlier. In terms of other areas, there have been some improvements too. For example, in the registration time before seeing the doctors in the clinics. In SGH, in 1989, it took a patient 30 minutes to be registered. It was a long wait. Even before going to the clinic he has to wait for 30 minutes. Today, that waiting time has been reduced to 12 minutes, again, a significant improvement. The area where we have had problems, and that is the area that has been identified by Mr Yeo, is the pharmacy. I admit that the pharmacy faced a little hitch. When SGH was restructured they managed to improve the pharmacy waiting time. For example, prior to 1989, the median waiting time was 30 minutes or thereabout. By August 1990, they had managed to bring their waiting time in the pharmacy down to 22 minutes, from 30-plus minutes down to 22 minutes. But between August 1990 and December 1990, they faced certain problems and the median waiting times in the pharmacy increased to 41 minutes, almost doubled. There were two reasons. One is between the middle of the year and the end of 1990, the patient load in the Singapore General Hospital increased by 15%.”
“When I said "median", it does not mean that in every department the median waiting times are the same. There are many departments. Some departments have smaller patient loads, others have had big increases in patient loads. So when I say the median time is 37 minutes, it means that for SGH, 900 patients every day wait less than 37 minutes; but it also means that another 900 patients every day wait more than 37 minutes. Sir, the problem is that in the specialist outpatient clinics, the waiting times are not very predictable. There are many reasons. One is that some of the cases may be more complicated than anticipated and therefore the doctors will have to spend a lot more time examining them than would the average patient. This is also because as these are general hospitals, they will also have to be called away occasionally to deal with emergencies in the A&E; they may be called away to deal with emergencies in the wards as well as for deliveries. And for surgeons who are scheduled to go to the outpatient clinics after surgery, certain operations may take longer than anticipated. Therefore, they turn up late and then the queue builds up. The answer to all these is, firstly, as pointed out, to ensure that the appointment times being allocated are realistic. The hospital will continue to review this and make sure that there is a close feedback loop. They will review what are the actual times taken, feedback to the appointment system to make sure their appointments are scheduled, take those times into consideration.”
“Last year, after restructuring, they had reduced it significantly to only 25 minutes, a reduction of 35 minutes in the median waiting time. Kandang Kerbau Hospital started off with 69 minutes median waiting time. By last year they have reduced it to 53 minutes, a reduction of 16 minutes, but it is still long at 53 minutes. For the Singapore General Hospital, in 1989, it was 48 minutes. Last year, it had reduced to 37 minutes, a reduction of 11 minutes. Sir, there are some reasons as to why these figures are there. One reason is that when Toa Payoh Hospital was restructured, we transferred some departments over to Kandang Kerbau Hospital. Therefore, their attendance rate has dropped and that has enabled them to improve their level of service. For Kandang Kerbau Hospital, they face a big challenge. When they were restructured, we transferred many departments from Toa Payoh Hospital and Alexandra Hospital to Kandang Kerbau Hospital. As a result, their patient load went up from 28,000 in the first quarter of 1990 to 48,000 in the fourth quarter of 1990. This represents a 70% increase in patient load. I think in any institution, such increase would swamp the operations. For Kandang Kerbau Hospital to have been able to improve the median waiting time to 53 minutes is still very commendable. For the Singapore General Hospital, this is the hospital with the biggest patient load. For the first quarter of 1989, 90,000 patients in the specialist outpatient clinics. For the fourth quarter of 1990, the numbers had increased to 117,000. This represents an increase of some 30% over eight quarters. So patient load is increasing, yet at the same time they have managed, on the average, to reduce the waiting times. Sir, again, the waiting times are not uniform.”
“I think the problem here is that the restructured hospitals have recruited many clerical and administrative staff in the last two years. It will take the staff sometime to be familiar with the many terms and procedures. So I think we should try to give them more time and I am sure their knowledge of the hospital operations and medical terms will improve. They are also given training in public relations and communications. This will enable them to interact in a much friendlier and more effective manner with the patients and the public. Sir, to-date, the number of staff that have been sent for training has been quite significant. For example, in the Singapore General Hospital, 2,700 of their staff have been trained in these areas, in Kandang Kerbau Hospital, 970 and in Toa Payoh Hospital, 500. In terms of service quality, the hospitals' objective has been to improve the service quality. The key areas are in the clinics, in the pharmacies and in the admission waiting areas. What they have done is to review the work flow, the work processes, and they have streamlined them. Because of the greater autonomy that they have, they have been able to recruit more staff and therefore to reduce the vacancies. They have also made better use of computers and introduced more automation. The main complaint so far is, as Mr Yeo has brought up, queuing times in the various departments. Sir, the hospitals have made attempts, and I think they have achieved some improvements in the service areas. Let me give some examples. In the specialist outpatient clinics, in Toa Payoh Hospital in 1989, ie, before they were restructured, the median waiting time was 60 minutes.”
“Sir, Dr Wong Kwei Cheong has asked for a status report on the restructured hospitals and Mr Yeo Toon Chia has talked about the poor service in the restructured hospitals. Sir, within the limited time that I have, I would not be able to give Dr Wong a full status report, but what I will try to do is to give a very brief overview and then answer Mr Yeo Toon Chia. Sir, the restructuring programme, which is meant to give the management of the hospitals full autonomy, has worked very well because now the hospitals only have to go to their Boards to get approval and implement whatever improvements they want to have. They do not have to go through a long chain of approval processes. As such, the hospitals have been able to make many physical improvements, for example, Toa Payoh Hospital and Kandang Kerbau Hospital. I think any visitor going there today would be quite pleasantly surprised by the very drastic change, which has not incurred very much expenses at all. They have managed to renovate their Specialist Outpatient Clinics (SOCs), make them more pleasant and better ventilated. They have installed better signages. Patients now would not get lost wandering round the hospital and, therefore, the place is more patient-friendly. They have also managed to repaint their hospitals with warm friendly colours, not the normal sterile white colour. So, overall, the physical environment has improved. He has asked for staff training. Sir, in the restructured hospitals, all staff are provided training in two areas. Firstly, hospital policies and procedures. This meets the point raised by Mr Yeo Toon Chia. The staff are given training in the hospital policies, procedures and medical terms.”
“Mr Speaker, Sir, I beg to report that the Committee of Supply has made further progress on the Main and Development Estimates for the financial year 1991/92, and ask leave to sit again tomorrow.”
“Sir, the public has a full range of qualified doctors to go to, ranging from doctors in the polyclinics whose fees are very, very affordable and much cheaper than many Chinese physicians, to very high price physicians in very fancy offices. If Singaporeans choose, in spite of the existence of qualified doctors trained to certain standards, to go to a Chinese physician, I think it is important for them to realise that they should choose their physicians carefully. Mr Chiam See Tong rose -”
“Sir, Chinese physicians have been existing in Singapore for many, many years. They have gone through many, many different types of training, from apprenticeship with friends, with parents, to training in other countries for which we have no information about the content of the training or the sort of training that they have received. It is not possible for the Government to step into an area where there is no control and no standards. So this situation will have to remain. And I think Singaporeans will have to be very careful in terms of choosing which Chinese physician to go to.”
“Sir, he should look at the name of the scheme. It is a Catastrophic Illness Insurance Scheme. It is not a scheme to cover the average medical case. It covers only those cases that belong to serious disease groups or who require long hospitalisation. This is the group which will be incurring heavy expenses and this scheme is meant to alleviate their burden.”
“Mr Peh has also asked for traditional Chinese medicines and herbs to be registered. My Ministry has been randomly sampling imported processed and manufactured Chinese medicines to ensure that they do not contain arson, mercury and other heavy metals or poisonous substances. Those items found to be dangerous are banned. I must stress that we are only randomly sampling and even then for the presence of heavy metals and poisonous substances. We do not have the capability to check and analyze every brand or type of Chinese medicine that is put on sale here. For a drug to be registered, it would have to comply with accepted standards of manufacture and quality control. The manufacturer is also required to analyze each and every batch produced for its exact composition and to be audited periodically by our local authority. With regard to herbs, I am not too sure how a herb can be registered, since it is a plant item whose quality varies very, very widely. My Minstry therefore does not intend to register Chinese herbs and medicines. We will continue to study what is being done in other countries and to learn from their experience. Sir, with regard to the Faculty of Chinese Medicine, I am sorry that it is not within the purview of my Ministry. Mr Peh may wish to pursue this further with the Minister for Education.”
“Yes, I agree with him, and we do provide good health care, as I have stated earlier this afternoon. And that the B2 and Class C patients, not only have access to the full system, but they pay extremely low rates, rates which are very heavily subsidised by the Government. Sir, Mr Peh brought up three main points: that my Ministry should control the practice of traditional Chinese medicine by registering all Chinese physicians; that we register all Chinese herbs and medicines; and that the NUS establish a Faculty of Chinese Medicine. Currently, there are no requirements for Chinese physicians to be registered since the Government is not involved in their training in any way. My Ministry will continue this present practice of not registering them. Mr Peh has also expressed concern that there are some people who call themselves Chinese physicians only after a few months of training. He has also highlighted the dangers of Chinese physicians mixing Western medicine such as Aspirin and Paracetamol in their traditional medicines. Mr Peh is certainly correct to point out these problems. Chinese physicians are not allowed to prescribe or use scheduled drugs. They are also not allowed to mix scheduled drugs such as antibiotics and steroids with their traditional medicines. We will not hesitate to take legal action against Chinese physicians who are found doing this. Sir, over the past two years, a total of 42 Chinese medicine shops were caught and prosecuted for illegally selling scheduled drugs. The fines imposed on them by the courts ranged up to $35,000. However, there is nothing to prevent them from buying over the counter drugs such as Aspirins and cough mixtures and selling them in a pre-packaged form to their unsuspecting patients. So I will urge patients to be cautious.”
“It is very inexpensive compared to the private sector. The Member talks about life-time payments as being too low. The life-time payment for MediShield is $50,000. For a Class C patient or Class B2 patient, I think even in 10 lifetimes, their bills will not go up to $50,000. So it is more than adequate to cover the disease conditions of those patients who go into B2 and Class C wards. He said that the deductible is too high. Sir, this is a catastrophic illness insurance meant to cover serious illnesses. The quantum has been computed such that it averages 15 days of stay. So any patient who suffers a serious illness and who stays more than 15 days, straightaway they can start claiming. Sir, the number of people who have been paid from MediShield so far shows that it is working. So far, in the short six months from July to December last year that the MediShield has been operating, a total of 2,000 members have already received payment. Of those members who have received payment who are aged 50 and above, they comprise 44% of the number of claims. So I think it is of great benefit to those in the older age groups and that is why although some have opted out, there is still a large number in that age group who have stayed in. He has also asked that pre-existing conditions should also be covered. Obviously, he does not understand the meaning of "insurance". "Insurance" means you insure against future risks. If you also insure against existing risks, then the word "risks" is no longer there. I think he should realise first and foremost that this is an insurance system to insure against future risks. He has also said that it is Government's responsibility to provide health care.”
“It is not a compulsory scheme. I think nowhere else in the world, would you be able to find in a voluntary scheme a participation rate of 88%. So we should not be dismayed that 12% have opted out. We must also remember that a large number of workers are actually covered by company medical coverage, or some of them will also have their own medical insurance although this number of coverage is small. On the question of what we are doing to ensure that the participation rate remains high, the CPF Board will be enhancing its communication programme. It will be carrying out a survey amongst those who have opted out to find out their reasons why they are actually opting out. They will also have a direct mail programme where they will send letters to members who have opted out to encourage them to rejoin the scheme. The CPF Board will continue to publicise the benefits of MediShield and to encourage future members to participate. Dr Lee has asked his usual questions, or made his usual statements as he did last year that the MediShield programme is a dismal failure and that it is not attractive enough. Firstly, he claims that the premiums are not low cost. The premiums are very cheap for a person aged up to 30, he only pays $1 a month. For those aged 41 to 50, they pay $3 a month and all these are deductible through Medisave. The payments by Medishield are also very attractive. For those people who go to C Class wards after an initial expenditure of $500, they can start claiming from MediShi eld and MediShield will pay 80% of whatever they incur. For B2 patients, they pay $1,000. 4.15 pm In comparison to a scheme run by private sector companies, we found that the premiums which have been set by MediShield are between half and one-third of those in the private sector.”
“Sir, Mr Abbas has asked about Medisave, whether we are auditing and what are we auditing. The CPF Board carries out the financial audits while my Ministry carries out the medical audits. In 1989, we carried out a total of 9,500 financial and medical audits. Last year, 1990, this number increased to 12,100 which made up 4.4% of total Medisave claims. In both years, we found that there was no attempt at deliberate abuse of the system. Most of the audits showed that there were no errors and most of the errors that were found were due to administrative errors. For example, certain parts of the form were not filled in completely, or the relevant documents were not submitted with the form for the record. The doctors also had a few cases of wrong coding of operation. What we found was that there were as many cases of wrong coding, which allowed a lower reimbursement of Medisave, as there were for those with a higher reimbursement of Medisave. Upon investigation, we found that again it was an error in interpretation and there was no attempt at abuse of the system. He also asked for a profile of the Medisave accounts. The balances in the Medisave have increased quite significantly since 1984 when Medisave was started, for example, for those accounts with balances above $5,000. In 1985, when we started there were 240,000 accounts with balances above $5,000. By the end of last year, that number had more than doubled to 540,000. Similarly, the average balance had gone up. In 1985, the average balance was $2,500. Today, the average balance is $3,700. Sir, on MediShield, Mr Abbas has asked what are we doing to ensure that the participation rates are improved. MediShield has a 88% participation rate. First, we must remember that this is a voluntary scheme.”
“Sir, as I have pointed out earlier on, he should direct these detailed questions to the SMC, not to this House.”
“Sir, firstly, he has not quoted anything that says that the SMC cannot issue a press statement. I think it is within the prerogative of the SMC to choose whichever avenue it wishes in terms of communicating with the members. Secondly, just because a person of integrity is nominated, it does not mean that he does not function as an individual.”
“Sir, I am surprised that Dr Lee brought all his questions here. Being a doctor, I would expect him to know what are the functions of the Singapore Medical Council (SMC) and to realise that the SMC is an independent body that in no way reports to the Minister for Health. On those detailed questions of his, I would invite him to write direct to SMC for the necessary answers. But, Sir, since he has brought up this issue with all those questions, I think it is important for me to clarify to the public the role of the SMC. Sir, the SMC is an independent body whose job is to register medical practitioners and to determine and regulate the professional conduct and ethics of medical practitioners. He is right that when a complaint is made, a statutory declaration is normally required. But that refers to a case when a member of the public lodges a complaint against an individual doctor against his medical conduct. Sir, when the NTUC scheme was announced to the press, I am sure Members would remember that doctors in private sector were also airing their views in the papers. The SMC had also received approaches from the Association of Medical Practitioners seeking its views and guidance. If they did that, then it is very much within the capability of the SMC to reply to them and to set the controversy to rest with a public statement. I do not see anything wrong with that.”
“Sir, unfortunately, he is not a statistician. Anyway, if he requires more information, my statistician would be very happy to give him some pointers. Sir, I will now ask my Minister of State to reply to the other points.”
“Sir, these are figures which can be confirmed. If the Member wants more details, he can either write to me, in which case we will be very happy to give them to him, or he can file a Question. Dr Arthur Beng Kian Lam: Sir, for average cost like this, as I consulted my statistician colleague, Dr Ho Tat Kin, one would have to have a very average illness. What is an average illness?”
“Sir, I am sorry my Ministry has not received such a proposal from him.”
“Sir, he must check the Hansard to ensure that he understood what I said. I said that if Dr Tan Cheng Bock is interested, we will be very happy to receive his proposal and I will get my officers to look into it.”
“Sir, as I said in my last budget debate, if Dr Tan Cheng Bock is interested, we look forward to receiving his proposal. Check the Hansard, please. Dr Tan Cheng Bock: Sir, I accepted the proposal to run the hospital. If the Minister remembers, I had lunch with him to discuss this proposal. Actually, I am waiting for him to give me the details.”
“For example, as pointed out by Dr Hong Hai and Dr Tan Cheng Bock, with the restructuring programme, tremendous competition is bound to arise, how do we coordinate development? The Committee will look into the role of the Ministry of Health as the national health authority. It will also look into the need to develop further sub-specialties and the need to develop other centres similar to the National Skin Centre and the Singapore National Eye Centre which will allow us to pool and develop our limited resources and also to ensure that we avoid wasteful duplications that would otherwise develop. Sir, the other members of the Committee have not been finalised yet and I will announce them after consulting with the Prime Minister and with Dr Aline Wong. The review is expected to take between 9-12 months and I will keep the House informed of its findings when their report is ready. Sir, Mr Choo Wee Khiang had asked about the costings. I wish to inform him that for Class B2 and Class C patients, the costs of the infrastructure, namely, equipment, building and land, are fully subvented by the Government. So they will not have to bear it. For Class B1, it will have this cost subvented as well, but for Class A, we expect to recover at least a portion of such costs. The subventions will take into consideration this policy.”
“We have restructured our hospitals and, as pointed out by Dr Arthur Beng and also Dr Tan Cheng Bock, with the many new equipment, tests and procedures coming on line very rapidly, the chances of these being introduced in Singapore are also very great. The increased health care costs have come about because of this demand for not just better services but also better facilities. Sir, it is timely that we now take stock of our position in order to better position ourselves for the 1990s and the 21st century. I would therefore be setting up a Review Committee on national health policies to be chaired by my Minister of State, Dr Aline Wong. The Committee will review and make recommendations on four broad areas. These are: Firstly, policy directions. It will review progress in the implementation of the National Health Plan and the priority areas for action, including changes due to changed circumstances. Secondly, the Committee will look into the area on health care financing which is a very key issue. It will look into Medisave, rate of usage, accumulation of Medisave, whether the Medisave contribution rate is adequate and Medisave for the self-employed. It will also look into the subvention policy. Is it adequate? What are our recovery rates and how do we ensure that the basic health care remains highly affordable. Thirdly, the restructuring programme. It will look into the achievements to-date and what are the areas for improvements. It willalso review whether and when should the restructuring programme be extended to remaining MOH hospitals like the Alexandra Hospital and the other hospitals and other MOH institutions. Fourthly, the Committee will look into medical matters and policies.”
“This year, we will also set up a new unit in the Ministry called the Hospital Accreditation and Medical Audit Unit. The job of the Unit is to undertake the accreditation and auditing of hospitals. We will monitor and audit the professional standards of each hospital and the practising doctors. This will include utilisation reviews of expensive investigations and procedures. We will also consider making compulsory for all tissues and organs removed during surgery to be submitted for histological report. This way, we will then ensure that the operations are not being carried out unnecessarily. I think this would be adequate safeguard to make sure that machines that they buy are not being used unnecessarily as well. Sir, Dr Hong Hai and Prof. Maurice Choo in his budget debate had suggested and I quote Prof. Maurice Choo, "that the Ministry reach out to affect not just Government and restructured medical services, but also academic and private medical centres." They have stressed the need for the Ministry of Health to coordinate the overall developments in the health sector. These are indeed sensible thoughts. Many countries today are facing huge problems and we have to guard against such problems. It is not wise for us to take for granted what we have. Sir, in Singapore, health care has undergone significant changes since the National Health Plan was first launched in 1983. For example, over the last eight years, we have Medisave and MediShield. The population has also changed and there is now a tremendous demand for medical services that are similar in quality and in range to that available in the developed countries.”
“Sir, most patients stay only four to five days. There is no need to update those on short stay. For those who are staying longer, more than two weeks, for example, then they should be given frequent updating. Sir, Dr Arthur Beng has also asked that we control and coordinate the purchase of expensive equipment. I would like to assure Members that before the Ministry of Health, as well as the restructed hospitals under the Ministry, purchases expensive equipment, we thoroughly evaluate the need and usefulness of such equipment. Let me give an example, CAT scanners. They were already available in the early 1970s, but it was not until 1983 that MOH approved the purchase of a full body CAT scanner, the first in Singapore, by SGH. Similarly, with the machines called Magnetic Resonance Imaging (MRI). These are very expensive imaging systems and are useful for very specific diagnosis. These MRI machines can give better results and are more effective than either standard X-rays or CAT scans. These machines were introduced more than 10 years ago. Most American Hospitals and even the smaller hospitals have at least one. In Singapore, the first MRI machine was brought in five years ago by a private company. MOH has only approved the purchase of the first MRI by SGH and that was only recently. I understand the machine will be arriving shortly. So we do evaluate very carefully. We will continue to do that, but we do not have any mechanism to control the purchase of such equipment by the private sector. The private sector will have to carefully evaluate its own business plan and carry out its own feasibility studies. But as a precaution, we will not allow the use of Medisave for machines which are new in Singapore until we are satisfied of its proven value.”
“Sir, I now move on to the points made by Dr Arthur Beng. He asked that we update families of long stay patients with weekly bills and to allow such patients to downgrade. Sir, the answer is yes to both the requests. I will take this opportunity to remind the management of MOH and the restructured hospitals that they should be keeping their patients informed on a weekly basis and that for those who require downgrading, to request the medical social workers to look into their cases sympathetically.”
“Sir, the restructured hospitals are still coordinated through the Health Corporation of Singapore. There is still a top level that endorses all the programmes and we are represented on that body, so we will ensure that this is closely monitored. This is an assurance which I can give to the Member.”
“Sir, what I can assure him is that these hospitals will continue to have secondary care services. But as the hospitals evolve, and as the patient load builds up, there may have to be certain adjustments. For example, if certain specialties now have enough patient load where they outgrow one hospital, then the question is: should we just enlarge the hospital with a tertiary department, or should we allow another department to be set up elsewhere, because there is enough patient load to justify another department being opened up elsewhere? It is like, for example, O&G. When we started developing and we had more births, KK Hospital was not the only one with O&G facility. We were prepared to expand to other hospitals. Similarly with orthopaedics. Because there are plenty of orthopaedic cases, therefore, we now have orthopaedics in most of the other hospitals. So it is a question of patient load. But we will ensure that we do not have unnecessary duplication of tertiary development where those are not warranted.”
“Because for those who can afford to choose Class A and B1, they choose so knowing that the subsidies will not be there. At the present moment, they are still getting subsidies. But in the future, we must try to ensure that the lower income groups are the ones who enjoy the bulk of the subsidies, because they are the ones who require these subsidies. For a person who is in the middle-income group or high-income group, if he chooses to be subsidised, he can still be so subsidised by opting for Class B2 or C, because we do not have a means test. So we are not preventing those who can afford the luxury, those who can afford the comfort of the A Class wards, from actually getting the subsidies. They can go in to the more basic wards and they will be given the subsidies. Sir, the demand for the A and B1 wards is already high. Evidence shows it. We did a survey and we found that in the Class C wards, 10.5% of the Class C patients were actually held in the Class C wards while waiting for vacancies to be available in the A and B1 wards. For Class B2, about one in five. 21% of Class B2 patients were actually waiting for a transfer to A and B1. I do not think it is wise for us to subsidise higher class wards. It will only encourage some patients to spend beyond their means and, at the same time, it will reduce the available subsidies for the lower income groups. I think that would be something which we should avoid.”
“Sir, the subsidies have reduced somewhat. But as I have said, our policy is to move towards totalreduction of subsidies.”
“Even for the lowest income earners, their Medisave is more than adequate. The question which Dr Hong Hai has raised is: Should we also make A and B1 more affordable by giving them subsidies? Sir, the policy, as I have stated here in the House many times, is that our aim is to ensure that we recover at least recurrent cost from the A and B1 patients. In SGH, they have managed to recover the recurrent cost, but not capital cost. In Toa Payoh Hospital and the other Government hospitals, each A Class patient still gets $200 subsidy per hospitalisation. So they are still getting subsidies. For the B1 patients, although they are not supposed to be getting any subsidies on the recurrent expenditure, SGH still has to give the B1 patients $250 subsidy per hospitalisation. At Toa Payoh Hospital and the other Government hospitals, the subsidy is even higher - $500 per hospitalisation. So it is not that we are not giving subsidies. Despite the policy of trying to recover recurrent cost, we are still giving substantial subsidies to the A and B1. We will try to gradually reduce these subsidies so that in this way we will be able to free up more of the future subsidies for the B2 and C Class patients who are the ones who truly need these subsidies. The principle must be that we let each patient choose the ward that he wants to get into.”