MAIN AND DEVELOPMENT ESTIMATES OF SINGAPORE FOR THE - FINANCIAL YEAR 1ST APRIL, 1976 TO 31ST MARCH, 1977
Mr Speaker. Sir, I am not quite sure what questions are being asked of me. However, to come to what the Member for Anson has said with regard to the behaviour of nurses in our hospitals, I would like to say that, by and large, I believe the nurses are doing their best. I would like to ask any Member of this House whether he would like to take on the job as a nurse and work on a night shift and, probably with a wife waiting for him in the house, to see whether he would be able to withstand all the stresses and strains that are demanded of him without losing perhaps his composure. That settles the complaint that nurses are rude. We have initiated a scheme in the Ministry whereby nurses are being encouraged to regard patients as human beings and not just objects to be treated. Somebody has given us a sum of $10,000 and this has been deposited in the POSB. The interest accrued will be used for merit awards to nurses commended by the Medical Superintendent or the Heads of Units. It will not be granted on the basis of patients voting for the best nurse, because it is not possible to ask a pediatric patient or a geriatric patient or a mentally unsound patient at Woodbridge Hospital to vote which nurse is the best nurse. Hence, we have to have a scheme which will allow some Unit Heads leeway to judge which nurses are performing their duty and more than that. Far from receiving complaints that nurses are rude, I have on the other hand received letters, and there have been letters written in the Chinese papers, commending on the good behaviour of nurses. I have been very pleased and I have transmitted these letters to the Medical Superintendent of the hospital concerned. I do not believe we are facing a situation where it is impossible or difficult to recruit nurses. On the contrary, the demand to enter the nursing profession is there and I can assure the House that we will be able to tap the best of applicants. Whether or not the younger nurses are bullied by their superiors, that is a matter which I am not aware of. All I know is that I visited a private hospital recently and when it was known that I was going to visit this private hospital, everything was made spick and span. The attendants and the nurses were alerted. Patients were given new pyjamas and the Administration told me to come along again another time. It is true that sometimes the administration of a hospital can be slack. Because a hospital operates 24 hours a day for 365 days a year, many of those working in the hospital - doctors, nurses and paramedical staff - sometimes, do take things for granted and that many of the routine matters appear to them to be unimportant whereas they are important to patients. I have emphasised to the Medical Superintendents that this point must be looked into and I hope to see a distinct improvement. The Member for Kim Seng himself incidentally works in the General Hospital and so he should be in a position to know whether there is any improvement or not., If he does come across rude nurses, please do let me know and if he comes across affectionate nurses, please also inform me. With regard to emigration of doctors. I am afraid this is a problem which is of concern to the Government. As such. we did do a survey on doctors who were in Government service, asking them the reasons for leaving the Ministry of Health. The first results which have been evaluated have come in. The reasons given for leaving Government service are as follows: Higher income - 48.1% More job satisfaction - 25.5% Better working conditions - 5.2% More freedom - 6.7% Completion of contract or termination of temporary appointment - 4.5% Other reasons - 10.0% So there are at least 48.1% of doctors who were honest enough to admit that they were leaving the Government service because they could earn a higher income. I am just asking myself: how long is the Member for Kim Seng going to stay with the University too' I hope he does not let me down. It is a fact of life that doctors are mobile. At one dinner function I had occasion to meet the President of a Royal College of Surgeons from the United Kingdom. I asked him why did he study medicine instead of engineering, since his country was in the forefront of the industrial revolution and that engineers performed a dominant role in promoting economic growth in his country. His answer was very simple: medicine is the most secure job. It means that doctors can move about, particularly doctors in the English speaking world. Singapore doctors are brought up in the English language and so they are welcome to migrate to Australia. Canada, the United Kingdom. New Zealand and the United States. It is a fact of life that many of our young graduates, while preparing for the final year for M,B.B.S., do go up to Bangkok or Kuala Lumpur to take the external examination conducted oy the American Council for Foreign Medical Graduates, so that after they have graduated they could put after their names "M.B.B.S., E.C.F.M.G.". I am not sure whether the Member for Kim Seng has done that, but he should know as he has lived in a hospital among the medical undergraduates, most of whom have done this. This applies not just to the Malaysian undergraduates but also the Singapore graduates as well. Assuming that we are critically short of doctors, I have no hesitation to impose compulsory national service .for women doctors, just as of this moment male doctors are obliged to undergo 2� years' national service. Some of these national service doctors come under the control of the Ministry of Health. Others are under the Singapore Armed Forces. There is indeed a complaint about discrepancy between the treatment accorded to male graduates and female graduates and I give due notice that (it may be at some future date) I will make it compulsory for all those who have undergone an expensive medical education to return in kind by performing similarly 2� years' service in the Ministry of Health. With regard to the recruitment, loss and establishment strength of doctors. I can provide figures for four years as follows: Number of Doctors Resigned Recruited or Retired Net Gain 1972 61 59 2 1973 144 61 83 1974 119 87 32 1975 90 74 16 It is fair to say that those whom we recruited were of medical officer grade and many of them did not have a higher or postgraduate medical qualification. Some of those whom we lost did have seniority and specialist qualifications. In 1975. 13 Singapore citizen doctors with a higher qualification and 42 without a higher qualification, had resigned. Among Malaysian citizen doctors, no one with a higher qualification had resigned, but nine without a higher qualification had resigned. One doctor from India with a higher qualification had also resigned and there were others too - one with a higher qualification and two without a higher qualification - who had resigned. I must confess that it is not a good trade-off -losing an experienced doctor and gaining inexperienced medical officers. But we have to face the fact of life that many doctors do make use of our hospitals and the University as a stepping stone whereby they can acquire experience at public expense and after some time they resign. When I was at the University it was very marked indeed that the moment someone was promoted to an Associate Professor, he was called "Professor" by his students and patients. In less than three years, most of them would resign. So knowing that this is the way doctors behave, I think the remarks of the Member for Kim Seng should be directed at his own colleagues and not to the Minister for Health who, after all, is trying his hardest to keep the doctors. It is not in my position to go along and give them more money. This is a prerogative of the Treasury which ties salaries up to other professions. But if taxpayers are willing to pay a special sum of money for better health service, then we can suitably reward doctors, nurses and other para-medical staff. If the Member for Kim Seng were to go round and propagate his idea that there should be a special health service tax. then I think it is quite possible for us to retain our more senior doctors so that they do not go into private practice or migrate. I live to regret what I said in a speech when I was at the University - that Orchard Road was the Harley Street of Singapore. The end result was that "specialist centres" popped up all over the place. Orchard Road is bigger than Harley Street now. Anybody who has got a little cubicle in the complex called the Specialist's Centre becomes a specialist. Whether or not this helps the migration of doctors from the public sector to the private sector is debatable. I thought I was boosting the morale of the doctors, but it turned out to the disadvantage of the Ministry of Health and the University. It is also true that doctors are not stupid. They do read their newspapers. They follow political events in the region and they know what has happened in Indo-China. When a three-star General buzzes off to the United States, he becomes either a taxi-driver or a waiter in a restaurant. On the other hand, ri you are a doctor and you migrate to the United States you are wanted. I have my own forebodings that a good number of our doctors in Singapore are registered not only in Singapore but also registered overseas, because Australia. New Zealand and the United Kingdom permit the registration of doctors even though their physical presence is not required in those countries. 4.45 p.m. I remember it was last year, just before the Australian Government announced the closure of its registry for medical doctors, when I was told the story that SIA was carrying Singapore doctors to Perth or Sydney and Qantas was bringing them back, These are human failings and doctors are not without their failings. I would be the last person to say that doctors are "Gods". Although they are healers, they do look after their own welfare as well. Let us be honest. The Member for Kim Seng would be a good Political Secretary to me if he is willing to serve in my Ministry at a salary of $1,750 per month. He can resign from his present post in the University where he is probably getting more than I can give. He can be my Political Secretary and do a little campaigning on how to keep our doctors in the Ministry and in Singapore. It will not be a great loss as long as these doctors stay and practise in Singapore. But it will be a loss when they migrate. It is a fact of life that even Colombo Plan scholars who were sent abroad to study medicine, had paid up their bonds at substantial rates, $40,000 each, and just buzzed off. I was responsible for trying to bring the establishment of the Medical Department in the University of Singapore to full strength by changing the scheme of service in the University, hoping to get better and brighter young doctors willing to teach. But unfortunately not all of them have lived up to my expectation. Worse still, the seniors have set the bad example in that after promotion either to the professorship, associate professorship or even to senior lecturership, they would pack off within three years or so. This is the answer to the Member for Kim Seng. As for the nurses, my sympathies are always with them. Mind you, if you are a patient in a hospital, you see the doctor only once in the morning. But the nurses see you for 24 hours a day. If I were the Member for Anson, I would be very careful when talking about the behaviour of the nurses, because they are going to look after me for 24 hours a day. The doctor diagnoses the ailment and puts the stethoscope to your chest. The technician takes your electrocardiogram. The doctor then prescribes the medicine and that is that. It is the nurses who give you the medicine and the injection. It can be very painful sometimes if they inject you at the wrong place. Mr Speaker. Sir, I really do not know how to put my finger on the particular problem that the Member for Anson or the Member for Kim Seng has raised, But one point raised by the Member for Kim Seng is about dental therapists. In China they have what they call "bare-foot" doctors. It is a very simple philosophy which is being practised in many developing countries, viz., make the most use of whatever manpower resources you have. It is impossible for a country with 800 million people to provide medical services of the standard that we see in Western countries. I do not see how China will ever have such large numbers of Western-trained doctors to serve every commune in the countryside. Therefore, they have a short course of three years for "barefoot" doctors after which they can provide primary health care. The same situation applies to Singapore, particularly to dentistry. I do not say that Division II dentists are quacks. By gosh! I have not yet been to a Division II dentist but my old amah used to go to a Division II dentist and she paid only $3 for a tooth extraction, If she had gone to a Division I dentist she would have to pay $30 There is an enormous difference in fees between going to a Division I dentist and a Division II dentist. The dental therapists that we are recruiting will come from the dental nurses who would have to have a minimum of five years' experience after three years' training. Dental students who graduate from the University of Singapore undergo a mere four-year course of training, immediately after which, even without housemanship, they are allowed to treat patients by themselves. On the other hand, dental therapists are not permitted to do so. Even after training for four years, they need to have ten years' supervision by professionally qualified dentists before they are allowed to go on their own. Therefore, if a patient has to decide whether he wishes to be treated by an experienced person or by an inexperienced one, he would rather be treated by a person who has the requisite experience. Much of the bread-and-butter of dentistry involves simple filling and extraction, Dental therapists are not allowed to perform an operation on the soft tissues. They are not allowed to do orthodontics whereas the professional dentists are allowed to do so.The difference is that dental therapists do not have the two year-course of Higher School Certificate that the University dentists have. All in all. I think it is very unfair for the Member for Kim Seng, who has just returned from London and who was not here when the Dentists Registration (Amendment) Bill was passed, to give the poor dental therapists a bashing. We have got the first batch of dental therapists in the first year of training. They will not pass out until after 1978. Even so, they would have to have another 10 years' supervised experience before they can be out on their own. It was a mistake of the Ministry of Health to have allowed the Division II dentists' registry to run down. The end result is that dental assistants who had been hired by these dentists are finding themselves out of job because their bosses have retired and they have not been replaced. I know it because they have written to me. We have got to understand what exactly it is that we are prepared to pay for. If the taxpayer in Singapore is prepared to pay a special levy for medical and dental services, then I would be fully in favour of charging the taxpayer accordingly and give the service that he is asking for. But the Member for Anson earlier on complained about the increase in hospital fees. Here, we have a contradiction. On the one hand he wants a service and on the other hand he refuses to pay. You cannot have your cake and eat it. Either you pay for what you consume or you do not consume because you cannot pay. Again, this is a problem which is being examined very closely in my Ministry apart from the other programmes which we hope to implement within the Ministry. Over and above all this. I would like to emphasise that the Ministry of Health's primary function is probably less curative and more on preventive medicine. The way to do it is to activate medical education for the man-in-the-street, so that he learns how not to fall sick and, therefore, how not to go to the hospital. It is not necessary for a sick person to be referred immediately to a hospital. There are outpatient dispensaries where doctors are well qualified to examine the patients and the charge is only $3, including medicine. The Member for Anson has also said that the medicine dispensed by the hospitals is not effective whereas the medicine dispensed by the Chinese sin sehs is effective. He rather shook me. If that is true, then I think we ought to close down our hospitals and advise all patients to seek whatever treatment is available in town. But I do not believe it is as simple as that.