MAIN AND DEVELOPMENT ESTIMATES OF SINGAPORE FOR THE - FINANCIAL YEAR 1ST APRIL,1977 TO 31ST MARCH, 1978
Mr Speaker, Sir, may I just take up the specific points raised by Members of the House before I enter into a general statement, particularly with regard to staffing the hospitals with doctors. The Member for Anson has stated that we are spending money to improve hospitals and he has enquired whether we have adequate doctors to man these hospitals. I would like to explain that improvements which we are going to make to the hospitals will amount to only $9 million, and they are intended for old hospitals, such as the Tan Tock Seng Hospital, Alexandra Hospital, Kandang Kerbau Hospital and Woodbridge Hospital. All these hospitals were built before the war. I have visited all the hospitals but I must confess that I have not made an exploration into public toilets. If the Member for Anson reports that the toilets are in a disgraceful state, then I must say that it might be a good idea if he carries out an education campaign among the users of public toilets so that they do the right thing in the right place. However. I shall bring this matter to the attention of the Medical Superintendents and the secretaries in the hospitals so that public toilets will be used for what they are intended to be. The Member for Anson also mentioned that the Maternal and Child Health clinics are understaffed. Strangely enough. I hear from the Member for Toa Payoh that his Maternal and Child Health Clinic is irrelevant because, as a result of a very successful family planning campaign, there are very few mothers taking their children to the Maternal and Child Health Clinic at Toa Payoh. And he is requesting that this clinic be converted into an outpatient department. It is true that in the past the Maternal and Child Health Clinics were run separately from the Outpatient departments and from the school services. Because of this set-up, the utilisation of manpower was not optimum, and last year we integrated the Maternal and Child Health Clinics and the school services together with the Outpatient departments so that we can make full use of the staff. In this way we hope to be able at least for the next three years to overcome the problem of shortage of doctors. The ambulance services will be integrated by April or May of this year after a discussion between my Ministry and the Ministry of Social Affairs. In future the public need ring only one number and they will be able to get a public ambulance provided by the Fire Brigade. There will be a distinct improvement in the ambulance services, Moreover. these ambulances will be controlled by radio so that there will be constant contact between the ambulances and the Accident and Emergency Departments in the hospitals. However, with regard to ambulances carrying patients from one hospital to another hospital, I would say that after the integration the load on hospital ambulances will be eased and therefore patients need not have to wait that long if they have to be transported from one hospital to another for specialist treatment. The Member for Potong Pasir has mentioned about the prevalence of tuberculosis cases. For his information, there were 4,711 cases in 1965 and 2,815 cases in 1976. If we were to calculate the rate per thousand population, they work out to 250 in 1965 and 124 in 1976. This means that the rate has gone down by 50.6% in 12 years. So there has really been no increase in the number of tuberculosis cases. The reason why we are still seeing a significantly large number of tuberculosis cases is that tuberculosis is prevalent among that generation which has never received BCG vaccination. BCG vaccination was introduced in Singapore only in the late 195Os and it is to be expected that the older generation will be carrying tuberculosis and spreading it to those who are at risk. So it will be many more years before tuberculosis disappears entirely from Singapore. SATA is a separate organisation. It has no connections with the Ministry of Health. It receives a subsidy of $35,000 from the Ministry of Social Affairs. I am told that operations of SATA have now expanded to cover heart and chest diseases. However, SATA is bound to notify the Ministry of Health of tuberculosis cases that it comes across, SATA, like any other private practitioner, is entitled to treat tuberculosis cases. With regard to his question on swine-flu vaccine, the Ministry has ordered several thousand doses of vaccines, but they have not yet arrived. Off the cuff, I think that the total cost would come to about $600,000. The number of doses ordered has been calculated to provide, first, for those who are working in essential services. If there is a demand by members of the public, then more doses will be ordered but they will have to pay at about $5 per dose. The vaccine that we have ordered will offer protection against swine-flu, Hongkong flu and Victoria `A' flu. It is a tri-valent vaccine. When the vaccine arrives, we will first vaccinate national servicemen because they live together in camps and are very likely to spread influenza among themselves and to their families when they return home from camp. 4.30 p.m. In response to the Member for Kim Seng as to whether there will be any increase in medical charges. I must say that this is being looked into. In the first instance, we are studying the rationale for an increase in dental charges. As of this moment, Members are aware that the Ministry is charging only $4 per patient per treatment. This, of course, leads to pressure in the demand for treatment in the Ministry's Dental Department. For a charge of $4, the dental surgeon has to spend probably half an hour on a patient. This is patently absurd. So we are looking into the matter to vary the charges, according to the type of treatment that is to be provided as well as according to the time that has to be spent on a particular patient. When there is any increase in dental or medical charges, we will announce them in this House. The newspapers have got hold of a story that we are contemplating on introducing five classes of wards. It is a true story. As of this moment, there are only three classes - A class for which we charge $60 per day. B class $30 per day and C class $4. There is an enormous gap between $4 and $30 and $30 and $60. With successful family planning and greater acceptance that two children are enough, more parents are anxious that they and their children receive the best medical care. Doctors and the nurses at the Kandang Kerbau Hospital have been plagued with requests from C class patients, even B class patients, to be lodged in A class wards. The number of requests amounts to about eight to 1 2 per day. I believe that $60 per day may be too high for some middle income groups, and likewise $30 may be too high for some working class people. But bearing in mind that there is increasing affluence, and there has been a rise in wages or income among the population, we have decided to introduce a second A class ward and a second B class ward so that a patient can pay according to a progressive scale of charges. This. I think, is fairer than the present system where there is an enormous quantum jump from $30 B class to $60 A class and from $4 C class to $30 B class. The C class ward will be intended primarily for those who really cannot afford to pay, and I think it is fair that the people of Singapore should be conscious that medical costs have gone up by 300% in the last five years, or about 1.15% of the GNP in 1975, and therefore part of the cost will have to be paid for. On the Member's suggestion that we should open a nursing or convalescent home for stroke and other chronic patients. I regret that our studies indicate that it is going to be very difficult to do so because we have discovered from the experience of the United Kingdom that nursing homes or even homes for the aged are very expensive to run as compared to treating them as outpatients. In 1970, the expenditure spent by the British Government on in-patients was �293 million. On outpatients �24 million. On home nursing only �12 million. But the cost of running homes for the aged shot up to �53 million. And presumably the same economic rules will apply to us if we try to run homes for the chronic sick. Worse than that, I am afraid that in future years we are going to face a labour shortage. Mindef is already facing that problem. It has announced the need to recruit women into non-combatant national service and maybe in 10 or 15 years' time we may not even find the people who want to work in convalescent homes or in nursing homes for the chronic sick. This is a nagging problem. I am already finding it difficult to recruit people who will want to work, let us say, in Woodbridge Hospital. Woodbridge Hospital is intended to house those who are mentally ill. But those who are mentally ill have become geriatric cases. From a state of mental illness they have advanced to a state of mental senility. So Woodbridge Hospital is really a combination of a home for the aged as well as a home for the mentally ill. Doctors in particular are very reluctant to work in Woodbridge Hospital, and that is why my sympathies and my encouragement go to those who are prepared to take on a job which is unpopular and not at all very attractive, because working in a home like that does not provide an outlet and encourage a doctor to leave the Ministry to enter into private practice. We have therefore decided to concentrate on home nursing as explained in the Addendum to the President's Address. The Home Nursing Foundation will deal with patients referred to by hospital doctors in the first instance, and it is part of primary care service. This is one sector which we hope to expand and on which money will be spent. More nurses will be recruited for this particular aspect of home nursing service. Lastly, let me come to the vexing problem raised by the Member for Anson and the Member for Punggol on the shortage of doctors. I am afraid that there are many factors relating to the exodus of doctors from the Ministry of Health, and it is a problem which requires some degree of analysis. I would like to make it quite clear that we should make a distinction between doctors who migrate and leave Singapore and doctors who leave the Ministry of Health to enter private practice. Members may be aware or recollect that the Ministry of Defence last month advertised that two of their doctors holding the rank of Captain deserted national service by absconding overseas. Both of them were doctors trained in foreign universities and, therefore, were registrable abroad, one in Canada and one in the UK. They did not therefore require certificates of good standing from the Ministry of Defence or the Singapore Medical Council in order to register abroad. This made their flight from Singapore easier. The Member for Delta will recollect that in July last year he questioned me on the number of Singapore doctors who were registered in foreign countries. (Hansard, dated 23.7.76, cols. 983-5). I could not then give him an accurate answer but provided the House with information on the number of certificates issued from 1973 to 1976. I have since examined the problem and discovered that it is not obligatory under the written law for such certificates of good standing to be issued at all. Furthermore, such certificates have been issued freely without the applicant providing evidence that he is of good standing during his period of practice. In fact, every doctor who has just finished his housemanship if he asks, will be automatically given a Certificate of Good Standing. This, of course, is an extraordinary position. I feel that in future applicants will have to prove that they are of good standing, and I do not see how good standing can be proved unless the applicant has at least three years of practice, either in the private or public sector, to show his competency. A Certificate of Good Standing as I see it, is like a testimonial, very much like one given on behalf of a person by his referee to a prospective employer. I can say from experience that not all referees write good testimonials. Any doctor who wishes to register overseas can produce his own Certificate of Registration in Singapore. But we are going beyond our obligations to issue so-called Certificates of Good Standing to every applicant. Let me now come to this problem of doctors who move out of the Ministry of Health into private practice, because it does hurt the Ministry. I think I ought to expound a little. There are many reasons why doctors move out. Some of the major reasons which have been listed by private practitioners who once upon a time worked in the public sector are:- Job is not challenging. No opportunity for promotion. Poor physical working environment. Poor salary Poor staff relationship. Inability to get requested postings. These are the major reasons. The other reasons are that they have got more freedom and that they are able to do other business. Obviously, we cannot satisfy anyone or everyone because of the numerous reasons that have been given. However, let me deal with some of these reasons. In the case of salaries and promotions, I would like to say this for the information of Members of the House. In the Soviet Union doctors are paid less than the ordinary industrial worker. Doctors are paid 120 roubles per month. The industrial worker is paid 162 roubles per month because he is the person who produces the goods. And the rate of inflation of retail prices has been kept at 2% in the USSR. I am not suggesting that Singapore can operate like the USSR because we are an open economy. There is a free market here and we operate on free market rules. But bearing in mind that expenditure for the health services has increased by 300% in five years, and now our health expenditure is as high as 1.15% of the GNP, I think it is very difficult indeed to satisfy doctors or to match doctors' salaries with what they can earn as private practitioners. By the time a Chinese newspaper editor comes to the conclusion that the private practitioner can earn two to 10 times that of a Government doctor, I do not see how it is possible for the Minister for Finance to agree that the immediate solution to the shortage of doctors in the Ministry of Health is to proportionately increase their salaries. It will lead to a demand for similar increases among other professional staff - the lawyers, the architects, the engineers, the accountants and so on. 4.45 p.m. On this score, therefore, I can say that little can be done but on promotion something can be done. I am in sympathy with those doctors who have worked for many years in the Ministry of Health. I think they deserve consideration for promotion although they may not have a post-graduate qualification. I am convinced that medicine is still an art acquired through experience and medicine relies on clinical judgement, which again is based on experience. Therefore, by virtue of this experience, I believe that those with eight years' service deserve consideration for promotion regardless of the fact they do not have a higher qualification. After all many civil service administrators have been promoted not because they have a Ph.D or any other higher university degree but because of their experience and their personal capability. I think, likewise, the same criterion should be applied to doctors. However, this does not mean that we are discouraging doctors who wish to improve their knowledge and learning by taking higher examinations. On the contrary, the present practice of awarding doctors with allowances, if they hold a higher qualification, should be continued. On the question of poor staff relationship, this is a point which I am afraid the Minister is in no position to handle. Staff relationship has got to do with doctors and doctors. Some doctors are soloists. You will notice that some doctors who go into private practice do not practise as a group but practise solo. So also, I feel that such people will not fit into a team in a hospital because in a hospital doctors are required to work as a team. Once they are in a team there is a hierarchy. The junior doctor or medical officer has to take orders from the Registrar, who takes orders from the Senior Registrar, and who in turn takes orders from the Consultant, and so on. There is a "hen pecking" order. It is very much like what you get in the Singapore Armed Forces. I am concerned indeed that the man at the top should be sound headed and competent so that he can hold his team together. I would be very worried indeed if we do not try to bring up a generation of gurus or teachers who can collect around them disciples. because it is through their leadership that a tradition can be built in the hospitals. If each doctor looks after his own interest, I am afraid all medical traditions will disappear. It is not the private sector or the private medical practitioner who is setting tradition in Singapore, or standards if I may add. It is those who work in the hospitals, in the University units, who have a very large responsibility for collecting disciples around them, for building a medical school. And you can only do that if there are good gurus. So long as we search for good gurus and as long as there is hope that we can find good gurus, I think they ought to be duly rewarded. But I am afraid doctors are difficult persons to deal with, like lawyers. You know, lawyers never agree with each other. So also, doctors rarely agree with their diagnoses or even their treatments. That is why both lawyers and doctors have one thing in common - plenty of words. The other reason why they leave is that the job is not challenging and that they are unable to get a requested posting. I have discovered that doctors have been posted by computers. I believe this is not a clever idea. For one thing, the man who did the programming had left the Ministry. Circumstances have changed and there is nobody to change the programme. So the computer is operating on old yardsticks for a new generation of doctors. So wrong people are being posted to the wrong places. For instance, when I visited Woodbridge Hospital I was greeted by a young medical officer. Far from smiling at me, he grimly told me "I want another posting." Looking into the complaints made on the inability to get the right posting, I have suggested to my officers that henceforth the posting of doctors will be made according to where vacancies occur, so that when a person applies for a job he knows what he is in for. I would rather have happy doctors working in the right places than reluctant doctors in the service, because they will demoralise the whole service. These are the gripers and grumblers who will collect around them dissidents and who keep on pressing home the point that there is no job satisfaction. A doctor is a doctor. If a doctor cannot find satisfaction in his job, then obviously he has chosen the wrong profession. If I were given the responsibility of having to build a completely new medical school in a completely new country, I would insist that all those who aspire to enter medical school should do a spell of nursing for two years. As it is, entering medical school is like first passing your GCE "O" Level, then the "A" level, then the first MBBS and then the second MBBS: a series of passing examinations. Medical students have little concept that their profession is a vocation and even among nurses there is a 20% dropout during the training period. I am quite sure that if we ask those who wish to be trained as doctors to do a spell in nursing, some of them will change their minds after they have gone through a period of nursing. I am more particularly concerned because last year 50% of medical students in the first year are girls. So this is going to pose a genuine problem, not only for my Ministry but for the Ministry of Defence. The Ministry of Defence requires male doctors for national service. So if there are less male doctors. there are going to be less doctors for national service. Since the lady doctors have prospects of getting married and bringing up a family, in the end we might not be having the effective number of material whom we can recruit as doctors, particularly when the experience of Britain shows that at least 15% to 20% of female doctors are lost to the profession. This is a point which I ought to bring to the attention of the House because it is food for thought and I am just thinking what I ought to do with regard to future intake of students into the Medical School and how I ought to correspond with the University of Singapore. To be truthful, I believe there is a trend among the younger generation. This is a new trend which we did not see 20 years' ago. In the 50s I remember some colleagues of mine who retired from the University Service as doctors did not collect enough from their pension or the Provident Fund to buy a house. These days the young doctor who graduates immediately asks for a house. The Member for Kim Seng mentioned in a speech at a Rotary Club which was reported recently -