MAIN AND DEVELOPMENT ESTIMATES - OF SINGAPORE FOR THE FINANCIAL YEAR - 1ST APRIL, 1982 TO 31ST MARCH, 1983
Sir, the Member for Clementi has warned about the danger of increasing medical costs as a result of Singapore being developed into a medical centre. The warning was also put forward by the Member for Kebun Baru. I share the concern of these Members that the development of Singapore as a regional medical centre should not unduly push up the cost of health care, particularly for Singaporeans. Singapore's medical reputation will depend ultimately on the quality and pricing of the services. Foreign patients will continue to come to Singapore only if they are satisfied with the quality of these services and the fees charged. The locals, i.e. Singaporeans, should not worry too much about the exorbitant charges in the private sector in Singapore because they have recourse to the public hospitals which play a dominant role in the provision of health care in Singapore. My Ministry has initiated discussions with the Singapore Medical Association and the Association of Private Medical Practitioners to explore the feasibility of introducing a scale of fees charged by private medical practitioners. The scale of fees, if introduced, will serve as a useful guide to patients. Unfortunately medical skills and services differ even for the same type of services or operation. So it would not be practical or desirable to enforce, through legislation, charges in accordance with a schedule of fees. But a published schedule of fees will serve as a useful guide to the public who use the services in the private sector. We would like to see self-policing by the medical profession in the first instance. Its good name must not be tarnished by an avaricious few. I agree with the Member for Clementi that an adequate supply of doctors and nurses is crucial to the development of our medical service. The number of doctors registered with the Singapore Medical Council at the end of 1981 was 2,091 which is higher than the figure quoted by the Member for Clementi. By 1985 this will increase to 2,400. Based on projections of hospital beds and outpatient attendances, the number of doctors required by 1990 is estimated at 3,000. We have already taken steps to increase the supply of doctors in Singapore. The National University of Singapore has increased its intake of medical students from 140 to 170 since 1980. It has further increased the intake to 203 from this year. The expected supply of doctors will be 2,800 by 1990, which will lower the doctor/population ratio from the present 1:1200 to 1:950. 5.45 p.m. So long as there is a shortage of doctors in Singapore, foreign doctors from the better known medical schools, within the Commonwealth or outside, will be permitted and even encouraged to practise in Singapore. In fact, the list of qualifications for registration in Singapore has been expanded from 58 to some 200 since 1980. This list will be reviewed and enlarged periodically. It is true that the Government hospitals are presently facing a shortage of nurses. This has been brought about by the rapid expansion of private hospitals in recent years. However, the recruitment and training of nurses has been stepped up since 1980. The Ministry has reverted to the former practice of recruiting both student nurses and pupil assistant nurses, in parallel. Prior to this change, applicants had to go through the route of pupil assistant nurse before becoming student nurse which, therefore, made it unattractive for applicants to the nursing service. Currently, 1,250 nurse trainees are in various stages of training. Another 1,000 school leavers will be taken in this year. Terms and conditions of service of nurses are being reviewed. I believe the Ministry of Finance is sympathetic towards the review of terms and conditions of service for the nurses. Hopefully in the next few years the nursing shortage will be alleviated. The Ministry is also encouraging, in the meantime, the large number of qualified nurses who have left the profession to come back on a part-time basis. Private hospitals are also encouraged to recruit foreign nurses with suitable qualifications. These steps should help solve the nursing shortage problem. The Member for Kebun Baru touched on the question of medical ethics when he referred to letters to the press. One swallow does not make a summer, just like one opposition MP does not mark the dawn of a new era, Isolated reports of unethical practices, therefore, do not mean that there is a degeneration of medical ethics. But just as one cantankerous, obstreperous, obscurantist charlatan in Parliament will tarnish the high standing of MPs, one blatantly unethical medical practice will bring the medical profession into disrepute. Therefore, we must try to eradicate all unethical medical practices, just as we must try to block all charlatans and scallywags from entering Parliament. With regard to ethics there is no legislation to enforce this. The medical profes- sion, however, has an obligation to look into this, whether it ranges from high fees or non-response to urgent calls for attention. The Ministry of Health is working with the profession to see how this can be done. The Member for Kebun Baru also touched on the question of medical certificates. Employers no doubt have their reasons for wanting to recognize only medical certificates issued by the company doctors. Putting aside professional consideration, my Ministry is of the view that private employers could be more flexible and make it less inconvenient for their employees in seeking medical treatment when they fall sick. The Government allows its employees to produce medical certificates from private practitioners but these will have to be endorsed by its own doctors. Similarly, employers could consider allowing their employees to consult doctors other than those on the company's panel but requiring the medical certificates issued by these other doctors to be endorsed by its own company doctors. Alternatively, companies could increase their panel of doctors to make it more convenient for their employees. For instance, company doctors could be appointed on the basis that the location of their clinics is close to the place of work and/or the employee's homes as far as possible. Before I discuss some aspects of the National Health Plan, I would like to answer the comments raised by the Member for Ayer Rajah. He has made a fundamental error when he looked at the accounts - the sums budgetted for hospitals and outpatient clinics - and compare them with their respective attendances. The two are not comparable. The sum provided for Hospitals includes in-patient care and not just attendances at the specialist clinics and the A & E departments. As he will know, the cost per attendance at the outpatient clinic is very much lower than that for hospital care. On a per day basis, the cost per attendance at outpatient clinic is $4.50 as against $124 per patient-day in the Singapore General Hospital, or an average of $15 and $22 per attendance at the hospital's specialist out-patient clinic and A & E department respectively. The two are not comparable. But I agree with him that we should emphasize the importance of primary health care, that being the first line of patient contact. Total primary health care service is provided by Government and private practitioners play an important role in keeping the population generally healthy and, as he rightly pointed out, reducing the need for costly hospitalization. Under the National Health Plan the primary health care service will be consolidated to improve the quality of service. New and better equipped polyclinics will be planned for HDB new towns, and old and uneconomical clinics will be closed down. We are studying the feasibility of extending the working hours of selected clinics when the supply of doctors increases in the Ministry, to meet the needs of working families. Outpatient clinics will be made available to Government or private doctors to run in the evenings on a fee-sharing basis. The dominant role played by the 500 private medical clinics manned by over 600 general practitioners will be maintained. To improve their service to the public, the Ministry of Health will propose to HDB to allocate space for future private medical clinics in its new towns on the basis of anticipated demand. As for the working conditions of doctors in the primary health service, most doctors in polyclinics and OPDs are generalists without specialist qualifications, unlike their counterparts in the hospitals. But there is no bias in the Ministry towards specialists in so far as compensation for contribution to services is concerned. It is true that in the past doctors in the primary health service lost out in promotion simply because they did not have a higher qualification but the situation has been rectified. The condition of a higher qualification for promotion to a higher grade was waived in 1978. Since then three promotion exercises were held which benefited the primary health care doctors. Quite a few of these doctors have been promoted to Registrar level as well as Superscale Grade 'H'. The doctors in the primary health care will also be considered for formal training, for practical attachments locally and abroad, under the Ministry of Health's manpower development plan. The Member for Ayer Rajah emphasized the importance of paying attention to the medical needs of elderly people. We agree and I will also touch on this when I discuss the National Health Plan. The Health Plan requires time for debate and Budget session is not the best time to do this because of time limitation. I propose to have the Health Plan debated fully both inside and outside Parliament at a later date, hopefully in the next few months. Hence I would ask the House to bear with me if I do not go into details this afternoon. I shall only outline the philosophy behind the plan and give a few assurances to dispel unnecessary fears. 6.00 p.m. Let me emphasize at the outset that it is not the purpose of the National Health Plan to increase medical charges and recover more revenue. If revenue is the only consideration, it will be far simpler and more effective to ask the Minister for Finance to increase taxes, or not to reduce them as had been consistently done over the last four years. We can then continue to subsidize health care heavily, as we have always done, 90% for C-class and 80% for B2-class. Health care is a basic need, as basic as food, clothing and housing. No one expects the Government to provide free food, clothing and housing, except for some small political parties. So no one should expect health care to be provided for free. These same parties want an immediate repeal of the charges that are now being levied at Government hospitals and clinics regardless of the capacity to pay for those who seek treatment. They want to introduce a free health service for all citizens without any discrimination based on wealth. If the medical service is available to all, regardless of the ability to pay, the poor must suffer, not the rich. I will explain. Well-heeled lawyers who can now afford to be treated by private doctors will want free treatment at Government hospitals. Accountants, expensively-dressed business executives, chauffeur-driven bankers and loaded stock brokers who now do not use Government hospitals and clinics will flock to these hospitals, competing with poor patients for the limited facilities and specialist doctors. They will demand to be treated by the best specialists and accommodated in the best class wards because medical care is for free. And contrary to popular belief, there are more well-to-do Singaporeans than poor Singaporeans. According to CPF records, more than half the employees earn more than $500 per month. A high proportion of those earning less than $500 per month are young workers. They are, therefore, not necessarily poor. Demand for health services will explode if medical care is rendered free to all, regardless of the income status. When a system is overloaded, it is the poor who suffers, not the well-to-do who can opt out for private medicine. The poor cannot do that. This argument that the poor will benefit from a free medical service is not unlike the argument that income tax reliefs should go up to benefit the poor. But the effect is the opposite of what is intended or expected. There is no such thing as free medicine. Medical care is expensive. The Ministry's budget is $368 million this year, $322 million for doctors and nurses'wages and to pay for other running costs, and $46 million for hospital expansion. The question is: how is health care to be financed, not whether it should be available for free. Many countries have a comprehensive health care system. They finance it in the following ways to keep charges within the affordability limit of the population. (i) From general taxation, with the patients paying nothing as in the UK, or the patients paying something, as in Singapore. (ii) From a levy on employers or employees to run a national health insurance scheme. West Germany offers such a system. Both the employer and the employee contribute 7% (I repeat 7%) of the employee's wages towards a national health insurance scheme, making a total of 14%. France also operates a compulsory national health insurance scheme. The employee contributes 3% of wages, but the employer contributes 11%, again making a total of 14%. In Japan, the employee and employer contribute a total of 8% of wages towards national health insurance. In the United States, 65% of the population are covered by voluntary private insurance, There is a compulsory national insurance scheme, called Medicare, for those aged 65 years and above. This is financed from payroll tax contributed by employer and employee over a person's working life. Thus, Medicare for the old is actually financed by the people themselves during their working lives. There is a health plan for the poor called Medicaid financed from general tax revenues. Medical care and treatment are invariably given free or heavily subsidized at the point of consumption under these health delivery systems. This may have created the impression in many that health care is provided free to all, regardless of the ability to pay in many countries. This is a serious misconception. Health care is not provided free. Indeed, the population has made a pre-payment, either in the form of taxes or a levy on wages. It is a hefty pre-payment, high taxes in the case of UK and a high levy of 14% of wages in the case of West Germany and France. It is not just the rich who have to pay high taxes. Workers too pay high taxes, 7% of wages in West Germany and France.