Thank you, Mr Speaker, for allowing me to speak first. Being the first speaker to open this debate on the National Health Plan (NHP), I thought I would have the advantage of being able to cover a lot of ground on this subject. But going through the 17 letters submitted to the Ministry of Health plus the numerous letters written in the press on this subject and this morning's centre page on Medisave in the Straits Times, I found no advantage, as nearly every aspect on the Health Plan that I would like to comment has been covered. While I would like to think that this is a deliberate attempt by the Ministry of Health to diffuse the issue by the time it reaches Parliament, I must admit that this has been a good PR exercise and I join my colleague from Alexandra in saying, "if we can do it with Medisave, why not with all major Government policies?" The Second Minister for Health has said that the heart of the National Health Plan is the Medisave. I beg to disagree. Over-emphasis on Medisave The Ministry of Health has asked this House to approve in principle the Medisave Scheme after having "Noted the National Health Plan". This is an assumption that this House has already accepted the first part of the National Health Plan i.e. the Health Development Strategies. There is an over-emphasis on Medisave, little realising that this part is equally important, if not, more so, because this is where the money from the Medisave will be spent. Too much attention has been paid to the funding of our health care system, and less attention has been paid to the Health Care Delivery Planning. I think before we expect the people to share in the funding, it is only right that we ask ourselves why is the cost of medical care going up? Is it because of increased demand, or is it because of abuse of our system, or is it because our system is inefficient, or is it because of increased services, building new hospitals, new technology like ultrasound, brain scan or expensive programmes like test-tube babies? We must address ourselves these questions because all these and many more will increase cost which the consumers will ultimately have to pay either through higher taxation or higher Medisave payment. It is in this context that I want this House to know, before approving the Medisave Scheme, so that the Ministry of Health will always be on their toes to check areas of medical programmes and care that cost a lot more but has little benefit to society, and also, whether Medisave money, if spent on other programmes would be more profitable to society. I would therefore leave the detailed discussion on Medisave to my other colleagues while I examine the many areas in our Health Services which will directly or indirectly affect Medisave. Quality of Care Going through the first part of our National Health Plan, i.e. the Health Development strategies, I am impressed by the statistics showing how many hospital beds we need, how many nurses, doctors, dentists, pharmacists we require. by the year 2000. How many outpatient dispensaries will be closed down and how many new polyclinics and hospitals will be built. Little mention is made, however, on the quality of future medical care. Quality of medical care is not necessarily related to cost. It involves more than that. It involves careful planning and training of the appropriate personnel to look into the needs of the patient. Today if you are ill and you have to see a doctor at our outpatient clinics, you will have to wait for a few hours to be seen by a harassed doctor. Investigations are minimal and patients have to go to a few designated centres or even hospitals for further investigations. This is not quality. If you are discharged from hospital after a stroke and sent home, what home support have you if your children are working, and what community support have we? None, except our Home Nursing Foundation. This is again not quality care. Community Health Team - An Essential Link If you want to discharge patients to their home environment for further care, you must have a team at the other end to take over. I see no provision in the National Health Plan except that the Ministry of Health will play a catalytic role. This is vague. I think the Ministry of Health must not merely be a catalyst but must be directly involved in starting a "chemical" reaction. Direct involvement of the Ministry is vital in the provision of better health care. To this end, I would like to suggest the formation of the Community Health Team. This Team would be part of our Outpatient dispensary set-up, or by itself. It can consist of doctors, nurses, social workers, health educators and volunteers from the community. This Team will be responsible for providing support to the discharged patient, the chronic sick, the aged, and the aged infirm. If I were half-paralysed, I would be happy to know that the community has a unit for the continuation of home treatment waiting to look after me when I am discharged from hospital. If I were a lonely old man with little home support, living in a 3-room HDB flat, I will be most happy to know that the community geriatric services will be knocking at my door to see to my basic needs. I would just refer Members to Appendix I (Cols. 115 - 116). The details are all there, so I will not talk more on that. Appendix I - Community Geriatric Services (Cols. 115 - 116) I know the next question that the Minister will be asking is "At what cost?" Of course, the initial sum to set up such an organization will be high because you have to train doctors to be community doctors, nurses to be community nurses. Here again, I refer Members to Appendix II (Cols. 115 - 116) on community nurses. Of course, you need the supporting staff and a place to operate. In the long run, (we are talking about a 20-year Plan) this well-organized Team working in close association with our improved outpatient dispensaries, general practitioners, volunteer organizations, religious bodies, and community leaders will set a high standard of care for our chronic sick, the aged, the aged infirm, disabled people and the recent hospital-discharged patients. We would have shifted from an expensive area of health care, i.e. hospital care, to a non-expensive area with no loss in quality of care. But most important of all, it will provide the link between the hospital, the outpatient clinic, the voluntary organizations, the general practitioner and the patient. Appendix II - Community Nurses (Cols. 115 - 116) I believe that the future of our health care in the community will depend largely on this total concept of community nursing. This is because of our aging population and its related problems. Community Hospitals I am not quite sure that we should set up community hospitals of the kind the Ministry wants. Firstly, setting up hospitals, community or otherwise, is an expensive affair. Then the running and maintenance of these hospitals is going to be a problem. The Ministry hopes that GPs will run these hospitals. I do not see how the busy general practitioner, working from 8.00 a.m. to 9.00 p.m., can run these hospitals. This is an important practical point. The specialist doctors are mainly concentrated in the city area where private hospitals are nearby. I therefore do not think they will want to use these hospitals with such limited facilities. Moreover, patients' preference for well-equipped, better hospitals must be taken into consideration. Patients prefer to go to the Singapore General Hospital instead of Alexandra Hospital or Toa Payoh Hospital or Tan Tock Seng Hospital. What more with Community hospitals which cannot match up to these hospitals in terms of equipment or reputation? Moreover, our size, the smallness of our republic makes travelling to our hospitals not a big problem, unlike countries like Britain where community hospitals are needed to serve communities in far-away areas. Lastly, our National Health Plan has provision to build hospitals in Bedok, Woodlands and Zhong Bang, when the need arises. I therefore question the need for building community hospitals. Upgrade our Outpatient Services If it is the intention of the Ministry to build community hospitals to take care of the simple surgical cases and less serious medical ailments, I would suggest that we reorganize the present Outpatient clinics to meet such needs. We have this basic infrastructure of Outpatient dispensaries spanning across our country covering practically every corner of the island. Let us build on it to provide a higher standard of care with doctors, nurses, physiotherapists, X-ray services and proper laboratory services. I know the Ministry is doing up some Outpatient dispensaries into poly-clinics and even building new ones but you must be bold enough to provide more facilities in these to include, amongst others, physiotherapy, psychiatric, geriatric and day-surgery with operating theatre to do simple surgery like the lumps, bumps, cysts, cuts, fractures and even ligation and abortions (with apologies to the Member for Whampoa). Even beds for the elderly could be provided who might otherwise have been forced into hospitals. We could invite doctors to join your set-up by renting out spaces to them. We must look into the better use of our outpatient clinics rather than building community hospitals. Hospital care as the Minister has pointed out, costs more than primary health care. This cost will be ultimately passed on to the taxpayer. Our Second Minister for Health who is also the Minister of Defence and the present Minister who was the former Minister of Defence must be aware that the front-line soldiers play an important role in our defense system. I am asking them to apply this strategy to our health system. Beef up our primary health care and the Community will be better off in the long run. In Finland, for example, the Finns realised that hospital-centred care was simply incapable of meeting the challenge posed by the high-adult mortality and chronic morbidity and that more money had to be spent in the community where some of the aggravating circumstances of the illnesses were created. They have set aside approximately one-half of the 6.2% of GNP spent on health care in the country on primary health care and health education. They have the lowest infant mortality rate in the world. I refer you to Appendix III (Cols. 117 - 118). Appendix III - Expenditure on hospitals and primary health care, Number of new posts in primary care (P) and hospital services (H) between 1975 and 1979 (Cols. 117 - 118) Private Practice & NHP Then there is much talk about involving the private sector in our future medical care. This is well and good, but I wonder if the Ministry has examined whether the private sector can discharge such a role effectively. At present the care provided by General Practitioners is basic. It is effective but not efficient. Unless the Government is prepared to open its facilities at the Outpatient Clinics to these doctors, their contribution will not change much from the present in the Year 2000. Moreover, HDB encourages individual practitioner, by its present method of tendering, and solo practitioner will not be able to contribute much because of the very nature of his work. The Ministry of Health in the 20-Year Plan has realized this and will be working with HDB to solve this. May I suggest that HDB build clinic complexes to encourage group practice? If it is the Government's intention to encourage private practice, then in line with this trend, the University of Singapore Medical School must include a Department of Community Medicine to train medical students to be community doctors. Only then can GPs in private practice be able to participate in your programme. There are a lot of expertise in the private sector. It is a sheer waste of medical talent and expertise to find top surgeons doing bread and butter surgery when they were once doing renal transplants and complicated surgery. Similarly, it is disappointing to find top Obstetrics and Gynaecology consultants doing abortions mainly, when once they were teachers of our medical school imparting their skills to medical students. Our National Health Plan must examine how we can maximize this potential source of valuable manpower by inducing them back to teach and train our medical students on a part-time basis. I know that there are at present some private consul- tants in the hospitals but I ask them: How do they fit into the hospitals? Many feel that their expertise is not fully utilized. Why is this so? Hospital Doctors and Medisave I would now like to draw your attention to how hospital doctors' behaviour can affect Medisave. While doctors' services account for less than one-fifth of the grand total health expenditure in many United States Hospitals (I do not have the Singapore Figures), doctors control or exert very strong influence over most of the rest of the health care spending, especially hospital spending. Physicians recommend hospitalization and admit patients. They recommend and perform surgery. They order and perform other diagnostic and therapeutic procedures. They prescribe drugs and they decide when to discharge patients. Blumberg, in 1979, has estimated that physicians control 70% of total health spending. Thus, physicians' propensities to prescribe costly services are of particular interest from the point of view of total health care spending and medisave. I quote from page 173, paragraph 2 of THE HEALTH, ECONOMICS AND HEALTH ECONOMICS. "Inducing providers to curtail the rendering of those services which yield very low or no marginal health value may be a far more effective and acceptable way to limit spending than attempts to reduce the price or unit cost of services, or to make consumers pay a larger fraction of the price". Let me give you evidence of what I mean by low marginal health benefits. Hutter and his colleagues at the Massachusetts General Hospital, in 1973, reported a study of early hospital discharge from myocardial infarction, that is, heart attack. Uncomplicated patients were randomly assigned to either a 2 or 3-week hospital stay. During the 6-month follow-up period, there was no difference between the 2-week or 3-week patients in frequency of return to work, anxiety or depression, heart condition or survival. A more recent study tried sending half the uncomplicated patients home on the 7th day, with similar results. Later two British groups, Mather et al in 1976, and Hill, Hampton and Mitchell, in 1978, did randomized studies by comparing home and hospital care for acute heart attacks and found no discernible benefit from hospital as compared to home care for most patients. This and many other studies have shown that there is a substantial body of evidence that suggests that, at least in many cases, higher utilization rates yield zero, or possibly negative health benefits. In other cases, higher utilization rates yield marginal benefits that are too small or too elusive to be measured. In still other cases, it appears that utilization of costly services has been expanded in the absence of evidence of efficacy. Allow me to explain. You must have heard of coronary artery bypass graft surgery now in vogue. Many top politicians in the United States have a bypass done for their ailing heart. It is a costly medical technology put into widespread use before its efficacy was established. This operation was first introduced in the late 1960s. By 1977, its annual volume exceeded 70,000 at a cost of roughly US$l billion. The Veterans' Administration started a randomized clinical trial in the early 1970s with more than 1,000 patients, roughly half of whom were treated medically, the other half with this operation. The results were published in 1977 by Murphy et al. Surgical treatment was found to prolong life for the 11% of patients having diseased left main coronary arteries. In the rest, there was no statistically significant difference in survival between the two treatment groups at follow-ups, 21 and 36 months after entry into the trial. There has been considerable debate over the significance of these results. Some have argued that surgical technique has improved considerably since the trial was conducted, and that there are important quality-of-life benefits not measured by survival rates. Be that as it may, the point remains that a great deal of spending took place in the absence of any scientific evidence that this use of resources produced better health. Nevertheless, we may proceed with the hypothesis that it is possible to reduce the utilization of some hospital services with- out harm to the health of the population served. Doctors, the providers of our health care, have therefore a crucial role to play. They can create demand, as I said, by unnecessary admissions to hospitals, unnecessary procedures, both medical and surgical. This is due in part to the training he receives as a student. He has been taught to cherish clinical freedom. The relationship between the patient and the doctor is sacrosanct and cannot be interfered with. The doctor is concerned that his patient receives the treatment appropriate to need, regardless of cost, and from his point of view it is not in his interest to become involved in the issues of resource allocation, financial stringency and priorities. Provided he receives what he needs to care for his patients, that is his only concern. Doctors, therefore, are the prime users of resources in the Health Services and, as such, must be involved in the management of these resources. The University of Singapore Medical School should, therefore, teach medical students the concepts of cost-effective practice. I am serious about this. Medical students are often asked by their professors, "Why didn't you order these tests?" rather than "Why did you?" I remember an incident in my houseman days when a fellow houseman ordered so many X-rays for a person who was involved in a road traffic accident. That person only suffered simple abrasions and cuts. When I asked him why, he said this was to make sure that our superior did not ask him why he did not do this or that. Of course, you could say that this particular doctor is inexperienced and was working under pressure. But the point I am making is that, unless the provider of the health system is involved, all our attempts to cut down costs will be negated by their non-involvement. Mr Speaker, Sir, we must realize that Singapore is an international city. Ships call at our harbour, planes land on our international airport, cars come in from the causeway. We are vulnerable. Diseases from these countries can easily be spread to us. Constant vigilance in these areas must continue to be top priority. We import workers from other countries. Therefore they must be thoroughly screened. Our number one major cause of hospitalization is accidents, poisonings and violence. This is followed by diseases of the digestive system, diseases of the circulatory system (including the heart and blood diseases), diseases of the lungs and infective and parasitic diseases. These illnesses are to a large extent environmental and socio-economic in origin. It follows, therefore, that our water supply and sanitation must always be of a high standard, our hawkers must be clean. Singaporeans must be advised to live an easier and less stressful lifestyle: smoke less, eat properly and keep away from too much alcohol. Pumping more money from our Medisave to an expensive area of care like hospitals and sophisticated programmes must, therefore, be weighed carefully. On the other hand, community based projects like Community Health Team working with a better equipped and planned Outpatient dispensaries may be better in the long run. My fellow MPs, you must remember that this country is free of small pox, polio, cholera, diphtheria and malaria, because these diseases were eradicated by basic primary health care team of doctors, nurses and community leaders. Mr Speaker, Sir, I support the National Health Plan and Medisave with some modifications. I agree with the Second Minister for Health on the dangers of third party payment like insurances. I concur with the Minister the need for sharing health costs and that Medisave will to a certain extent provide for this. However, I fear that Medisave may not be enough for the chronic sick and some form of insurance coverage may be necessary. We could either allow a percentage of a person's Medisave for this insurance, similar to the home insurance scheme we have for our HDB flat owners. Lastly, Medisave will have many problems during its initial stages and I am glad that the Minister recommends that, I quote him, "there be periodic reviews in the implementation of the scheme and that adjustments be made when experience shows this to be desirable". In a nutshell, the Ministry must be flexible. Don't quarrel or haggle over whether a person has enough Medisave or not when he is in pain. Treat him first and ask him to pay later. If Medisave starts off on the wrong footing, then all this PR work will be wasted and the Ministry will be in trouble. Thank you, Mr Speaker, for your patience in listening to my fairly long discourse. 5.30 p.m.