MAIN AND DEVELOPMENT ESTIMATES OF SINGAPORE FOR THE - FINANCIAL YEAR 1ST APRIL, 1988 TO 31ST MARCH, 1989
Sir, first, I would like to thank all the Members for their views. There are many proposals and questions. The Member for Changkat raised the question of the manpower resources in my Ministry. Members will be aware that in health care the level of labour intensiveness is very high. Manpower resources therefore are very important and to continue providing a high standard of health care, my Ministry will strive to ensure that all the essential services are not only adequately staffed but are staffed with appropriately qualified and trained personnel. However, the achievement of this objective of providing a high level of service must take into consideration Government's policy of restraining manpower growth on the one hand and on the other hand, the need to cap the very rapid increases in health manpower expenditures experienced over the last 10-15 years. It is important therefore for my Ministry to ensure that the available staff that we have, whilst we are shorthanded in many places, are still able to perform effectively and efficiently. We can help them do this by providing them with adequate training. In this regard, we have been sending more of our staff for training in management and supervision. We will be holding more inhouse courses to ensure that a broader level of supervisory staff are trained. This will help us strengthen the administrative capabilities in the Ministry and also will help us to take short-term measures to overcome whatever manpower shortages we face. With regard to the specific shortages of nurses and physiotherapists, as I have informed the House recently, we have been taking several measures to overcome this problem so I will not repeat them. With regard to therapists, the Member is wrong in quoting the number in terms of percentage of vacancies. Actually the vacancy rate is much higher. I am sorry to inform the House that in the area of therapists, the vacancy rate is actually about 40%, not 12%. There are many reasons as to why this has happened. The Member for Changkat has put her finger at the right place, namely, there is no local training available. Therefore, Singaporeans who wish to take up this career or profession have to be trained abroad. But if they are going to spend so much money in being trained overseas and on coming back, finding that their salary is equivalent to that of a General Science graduate, they may find that it is not really worth their while to invest that much money and not be able to get an equivalent pay-back. They might as well stay in Singapore and do a Science degree at the local university. Most of our physiotherapists and occupational therapists have been sent abroad under scholarship and even today we have a number who are being trained abroad under scholarship. The PSC has been offering scholarships every year. Unfortunately, the take-up rate is rather low. The reason is that the qualifications criteria imposed by PSC in the past have been much too high. Therefore, many of those who applied did not qualify, whilst those who did qualify were not prepared to accept the scholarships because they could opt to take up scholarships in other more lucrative professions. So we are caught in the bind in terms of our ability to train the required number of therapists. I am glad to report to the House, however, that after consultations with the Ministry, PSC has recently agreed that the qualification requirements for applicants applying for these therapist scholarships will be lowered so that more will qualify and hopefully the available scholarships can be taken up. Consequently, we should be able to overcome the shortage within the next six to seven years. We are also looking into the possibility of establishing a local college for therapists. We have been discussing with various parties abroad and we have also been discussing with the Ministry of Finance in terms of financing for this project. It is still at a very exploratory stage, so I would not like to give Members any false hope in this area. The Member for Kaki Bukit has suggested that the Ministry should perhaps form a task force to study the problem and come out with an integrated approach to solving this problem. I wish to inform the Member that we have studied this problem quite extensively. We have identified a multi-pronged approach that must be taken towards resolving this problem of shortage of nurses as well as therapists. We have been able to proceed with actions that are within our control. For example, the examination of the work content of the nurses. How do we make sure that nurses are more efficiently occupied and are doing mainly nursing work? How do we make sure that non-nursing functions which can be removed are being removed so that the nurses can be more effective in their work? All those have been going on for the past few years as part and parcel of the process of internal improvements. How to improve the working conditions, how to ensure that the night shift roster which is very, very unpopular, is more evenly distributed so that we do not cause more nurses to resign or to retire? How do we improve the status and image of the nurses? All that we are able to do on our own, we have done, quietly without fanfare. With regard to the private hospitals, I agree with the Member that the private hospitals have not been playing their part in solving this problem of shortage of nurses. They too have been very badly hit, although not as badly as the Government hospitals. As far back as 1985 I had, in one of my speeches, called upon the private hospitals to undertake their own in-house training. This way they can be guaranteed of their own supply of nurses and they do not have to pinch from the Government to meet their future needs. Sad to say, there was no response, no reaction at all until recently. We have now tied the training of nurses by the private hospitals to the supply of nurses from non-traditional sources. This has resulted in some interest on the part of private hospitals. Now, several of them are discussing with my Ministry on how to implement training programme for their own nurses so as to meet their own future needs. Over time, this problem of private hospitals' participation will be overcome. In terms of the needs of private hospitals and why the nurses have been resigning or retiring from the Government service, I think it would be useful for me to give Members some additional information. Sir, from 1984 to 1987 1,502 Government nurses either resigned or retired from the Government Nursing Service. The bulk of them resigned, as only 40 or 50 retired during that period. In contrast to this figures of 1,502, the number of nurses in the private sector actually increased by only 734. Of these 734, 455 were absorbed by NUH. So Members will see that out of the 1,502 nurses who resigned or retired, only 279 of them joined the private sector other than NUH. The needs of the private sector has not been that great and it has not been a significant pull factor in terms of the resignation rate. In terms of the number of private nurses in the private sector, that is, those who do it on a contract basis - I think they charge between $80 and $100 per session - that number has only increased by 40. So the number that joined the private hospitals would be around 220 to 230. It is very, very small compared to our overall turnover rate. Sir, with the restructuring of the hospitals and with the hospitals being given more autonomy in management, in manpower deployment, in career development, I think our Government hospitals would be able to come up with more attractive career schemes, better scope for promotion, for training. And I am sure our ability to retain the nurses that we have on hand as well as to be able to recruit new trainees will be far greater than at present. So I urge Members to be a bit more patient. With regard to Medisave, the Member for Changkat is very correct in stating that although the Medisave scheme is very commendable, unfortunately it probably would not be adequate for those account holders who have serious catastrophic and long-term illnesses. My Ministry has been looking into this catastrophic illness insurance scheme or CIIS for quite some time, in fact, since late 1985. It is a fairly complicated scheme with tremendous long-term implications. We want to be sure that whichever scheme we embark upon does not land us 20 - 30 years down the road where the US and the other developed countries have landed today. Their schemes also started on very good grounds, very good premises. Unfortunately today, if you look at their schemes, there is great unhappiness for everybody. My Ministry has been working with the CPF Board on a scheme that will automatically cover all Medisave account holders. However, we will take into consideration the Member's suggestion that opting-out be allowed. In fact, that provision has already been built in to the present proposal. Also, the immediate dependents of account holders will be covered on a voluntary basis. This scheme will be designed as a very basic and low-cost scheme and will be underwritten and managed by the CPF Board. Those who require a more comprehensive coverage can purchase supplementary coverage from the private sector. I am sure the private insurance companies will be very happy to compete among themselves to get all this coverage. In fact, those who prefer to be fully covered by a private company's CIIS will be allowed to opt out so as to purchase coverage totally from the private companies. In fact, there are already a few companies that are offering CIIS and, as the Member mentioned, ICS already has a system in place. I think many other insurance companies also have similar proposal in place. Sir, we are still looking into the details of the scheme as well as the long-term ramifications. When the full details are finalized by my Ministry and by the CPF Board, I would be very happy to make them available to this House. Sir, with regard to deductibles, I agree with the Member for Changkat that it would be difficult not to allow deductibles from Medisave funds because Medisave account holders are already able to draw on their Medisave at the present moment for whatever disease-type it may be, so long as they are hospitalized. We will definitely check to see whether there has been any abuse or misuse of the Medisave scheme. Although I have told the House that my Ministry and the CPF Board have to date found no evidence of any abuse, misuse or overuse of Medisave funds, I must however qualify this statement a little bit, because it is only recently that the CPF Board and my Ministry have started to audit the Medisave claims. Even then only Medisave claims from Government hospitals have been audited. The tools that we have available at our disposal for analyzing such claims are also very basic and limited. To correct this administrative weakness, we will be sending a team of officers to several countries which have already had many years of experience in handling either national medical insurance claims or medical reimbursement claims. We hope to learn from their experience and to be able to implement our own monitoring and assessment systems in the near future. With such systems, I can have a higher level of confidence when pronouncing on whether or not there has been any abuse. In the meantime, we will of course continue to advise Medisave account holders that they should use their Medisave funds carefully. They must never fall into the trap of believing that they or their family members will never fall seriously ill or be involved in a serious accident at any time. By using theirMedisave funds carefully and only when their medical conditions warrant it, they will have adequate Medisave reserves when they grow old. That is the time when their need for medical care will increase very dramatically and, in line with that, the funds required for such medical care. Doctors also have an important role to play in safeguarding their patients' Medisave funds. Doctors are responsible for deciding on whether and for how long a patient should be hospitalized. They are also responsible for the number and type of tests to be carried out and on the need for a surgical procedure to be performed. A doctor will not be true to his profession and himself should he allow the easy availability of Medisave funds to influence him into causing his patient to spend more than is necessary. Sir, it is my belief that most doctors do take this responsibility seriously. We will continue to monitor and ensure that the long-term objectives of the Medisave scheme are safeguarded. Sir, with regard to renewability, the thinking at the moment is that for those Medisave account holders who are already insured with the CIIS, renewability would be automatic. There should be no need for them to undertake annual medical check-ups. So as long as they are in the scheme, it would be automatically renewed. We have not decided yet on whether there should be differentials according to the age group. Most of the schemes offered by the private sector do take into account the age group of the policyholders, and for good reason because the older the patient is, the more likely he is to be hospitalized. Therefore there appears to be good grounds for a differential scale of premiums. But we have not decided on that. It is still under review. As to whether premiums would be revised periodically, I think the answer to that must be yes. Costs go up. The insurance scheme is for the good of everybody. No one will be in a position to subsidize the systems. Therefore premiums must go up in line with the number of claims being made and in line with the costs. That is why it is important that there must be adequate safeguards to ensure that costs do not run away because of over-usage. In the case of private companies, yes, we will allow private companies to participate in terms of offering supplementary coverage.