Hansard, 1990-03-27

Order read for consideration in Committee of Supply [10th Allotted Day].

Head P (cont.) - Resumption of Debate on Question [26th March, 1990], "That the total sum to be allocated for Head P of the Main Estimates be reduced by $100." - [Dr Aline K. Wong]. Question again proposed.

Sir, yesterday, I was replying midway through the points raised by Dr Aline Wong. I will continue from there. Sir, in view of the fact that many of the MPs had spoken on restructuring in various parts of their speeches, what I intend to do is to collect all those points on restructuring of hospitals and take them at the same time. Dr Aline Wong has asked about the subvention quantum for the hospitals. She gave the example that SGH, before restructuring, had a deficit of $40 million. Yet the year after, when SGH was restructured, the subvention was $66 million and that increased to $72 million in 1990. Similarly for NUH, the subvention increased from $21 million in 1989 to $23 million in FY 90. Sir, the difference in the deficit of SGH before restructuring and the subvention quantum provided to SGH after restructuring shows that the Government hospitals have been receiving a substantial amount of hidden subsidies and which after the hospitals are restructured, they would then have to pay for these costs. Let me give some examples. As a Government hospital, the hospitals receive maintenance services, engineering services from the PWD, computer services from the Ministry of Health and they also receive personnel and financial services from the Ministry of Health. All these are not paid for. They are borne by the Ministry. After restructuring, they now have to pay for such services and therefore the subvention for the hospitals takes into account the quantum of those services that are being borne by the subsidised patients. This accounts for the increase of $26 million from a $40 million deficit in 1988 to a subvention of $66 million in 1989. Sir, the fact that the subventions have increased between 1989 and 1990 also shows that the Ministry of Finance and the Ministry of Health do take into consideration cost increases for services provided to the subsidised patients - the lower income group who uses the B2 wards in these hospitals. Mr Chew Heng Ching has asked for a status report on the restructuring programme. In the limited time provided I think it will not be possible for me to give a full report. I will instead summarise some of the key points which I had used in my reply to this House on 26th February in reply to a Question for Oral Answer from Dr Vasoo. I informed the House that the restructured hospitals, having an autonomous management, are now able to review their operating systems, streamline and reorganise operations when necessary, and have therefore managed to achieve significant improvements in the level of service to the patients. They have also been able to set up and staff new departments and, very importantly, they have been able to go out and recruit the necessary people. As Members know, through the years Government hospitals have experienced a 20% vacancy rate. The restructured hospitals have been able to go into the marketplace and recruit the necessary people and they have therefore been able to upgrade the services to the patients. I had also reported to the House that the surveys carried out by the hospitals showed that the patients have appreciated the improvements. I am not going into the details and if Members are interested they can refer to the Hansard for those details. Mr Chew also asked whether we had encountered any problems and whether these were mainly external. The main problem facing hospitals, restructured or otherwise, is always manpower and that is because hospitals are labour intensive and all services are provided through the staff. Any shortage of manpower will always have an impact on patient service. The problem of shortage of manpower, in particular in the health industry, is international. All the developed countries suffer from shortages of nursing and other paramedical staff. In Singapore the situation is made worse by competition from other employment sectors for people with common-user skills, ie, clerks, housekeeping staff, secretaries, laboratory technicians. These are people whose skills are very transferable and who can obtain employment outside of the hospitals. The solution to this problem is to ensure that our personnel management in the restructured hospitals is enlightened and that they are able to ensure that the staff can see a career path ahead of them and that they are also being trained to do their jobs efficiently and properly. They need to improve the working conditions and a very basic point is that they must be able to offer competitive wages. If they are not able to offer competitive wages, they will lose their existing staff and, worse, they will not be able to recruit replacements. In the case of NUH and SGH, this flexibility has shown good results. Let me give an example for SGH. In December 1988, before restructuring, SGH had about 3,200 staff and a vacancy rate of 19%. This vacancy rate has been fairly consistent through the past few years. By the end of last year, SGH had managed to build its workforce up to about 3,900. The vacancy rate has now been reduced to only 4%. Similarly for NUH, which has a staff strength of about 2,000 and a vacancy rate of 8%, which is again significantly lower than that of the other hospitals. The restructured hospitals have also been able to participate actively in the training of trainees. So both SGH and NUH have gone out to recruit trainee nurses, for example, and this helps to complement the efforts of the Ministry of Health. By the end of December last year, SGH had managed to recruit 141 student nurses and 46 pupil assistant nurses. As these student nurses go through their training programme, after three years they will also add to the pool of trained nurses that are available. The flexibility that the restructured hospitals have is important. Several MPs have asked that perhaps we should consider slowing down the restructuring programme for the hospitals. Sir, the autonomy provided to the hospitals that have been restructured has been crucial in their being able to improve services, and being able to provide a level of care to patients that is well appreciated. They are able to cope with the rapidly changing market conditions. When people leave, they are able to recruit straightaway and replace them. In the Ministry of Health, under the civil service conditions, when clerks leave, the hospitals have to wait for the next recruitment exercise which may or may not result in a replacement. In the meantime, queues build up at the counters. The only solution is to take nurses to do the job of counter clerks which I think is the wrong way to go. If we are concerned about giving everybody a good level of medical care, in particular the low income group who use the B2 and C class wards and who have no recourse to private sector treatment, let us make sure that we are able to restructure the other hospitals We should do it quickly so that they can put in the changes necessary. Encik Othman Eusofe had disagreed with the requests to slow down the restructuring programme. He has suggested that we go ahead. I think that is the right approach. So we will proceed with the restructuring of Kandang Kerbau Hospital and Toa Payoh Hospital which has been scheduled for April, ie, next month. Several MPs have also asked that perhaps we should at least ensure that one acute hospital remains unrestructured. I think that is a sensible approach. We will therefore retain Alexandra Hospital for the time being as an unrestructured hospital. It will still remain as a Ministry of Health hospital. We will do our best within the constraints that the hospital management has to work within to see how to improve Alexandra Hospital. In this way, patients will have the ability to choose between restructured hospitals like NUH and SGH, newly restructured hospitals like Toa Payoh Hospital and Kandang Kerbau Hospital which will be operating from their existing hospitals, albeit with some upgrading of facilities that the new managements will be able to implement, and the existing Government hospital, namely, Alexandra Hospital. Dr Aline Wong, Dr Tan Cheng Bock and Dr Arthur Beng also spoke about the need to ensure that activities of the restructured hospitals are coordinated. This is to ensure that we avoid duplication of expensive services or expensive equipment. That is the right approach. It is a sensible way. This is in line with what the Ministry has been doing and will continue to be doing. The Ministry has always controlled the development of clinical services in all the hospitals. This is because some of the sub-specialties can be very expensive to operate and we will still coordinate the development of such services in the hospitals to ensure that there is no duplication. Perhaps with the changing demographic profile and if the increased patient load requires an additional unit to be set up, then we will decide which hospital is best suited to have that unit. We will also ensure that equipment, especially the expensive equipment like radiotherapy equipment, are not duplicated. These are multi-million dollar departments and it will not make sense at all for us to have an equivalent department elsewhere because of both the heavy investment in the equipment as well as the heavy investment in the very skilled and high level manpower that will be required to operate such equipment. Dr Aline Wong requested that we ensure that the system of transferring patients from one hospital to another is maintained. I think this is the right approach too. And we will be able to do that because the hospitals, restructured or otherwise, share the same computerised patient database. This means that the hospitals can just key in at their terminals and get the full information on each patient. Copies of the medical reports can also be easily transferred. Nowadays, with the fax machine, it is very easy to fax from one hospital to another. There is also the existing system of inter-hospital referral whereby specialists in one hospital who require the patients to be seen by a specialist in the discipline which is not available in his own hospital, can consult the other hospital's specialist. This system of inter-hospital referral will continue and, in fact, it is being done between SGH and the other MOH hospitals which have not been restructured at the present moment. They will continue this procedure, because it works to the benefit of all, ie, the doctors concerned, the hospitals concerned as well as the patients who are involved. Dr Aline Wong has expressed some concern about the proliferation of high-tech facilities in Government as well as the private sector. We believe in the mechanism of a free market. It is therefore not possible for the Ministry to dictate to the private hospitals what equipment they should or should not buy. I think the private hospitals will have to do their own financial analysis and justify such expansion or purchase purely on their own commercial grounds. Of course, if they do not have the patient load to justify such expensive investments, they will have to charge a very high fee. And if Singaporeans choose to go there in spite of the high fees rather than use the facilities in our Government hospitals that are charged either at cost or for low income group at highly subsidised rates, there is nothing we can do to prevent them. But we will ensure that audits are carried out so that the equipment are used properly. As for indirect advertising, I think it is inevitable that when a new service or equipment that is new, either to Singapore or the region, is introduced, both the press doctors and Singaporeans will be interested to know about such services or equipment. So long as the information given is factual and is not a sales promotion effort, I think providing such factual information is good, because it adds to the knowledge of Singaporeans. Ultimately the best solution to avoid abuse or misuse by providers through such indirect advertising, as Dr Aline Wong had feared, is for all patients to ensure that they have a good family physician. We have been promoting that and we will continue to promote this concept of a family physician strongly through our family health care clinics and also through the College of General Practitioners. I think patients who are able to look to their family physicians for judgment on the need or otherwise of a specialist service can then be assured that their long links with their family physician will enable them to get honest opinion and that the doctors that they are being referred to are doctors who will give them good service and will not charge excessively. Dr Arthur Beng had asked whether the Ministry of Health is deviating from the concept of economies of scale. Previously, the Ministry of Health provided through the Ministry HQ centralised services such as personnel services, computer services, planning of manpower, recruitment of manpower. He asked whether by restructuring the hospitals and requiring them to perform these functions, we are not losing economies of scale. As I have stated yesterday, our hospitals are large and complex organisations. Many of them have over 2,000 staff. The smallest one has at least 1,000 plus employees. These are not small organisations. Under the Ministry of Health, each hospital is only entitled to four senior managers, namely, the Medical Director who is also required not just to run the hospital but to ensure that the medical/professional services are of a high level. They have a hospital secretary, a matron and a deputy medical director, a total of four senior staff. They do not even have an accountant. With a multi-million dollar budget every year, they do not have a single accountant to ensure that the money is being spent wisely. They have over 1,000 people and not a single personnel manager to ensure that personnel problems are being resolved quickly and at the local level. Instead, personnel problems have to grow to the extent that they are big enough to be observed and recognised by the Ministry before action is taken. It is necessary that the hospitals have a proper management to ensure that the hospitals are being operated efficiently and effectively. Operational functions, such as personnel management and cost accounting, must be done at the local level. Otherwise the approach of centralising everything in the Ministry of Health would result in a penny wise pound foolish situation. Let me give an example of how SGH has been able to expand its management staff. Under the old style system, four senior managers with no middle management looked after SGH 4,000 employees. I think it was a herculean effort and it is a credit that the managements worked very hard and managed to make the hospitals work. But I think we can make SGH work better. To do that, we need to provide them with the proper management - senior, middle and lower-middle management. SGH has therefore been able to build up a management staff of 29 professionals. This way, if will be able to ensure that each department is operating efficiently. They know what it is costing them to provide the service. They know where there is any wastage and they would then be able to take the necessary actions to cut out all these wastages. Dr Aline Wong and a number of MPs have also asked about the availability of class C and B2 beds for our low income groups. She mentioned the figure of 70% and 30% distribution between subsidised and non-subsidised beds. Sir, that figure of 70% is still valid today. But I do not think it is a figure that should be iron-clad. What is important is to ensure that there will always be adequate numbers of subsidised beds for patients who choose to go into such wards. Even the socialist countries have now recognised that market forces are the best determinants of supply and demand. Singaporeans through the years have been opting to go to the better wards such as B2, B1 and A. At the present moment, many of them are being forced to go to the class C wards in Tan Tock Seng Hospital, for example, because there are no vacan- cies in the B2 and B1 wards. I think it does not make sense at all for us not to allow Singaporeans who can afford to go to the better quality class wards to use them. It helps, because if they can afford it and they are able to be admitted to the wards that they want, they will be using lesser subsidies, thereby making more subsidies awailable to those in the low income group who have no choice but to go to C class. Sir, it is in the interest of the low income group that we allow those who can afford, access to the B2 and B1 beds. The Ministry will also ensure that the restructured hospitals retain enough subsidised beds. We will monitor and we will make sure that there are always enough beds in the C and B2 wards to cater for those who want them. Mr Chiam See Tong has made two points. One, is that the SGH when it was restructured lost a significant number of staff. He quoted the figure of 40%. Sir, the figure is not 40%, but 20% of experienced staff opted to stay in the civil service for various reasons. SGH has been able to make the necessary redeployments as well as to recruit staff from outside to fill these vacancies. For those vacancies that could not be filled immediately, the Ministry, as he had mentioned, has seconded to SGH the existing staff who had opted not to join and they will remain there until SGH is able to replace them or to train replacements from within the hospital. This way, we will ensure that the services are in no way affected. And as I pointed out earlier, SGH has actually been able to recruit a lot more staff and therefore has now more personnel than before, because it has been able to fill up the vacancies. The level of service has actually gone up rather than gone down. Mr Chiam has also feared that the restructured hospitals will be given a licence to make profits. Sir, he cannot be further wrong than that. That is because the restructured hospitals will still have a significant number of subsidised wards. As I had pointed out yesterday, the subsidy per patient in these subsidised wards is very, very significant - over $800 for class C, and over $900 for class B2. Therefore, there is no way that the hospitals are going to make any profits. In fact, for the hospitals to provide such subsidised services the Government will have to continue providing each restructured hospital with a significant subvention. Sir, I believe I have covered all the questions on the restructured hospitals. I just want to assure Members that whilst the restructured hospitals have management and operational autonomy, the Ministry will still continue to closely monitor their performance, and to coordinate the development of sub-specialties and the purchase of expensive equipment to ensure that there is minimal duplication. In the long term, Members and Singaporeans would be able to see that the restructuring of the hospitals would have enabled our hospital care to improve and also to allow the hospitals to operate more efficiently and more effectively. Everyone will benefit, especially those in the low income group who have no choice but to use our hospitals since they will not be able to afford private sector treatment. Sir, I will now take the individual points raised by each Member on other subjects. Mr Heng Chiang Meng, Mr Chandra Das and Dr Vasoo have asked that the expenditure on health care as a percentage of GDP be increased. In fact, Mr Heng Chiang Meng recommended that it be increased to 1.5% instead of 1.1%. What is crucial is not the percentage of GDP that is being spent on health care, but how well the money is being spent and how the population as a whole, not a select group, has been able to gain access to health and medical care of a high quality level; and whether everyone has an equal accessibility to a cure; whether each person can get treatment for a quick recovery when he falls ill. Sir, as I have pointed out yesterday, our state of health is very good, comparable to all the developed countries. I think this shows that although our health expenditure as a whole is low, we have been able to use the money wisely, effectively, and therefore, been able to obtain maximum value for the money spent. Sir, the Ministry of Health will carefully plan our programmes and if the budget required grows, as I am sure it will, we will go to the Finance Ministry and persuade them to give us the necessary budget to ensure that the health programme can be carried out properly. Sir, I will take the points raised by Members and keep them in mind and, if necessary, will use the Members' arguments in getting a higher budget from the Ministry of Finance. Sir, Dr Lee Siew-Choh also spoke yesterday and I felt very sad when listening to him repeating his old rhetoric about the plight of the poor and when he went on to suggest that we adopt the UK's NHS system in Singapore. Sir, he has obviously not awakened from his deep slumber despite the many nudges given by my colleagues these past few weeks. The Government has been helping the poor in the best way possible since we gained independence, and that is by creating the conducive climate and conditions for the economy to grow and for businesses to prosper and to expand. Sir, job opportunities now are so plentiful that we have jobs running after people rather than the other way round as in every other country. Our per capita GNP in 1960 was $1,300. I wish to inform Dr Lee that our per capita GNP today is $19,400. No able-bodied Singaporean today need be poor as he or she can easily obtain a well paid job. As I had explained yesterday, low income earners using B2 and C class wards do not have any problems paying their hospital bills because these are heavily subsidized and therefore very affordable. The small number of Singaporeans who are genuinely poor also do not have any problems seeking medical care and treatment because they either qualify under the Social Welfare system or they can apply for waivers of fees and these are liberally approved. Sir, the UK Government, recognising the shortcomings of the National Health Service, is today trying hard to restructure it. The NHS has resulted in an equally poor health service for all. Patients have to wait for months and even years for operations and treatment. In fact, it has been reported that some patients who require orthopaedic operations had to wait up to six years. In many hospitals, services had to be curtailed because of lack of funds. The standard of equipment and the level of maintenance in many hospitals are also sub-standard. Sir, the system is not cheap. It costs the British 6% of their GDP each year to run the NHS. Of course, all these shortcomings do not bother those who are rich and who are better off. They just obtain immediate treatment from private sector specialists in private hospitals. This has resulted in the number of private hospitals increasing from about 150 in 1979 to 203 in 1988, a significant increase. Yet Dr Lee would have us impose such an outdated and inefficient system on Singaporeans. Perhaps he is referring not to the NHS but really to the concept that free medical care should be available for all Singaporeans, just like it is provided in USSR and in China. Perhaps he believes that a free medical system means everyone in the country is entitled to free and good medical care. Sir, a free system never results in good medical care for all. It only results in an equally poor level of medical care for the whole country except for the privileged few who either by status of authority or because of their wealth are able to obtain a better level of care. A free system only results in uninhibited usage of the services. There is no incentive to save. There is only incentive to use. Because if you can stay in a hospital for 30 days for free, why stay at home - free food, free care, free lodging. In the USSR, they have released data that show that Soviet citizens use medical services 15 times a year, double the US figure. The USA's rate of usage is already high enough by most standards. Sir, I would encourage Dr Lee to wake up, take a good look at what has happened in the world, compare and, as a doctor, I am sure he realises, although he would not admit it publicly, that our level of service is good and it is one which does credit to the people and the Government of Singapore. Sir, Mr Heng Chiang Meng, Mr Choo Wee Khiang and Encik Abbas asked about shortages of staff in the Government hospitals, and what we are doing to overcome that problem. Sir, the main shortages in our Government hospitals are the nurses and health therapists. Other para-medical staff are not as bad, and we can work quite well with the system of in-house training. These are the steps that we are taking to overcome the shortages. We have already improved the salary for nurses and the health therapists and this has enabled the Ministry to recruit more trainees. For example, before 1988, before the pay increase or salary revision, we were only able to recruit 550 trainees each year. In 1988-89, under the new salary scales, we have been able to increase the intake to 740 each year, a significant increase. We have also been able to increase the number of overseas scholarships for health therapists. For 1988, we only had four, in 1989 that increased to nine. This year, we hope to further increase the number. The restructured hospitals have also been able to use new grades of staff in place of nurses and therapists for some of the basic and routine functions. They have been able to use therapist aides, ward and clinic assistants in place of the nurses who were being used previously. Unfortunately, for the Ministry of Health hospitals that flexibility is not there. They still have to make do with the nurses who are being used at the present moment. We will continue to work on the Ministry of Finance to create these new grades of staff. Sir, we are therefore taking advantage of all possibilities to help reduce the shortfall. Dr Vasoo and quite a few other MPs have asked that we re-introduce the C class wards in SGH as soon as possible. Sir, the SGH management is now very actively looking into that and they hope to be able to implement the C class wards by renovating the existing wards and have them ready within 12 months. We hope to have about 150 C class beds. Mr Chandra Das also asked whether there are any plans to increase the Medisave rate. Sir, the present rate of 6% is adequate for those patients going to the B2 and C class wards. As I showed yesterday, for a class C patient in the low income group, six months' contribution of Medisave will top up whatever he has used. For the B2 patients, 10 months will allow him to top up. The present rate of contribution is still adequate. However, it will not be adequate, of course, if the low income group chooses to use the A or B1 class wards. We will counsel patients so that they are using the right level of wards. Sir, if the medical cost continue to increase at 12% a year, the 6% contribution rate may not be adequate in the longer term. We will therefore monitor closely the usage of Medisave and review the need for any increases. This point on the need to enhance the awareness of medical costs and the cost of hospitalisation so that patients choose the right ward to be admitted into was also pointed out by Dr Ow Chin Hock. We will be printing a new Medisave brochure which will be printed in four languages to explain to patients what are the factors to take into consideration when deciding on the class of ward. For example, we will give information on the average cost per day for A, B1, B2 and C wards. We also give the average cost per day for wards in the private hospitals, and we also warn patients that there is a daily limit of $300 for Medisave withdrawals. So this way patients who are being admitted to the hospitals will be informed patients. I hope with this, they will then be able to choose prudently the class of ward that they wish to be admitted into. Dr Ow Chin Hock has also suggested that the age limit for MediShield be increased to 70, instead of 65 as presently proposed. Sir, we will first implement the MediShield based on the age limit of 65, then we will collect as much information as we can on the usage rates for those around 65, so that we will be able to compute the necessary premiums, and after we have had a better idea of the utilisation rate of hospital services. But it is our intention that down the road, we will increase the age limit. Mr Choo Wee Khiang has talked about the need for compassion. He mentioned that our doctors are very competent, but the doctors and nurses lack compassion. I think that is a very general statement. I am not too sure whether our five doctors, including the NCMP, in the Chamber will agree to that statement. Sir, most people who go into the medical profession, I am sure, choose the profession because of their attitude, which is they must have a caring attitude. When they go through university, these qualities are also imbued into them - that their role is to serve the patients. And after they graduate and before they are attached to the hospitals for their housemanship, this message is again driven into them. I think at the end of the day, doctors and nurses are, by and large, highly compassionate. Of course, in every profession there will be some black sheep. Our aim is to train, re-train the whole workforce and also to be able to identify who are those who are still lacking in manners, in courtesy. If the Member for Marine Parade GRC has information as to who lacks compassion and who has been discourteous, please let us know. We will take the necessary action. He has also asked for free treatment for class C patients in the children's hospital. Sir, I will refer him to the Hansard last year. I think the class C rates are extremely affordable. Young parents with a few children have no problems putting their children into C class wards and paying for them. Let us ensure that the limited subsidies that are available are used on those who really require help, rather than to give it to everybody. Then it must mean that everybody gets a small share, the fees are high, rather than having the few who really require such help to receive free medical care. Dr Arthur Beng has also made quite a few points. He has asked that we avoid duplication and that the SGH and NUH be kept as tertiary hospitals and the other hospitals be retained as secondary care hospitals. Sir, that is a sensible approach, and that is the approach that the Ministry of Health has adopted. We will continue to ensure that the super-specialisations are done in SGH and NUH and that the other hospitals will have general departments and will have only specialties which are general in nature. Sir, he has also asked some questions on primary health care. He has asked whether we are going to have a permanent health exhibition hall similar to what we have done last year for the National Health Fair. We are planning for one. The new National Institute of Health, which will be built in the grounds of the SGH, will have a permanent exhibition hall. We will then be able to refine the exhibits and not only that, as pointed out Dr John Chen, we will also be able to make sure that the medium of communication is appropriate to all groups, because our aim is to attract not just school children, but people of all age groups and all backgrounds. He has also asked about the health education programme this year. We will be having two big health education programmes, namely, the Anti-Smoking Campaign which will start in May and last for a month, and the Cancer Education Programme which will be from September to December this year. This is quite an extensive programme. This is because cancer is our main cause of death. So we wish to concentrate on this cause this year. He has also commented about the service in the polyclinics - that there are long queues for service. Sir, I am happy to report that the average waiting time for patients in the polyclinics has actually reduced from one hour in 1985 to an average of half an hour today. These are averages. What happens, and this is a trend which we have not been able to overcome, is that most patients will flock to the polyclinics at the same time, which is early in the morning. Those who are smart will go later. They wait for a shorter period. We have advised them to try to space it out so that they will be able to obtain service no matter what time they come, but this message still has not been well absorbed by the patients. We will continue to educate them to spread out their attendances throughout the whole day. He has also asked about the workload of doctors. I am happy to also report that the workload has in fact been reduced. In 1985, the doctors saw an average of 100 patients a day. For today, the scheduled number is only 80. So the workload has gone down. It is high, but it has gone down. Dr Ow Chin Hock has asked that more resources be spent on primary health care. Sir, the Ministry places high priority on primary health care and we will allocate the necessary funds to ensure that the level of services are enhanced and expanded. The budget for primary health care has tripled over the last 10 years. In 1980, it was only $23 million; today, it has expanded to $68 million. This does not take into consideration the capital cost of the service. As I stated yesterday, the 10 new polyclinics alone cost the Ministry $66 million. Dr Arthur Beng commented on the disparity in income levels between surgeons and non-surgeons, and he has asked about the impact on the lifting of the earning limits on doctors. This was also referred to by Dr Aline Wong and Mr Choo Wee Khiang. Sir, the aim of the lifting of the limit is to allow the big gap between earnings of private sector specialists and the earnings of doctors in the Government service to be slightly narrowed. It is a big gap and I think the lifting has only resulted in the gap being reduced slightly. The end objective is to ensure that we are able to retain at least a core of the better specialists. This is because they are needed for two important jobs. Firstly, to provide training for our future doctors, undergraduates, as well as post-graduates. And secondly, to provide service for patients who come to our Government hospitals. And as Members know, most of our patients are from the low-income group who use the 70% subsidised beds in the Government hospitals. In terms of the disparity between surgeons and non-surgeons, Sir, unfortunately, that is a fact of life. In every country, surgeons for various reasons earn more than the non-surgeons. In fact there is a big controversy in the US now as to whether the gap should be closed and how it should be done. Contrary to the impression given earlier by the press, I think it is necessary for me to give some information about the earnings of doctors, to ensure that Members do not get a wrong impression that all our specialists are earning a lot of money. Sir, in the private sector, 25% of the specialists earn in excess of $20,000 a month. This is the declared income. They earn more than $20,000 a month, a quarter of them. In our Government as well as restructured hospitals, only 8% of our specialists today earn more than $20,000 a month. And for those who earn over $30,000 a month, at least 12% of the specialists in the private sector earn more than that every month. In contrast, only 2% of the specialists in our Government and restructured hospitals earn more than $30,000. I think the earnings are still reasonable. But of course those doctors who place high priority on earnings can always leave, join the private sector, and earn more. Furthermore, I think they will have the advantage of being their own bosses. I am sure Dr Tan Cheng Bock will find it is a very beneficial factor, being his own boss, without having to report to a whole host of people who are in charge of him. However, Members can be assured that the Ministry and the hospitals will continue to monitor the work of every doctor, every specialist, to ensure that they are not abusing the privilege that has been given to them. We will ensure that seven out of the 11 sessions a week are spent on the subsidised patients. In fact, we carried out a comprehensive survey earlier this year on all our specialists in both Government and restructured hospitals. And I am glad to say that the comprehensive study showed that all are complying with the seven out of 11 sessions. Sir, Dr Aline Wong has asked: how do we ensure that the teaching functions of the hospitals will be safeguarded, in particular the role of NUH as a teaching hospital. Sir, in February this year, a committee chaired by Dr S.K. Cheong, Deputy Chairman of the PSC, and comprising the Head of the Civil Service, Permanent Secretary (Health), Permanent Secretary (Education) and the Vice Chancellor of NUS was set up to look into the governance of NUH as the principal teaching hospital of the NUS Faculty of Medicine in the context of developing it as an academic centre of medical excellence. The committee reviewed and recommended that since the priority of the Ministry of Health is more on clinical service, the governance of NUH should be transferred to NUS. This will allow NUS to plan, manage and develop NUH as its principal teaching hospital in line with the mission of its Faculty of Medicine. Sir, the Government has accepted the committee's recommendation and arrangements are now being made for the transfer of NUH to NUS in the next few months. Dr Tan Cheng Bock has asked quite a few questions. He has asked why the performance indicators of the restructured hospitals are not indicated in the budget documents. Sir, the budget documents only show the performance of Ministries and not the performance of Government companies. However, Members can obtain information on the restructured hospitals by filing Oral Questions or by writing to the Ministry for such information. He has also asked the Ministry to ensure that when Toa Payoh and Kandang Kerbau Hospitals are restructured or whichever hospital is being restructured that they be given adequate subventions. Sir, we will do that. Sir, he has also asked why the number of home visits for the elderly has declined. The number of elderly patients who were visited at home has increased actually from 2,850 in 1985 to 3,740 in 1989. The number of elderly visited has increased by 31%. But the number of home visits has declined, as correctly pointed out by Dr Tan. And that is because with the opening of the senior citizens health care centres, more of these patients are going to the health care centres which have good facilities for rehabilitation and for day care. The health care centres are also supervised by doctors and they have physiotherapists and therapist aides. So by going there, they can actually recover faster. He has also asked why the cost per outpatient treated has increased. There are many reasons. I will give him the main ones. First, the level of care has improved. For example, in the past, a doctor saw 100 patients a day. Now, the doctor only sees 80 patients to enable him to give more time to each patient. The costs of labora- tory and X-ray investigations are now paid through the polyclinics. That means they are paid out from the polyclinics budget. Therefore, they are reflected there. And the polyclinics are now using a wider range of drugs as compared to previously when only basic simple drugs were available. Another reason is that we have introduced an expensive procedure in the polyclinics and that is the hepatitis B immunisation. That has increased the budget for the polyclinics. In 1985, we only gave 1,700 doses and last year the polyclinics gave 113,000 doses. All these have contributed to the increased costs, as pointed out by Dr Tan. He has also asked why we need a non-emergency unit in the A&E departments. It would have been best if the A&E departments did not have to resort to this. But unfortunately this is being imposed on them by the patients themselves. Let me give you some information. In 1986, A&E attendance was about 32,000 a month. Three years later in 1989, the number per month has increased to 43,000, an increase of 11,000, a far higher rate of increase than our population's rate of increase. What is disturbing is that 40% of all these attendances were triaged and found to be non-emergency cases. Sir, these non-emergency cases will have an adverse impact on services to those who are genuine emergency cases. What NUH has done is to set up a separate unit so that patients who are triaged to be non-emergency cases can then be sent to this unit and not clutter up the A&E department. The Singapore General Hospital is also looking into such a system. Dr John Chen made many points and I have taken note of them. National health fair and the need for other languages, yes, we will implement. We will also investigate any complaints that patients in the B2 and C class wards are receiving poor service. If Members have any cases of such poor service, let the Ministry know. We will definitely look into them and take the corrective actions. Mr Chiam made another point, ie, that the question of affordability is very subjective. Sir, the question of affordability can- not be subjective, because you know how much it costs, you know how much the average worker earns, you know how much he has to put into his Medisave account every month to make up for that. For the B2 wards, it takes the average worker about 10 months to put back what is spent in his Medisave. And it takes the low income earner staying in a class C ward, and earning $600 a month, only six months to top up his Medisave account. I think those are not subjective by any measures. Those are absolute figures that we know and we can compute and we should know it is highly affordable. Sir, I believe I have answered all the questions.

May I seek some clarifications from the Minister, Sir?

Yes, Dr Lee.

The Minister has spoken quite a lot, going all round the mulberry bush and never short and to the point. Anyway, I just want to ask the Minister whether he is aware of the complaints that have been made that teaching time of students, junior doctors and even nurses has been greatly reduced. He has not given any answer to this question so far. Another point which I want to ask is this: he has mentioned that Alexandra Hospital will not be restructured, and will be left as a comparison and a choice for patients as to whether to go to a unrestructured hospital or a restructured hospital. I ask whether the Minister is aware that many patients would rather go to the Singapore General Hospital today even if they happen to be staying very close to the other hospitals nearby. This is because many people have the misimpression that the Singapore General Hospital is the best equipped hospital and also has the best doctors. Whereas the other hospitals are more or less Cinderellas, which provide poorer sub-standard treatment and are staffed with sub-standard doctors, although we all know for certain that many of the doctors who are in these non-SGH hospitals are some of the very best that we can find in Singapore. I ask the Minister whether he will ensure that adequat facilities will be provided to Alexandra Hospital, which is today one of the most poorly supported hospitals in Singapore. He has also said something about the number of subsidised beds being adequate but that people are nevertheless still opting to go to B2 and even B1 beds. Surely the Minister must realise that if the quality of the C class beds is good, then they would not go and pay more for B2 and B1 or A class beds. And if the Government should pay more attention to this aspect and upgrade and improve the quality of class C beds, then he would see that many, many more people will demand for class C beds. He has also mentioned something about the national health service. I suggested one similar to the national health service in UK. He also mentioned something about the United States. I wonder if he realises that today the health system in the United States has been condemned even by its own doctors. And the general health system in the United States is inferior to the general health system in Britain. In fact, even Mrs Thatcher has not dared to interfere with the national health system in Britain today. We do not ask for free medical treatment. We ask for medical treatment which is really affordable and not at a cost which the Government imposes on the people. He has also said something about being compassionate and of the disparity in the incomes between surgeons and physicians. This disparity is a direct result of the profit system that has been brought about by the restructuring of the hospitals in Singapore today. If there had been no such restructuring, there would be no grievances, no dissatisfaction in the hospitals right now. As it is, some of the senior physicians earn much less than much more junior surgeons. And that of course saps their team spirit and will also ultimately affect the patients in many ways. I am glad he says that he is going to talk about health education later on, and I will speak a little on that when it comes to my amendment. But I wish to inform the Minister that I am quite awake all the time and that if he has not been able to know what is happening in the hospitals, it is he who has been sleeping most of the time.

Can I seek a few clarifications from the Acting Minister? First of all, let me thank him for telling the House why the subventions for SGH and NUH had increased by such a hefty amount between FY 1988 and 1989. But my question is, if a large part of this increase is due to the accounting system, ie, these subsidies are now made more evident under the Ministry of Health and the restructured hospitals accounts, then will he not say that the large amount of Government subventions given over these two years were not real increases but were just paper transfers? So in that sense, was there any need to press for cost recovery to justify the increases in Government charges? I mean they were paper transfers. That amount as such has always been there. The increases were not real. So why should there be so much pressure for cost recovery based on this set of figures? The second question I have is with regard to Alexandra Hospital. If this is to be retained as a non-restructured hospital, and given the present state that Alexandra Hospital is in, it is old and its facilities are very inadequate, could he tell us a little bit more about the plans to bring up the quality of Alexandra Hospital so that it would definitely not be seen, and surely it will be seen if it is not done, as a second class hospital? The third query I have is with regard to the indirect advertisement practice. I agree that perhaps the best way is for people to develop a very close relationship with the family doctor so that in case of need for referrals to specialists he can actually seek an informed opinion. Then in this case, does he not think that SGH and the restructured hospitals should tighten up the system of referrals? In other words, right now people can walk in and demand to see the specialist resulting in a waste of the specialist's time and resources. To rationalise resources and to make people go through the GP first before they seek a specialist's care, which will save the coun- try's health cost, would he not look into tightening up this referral system? Another question I have is with regard to the specialist consultancy fee scheme. He told the House that a comprehensive study has been made and it was found that the 4:7 sessions have indeed been adhered to. But I am not satisfied. I wish he could tell us a bit more about how this was done. He should give us a bit more details so that we can be rest more assured. Also, is he not aware that some specialists have been working overtime, so to speak, to see private patients? As a result, the supportive staff also have to work overtime. But we hear complaints that the supportive staff do not benefit from the increase in income of the specialists. So there is a bit of unhappiness there. It is not just unhappiness between surgeons and physicians about the different levels of income. But the supportive staff have to do this for the specialists who would be adding to their own income. Finally, I have a query on his statistics on the home visits to the elderly. He told us that actually there has been an increase in the number of elderly seen, although the number of home visits has declined, and he gave the explanation that since the senior citizens' health centres at polyclinics have been opened, more elderly people have gone to these centres instead of receiving home visits. But the figures from the budget document show that in fact even before those new polyclinics offered these day services and rehabilitation services for the elderly, the number of home visits has actually declined, starting in 1986, in fact it started to decline slightly earlier. But in 1986, there was a big drop. In 1985, for example, the number of home visits was 46,733. For FY 1986, it was 39,155, declining steadily to a projection of 25,680 for FY 1990. My point is, Toa Payoh Polyclinic was the first to have this kind of services. It was opened only two years ago. But the decline in the number of home visits has started even before the Toa Payoh Polyclinic had these services. So my question is, how much has this gradual decline to do with the fact that, beginning in 1986, patients receiving home visits had to pay a fee, whereas before it was free? I raised this point last year and I then asked the Goverment to look into the possibility of reducing the fee the patient has to pay for repeat visits. Surely the figures showing a decline in home visits must have something to do with the fee scheme and patients began to ask for less repeat visits because of the fee.

Sir, first, I would like to ask the Minister what role would the Ministry of Health be playing after hiving off all the hospitals to the restructured hospitals? Has he worked himself out of a job? Secondly, will each restructured hospital have to be administered in the same way as the presently restructured hospitals? If the Ministry is so convinced of their success, why not then have some fully privatised hospitals by opening up the beds to other specialists in the private sector? Then the Minister's argument of open market forces will be more convincing. Lastly, the point about differences in remuneration between surgeons and non-surgeons and how to close the gap. Here I feel the Government should set the example. Why? Because the Government should aim to provide the whole range of medical services, from paediatrics to medicine to the surgical disciplines. If this present trend continues, then we will see the next generation of medical students and doctors all opting for the surgical disciplines and we will then be depleted of doctors and specialists in the non-surgical disciplines.

I would like to ask the Minister a few questions. First, I want to ask him about this specialist treatment for C class patients. He has given this House examples of about 73% being operated in Tan Tock Seng Hospital by the neuro-surgeons. I think this House must be fully aware that such operations cannot be operated by medical officers or ordinary surgeons. They have to be operated by neurosurgeons. So his figure of 73% is a bit deceiving. Then the other example he gave was 54% for paediatric surgery. Who can do paediatric surgery? I cannot do. The ordinary medical officers cannot do. So this is again very deceiving. Then on open heart surgery, I think only the Minister knows who can do such big things? So he should zero in on the surgeons who are actually working in the hospitals. How much of their surgical skills are being used for the C class patients? He says there is a monitoring programme. I do not know whether he knows what this monitoring programme is. I am not sure. He has to give us more details on this programme. But is the time spent by surgeons on C class patients the actual operating time, involving the surgeons operating skill? They would say, "Okay, I spend the other time looking at C class patients." But they are timespent on non-surgical. I hope the Minister is clear, or else I will explain again. Then he said there is a coordination committee which will ensure that there will be no duplication of sub-specialties. I wonder how come seven hospitals have already been given permission to do this IVF programme. You must be careful when you allow this IVF programme and all these procreation programmes to be conducted by hospitals. Because, as I pointed out earlier, and so did my colleague, Dr Aline Wong, you need neo-natal care. I learn that the Ministry of Health has now asked the various hospitals who have set up all these programmes to have neo-natal units. Do you know the cost involved to get a neo-natologist? Let me explain to this House what neo-natal units are used for. Actually, neo-natal care is for the first one month of a baby's life, and that is a very, very difficult period for any paediatrician to take care of the child. I think it involves very special equipment, special skills and these doctors are called neo-natologists. The Minister has now asked them to set up such units and he has given permission for seven such units to be set up. Now he wants them to have similar neo-natal units to be set up. It will involve a lot of cost. Do not forget that you need the embryologist. I do not want to take up too much of your time. But you need embryologists and they are very expensive people to bring in. So I wonder whether the Minister has taken into account all this before he allows the setting up of all these units. Then he said that many people want to go to B2 class and they do not want to go to C class. I asked some of my patients why they want to go to B1. They said, "I have no choice. My doctor would not operate on me if I stay in B2 or C class. So I have no choice. I have to go to B1 or A class." Of course, this is aided by the scheme to allow the children's Medisave to be used and this will encourage more of them to go to the B1 and A class wards. There are so many questions I want to ask, but I am sure the other Members also want to ask questions. So for the moment I will stop here.

Sir, I want to ask the Minister about the nurses. He says that there is an acute shortage of nurses in our hospitals. Nurses are the backbone of our hospital services. What is the Minister going to do to correct this shortage of nurses? Why is it that our school leavers are not so willing to enter this noble profession? Is it because the pay is not attractive enough or there is no good career path for them? Or is it because that while they are at work they are treated shabbily? There is no prestige in their work? Perhaps the Minister can tell this House what he is going to do to remedy the shortage of nurses in our hospitals.

Can I make a small point, Sir? In replying to my point on lack of compassion, the Minister implied that I am saying all the doctors and nurses lack compassion, which is not quite the case. I said "many". It is not all. The way the Acting Minister put it, he is going to make all the doctors and nurses dislike me!

Sir, Dr Lee Siew-Choh asked whether we know that teaching time has been reduced and that the impact on teaching has been adverse. Sir, a study was carried out earlier this year and a questionnaire was sent to trainees (to be returned anonymously) asking for their feedback on the quality of training. I am happy to say, although I do not have the information here, that the bulk of the trainees replied that they felt that the quality of training has not declined in any way. I think the figure for that was in excess of 85%. If the NCMP likes, he can file a question on that and I will provide him with full information on the survey. He stated that patients would rather opt for SGH rather than Alexandra or any of the other Government hospitals. I think that is only commonsense, is it not? It is their choice. All the hospitals are available. If there is a hospital next to them, Tan Tock Seng or Toa Payoh Hospitals, there are all the facilities. And as Dr Lee Siew-Choh pointed out, they also equally have good doctors. If patients choose to go to SGH rather than go next door, it is their choice. This is Singapore. This is not China, please. He has also said that if C class was better, then people would opt for C class. They again have a choice. They want a better mode of accommodation, they want a little bit more privacy, there is B2 available for them. If they prefer something even better, there is B1. If they prefer to be isolated in a A class ward, single room, are prepared to pay for it, sure, the choice is there. They choose based on what they can afford. They choose based on what level of comfort they want. And we respect their choice. This is the free system that we have here. Sir, we should not be forcing everyone to go to C class if they do not want to. I think that would be very retrogressive, much as Dr Lee would like us to do. Sir, he talked about the US system being inferior. I did not say that the US system was better. I said that, if he had been awake and listening, the Soviet Union, with its free system, has 15 more times usage of medical care than the US. And the US is really bad enough, because US has one of the highest usage rates. And I think Singapore would be well advised and well served if our people do not follow what is happening either in the US or, worse, in USSR and China. Sir, he said that if we had not lifted the cap on earnings, there would have been no grievances about salaries. Surely he knows that every year the Government service loses large numbers of specialists to the private sector because, firstly, they can earn a lot more; and secondly, they have a much higher degree of freedom and autonomy by being their own boss. The least we can do is to ensure that the gap in salaries is closed a little bit. They cannot be their own boss, but we try to allow them as much autonomy as possible in carrying out their practice in the Government service. This way, we will then best serve the lower income group that MPs and the NCMP profess to be very concerned about. Dr Aline Wong talked about the subventions for SGH and that the increase between 1988 and 1989 did not appear to be real, because they reflect hidden subsidies. Sir, yes, they reflect hidden subsidies. But, as I have shown earlier, the hospital has also been able to recruit staff to provide a better level of service. That cost must be recovered, otherwise SGH will be forced to allow attrition to bring that down to where it was before. If patients want that, it is very easy for us to force SGH to do it. But again I do not think that is in the interest of patients. What plans do we have for upgrading Alexandra Hospital? Sir, we are looking into it on what we can do with AH, in terms of improvement of facilities, and to ensure that the equipment that it has is at least adequate. Dr Aline Wong suggested that we disallow walk-in referrals. I think that is a good suggestion. I will ask my officers to look into that. She also mentioned about specialists working overtime and that the staff are not benefiting. Sir, I would imagine that if the staff are asked to work overtime they should be paid overtime rates. Let me look into that again. Otherwise, I do not think they will be working there voluntarily. But I will definitely ask my staff to look into it. Dr Arthur Beng has asked about the role of MOH after the restructuring. Sir, the role of MOH would be, firstly, the primary health care. Then, we have preventive health care and promotion of health, which are very crucial activities. We will still be monitoring and coordinating the activities of the restructured hospitals. Let us not forget that even though they are restructured and autonomous, they are still Government-owned. We must still ensure that the subventions that they are getting, which are tax money, are being used properly, and that those in the lower income group who seek treatment there are being given a good level of care. And with the restructured hospitals, I think that would in fact take up even more time than with the hospitals operating as a MOH hospital. He has asked whether we would be prepared to let a new hospital be operated by private sector people. Sir, I think that is a good idea. If there is any private sector group that is prepared to take over one of our hospitals and operate it with the subventions that are available, and still provide subsidised care of a comparable level to the other hospitals, with comparable charges for those in the lower income group that use the B2 and class C wards, there is no reason why we should not. I hope Dr Arthur Beng and maybe even Dr Tan Cheng Bock himself may want to have a try at running it. [Interruptions]. If he is interested, he can also come forward and make us an offer, and we will review that.

I accept that challenge.

I will ask my officers to get in touch with him to work out the details. An hon. Member: Alexandra Hospital.

I think I will be fair to him. I will not load him with an old hospital. To be fair, if he is prepared to, we will give him a new hospital to run. Sir, Dr Arthur Beng asked whether the lifting of the consultation fee scheme limit will also result in more trainees opting for surgical disciplines. First, I want to bring Members back to the point that even before the lifting, the surgeons were already earning more than the non-surgeons. Those who are interested in the salary would have left for the private sector and will earn even more. So I do not think lifting that cap would in any way influence the trainees to opt more for surgical disciplines. But in any case, the number of surgical traineeship posts is always limited, and they have always been filled. So if more opt for them, it only means that the departments will have a bigger choice of trainees to choose from. Sir, Dr Tan Cheng Bock gave a long speech about the specialists performing operations under Tables 5 to 7. That was the point which I was trying to make - that no matter which ward you are in, if you require a specialist of that order to operate on you, you will be entitled to one, and you are not going to be given to a trainee or a Medical Officer to practise upon, which is what I think many Singaporeans fear. So my aim, if he had been listening properly yesterday, was to inform the House and Singaporeans that, don't you fear, if you have a serious condition, no one else but the consultant or the Senior Registrar will be looking after you. So I was in no way deceiving the House with data. It was meant with that in mind. So it was not an attempt at deception. Sir, he also talked about IVF and whether we know that for IVF we need high level staff and that it is a very expensive service. We realise it is an expensive service, and that is why we have ensured that those people who want to use the service pay the cost for it. We also know that the success rates are low world-wide. In Singapore, our success rate for the IVF programme, if I recall correctly, is about 14% for pregnancy rate, which I think is fairly high, in comparison with centres around the world. It shows that doctors are careful in selecting the patients for admission to the IVF programme. We have also informed the private sector IVF centres that we will monitor their pregnancy rates very closely too. And if their pregnancy rates are low, it means that they have not been strictly vetting their cases, we would withhold permission for them to continue operating. I think the IVF centres are fairly new. Let us give them time to operate, to build up their experience and to ensure that the service that they are giving is of a high level. He has also talked about patients who are being encouraged to use B1 and A, otherwise the doctors will not operate on them. I have some data here that show the results of a survey carried out in February this year among patients in A and B1 wards at SGH and NUH. A total of 176 patients in these wards who had undergone surgincal operations were reviewed and a total of 113 patients were asked and these were in the medical wards.Again, these are forms given to them and they are anonymous. They filled up the forms and they just popped them into the boxes. We asked them: Who influenced you in the choice of wards? And we listed: own choice, family friend, employer/insurer (because some employers do offer certain benefits as well as insurance schemes that they purchase), doctor, nurse, others. I will, first, mention the surgical patients, because I think that is the more significant one. This is where Dr Tan mentioned that they can earn more if they operate on them in the private ward. Own choice - 55%; family and friend - 20%; employer or insurer - 11%; doctor - 8%; nurse - 2%; others - 4%. For the medical cases, own choice - 55% (same as for surgical); family and friend - 29%; employer or insurer - 6%; doctor - 9% (surprising, because medical doctors do not earn significantly from private patients; it makes no difference to them, whether it is A, B1 or C); nurse - 0%; others - 1%. Perhaps I will ask them to do another study. In the case of doctor, what did the doctor influence them? Did the doctor explain that for A and B1 wards, you have privacy, air-conditioned? Or did the doctor influence them by saying, "Look, if you don't go into A or B1, I won't operate on you." But whatever it is, it is 8%. We will look further into that to ensure that the doctors are not abusing the system. Mr Chiam asked about nurses. What are we going to do to solve the shortage? Sir, I thought I have been explaining that all along just now. Do you want me to repeat the answer? [Interruptions]. We will ensure that we are competitive, and we will try to recruit more, as we have done. I thought I saw Mr Choo writing down the figures just now. Do you have the figures? Maybe he can tell Mr Chiam afterwards.

It comes from the horse's mouth.

You can recruit from overseas.

We will recruit locally the bulk of what we need and we will try to recruit what we can from overseas, the numbers of which I think will always be small.

Why are school leavers not opting for this noble profession?

Because there are so many other attractive employment opportunities for school leavers. That is why we have to pay them more and that is why health cost must go up. That is why fees must continue to rise. Otherwise, we will not have any nurses in the future.

Not necessarily.

Yes, otherwise ---

Order. Members will not engage in private conversation.

Mr Speaker, Sir, if Mr Chiam would like to help us recruit, we will of course be very grateful for his assistance. Are you going to, Mr Chiam? Let me get on to the last Member, Mr Choo Wee Khiang. He mentioned "many". I think "many" are still not doing justice to the medical profession.

Last statement, Sir. The answer which the Minister has given concerning free choice and class C beds implies that people opt to go to B2, B1 and A class beds simply because they like to pay more. This argument is based on one of the most upside down and ridiculous logic I have heard for a long, long time. Such an answer is typically representative, I would say, of the PAP non-caring attitude and non-conscience and of a government with no social conscience.

May I just ask another clarification, Sir. With regard to the kind of serveys that the Minister plans to carry out on doctors and inhouse staff, does he think that the doctors and inhouse staff will really give him true and honest answers to questions like whether you have taken care of subsidised patients and, whether you have told your patients that if you do not stay in B1 beds and A1 beds, I won't see you? Does he expect honest answers for these questions?

Sir, Dr Lee again has not waken up. He is still saying that people should be forced to go to C class. He asked whether people like to go to A, B1 and B2 because they like to pay more. Sir, on that he is right. People do not like to pay more than they can get away with. That is human nature. But Singaporeans have a choice of what service they want and how much they pay for that service. It is just like the difference between a taxi and a bus. Every Singaporean has a choice between a bus and a taxi. He wants a taxi, he takes a taxi and he pays more. He wants to pays less, he takes a bus. They are given a choice. Similarly, with the hospitals. If you want to pay less, the C class is very affordable, it is available. If they can afford more, they go to a better class. What we should be happy about, Sir, is that Singaporeans are more and more able to afford the better services. And this is the best reflection of what the Government has done for Singapore in the last 30 years - create, the environment for businesses to prosper, to grow, create the environment for jobs to be plentiful, and not just low-paying jobs but jobs which are high-paying and which allow Singaporeans to have a good standard of living. It is a natural progression that once they have all these and when they go into a hospital the few times in their lifetime, they would opt to do what is right for themselves, which is to go to the ward that they can best afford. Sir, I think we should be happy that Singaporeans can do that. Dr Aline Wong talked about surveys and whether we expect to get an honest survey and an honest reply. I think she missed the point. The surveys are not carried out on doctors. The survey forms are given to the patients themselves to fill in anonymously and to return. So I do not think they need to fear.

Mr Speaker, Sir, I am glad to hear that the Ministry of Health would take on a greater supervisory role after restructuring is completed. Here I think it is important because, as has been mentioned by my colleagues, the IVF programme will result in more premature births. And here is an area which I feel that the Ministry of Health should look into very seriously to see that all the approved centres have good neo-natal support programmes.

Mr Speaker, Sir, on this question of subvention grants, I am still not satisfied. I still feel that since the Minister is asking for approval for this sum to be given to the various restructured hospitals, they must account for it in the budget in the next Parliament. It is very important because we in this House want to know how that money is spent. It is not just showing us the annual reports and so on.

Sir, we will look into this with the Ministry of Finance, since the budget documents are published by the Ministry of Finance, as to what can be done. But this is the established practice for all Government companies that whatever subventions they are receiving are shown just as subventions rather than the details of the companies' activities. However, as I have stated, Members, in the meantime, are free to ask for information. With regard to Dr Arthur Beng's points, we will ensure that they have a good neo-natology service.

Sir, I like to thank the Minister for his very detailed replies. I think he is patient with us. To be fair, the process of restructuring has just gone on for a short while in spite of the pilot project which has taken place with NUH. We really should give the officials a bit more time to see the results. As long as the Minister keeps telling us his frank opinions, gives us the statistics, I think we are happy. And to be fair to the Ministry officials, we are giving them a very tall order. We expect them to cut down on the need for subventions. We expect them to go for medical excellence and all of that within a short time. May I still impress on the Minister that, to help your officials accomplish their task, I think you should really convince the Cabinet to consider all capital costs, including investment in equipment where justified, to be sunk costs and not expect MOH to go for recovery of such expenditures. With this, I beg to withdraw my amendment. Amendment, by leave, withdrawn.

Sir, I beg to move, That the sum to be allocated for Head P be reduced by $10 in respect of Code PA 1500 of the Main Estimates. Sir, credit card holders usually receive a lot of brochures and I happen to be one of them when I received a letter which says: 'Nowadays the cost of a hospital confinement can be staggering. Medical and hospitalisation costs have been rising as more hospitals privatise and upgrade their facilities to provide better medical care. Just ask any one who has been hospitalised recently they would tell you how much more they had to pay out of their own pockets despite employer provided benefits.' Sir, from this letter, we can understand that not only we MPs feel that the cost of medical care is so expensive, but it is a general perception of people. I think the role of the Government is to provide good medical care to people in Singapore and also to make sure that charges are being kept at a very reasonable level so that even private hospitals will not capitalise on the rising cost. Sir, when it comes to restructured or privatised hospitals, the first impression one gets is the rising costs. Let me give an example, car parks. People who used to visit patients in the restructured hospitals did not pay a single cent for car parking. But now, immediately after restructuring, people who genuinely visit their friends and relatives have to pay. I think the Minister has to look into it and see that people who are genuinely visiting their friends and relatives will get a waiver of parking fees. Only the doctors and nurses will know and the relatives who are patients. Sir, I was told by my friend that if you were to go to a hospital regularly enough, you would hear stories about how families are having difficulties in paying $3,000 medical bills that are still going up because their loved ones have not been discharged. Indeed, a friend of mine witnessed a patient in one intensive care unit, threatening to pull out his life sustaining tube and to leap off the top most floor of the hospital when his wife informed him that his medical expenses at the point in time had reached $10,000. Eventually, the medical bill was settled through his daughter's Medisave account and borrowed money. Sir, I am truly pleased that the Government has introduced Medishield, because the Government realise that our people's average Medisave account is slightly more than $3,000 only. It is grossly inadequate to cover expensive medical care. But then why should Medishield stop at 65 years old? Earlier on, the Minister gave an explanation which I think is truly not satisfactory and I wish the Minister could look into this very seriously, because the life span of Singaporeans has now prolonged to beyond 65 years. And why do you want to be not so equitable towards people who are more than 65 years old? In terms of using Medisave, I hope the Minister will look into ways and means to ensure that patients and their relatives will not over-withdraw their Medisave nothwithstanding the fact that there are so-called overdraft facilities available. Maybe you should give a particular patient some kind of quotation or rough estimate and look into their Medisave account and tell them, "Please don't over-use it." Otherwise many sad stories will happen again. Sir, on medical bills, apart from consultation fees and others, I like to draw the attention of the Minister to look at two bills which I have here. The first bill is from the National Skin Centre (Singapore) Pte Ltd. The total cost of the bill is only $11.30, but to my surprise this particular patient is able to get similar medicine at a commercial pharmacy for one-third less than this particular price. Another bill, which is not from the National Skin Centre, is from NUH. The total bill for this particular patient amounted to $27,576 and paid by three persons. I suppose they are relatives of this particular patient and the amounts were $12,215, $7,500, and $1,255. Sir, the amount is staggering. I really wish the Government would look into the medical bills and see that all bills are checked properly to make sure that patients are not overcharged. Like the medicine from the National Skin Centre, I can see the rationale of making some money, but I would imagine that if it were to make money it would be at the normal commercial rate rather than at a super-profit. Sir, may I take the other amendment on audit on Medisave.

You have to, you are the only one.

Thank you. You are being very compassionate and patient. Sir, as far as the audit on Medisave is concerned, the Ministry of Health established a Medisave audit unit in June 1988 to check on Medisave claims. I would like to ask the Minister to enlighten the House on the development and progress of Medisave audit. I have a few questions: How many cases have been examined and what was the sample size? And also in terms of percentages, what methods were used in arriving at such samples and what methodology was adopted to test these cases? How many abuses have been found? How many exceptional and extraordinary items have been noticed and whether actions have been taken? Does the Ministry intend to enlarge the Medisave audit unit so that it can perform and function more professionally and comprehensively? Sir, most importantly, the unit should comes out with some kind of preventive audit programme so that we will be able to monitor and ensure patients will not be wrongly charged and abuses will not take place.

Order. We will take the tea break now. Thereupon Mr Speaker left the Chair of the Committee and took the Chair of the House.

Order. I suspend the Sitting and will take the Chair again at 3.05 pm. Sitting accordingly suspended at 2.35 pm until 3.05 pm. Sitting resumed at 3.05 pm

Debate in Committee of Supply resumed.

Head P (cont) -

Sir, before I reply to Mr Choo I would like him to clarify a few points. Firstly, the two cases that he quoted, the patient with a bill size of over $10,000 and the patient in NUH whose bill size was over $27,000. What class wards were they in?

Sir, according to the bill it is stated as ward B1.

Sir, he also read from a certain part of a letter. Could he tell us from the letter which class ward was the patient in?

No, it is a copy of the bill.

Oh, it is a copy of the bill. Sir, I have spent quite some time explaining about hospital cost and what patients should be expected to pay in the respective classes of wards. Sir, the Government's policy has always been that the low income group who uses B2 and C will be heavily subsidized and therefore the bills in those wards would be highly affordable. The Member has come quoting figures without telling the House what class of wards they were in. I think the impression gained has been that those are patients who were admitted into the lower class wards, maybe unintentionally. I think it is important for us to realise and for us to give the right message to Singaporeans that, depending on your income level, you should be using the class of ward that is most appropriate to your level of affordability. B2 and class C will always be affordable. Adequate subventions will be given to them. But I do not think the Member is suggesting that for patients who are admitted to B1 and A, who choose to go to those wards for a higher level of privacy, for a higher level of air-conditioned comfort, I am sure he is not suggesting that we also subsidize them in order to make it possible for them to go there. Sir, the cost of hospital care is very, very high. Those who choose to go to the A and B1 must expect to pay the full cost of those services. At the present moment, they are still not paying the full cost because they are still receiving a subsidy. So the $27,000 and the $10,000 that the Member has spoken about are still too low because by right they should not have received any subsidy. So Singaporeans must take note that if they choose to go to the A and B1, they must be able to afford those wards. Otherwise they will have to top up over and above what they can claim through Medisave. Medisave has a safeguard of $300 a day. Anything that is above that has to be topped up in cash. So the patients who go there must know that they must have enough cash available to top up. Otherwise they should choose the B2 or the C class for which there are plenty of vacancies. He has also made some remarks about car parks. He said that the moment the hospitals were restructured paid parking came in. I think Members speaking in the House also owe it to themselves to verify what they say. I do not think Members should come to the House and make statements that are not true. Sir, the Government hospitals have been having paid car parking all along. In the Government hospitals, the car parks were operated by the URA on the coupon parking system. When the hospitals were restructured, and being a private hospital or owned by a private company, the URA was not prepared to continue with its coupon parking system. Therefore, the restructured hospitals have no choice but to offer the management of the car parks to a company which actually provides a better level of service, because now you do not have to worry about coupons. You just go in, take your parking ticket, and stay as long as you like, or as short as you like. When you want to go back then you pay. So it is an even higher level of service to the visitors. Therefore, it is not true that the restructured hospitals took the opportunity to introduce paid parking the moment they were restructured. Sir, he has asked that we educate patients on avoiding overuse. That is a good point. As I have mentioned earlier, we will be doing that. The brochure on this will be ready very soon. We will look into how we can make it compulsory even for all patients who are to be admitted into hospital to receive this multi-lingual brochure so that they can be informed patients before they gain admission. Incidentally, the brochure will also advise the patient on what information to look for or to ask from their doctors. For example, likely length of stay, likely complications, costs. All these pointers are there to help the patients. Sir, I think the patients who do read through those brochures will be fairly well informed. He has asked for a report on the Medisave audit. Sir, the Medisave audit scrutinizes both the financial as well as the medical professional aspects of Medisave claims. The financial part is carried out by the CPF Board auditors and they review regularly whether the Medisave withdrawals are made in accordance with the Medisave regulations and guidelines. They also verify, for example, the relationship between the owner of the account and the patient for whom the account is being used. This is to make sure that the Medisave account holders are not using the Medisave funds for people other than their immediate family. So this is to safeguard against abuse. The medical professional audit is conducted by my Ministry and we check for any irregularity in diagnosis and medical procedures carried out by the doctors. We also look into whether there is any gross investigation, any gross over-medication and whether patients are over-staying. It also ensures that the claims for surgery and other charges are in accordance with the Medisave schedules. Sir, he has asked for the number of cases that were audited. In 1989 a total of 2,716 claims, making 1% of the total claims, were audited. For the private sector Medisave claims, this represents 3%. So we do audit the private sector claims more often. What was found? Sir, the audit reviewed that the errors were mainly minor. First, there were few errors and those few errors that were found were mainly minor errors, and there was no deliberate attempt to take advantage of the Medisave system. There was no over-treating of patients and there were no overstays that were found. On the methodology, Sir, I do not have the information. But from memory, the auditors will sample Medisave claims and they will then ask the respective hospitals and doctors for the medical records of the case. They will then audit through the diagnosis of the patient's conditions, what were the complaints and what was the treatment that was carried out. So they do look into the medical details and also to ensure that the treatment was in accordance with the patient's medical conditions. He has also asked whether we have any intention to enlarge the audit. At the present moment, we are quite satisfied with the results of the audit and therefore there is no intention to expand it further. However, if the trend proves to be disturbing, then we will definitely increase the number of audits to deter any wrongdoing. He has also asked whether there is an intention to implement preventive audit. I am not too sure what he means. But what we intend to do in the future is to make the Medisave claims into a computerised format. In this way the doctors, who make a claim on behalf of their patients, will then be able to vet whether the claim is correct, whether the operation carried out is correct, and therefore avoid any of those minor errors that had been found. So we hope that in this way we will also avoid those minor errors that we are finding.

I just want to make an observation. I think Mr Choo was just trying to show the medical bill size of today. It was unheard of in the days before Medisave. So the Minister should not be too harsh on him. It was an honest observation. I agree that A and B1 patients should know the cost if they want to go to such wards.

Sir, I thank Dr Tan for being such a nice and compassionate person. He is full of sympathy. At least I am wrong once. Actually, I was trying to substantiate my point that medical care is not cheap. I am in full agreement with the Minister. My main point was to ask the Minister to set up some kind of counselling system to ensure that people who cannot afford to go to more expensive wards should instead go to B2 or C class. I was trying to help him promote the idea. So I think he has been very harsh on me, which is very unfair to me.

Sir, unfortunately, his message did not come through clearly. If that was his intention, I fully appreciate his intention and I hope that this message will go down to all Singaporeans. He has also raised a point which I overlooked, and that is, the bill size for the National Skin Centre, the medication being more expensive than what was available from the private sector. Sir, I am not familiar with the item. In fact, he did not even mention the item. But I can say generally that the guideline adopted in the National Skin Centre is that they will have a small mark-up on the actual cost of the medication to cover the overheads. It is a small mark-up and I think it is fully justifiable. Patients have a choice of going to the Centre's pharmacy to buy the medicine or they can buy the medicine elsewhere. The case mentioned by Mr Choo again is also a non-subsidised patient. For subsidised patients, those who are treated at the National Skin Centre, are charged only $1 per item used.

Sir, I would just like to clarify. When the Minister mentioned about the medicine and drugs available at the National Skin Centre for non-subsidised patients, obviously it is going to make some profit. My argument is, make profit, yes, but it should be comparable to the outside pharmacy. That is one point. Secondly, as far as the staggering size of the bill is concerned, I support what he said earlier on. But I would like to request that there must be some kind of checking, so that patients know what they are paying for.

Sir, as I have mentioned, NSC imposes a small mark-up to cover the overheads. If he could give me the bill size of the item, I will find out why it is more expensive. I am sure that the NSC would be shown to be not over-charging.

The last point, Sir, regarding car parks. I must thank the Minister for telling me that it was already introduced before restructuring. But then, Sir, my point is this. People do not go to hospitals for fun. They go there to visit their friends and relatives who are sick. So I would like the Minister to consider, in order to avoid unnecessary summons, coming up with some kind of scheme to give waivers to people who genuinely visit their friends and relatives. That's all.

Sir, Mr Choo Wee Khiang is trying to show that he is very compassionate. I appreciate that. But unfortunately the hospitals have to recover what it costs them to operate the car parks. Therefore, visitors who use the car park pay for it; those who do not use the car park, ie, they go there by bus or by taxi, are not required to pay for the car parks.

Mr Choo, I do not want to be harsh on you. We are falling behind time.

Sir, I thank him for his reply. I beg leave to withdraw. Amendment, by leave, withdrawn.

Amendment No. (4), Mr Choo is not moving. Amendment No. (5), Dr Wong.

Sir, I beg to move, That the sum to be allocated for Head P be reduced by $10 in respect of Code PE 1500 of the Main Estimates. I have only a very brief observation on the community health services, including services for the elderly. Sir, I note with satisfaction that over the last two years, a higher proportion of the health budget has been allocated to primary care services, the development of polyclinics, health screening and health education. I think everybody in this House would agree with the fact that primary health care is probably the best strategy to fight the rising health care costs. Sir, a couple of the new polyclinics have senior citizens health care centres, com- plete with day care facilities and rehabilitation services. There is a great need for such services for the elderly. What I wish to see is a general extension of such services to all the polyclinics. However, to achieve this, certain infrastructure must be in place, and I would like to urge the Minister to look into two such kinds of supportive services especially. First, the Ministry must assign more medical officers to these centres. I understand right now there are only two medical officers assigned to this health care service for the elderly. I may be wrong, I stand corrected. Second, the Ministry must try to allocate more nursing staff and rehabilitation therapists to these senior citizens health care centres. Of course, I understand there is a general shortage of these staff. But if MOH is genuinely trying to promote health services for the elderly, there is no escaping from allocating more of these supportive staff to the health care centres. I also think that health care services to the elderly need to be provided on a broader front, including home nursing care. So I still would like to see more Government funds going to help the Home Nursing Foundation. I had spoken on this before last year. I have seen some improvement in the situation, but I still like further efforts along this line. And I have already mentioned the fact that the number of home nursing visits has gone down, and I think this is something that the Ministry should really watch out for. Although we have been talking about the problems of the aging population for some years, I feel the Ministry is not yet giving sufficient attention to the health care services for the elderly on a comprehensive basis. No doubt, the hospitals are beginning to develop geriatric medicine; but what we need is a broad-based programme for the elderly at the community level. I would suggest that MOH should work closely with MCD to look into how more day care centres can be developed, with inputs from the volunteers and grassroots organisations. All these will involve a lot of hidden subsidies from the Government, and I would expect there would be a lot of reshuffling of paper accounts again. In order to facilitate Parliament in checking the record of development of health care for the elderly, may I suggest that this programme be treated separately from the Primary Health Programme for the purposes of budget presentation? In this way, I believe, we will be able to follow the progress of this programme much more effectively in future.

Sir, I wish to speak on one special aspect of community health service, namely, on care and services for the chronic sick in general, and for the terminally ill in particular. Cancer deaths, I have been told, number nearly 2,500 every year, and if we add also deaths from other causes associated with the aged, then the number comes to much more than 3,000, about one-fifth the number of total deaths from all causes every year. The Minister has also said that the number of elderly will be 300,000 in another 20 years, and we may therefore expect that our aged will increase in number and the need for care for the aged will correspondingly increase. Government has also stated in the Yearbook that it is turning its big guns on the major killers of today, one of which is cancer. And the Minister has already told us that this year, we will be having a cancer education campaign. But, apart from geriatrics and health screening in some Government polyclinics, what provisions have been made for the care and services of the aged for the large numbers who have suffered from strokes or cancer? There is a big shortage of physiotherapists and occupational therapists, as already mentioned by other speakers before me. Many of the elderly do not benefit from these essential services, since they cannot easily go to the health care centres to have such treatment. And worse, Sir, Government has neglected a much needed service to help relieve the pains and sufferings of those who are terminally ill. On 25th March, in the Sunday Times, Mr Tan Harn How, in his column "Mercy killing: drafting better laws is the answer" has helped to focus public attention on mercy killing and suicides, may I quote, '... to be provided as an escape route for the unfortunate people afflicted by irreversible and terminal illnesses.' He refers to the use of euthanasia as a humane course of action. But because of various reasons, many people would not agree to the recourse to euthanasia. Presently, it is not generally acceptable to the public. What then is a better way to look after those who are terminally ill? Presently, such care and services have been left to the families themselves and to volunteer organisations. I refer to the hospice care services. For several years now, a dedicated group of doctors, nurses, paramedical and social workers have selflessly spent much time and energy to help terminally ill cancer patients and their families through the most trying times. The hospice care service workers help to give social, emotional and spiritual support to those who know that their end is near so that they may take courage and accept the end stoically, calmly and fearlessly, ie, to die peacefully and, equally important, Sir, to live painlessly until they die. Hospice care services also give support to the family during the period of bereavement and beyond. Today, hospice care services are given at home to those who wish to die at home where they have lived for many years, close to their families and loved ones, and not in the strange surroundings of a hospital. That is why most terminally ill patients prefer to die at home. Others who have no family ties and have hardly any financial support have hospice care in the St Joseph's Home in Jurong and in the Assisi Home in Mount Alvernia Hospital. Dr Anne Merriman, writing in the Straits Times on 6th March 1990, has clearly and eloquently stated the case for the hospice approach. I suggest that the Minister read the letter if he has not yet done so. Today, the hospice care approach is practised in countries like Britain, the United States, Japan, Australia, India and maybe very soon also in Malaysia, Thailand and the Philippines. It is therefore time that our Government gave good financial support to help expand such much needed services for the aged. I learn that since February 1990, the Community Chest has come forward with some token funds to help the hospice care services. But the funds given are hardly enough to maintain even a few workers. Government should step in to help maintain and expand the hospice care services, as part of a community service for the aged. Funds are urgently needed to employ and train more nurses and social workers. Funds are also urgently needed for emergency cases, those who have persistent vomiting and profuse bleeding and so on for short stays in hospital. If Government is serious about the care for the aged, then it should not hesitate to allocate the necessary funds for the hospice care services. It is a service that deserves strong Government support. Government should not leave such an important part of community health service entirely to volunteers. More and more of the aged and even the young who are unfortunately stricken with cancer and their families will benefit. In December 1986, the World Health Organisation noted that there were 3 1/2 million terminally ill people in the world, and recommended that every government should adopt the hospice approach to help relieve those unfortunate people of their painful deaths. As has been said by some people and I quote: 'We are all on a journey. Hospice cares for us on the last stage of that journey on earth.' Sir, I earnestly ask: would Government respond to this WHO call and allocate suitable funds to maintain and expand the hospice care services in Singapore, so that those in need will be able to go on the last stage of their journey on earth peacefully, fearlessly and painlessly? I hope Government will not ignore such a deserving cause out of hand.

Mr Speaker, Sir, I would like to join my GPC Chairman, Dr Aline Wong, to speak about health care for the elderly. Our population is greying. At present, the number of aged persons is 239,000 or 8.7% of the population. By the year 2000, the number of elderly will be 332,000 or 11%. And in the year 2030, the elderly population is expected to reach 835,000 or 26% of our total population. Today, the elderly accounts for 20% of outpatient attendance, 18% of hospital admissions and 27% of hospital beds in our acute hospitals are occupied by the elderly. Sir, the demand for health care and health services will continue to rise. If efforts to promote, educate and expand our health service are not quickly and effectively carried out, in the year 2000 and beyond, not only will we see a significant increase in the elderly patients, but most of our hospital beds will be occupied by the elderly. To arrest this problem, I would like to urge MOH to address the following points as soon as possible. (1) As the elderly are high consumers of our health services, these services must be easily accessible, convenient and readily available. In this respect, I would like to ask the Acting Minister whether there are any plans to introduce mobile health services such as X-rays and other routine check-ups at all polyclinics and even at community centres for the convenience of our elderly. (2) Since early detection of chronic degenerative conditions will reduce the need for hospitalisation and reduce the medical cost, the health screening programme to be introduced by MOH is a move in the right direction. However, in order to benefit the general public and the success of a screening programme, MOH should ensure that the fee will be affordable to all, especially the senior citizens and the low-income group. Will the Acting Minister enlighten the House on the details of the screening programme and will this programme be extended to all polyclinics in the public housing estates? (3) The setting up of the Department of Geriatric Medicine, as announced by the Acting Minister a few weeks ago, is timely, as the elderly sick usually have complicated illnesses and take a longer time to recover. However, as there is already an acute shortage of professionals, like geriatricians and physiotherapists, I wonder what MOH is doing to ensure that the elderly are adequately cared for. (4) As many of the medical conditions among the elderly can be cared for at home, I would like to ask the Acting Minister what sort of home support is being provided by his Ministry for the families who are looking after the elderly sick at home.

Sir, Dr Aline Wong has suggested that the Ministry extends the senior citizens health care centres to all polyclinics and that we assign more MOs and more paramedical staff, nurses and therapists. The plan is for the senior citizens health care centres to be set up in all the 10 new polyclinics. These will be open by the end of 1994 when the last one is completed. We will definitely look into her suggestion that we look into how to expand the facilities to all polyclinics as well. I think the problem is that the existing six polyclinics, which are of the older generation ones, already suffer from shortage of space. And the senior citizens health care centres are quite space intensive. So we have to see how we can get around that problem. On the grant for more funds, the Ministry will ensure that adequate funds are given to ensure that the programme can operate well. On the question of whether the day care centre programme can be stated separately in the budget presentation, we will look into that. Dr Lee Siew-Choh has talked about hospice care and he has asked that the Government gives support to this programme. Sir, we believe that a person's last days should be made as comfortable and as free from pain as possible, as pointed out by Dr Lee. We feel that there should be dignity in dying and that this should be in the environment of the home among the immediate family and the loved ones. As such, we encourage the concept of hospice care at home. This means that the terminally ill will be nursed at home by the family with the support of voluntary organisations and existing services from the Home Nursing Foundation. Sir, hospices, if not run properly, are likely to deteriorate into places where families dump their elderly sick. I think it will lead to a situation not unlike the former death houses in Sago Lane. This would be a retrogressive step if that were to happen. As pointed out by the NCMP, 10-15% of the patients are admitted into the hospitals and they are admitted in their last illness. This is unavoidable and my Ministry will cope with them. The development of the community hospital will in a way help to alleviate the problem. The community hospital will provide facilities for the terminally ill to be admitted in the last few days of their life. This would ensure that they are made comfortable and free from pain. The provision of hospice services requires dedicated volunteers, ie, people who are fully committed to the role that they have undertaken. It is a function which is best left to volunteers, because I do not think paid staff would be able to do the job very well. My Ministry is therefore prepared to provide support to such voluntary organisations. For a start, we have already made available office space in the primary health offices in Dunearn Road to the Hospice Care Association. We are also helping the Home Nursing Foundation to provide nursing care to the terminally ill in their homes. We will also run special training courses for our doctors and nurses to deal with the medical problems of the terminally ill. In this way, we will also be able to train members of the voluntary organisations as well. Mr Yeo Toon Chia has asked what the Ministry is doing in improving the care for the elderly. Sir, he has asked that easy access be made available for the elderly in terms of routine check-ups and in terms of X-rays and what are the charges for such programmes. Sir, we already have a mobile X-ray team that routinely visits the senior citizens' health care centres as well as the senior citizens' clubs at the various community centres. They also visit the homes for the aged. All elderly persons are encouraged through the grassroots organisations to make use of such mobile services whenever they are in the area. These services have been provided free to the elderly. We also provide free check-ups at the senior citizens' health care centres and this will continue. We also encourage doctors in the locality to participate in providing free health care screening for members of the senior citizens' clubs in the various community centres and I think this programme is available in many of the clubs in the community centres. In terms of geriatric care for elderly in the hospitals, we have already started a programme in Tan Tock Seng Hospital. They will develop another department in Toa Payoh Hospital when it is rebuilt with 80 beds. To prepare for the growing number of elderly, we have already embarked on a programme to train doctors, nurses, therapists and social workers in geriatric medicine. We have also invited foreign experts to come to Singapore to help train our local staff. Mr Yeo asked about the level of home support for families at home. Dr Lee Siew-Choh has also asked just now about what we are doing for stroke patients. Sir, we already have a home stroke rehabilitation programme for stroke cases discharged from our hospitals. The programme ensures that the rehabilitation is done early and is carried out in two stages. The first stage is at the home of the discharged patients provided through our Home Nursing Foundation. Then when they are well enough to go to the senior citizens' health care centres, they are then brought to these centres where the rehabilitation equipment is available. We also provide respite care for families with elderly sick so that they can bring the patient to the hospitals for a period of time in order to allow the family some respite from their work. Sir, we also provide training for independent living for the elderly as well as training for members of the family to be able to assist the elderly who are living at home. All these programmes will make it easier for the families to cope with their elderly relatives and therefore allow the elderly to be looked after in their own homes.

Clarification, Sir. I think the Minister has a wrong conception of the hospice approach for the services of the terminally ill. It is not to turn hospices into something like former Sago Lanes. Hospice care is to ensure that those who are terminally ill may have a higher quality of life before they die, to ensure that they do not have to die fearfully, painfully and the family around them will suffer less misery. The Minister must realise that a cancer patient needs social, moral and spiritual support, and this needs a lot of manpower. He has mentioned about nurses from the Home Nursing Foundation, but there are not enough of them. We need many more. If he talks about the stroke patients, then he must also realise that there are many stroke patients who cannot, for various reasons, go to these health centres for occupational therapy or physiotherapy. They just cannot go. Therefore, they need people to go along to their homes to support them in some way or other. If the Government really intends to give support, it should not merely provide a cubicle to the hospice care association for it to operate as an office. The Government must provide enough financial support for the hospice services to really do more work for the terminally-ill. Government claims to fight for excellence in health services. This is one aspect of health services in which the Government may gain excellence and must pay attention to. It should not merely pay lip service to it in providing a little office space and training.

Sir, I think the Minister did not answer the point about our health screening programme and whether this programme will be extended to other public housing estates.

Sir, Dr Lee stresses that hospice care givers will have to provide social, moral and spiritual support. I agree, and that is why this sort of support is best given by volunteers. It is also best given by members of their immediate families as well as friends. Sir, we will help the voluntary organisations in terms of training, but they must reach out to encourage more volunteers to come forward, volunteers who are fully committed to this role. The Ministry will provide the support to help them to carry out this job once they have identified those volunteers. Sir, in terms of health screening programmes, we already have a health screening programme for the elderly. As I have mentioned just now, these are carried out in the senior citizens' health care centres and these are provided free of charge for the elderly. If Mr Yeo is referring to the health screening programme for the general adults, it is also available from several polyclinics and our intention is that we would extend these health screening programmes for adults to other polyclinics as and when we are able to get staff.

I have said that the World Health Organisation has called on all the countries to provide such a hospice service. Will the Government allocate some funds for the hospice care service so that it may be expanded?

Sir, we will look into their needs and we will help them where necessary and where possible.

Sir, I beg leave to withdraw. Amendment, by leave, withdrawn.

Amendment No. (6). Dr Aline Wong.

Sir, I am not moving. The sum of $483,927,860 for Head P ordered to stand part of the Main Estimates. The sum of $112,125,400 for Head P ordered to stand part of the Development Estimates. Head W -

Sir, I beg to move, That the total sum to be allocated for Head W of the Main Estimates be reduced by $100. Sir, I will be very brief. Pensioners receiving less than $800 a month are finding it more and more difficult to keep body and soul together. The allowance they get is very small. As the Minister well knows, cost of living is daily rising. PAP MPs and Ministers themselves have spoken about inflation in Singapore. Compared to 1988, he has said me that the CPI has gone up by 3.6% or thereabouts. But we all know, Sir, that that is an under-statement. You know what our Statistics Department is. They are always slow. And considering the fact that salaries and wages have been raised all round, and that the Ministers have given themselves again such huge salaries, would the Minister consider this time increasing the allowance of the pensioners, especially those drawing less than $800 a month?

Sir, Dr Lee has raised this issue in last year's budget debate and again in January this year. As I explained at that time, the Singapore Allowance was last increased in 1986, and between 1986 and today the increase in basic living cost has not changed sufficiently to warrant an immediate adjustment at this time. Members will recall that the Singapore Allowance was first introduced in 1974 to assist pensioners in the lower pension groups in the then abnormally high inflationary situation. Since that time the allowance has been increased three times in 1980, 1982 and 1986. I would like to assure Dr Lee that I am not unsympathetic to the problems of the lower income pensioners and that my Ministry monitors the cost of living changes regularly and would make adjustments when this is necessary. However, Dr Lee should get his facts straight about cost of living data, particularly he should not just quote CPI figures and make general statements about cost increases. Whilst I agree that in some sectors of the Singapore economy costs have gone up, this has been largely confined to those establishments and goods catering to the middle and high income groups. As the Minister for Trade and Industry mentioned yesterday, Singapore has one of the lowest inflation rates in the world and the CPI for the lower expenditure groups in fact is even more stable. He has noted that bus fares have not changed since 1982 and neither have in any significant way, any rises in the basic living cost in HDB establishments. I have data on price increases for some basic food items which Dr Lee may be interested in, to illustrate what I mean. Taking 10 general items of basic goods, five have increased significantly since 1980, one stable, and four have gone down in price. This is something probably he is not aware of. Taking rice, for example, 100% Thai rice cost $1.14 per kilogram in 1980, it costs 87 cents today; wheat flour, 83 cents per kilogram in 1980, 80 cents today; bread has gone up from 60 cents per 400 grams loaf to 72 cents, a period of 10 years; lean pork per kilogram, $6.53 in 1980, $6.54 today; fresh beef, $11.33 in 1980, $13.02 today (an increase no doubt, but less than 15% over 10 years); chicken per kilogramme, $3.95 in 1980, $4.21 today (increase of 7% over 10 years); hen's eggs, $1.47 per 10 eggs in 1980, $1.47 per 10 eggs today; cooking oil (2 kilogramme), $5.46 in 1980, $5.25 today; sugar per kilogramme, $1.74 in 1980, $1.17 today; condensed milk per tin has gone up a bit from $0.93 to $1.14 today. I think the situation is not as bad as he makes it out to be. Undoubtedly, in an economy which is rising rapidly, there will be inflationary costs in the higher cost items, particularly imported goods. And I think where basic living costs are concerned, the Government has managed the economy, very satisfactorily.

Sir, from his list of items used by some of the people, one would have thought that pensioners have to live on rice and cooking oil alone. Probably the Minister has not really gone to the market to buy things. He takes out a $10 or $50 note, and it disappears in no time. So if that is not a high cost of living, what is? If a rise in allowance is not justified for the lowly paid pensioners, then how does he justify the high increases for the salaries for Ministers?

Sir, I suggest Dr Lee should do a little more careful marketing, because his $50 does not seem to last very long. Perhaps he needs advice on this. As far as the salaries of Ministers are concerned, it has no bearing whatsoever on the living cost of pensioners. And I think this had been explained at length, so I do not want to dwell on this.

With a hard hearted of the Government, I see no point in dwelling on the matter either. I withdraw the amendment. Amendment, by leave, withdrawn. The sum of $54,260,190 for Head W ordered to stand part of the Main Estimates.

I shall now deal with the remaining heads of expenditure in respect of which no amendment stands on the Order Paper Supplement. In respect of the Main Estimates, they are Heads C, D, F, G, H and Y. I propose to take those heads of expenditure en bloc. Question, "That the sum stated for those heads of expenditure which appear in the last column of the Schedule of Estimated Expenditure under the Main Estimates on page 47 of Paper Cmd. 6 of 1990 stand part of the Main Estimates," put and agreed to.

In respect of the Development Estimates, the remaining Heads are C and F. Question, "That the sums stated for those heads of expenditure which appear in the last column of the Schedule of Estimated Expenditure under the Development Estimates on page 48 of Paper Cmd. 6 of 1990 stand part of the Development Estimates," put and agreed to. Question, "That the sum of $7,511,972,950 shall be supplied to the Government under the heads of expenditure for the public services shown in the Main Estimates for the financial year 1st April, 1990 to 31st March, 1991, contained in Paper Cmd. 6 of 1990," put and agreed to. Question, "That the sum of $5,665,020,600 shall be supplied to the Government under the heads of expenditure for the public services shown in the Development Estimates for the financial year 1st April, 1990 to 31st March, 1991, contained in Paper Cmd. 6 of 1990," put and agreed to. Resolutions to be reported. Thereupon Mr Speaker left the Chair of the Committee and took the Chair of the House.

Mr Speaker, Sir, I beg to report that the Committee of Supply have come to certain resolutions. First Resolution reported - "That the sum of $7,511,972,950 shall be supplied to the Government under the heads of expenditure for the public services shown in the Main Estimates for the financial year 1st April, 1990 to 31st March, 1991, contained in Paper Cmd. 6 of 1990." Second Resolution reported - "That the sum of $5,665,020,600 shall be supplied to the Government under the heads of expenditure for the public services shown in the Development Estimates for the financial year 1st April, 1990 to 31st March, 1991, contained in Paper Cmd. 6 of 1990."

Sir, I beg to move, "That Parliament doth agree with the Committee on the said resolutions."

Question put, and agreed to. Resolutions accordingly agreed to.

Order for Second and Third Readings read.

Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time." In accordance with Article 145 of the Constitution of Singapore, heads of expenditure to be met from the Consolidated Fund other than statutory expenditure have to be included in a Bill to be known as the Supply Bill. The purpose of the Supply Bill before Members is therefore to give legislative approval to the appropriations from the Consolidated Fund to meet expenditure in the financial year 1st April, 1990 to 31st March, 1991. The heads of expenditure and the sums that may be incurred in respect of each head are shown in the schedule to the Bill. These have been approved by the House in the Main Estimates of Expenditure for the financial year 1st April, 1990 to 31st March, 1991, and appear on page 47 of Command Paper No. 6 of 1990. The Supply Bill, when approved, will empower me to issue warrants, authorizing expenditure up to the amount for each head as shown in the Bill to be paid out from the Consolidated Fund. Sir, I beg to move.

Question put, and agreed to. Bill accordingly read a Second time.

Sir, I beg to move, "That the Bill be now read a Third time."

Question put, and agreed to. Bill accordingly read a Third time and passed.

Order for Second and Third Readings read.

Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time." The purpose of this Bill is to make provision in accordance with Clause 2 of Article 145 and Clause 2 of Article 147 of the Constitution of Singapore for additional expenditure in excess of the provision authorised by the Supply Act, 1989. The additional sum has been scheduled as a Supplementary Main Estimates which has been considered and approved by the House as Command Paper No. 4 of 1990. Sir, I beg to move.

Question put, and agreed to. Bill accordingly read a Second time.

Sir, I beg to move, "That the Bill be now read a Third time."

Question put, and agreed to. Bill accordingly read a Third time and passed.

Mr Speaker, Sir, in addition to the two days of debate on the Budget Statement, we have had 10 full days of debate on the Committee of Supply, and you have sat through very patiently and listened to all the arguments on behalf of the Members. We will resume tomorrow to debate the outstanding Bills.

Resolved, "That Parliament do now adjourn." - [Mr Wong Kan Seng]. Adjourned accordingly at Twelve Minutes past Four o'clock pm.