Hansard, 2003-03-18

Order read for consideration in Committee of Supply [5th Allotted Day].

Head T (cont.) - Resumption of Debate on Question [17th March, 2003], "That the total sum to be allocated for Head T of the Main Estimates be reduced by $100." - [Dr Teo Ho Pin]. Question again proposed.

Sir, yesterday, Dr Chong Weng Chiew spoke about the impact of the move of HDB's headquarters from Jalan Bukit Merah to Toa Payoh Central. Allow me to spend a few minutes to explain why HDB made this move. At that time, the previous HDB office, which was at Jalan Bukit Merah, was facing a severe space shortage, which was affecting the level of service as well as the working environment of its staff. After considering several options, HDB decided in 1995, at a time when the Singapore's economy was growing robustly, to move to this new location in Toa Payoh. Moving the office to a suburban location that was served by an MRT station would, obviously, help ease congestion in the urban areas but, more importantly, also provide greater convenience for HDB lessees. The HDB hub in Toa Payoh was also a very integral part of the estate renewal strategy for Toa Payoh Town Centre. When the move was made in 1995, HDB did take into account the impact on residents and shopkeepers. But as the economy was doing well at that time, HDB anticipated that it would be able to sell the HDB Centre and ensure that there would continue to be activity in that area. But, unfortunately, the market turned dramatically. And as I informed the House yesterday, there has been a drop in demand for office space island wide, and this has resulted in over supply of space in the market. Nevertheless, I recognise that this is no comfort to the shopkeepers in Bukit Merah, and I will urge HDB to redouble its efforts to bring in new tenants to the HDB Centre. Let me now turn to Mdm Cynthia Phua's question which is on a related topic, this time on the relocation of one of the neighbourhood centres in Hougang. This is Neighbourhood South II. I must, first of all, emphasise that when HDB plans new towns, it does so with many other agencies - LTA, MOH, MOE, Library Board, PA and so on - to provide a wide range of facilities like bus interchange, recreational facilities, shopping centres and so on. But over time, as the town expands, it is sometimes necessary to relocate that town centre to better serve residents. In the case of Hougang South Neighbourhood II, or Kovan City as it came to be called, as Hougang town expanded northwards, an MRT station and a new town centre were planned at Hougang Central, Neighbourhood VIII, because this is more centrally located within the expanded town. To better serve the residents, all the bus services that were originally in Hougang South were to be moved and centralised in the bus interchange at the town centre or Hougang Central. The vacated bus interchange site and the vacated Hougang Branch Office would be designated for residential development. Obviously, because there is no need to provide more residential development at this point in time, nothing has been done so far. Let me assure Members of this House that decisions like this to relocate town centres and therefore cause disruption to shopkeepers and even to residents, are not taken lightly, but sometimes they have to be taken. And when they are taken, certain measures are also put in place to mitigate the impact. For example, the downgrading is implemented gradually over several years to ensure that both residents and shopkeepers have time to adapt to the change. Notice is given as early as possible. In the case of Kovan City, for example, the shopkeepers were informed as early as 1986. The planned closure of Hougang South bus interchange was conveyed to the shopkeepers as early as 1992. When the shops were sold to them in 1993 under the Sale of Tenanted Shops Scheme, HDB took this into account that it would be downgraded from a town centre and that the bus interchange will be closed. So, HDB valued these shops not as town centre shops but as neighbourhood centre shops, and re-priced them accordingly. Secondly, HDB works closely with other agencies to schedule the relocation of facilities such as bus interchange from the old town centre. In this case of Hougang, for example, the relocation of the bus interchange coincided with the opening of the new Kovan MRT Station, which is just across the road. And, hopefully, when Kovan MRT Station is opened, this will help to balance part of the loss due to the relocation of the bus interchange. Where HDB can do so, it will assist the shopkeepers affected by relocation, eg, by exercising greater flexibility in change of use approvals, by allowing shopowners to convert to shorter leases, by sub-letting the shops and so on. Mdm Cynthia Phua also asked whether there is any agency that is overall in charge of land use in HDB town centres. I will ask HDB to work with relevant agencies to take the necessary measures needed to minimise the impact of such plans in future. But I cannot give any undertaking that such relocations will never take place or that such relocations will only take place if there is no adverse impact on the shopkeepers. Finally, to respond to Mr Wee Siew Kim on wet markets, as Members would know, HDB used to build wet markets in its housing estates. But for public health reasons, after 1982, HDB replaced the wet markets with dry markets, and these dry markets comprise a cluster of shops as well as a supermarket. Unfortunately, these dry markets soon became wet again, and public health concerns resurfaced. So, in 1982, based on the review of the situation and feedback from advisers and residents, HDB started to build new markets - not wet, not dry - but new. These are similar to wet markets but they are designed with improved features, much cleaner, much more hygienic, larger market stalls and wider aisles and so on. These new markets are usually co-located with other retail and eating facilities in stand-alone commercial complexes at neighbourhood centres. These integrated facilities have helped to provide a good marketing and shopping environment for the residents. Some Members may be aware of such new developments. For example, in Sengkang, we have Rivervale Plaza; in Chua Chu Kang, we have the Yew Tee Shopping Centre. I would like to inform Mr Wee that HDB has also started to tender out designated sites for the provision of retail marketing and eating facilities. And the successful tenderer has the flexibility to build whatever type of market facilities that he thinks the residents need and want, whether it is a new market or whether it is a supermarket.

Sir, the Master Plan provides short to medium term planning of land use and the intensity of individual land parcels. The Master Plan 2003 aims to make Singapore a great city to live, work and play. But, how do we measure the achievement of our Master Plan? We need to define key performance indicators to monitor the progress of our Master Plan. To date, we have not defined any quality of life indicators for Singaporeans. Sir, we need to determine quantifiable indicators which Singaporeans can understand. In this way, we will all know whether we have planned successfully to maximise our land use to provide a quality living environment. Sir, I must commend the URA for adopting an open and consultative approach to solicit public feedback for the Master Plans of different regions. In order to develop a better sense of belonging among Singaporeans, we should reach out to more Singaporeans, especially the HDB heartlanders to participate in land use planning of Singapore. More outreach efforts are required to encourage active citizen participation in our land use planning. Sir, I wish to ask the Minister the following questions: (a) How much has been achieved in the Master Plan 1998? (b) What percentage of State land has its plot ratio increased as compared to private land? (c) What measures have been taken to improve the jobs and home accessibility for Singaporeans? (d) What are the key performance targets of Master Plan 2003?

Sir, I support the URA's move to give developers and businesses more flexibility in their land use by having sites with new expanded white zoning under which a wider mix of uses will be allowed, ranging from residential and commercial to sports and R&D facilities. This also implies that landowners have greater flexibility to change a portion of the uses of their building in future according to market demands without attracting development charge. Nonetheless, I would like to suggest that when tenders are invited for such plots, unless the intention is merely to allow greater flexibility, some weight should be given to the proposed uses of the land which may add more vibrancy to the area and thus indirectly bring in more and wider economic benefits, than just the bid prices for the land. Otherwise, for sites such as those next to the Jurong East MRT Station recently unveiled in the draft Master Plan 2003, the wider mix and combination of uses allowed may be purely academic, since commercial and residential uses would generally yield the highest residual land values. Previous whites sites in the Central Area, for instance, have been developed largely for commercial uses. I would also like to propose that for white sites, the Ministry could, in future, instead of prescribing the permissible uses of the land, provide an exclusion list of uses that are disallowed, because they will be incompatible with the surrounding land use. This could allow for even more creative and flexible use of land and enable land owners to adapt more quickly to changing market conditions. With regard to land use, I would also like to ask what the Ministry's thinking is with regard to land for retirement housing. I understand that feedback has been given to the Ministry regarding the need to look into provision of retirement housing in view of an ageing population. There are already lands designated for nursing homes which have been sold by the Government on 30-year leases. I would like to ask whether the Government can also consider designating land for retirement housing and selling them on, say, 30-year leases. HDB already builds granny flats and perhaps the private sector and NTUC affiliated organisations could be given the opportunity to participate in this area of social provision. Sir, as one of the MPs in the west region, I am also very happy to note that there are plans to improve the accessibility within the Jurong area with a light rail system for the future Jurong Regional Line. I would urge the plans to improve accessibility of the area to be implemented as soon as possible, as this is one of the main reasons which makes the Jurong area less attractive to live in than the East. Tuas, for instance, is infamous as a place that employees try to avoid as their place of work. Indeed, the ERC Report accepted as one of the recommendations of the Land Work Group for the Government to invest in transportation infrastructure ahead of demand if there are sound reasons to do so. Hence, I would like to ask the Minister how the proposals in the Master Plan 2003 for this area would help to enhance the attractiveness of Tuas as a place for work, if not, live and play. 11.15 am

Sir, the setting up of the 3-in-1 service centre in Jurong East took only 11 months from approval to operation. I would like to thank MND for this. So, instead of cutting $100 off the budget, I believe maybe we should add $100. The concept of "a first world oasis in a third world region" gave Singapore a competitive advantage for over 30 years. We clearly did well. But the world has changed. Not only do we have to compete for investments among cities, we also have to compete to be the best place to live in. Sir, the Esplanade is our latest pride. But when you travel along Sheares Bridge at night, it is hardly seen, unlike the Fullerton Hotel which is brightly lighted up. Bright lights and big cities are a natural combination. Think of the theatre district of London where the flashing lights create a vibrant and buzzing atmosphere, or the chaotic and colourful shops of Shanghai, and Harajuku in Tokyo. I am glad that the Ministry has allowed some neon lights to add colour and life to our night skies. We have to make it well known to the people and identify more areas for such lights. Some of the countries came and learn from us. So we should put in more effort in our much praised "Garden City", if not, it will be slowly losing its shine when compared with some other cities. Our population too has changed. With economic wealth and rising standard of living, their expectations have risen. They travel all over the world. They compare our city state with other countries. Our students study overseas and expect to have the same quality living conditions as the best cities in the world. The competition for talent, tourists and investments has now become global. We should use this economic downturn period to sharpen our competitive edge. I would like to urge the Government to increase MND's budget further to re-energise and consolidate our development, position ourselves strategically for the next wave. MND must aim high to make Singapore truly a city of excellence. Our buildings should reflect our multi-cultural and multi-racial background. If we keep building boring and "so-so" looking buildings, Singapore will soon become a "so-so" city. We should start building buildings that will stand up to the best designed buildings in other cities. Better still, we should encourage buildings designed for our humid and hot weather. We would save money through energy conservation and we could even become a world leader in design for the tropics. Good-looking buildings need not necessarily be more expensive and less practical. Sir, we should benchmark against the best cities in the world. When we built Changi Airport, we learned very aggressively from the best. We should do the same for everything that we do. To promote a healthy lifestyle, it is a good idea to connect the parks, and park connectors are very well used.

Mrs Yu-Foo, your speech is becoming so-so long!

All right, Sir, I will try to sum up. So we should speed up. Another area is, as a city state, we need to accelerate the building of an island-wide MRT network. Sir, at the end, I would like to say that MND must aim to make Singapore a "WOW" city.

Mr Zainul Abidin is not present. Mdm Cynthia Phua.

Sir, my concerns are these. In view of the advancement in technology, the different business uses are now more integrated. MOS Vivian Balakrishnan has just announced the integration of the various types of uses within an industrial land. What about the integration of the industrial, commercial and residential uses within a parcel of land, so as to have a better home-office connectivity and a better provision of commercial amenities to support the work environment? Can the Ministry allow the existing vacant industrial land to have this flexibility of integration to allow vibrancy and increase economic value? For residential property, the trend is towards high-density residential development. What are the planning considerations taken to ensure that the intensity of living does not cause social and communal dislocation? This is especially important where good private residential estates are now faced with 5-storey apartments overlooking into their houses, in view of the plot ratio of 1.4 for landed residential estates. The mobility of residents for social and communal interactions, as well as personal well-being with regard to a 4-storey high public housing, has to be studied carefully before duplicating in other estates. What are the planning considerations of the places of worship, especially in private residential estates? And what are the planning considerations of columbarium within these places of worship? This is extremely sensitive in private landed housing estates. In HDB estates, these places of worship are usually designated and pre-planned. In the Master Plan 2003, land use plans were prepared for five large areas. Would URA consider detailed planning at areas where it is a necessity? For example, Toa Payoh is such a vibrant town now because of the detailed development guide plan that was drawn up in 1996.

Dr Michael Lim is not present. Dr Wang Kai Yuen.

Sir, in land-scarce Singapore, everyone has the impression that in Singapore, there is always going to be short of land, Government landfills notwithstanding. Therefore, investing in land cannot be that wrong. Government has also reinforced this concept through very careful and controlled release of land through its tendering system. As a result, often times, property investment yields fantastic result not because of its intrinsic value but because of Government's land policies. This has led to over-investment in land by businesses and individuals. Regardless of whether it is residential, commercial or industrial land, their value has escalated over the years, leading to the current high land cost in Singapore and contributing much to our current difficulties. In fact, it was a surprise to learn from the Minister for Finance in his recent Budget Statement that there is no shortage of industrial land in Singapore - not now, not ever. So, in a way, one wonders what has JTC been doing over the years, allocating industrial land at ever increasing land price, until recently. Sir, unwinding the current situation is extremely difficult. As the Minister for Finance has indicated, we would all be very worried if Government causes a collapse in land price, leading to negative equity suffered by all Singaporeans. On the other hand, if we were to leave the current situation to slowly digest the inflated land price, it would also delay our economic recovery. In the ERC Report, the concept of competitive factor pricing for land use has been introduced. I would like to find out from the Minister how he proposes to implement this concept.

Mr Ong Kian Min is not present. Dr Amy Khor.

Sir, being the largest landlord in Singapore owning some 90% of the land in this country, the Government has repeatedly assured that it will ensure an adequate supply of land to achieve a stable property market and rein in price increases. Its vast land holdings give it leverage to steer the market in its long-term strategic direction. Most recently, DPM Lee has assured this House that the Government will ensure an adequate supply of industrial land to achieve stable and internationally competitive prices. Over the past few days, and just a few minutes ago, it seems to me that many in this House have tried to make land cost the chief villian for our business woes, the destroyer of entrepreneurial drive and the cause of national embarrassment (as in the case of the loss of Maersk and Evergreen to Tanjong Pelapas). The truth of the matter is that our present business woes are due to a combination of factors which include land, but also labour costs, other than the cost of materials. In fact, for most large companies, land costs make up only a small fraction of their entire cost structure, the bulk being labour costs other than material costs. In reality, to remain competitive, all costs must be reined in. The danger, of course, is when land costs rise out of sync with the rest of the economy. As a property consultant, I would also like to note that since 1996, land prices for almost all sectors of the property market, including industrial and commercial land, have fallen by about half or more. So, too, have rentals, and our office space occupancy cost is now lower than even those of Mumbai and Beijing. The locational preferences of multinationals and blue chip names reflect multi-dimensional decision processes, including quality of life and quality of infrastructure. Land cost is only one of these factors. For this reason, while I appreciate the difficulty of obtaining data, every effort should be made to derive, as the ERC Workgroup has proposed, authenticated value added per land area by sector, taking into account the entire package of interests and liabilities that go with the land for more accurate cost comparisons. While high land costs will make us uncompetitive, there is also an opposite danger that an oversupply of land, and thus built-up space, is a waste of valuable economic resources. For instance, island-wide, there are currently more than 43 million square feet of vacant industrial space and about 11 million square feet of vacant office space. This amount of vacant office space is nearly three times the amount of space proposed for the Business Financial Centre and enough to fill 12 Republic Plazas. In a knowledge-based economy and with recent changes to the land use groups in the Master Plan 2003, the distinction between office and industrial space and even residential space will become increasingly blurred with the proliferation of business parks, home offices, live-work, high-tech industrial space, etc, including One-North. My question to the Minister is how would his Ministry track the supply and demand for office and industrial space which impinges on the Government's land sales programme, so as to avoid large volatilities in the market as the traditional definitions of such spaces have become increasingly obsolete, and there is considerable overlap between the two.

Sir, first of all, let me respond to Dr Teo Ho Pin's questions on the Master Plan. As Members know, the Master Plan is reviewed every five years. The last review was done in 1998. What the Master Plan does is to translate the Concept Plan 2001 into more specific land use plans for the medium term, and the Concept Plan 2001, in turn, ensures that we have enough land to meet our development needs in the longer term. Dr Teo asked what has been achieved since the last Master Plan review in 1998. Let me just go through some of the developments since then. First of all, new towns such as Sengkang and Punggol were developed after the Master Plan 1998. New rail networks such as the North East MRT Line and LRT systems in Bukit Panjang and Sengkang were also established. As far as parks were concerned, there were new parks - the Hindhede Nature Park for one. Existing parks were redeveloped, for example, West Coast Park. New commercial space at Novena Square, Far East Square, Compass Point in Sengkang and other HDB town and neighbourhood centres were built. New industrial estates and business parks such as Woodlands Spectrum and Changi Business Park were developed to provide jobs closer to home. What about Master Plan 2003? The new Master Plan will focus on two things: (1) enhancing the quality of our living environment through green spaces; and (2) reinforcing the identity of familiar places in Singapore. As for the business community, we will be looking at ways to provide greater flexibility for businesses. Please allow me to elaborate. The public has given great support for the proposals in URA's Parks and Waterbodies Plan - a key part of our plan to realise our vision of Singapore as a "tropical city in a garden". So, Master Plan 2003 will provide for an additional 1,200 hectares of parks and park connectors. To give you an idea of what this means - 1,200 hectares is equivalent to something like 20 Bishan Parks, or if you consider the existing amount of land that we set aside for parkland, it is another 45% of parkland for the enjoyment of Singaporeans. Residents in several of our newer towns - Sengkang, Jurong West - as well as in Woodlands, can look forward to new parks in their neighbourhood. And for existing parks, like Labrador and Pasir Ris, we will be extending them. 11.30 am Previously, unexplored areas, like the central catchment, will be opened up for recreational activities. There will be plans for canopy walk, an observation tower and more hiking trails and boardingwalks. All these plans will be obviously implemented in conjunction with the PUB. To recognise and to safeguard our natural heritage, nature reserves and nature areas will be reflected in the draft Master Plan 2003 for the first time. With all these initiatives and programmes in place, there should be no reason for Singaporeans to complain that there is nothing to do in Singapore. Indeed, even now, there are some quite breathtaking and very beautiful places in Singapore, places like Sungei Buloh, Chek Java, Bukit Timah Nature Reserve, Labrador Park, and many other places, which I hope more Singaporeans will take their time to visit and to appreciate. Another important aspect of this draft Master Plan 2003 is the identity plan. What the identity plan seeks to do is to retain the unique identity of some parts of Singapore. Again, I am pleased to note that this plan has received very strong support from members of the public. Everyone of us has a favourite building, park, or place in Singapore where we have enjoyed good times with family and friends. These physical markers in our lives serve to root us in time and space. We should not underestimate their importance in our ongoing efforts to forge a Singaporean identity. For the Master Plan 2003, we intend to preserve both such places. The identity plan goes beyond just retaining old buildings. It also recognises that the existing community life, the streetscape, the activities - all these contribute to the identity, character and colour of the place. MND is supportive of the recommendations to conserve about 600 additional buildings, or about 10%, of the existing stock of conservation buildings. There are four key nodes of the identity plan, namely, Balestier, Jalan Besar, Tanjong Katong and Joo Chiat. Sir, we have to bear in mind that there is a limit to conservation. Much as we want to conserve many buildings and areas, this cannot, and should not, be the overriding consideration when we plan for Singapore. We live on a small island with many competing land needs. So land use planning is always a fine balancing act with many trade-offs to be made. Do we conserve or do we sacrifice some infrastructure that is important for economic growth? Do we conserve and diminish the economic value of some pieces of property? The National Library, for instance, many Singaporeans have asked for its conservation. But, unfortunately, it has to be relocated because of the need for a new road and tunnel system in the area which will allow our city to grow. More recently, there were calls for the Portsdown Road area to be kept as it is. Again, it has to be disturbed because there is a need to construct a vital road link through the area. We can of course try to mitigate the effects of these developments, and we will. SMU and the National Library Board are exploring ways to capture the memory of the existing National Library. JTC is trying to relocate the popular cold bar restaurant to somewhere nearby. But while we seek to preserve memories and identity, it is not possible to conserve everything and freeze our growth. Some Members, like Dr Teo Ho Pin, Mdm Yu-Foo, Mdm Cynthia Phua, have commented that we need to improve the accessibility of jobs to homes. Mdm Yu-Foo, in particular, asked whether we can find ways and means to increase the vibrancy of our city, to turn it from a boring and so-so city into a wild city. An hon. Member: WOW City!

Sorry. I heard it wrongly. While I am afraid that turning Singapore into a WOW city must be the responsibility of other agencies as well, not only MND, we will contribute our part to that effort. I would also like to thank Mdm Yu-Foo for the $100 ang pow which she has contributed to the Ministry and I hope that, after she hears my reply, she will not withdraw it. Indeed, HDB does offer a wide range of facilities for accessibility. Facilities, like schools, parks, polyclinics, community centres and so on, are well located within our new towns and they are within easy reach of residents. That we can do, and we will. Regional centres, such as Tampines and Jurong, will be developed into an integrated live, work and play environment. Housing, shops, entertainment and institutional developments will be introduced into the Jurong Regional Centre. And URA, HDB and SLA will work closely with grassroots organisations to allow vacant state land that is not needed in the short term to be put to interim community and recreational use. To bring jobs closer to homes, the Master Plan 2003 will safeguard more industrial lands in residential areas, such as Sengkang, Sembawang, Hougang and Punggol. New housing units will also be introduced in the west region, as Dr Amy Khor pointed out. This will be in mature estates, such as Clementi as well as in newer ones, such as Choa Chu Kang and Bukit Batok. As the central area is a major employment centre, we will also increase the number of homes in the central area. One area where we will do this is in Outram. URA will be proposing a new high density residential precinct at Outram. This will capitalise on two very positive attributes of this area, one, the hilly terrain in the area; and, two, its internal city location. I fully support Mrs Yu-Foo's call for us to build a city of excellence. It is indeed our intention. In fact, if Members will recall, the URA some time ago revealed the landmark and gateways plan. What this plan does is to earmark certain strategic sites for landmark developments, landmark buildings. We have started to hold design competitions as a way to draw new and creative ideas. For example, for the Duxton Plain high density public housing project, we held an international design competition in which many international architects participated in this competition. I am pleased to note that the competition was won by a local architectural firm. To add even more buzz to the city, URA plans to establish a cultural and activity loop around the Marina Bay area. So if you look at the Marina Bay area today, you will see the Esplanade, you will see the Fullerton, the developments along One Fullerton, etc. We would like to develop that even further around the Marina Bay so that Singaporeans can look forward to even more world-class attractions to arts and cultural activities along the waterfront and, hopefully, this will contribute to Singapore becoming a WOW city. We will selectively increase density of residential land around MRT stations so that more people can live within easy reach of public transport. This is a concern of some Members that we do not have a sufficiently extensive rail network for Singapore. Dr Teo Ho Pin asked about increase of plot ratio on public and private lands. Let me explain, first of all, that when we assign plot ratio to land in Singapore, we do so on the basis of planning objective, and not on who owns the land, in other words, not whether it is public or private. While the planners will seek to intensify land use, they also have to be guided by many other considerations, for example, technical considerations. There are tight controls imposed by, say, flight paths, which need to be taken into consideration. And we also need to take into account the need to maintain the ambience and character of certain areas. In the last Master Plan Review 1998, there was already a major review of land use and development intensity and many parcels of land had their plot ratio increased. For the Master Plan 2003, we will focus intensification on undeveloped lands, or what we call, soft lands, especially those near MRT stations. This is done with the knowledge that it will be sufficient to meet our medium term needs for housing. Sir, let me now touch on how we can allow greater flexibility in land use for businesses. We are in a rapidly evolving business environment. So the ability to adjust quickly to changing business needs is important to our competitiveness. In this regard, the Master Plan 2003 has incorporated several features that will provide this greater flexibility for businesses. First, on white sites, we propose to allow more uses within the so-called white sites. As Members will know, the white site concept was introduced to give developers greater flexibility to allow a mix of uses - commercial, residential, hotel - on such sites. We will expand this new white site zone to allow for other uses as well, such as sports and recreation, clean industrial uses and R&D facilities. Secondly, we will introduce new Business One and Business Two zones (B1, B2 zoning). Basically, these new zonings will also allow industrialists to change the uses according to changing business conditions without the need to apply for rezoning of industrial land. Mdm Cynthia Phua asked whether we can allow more types of businesses to be conducted in residential premises. I remember this was a matter which was also raised last year by several Members. We did a review and I am pleased to inform Members of this House, yes, we will allow more uses in residential areas. My Ministry will be introducing a Home Office Scheme for both HDB and private developments that allows home owners to conduct certain small scale businesses from their homes within zones that allow for mixed uses. Under this scheme entrepreneurs can operate small scale businesses from their own homes without incurring high start-up cost. We will adopt a negative list approach to kick off this scheme. Uses that could potentially generate disturbances, such as noise, pollution and traffic, will be excluded. Examples include retail, maid agencies, car trading office, commercial schools and food catering. Uses specified in the negative list will not be allowed. Everything will be allowed, provided they satisfy some guidelines. The negative list will be regularly reviewed based on public feedback and I expect that many small businesses, such as professional consultancy services, design offices, financial planning offices, etc, will benefit from such a scheme. To ensure that the premises do not become full-fledged offices and to protect the amenity of the residential environment, some guidelines will be put in place, for example, the business activities must be confined within the premises and the number of employees will be limited. I hope Members will understand why there is a need for such rules to be put in place. Otherwise, those who have bought into these developments, with the hope of enjoying some peace and quiet, will feel aggrieved, and rightly so. My Ministry is now finalising the details of the Home Office Scheme and we will announce the guidelines to them in the next few months. 11.45 pm I would like to take up some Members' comments that flexibility in some cases can result in undesirable side effects, like increase in value of land. Yes, today we do allow some ancillary uses, eg commercial and supporting uses, such as childcare centres, canteens, showrooms, etc, within business zones. Mdm Cynthia Phua, in fact, asked why do we not extend the allowable uses in industrial developments to other complementary uses, particularly today when many industrial developments are under-utilised or not utilised. Industrial land developers have asked that pure office or retail users be allowed to fill up vacant industrial space. There are many such requests that my Ministry receives. On the surface, they appear quite reasonable. Why do we zone land? Why do we specify that this land can only be used for this purpose? If land that was zoned industrial were used for higher value uses, eg, offices or shopping centres, we would soon use up our stock of industrial land. The price of industrial space would start to escalate, and our competitiveness would be affected. We also need to zone land specifically to safeguard sufficient land for housing, parks and for community uses, such as schools and hospitals. Furthermore, zoning ensures that uses are compatibly located. For example, I am sure we do not want our residents to live next to a chemical factory or, suddenly, to find, after they have moved into a neighbourhood that, overnight, they have got a repair workshop next door to them. Zoning is also essential to ensure that the transport facilities can be planned to match such activities. For example, if we have a factory or part of a housing estate suddenly to be converted to a shopping centre, we can expect a lot of traffic congestion in these areas. So, for all these reasons, I hope Members will appreciate why URA needs to enforce zoning controls. Sir, the draft Master Plan 2003 for the west region has been launched. This is the first in the series of five regional plans that would be launched over the next few months for the north, north-east, east and the central regions. All these plans will be exhibited. Before firming up these plans, I hope to receive views and suggestions from Members to help us to improve our plans. Sir, let me now address the property market. Many Members of this House have asked what the Government is doing to ensure that our land prices do not hinder our competitiveness, particularly for commercial and industrial land. Other Members have highlighted that in ensuring that Singapore remains cost-competitive, we do not inadvertently destabilise the property market and erode the asset values of existing land and property owners. This House has already discussed industrial land pricing in detail. Deputy Prime Minister Lee has already explained that we cannot match the lowest land prices offered by our competitors, nor do we need to do so. But, the Government will safeguard and ensure that there is an adequate supply of industrial land released to achieve competitive and stable prices. Let me now touch on the Government's land release policy, in particular, for the commercial and residential sectors. The Government's objective behind the supply of land is to sustain economic growth. We will safeguard sufficient land over the long term, and we will phase the release of this supply to generate growth. Prices of land and properties will rise and fall according to economic conditions. Our aim is not to control property prices in the short term, eg, by subsidising it to maintain competitiveness when it is high, or boosting it when the market is down during economic downturns. Rather, it is to ensure a stable property market over the medium term. To achieve this, the Government's strategy is to ensure that there is a sufficient supply of land released to meet the end-users' medium-term demand for space. With sufficient supply, prices will not escalate sharply, and the market will be more stable. One way that the Government releases land is through the Government Land Sales (GLS) programme. Dr Amy Khor commented on the importance of taking into account all available supply when determining the GLS programme. Let me assure her that MND and URA will take this into account. We do account for all sources of supply when planning for the GLS programme, ie, existing supply and supply in the pipeline, and those released by private developers as well as Government agencies. MND and URA, together with MOF, MTI and MinLaw, are now studying ways to see how we can improve this operating framework. We recognise, however, that it is difficult to determine demand accurately, as the market is dynamic, and this is the reason why in 2001 we introduced the reserve list programme. The reserve list system enables the GLS programme to be more responsive to market demand. Sites will only be released for sale when developers apply for them. With this approach, Singapore's commercial space has remained, by and large, competitive. As Dr Amy Khor has pointed out, Singapore is competitive by international standards, whether we are talking about office or retail space. Property consultants do regular surveys and, for office space, we are ranked in the latest survey, 35th in the list of global cities in the world. Our office rents, in fact, are cheaper than those in Tokyo, Seoul, Beijing and Sydney, even Mumbai, I am told. As for retail space, again, property consultants have ranked Singapore 12th in the world. We are more competitive than cities like Hong Kong, Sydney, Seoul and Tokyo. The office market is, however, currently in a state of over-supply mainly because of shrinkage in demand due to the economic slowdown. The private residential market is more stable. Prices fell marginally last year by 1.8%. But sentiments in the property market are still uncertain. The Government has, therefore, taken a more cautious approach towards the commercial and residential markets, and has not released any sites through the confirmed list of the GLS for residential or commercial developments since the end of 2001. We also deferred plans to release a site for the business and financial centre in the first half of 2003, and tightened the controls to ensure that Government agencies build office buildings only when there are no suitable alternatives. However, we have still made sites available through the reserve list. Despite the Government's suspension of the confirmed list, interested parties have, to-date, successfully applied to release nine land sale sites. Eight of them have been sold, and the tender for the last site will close in the next few days. Sir, let me conclude by restating that Singapore will never be as cheap as some other countries with a large land mass. We cannot compete on property prices and rentals alone. There are serious implications to the rest of our economy, if we deliberately depress the true market value of land. It is far better to ensure that an adequate supply of land is released to achieve competitive and stable prices.

Sir, as a multi-religious society, we must provide necessary places of worship to fulfill the spiritual needs of Singaporeans. The present open tendering system of allocating land for our religious activities does not provide a satisfactory means to ensure that places of worship are conveniently located to serve the needs of Singaporeans. In fact, some places of worship are located on remote industrial sites where public access is difficult. Others are located in areas where there is no carpark available, resulting in serious traffic congestion during religious occasions. Sir, we need to develop a master plan for places of worship in Singapore. Based on the proportion of different religious groups, we should adopt a religion quota system to allocate land to the respective religious organisations. At the same time, efforts must be made to encourage religious harmony through land use allocation. Sir, I wish to ask the Minister the following questions: 1) What is the basis of allocating for places of worship? 2) What are the measures adopted by URA to promote religious harmony in Singapore through land use planning? and 3) How can URA ensure that places of worship are easily accessible to worshippers by public and private transport?

Sir, we have a fast-aging population. Indeed, many Members have raised issues relating to the elderly and, to be fair, many in the Ministry have paid attention to these areas. I would like to add another to the list, and this is to resurface the issue of retirement villages which was brought up before but has not quite taken off. The whole idea is to allow the elderly to live together and, from the logistics point of view, this has merit because it will allow for care-giving activities to be better organised, and it will also be easier to conceive recreational and safety facilities as well. But it has not quite taken off, because what we have at the moment are some HDB blocks across Singapore and, as one of the social workers said to me, it is a colony of the old, the frail and the sickly. We will get a funeral every other week. So, it is quite depressing. We have organised the hardware, but not really the software side. Admittedly, this is a new concept, and it requires some change in mindset. It also requires time for the idea to gain acceptance. That is why people say it is far easier to integrate the old with the young, so that their spirits can be uplifted as well. But this idea of retirement villages has, in fact, worked well in other countries, and perhaps we can learn some best practices and ideas from them as well. In some countries like Thailand, retirement villages are in fact set up even through the lure of foreigners. But I am not advocating that this should be done for non-Singaporeans. It is just an idea for Singaporeans. So, we should move from the concept with just a cluster of houses, and we should add software to it, eg, get it well managed, get the facilities in. But, as with all things in Singapore, it would need to be spearheaded, championed and sponsored. Perhaps, to incentivise the private sector or, in fact, the VWOs, we need to put some real incentives in it. One of the main prohibitive areas is land cost again. That is why I have directed the issue to MND. Perhaps it could consider making it more affordable, so that the whole idea can then take off. So, what I am saying here is that it remains a good idea and we should not allow the lack of success in the past to deter it. 12.00 noon

Sir, three Budget debates ago, I asked the Minister if he would consider granting gross floor area (GFA) exemption for space to be set aside in business and industrial complexes for childcare or multi-service centres as one component of a total approach to creating a family-friendly environment in Singapore. The Minister thought that developers should be willing to provide such facilities on their own volition, as it would surely add to the attractiveness of their developments. Sir, in the ERC report which was released just last month, one of the recommendations, in the segment addressing land issues, was to grant more GFA exemptions to encourage the provision of communal areas for residential developments and common areas for commercial developments, so as to improve the quality of the living and working environment. I am therefore encouraged to try my luck at persuading the Minister yet again to make similar GFA concessions for space set aside, specifically for childcare centres in business and industrial complexes, as I cannot think of any better way of improving the living and working environment, than by providing more on-site or near-workplace childcare centres. Childcare arrangement is one of the two most important factors cited by women in enabling them to balance their work and family responsibilities. Apart from the quality of care provided, convenience of location is an important factor. Best for the parents are childcare centres conveniently sited at a location near to home or a workplace centre. Generally, only big companies with large establishments would even consider having an on-site childcare centre, as it makes little sense for a small company with a small staff to set up one of its own. The economies of scale to run such a centre are just not there to make the enterprise viable without a huge subsidy, something small companies are not in a position to undertake, and the number of staff benefit is small. In a big industrial or business development, however, the employees of many companies sited within such a complex would find a childcare centre, conveniently located somewhere within the complex, most useful and, with their combined numbers, make the running of such an establishment a viable proposition. As part of our on-going efforts to create a family-friendly environment - an important consideration, both from the perspective of our on-going attempts to boost our fertility rate as well as being an integral part of the enhanced working environment that the ERC seeks to make a reality - I hope that the Minister will give this proposal consideration this time.

Sir, the topic of heavy vehicle parking must have been discussed many times in this House. Nonetheless, in new towns, I would like to see some flexibility in the policy of heavy vehicle parking. In new towns, residents do not have much of an option if he drives a van with a high roof or a heavy prime-mover. This is because multi-storey carparks are the norm. Their vehicles just would not get in. Moreover, the new towns are generally further away from the centres of employment. So, one would empathise with the frustration felt by many residents who are unable to find parking, especially for those who have to hit the road early and wind up the workday late. I am aware that there are rationally correct arguments that such vehicles are meant for business and should not be used as a mode of transport to and from work or the employers must provide transportation for the employees. However, there is a human face behind each problem and, if a solution also lessens business cost as well, so much the better. I hope we can find some accommodation. Noise and safety considerations also merit the position that heavy vehicles should be kept out of residential areas. Noise and safety considerations must be respected. However, I hope that the Minister would consider allowing the public and private sectors to build and operate heavy vehicle parks, say, 2-3 kilometres away from the dense population centres. This way, heavy vehicle drivers can either walk or cycle back and forth between their home and the parking space. With our much respected long-term town planning, land earmarked for facilities like light-industrial estates - and possibly would not be built for some years - could be temporarily released for such purposes. The need is more urgent, now that the recent amendments to the Road Traffic Act allow for the possibility of enforcement action on vehicles which are not parked in their statutorily declared sites. Yes, island-wide, there are many and adequate parking lots, but there is a wide disparity between where the lots are located and where people live and where the demand is. I hope that in the new towns, the Minister would consider flexibility in the implementation of the policy on heavy vehicle parking, and that the plight, and the alleviation of the pains and frustrations, of these key players in our logistics chain be taken into consideration.

Sir, the Istana, located along Orchard Road, is the official residence of the President of Singapore where he receives and entertains State guests. The office of the President is also at the Istana. The entire domain of the Istana occupies over 100 acres. The Istana Building, which was known as Government House, was completed in 1869. The Building is dominated by a three-storey 28 metre high tower block, and there are two-storey side wings. There are extensive grounds and a nine-hole golf course. Sri Temasek is a 19th century bungalow which was built in 1869. It was the Colonial Secretary's residence. The Villa was built in 1908, and is the official residence of the Aide-de-Camp. It later became the Private Secretary's bungalow in 1916. Thereafter, in 1958, it became the Attorney-General's house. It is now used mainly for functions. In the past, the Villa was used to house many foreign dignitaries while they were guests of the State which included Dr Mahathir, Mr Deng Xiaoping, President Suharto and Ex-President George Bush. The Military Guardroom was built in the early 1900s. Sir, there is a great deal of dignity and pride in the office of the President. And we, citizens, have great respect for our President. I wish only to raise an important issue about the maximisation of the use of the physical land space in the Istana. I do recognise the tranquility and the lovely ambience of the Istana. I do hope, if changes do take place, it would not affect the overall ambience of the Istana. The Mission Statement of National Development is, and I quote, "To create the best physical and living environment for building a robust economy, a vibrant city and cohesive communities." The Ministry's desired outcomes include, inter alia, a vibrant, central area contributing to a world-class city, sufficient land for development and provision of optimal greenery, parks and recreational space for quality living. In line with the desired outcomes of the Ministry, my query is whether there is currently a maximum utilisation of the grounds of the Istana. Would it be better if part of the Istana were to be transformed into a public park for the better utilisation of the same by the people of Singapore and, for visitors to Singapore, as a tourist attraction? Currently, the Istana is not open to the public, except during the occasions of Istana Open Houses, for instance, on New Year's Day, Labour Day, National Day, Deepavali, Chinese New Year and Hari Raya Puasa. One would put up a case for and recommend that such a beautiful and tranquil place, which could give peace of mind and happiness to many in Singapore, should be enjoyed by more people frequently.

Please start wrapping up your speech, Mr Mohan.

I understand our President does not stay at the Istana. I take it that no one in high office stays at night. If so, could we have a portion of Istana converted and used as a beautifully-lit park for Singaporeans to enjoy? Security measures, if any, could always be taken.

Your time is up, Mr Mohan. Mr Mah.

Sir, first of all, in response to Dr Teo Ho Pin on the planning norms for places of worship. URA and HDB work together to ensure that there is adequate land for places of worship to meet the different religious needs of our residents. He asked what is the basis for allocating land. The number and the distribution of sites for the different places of worship are based on planning norms and standards, which are set not just by URA alone but in consultation with various authorities, like the Ministry of Community Development and Sports. The key factors in determining the number of sites include the size of the residential population in the area, as well as the needs of the different religious groups. Places of worship are one of the many community facilities that are provided for residents in HDB new towns. When HDB plans these new towns, various types of religious institutions are catered for, and they are distributed throughout the new towns. As a result, residents can pursue their own religion in a place of worship near their homes, well-served by public transport and a good road network system. But, in a few instances, where land is not so readily available, sites are also provided in industrial estates. How are sites allocated? They are allocated by open tender. We specify the type of religious institution, whether it is church, Chinese or Hindu temple. I believe that this is a fair and transparent system. Apart from tender, we also use the auction system. As for mosques, the sites for mosques are traditionally allocated directly to MUIS, and MUIS will do the development. I would like to assure Dr Teo that my Ministry is very mindful of the need to provide adequate sites for places of worship for the different religious groups in Singapore. For his information, we are also exploring this concept of community clusters, where civic and community facilities, such as community clubs and nursing homes are allocated together with one religious institution per cluster. We are trying out this concept in Punggol 21. Apart from optimising land use, these community clusters will also serve as a focal point, a gathering point, for residents to interact. Mrs Fang Ai Lian raised the issue of retirement villages. I believe Dr Amy Khor also raised this issue earlier in her cut. Let me, first of all, say that the issue of retirement villages was deliberated extensively when the IMC for the Aging Population met and discussed. First of all, we agreed that our priority was to allow for "aging in-situ". As I have explained, we try and provide good facilities so that the elderly can live with their families in places that they are familiar with. Having said that, of course, yes, there are also times when the elderly may want to live on their own. For this reason, the HDB has also provided the housing option known as the studio apartment. Studio apartments were originally built as stand-alone blocks. There were some valid concerns about having all the elderly together and, for this reason, we have reviewed the situation. We will be integrating studio apartments in blocks with other 4- and 5-room residents, so that the young as well as the elderly can live together. This scheme has been well-received and we will be doing more, as I explained to this House yesterday. But there may be demands for other housing options for the elderly, such as retirement villages. If there is such a demand for a retirement village, private property developers will cater to this demand. I do not think it is the business of Government to step in to meet this demand for private retirement villages. We have already done so in the case of HDB residents. How can we incentivise it? What we can do is to make sure that the norms, the building guidelines, the planning guidelines do not unnecessarily impede the development of such retirement villages. Just to give Members a small example. A feedback was that some of the current planning guidelines for developments in general specify certain minimum car parking requirements. We have looked at it and we have decided that for retirement villages, we can relax these guidelines because they are not relevant. But as I have said, I do not believe that Government should directly incentivise the development of retirement villages. It is best left to the private sector as a business decision. One feedback that we have received is to provide land on a shorter tenure. In other words, instead of providing land for 99 years, why not provide land for 60 years or even 30 years? This is something that we can consider, and if it is helpful for developers in encouraging them to provide retirement villages, then we will certainly look into it favourably. But, as for land specifically zoned for retirement villages alone, I do not believe there is any need for such specific land use zoning at this point in time. 12.15 pm Dr Jennifer Lee asked whether we will provide bonus GFA for space used for childcare centres. First of all, may I spend some time to explain why we provide GFA exemptions in certain situations. GFA, or gross floor area, is something that developers pay for. They tender for it and they bid on the basis of the specified GFA. Having done so, they are allowed certain exemptions. Exemptions are selectively granted to satisfy certain planning objectives. What are these? For example, there may be a need to provide for greater design flexibility, for more pedestrian linkage, so there are GFA exemptions for covered public walkways. Or there may be a requirement to achieve more greenery within developments, and so things like planter boxes, sky terraces, etc, are granted GFA exemption. But, GFA exemption should not be freely used as a tool to achieve every and any objective. So, for example, if there is a need to provide social facilities like childcare centres, we should be looking at other ways of facilitating such developments, rather than look to GFA exemptions as the only way of doing so. Because the moment you start to expand the GFA exemption list you are, in effect, compromising the planning norms. What are these other incentives? Perhaps we can look at tax incentives as one possibility. But, as I said in my reply three years ago, I still believe that it is important for the market to be allowed to operate in this case. If really there is a need for, say, a commercial development to have a childcare centre, or any other family-friendly facility, I believe that developers should seriously consider providing for such facilities, in the same way that it provides other facilities to make its development more attractive. I believe that this is an attractive facility and that if there is a childcare facility, this would be a plus for that development. But this is a decision not for the Government to make, but a decision properly left to the developers to make. I turn now to the issue of heavy vehicle parking by Mr Wee Siew Kim. This is a perennial problem with developments in HDB estates, and many MPs have approached my Ministry on this. What is the issue? The issue really is whether to take into account the disamenities - the disturbances, noise and smoke caused to residents - or whether we put more weight on the convenience of the heavy vehicle owners. There are heavy vehicle parks located in HDB estates, but where they are located directly inside HDB estates, we can get a lot of complaints from the residents. Five o'clock in the morning the vehicles start up and they disturb the residents. In fact, recently, I have received several requests from MPs to actually re-locate heavy vehicle parks outside HDB estates, and we have done so. So, we will provide heavy vehicle parks close to HDB estates, where there is space available, but we have to also recognise that heavy vehicles are not meant to be used as a personal transport. They are, in fact, to be used for businesses. We will try to accommodate the demand for such parks on an interim basis, as Mr Wee suggested, in certain areas where land is available, where vacant land is not required for development in the near future. But we have to recognise that in the longer term, all the heavy vehicle parks, once land is progressively used up, will have to start to move. For this reason, we have provided permanent heavy vehicle parks in many purpose built heavy vehicle parks near workplaces, like industrial estates in Jurong, Kranji, Senoko, and so on. And when we do so, the intention is to have the heavy vehicle owners make their own transport arrangements to travel between their home and the designated parking places of their heavy vehicle. This is, I recognise, not the ideal situation. Ideally, they would prefer to park their vehicles just next to their flat but, as I explained, this is not feasible and it is also not conducive to the living environment of the estate. Let me just add that there are sufficient parking lots island-wide for heavy vehicles, and owners and drivers of heavy vehicles should not have problems securing a parking space for the vehicles in these areas. Finally, Sir, let me address Mr Chandra Mohan's cut about the site of the Istana and his proposals. As Mr Chandra Mohan pointed out, the history of the Istana is a very colourful and important one. It was built in 1869. It has housed many, many dignitaries, ranging from the British Colonial Governors, and all our Heads of State since self-government and independence. It has also played host to many important people. The current Istana site is zoned "Civic and Community Institution" (CNCI) in the Master Plan. Should the Istana grounds be better used, considering that it is sitting on prime land in the city area? The Istana is a very important part of our history. During the Japanese occupation, General Yamashita, who was the Commander of the Imperial Japanese Forces, resided in it. So did General Tojo, who was then the Prime Minister of Japan, when he visited Singapore. Lord Louis Mountbatten, the British Commander-in-Chief, when the Allied Forces returned in 1945, lived in it and so did many others, as Mr Mohan pointed out. If walls could speak, it would tell fabulous tales of Singapore's past. Within the Istana grounds there are also several buildings of significant architectural and historical interests, and two of these buildings have been gazetted as national monuments in 1992. The Istana is the official residence of the President. This is where he receives and entertains State guests. It is, therefore, a symbol of authority as the abode of the Head of State. Due to its national significance, we should consider very seriously before we shift it around or relook at its use. There was a suggestion, in fact, made in the early 60s by Mr Ong Eng Guan, who was then the Minister for National Development. He suggested that we should free up the land for public housing because, at that time, housing was in short supply and in great demand. The Government rejected the idea because of the significance of the Istana. Had it done so, instead of the Istana today, with all the grounds and all the buildings available, we would have a public housing estate, something like Bukit Ho Swee, because at that time we were thinking of whether we should be building flats in Bukit Ho Swee after the Bukit Ho Swee fire, if Members recall. Sir, the Istana should not be moved from its present location, and there is no pressing need to free up the Istana land, whether it is for use as a public park or otherwise, because there is sufficient State land in the central area to meet our future development needs. As far as park land is concerned, as I have just explained in a previous response, we are providing more park land, more green spaces for our residents to enjoy. Indeed, currently, the public can visit the Istana grounds and even the buildings themselves. There are plenty of opportunities. It is open five times a year, all the festivals - Chinese New Year, Labour Day, National Day, Deepavali, Hari Raya Puasa. In addition, the Istana is used for many important State and other large Government functions, eg, the Armed Forces, the Police, teachers, nurses, VWOs, community leaders and workers. So, it is open for use by members of the public and I am sure that members of the public have enjoyed the Istana grounds during these times. The Istana is a crucial national symbol for Singapore, and we would preserve and maintain it for posterity.

Sir, AVA aims to provide a resilient supply of safe food to Singaporeans. With an ageing population and the vulnerability of food-borne diseases, we need to develop a more water-tight system to control the hygiene of food in Singapore. Today there are many reports on certain food compounds, such as Thalidomide claiming to cause cancer. Many consumers are confused by such reports and may not know how to take safety precautions to protect their health. Sir, I hope that AVA can work closely with various Government agencies to keep Singaporeans more informed on food safety. Singapore imports 90% of our food supply. As such, we are heavily dependent on overseas food supply. This food may sometimes come from farms which use pesticides, growth hormones or antibiotics harmful to human beings. Besides the control of food safety, we must also have a sufficient supply of food to overcome any food shortage crisis. Sir, I wish to ask the Minister the following questions: What are the key policies in ensuring that Singapore has a resilient supply of food to cope with any food shortage situations? What are the anti-bio threats to our food supply? What are the measures taken to safeguard our food supply? And, how can we reduce food prices in Singapore?

Sir, I would like to add to what Dr Teo Ho Pin has raised. I just want to be sure that the AVA has adequate resources to achieve the desired outcome of "safe and resilient supply of food", and whether AVA will look for more diversified food sources which are competitive so that we can have stable food prices. Sir, another question is the import of genetically modified food. I believe we import them and so I want to make sure that they are safe for consumption and that AVA will check them. 12.30 pm

(In Mandarin): Sir, the meat that we consume in Singapore can be classified into four categories: freshly slaughtered; chilled; frozen; and frozen for many years. They differ in price and, of course, in taste too. Why do people want to pay a high price for the freshly slaughtered? Simple! Because it is fresh and hence tastes delicious. The moment you taste it, you will know. It has a natural taste. Eating this type of fresh meat is plain enjoyment. Why do we eat? There are people who eat in order to survive. They are also people who eat as a form of enjoyment. To the former, it does not matter to them what they eat. So long as it is edible and can sustain life, it is good enough. But, to the latter, they want to eat the best, the most delicious and appealing food, never mind the price! To them, the greatest enjoyment in life is to have a deliciously and well-cooked meal at home or in a restaurant after a hard day's work. For this purpose, they make sure that the meat served to them is fresh and succulent. Many people who go to Hong Kong enjoy the food there. This is because the Hong Kongers also insist on fresh meat and vegetables. If the fish is not alive and swimming, it will not make it to the table. Meat must be fresh, even the chilled one may not qualify. Frozen meat is definitely out. That is why the food in Hong Kong always tastes better. Now, let me talk about the supply of meat in Singapore. After the spread of Nipah virus in Malaysia some years ago, one of the two abattoirs was shut down, and the supply of fresh meat was reduced by half. Ducks and chickens are no longer permitted to be slaughtered in the wet market. They are now being slaughtered in the authorised poultry slaughter-houses the night before, and supplied to the markets the following morning. We are not as fortunate as the Hong Kongers, as far as the supply of fresh meat is concerned. There is a Teochew saying, "If you do not have fish, shrimps will do." So, with no agricultural resources, we should count ourselves lucky that we have meat to eat at all. I heard that even the only abattoir in Singapore will be closed down. If that is the case, then the best we can get will be the "Air Pork" which is Australian pork air flown from Australia to Singapore. The price will certainly be higher, and it will taste as good. On the other hand, there is also a rumour that poultry slaughter-houses will also be closed, because the import of live chickens and ducks will soon be banned. If that is the case, then we will not have any more good and delicious meat to eat in Singapore. This may well be another reason for some people to want to migrate to other countries. Can the Minister tell us whether there is any truth in these rumours?

Sir, we always enjoy a good joke from Prof. Low. I wish he could keep his jokes halal! Recently, I visited an egg farm in Lim Chu Kang and also the AVA HQ in Jurong. There, I learnt that Singaporeans consume one million eggs a day, most of it imported though. In these days of very health conscious Singaporeans, I wonder whether that is good. Nevertheless, I am glad to learn that many of the sources of egg supply are now run by companies with Singapore investments, although they are overseas. Food, we all know, is of strategic value, and in these days of terrorism, including bio-terrorism, one cannot be too careful about our food supply. I also learnt that the egg farm I visited is the only one in Singapore. I realise we are short of land, but is one egg farm all that we can afford in Singapore? I would like the Minister to answer that. On a wider issue, Sir, what is the progress of Singapore's efforts to be less dependent on food imports, and our move to be more self-sufficient in food supply? Sir, I was also very impressed by the work done by AVA, specifically on food testing and food control. I saw the growing use of technology at the AVA but also how crammed the office space was. Thus, I was glad to learn that the AVA will be moving to its new and better premises somewhere in Jurong too. May I ask the Minister what provisions have been made to meet the growing challenge of technology in meeting AVA's role, including coping with genetically modified (GM) food?

(In Mandarin): Sir, AVA is responsible for the inspection of all imported meat, seafood, etc, to ensure our food hygiene. Last year, there were less than 1,000 cases of food poisoning in Singapore. In comparison, there were 10,000 cases of food poisoning in New Zealand, and the number in Europe and the USA was even higher. This shows that our food hygiene has surpassed international standards. Recently, we visited the AVA office, and we were very impressed with its technology and the work attitude of the workers. They are very impressive indeed. However, I found that their office is too crowded. Can the Minister provide them with a bigger office, so that they have a better working environment? Now that the former HDB Centre in Bukit Merah is vacant, can some arrangement be made to move the AVA office there? Since the AVA possesses the professional skills and technologies which are of international standards, we should encourage them to make use of their expertise to establish a regional testing centre so as to go regional and even global. At the moment, AVA has a staff of 800 and their annual expenditure is $70 million. Apart from the $20-odd million revenue collected from services provided, they still need about $40 million to cover their activities and operational costs. If we can allow AVA to provide their professional services on a regional or international basis, it would have derived revenue on its own, and we can cut down on dependency on the Government. With a steady source of income coming in, we can avoid retrenchment. Sir, more and more of our food imports are coming from China, like vegetables, meat and canned food. Recently, some of our enterprises like the pig farmers have gone to Qingdao, China, to set up pig farms. At the moment, they are having some 50,000 pigs there. Once the pigs are slaughtered, they can be exported to Singapore. But the businessmen do not have confidence in the food testing facilities over there, and whether or not the import will be approved by the health authority in Singapore. If AVA can join up with the ICQ of China to set up a testing centre in China, it will clear all the doubts of our pig farmers there. Our entrepreneurs will then have more confidence to go overseas to invest in pig farming, and the food price here can then be lowered. This will certainly benefit our consumers here. I hope that the Minister will consider this. I have sounded out this idea to the CEO and senior officials of AVA, and they are enthusiastic towards it. They have the entrepreneurial spirit but the Ministry of Finance does not support this idea. Can the Minister for National Development take up the matter with the Minister for Finance? 12.45 pm

Sir, I would like to ask three questions about farming. First, what are the key policies supporting the farming industry in Singapore? Second, what are the key incentives available to attract investors in the farming industry? Third, can URA allow more flexibility to allow integrated uses of agricultural land? My second cut is on the Building and Construction Authority (BCA). The BCA was formed to spearhead the construction industry in Singapore. Its mission is to develop an advanced and competitive construction industry. Sir, today, the construction industry still faces many problems and suffers from an image problem. It is flooded with problems of poor quality work, unfair business practices, unprofessional conduct and lack of innovation. Despite all the quality schemes and awards, we have failed to develop a quality culture among building practitioners. We need to restructure BCA to focus its efforts to upgrade the construction industry. Self-regulation will never work in the construction industry. We need rules and regulations to provide a total approach to improve business practices and increase the quality of our buildings. We need a top down approach where authorities would guide developers, consultants and contractors to work jointly as a team to produce quality buildings for users. Without strong commitment from the Government, the construction industry will remain a dirty and dangerous industry. In the last Committee of Supply, the Minister mentioned about forming an international advisory committee for the construction industry. I hope the Minister can update the House on the progress of this committee. Sir, I wish to ask three questions on this cut. What are the key achievements of BCA in upgrading our building industry? What is the output of the R&D efforts of BCA? Are there plans to corporatise BCA, and what are the key performance indicators of BCA? Sir, my next cut is on CoreNet. I have three questions to ask. First, what is the status of development of the CoreNet system and how much has been spent on CoreNet? Second, what percentage of construction related firms, architects, engineers, quantity surveyors and contractors have adopted CoreNet? Third, has CoreNet increased the cost of business?

It will be good if Members can follow Dr Teo's example. Dr Amy Khor.

Sir, I have one question, but it has got a preamble Sir, I acknowledge that bringing up the plight of our local contractors may sound like a broken record. Nonetheless, however low the productivity of this sector, it is still a contributor to our GDP, with probably a large number of SMEs struggling to cope with the shrunken demand for construction services. On the positive side, the value of construction exports by our local contractors has also shown some increase in the last two years, contributing to our efforts to expand our second wing. Sir, many contractors have gone bankrupt due to the economic slowdown. Feedback from these contractors is that whilst many of the policies implemented by the BCA and other relevant authorities are well intentioned, some can be more flexible to alleviate the problems they face. For instance, whilst the BCA Contractors' Registration System is to ensure minimum standards, there needs to be some leeway given to contractors, most of whom have had to downsize in such difficult times. These contractors find that it is not practical to keep a large pool of professional staff resulting in high overheads when jobs are scarce. But their grading will be jeopardised if they were to reduce their professional staff strength. Moreover, due to the scarcity of jobs and the desire by some to maintain their grading, they engage in price wars with bids often below cost. This had led to the failure of many firms. Those who have been inactive in the last few years have likewise had their registration downgraded, with the result that they will then be barred from tendering for the larger public sector projects. Getting downgraded also does not help them in their attempts to venture overseas. The recent introduction of e-bidding which allows the number of lowest bidders to bid again every five minutes until all except one are eliminated is also squeezing their already low margins. Undoubtedly, it is a very efficient system but brutal. The new multi-skilling requirement of foreign workers would also, in the short term, further squeeze their already razor-thin margins to begin with. Furthermore, contractors note that it is difficult to improve productivity in the sector as they face an uphill task trying to attract local workers to work in the industry, whilst foreign workers can only work in Singapore for a fixed number of years. To corroborate what the Minister for Manpower said yesterday, a contractor told me that, recently, he advertised for two lorry drivers. There were many applicants but no takers, because all the applicants were Singaporeans and did not want to work 28 days a month. Moreover, he added that margins are so thin, and he would not be able to continue business without hiring some foreign workers. He further noted that conditions are so tough, many contractors now feel that with all these regulations imposed by the Government, well-intentioned no doubt, it is as if they are being pushed to what they say pai tui tiou lou, ie, queue up to commit suicide. In fact, most recently, the contractor for our own CC also went bust, and we had to get another contractor to finish the work. I fully understand the undesirable consequences of over reliance on foreign workers.

Dr Khor, your one question is pretty long!

Sorry. I am coming to the question.

Please do.

Singaporeans gripe that foreign talents are taking their jobs away, but Singaporean businesses are actually griping that there are no Singaporeans to work for them. In sum, I would therefore like to urge the relevant authorities to re-evaluate the various policies that have been imposed on local contractors to see if their plight can be alleviated. Otherwise, our local contractors will become extinct.

It is a pretty long sum! Mr Yeo Guat Kwang.

Sir, one of the top five complaints the Consumers Association of Singapore (CASE) receives is against renovation contractors. The claims relate to defective works, unscrupulous sales tactics like not giving a breakdown of the work to be carried out, over-charging and unsatisfactory service resulting in bad workmanship. I understand that HDB has an approved list of contractors. But the list in itself does not guarantee a high standard of service of HDB-approved renovation contractors. I would like to ask the Minister for National Development the following questions: (1) What is the basis for approving the list of contractors? (2) How does HDB monitor the contractors on the list after they have been approved? (3) Will the HDB consider doing more to ensure the improvement in service standards of all the renovation contractors and enhance transparency in renovation deals, so as to protect the consumers? (4) Does the BCA play a role in this area?

Sir, the Land Titles (Strata) Act governs the management of strata title developments in Singapore. However, many purchasers of strata title developments do not understand the Act and also the concept of communal living. As a result, many disputes have arisen over the years among subsidiary proprietors concerning the management of strata title developments. This problem is further compounded when there is a mixed development comprising commercial and residential developments. The limitations of the Act have also led to a lack of transparency and poor management, thus causing many subsidiary proprietors to be unhappy. Sir, I wish to ask the Minister the following questions: (1) Will the Act be amended to cater to the needs of different subsidiary proprietors in strata title developments? (2) How can we ensure good corporate governance of management corporations? (3) Are there plans to improve the professional management of strata title developments?

Sir, I have three questions to ask the Minister to consider when reviewing the Act.

As long as they are short.

Firstly, share value. The existing COB's guidelines for share values have been in use for more than 20 years. To overcome the common complaint of home owners that they have to bear the same amount of maintenance charge, even though their unit is much smaller, it would be better to refine the floor area groupings by incorporating more bands than to leave the share value allotment entirely to the developer. Having a set of guidelines would provide some level of certainty and transparency to both buyers and sellers. Secondly, the role of managing agents. Unlike the more popular and perceived "sexy" professions, say, in the financial or legal sector, there is no legislation governing the minimum standards of professional property managers. While SPRING Singapore has published a set of guidelines on the appointment of managing agents, the performance standards required of them still need articulation. Sir, in order to ensure that management personnel employed by the managing agents possess the proper skill sets and qualifications, I would like the Minister to consider a system of accreditation for managing agents. This is to be developed with inputs from the professional organisations and practising property managers. I do not think that accreditation, in this instance, could be viewed as interventionist, because it is in the interest of the home owners. Lastly, the role of the Strata Titles Board. Sir, I would like to ask the Minister to consider enlarging the role of the Strata Titles Board. Presently, the Strata Titles Board is empowered to consider only 14 matters under its jurisdiction. It is suggested that the jurisdiction of the Strata Titles Board could be widened to deal with conflicts relating to management and operation, so that the parties need not resort to court proceedings.

Sir, my concerns are as follows. I would like to strongly call for a separate management corporation for the different and diverse unit owners in a mixed development. Presently, all the different types of unit owners in a mixed development belong to one management corporation. For complex mixed-use development, it is difficult for one management corporation to accommodate the different and conflicting needs of the different user groups. For example, the high car park charges would be welcomed by the residents as it would mean more income for the maintenace of the common property. However, for the commercial units, high car park charges mean less customers coming in to the shops. While we seek to review the Land Titles (Strata) Act (LTSA), some of the issues are more fundamental, ie, they arise at the time the strata is subdivided and not at the time of management, for example, the sharing of the car park between the residential users and the commercial users. If the car parks for the residential and commercial users are clearly and physically separated at strata subdivision level, ie, clearly defined, the car park can then be separately managed once the LTSA considers multi-management corporations for the mixed developments. I am requesting the relevant authorities, while reviewing the LTSA, to take the opportunity to review the strata subdivision guidelines under the URA too. This will ensure that the review of the LTSA is thorough and resolve some management issues of the strata property at source.

(In Mandarin): Sir, the National Parks Board manages some 287 parks and a million trees all over Singapore. The public parks in HDB estates particularly have provided the residents with a sense of serenity and a place to relax in. However, the Authority can further improve the facilities of these parks by providing more car parks, food kiosks, public toilets and exercise corners. The "Adopt-a-Park" scheme has been well supported by many schools in the neighbourhood. This is a very good concept. More schools and civil organisations should be encouraged to adopt the parks near their vicinity so as to promote a sense of identity with these parks. One other thing that warrants our attention is the security measures. The Bukit Gombak GROs had formed a Park Watch Group to further enhance the security at the Bukit Batok Nature Park. But we need money. Perhaps, the Ministry should initiate a "Park Activities Endowment Fund" for this purpose. The private sector can donate towards this fund so that we can provide better facilities for the residents.

Sir, it is difficult to talk about food at lunch time. That is our task, I guess. Singapore, given its limited land resources, has to import most of its food requirements. It is therefore imperative that we ensure that our external sources of food supply are stable and resilient. In a time like this, I think it is equally important that our imports meet Singapore's stringent food safety standards. The AVA adopts a strategy of diversifying our food sources so that our food traders can quickly turn to alternative sources to meet any disruption, due to either disease outbreak or even a terrorist act. Today, Singapore imports vegetables from 33 countries, meat from 25 countries, fish from 91 countries and fruits from 40 countries. The AVA will continue to seek out new sources of food and by maintaining free and open market competition among these sources will also help to keep the food prices in check. The AVA organises trade missions and provides technical assistance to facilitate overseas ventures by Singapore companies in agriculture and food production. Singapore investors have gone into pig farming in China, poultry farming in Malaysia, and fish processing in Vietnam, Myanmar, Malaysia and Indonesia. Mr Ang Mong Seng had asked if AVA could form a private company to assist local SMEs who have to set up farms overseas. I am glad to inform him that the AVA actually established the company in October 2000 to provide consultancy services to companies investing overseas on measures to assure food safety as well as on the use of appropriate technology. Sir, in order to ensure that the food we consume meets international safety standards, the AVA has an integrated food safety system which includes accreditation at source, product inspections and laboratory tests. To enhance its capabilities, a new veterinary public health centre, located at the Agri-Bio Park at Lim Chu Kang, will start operations by the middle of this year. The AVA's testing capabilities will be expanded and it will include the capability to test genetically modified food. Today, the AVA adheres to the guidelines set up by the National Genetic Modifications Advisory Committee for the safe import, release and use of such products in Singapore. The new centre would also have a level three biological safety laboratory to handle the more hazardous organisms and toxins. The new centre would also address the concerns of both Mr Ang and Mr Zainul Abidin for better working conditions for the staff of AVA. Sir, it is impossible to predict when and how an act of terrorism involving the deliberate contamination of food may occur. In the event of such an act, an Inter-Ministry Committee, coordinated by the Ministry of Home Affairs, will be activated to handle the threats, including those involving chemical and biological agents. If necessary, the AVA will play a part in coordinating food recalls to prevent the spread of such agents. Meanwhile, the AVA has enhanced its vigilance in inspection and testing, to look out for tampering of food products. In addition, our food industries have also been made aware of their vulnerabilities and also to take appropriate measures to prevent the deliberate contamination of their food products. It is not possible for Singapore to be self-sufficient in food production. But having said that, we produce 5% of our vegetable needs, 10% of our fish requirements and 30% of our egg requirements. The Government's policy on farming is to allow farming in Singapore as long as land is available and as long as the investors find it commercially viable. The AVA has issued 273 licences for activities such as vegetables, fish, egg layers and cattle farming. The AVA will continue to provide assistance to farmers in the form of technical assistance and training in the areas of animal and plant disease control and prevention. The AVA also works closely with farmers to develop and adopt appropriate farming technology in order to optimise production. Sir, land zoned as agricultural land is intended for agricultural and agricultural-related uses such as farming, processing and the packing of farm products. The current guidelines already allow for some ancillary uses to support the main agricultural activities in the farms. For example, small visitor centres, display areas and snack bars that are related to the main agricultural activities are allowed. We can consider allowing integrated agricultural activities provided the intended activity is compatible with the farm's existing activities and will not impact the surrounding farms adversely. For example, orchid cultivation which requires the use of pesticides would not be allowed within or near egg layers, as the poor chickens would be affected. Prof. Low Seow Chay has sought clarifications on the rumours about abattoirs being asked to cease operations. Let me reassure him that there are no plans to close down the pig abattoirs and the poultry slaughterhouses as they can cater to consumers like him and many others who prefer freshly slaughtered meat. These slaughterhouses will continue to operate as long as they are economically viable. It is also not true to say that there is only one licensed egg layer farm in Singapore. While some farms have stopped operations recently, there are still five of these egg farms which today meet 30% of our local demand. Let me move on to the cut from Mr Ang Mong Seng relating to National Parks Board (NParks). NParks takes into account the requirements of all park users. In this respect, it is not just the question of maintaining the parks but also ensuring that other facilities, such as car parks, toilets and security measures that Mr Ang mentioned, are provided for. In addition, we are also catering to an expanding group of park users, including the elderly, by providing things like hand rails for sloping footpaths, building ramps instead of steps, and providing coverings over drains. Apart from just physical facilities, we also have to cater for programmes and activities within the park itself. NParks' role has therefore evolved from just physically developing and maintaining parks to also meeting the social and lifestyle needs of all Singaporeans. While the Government will continue to provide for the basic maintenance and infrastructure in our parks, efforts are also being made to increase the involvement of the wider community. An example of that is the Adopt-a-Park scheme that Mr Ang mentioned. We believe that such activities and recreational programmes will help to encourage bonding and rootedness amongst Singaporeans. Mr Ang would be pleased to know that NParks is in the process of setting up a fund called the "Garden City Fund" which will support more such activities in the parks. Specific details will be announced later this year.

Sir, on behalf of the Minister for National Development, I would like to thank the MPs - Dr Teo, Dr Amy Khor, Mr Yeo Guat Kwang and Mdm Cynthia Phua - for their questions and their useful suggestions. Sir, Dr Teo asked about the key achievements of BCA. Before I answer this question, I think we need to know the core missions of BCA. There are two: first, BCA ensures the safety of all buildings in Singapore, public as well as private; second, BCA is a promoter of the construction industry. Therefore, Sir, the first achievement is that BCA has made buildings safe in Singapore, like Parliament House is safe, certified by BCA. And BCA has achieved this star with distinction. Sir, the second achievement of BCA is that it has worked with various agencies, including MOM and the Singapore Contractors' Association (SCAL), to improve the productivity of the industry which, admittedly, is low, but we are trying to raise the productivity level. And these efforts are documented in the Construction 21 Report. 1.00 pm Sir, the third achievement of BCA has many limbs. There are at least three. I will talk about them. BCA has facilitated companies to expand overseas by, firstly, actively leading missions overseas and marketing the Singapore Inc. brand name. I am not sure whether Dr Teo read yesterday's Straits Times' business page, page A19. It reads, "NeoCorp breaks new ground in Fiji and India." And according to the Managing Director of NeoCorp, he said he is able to penetrate the Fijian and Indian markets against the Australian, New Zealander and other MNCs because, if I may quote him, "because of the Singapore brand name." The Singapore brand name has been nurtured by all contractors, together with BCA. So this is a significant achievement. The other limb of the achievement is that BCA has encouraged and facilitated consultants and different companies to form consortiums on overseas projects using, as I just mentioned, the Singapore Inc. approach. An example is the very successful housing project in the State of Andra Pradesh in India, and the Minister of State himself led a mission some time, I think, last year to seal the deal. And BCA brought together a team of town planners, engineers, architects, surveyors, landscape architects, contractors and developers and together they went as one team and they shared the spoils among themselves. So this is the second limb of the achievement. The third limb of the achievement is that BCA is a collecting agency of all information and it disseminates the information to all contractors. In fact, BCA has a resource centre in Chongqing, China. In addition, the Minister himself, for example, actively sources for projects overseas for the construction industry. Last year, he mounted a mission to different parts of China to promote the Singapore brand name. Dr Teo asked about the progress of the international advisory board for BCA. We have not formed it yet. We are still in the process of looking for a suitable name. If he knows of any suitable name, we welcome his suggestions. What are the R&D efforts of BCA? Sir, there are many. A few key ones are BCA has promoted quality construction. Admittedly, the quality can be improved, but BCA has made some headway. BCA has developed the CONQUAS score. Today, the CONQUAS score is a highly sought-after score by developers. Because with a high CONQUAS score, developers can sell their flats for a higher price. The other achievement of R&D is that BCA has developed and facilitated the use of IT in the construction industry. It has developed the CoreNet. The CoreNet has different layers. It has an electronic plan submission layer. It has information retrieval layer and it has got a plan checking layer. Dr Teo asked about the progress of CoreNet. I am pleased to report that, today, 33% of all submissions are through CoreNet. A plan checking system would be ready by 2005. The first two layers are completed - e-submission and e-information. Dr Teo asked about the start-up cost to the system. It is low because it uses existing office automation system - PCs, printers, telephone lines, Internet services. For those who do not even want to invest in this small start-up cost, they can go to any of the six agencies - BCA is one, FFSB, URA - to use the e-kiosk free of charge. There will be a staff stationed there who has been trained by BCA to guide the user to submit the plans through the e-kiosk free of charge. Total committed cost on CoreNet so far is $13 million. Over 1,500 users have registered for e-submission, another 6,000 for e-information, and the usage of CoreNet is free of charge. The other achievement in R&D is that BCA has developed a system of pre-cast and pre-fab components in construction. With the assistance of a few developers, BCA has demonstrated that pre-cast and pre-fab construction is possible on site. It is not overly expensive. The initial investments will pay off through long-term gains and you need not have a big project to harvest the economies of scale. But of course, the bigger the project, the lower the unit cost. But even for small developments, like landed terrace houses, pre-casting is possible. I brought the GPC to see a project and I think they are quite impressed. BCA has also facilitated research in environmental recycling to ensure that waste materials can be used on construction site. BCA has also raised the professionalism of the industry by providing a medium between the professionals, the academics and the Government. Dr Teo has suggested a top-down approach - Government leading, sending instructions, guiding. They (the industry) prefer a consultation approach. In fact, we are moving away from a prescriptive approach where we think we know everything, or know best, to a system of performance-based, where we will specify the design outcomes and the industry decides how to go about achieving the outcomes. Of course, where red tape and bureaucracy exist, we will bulldoze them away. The other R&D achievement is the development of the energy efficiency index to promote energy conservation within buildings. It has also piloted R&D with NUS to eliminate the heat island effect that is building up in some parts of Singapore because of the concentration of a large number of concrete buildings over a small area. To achieve all these, there are tax incentives. Some of them are the Local Enterprise Technical Assistance Scheme, Innovation Development Scheme, Industry Productivity Fund, etc. These are all available for contractors to apply. Dr Teo asked if there are plans to corporatise BCA. The answer is a categorical no. BCA will not be corporatised. Dr Teo asked what are the performance indicators of BCA. First, coming back to the core mission, buildings continue to be safe. That is a very important performance indicator, and there is no compromise on this indicator. Second, MND has set BCA a productivity target of 1% to 2% over the next few years when all the policies come into play. These are buildable design legislation, the multi-skilled workers policy comes into play after 2005 and the man-year entitlements. When all these three are fully harvested in the next three years, we will ask BCA to raise the productivity to between 1% and 2%. Dr Teo, Dr Amy Khor and Mdm Cynthia Phua have also raised some suggestions on the proposed amendments to the LTSA, in particular, their views on how to encourage mixed use development are very useful. Because this is an area where the practitioner on the ground and the subsidiary proprietors (SPs) are very concerned. There are many views on how LTSA should be amended. Different stakeholders have different perspectives, as Dr Amy Khor alluded to. Even the same stakeholder may hold a different perspective at different times. For example, a subsidiary proprietor may not want a high share value when it comes to paying maintenance. But he may want a higher share value to ensure his voting rights for decisions like collective sales. For share allotment, how to allot the share, who to allot the share, is one area we should discuss at the coming forum. BCA has had a public consultation session. Not long ago, we have collated the views and we will put these views for a focused discussion with experts and stakeholders in April. The key issues that are under consideration so far are allotment of share values - how to allot share values, who to allot share values, how to facilitate mixed use developments in a single development where you have residential, commercial and, sometimes, office space. Then the issue of representation of multi-unit owners - one or two owners hold majority shares in the condominium. Also council members who are in arrears, should they be allowed to stand for election in a management corporation? An issue we also want to take is how to decriminalise some of the offences in the LTSA. Some of the so-called offences are not very serious. I think we want to decriminalise them. How to ensure good corporate governance? Hopefully, the new LTSA, after amendment, will promote good governance. At the end of the day, the subsidiary proprietors must take ownership of the problem. They must know who to bring into the office, who to vote out, what questions to ask and how to read the reports, basically. As the three MPs are practitioners of LTSA, I would ask BCA to invite the three MPs to this public forum. All views will be fully ventilated and I expect lots of views from these three MPs on that day. The discussion of this forum will form the basis for BCA's proposal for the LTSA amendment. MND has asked BCD to put the amendments on the fast track. MND will move the LTSA amendment in this House some time in the second half of this year. In the meantime, BCA is working with SPRING to review the technical reference on the performance of managing agents with a view to upgrading it to Singapore standard. I am not sure if Dr Amy Khor has gone through the technical manual in her capacity as President of SISV. She has participated in it, I am sure. Accreditation of managing agents, I think I would like to leave that at least for now, to the subsidiary proprietors and the management corporation who they want to appoint. There are enough qualified managing agents in town for them to select. Dr Khor asked for a review of the Strata Titles Board. I am afraid that comes under the purview of the Ministry of Law and I would pass her request to my colleague there. Dr Amy Khor asked about the need to revise certain policies in the construction industry at a time when the industry is quite down. While the industry is down, not because of all these policies - all these policies are meant to help the industry sail through this difficult period - the problem lies with the low volume of construction because of the underlying economic conditions. At the peak of the construction industry boom in 1997, the market was dishing out something like S$24.4 billion. Last year, it was something like $14 billion. It will probably stabilise to between $12 billion and $15 billion in the next few years, probably outside $15 billion. So because of a shrunken market, there are just not enough jobs for the thousands of contractors around. Therefore, 2-3 years ago, BCA decided, together with MOM, on how to reorganise the industry so that they will be better prepared to meet this downturn in the first instance and better capture a bigger market share in the region in the near term because the market here is very limited. So, companies like Neo Corporation has successfully penetrated Fiji and India. Some companies have gone to China and many of them are in Southeast Asia. The new CRS system, the registry system, actually helps to pool the resources of many smaller contractors together to become a big contractor. As experience has shown, it is companies like Neo Corporation, a fairly big contractor, that are able to leap beyond the Singapore shores to the region. Small contractors are just not possible. I think it is better that they have jobs and they work as subcontractors to good main contractors. Because even if you were to put a small contractor in a big league, when it comes to tender, the small contractor will be outbidded by the main contractor anyway. So we actually want to nurture a few good contractors so that they will be able to stay in Singapore, nurture in the homeland and also move overseas. We share the main concern with Dr Amy Khor and, that is, we want to keep the industry and keep it alive, and not to see it disappear. We also help the contractors to lower cost, for example. In the past, the levy was quite high. Some years ago, we decided to differentiate skilled and unskilled workers. For unskilled workers, the levy was $470; skilled workers went all the way down to a mere $30. And this has achieved one desired outcome, ie, many of the workers have become skilled to capture the low levy. So, we have decided to go one step further by making the skilled workers even more skilled. We say that if he has one skill, maybe he should try for another skill and become two-skilled, and we call him a multi-skilled worker. If he is unskilled, maybe he can learn something to become skilled. 1.15 pm To encourage companies to do that, we will lower the levy for a one-skilled worker to $320. In other words, from next year onwards, all new foreign workers in Singapore will be on two levies. Existing workers will not be affected. So, from next year, there will be two categories of new workers - either he is one-skilled or two-skilled. If he is two-skilled, we will call him multi-skilled, the levy is $320. If he is one-skilled, the levy is $30. So, these are ways to lower costs for the contractors. Finally, Mr Yeo Guat Kwang asked if BCA and HDB regulate renovation contractors. BCA does not regulate renovators. HDB has a list of approved renovation contractors. The purpose of this list is to ensure that renovators do not create any nuisance or do damage to HDB property while working in the flats. This is necessary because unauthorised renovation can do structural damage to the entire block of flats, and lives and limbs are at risk. HDB does not control the pricing, work schedule and quality of these renovators. Such arrangements are strictly private deals between the lessees and the renovators, because HDB is not privy to the price nor the scope of work between the lessee and the contractor.

Dr Teo, are you withdrawing the amendment?

Sir, I wish to thank the Minister, the Minister of State and the Senior Parliamentary Secretary for their comprehensive answers. There is still one building in China Square that is tilting today. I hope BCA can make it safe. I beg leave to withdraw the amendment. Amendment, by leave, withdrawn.

Sir, I beg to move, That the sum to be allocated for Head T of the Development Estimates be reduced by $10 in respect of Code TI 5100.

Sir, the Potong Pasir Town Council had written to HDB in January last year to request that the 29 lifts in the 12 high-rise blocks at Lorong 8, Toa Payoh, be included in the Lift Upgrading Programme (LUP) but, of course, that request was refused. The MND has announced that it has selected 62 blocks for its LUP. Yet, I notice that all the blocks at Lorong 8, Toa Payoh, on average, are older than the ones selected for LUP by at least 10 years. The lifts at Lorong 8, Toa Payoh, are about 28 years old, and are definitely due for replacement. The lifts there should have early priority for the LUP, but they have been neglected by the MND. According to HDB guidelines, a lift is due for replacement when it is about 25 years old. By these guidelines, all the lifts at Lorong 8, Toa Payoh, should be upgraded. The HDB itself has admitted in a letter to the Town Council that all the lifts at Lorong 8, Toa Payoh, should be upgraded soon. Many blocks in the nearby Kim Keat neighbourhood and 10 blocks of flats, ie, Blocks 225 to 234 further up the road at Lorong 8, Toa Payoh, have all been given their LUP, and yet the lifts at Lorong 8, Toa Payoh, in my constituency have been glaringly left out. Many residents in Potong Pasir are asking whether the LUP at Lorong 8, Toa Payoh shall be made an election issue at the next election. Many people are wondering why Singaporeans residing in Opposition constituencies should be discriminated against. Why must they vote for the PAP candidates at the election before they can be entitled to the benefits of the national policies? Do the voters in the opposition wards also not pay taxes? Do they also not fulfill their National Service liabilities? Are they not allowed a free choice to choose the one they want to be in Parliament as their representative? The HDB has written to say that the queue for LUP is about 4,000, although yesterday the Minister said that it was 3,500. At 4,000, if the Potong Pasir Town Council were to be last in the queue, it would take something like 333 years before it can get upgrading of the lifts, assuming that it takes one year to complete 12 blocks!

Can you wrap up your speech, Mr Chiam?

Yes, I will be finishing. Sir, it would be a waste of money if the Potong Pasir Town Council were to carry out its LUP and then, suddenly, the MND changes its mind and wants to carry out the LUP at Potong Pasir. For this reason, I would like to ask the Minister to confirm whether the blocks in Lorong 8, Toa Payoh, in the Potong Pasir constituency shall be given the Lift Upgrading Programme within the next two or three years. Logically, it is long overdue.

Sir, I want to distinguish two issues: the cyclical replacement of lifts on the one hand, and the Lift Upgrading Programme on the other. The 12 blocks and 29 lifts that Mr Chiam brought up are old, and some of them are due for cyclical replacement. As far as the Ministry of National Development is concerned, the Town Council should proceed to replace those lifts according to schedule. The question of lift upgrading, whilst it may be related, is a separate issue. Let me first address Mr Chiam's question about whether there will be any wastage of resources, if the lifts are replaced first, and subsequently undergo lift upgrading. I have checked with the HDB and they have assured me that all work done by the Town Council to replace the lifts will not be wasted, because that same lift cabin and shaft will be used. But the Lift Upgrading Programme goes far beyond simply replacing the lifts. It will involve, depending on the configuration of the blocks, either the creation of new lift shafts, lift landings, mechanisms, etc. In fact, the additional cost incurred to do lift upgrading is significantly higher than that incurred just for the provision of a lift replacement. For that reason, we have decided to keep these two programmes separate. Lift replacement will be done on a cyclical basis by the Town Council using its Sinking Fund, as that is the correct position as it should be. The Lift Upgrading Programme is a national programme which will be funded by the Government, together with contributions from the Town Councils as well as the residents. This is a national programme in which there are 3,500 blocks in the queue. At the current rate that we are doing lift upgrading, it will not take 300 years. It will take something like 15 years before we work our way through the queue. I will not be in a position to give Mr Chiam, or any other Member for that matter, an exact position in the queue today. We have announced the Lift Upgrading Programme recently, and those blocks that have been announced will proceed. Every year, depending on the budgetary position of this Government, and on the needs and requirements of the population, we will work through those 3,500 blocks. I want to say categorically that, as a Government, we have said that we will look after all Singaporeans, and we will continue to look after all Singaporeans. However, it is not possible for Mr Chiam, or any other Member for that matter, to insist that simply because the lift is old, his residents must have eligibility or, in fact, must receive the Lift Upgrading Programme immediately.

Mr Chiam, are you withdrawing your amendment?

Sir, I thank the Minister of State for his answer and beg leave to withdraw my amendment. Amendment, by leave, withdrawn.

Sir, I beg to move, That the sum to be allocated for Head T of the Main Estimates be reduced by $10 in respect of Code TJ 2100. Sir, HDB has liberalised its change of use policy for its shops. Shopowners and operators appreciate this. It shows that the HDB understands the needs of the market and is prepared to let market forces work. But this understanding is not all encompassing. The HDB is still hesitant in liberalising the change of use of shops to family restaurants and eating houses, and the use of common spaces for open recreation areas (ORAs). I understand the concerns of the HDB. But it should trust the market to do its work, even with restaurants, eating houses and ORAs. With a good transport system, the concern for a good mix of shops is no longer a must. Consider Holland Village. It has become a food centre, with no loss of functionality to nearby residents. In fact, they enjoy the good food. They hop onto buses and trains to buy whatever else they want from other shopping centres. They have the best of many worlds. If a shop wants to become a food establishment, they can be made to pay an equalisation fee, as owners of food shops have paid more for their shops. This equalisation fee should not be refundable, if the eating house business fails and the owner or operator requests for a change of use to other businesses. The rental can also be adjusted. Owners and operators must decide if they are prepared to pay this hefty equalisation fee, increased rentals and the renovation cost to change it to a food business. If they are prepared to do so because they really believe that the business is there, then so be it. Thereafter, let competition win, and let the best man or woman win. Customers will benefit from better food, more variety, better services and prices. There is nothing wrong with ORAs. ORAs, in fact, bring life to the place. ORAs along Orchard Road and in the town areas are welcoming sights. Can we imagine Orchard Road without the ORAs? We should do the same with ORAs in the HDB neighbourhood centres. What is important is that they are properly managed. Rules can be established and rent can be charged for the use of the common areas. We should apply these rules to all shophouses which want to use the common areas outside their shops. They must manage these areas. These rules should be rigorously enforced to ensure that the use of the common areas does not turn them into eyesores and an obstruction to pedestrians. If they flout the rules, then penalties can be imposed to bring them in line.

Dr Tan, can you start asking your questions, please?

Sir, we are trying to build a creative entrepreneurial society, one that makes decisions for itself and takes responsibility for the outcome. In this spirit, I suggest that we let our entrepreneurs and business people decide what they want to do. The community and the market shall pass judgment on their decision. As long as what the business people do is not dysfunctional to the community and market, the latter will support them. Let our business people take the risks. They can enjoy the fruits of the right decision. They will pay for the mistakes they make. Let us regulate the requests of our business people with a light touch.

Dr Tan, your time is up. Please take your seat.

Although this issue has been highlighted in this House, our flat owners still do not understand how this problem can happen with our Singapore brand name. My questions are: when we see spalling concrete after three or five years of owning a flat, is this natural deterioration of the concrete slabs? What are the preventive measures that can be taken by the house owner to prevent this natural deterioration or to delay the occurrence of this problem? If there are, can HDB inform and educate the existing owners to prevent or delay the occurrence, than simply ask the owners to repair it? If there are no measures that can be taken, would HDB, being the biggest landowner, carry out some intensive research into this problem? 1.30 pm

Sir, in 1997, the Hougang Town Council wrote to the HDB, alerting them to the condition of a lamp-post which we discovered was corroded and could pose a danger to the public and recommending to the HDB to carry out major replacement works. HDB refused to do so. In 2000, we wrote again to the HDB, making the same recommendation, and HDB again turned it down. It asked the Town Council to continue carrying out routine maintenance works to replace lamp-posts whenever the condition warrants it. HDB also informed us that it has no cyclical maintenance programme for the replacement of car park lamp-posts. Sir, these lamp-posts have been installed more than 15 years ago. Their condition has deteriorated and the HDB has no plans to replace the lamp-posts. Is it the intention of the HDB to push the responsibility to Town Councils to replace all the lamp-posts eventually when they are all corroded? Is this fair? First of all, it will place a heavy burden on the financial resources of Hougang Town Council. I do not know of PAP Town Councils, maybe they are richer and can afford to do so. Secondly, is it fair to ask the Town Council to do so by using money contributed by the residents by way of conservancy charges? Do not forget, the HDB owns the car park, collects the parking fees and pockets the money. In the past years, in the interest of the residents, Hougang Town Council had no choice but to replace quite a number of lamp-posts with corroded base to ensure public safety was not compromised. However, Sir, the question really is: to what extent would routine inspection ensure 100% safety without cyclical replacement of the existing lamp-posts? The Hougang Town Council recently conducted a sampling size of 10 lamp-posts to ascertain their general condition by digging out the lamp-posts and exposing the lamp-posts' bases buried underground. The result showed that all the 10 dug-out lamp-posts have different degrees of corrosion around their bases. Although the structural integrity of all the 10 dug-out lamp-posts has not yet been compromised, the question is: when would the corrosion set in to the extent that it would compromise public safety without cyclical replacement? Does the HDB expect Town Councils to dig out all the lamp-posts to expose their bases for inspection and then cover them up again every week or every month to ensure that there is no falling lamp-post that will cause a tragedy? I would like to know what is the HDB's response to the above.

Sir, it is said that the PAP Government does not treat all Singaporeans alike. Those Singaporeans who reside in Opposition wards do not get the benefits of the national policies as of right. In 1997, residents in Potong Pasir Constituency could get upgrading of their flats only if they voted for the PAP candidate, although some of the flats at Potong Pasir were definitely due for upgrading. These flats were about 23 years old at the time of the election in 1997. However, the flats of many PAP wards which were much younger than that benefited from upgrading. In the election of 2001, the same tactics were used by the ruling Party. The residents at Potong Pasir were told that if they did not support the PAP candidate, the North East MRT line might not run through the Potong Pasir Constituency. When it became clear that the North-east MRT line would run through Potong Pasir, it was made known by the PAP that if residents in Potong Pasir did not support its candidate at the General Election of 2001, the station at Potong Pasir would not be opened. It shall only remain a "box" and trains shall not stop at that station but only run through it. The name of that station would also be called Sennett MRT station and not Potong Pasir MRT station as many have expected. Later on, during the heat of the election, the Prime Minister himself came to visit Potong Pasir and made a promise that the majority of the residents at Potong Pasir need not vote for the PAP candidate in order for them to get upgrading. Any one of the five precincts in Potong Pasir need only to give the PAP candidate more than 50% and that precinct would be entitled to upgrading. The private estate, ie, the Sennett Estate, would not normally be entitled to the Government upgrading. But if they voted for the PAP candidate, they would have got the upgrading. As it turned out, the residents there gave the PAP candidate about 51% of the votes. Thus, the Sennett Estate was entitled to be upgraded by the Government. Now that one precinct at Potong Pasir has given its majority votes to the PAP candidate, it is left to be seen whether the Government shall keep its promise. Initially, the Minister tried to shirk his responsibility, but now the Prime Minister confirmed that Sennett Estate is one of the private estates that shall be included in the upgrading. I would like to know from the Minister when would the upgrading at Sennett Estate begin. And I would ask that the upgrading programme includes the alleviation of floods there, the enlargement of the roads and repairs of the drains to make sure that water do not stagnate in them but can flow freely, and also the erection of railings to make the monsoon drains safer. I hope that the Government would do all these things, including erecting the signages of the estate and also other works requested by the residents there.

Sir, the first question was from Dr Tan Boon Wan. I share his support for maximum flexibility to be exercised wherever possible. As far as shopkeepers are concerned, the HDB does allow shopkeepers to change the use of their shops, except in cases where the conversion is likely to cause disamenity to their neighbours and to other HDB residents. The HDB has allowed shops to be converted into family restaurants. I want to emphasise that family restaurants are different from eating houses. In the case of a restaurant, it is managed by a single operator, with a single kitchen. However, the HDB does not allow the change of use of shophouses into eating houses. It is not a price issue. Eating houses are large, purpose-built premises where the operators will usually sublet the internal spaces to individual stallholders, and where transit bins and high electrical loads have to be provided, in order to ensure the smooth operation of these premises. As the retail shops are very much smaller in size, the conversion of such shops into eating houses is very likely to cause disamenity to their neighbours because of heat, noise and smell nuisance and because the premises were not designed for such uses in the first place. HDB does allow Outdoor Refreshment Areas (ORAs) for eating houses. The size of an ORA would depend on the location of the premises and whether it would cause obstruction along the walkways, and, in particular, on the volume of human traffic along those walkways. As far as family restaurants are concerned, HDB will have to evaluate such requests on a case-by-case basis. But, obviously, because of the smaller scale of such businesses, it would be inappropriate for a large outdoor refreshment area to be provided for such premises. Let me move on to the next question by Mdm Cynthia Phua on spalling concrete. I think Members would recall that there was a long debate on this issue last year. She has asked whether this is a natural deterioration process after a period of 3-5 years and what are the measures which can be taken to prevent this from happening. Let me handle the latter question first. Spalling concrete is a natural process which could potentially occur in all concrete buildings. It is due to deterioration, due to a process called carbonation, in which corrosion of steel bars within the slab occurs, followed by expansion and then cracking and falling off of concrete. To reduce or minimise the occurrence of spalling concrete, flat lessees are advised to seal any cracks or holes in their flats immediately, as well as to have their flats painted regularly. A few coats of quality paint will also help slow down the carbonation process by minimising the ingress of oxygen, moisture and carbon dioxide into the concrete. Without oxygen, moisture and carbon dioxide, the steel bars in the concrete will not corrode. In addition, flat lessees are also advised to keep the level of humidity low in wet areas such as kitchens, toilets and bathrooms by keeping the doors, windows and vents open wherever possible. Under the lease, HDB flat owners are responsible for the repair of spalling concrete within the flats. HDB flat owners who encounter spalling concrete problems can report to the HDB branch offices which can assist the flat owners to investigate the cause of the problem and recommend appropriate remedial action. For flat owners who have difficulties in finding a suitable repair contractor on their own, HDB will also assist to provide them with a list of repair contractors with whom they can negotiate the price on a private basis. Now, I turn to the first question, which is, what is the cause. I think the real question there really is who is responsible. I suspect that is what she is really after. I will not do anything here except to quote what my Minister said previously on spalling concrete. He mentioned two issues. The first issue is on the cause of the spalling concrete. If the cause of the spalling concrete is due to the design, as some Members suspected, or alleged, and if that can be proven to be so, then obviously it is HDB's responsibility to fix it, either in the flat that is currently affected or in future designs. But if it is a matter of natural wear and tear and a natural deterioration process which occur to all buildings, then obviously the responsibility must lie with the flat owners. Next, I move on to car parks and, in particular, corroded lamp-posts. I listened with great anxiety when I heard Mr Low say that he had noted corroded lamp-posts as far back as 1997, and subsequently in the year 2000, in car parks maintained by Hougang Town Council. I am not sure if Mr Low is aware, but his Town Council has signed a maintenance agreement with the HDB to maintain the car parks, and HDB pays his Town Council a monthly amount, I think, in excess of $22,000, to perform the maintenance of car parks. In this contract, an agreement, which I have a copy of, Schedule A lists the things which are supposed to be done by the Town Council. It is stated very clearly, around here, "the repair and replacement and painting of lamp-post, including faded lamp-post numbers and luminaries." Sir, if any corroded lamp-post in a car park maintained by the Hougang Town Council leads to any problems or loss of lives and limbs or property, the responsibility and liability will be entirely that of the Town Council. I would strongly suggest that Mr Low go immediately to rectify all those faults. If his Town Council feels that it is not able to maintain car parks, then, please do not enter into an agreement with HDB. The contract will expire at the end of this year. Consider, perhaps, excusing himself and handing over the job to someone else who can do the job more properly and competently. So, if his question was who is responsible, my answer to him, unequivocally, is that it is his Town Council which is responsible. And I think in the light of recent events, his Town Council, and indeed all Town Councils, better make sure that they address this problem speedily and comprehensively. I move on to Mr Chiam's point. I was not sure, at the end of his speech, what the real question was. The estate upgrading programme in Sennett Estate was approved by the Ministry of National Development in response to a request put up by the Citizens' Consultative Committee of Potong Pasir and, in particular, the neighbourhood community in Sennett Estate itself. This is also entirely consistent with the promise made by the Prime Minister before the election. The working committee right now is working on the details of the upgrading programme. As far as the Ministry of National Development is concerned, the faster they complete the planning and the execution of this upgrading, the better. We have already set aside funds. With the cooperation of all the relevant Government agencies to embark on this upgrading, the residents of Sennett Estate can look forward to an enhanced living environment. The key thing here, however, is to make sure that as many people who are living in Sennett Estate as possible get involved in this process of deciding what necessary or desired improvements should be made, and then get it executed.

Yes, Mr Low. 1.45 pm

Clarifications, Sir. My question was: why is there no cyclical maintenance or replacement of the lamp-posts? Secondly, Sir, in view of the way the lamp-posts are constructed and installed, is there not a potential problem or a likelihood of falling lamp-posts, because of the difficulty in routine inspection? Does he agree that actually, it is safer for HDB to replace the lamp-posts?

I thought the answer has been given quite fully, but, anyway, Dr Balakrishnan.

If the lamp-posts need to be replaced, they should be replaced. However, in this case, because he has signed an agreement to maintain the car parks, which includes the replacement of lamp-posts, his Town Council is obliged to replace those lamp-posts.

Sir, I thank the Minister for his very clear replies and I beg leave to withdraw the amendment. Amendment, by leave, withdrawn.

Amendment No. (4), Mr Ong Ah Heng. You can take both cuts at the same time.

Sir, I would like to withdraw my cut as the Minister of State has already addressed my area of interest.

Both the cuts?

Yes. Amendments, by leave, withdrawn. The sum of $398,463,900 for Head T ordered to stand part of the Main Estimates. The sum of $6,291,271,400 for Head T ordered to stand part of the Development Estimates. Head O -

Head O, Ministry of Health. Amendment No. (1), Dr Lily Neo.

Sir, I beg to move, That the total sum to be allocated for Head O of the Main Estimates be reduced by $100. Sir, the demand in our hospital services can be over-prescribed by the suppliers themselves. By setting our public hospitals into two clusters, it has been noted that each cluster has taken more efforts to publicise and woo as many referrals and patients to their respective clusters. In other words, they are trying to outdo each other. Is this not creating unhealthy demands on our healthcare system? Sir, as consumers cannot exercise their sovereignty in purchasing the appropriate amount and level of medical care in most cases, they are invariably dependent on the expert judgement of the providers. Are our hospitals and doctors incentivised to effect higher demands for our healthcare services? Should our healthcare providers not be subjected to the ethical codes of conduct and to the audit of an effective watchdog body with a system of checks and balances? Sir, due to the economic downturn, C class hospital wards are in great demand as patients opt for the cheapest beds to save medical cost. Of late, our hospitals have frequently run out of these highly subsidised beds and have been temporarily putting patients up in a higher class ward while waiting for C class beds to become available. Thus, may I ask the Minister for Health whether there should be a further revision upwards on the availability of C class beds, which should form 18% of all hospital beds provided, by the year 2010, according to the White Paper on Affordable Healthcare? Have we achieved the 18% target yet? In view of the higher demand for C class wards, are hospitals deploying more personnel, nurses and doctors to cope with this increased demand? Are doctors under pressure to discharge patients earlier to make more C class beds available? Are patients sent home or transferred to the community hospitals prematurely? Is there a system in place to monitor and check on this possible unfavourable outcome, because C class wards in hospitals are bursting at the seams? Sir, may I ask the Ministry of Health on another issue, and that is, what are the extra cautions that have been taken by our hospitals with regard to the latest highly contagious atypical pneumonia, which had been given a new name of Severe Acute Respiratory Syndrome (SARS)? It has been reported that some of our hospital providers who looked after the patients with SARS had been infected. May I ask how many of our healthcare providers were affected? Is there special care given to those hospital providers exposed to the infection, but have not shown any symptoms? Is the Ministry of Health taking extra emergency steps to control the spread of SARS, especially in our hospitals, and safeguard our doctors, nurses and other patients? What has the Ministry done to better inform the public of SARS? Is there any collaboration with other Ministries to better contain the spread of the disease? Is the Ministry of Health taking extra effort to identify the causative agent of SARS?

Sir, the Minister has informed this House that the Government's restructured hospitals would be run on a not-for-profit basis. This has indeed provided assurance to the public at large that there will not be the typical pre-occupation with making profits that a commercial concern would have, which can otherwise undermine the Government's intent to make healthcare services affordable to all. Sir, some lingering concerns still exist, for which I seek the Minister's response. These revolve around, firstly, the motivation for cost control in order to ensure overall affordability; and secondly, the alignment of interests of medical practitioners with the hospitals and, ultimately, with the public. Sir, within the not-for-profit framework, how do hospitals control costs, both recurrent in the provision of healthcare and in the maintenance of facilities which are, to a large extent, overheads? I realise it is difficult to predict patient demands. But how do we guard against the over-supply of beds in restructured hospitals? Over-capacity attracts some maintenance cost, even if sections are closed. If nothing else, it reflects an opportunity cost. Next, I would like to echo Dr Lily Neo's sentiments on the state of the healthcare delivery system today. We now have two clusters, SingHealth and National Health, with the respective complements of specialities and facilities. How much oversight is there, at the strategic planning level, to ensure that there will not be unnecessary duplication of capabilities, or, worse still, no spiralling up of manpower cost from the limited talent pool? Furthermore, how do hospitals within each cluster operate within this not-for-profit framework? How much latitude do they have in cost control measures? Sir, as restructured hospitals attend to both subsidised and private patients, there is always a nagging suspicion that it is run on a not-for-profit basis for the subsidised patients, but on a totally commercial one for private patients. Some even conclude that medical practitioners are remunerated according to how much revenue they can bring in; in other words, how many private patients they see. In short, many wondered if there is a disincentive to treat subsidised patients properly. I am not advocating that the same basis should be applied to both, but it would be useful for the Minister to explain how doctors are remunerated at the restructured hospitals. Finally, one can argue that the best test of what is the right level of subsidy and what constitutes affordable healthcare might be to extend the subvention to the private hospitals. Generally, private hospitals contemplate capital expenditure carefully. They do not have the luxury of building ahead of demand and can thus provide a useful benchmark for the restructured hospitals. I would be interested in the Minister's response.

Mr Arthur Fong is not present. Dr Chong Weng Chiew.

Sir, let me first declare my interest as the CEO of Ang Mo Kio Community Hospital. I propose that the Minister consider allowing Medisave to be used to pay for domiciliary medical and nursing services, otherwise known as home care services. Sir, I had raised this issue earlier in Parliament too and the Minister had turned down the request. I would like to appeal to MOH to relook into this matter again based on the following reasons. We all know that Singapore is becoming an ageing population and rising healthcare cost is one of the concerns of an ageing population. Home care is known to be one of the ways of curbing rising healthcare cost as it would be the alternate route for quite a number of patients to hospitalisation, provided that the illness is one that could be treated at home by a visiting doctor and not requiring hospitalisation. Also, home care is one that could allow the doctors in acute hospitals to send certain patients home earlier as the doctors and nurses of the home care team could attend and monitor these patients at their homes. Thus, as you can see it, the home care element not only enhances the convenience and comfort of the patients and their families, it also helps cut down the number and length of hospitalisations of many patients - all these equate to bringing down healthcare cost. Earlier on, the Minister has cited that Medisave is one that prepares us when we get old, to be used during in-patient hospitalisation. I agree with him. However, with the changing trend in medical treatment, should MOH not be moving along with time too to allow Medisave to be used in home care? As pointed out by myself earlier on, home care would cut down on health expenditure, with fewer numbers of hospitalisation and also the length of hospitalisation. Thus, if a patient could not use Medisave for home care, what is the point of having a large amount in his Medisave and he could not use it on what is useful to him? I was previously a practicing medical doctor in a VWO providing home care services. I can tell the House that one of the main problems that acute hospitals and home care providers face in encouraging patients to take up home care is the inability of the patients to fork out cash for the home care services, despite the fact that they have sufficient Medisave. If MOH thinks that home care is the way to go for an ageing population, which I believe so, and MOH has funded operators of home care services, then it must also pave the way by allowing Medisave to be used. For otherwise, those patients who could actually be treated at home would still opt for the more expensive treatment in hospital, just simply because they could use Medisave in hospitals and not home care. Thus, I urge the Ministry to review my suggestion; otherwise we would end up with a service that we know is good, but could not be used.

Today, 90% of the working population is covered under MediShield or one of the Medisave-approved insurance schemes. The majority is covered under MediShield. Over the last few years, MOH has improved the benefits and features of MediShield. It is important that the Government continues to enhance MediShield to make it relevant and responsive. In a limited way, Sir, MediShield provides portable medical coverage for Singaporeans as long as premiums are paid, regardless of employment status. However, the system is not without weaknesses. First, it principally covers only catastrophic illnesses and does not cover general in-patient, day surgery and specialist outpatient treatments. Now that the ERC has formally endorsed the portable medical benefit scheme, I wonder whether the Government will review or revamp MediShield in that direction. This can be done by widening the coverage and claim limit. If need be, the premium for MediShield should also be reviewed to facilitate such a move. Second, I am also concerned that more than a quarter million of Singaporeans have opted out of MediShield. What is the Government doing to encourage them to opt back to the MediShield scheme? Will the Government consider making MediShield a compulsory national medical insurance scheme so that no Singaporean is left out? Third, on the issue of premiums. We know that the older we get, the MediShield premiums we pay will be higher. This is not just for MediShield but also for all kinds of medical insurances. In fact, the premiums are higher when a worker retires than when he is in the workforce. But the older he gets, it is most unlikely that he will be able to pay for the high expensive premiums. I suggest the Government consider introducing the "pre-funding" element to MediShield - let the worker pay higher premium when he is working, so that by the time he retires, he would already have "pre-funded" his future premiums and to continue receiving insurance coverage. 2.00 pm

Mr Yeo, since Dr Warren Lee is not here, you can go on to your next cut.

Sir, my next cut is on healthcare insurance scheme. Why is the Government not considering expanding the scope of Medisave approved medical insurance schemes? Medisave should be allowed to be used to pay for the premiums of all portable and transferable medical insurance schemes. In fact, I would take the argument a step further. Since Medisave is already compulsory, then it should be compulsory for MediShield to be a national basic medical insurance scheme for all. It will also be universal and no one would be left out, as I have mentioned just now. More so, there will be a great pooling of risks. Yes, I understand that there are weaknesses in an insurance-based medical coverage system. It may lead to the buffet syndrome, as we all worry about. But since they have already paid for the premium, they would do whatever they like, and get as much as they could. This is why I will prescribe two key features in the compulsory national Medisave insurance scheme, and we can be sure that it would not be made a buffet for all. First, it must only cover the basic medical needs. For those who prefer to have wider coverage, they can use cash or other options. Medisave should be used only for the basic tier of the coverage. Second, there should be an appropriate level of co-payment to encourage personal responsibility. In short, if the system is properly constructed and applied, it can lead to universal coverage and greater personal responsibility. Introducing a compulsory national Medisave-approved insurance scheme providing basic medical coverage will be a significant step to greater portability in our healthcare system. This will significantly enhance the well-being and provide for the medical needs of all Singaporeans. Still on Medisave, even as the Government considers the Medisave-approved insurance schemes, it should also constantly review the criteria for the use of Medisave. The criteria should be responsive and appropriate to today's needs. Currently, the use of Medisave, particularly for inpatients, is largely based on the number of hospital days. However, with the increasing popularity of day surgery, this criterion will be outdated and irrelevant. The bottom line is that the use of Medisave should be based on medical condition rather than hospital stay. I hope that the Ministry can consider all my suggestions.

Sir, over the past week, MOH has been rather busy with its media blitz to inform Singaporeans about affordable healthcare. We have Medisave, MediShield and Medifund to provide that cover. The radio advertisement spoke about the importance of the above three schemes to make healthcare affordable. It said that 99% of appeals for Medifund were approved. That is reassuring indeed. May I ask the Minister what is the experience with Medisave and MediShield, whether they both are meeting the needs of average Singaporeans when it comes to meeting hospital bills? How have Singaporeans coped with the total hospital bill when Medisave and MediShield can only cover partial cost of the hospital bill and also for selected health situations? What about outpatient charges? From feedback, it is not cheap. My own personal experience is that when I got my finger caught in the door, it cost more than $100 just for treatment and to visit the specialist. What more can MOH do to moderate charges at outpatient clinics, and thus make healthcare more affordable?

Sir, very often, during the meet-the-people sessions, senior citizens come forward complaining that medical costs are too much for them to bear, even choosing to die earlier if the choice were theirs. Such is the state of affairs on the ground. It is thus heartening to know that the Ministry of Health will be revising Medisave withdrawal limits based on the resources needed, and not hospitalisation days to treat a medical condition. However, I am not referring to surgeries or hospital days, but outpatient treatment or long-term prescribed medication that can be expensive. Does a person need to be hospitalised to be able to draw from his Medisave and MediShield? The question here is: are we too restrictive? Can more be done in this area? We need to step back for a minute and look at the macro picture that I am about to paint. We worry about surging ahead in the age of globalisation with its rapid technological and economic change, and we tinker with ideas of remodelling Singapore. Indeed, such concerns are pertinent. We are doing our job. However, simultaneously, we need to grapple with demographic changes and implications. Among other things, a longer life expectancy, the aged, the non-working population, out of which 88% have not saved enough for retirement. They spend too much on housing perhaps, but this realisation will not solve the problem for us. Additionally, with increased unemployment, the issue of medical coverage arises. Those in between jobs often do not enjoy medical benefits. The two-pronged predicament is banging on our door for effective and immediate attention. On this subject, the Government has accepted the recommendation of the ERC and intends to encourage companies to provide portable medical benefit scheme or the transferable insurance. Sir, can we do more besides encouraging the companies? We are not a welfare state and I am not suggesting that we try to be one now, just because we are in trouble. However, we are also here because we have made a commitment to the man-in-the-street. Where do we draw this line? When is it a hand-out and is it a response of genuine call for help?

Sir, over the last one year, I have received a number of requests for help from residents in my constituency to settle their medical bills. Those who face great difficulties are the elderly, those with long-term illnesses and those who have lost their jobs. Under our system, those who are really poor and needy can look towards Medifund to help them. But there are a number who are sandwiched in between. They are neither poor enough to fulfill the stringent requirements stipulated under the Medifund but, on the other hand, they cannot afford the existing rates. One approach would be to provide them with short-term financial assistance or loans or longer instalment payments. But these are largely temporary measures. In the long term, a fundamental issue that has to be addressed is what can we do to ensure that healthcare costs remain affordable. For some years now, the CPI for healthcare has been higher than the overall CPI rate. One explanation on how to contain costs is through the presence of two hospital clusters. But to Singaporeans, having two hospital clusters have not helped to reduce costs, as costs have continued to go up. There seems to be problems of coordination and economies of scale as well. The recent example of different prices being charged for non-standard medicines by the polyclinics and hospitals, even within the same cluster and across clusters, is a case in point. Sir, there are also public concerns over means testing. Means testing is currently used in step-down care services, those moving from private to restructured hospitals, and from upper class to lower class wards in the restructured hospitals. Recently, the Ministry has said that it may extend means testing to patients referred from polyclinics to the specialist outpatient clinics in the restructured hospitals as well. The problem with means testing is that the criteria and basis for it as well as the administrative cost of doing so are not very clear. Sir, I have the following questions to ask of the Ministry of Health. What is being done to contain healthcare costs and ensure that they remain affordable to Singaporeans? Secondly, what is the Ministry of Health's policy on means testing? What are the criteria and basis that it intends to use? How will the Ministry ensure that really needy patients are not denied access to healthcare? And before introducing means testing in other areas, will the Ministry first inform and educate the public widely, so that there is no confusion and anxiety?

Sir, our healthcare system is amongst one of the best in the world. We have a wider coverage for our population vis-a-vis many countries in the world. We have fine-tuned our system, including tweaking and competition, by introducing two clusters of medical providers. At the moment, our healthcare expenditure is close to 4% of our GDP. However, if we age adjust it to that of, say, the United Kingdom, it would be about 7.2% of our GDP. Hence, if we want to maintain the same level of healthcare, in a few years' time when our demography reaches that of the UK, we would expect to spend 7.2% of our GDP. If we continue to raise the standard of healthcare, the total expenditure will probably be much higher than the 7.2%. Sir, I would like to know if this level of GDP spending is sustainable in the long run for our country. When our population gets older, less people would be paying taxes. So, would our average Singaporeans still be able to afford to pay for their healthcare? What is the Ministry's measure to make sure that our healthcare providers do their best to contain the cost and operate in a cost efficient manner? I share the concern of other MPs who spoke earlier about the two clusters and whether they are operating in a very cost efficient and cost effective manner. I think one of the problems is probably the cost recovery model, which may not incentivise the operator to be efficient because he may just pass on the cost back to the consumer, the patient and also the Government who gives him the subsidies. So, I would like to urge the Ministry to review the approach for this cost recovery, maybe a price minus model where the price of a service is being fixed and the operator will have to work backwards in order to recover and to make sure that he is able to provide the service at a price that is affordable to our patients. Sir, I would also like to talk about ---

Dr Ong, you do not have much time to talk about whatever you want to talk about.

I want to talk about competition in the healthcare service, a point which I will allude to in my later cut. In conclusion, our Government has given the promise that no one will be denied basic affordable healthcare. We are very proud that we have delivered this promise so far. I hope we will continue to deliver our promise.

Sir, I share the concerns expressed by Mdm Halimah Yacob and Dr Ong Seh Hong, and also the other Members of this House on healthcare costs. What has the Ministry done to try and reduce healthcare costs? I am confident that the Ministry of Health would have seriously considered various avenues available to try and reduce or minimise healthcare costs. However, many lower income, average Singaporeans and Singapore residents have shown deep concern about the increase in and escalation of healthcare costs. As the standard of healthcare rises, healthcare costs would tend to rise also. Cost of medical equipment, scientific and medical examination, professional and staff costs and other expenses must inevitably increase as the years go by. What are the positive steps taken by the Ministry to try and reduce healthcare costs? Do we need such high class hospitals like Singapore General Hospital, National University Hospital and Tan Tock Seng Hospital, as they appear to reach almost five-star hotel status? What patients and their families generally expect are as follows: (1) A simple, clean and comfortable hospital bed and hospital surroundings. Forget about the luxuries and frills. (2) Caring and kind nurses and doctors and hospital staff ready with a smile and words of comfort, confident and professional looking to give patients peace of mind and some form of happiness whilst in hospital. (3) Does the Ministry have rules and guidelines to reduce the possibility of resorting to a hasty need to do too many medical tests on patients, using a lot of complex medical equipment? And medical equipment purchased by the Ministry may be expensive. Does the health authority have, as their goal, recouping of capital expenditure as soon as possible and expeditiously? Does the Ministry of Finance expect the Ministry of Health to recoup all or most of the cost and be in the black within a time limit, resulting in medical cost going up and making the patients pay more? (4) Does the Ministry try to have rules and guidelines to ensure that specialist doctors are directed to assist by not charging too high consultancy fees? (5) Does the Ministry have rules and regulations on pharmaceutical companies and medical equipment companies to reduce the cost of supply of drugs and medical equipment?

Sir, last year, I raised the concern on the cut-off of the Ministry's means testing that would result in only half of the patients being eligible for subsidised healthcare. I was relieved when the Ministry implemented the means testing at the community hospital last year. It was done in a gradual manner to phase in the impact. I commend the Ministry for listening to the people and thank the Ministry for taking appropriate steps to alleviate the concerns of the people. Sir, while I support the underlying principle of means testing, I am still concerned about the Ministry's intention to set the cut-off at 50% of the population, ie, only roughly half of the patients will receive subsidised healthcare when the means testing is kicked in fully. This is far too stringent a level to set. Sir, every Singaporean should be given access to affordable healthcare. By setting the means test cut-off at 50%, those in between, the not so poor and yet not so rich, will be deprived of good medical services they could afford. Let me elaborate. For example, it is common for a husband and wife, both working and with two children, to earn about a combined salary of slightly more than $5,000. This will be above the median household income and the family will fail the means test. When the means test is kicked in fully, say, at the acute hospitals, and the husband is unfortunate that he needs a bypass operation that would cost $20,000, the family would have a problem forking out four months' worth of their total income either in cash or it will wipe out their Medisave savings very fast. This would be a great burden on average Singaporeans. 2.15 pm Sir, with increasing healthcare cost, most Singaporeans look to the Government for good and affordable medical service. The Government should cast its net wider when applying healthcare subsidies to Singaporeans. Sir, I am speaking for the lot who are out of the band to qualify for subsidies and yet poor enough to be stressed by the rising healthcare cost. While means test has not kicked in at the acute hospitals yet, most are already anxious about their ability to meet the rising costs. Sir, I urge the Ministry to relook at the details of means testing for the healthcare services and ensure that the healthcare subsidies are given to a wider group of Singaporeans so that they are not deprived of affordable healthcare.

Sir, Primary Care Partnership Scheme (PCPS) is a scheme set up to provide outpatient medical services at polyclinic rates for those who are 65 years and above and have a per capita income of $700 per month or less. May I ask the Minister whether it is correct to say that, to-date, only 50%, or thereabouts, of those eligible have registered for this scheme and, that being the case, is his Ministry planning to better promote this scheme in order to benefit the rest of those who are eligible? May I ask the Minister why is there restriction on the type of medical conditions that can be treated under the scheme? I find it odd that chronic diseases, such as hypertension and diabetes, are not eligible for the scheme as it is chronic diseases like these that are more prevalent in the elderly. They are the ones that most crucially call for good treatment and follow-up to prevent the complications which usually require hospitalisation and incur higher healthcare costs. Allowing patients with chronic diseases to be cared for under this scheme will provide more convenience, better compliance and the achievement of secondary and tertiary prevention of illnesses and problems. I believe that the resultant cost need not be much higher than by limiting such treatment at polyclinics. The price of medicines can be pegged to polyclinic rates.

Sir, with the introduction of the PCPS, many residents have benefited from the scheme. I am glad that the scheme was expanded further last year. I think it has been a very effective and worthwhile scheme. Under the scheme, qualified patients no longer need to travel all the way to Government polyclinics, but instead they can be treated at any participating private clinics near them, while paying subsidised polyclinic rates. The best part is that the scheme does not cost the Government any additional subsidy as the same subsidy would have been borne by the Government had the patients gone to the polyclinics. Furthermore, it has the benefit of reducing the queues at the polyclinics as well as give business to the private clinics. Given the success of the scheme, I would like to urge the Minister to consider relaxing some of the qualifying criteria so that more patients can benefit from this scheme. Currently, only senior citizens who pass the means test and those who are under public assistance can qualify for the scheme. I would like to propose that the scheme be extended to three additional categories. Firstly, the non-senior citizens who may pass the means test. These are those in the lower income group and they would benefit from some savings in the cost of travelling to the polyclinics. Secondly, for patients who are handicapped, travelling is always a major task for this group of people, and it would be good if we can save them the inconvenience. Thirdly, patients who suffer from chronic diseases that require long-term and regular medication or treatment. These patients are already suffering from critical illnesses and we can help alleviate their sufferings by including them in the scheme. I believe these three groups of people deserve some help. I feel that we can afford to open the scheme to them because these groups can be clearly defined and they are small in number after all. They are, in any case, most likely to be patients of Government polyclinics already. If we open the scheme to them, it is unlikely to result in widespread abuse, or a significant increase in Government subsidy. Yet, it would undoubtedly benefit those who really deserve it. Sir, I would be most delighted if the Minister could consider my suggestions.

(In Mandarin): Sir, primary healthcare is one of the foundations of our healthcare system. Over the years, the Ministry of Health has intensified and strengthened the primary healthcare delivery network. This is indeed commendable. I would be grateful if the Minister could update us on the following matters: Firstly, the night polyclinics. I understand that seven night polyclinics are now in operation. What is the response of the residents to these night polyclinics? Does the Ministry intend to open more such night polyclinics? Secondly, the Ministry piloted the Primary Care Partnership Scheme (PCPS) three years ago and extended it nationwide last year, making it much more convenient for the residents in various parts of Singapore. In view of the successful implementation of PCPS, would the Ministry review its policy on polyclinic development? How many new polyclinics are in the pipeline? What is the Ministry's guideline in opening new polyclinics in the new towns? For example, I understand that Pasir Ris Polyclinic started operation only one year ago, whereas Pasir Ris New Town has been developed for quite some time. I hope the Ministry can coordinate the opening of new polyclinics with the development of new towns. Thirdly, the Interim Disability Assistance Programme for the Elderly (IDAPE). The scheme was launched to cover older Singaporeans who are unable to join ElderShield due to age limit or pre-existing disability. This is a good scheme. I want to know how many Singaporeans have benefited from the programme and how does the Ministry plan to reach out to those who qualify for the scheme but may not be aware of it?

Dr Michael Lim is not present. Dr Warren Lee is also not present. Dr Tan Cheng Bock.

Sir, I want to bring to the attention of the Ministry of Health one area of high cost which I think we should look into. At the specialist outpatient clinics, when patients go and see these specialists, they know the cost. If it is a consultant, they know how much to pay. If it is a Registrar, they know how much to pay. But then, after the consultation, a prescription is usually given. And it is this prescription that I want to bring to the attention of the Minister. Some of the drugs that are given to the patients are very expensive drugs. For those who suffer from heart illness and high blood pressure, cholesterol raised, the drugs used to treat all these conditions are really very expensive. Normally, they are given a three-month supply of medication which is actually a lot. The cost can be a lot. Sometimes, it is as much as $500. So I am suggesting that we should advise the specialists to give maybe a two-week supply first. If it is agreeable, then you have a further extension of the purchase of whatever drugs. Because, many a time, some of the patients do not agree with these drugs. And I think it is a lot of wastage here. I hope that the Ministry will look into it. One way perhaps is to ask the pharmacists to advise the patients maybe to just take a two-week supply first before they resort to taking more.

Dr Warren Lee, since we are on the same amendment, I remember you want to speak.

Sir, one of the problems that we face in the current downturn is when people go and see a private practitioner and the private practitioner tells the patient that a specialist's opinion is needed. Up to now, the practice has been that if the private practitioner refers the patient to a restructured hospital, it becomes a private consultation with high cost. Usually, this is justified on the grounds that, after all, you are choosing to have a named specialist. Although I know this has been a perennial problem, I would still urge that, when a private practitioner refers a patient to a hospital to seek consultation on a given medical discipline, but not with the named specialist in mind, consideration be given for these referrals to be done at subsidised rates.

Sir, Singapore probably has one of the highest cases of specialist outpatient referrals in the world. As the population gets more and more educated, our people invariably get more informed about their healthcare needs. Likewise, people are getting more demands for specialist referrals. In the past, a minor indigestion that could be treated with a simple prescription of antacid could now result in lengthy and numerous medical tests and investigations at patients' demand. All this drives up healthcare cost. Another cause of this phenomenon would probably be how easy it is for polyclinics to make referrals to specialist outpatient clinics (SOCs) and the low cost when referrals are made from these clinics. It is as low as $21, equivalent to seeing a private GP. Also, once a referral is made to SOC, it is almost certain to be caught in a loop of subsequent referrals for years and months. For most patients, if they are told to come back for more referrals, most would obediently follow, despite the fact that many of these cases could actually be sent back to GPs or polyclinics. Let me state that, while there is no evidence of abuse, such a system that we have currently is an open invitation for abuse. I am particularly concerned with graduating patients from this loop of endless further referrals and appointments with the specialists. At the moment, our public specialist doctors have little guidance on taking patients out for more future visits. Patients themselves would either adhere to future visits obediently, out of ignorance, or simply because of the subsidies and are not deterred by the cost of subsequent referrals. Thus, there is a need to regulate the specialist outpatient clinics with either a set of new guidelines, or a department housed in the Ministry, to monitor that. In Queensland, Australia, for example, there are guidelines for SOCs where SOCs must follow certain guidelines which spell out periodic audits to ascertain if the individuals still require the appointment. These guidelines spell out, amongst other things, the waiting time before a patient gets to see his or her doctor as well. To ensure the audits are competently carried out, the Audit Committee comprises peers from the medical profession. Currently, we do not have this audit system in Singapore. Sir, the containment of rising medical cost in Singapore needs a multi-pronged approach. We must spare no effort, including a need to regulate our SOCs.

Order. I propose to take the 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 2.55 pm.

Sitting accordingly suspended at 2.30 pm until 2.55 pm.

Sitting resumed at 2.55 pm

Debate in Committee of Supply resumed.

Head O (cont.) -

Sir, affordability for healthcare services has become a major concern of many Singaporeans. This has been highlighted by many Members who spoke earlier and I, too, share a similar concern. With the current economic downturn, many workers are retrenched and a vast majority of workers also experience wage cuts or a wage freeze. Sir, medical cost has become a major burden on the ordinary workers, especially for those who are affected by the economic downturn, and many Singaporeans are facing reality by seeking medical treatment at subsidised wards. I wish to ask the Minister whether more subsidised wards in Government or restructured hospitals would be provided if the situation warrants. At the same time, many workers have raised their concerns to me. Many workers who had sought medical treatment provided by their employers at non-subsidised rates before could no longer continue the same. They could have been retrenched or retired, and could not continue with the same treatment at non-subsidised rates. Would the Minister allow such Singaporeans, who have earlier sought medical treatment at non-subsidised rates at specialist outpatient clinics or wards, to switch to subsidised specialist outpatient clinics or wards? Finally, would he consider freezing all healthcare cost increases for the next two years for subsidised patients? Or, at least, if cost increase is necessary, can it be kept as low as possible? Sir, we need a humane approach in dealing with this human problem. This will go a long way in further strengthening the bond between the people and the Government.

Sir, the Ministry of Health has provided Singaporeans with a high standard of healthcare comparable to the best in the world. This is possible not only because we have access to good doctors but also because we have access to the best in medical technology and devices. The Ministry must be careful about putting in place healthcare policies which will add to healthcare cost. Some of its policies may have the unintended effect of raising cost of healthcare for Singaporeans. One recent policy, ie, the change in the regulation for the control of medical devices in Singapore, will eventually translate into higher healthcare cost for Singaporeans. The policy aims to control the use of medical devices, and medical devices include all products used in healthcare for the diagnosis, prevention, monitoring or treatment of illness or handicap, but exclude drugs. The stated aim of the new regulation is to strike a balance between ensuring product safety, quality and effectiveness, and providing the public with timely access to medical devices. It further states that it will expedite availability and access of new medical device technologies to patients, consumers and the clinical community in Singapore while preventing the entrance of unsafe and ineffective devices into the Singapore market. On paper, it looks fine. But, in reality, what are its implications? The submission format is extremely tedious and onerous and requires substantial data to be submitted. The requirements are even more stringent than that of FDA requirements. If we do follow these regulations, we will probably become the most tightly regulated market in the world for medical devices. I would advise that this is not one of the things that we should aim to be number one in the world. We must not follow blindly and make our system the most stringent of all regulations. We do not have a big market and neither do we have the resources. We cannot, and must not, act like the FDA. While the manufacturers are prepared to spend tremendous amounts of money and resources to get their devices accepted in the US or EU market, they are not likely to want to spend significant resources for a small market like Singapore. Even FDA-approved products and CE-marked products from EU will be subject to our stringent regulations and are not exempt as well. Feedback from manufacturers and distributors indicate that the Singapore market is too small and, if they were to be subject to all these additional paperwork and cost, it will not make any economic sense for them to bring in some of their medical products. I wish to ask the Ministry, firstly, why do we need to change the system? What are the shortcomings in the current system that have resulted in the desire to change it to a highly tedious and onerous system? Are there medical device failures in the past that have compromised healthcare outcomes in Singapore where the manufacturers have not taken responsibility? I hope that this is not a case of finding more work to do, so that more revenues can be generated. The second question is that the new regulation states that it will expedite availability and access of new medical device technology to patients, consumers and the clinical community in Singapore, while preventing the entrance of unsafe and ineffective devices into the Singapore market. However, does the Ministry or the Health Sciences Authority (HSA) have the resources to perform these duties diligently, professionally and without delay in its review process? I have serious doubts. Clinical data require special in-depth knowledge and also end user experience which is not available in HSA. So I do not believe that HSA has the resources or the ability to view these documents in a timely fashion. Neither do I believe that they have the expertise to understand all the technical data, the clinical data that they have requested the manufacturers to submit. If that is the case, why does the HSA want such voluminous amounts of data?

Order. Your time is up, Dr Lim. Dr Chong Weng Chiew, you have two cuts. Please take them together.

The ERC has highlighted that we could develop our medical services further and transform Singapore into a medical hub. On reading that, I was really wondering what direction should our two largest clusters of medical services, namely, SingHealth and NHG, be heading to. Would it be to further enhance our medical services to one that is world-class and to attract patients from neighbouring countries, or even countries far away? Or should they be concentrating on providing basic affordable health services for Singaporeans or maybe both, as what they are doing now? Sir, in my humble opinion, achieving both is almost impossible with the limited talent pool in Singapore and also the limited resources that the two groups have. To be able to provide world-class medical services and yet be able to meet the basic needs is like asking our national body-builder to strive for the Olympics but to keep slim to fit into a small-sized T-shirt. Currently, a lot of resources of our two clusters are spent on meeting world-class medical demands and we have achieved that in many of our medical services. Our Heart Centre at SGH is perhaps among one of the best in the region and it stands shoulder-to-shoulder among some of the best heart clinics in the world. I understand that in our bid to top the medical deliverables, some of the hospitals in the two clusters have to pay high wages for top-notch doctors and to equip the hospitals with the most modern and up-to-date equipment and facilities. Given the finite subventions that our hospitals receive, the cost of such talent and equipment will naturally have to be borne somehow. It is either passed down to consumers and hence the perception that the healthcare cost is high, or some areas of services will have to suffer a reduction in allocation. Sir, it is not helpful or healthy for public misconceptions to persist, while our medical services work very hard to give Singaporeans the best medical services there are. Perhaps, the Minister could provide a clear direction for the roles the healthcare clusters should play so that they could meet healthcare demands adequately. I would also like to ask the Minister to study the feasibility of introducing a third cluster that will look into the ERC's recommendation of spearheading Singapore into providing excellent medical services. This third cluster could address the demand for premier healthcare services, while NHG and SingHealth could focus on providing adequate basic healthcare upon which Government subsidies can be applied. Sir, with that, I would like to move on to my second cut. Under my second cut, I have two points to make. The first was raised earlier on by Dr Lily Neo about the surge in recent requests for C class beds and the call for more allocations of C class beds in hospitals. I shall not dwell on that further. The second point which I would like to speak on focuses on those Singaporeans opting for higher class of services only to find out later on how unaffordable they are. Sir, we need to address the growing concerns about the level of understand- ing the public has on the ability to pay for their healthcare cost. It has become apparent that a growing number of Singaporeans are not too clear on how they can go about paying for their healthcare cost. I have seen reports that the expenditure for more expensive hospital-based services has increased, primarily because they are perceived to be of a higher quality. I know of many cases where the next-of-kin, upon admitting their loved ones for surgery, would invariably opt for a higher class bed. Many thought that they are just being filial by giving their loved ones a better class without realising the level of subsidy, or the lack of it. They would later question why the treatment for their father or mother is so expensive. What are the possible reasons for this? In my humble opinion, the main reason is that there are serious misconceptions about the quality of healthcare available in the different wards and in the different hospitals. This is despite the fact that MOH has re-emphasised time and again that the level of medical and nursing professionalism is irrespective of the class and ward you stay in. There is also a considerable ignorance on the part of the public with regard to the limit of Medisave coverage, creating an illusion that more money is available than there really is, and what it can be used for. Many also erroneously perceive Medisave funds as frozen assets and, if unspent, will be retained by the Government. All these misgivings have induced many Singaporeans to opt for more luxurious services than they would have consumed otherwise. This is a serious problem and it could lead to a situation where no funds remain for their old age when they are more likely to need it. In conclusion, I would therefore like to ask the Ministry to make greater efforts in embarking on a public education exercise to educate the public about potential healthcare cost and the means through which this cost can be managed.

Sir, the Minister for Finance, in his Budget Statement, announced the introduction of market-testing for non-core Government services this year, beginning with new services. Public sector agencies will be required to compare the cost of providing the service in-house against the price quoted by private sector vendors. If a private sector vendor can deliver the service more cost-effectively, it will be engaged to do so. Sir, this is an excellent approach to make sure that we get value for our money. I urge the Ministry of Health to also consider introducing market testing in healthcare, allowing the private medical providers to bid for the service in the public healthcare sector. Currently, the two healthcare clusters enjoy a captive market. They also practise cost-recovery. It is almost like a monopoly. There is little incentive for them to operate cost effectively as whatever the cost is it will be recovered from the Government subsidy and topped up with the fee payable by the patients. It was not surprising to hear that one could avoid the long queue at a specialist clinic to get a consultation at a private clinic for an average fee of, say, $60-$80. I believe this is not much different from the subventions from MOH to all these specialist clinics plus the fees payable by the patients. As an example from overseas, in a comparative study between the National Health Service (NHS) of UK and a non-profit private medical service provider, Kaiser Corporation in California, it was concluded that Kaiser achieved better performance at roughly the same cost as the NHS because of integration throughout the system, efficient management of hospital use, the benefits of competition, and greater investment in information technology. Sir, in order for us to become the regional hub of medical excellence, allowing the private sector to participate in the provision of public healthcare will introduce the much-needed competition in this sector. This would result in lower healthcare cost to our nation. I urge the Minister to consider my suggestion.

Most of the Members of the House have already voiced their concerns about the high cost of Government hospitals. Some of it are due to the clustering section that is occupying 80% of the market share of the total hospital services that are provided by the Government. I would try not to repeat the concerns of the Members which I support, but I would just like to ask the Minister whether occupying 80% of the hospital share of the market in Singapore is going to be the long-term view of the Government. And, if so, can the Minister make it clearly known to the House so that we can be prepared for the high cost that we will be expecting in the years to come. When I was looking at the Budget Book, subvention funds for restructured hospitals rose from $769 million in FY 2000 to $1.6 billion for FY 2003, almost double the amount spent in the year 2000. If this trend is going to continue, the House must be prepared for it. However, if it is not going to continue that way, can I suggest that maybe we privatise certain hospitals in the clusters, while the Government keeps one or two large hospitals like the Singapore General Hospital and the NUH together with other research facilities? The Government can then regulate the cost of medical services of private hospitals through a subvention fund and leave market forces to determine which hospital is more cost-efficient than the other.

Sir, let me thank all the Members for raising issues and concerns on keeping healthcare cost affordable. This is a perennial issue and it must remain the main focus of our efforts. Let me first just give the overall picture and after that, I will go into the details of how the Ministry is proceeding to control healthcare cost. First, the overall picture. Healthcare cost went up by 4% last year. We must see this in comparison with the healthcare cost in other countries. It went up by 4.6% in the US and 6.6% in Australia. We cannot avoid healthcare cost going up, because we buy the same pharmaceuticals, we buy the same drugs, we use the same high quality medical devices, we use the most recent medical technology, unless Members are serious in saying that we do not progress as much as other countries. If we want to keep up, then I think this is the price that we have to pay. But what we do is to try and keep this cost down as much as possible, while still providing good quality care to Singaporeans. But despite healthcare cost going up by 4% last year, our overall national healthcare expenditure last year accounted for about 3.5% of GDP. Members will have noticed that this has gone up compared to previous years. In previous years, it was 3%. The main reason this has gone up is because our GDP did not increase very substantially in the last two years. The denominator has gone down and so our national healthcare cost has crept up to 3.5%. 3.5% is still quite low, compared to 7%-15% of GDP in other developed countries. The other parameter that we should be aware of is that the average Singaporean household spends only 3.3% of the household expenditure or $120 a month on medical services, meaning the out-of-pocket expense by Singaporeans is $120 per month. This is about the same amount that a household spends on telephone, pager and Internet charges. 3.15 pm So, overall, our healthcare expenditure is not high. Our problem is that healthcare expenditure is not a steady outlay across the population, nor is it a steady outlay throughout our lives. In fact, healthcare expenditure is very lumpy, and comes mainly when we grow old. That is why we have to deal with the lumpiness of healthcare and the incidence during the last 5-10 years of our lives. And that is the reason why we need a very, very sound healthcare financing system. In Singapore, we have developed our 3M framework - Medisave, MediShield and Medifund - over the last 20 years. This 3M framework has served us well, but we need to constantly adapt it so as to meet our future needs. There are two main reasons for this. First, our population is ageing. Today, 7% of our population is aged 65 years and above. This number will increase to 19% by the year 2030. We know that healthcare expenditure for an elderly person is between 3-4 times higher than that for a younger person. So, as the society ages, we can expect the national healthcare expenditure to increase. The second trend is that our economic growth is likely to slow down. We managed an economic growth of 7.3% per year in the last 15 years. We could therefore afford to spend more on healthcare without the share of the GDP going up by very much. The Economic Review Committee, however, estimates that GDP growth going forward will slow to 3-5% per year, in the medium term. With this slowing of our economic growth, and with healthcare cost still going up by between 4-6%, our national healthcare expenditure, as a percentage of our GDP, will therefore increase as a result. So, this is a very major challenge for us. We expect healthcare cost to go up, and we expect healthcare cost as a share of the GDP to go up. So how do we address this? My Ministry has worked out three strategies to deal with it. First, we have to strengthen the 3M framework. Second, the money that the Government is prepared to spend, the subsidies that the Government is prepared to give, should be targeted at those who are most deserving. Third, we should take all steps to manage cost. Let me deal with the first strategy, which is to strengthen the 3M framework. Let me start with the first M - Medisave. Medisave, as we all know, is the foundation. We must build up sufficient savings, otherwise we would not have enough savings to pay for healthcare cost. That is the reason why we have decided to raise the Medisave contribution rate by an extra 1% in the near future. The Government is also pitching in by paying a higher interest rate of 4%, instead of 2.5%, for the Medisave account. We have done so since 2001. Last year, for example, the Government paid an additional $380 million into Singaporeans' Medisave accounts because of this change in paying a higher interest rate. This is to help Singaporeans build up their Medisave account. Let me stress that the Medisave contribution rate of between 6-8% is really not very high. In France, the equivalent contribution is 20% of the employee's salary. In Germany, it is 13.5% of the employee's income. So Medisave funds are not infinite. We know there are many competing demands for it. Members have raised it all the time. We use Medisave for hospitalisation expenses, for health insurance premiums and for certain outpatient treatments. We must, therefore, strike a balance between extending Medisave for more healthcare uses and preserving it for the time when it is most needed, ie, hospitalisation expenses in old age. The Medisave contribution and savings account is designed such that, for the average worker, he will save enough in his Medisave account to pay for around eleven episodes in the hospital. Our study shows that a normal person would probably have three episodes before he reaches 65 years old and, therefore, the remaining eight episodes are for the last 5, 10, 15 years of his life, depending on how long he lives. So when we look at the Medisave account, he must keep eight-eleventh of his Medisave total savings for his old age. If he were to deplete his Medisave account very early, then he would not have enough for his old age. So I am very sympathetic to Dr Chong Weng Chiew's request. He kept raising the point whether we can extend the use of Medisave for home medical and home nursing services. I have explained previously that by allowing Medisave to be used to pay for the premiums of ElderShield, we are, in fact, extending the use of Medisave to the more severely disabled, so that they can use the payouts to pay for home medical, home nursing and nursing home services. For those who are not so severely disabled, and if they meet our income means test, they will be highly subsidised by the Government. An average home medical visit, after subsidy from the Government, would therefore range between $30-$60, and an average home nursing visit, after subsidy by the Government, will be between $13-28. So, these levels of expenditure should be affordable, and seen as the same range as outpatient GP cost. I accept Dr Chong Weng Chiew's argument that if, indeed, home care is a substitute for in-patient care, that means, if there is medical evidence to say that instead of being hospitalised, home care is sufficient to meet the problem, and instead of eight episodes in hospital, you only need four episodes in the hospital, and the funds that we set aside for the four episodes can now be spent for home medical and home nursing, then I think there is a case to extend it. So we will examine this, and I will be very happy if he can give us proper scientific evidence to say that home medical, in fact, is a substitute for in-patient. Then I think Medisave can be extended for home medical and home nursing. Having said all these, we are not frozen in time. We have regularly adjusted the Medisave withdrawal limits. We have also progressively extended the use of Medisave to more outpatient treatments. Medisave withdrawals increased by 62%, from $250 million in 1991 to $400 million in 2001. If we had frozen the criteria for Medisave withdrawals, you will not see this major increase in the withdrawals. But I agree with many Members - Mr Yeo Guat Kwang, among others - who raised the point that Medisave withdrawals ought to be attuned to the medical condition, and that our present system of allowing Medisave withdrawals by days in hospitalisation and by the tables of operation, is outdated. So, today I would like to announce that from 1st July 2002, my Ministry will reset the Medisave withdrawal limits based on the DRG system. This new system will allow Singaporeans to withdraw more Medisave for the more severe medical conditions. Let me explain. Currently, Medisave withdrawal limits are set based on the number of days of hospitalisation and the type of surgeries performed. This is a very blunt tool that is not customised to take into account the seriousness of the medical conditions and the resources required for treatment. In some instances, it is also restrictive as sub-limits are set on the amount patients can withdraw for each surgery performed. With improvements in medical technology, some patients may require very intensive treatment, but only require a very short hospital stay, eg, for certain types of heart surgery. In such instances, the amounts that the patients can withdraw from Medisave may not be commensurate with their medical condition. The DRG system is based on the resources required to treat the medical conditions, ie, the more resources required, the higher the severity level, the more the patient can withdraw from Medisave. This means that they will need to pay less out-of-pocket cash. These changes will apply to in-patient episodes and day surgeries at both the public and private hospitals. With these changes, more than 96% of B2 patients can have their entire bill paid for by Medisave, compared to 80% of B2 patients today. This means that more Singaporeans will not need out-of-pocket cash for their hospitalisation. Let me now ask the Parliament staff to distribute the brief on these changes, which contains some examples of how patients with serious medical conditions would benefit from these changes. [Copies of brief distributed to hon. Members.] Next, let me turn to the second M - MediShield. We discussed this last year and I mentioned that MediShield in fact plays a very limited role in our 3M framework currently. Today, MediShield payouts account for around 1.1% of our national healthcare expenditure. This, I think, limits the role of insurance in our overall healthcare financing framework. My Ministry has attempted to make, over the years, changes and enhancements to the MediShield, to try and keep up with the medical cost, but we have been constrained by not raising premiums. Premiums have remained unchanged since the scheme was introduced in1990. So, these enhancements are really not adequate to keep up with the medical needs of today. As a result, today, 4 in 10 B2 bills are higher than the existing MediShield claimable limits, which means that MediShield does not fully cover catastrophic bills, as it is meant to do. And this number of non-coverage would go up with medical inflation. So we need to make quite major adjustments to our MediShield if we want to meet the objectives that many Members have raised. Mr Yeo Guat Kwang gave many suggestions on how to enhance MediShield. I am happy to note that Mr Yeo is supportive of increases in the premiums for the enhanced MediShield scheme. I agree with Mr Yeo that we should also go for pre-funding of the policies, so that you pay more when you are younger and you are covered when you are older. This is in line with our move to make medical benefit more portable. So I assure the House that changes to the insurance element of our financing framework will be a major item in our agenda over the next two years. We need to make many changes, if we want to allow MediShield to play a bigger role in providing coverage for Singaporeans, not only during employment and in between jobs but, more importantly, also after retirement. These are very major changes and we need to prioritise the changes, otherwise Singaporeans may not understand and keep up with these changes. To me, the first priority is to raise the MediShield claimable limits. Today, the MediShield claimable limits are set too low and we must raise it so as to allow patients with high hospitalisation bills to claim more from MediShield when they most need it. They then need to withdraw less Medisave and pay less out-of-pocket cash. And, we have to adjust the MediShield claimable limits in line with the DRG system. I hope Members understand the role of MediShield as a catastrophic insurance scheme. This means that as the medical bills go up, you cover the highest bill. For the average bill, Singaporeans are able to pay on their own using the subventions from the Government and using Medisave. But for very high bills, this is where you want the MediShield to kick in. And, therefore, we must raise the upper limits of the MediShield claimable limit so that it covers the top end of the bill. My Ministry will announce more details of how we will enhance MediShield subsequently. But, as I said, we need other changes, and we will definitely come back to the House over the next few years to discuss this. One big issue that we have to discuss and decide, for example, is the issue of whether we want to make medical insurance compulsory. Mr Yeo Guat Kwang asked whether the Ministry has any plans to make MediShield compulsory. Let me say that this is a very major step and we will need to consider this very carefully. Today, more than 90% of the working population is covered under either MediShield or one of the MediShield-approved private medical insurance schemes. This is quite a high participation rate. But, of course, as Mr Yeo pointed out, more than 200,000 are not covered, and many of these are the non-working spouses or people who are self-employed, and these are the most vulnerable people. So we will have to evaluate whether or not we want to make MediShield compulsory. But as I said, this is a very big step. What we can do right now is to encourage Singaporeans not to opt out of MediShield. Because if they opt out and when they retire or become jobless, they will not be covered by their employers. There is also no guarantee that when they are no longer covered by their employers that they will be insurable at that stage, because they may then have pre-existing illnesses. Therefore, I think our first step is to encourage Singaporeans to opt back into MediShield while they are still young and healthy. 3.30 pm Mr Yeo Guat Kwang also suggested other changes to MediShield, so as to make it a national scheme, eg, covering only the basic tier and to have appropriate levels of co-payments. I think these are very important principles, because we want to minimise the buffet syndrome. If you introduce a national medical insurance scheme and you have a buffet syndrome, it will lead to escalating premiums. I was just describing to some Members during the break just now the experience of Taiwan. Taiwan introduced a national medical insurance about five years ago and they extended the medical insurance to cover visits to the GP. In Singapore, Singaporeans visit the GP, on the average, six times a year. In Taiwan, it is around 11-12 times. Why is that so? The Taiwanese Health Minister told me that in some clinics in the suburbs, it is very common for school children to visit the clinic and pick up pocket money from the GP, because every time the GP sees a patient he can claim, say, $20 from the state. So, he gives a small pocket money to the student, and there is no way you can stop this abuse, because it is entirely within the right of a school boy to go to a clinic, complain of headache or tummy ache and be seen by the GP. So, you may run very elaborate audit systems, but if the national average has gone up to 11 times, the school boy is entitled to visit his GP 11-12 times and collect his pocket money. Although we do want to make sure that we have good coverage, we also want to make sure that it does not lead to abuse. Let me next turn to the third M, which is Medifund. Medifund kicks in for the small minority of Singaporeans who are not able to pay for their share of healthcare cost, even after Government subsidy, Medisave and MediShield. Over the years, the Government has steadily built up the Medifund capital sum. It grew from $200 million in 1993 to $900 million this year, with the latest $100 million injection, as announced by the Minister for Finance. I remember one Member mentioned why is the Ministry of Finance injecting an extra $100 million when, in fact, the Ministry of Health is quite comfortable with $800 million and using the interest income from the $800 million. The answer is that we believe that Medifund is a very important safety net and, with the additional funds given by Ministry of Finance, MOH is now in a position to gradually extend the coverage of Medifund. For example, when the Ministry of Finance raised the capital sum last year, MOH is able to extend the use of Medifund to step-down care organisations. Similarly, we will continue to make full use of MediFund to provide assistance to needy Singaporeans. So, I urge Members that when they come across a deserving case during their meet-the-people sessions, such as those mentioned by Mr Zainudin and other Members, whether they are the elderly, the handicapped or the retrenched, for chronic cases and other cases, do refer them to the medical social workers at the hospitals and clinics. Today, more than 99% of Medifund applications are approved. And with the additional funds that we have in the Medifund, I can assure you that Medifund, as a safety net, will continue to be there for all Singaporeans. The second prong of our strategy is to increasingly target subsidies to the most deserving. With increasing healthcare costs, the Government would do its part to increase its share of healthcare expenditure. We have done so. Government subsidies for Singaporeans' healthcare costs through the hospitals, the polyclinics and the VWOs have increased by more than 34% in the last four years. For example, in FY 2000, we spent $896 million in such subventions. And this year, we expect to spend $1.2 billion. Mr Andy Gan wonders whether it is wise for us to keep this 80% market share because this will result in high cost to the Government, as he observed the higher budget that the Ministry of Health is given year after year. His suggestion is to privatise the hospitals, but I notice the other Members are, in fact, asking for more C class wards and more B2 Class wards. So, we have to strike a balance somehow. I think all of us know that financial resources given to healthcare cannot be unlimited and, therefore, I hope Members will agree with me that Singaporeans who are able to pay for their medical bills should do so themselves, or with their families' help. Then the resources that we have, we can target these subsidies at Singaporeans who are most deserving. In line with this philosophy, we have selectively implemented means testing for the Primary Care Partnership Scheme (PCPS) and also the step-down care and home care services managed by the voluntary welfare organisations. Going forward, my Ministry will consider extending means testing gradually and selectively, to more healthcare services. If there are proxy methods to moderate demand and target the services to the more deserving, then there is less need for means testing. But if our proxy methods are not effective, then I think we have to consider means testing, so that the subsidies can be more equitably distributed to those who are more deserving. Some Members raised the situation in the specialist outpatient clinics. Dr Chong Weng Chiew and several others said that there are long queues and that it could be abused because the fees are only $21, which is sometimes cheaper than a visit to the GP. Singaporeans know that they can enjoy substantial Government subsidies simply by obtaining polyclinic referrals. So the polyclinic referrals, as a proxy, are not discerning enough to differentiate between those who are deserving and those who are not. Means testing at the SOCs will make the distribution of Government subsidies more equitable by delinking subsidies from the referral source. It will therefore enable us to redirect public healthcare resources and do more for the lower income. But we will have to study the implications of this and we will have to make sure that if we do implement means testing, that it achieves the purpose set. Mdm Halimah is right that if you want to do means testing, the criteria must be made clear. And to us, the fairest and simplest criterion is per capita income. I also agree with both Mdm Halimah and Dr Ong Seh Hong that we need not run a single means test system. It is possible to vary the income cut-off, depending on the cost of service. So, even though we have implemented means testing in the step-down care sector, previously the subsidy in the step-down care sector was a standard 50%. When we introduced means testing, we provided three tiers - 75%, 50% and 25%. So, it went down very well on the ground. But it does not mean that we will necessarily use this same method for the hospitals, because in hospitals today, Singaporeans already enjoy 80% subsidy in C class wards, 65% subsidy in B2 wards; 50% subsidy in the B2-plus wards and 20% subsidy in the B1 wards. So it is possible for us to vary the income cut-off as well as the level of subsidy, depending on the cost of service. The third prong of our strategy is really getting down to the brass tacks and managing cost increases. How do we do so? My Ministry plays the role of purchaser of healthcare services on behalf of Singaporeans, especially the low and middle income. As a purchaser, I wish to reassure Mr Zainul Abidin, Mdm Halimah and Mr Chandra Mohan that my Ministry will ensure that clusters are accountable and that their interests are aligned with the Ministry's goal of providing good and affordable basic healthcare to all Singaporeans. I agree with Mrs Lim Hwee Hua that performance measurement is necessary to do so. And to this end, the Ministry has set out its requirements and expectations of the two clusters in a service agreement with them. We will review the service agreement with the clusters periodically to make sure that they abide by it and that it is relevant and effective. In addition, my Ministry provides the strategic oversight on overall public healthcare capabilities and facilities. We want to make sure that on capabilities, we have in place a medical capability framework to ensure that there is no unnecessary duplication of the more specialised and the most costly services and facilities. Such facilities and services are concentrated in the tertiary hospitals and national centres. On facilities, the Ministry determines the number of beds and its distribution by ward classes in every public hospital to minimise over supply at the national level. Public hospitals also need to seek the Ministry's approval before they can expand their facilities. As a purchaser, my Ministry will also ensure that the clusters provide quality care that is appropriate to needs and not drive up healthcare costs unnecessarily, eg, the example which Dr Lily Neo raised that they use more expensive stents when a cheaper one is adequate. In fact, we have several mechanisms in place to prevent such things from happening. The first mechanism is, of course, all healthcare professionals are bound to abide by their respective ethical codes. Breaching the code could lead to healthcare professionals being asked to defend their actions and, ultimately, to face disciplinary proceedings for professional misconduct. The second mechanism is that the Ministry regularly produces clinical practice guidelines, so as to assist healthcare practitioners to manage their patients based on the best available evidence to date. Third, the Ministry also monitors key clinical, financial and other operational indicators so as to detect trends and outliers that deserve further investigation or audit. Let me just use the example which Dr Chong Weng Chiew raised that the specialist may ask patients to make extra follow-up visits beyond what is necessary. We track this and our data over the last three years have shown that the ratio of re-attendance to first visit is very stable. It is between 3.6 and 3.

8. So there is no escalation in repeat visits. Several Members like Dr Lily Neo and Mrs Lim Hwee Hua also asked whether the remuneration structure for the doctors in the public hospitals is properly set, so as not to create the wrong incentives. This is so. We make sure that the doctors pay equal attention to both private and subsidised patients. Their remuneration takes into account several factors, of which clinical service load of the doctor is only one of them. I also want to assure Members that the clinical service load includes both private and subsidised patients seen by the doctors. So the public sector doctors do not have a financial incentive to order more expensive tests, drugs, or stents, because they do not personally get a cut from these items. The revenue from these items goes to the hospital. And at the hospital level, my Ministry has put in place a revenue cap framework to discourage over-servicing. Under this framework, excess revenue that exceeds a pre-determined cap will not be allowed to be retained by the hospitals. So there is less incentive for over-servicing and over-pricing. What this means is that, every year, we do not allow the hospitals to increase costs beyond a certain limit. So if they charge more, they do not keep the money. The money goes back to the Government which will then reuse it for subsidies for the system. 3.45 pm Sir, as the purchaser, my Ministry will ensure that Singaporeans get the best value for money for their healthcare services. My Ministry is not obliged to buy only from the public sector restructured institutions. Dr Ong Seh Hong and Mrs Lim Hwee Hua have suggested, and I think several others as well, that the Government buy services from the private sector as well. I am open to this option. If the private sector can offer lower cost with the same or better quality in service, my Ministry will consider contracting the service from them once we put the proper framework in place. For example, under the PCPS, the Government engages private GPs and dentists to provide outpatient medical and dental services to the needy elderly. The patients pay polyclinic charges and the Government provides a subsidy to the participating GPs. My Ministry has also put in place a similar framework for the step-down care sector. This framework will include means test, accredited private sector facilities, properly audited norm cost and revenue caps. So the accredited private sector nursing homes will be able to take in subsidised patients as of 1st April this year. I know many Members have raised this whole issue about healthcare cost. Dr Lily Neo and Mdm Halimah suggested a watchdog body to monitor healthcare cost. Let me just say that controlling and managing healthcare cost is a job for all of us. It is not the job of MOH alone, although, as I have outlined earlier, we have a very comprehensive scheme in place. The individual and his family must also take the effort to understand the cost implications of their choices. Dr Chong Weng Chiew suggested that we do public education and counselling to make sure that people understand what is the cost implication of their choices. We have done this. If anything else, we err on the safe side. We counsel them and many of them then take up class B2 or C. And this is part of the reason why we have an over demand for these subsidised wards. In addition, over time, as the medical insurance component increases, I hope that the insurance companies will also build up the competence and interest to control healthcare cost. Sir, let me, over the next 10 minutes, cover the other specific issues which have not been covered in my reply so far. Let me take it systematically. First, in the primary care sector, Mr Yeo Guat Kwang asked about night clinics. We have night clinic services now in seven polyclinics. The reason why we introduced it is to make it much more convenient for Singaporeans to seek care at night, instead of having to wait till the next day. As these night clinics are popular among Singaporeans, my Ministry plans to extend night clinics to five more polyclinics this year. Mr Yeo also asked about our plans for development of new polyclinics. As we have announced earlier, we plan to develop new polyclinics in Sengkang, Jurong West and also to redevelop Queenstown Polyclinic. Several Members asked about the Primary Care Partnership Scheme (PCPS). I thank Members for their favourable comments on PCPS. We agree that the scheme is working well. But we really need to reach out to more elderly to make sure they sign on under PCPS. Dr Lily Neo said that, today, we have probably achieved less than 50% of those who are eligible. I agree with her. We should work harder so that we could reach out to more elderly. Today, some 6,200 elderly are participating in PCPS. Singaporeans, who are on public assistance, are automatically eligible regardless of their age. My Ministry, together with the other community organisations, like CDCs and VWOs, has started a joint programme to promote subscription to PCPS and the IDAPE scheme. Voluntary organisations, like the Home Nursing Foundation, are doing a lot of promotion and I would also like to encourage Members, when they do block visits, to help us distribute these brochures to get more elderly to sign on the PCPS scheme. Dr Lily Neo suggested that we extend PCPS to chronic care. Mr Gan Kim Yong also wanted PCPS to be extended to the handicapped, the other low income group, as well as people with chronic diseases. These are worthy suggestions and we will consider possible extensions of PCPS later. Because right now, our priority must be to reach out to all the elderly who are eligible but who still have not signed on. Let me then turn to the hospital sector. Mr Nithiah Nandan wants to know if more class C beds would be created in the tertiary hospitals. The answer is yes. Dr Lily Neo wanted to know whether we are deploying more doctors and nurses to areas where there is an increase in demand. The answer is also yes. NUH will increase its number of class C beds from 56 to 160 beds, an increase of 104 beds by April this year. And SGH will increase its class C beds from 134 to 214 beds, an increase of 80 beds by September this year. Let me assure Members that any patient who requests for subsidised beds in a particular class ward and if the class ward is already full, he will be lodged in a higher class ward temporarily. But he will continue to pay only the subsidised rates of the class ward of his choice. So even though we may not have renovated the class C or class B2 wards to meet the demand, anybody who requests for such a subsidised ward, if it is already full, we will temporarily lodge him in a higher class ward but he pays the rates of the subsidised ward that he has requested for. When the bed is available, we transfer him back to B2 or C class ward. So he is not penalised in any way if there are temporary shortages in the B2 or C class wards. Several Members also raised about the difficulty of specialist outpatient clinic patients who, because of changes in their financial situation, may request for downgrading. I assure Members that, if indeed they are in genuine financial difficulties, please raise them with the medical social workers and they will take care of them, and if they do qualify, they will provide Medifund support for them. Dr Tan Cheng Bock wants to know whether the specialist outpatient patients can request to break down their prescriptions or medications into smaller allocations so that they do not have to pay three months' worth of medication at one go. In general, I would not want to interfere with the doctor's judgement of how much prescription is needed. But I would like to assure Dr Tan Cheng Bock that indeed if a patient tells his doctor that he cannot afford it and he prefers a shorter period, say, two weeks, as Dr Tan Cheng Bock suggested, I think the doctor will accede to his request. But as a rule, I do not think the Ministry wants to impose the rule that doctors should only prescribe two weeks first, and not three months. I think we have to leave it to the professional judgement of the doctor. If he prescribes too short a period, then we will be forcing the patient to make more return visits to SOC or to the pharmacy. If indeed he faces financial problems, please do talk to his doctor. He or she is there for him to talk to. Let me next turn to the whole issue about the way we organise the clusters, whether we should have two or three and how we should encourage competition. I think the jury is still out. Some can argue that if you have more competition, you bring healthcare cost down. Other Members have made out an equally cogent case to say that competition means the clusters try very hard and they induce demand. By and large, today, we have decided to have two clusters. Why? Because we want to make sure that we have a full, integrated service and that the services provided to Singaporeans are seamless between different levels of institutions, whether it is from the national centres to the tertiary hospitals, to the regional general hospitals or to the polyclinics. Because we believe that integrated care is the most cost effective setting. If you have an integrated care, the doctor can assign the right level of care commensurate with your medical condition. If your condition is not so serious, he can assign you to the polyclinic. If it is more serious, he can assign you to SOC. Or if it is even more serious, he can assign you to the tertiary centre. To minimise duplication, we make sure that the more specialised services are located in the tertiary hospitals and the national centres so that the regional general hospitals focus on the management of the common medical conditions. Dr Chong Weng Chiew suggested that we keep the two clusters to only doing the frills and we set up a third cluster to focus on the top-end medical treatment. Let us try out the two clusters system first. If we create a third cluster, I think there will be a lot of unhappy comparison between what is available in the third cluster compared to the other two clusters. There is also a likely discussion about what we should do with the ERC's recommendation on the regional medical hub. Our position is that we will encourage the private sector health institutions, facilitated by the economic agencies, such as the EDB, IE Singapore and the Singapore Toursim Board, to spearhead this effort. The public sector healthcare institutions will play a very important role to support these efforts, especially in the area of training and research. But the main focus of the public healthcare institutions must be to provide good and affordable healthcare to Singaporeans, and we will do so. In the 1993 White Paper on Affordable Healthcare, we stipulated that no public sector hospital should have more than 13% Class A beds to serve private and foreign patients. In that White Paper, we also envisaged that the overall private sector market share would grow from 20% to 30%. I believe these guidelines are still relevant today and my Ministry would continue to support the private sector institutions in achieving these guidelines. And we will ensure that the public hospitals remain focused on their role to service the majority of Singaporeans. Let me turn to two other issues. Dr Michael Lim has spoken on HSA's role. We need to strike a balance between regulating medical devices so that they are safe. At the same time, we do not want to impose so much regulation that they incur cost. I assure Dr Michael Lim that HSA's regulatory requirements would be closely aligned with those set out like their counterpart regulatory agencies in the USA, EU, Canada and Australia. We will keep ourselves in line and we will not be more stringent than them. More importantly, HSA will have regular meetings, every six monthly, with the medical device industry to obtain industry feedback. So I am sure HSA will get in touch with Dr Michael Lim and encourage him to bring up the specific instances where we have over regulated, and we will evaluate the cases again. Dr Lily Neo asked about the precautions taken for SARS and how we are protecting our healthcare providers. As Members may have read in the newspapers this is a worldwide problem. We suspect the cases could have emanated from Guangdong, Hong Kong and Hanoi. That is why we have set out a travel advisory, advising Singaporeans not to travel to these places, unless it is absolutely necessary. Right now, we have 23 reported cases, 21 in the hospitals and two have been discharged. All these cases stemmed from three index cases, ie, three original source cases, and then they spread to the others. They have spread to eight healthcare workers and 12 family members and friends. So, if we are able to contain the situation by not allowing it to spread further, over time, we will find fewer and fewer cases, and the situation will be completely under control. But if Singaporeans travel, get infected overseas, come back and infect other Singaporeans, then I am afraid the cycle will continue. That is the reason why we made it a point to advise Singaporeans to avoid travelling to these three places, unless absolutely necessary. We have gone through these difficulties before. A few years ago, we had an outbreak of the Nipah virus. In that situation, fortunately for us, we were able to cut off further infection by not allowing pigs to be imported into Singapore. Therefore, by cutting off further infection, we were able to control and contain the situation. In the SARS case, the infection is brought in by humans. So, unless we encourage Singaporeans not to travel and avoid being infected overseas, we have no effective means to stop the chain reaction. Again, let me emphasise, please avoid these places, unless absolutely necessary. We are monitoring the situation very carefully together with our regulatory counterparts in Hong Kong. We have got assistance from WHO and from the CDC in the US. So far, things are under control. It will require us another 10 to 14 days, ie, two more incubation cycles, before we can declare it all-clear, if all things go well. But if there are additional infections, then I am afraid we will have to continue with the current measures.

4.05 pm As for the healthcare workers, I must say I am very proud of them. They have discharged their responsibilities admirably, taken all the precautions, even though eight of them have been infected. I can assure Members that we will spare no efforts to make sure that they are well looked after. I missed out one point about cost management, ie, just to emphasise that the cost that we set for the hospitals is not on a cost-recovery basis. The Government provides the norm cost, and we expect the hospitals to manage their cost within that level. So, it is very similar to your price-minus proposal. The hospitals are not allowed to incur cost and then expect the Government to pay for all cost increases. This is part of the discipline of managing cost. To respond to Mr Chandra Mohan who described SGH as a 5-star hotel, I am very flattered. I am sure the SGH would be very flattered. SGH was built 20 years ago and, if it leaves the impression that it is a 5-star hotel, then I think it is doing a good job in maintaining the hospital.

Sir, I want to clarify that I did not mention anything on stents or the price of stents which the Minister gave the answer to. Sir, on my cut on doctors, in June last year, strict new limits on work hours for American medical residents were imposed by the American Accreditation Council for Graduate Medical Education. It said that up to 120-hour work-weeks were harmful to young doctors and could endanger patient care. In America, thousands of people die annually from medical mistakes. Under the new rules, the normal resident work-week would be limited to 80 hours. The standards also imposed mandatory rest periods of 10 hours between shifts, one day a week off, restrictions on moonlighting, and close faculty supervision. It was reported in the Straits Times four months ago that junior doctors here work on a 34-hour shift. May I ask the Minister if such long shifts are not affecting their concentration and standard of patient care? Are our junior doctors not subjected to long, unhealthy work-weeks? Morale has been low among junior doctors for many years. Lately, there had been another issue contributing to this. It seems that there was favoured-treatment of Singaporean medical graduates from overseas, as compared to locally-graduated doctors serving under bonds. Could the Minister enlighten us on this? Sir, there is a need to pay attention to the training of our junior doctors to ensure the competency of future generations of our healthcare providers. May I ask the Minister for Health what steps have been taken to ensure this? May I also ask whether our hospital doctors are too preoccupied with daily routines that require them to manage maximal numbers of patients and leave the seniors with little or no time to teach the juniors who, in turn, have no time to be trained?

Sir, the Ministry of Health and the Ministry of Manpower have launched the Strategic Manpower Conversion Programme for the healthcare sector recently. It aims to increase the pool of healthcare professionals by helping non-healthcare sector individuals acquire the relevant skills in the industry. Some features of this programme include a shortened training period, cost fee support and training allowances. It also provides an on-the-job wage support to sponsoring institutions that hire these individuals. I must take this opportunity to compliment the two Ministries, as this is indeed a good programme and it brings relief to our current employment status. Times are bad. Encouraging individuals to re-skill into a sector that is critically understaffed is definitely commendable. However, I must say that we are spending a lot of resources and effort on this programme. It is therefore imperative that we do not spend all this money, only to lose the individuals once they are fully trained professionals. I would urge the Minister to put in place a clear career path for these individuals, with a competitive compensation plan, so that the trainees do not take this as a stop-gap measure and leave the industry the moment the economy recovers. Sir, the competition for healthcare staff in the global arena is very competitive. We need to be vigilant to guard this pool of manpower resources jealously. Otherwise, other countries would draw away our new nursing talents.

Sir, if one were to visit our local hospitals, especially when approaching the nurses' station, one sometimes wonder whether one was in Manila! This reminds us how short we are in terms of our local nurses. Indeed, there is a shortage of nurses worldwide. Just as our nurses are sought after from all over the world, including the Middle East and the UK, we too open our hospitals to foreign nurses. I believe we have employed nurses from various countries, including China and the Philippines. Which other countries do we have nurses from? What was the experience like with these foreign nurses in terms of the quality of their professional nursing skills? Are there plans to open the door to nurses from other countries too? In addition, Sir, what is MOH doing to attract and train more local nurses?

Sir, the nursing profession is the backbone of the medical industry. There is no doubt about it. In meeting the manpower requirements of our nursing profession, we spare no efforts in recruiting nurses, both locally and from abroad. In fact, we have nurses from the Philippines, India, China and elsewhere. At the moment, foreign nurses form about 25% of our nursing workforce. There are more than 4,000 foreign nurses in Singapore. Having recruited them, we similarly spare no efforts in training and orientating our foreign nurses to enable them to perform according to the way nursing care is administered here. We have also given due recognition to our foreign nurses' professional qualifications and the importance of their contribution through opportunities for upgrading and career advancement. Yet, in spite of all these, many of these foreign nurses do not stay in Singapore for long. Some stay in their jobs for only between six months and two years. The global competition for professional nurses is hot, and definitely getting hotter. For instance, the UK made no bones about their shortage of nurses. Until recently, they have gone on aggressive recruitment campaigns in some of our sources of foreign nurses, such as the Philippines as well as China. The campaigns also include Singapore, where they advertised in our Straits Times to recruit our nurses. Attractive carrots, such as offers up to treble their salaries, free flights, and a chance to see another part of the world, were used to entice them to work in Britain. Sir, we are up against fierce competition and need stronger measures to retain our foreign nursing talent. Many of my colleagues in the healthcare industry are lamenting the short-term nature of our foreign nursing profession here, after investing vast resources on them. The people who join the nursing profession do so because they are driven by more than just the will to serve, and definitely less by the motivation of money. I simply refuse to believe that having being here they would leave for other destinations by the pure motivation of more money. The slogan of the nursing profession is definitely not the quest for more money. Thus, we need to look at other areas on how we can do more to retain these foreign nurses in Singapore. Have we done enough to make them feel at home? We need to treat them not so much as commodities but as human resources. If we treat them like commodities, they will behave like one and go off the moment their contract is up. Thus, we need to provide for their welfare, especially recreational facilities outside their work, and their commitment to Singapore. We need to do more to make them really feel that Singapore is also part of them. I therefore hope the Ministry of Health could show leadership on this.

Dr Lily Neo, you can take both cuts together.

Sir, 99 patients, or 11%, of the 924 patients admitted to St Luke's Community Hospital in 2000 had to be re-admitted to a general acute hospital within one week. Fifteen died after their return. Another four died before re-admission. These deaths were attributed to early discharge of unstable patients from acute hospitals to St Luke's Community Hospital. It was believed that the medical problems these patients had were not adequately worked out before their discharge from the acute hospitals. Sir, our community hospitals cannot and should not be expected to provide the level of care available in the acute hospitals and, therefore, there should be more caution on discharging patients. Has the Ministry of Health done any surveys on this? What has the Ministry done to improve this situation? With casemix in force, when hospitals are reimbursed on the diagnosis of medical conditions of patients and not on the length of stay, are doctors under pressure to discharge patients even earlier and, thus, exacerbating this problem? Sir, patients in the subsidised wards in the public hospitals now have to pay full price once the doctors certify them as ready to be discharged. But many patients, especially the older ones, may still consider themselves as not fit to be discharged, and also may not be able to leave the hospitals for various reasons. Are they not penalised unduly? With casemix, will there be more patients subjected to this type of discharge? Sir, on my next cut on nursing homes, the Ministry of Health has introduced means-testing to decide on the subsidy to be given to patients in nursing homes, based on a person's per capita family income. In other words, this means-testing is based on the total income of older family members divided by the number of members in the family. This means-testing is thus unfavourable to small families and will be felt by even more people in time to come, because the trend has been tending towards smaller units of families. Often times, it is difficult to get information on income from all the members of a family, and many elderly fail to get subsidy because of this. Other times, family members of applicants are not willing or unable to submit their documents for a variety of reasons, such as confidentiality or self-employed situations. Would the Ministry of Health further refine this method of subsidy in view of these factors? 4.15 pm The subsidies are only given to those with less than $1,000 per capita family income. Would the Ministry of Health raise this cut-off point so that more elderly can qualify? May I also ask whether there will be a centralised government-run "means-testing" agency to facilitate and expedite applications and services?

Dr Jennifer Lee, please take both cuts together.

It has been over three years since the report of the IMC on the Aging Population was published in November 1999. One major area identified was for attention to be paid to healthcare needs of the elderly. In the period, since the Ministry of Health has moved many initiatives and programmes for the elderly, I would like to ask the Minister for his assessment and satisfaction with the progress made so far, and to put forward a few suggestions for his consideration. In particular, I would like his observation with regard to the following components in the delivery of an integrated healthcare service to elderly Singaporeans: (1) The roles of GPs in the system; (2) The role of VWOs in the private sector in the provision of residential care; (3) Raising standards of care and service of providers; and (4) Assessing subsidies. Regarding the GPs, I know that the Minister has already responded to earlier speakers on the PCPS. I do have one additional point to make on the subject. The Minister has said that extending the reach of the PCPS is the current priority. However, I believe that there is a need to enrol both senior citizens as well as sign up more GPs into the scheme. Dr Lily Neo has spoken of the restrictions on management by the GPs of chronic illnesses and this may be a reason why some GPs have not signed up. If there is a concern that GPs are not quite up to the job, should we not be looking to upgrading the skills and competence of the GPs since they form a wide network? Indeed, the intent captured in the 1992 White Paper was that 80% of primary care is to be provided by GPs. The Ministry had invested in a grant with the College of Family Practitioners in 1999 to develop the Graduate Diploma in Family Medicine (GDFM). That investment has yielded good results, with GPs demonstrating that they are keen to upgrade and indeed willing to invest in their own development. Three batches of GPs have since signed up for the two-year course. The first batch of 40 had graduated and the latest batch numbers 70. These GPs pay their own fees of about $3,600. Why not take the route to widen the scope of the PCPS, and tie it into the GDFM qualification? It would be a win-win situation for all involved. With regard to the provision of residential care, MOH has set aside 17 parcels of land for commercial nursing homes to encourage the development of the private sector. What is the Minister's level of satisfaction on how this is progressing? Three parcels of land had been awarded. What have the outcomes been? What is the current thinking regarding VWOs versus private sector provision of residential care services for the elderly? If the intent is to promote private sector participation, I believe that we must set the parameters so that we do not end up with developers jumping into the arena, thinking there is an opportunity for a property play. One hears the usual private sector feedback that they are somewhat squeezed between competing with the restructured hospitals for staff and in this sector, competing with the VWOs whose capital costs are highly subsidised. The result may be a tendency to warehousing, to squeeze as many batches as possible out of each project with less than satisfactory standards. With regard to standards of care, I expect that, with notable exceptions of course, there is room for improvement in this area. The question is how to achieve this. Currently, many VWOs, while having the best of intentions, say that their efforts are compromised with the constant concern regarding finding adequate funding for their activities, despite Government subsidies. Norm costs that are calculated based on current level of activity and standards will likely be too low and tie the VWOs into a vicious cycle. So, might we want to consider putting in place a two-tiered level of norm cost, with the top set at a very generous level but tied in rigorously to professional management and stringent requirements on standards of care while the bottom level can stay at current norms? Finally, regarding assessing of funding and subsidies, most of my points have already been taken up by Dr Lily Neo. The only other point I wanted to bring up was that, as the patient navigates through various parts of the system, from outpatient and day-care to residential care and home care, the process of means-testing is sometimes repeated over and over again, because each provider requires slightly different items of information based on their estimation of what they subsequently need to satisfy an MOH auditor. Might it not be a good idea for the Ministry to specify a standard set of assessment criteria since all the subsidies that may be disbursed through it, and if some are also disbursed through MCDS, then to engage MCDS into the picture, so that we can do the processing only once? These are for the Minister's consideration. On my second cut, Sir, may I declare at this point that I sit on the Board of the Tsao Foundation which is a not-for-profit organisation providing home healthcare for the needy in Singapore. In October 2002, MOH implemented subsidy for home care providers. This was a significant step as it signalled the importance that the Ministry puts on home healthcare and the funding is much appreciated. The subsidy provided is subject to means-testing and is tied to a norm cost of $120 per doctor visit for up to two visits per month and $55 per nurse visit, up to eight visits per month. This approach of per visit reimbursement in home care is not ideal in that it perversely encourages providers to be less efficient and make more frequent visits. This is even more so when the norm cost of both doctor and nurse visits based on Tsao Foundation experience is low on a per visit basis, but potentially very generous on a yearly basis. You can claim up to $2,880 for doctors and $5,280 for nurses, adding up to a total of $8,160 per annum. So there is a tendency to encourage them to make more visits, rather than just what is necessary. Might the Ministry therefore wish to consider reimbursement based on care over a specified period, say, monthly, rather than on a per visit basis? The Minister has responded to Dr Chong Weng Chiew regarding the use of Medisave for home healthcare. I would like to pick up on the Minister's point regarding the possibility, indeed, I believe the likelihood, that good home healthcare will reduce in-patient episodes. I believe that a comprehensive study and cost benefit analysis into the cost of keeping elderly patients well cared for in the home environment, compared to the cost that is incurred the moment a patient needs to be admitted to a general hospital for acute episodes of an illness, a community hospital for rehabilitative care or a nursing home, will be most helpful to the Ministry, as the trade-offs and balances in setting long-term policies and decide on resource allocation for many services for the elderly that need to be established and developed, including the issues of level of norm cost and subsidies and use of Medisave.

Sir, at the moment, the Ministry of Health is organising step-down health services for the elderly around three zones, ie, the west, central and east. Each zone will be anchored around an acute regional hospital with geriatric department, for example, Changi General Hospital in the east, Tan Tock Seng in the central zone, and Alexandra in the west. As the needs of the elderly change over time, with some having disabilities that require extended care and step-down facilities, may I ask the Minister what are the future plans the Health Ministry has in healthcare for the elderly? Are there plans to increase the number of community hospitals to meet higher demands as well as more trained doctors and care-givers? Still in keeping step-down care facilities affordable and attractive to all sectors of the population, more has to be done, especially in attracting private sector initiatives in such services. I believe that private hospitals may be encouraged to venture into such an area and develop their own wing or subsidiary companies to handle this service. Image will improve and more people will be encouraged to opt for such services that will eventually help ease bed shortages in acute hospitals. Upgrading the standards of step-down care services has to be given greater priority if the total health industry, from primary care up to tertiary care and recovery, is to be of world-class standard.

Sir, my points have already been answered by the Minister. I would thus like to withdraw my amendment.

Sir, firstly, I would like to thank the Minister for being extremely patient with me on this subject of ElderShield. Sir, I do not wish to belabour this issue more than what is necessary but it is an important issue and it affects a very important segment of our population, and the bulk of the Members in this House are part of that scheme. In fact, over time, all of us will be part of it. I am pleased to note that in the Minister's reply to my earlier question the Ministry has been working closely with the operators to ascertain the reasons for the lower than expected take-up rate and it will review the scheme at the appropriate time. Sir, I would like to urge the Minister to consider three specific areas in reviewing this scheme. These areas arose from a survey that I have conducted in conjunction with some students from the university. Firstly, the premium. Many residents feel that the premium is too high. Some feel that they could not afford it, especially those who are already affected by the economic crisis. As a new scheme, I understand that it is not easy to determine what premiums will be appropriate. However, after we have gained some experience in the claim patterns, I hope the Ministry will be able to review the premiums. It may even be possible to consider a rebate system to return some of the surpluses after providing for reasonable profits for the operators. Secondly, the qualifying criteria may need to be relaxed. The second most common complaint is against the stringent criteria to qualify for the claim. Psychologically, it is difficult for a person to imagine a situation where he or she cannot perform three of the six daily routines. If it occurs, there is a good chance that the person might have many other problems to worry about. Then, the amount of the payout from the ElderShield will be of no comfort to him. It will be more meaningful and more attractive if a lower degree of disability is adopted, perhaps, different levels of payout can be given to different degrees of disability so that it is not an all-or-nothing situation. Thirdly, a higher payout will make the scheme more attractive. One of the key attractions of any insurance scheme is to have peace of mind. Therefore, a half solution sometimes is no solution at all. Yes, the payout will be helpful somehow but it is not designed to provide full financial support. It therefore does not provide the much needed peace of mind. If the payout cannot be increased without increasing the premium, then we can consider an add-on scheme with higher payout and higher premium for those who really want to have complete peace of mind and can afford it. Sir, ElderShield provides a much needed safety net, especially for the lower income families. It is of grave concern that many of the lower income Singaporeans have opted out of the scheme. I hope that the Ministry will review the scheme as soon as practicable with some of these adjustments so that, hopefully, fewer people will opt out of the scheme. And I know that the Minister will say, "Give the scheme some time to operate and we will review it in good time." Sir, I shall patiently and eagerly await for the review.

Sir, I would just like to comment on the Interim Disability Assistance Programme for the Elderly (IDAPE). Last July, the Ministry of Health announced a very generous scheme, setting aside $300 million for the disabled elderly for a period of five years and with monthly allowances of $100 or $150, as the case may be. Under the scheme, an elderly has to be at least over 70 years old, and must be possessed of at least three disabilities and also come from a family with not more than $1,000 income per head. Since the inception of the scheme, and as at 1st November, I understand that only slightly more than 2,000 people have qualified and about a quarter million dollars has been disbursed. If we do some Mathematics, at $100, we should have about 50,000 people, and for $150, about 33,000 should qualify. So it would appear that not many people have qualified, and I would like to suggest a few revisions for the Minister to kindly consider, now that we have about nine months of experience. 4.30 pm Firstly, the age limit ought to be reduced to, say, over 55 years old. Secondly, there should be a redefinition of disability again, so as to capture more people. I was a little taken aback that a patient in a wheelchair was told that she was not disabled enough because she can sell tissue papers to earn a living. Under such difficult conditions, we ought to reconsider the definition of disability. Thirdly, we can also increase the allowance of $100-150 because it does cost a lot more to look after a disabled patient. So I would like the Minister to kindly reconsider because it is really heartening to know that under such difficult times, a very generous fund has been set up, but it is not very meaningful if not too many people qualify.

First, let me address the issues of junior doctors raised by Dr Lily Neo. I agree with her that we want to set in place sensible requirements for our doctors, especially the junior doctors, to make sure that when they serve the people, their hours of service are reasonable. And, at the same time, when they undertake training, they have time to develop their career further. The situation in the past had not been entirely satisfactory and that is the reason why we have been progressively setting tougher and tougher standards for the clusters to meet. Right now, my Ministry closely monitors the number of night calls performed by our junior doctors, and the latest figures we have is that, in the two clusters, 74% of our junior doctors do an average of six night calls, or less, per month. So we are setting higher standards for the clusters to meet, and the clusters are working hard to increase the percentage of junior doctors who do six night calls, or less, per month. So, I want to assure the Member that the clusters will progressively set better and better standards. We have also asked the clusters to ensure, as far as possible, that the junior doctors are able to go off work by lunch time, the day after their night call, so that the total duration of the call is not more than 28 hours. The clusters are, again, trying to achieve this. We obviously monitor the working hours guidelines in other countries, and we are benchmarking against them. But I hope Members will understand that based on the current manpower situation, we cannot adopt these benchmarks overnight and, therefore, we are working closely with the clusters to try and improve this situation. The clusters are actively recruiting more foreign-trained doctors to address the shortage of junior doctors in the public sector hospitals. I believe these recruitment efforts would be greatly facilitated by the recent expansion of the Schedule under the Medical Registration Act. On her second point about the different training, whether you are a foreign-trained or local-trained doctor, let me assure the Member that there is no policy of discrimination in our public sector hospitals, either for or against overseas-trained Singaporean doctors. All doctors are appraised and assessed based on their performance and ability, and not which medical school they come from. Similarly, all opportunities for higher training and career advancements are awarded on the basis of the doctor's individual merit and whether he or she has satisfied the necessary professional criteria. On the need to make sure that our junior doctors are adequately trained, I totally agree with her. We need to make sure that the training of our junior doctors continues to be a major priority area for us. We are working with our partners, like the Singapore Medical Council and the Joint Committee on Specialists Training, to set the training objectives, the standards and the programmes for both the housemen and the medical officers, as well as specialist trainees. We have a system in place to look at and monitor the training that is conducted. To audit this training programme we have a system of collecting trainee feedback so that we can be assured that these training programmes are effectively carried out on the ground. Let me next turn to the comments raised by several Members on nursing. The nurses are a very critical component of our healthcare system. We have to do all that we can to train more nurses and to retain them, whether Singaporean or foreign nurses. So we have done several things. First of all, to set the backdrop, the public healthcare sector is short by about 364 nurses, which means a vacancy position of about 4%. We are aware of the current shortage of nurses around the world and we know that we have to compete for these nurses. Therefore, the onus is on us to make sure that we can attract more local nurses to join the profession, and the foreign nurses that we attract to come to Singapore, stay with us as long as possible. We have worked with the Nanyang Polytechnic and the Institute of Technical Education to raise the total nursing student intake. The target now has been raised from 728 to 820. Because of the extensive publicity that we have done, both with the clusters and with the educational institutions, we managed to attract almost 900 nursing students last year. So we hope to do just as well this year. More importantly, as Dr Chong Weng Chiew raised, is really to make sure there is a proper career path for nurses. I believe he understands what we have been trying to do the last few years. It is not just adjusting the pay to be more competitive. It is also giving the nurses a wider range of career prospects so that they can develop in the management arena, if they want to, administration management or they can be educators and trainers, or they can be specialist nurses. We have also widened the scope of training possibilities. Many of our nurses now go overseas for a stint of training and attachment under the HMDP programme, and they are very, very happy with this arrangement. Similarly, for foreign nurses. We attract foreign nurses from all over, and over time we would like to reduce our dependence on them but, quite realistically, I do not see the day when we can be totally localised. We have to have both local nurses, as well as foreign nurses, for the simple reason that we need to top up our talent. We need to attract these nurses to come here to work with us, and those who are better, we would like them to sink roots in Singapore. So, I assure Members that this is an area that we are definitely very concerned about and we will work continuously to improve the career path for nurses, both for the local as well as foreign nurses. Let me turn to the several questions raised on the step-down care sector. First, Dr Jennifer Lee asked whether I am happy with the progress so far since we started seriously to develop this framework two or three years ago. There has been some progress, but obviously we need to make more improvements. We still have a long way to go. I think we have done quite well in developing and becoming adequate in terms of facilities. We have put more funding into the step-down care, but we need to do more now on standards and making sure that the care is properly integrated across the board. We have also put in place means-testing for all the step-down facilities - a three-tier subsidy level. So, I think we have set in place the key things that we want to do. But, as I said, there are many improvements, and the questions raised by Members point to the improvements. So let me take these questions one at a time. First, on means-testing. The most equitable way of means-testing is per capita income. This means dividing the household income by the number of family members. So it does not discriminate against bigger or smaller households. The per capita approach is really the most equitable and it makes sure that there is a minimum income level per head. If we use family income as a measure, then it will disadvantage the larger families. So the per capita income approach, to me, seems the most sensible approach. On how we go about adducing the income, how we go about assessing the means-test, we require the family to produce income statements. I think this is a pragmatic approach rather than asking them to self-declare. And, we are prepared to accept a number of different documents as evidence of family income - whether it is their pay-slip, income tax statement, CPF statement, or bank book showing their monthly salary. We are prepared also to review this and accept self-declaration provided they also authorise us to check with IRAS on their income. So if the person says, "I declare this is my income and I authorise the Government to check with IRAS that that is the income", I think we can examine that as a possibility. But basically we need to have the means to determine income and I do not think the various measures that we have adopted are overly onerous. Dr Lily Neo asked whether we will raise the cut-off point. As I have explained earlier, previously the step-down care had a single level of subsidy of 50%. We raised it to 75% for the more deserving, and then we have a three-tier system. Obviously, in due course, we will look at the income cut-off, but I just want to make the point that when we changed over, we were already doing it in a more generous way. She also asked whether we would have a centrally-run means-testing mechanism. There are pros and cons. If we have a centrally-run bureaucracy for means-testing, some Members earlier preferred variable criteria and variable means-testing to tailor it to the different needs, whether it is in-patient, SOC or step-down care. We have to be quite realistic. The subsidy levels are quite different. What is suitable for step-down care, because the person goes in, spends weeks, maybe months, may not be suitable for in-patient where the episode may be 4-5 days and you want a very quick way of doing means-testing. But we are prepared to look at the various possibilities. Whether or not we should have the same system with MCDS, this is something that we are studying. Dr Lily Neo pointed to some statistics about the high unscheduled discharge rate and the premature transfers from acute hospitals to community hospitals. I agree that this is not entirely satisfactory. Our community hospitals are not fully functioning as a step-down community hospital because they have not quite built up their sub-acute capabilities. I have to be candid. Some of our community hospitals are just a little bit better than nursing homes and, therefore, over the last few years, we have aggressively moved to upgrade their capabilities. Having said so, we are not slowly upgrading, particularly the sub-acute capabilities of our community hospitals, and so as we progress in this area, I am confident that this unscheduled discharge rate would drop. In fact, a survey by MOH for the last quarter of last year showed that the average unscheduled discharge rate was 3.7% overall, and St Luke's Hospital achieved a rate of 5.4%. So there is some improvement. But I agree with Members that we have to move aggressively so that the community hospitals are able to receive the patients and take care of them. 4.45 pm I would like to assure Members that casemix does not incentivise or encourage the doctors to prematurely discharge patients from the acute hospitals. This is because, over and above the funding based on the episode, if a doctor says that the patient is not ready to be discharged and the patient is an outlier, the additional days that the patient needs to stay in the hospital will be funded by the Ministry of Health on a per diem basis. So, under DRG, we fund based on the norm cost per episode as well as on a per diem basis if it is an outlier. This is to remove the concerns by Members that if we just only fund per episode, then there may be a wrong incentive to discharge patients early. I have assured the House earlier that we also fund outliers on a per diem basis. Sir, in the end, we are counting on the doctors to be professional and to make the professional determination when a patient is ready to be discharged. And if the patient is not ready to be discharged, we will continue to fund that case as an outlier. The development of the step-down care has been progressing reasonably well. Today, we have 51 nursing homes with about 6,700 beds. 75% of the nursing home beds are run by the VWOs, for which our Ministry provides 90% of the capital cost as well as the operating subsidies, depending on the means-testing of the patients. We have encouraged the private players to come into the nursing home sector by making land sites available. The means-testing allows us to channel subsidies to those who are financially deserving, and such patients can either be managed at the VWO homes or in the accredited private nursing homes. As I said, our attention now is to focus on quality, and we do so through our licensing mechanism and through several clinical quality assurance initiatives as well as a fairly stringent clinical audit. It is our intention to develop this clinic audit so that every nursing home will be inspected and audited for quality every year. We have also produced guidelines to help providers enhance the standard of care. So I agree with Members totally that quality will be the focus from here on. Dr Jennifer Lee also wants to know whether we can involve more GPs in the Primary Care Partnership Scheme (PCPS). Today, we have 600 GPs in the scheme, and I am sure all Members know of the clinics participating in the scheme in their constituencies. In Telok Blangah, for example, for each of the estate that I look after, whether it is Telok Blangah, Dover Road or Depot Road, there are at least two clinics participating in the scheme. And we do that systematically for all the constituencies to make sure that there are enough clinics for the elderly to have access to the GPs. Sir, I do not think accessibility to the clinics is a problem. But we will continue to encourage more GPs to sign up. Right now, we have 600 and we will try harder to get more to sign up. As regards norm cost, we will continue to review it. This is very important. If we set norm cost too generously, then, of course, we are encouraging inflation and higher cost. We want to set a sensible norm cost and try to persuade the providers to try and meet this norm cost. Of course, if we set it too low, then Members are concerned that this will be at the expense of quality. So we will have to review it regularly and make sure that the norm cost is sensible and, at the same time, it does not lead to cost escalation. Mr Andy Gan wants to know the plan for the number of community hospitals. Our intention is to have one community hospital co-located with each regional general hospital. So, for the next general hospital that we are building in Jurong, we will have a community hospital there too. Through this plan, we are confident that we will have enough community hospitals to serve the needs of Singaporeans. Our intention is to increase the proportion of private nursing homes from the current 25% to 40% by 2010, so that the private sector can contribute actively in this step-down care sector. We have tendered out several sites. The development is on schedule. So the provision of the private nursing homes is coming on stream as we planned. And by extending the subsidy to the private nursing homes, we are, in fact, creating a level playing field between the VWOs and the private sector. In so doing, we think this will incentivise the private sector to participate more actively in this sector. As Members know, my Ministry runs annual dialogues with the key providers in the step-down care sector. To this end, we will welcome any new initiatives from the private sector to develop the step-down care sector further. Finally, on ElderShield and IDAPE. I commend Mr Gan Kim Yong for his patience and his perseverance. I hope he will continue to be patient, because the claims pattern cannot be determined in a matter of months. It must be clear after a matter of years. So I think we need time for the claims pattern to settle. With that claims pattern data, we will be able to make a sensible review of ElderShield. Mr Gan Kim Yong is an extremely sensible person and he knows that there is this trilateral relationship between premiums, pay-outs and qualifying criteria. We cannot have low premiums, high pay-out and low qualifying criteria. Something has to give. So we will look at the system when we get better claims history. But I would like to assure him that we do have a clause in our contract with the two private sector insurers, that if the pay-out is less than what they anticipated in their calculation of the premiums, there will be a rebate. It is in the contract. Ms Fang Ai Lian asked about the IDAPE pay-outs. To date, more than 3,600 Singaporeans are benefiting from the monthly IDAPE pay-outs. I agree with her that the budgetary provision for the IDAPE has been set very generously, because we expected a higher pay-out pattern. As it turned out, the people who qualify are fewer than budgeted. But we have to work this system for a few more months to be confident that this pattern is indeed the level of disabilities in our senior citizens. Let me also qualify that for those who are already handicapped or severely disabled, there is no age criterion. Age criterion above 70 years old is only for those who are currently not disabled. And if they become disabled subsequently, then they qualify under IDAPE. For those who are already handicapped and below 70 years old, they already qualify. I will take into account her suggestions, but let me respond quickly. First, to reduce the age limit. The reason why we set the age limit at 70 is to encourage those below 70 to opt into ElderShield. What we are saying is that if we put those above 70 in the risk pool of the ElderShield, it will cause a very high burden on the rest of the people in the risk pool. The Government undertakes to fund the risk of those above 70 years old, so that the premiums of those in the ElderShield risk pool is lower. So the age limit is determined on that basis. On the definition of disability, we chose three ADLs, because that is the market standard. This is the current insurance standard. We are working with the GPs very actively to make sure that their assessment of what constitutes three ADLs is consistent and sensible across the board. With experience, I am sure we can sit down with the College of Family Physicians and the SMA to make sure that the criteria can meet the needs of the insurance companies and can serve the needs of Government without causing a huge pay-out if we change the criteria too drastically. I think there is scope for us to fine-tune the criteria of what constitutes three ADLs as we go along. As to whether we can increase the allowance, this is something that we have go back to the Ministry of Finance. The fact that we have over budgeted does not mean that we can increase the allowance. We have to go back to MOF and make out a sensible case why the allowance of $100 or $150 ought to be increased further to help these people. Sir, I believe I have addressed most of the issues.

Sir, can I seek clarification from the Minister?

Yes.

Sir, when I listened to the Minister's reply to Dr Lily Neo's query on the statistics of mortality at the community hospitals, I am a little bit disturbed. Because, sometime ago, when casemix was brought before this House, I did warn the Ministry that they must be able to match the casemix programme that they are introducing with the high end step-down care. When the Minister says that the community hospitals are inadequate to take care of the acute cases discharged by our hospitals, I think it is very telling. We have not actually planned for this high end care very well before we introduced casemix. What I want is an assurance from the Minister that more funding should be put into this high end care, or else we will get more mortality, like the statistics given by Dr Lily Neo. I am asking that the Minister should, first, make sure that the discharged patients are carefully evaluated; and, second, more funding for this high end step-down care.

Sir, as I have explained in my answer, first of all, casemix is not the culprit in discharging patients. We have to trust the doctor. If the doctor says that the patient is ready to be discharged, that is his professional opinion. I think we have to trust him. The casemix system does not incentivise the doctor or the hospital to discharge the patient, because, under casemix, we are subventing both the funding per episode, and if the patient needs to stay longer in the hospital, we will continue to fund on a per diem basis. That has been my assurance and that is what is happening on the ground. When Dr Lily Neo quoted this study done on St Luke's Hospital which showed a very high unscheduled discharge, the sub-acute capabilities of our community hospitals are still not there yet, and I readily admit to it. And that is the reason why we are building the capabilities. We have a regional general hospital with a geriatric department supporting each community hospital, so that the hospital does not just discharge the patient and shed its responsibility. The regional general hospitals continue to provide the professional support to the nursing homes within the regional catchment. We are providing the funding for the community hospitals to develop their capability, particularly in the sub-acute areas, as I mentioned. And as a result, our survey showed that the situation has improved and my Ministry will continue to monitor this and make sure that the situation gets better and better. 5.00 pm So I want to assure Dr Tan Cheng Bock that casemix is not the cause for premature discharge. He and I must agree that, in the end, we have to depend on the professional judgement of the doctors in signing off the discharge. And I believe that all our doctors discharge that responsibility professionally. They do not discharge a patient if they, in their opinion, think that the patient is not ready. And our system is such that if the patient is not ready, the patient continues to be funded by us.

Thank you, Minister, for the assurance. Sir, in year 2000, the Health Ministry here set up a Group Purchasing Office to buy drugs in bulk at better prices for the entire public sector. This led to savings of $12 million a year, despite the fact that it bought only roughly 700 essential drugs this way. Hospitals and polyclinics bought other non-standard drugs themselves from drug companies. This has resulted in differences in the selling prices for certain drugs at the various public hospitals and polyclinics. May I ask the Minister why the Group Purchasing Office could not extend its service to include buying all drugs for the public institutions? Now that the Government has involved the private sector in the care of subsidised needy patients as in the Primary Care Partnership Scheme, why has this scheme not been extended to include the private sector to save patients' medicine costs? Sir, last year, the liver damaging drug "Slim 10" was brought into Singapore and sold as Chinese proprietary medicine. Chinese proprietary medicines and health supplements were sold over the counter products that could be purchased without prescription. This contrasts with western medicines that are stringently evaluated by the Health Sciences Authority for their quality, safety and efficacy before marketing is granted. "Slim 10" has caused two persons to suffer from liver failure and one person to die from liver failure. What has the Ministry of Health done to-date to prevent such repeat incidents? As most consumers are trusting the local system that the Government has in place to ensure that products available for sale are safe for consumption, are there now more stringent marketing regulations for Chinese proprietary medicines and health supplements? What has the Ministry done to improve our system to ensure that no adulterated drugs are sold? Has the Health Sciences Authority been more proactive in the surveillance of the available drugs sold over the counter? Should I go on to my next cut, Sir?

Carry on.

Thank you. Sir, on biomedical research, Singapore is continuing to drive for excellence in biomedical research and development. Whilst this holds the promise of tremendous advantages for mankind, especially in finding new treatments for diseases and promises of vast monetary benefits in a new economy, we must be sensitive to the ethical, legal and social issues in this area, especially in our multi-cultural and multi-religious society. What has the Ministry of Health done to ensure proper conduct in the various aspects of research, especially in clinical trials and human stem research? Are patients and donors able to make voluntary and informed choices? Are there guidelines in place to ensure that donors of research are not under any financial, or therapeutic inducements, or coercions for their donations? What is the Ministry of Health's stand on human cloning? Does the Ministry of Health specify the distinction between surplus embryos and research embryos and the protection of human embryos because there is contention that human life begins from the moment of conception? How do we ensure protection of the human embryo against the scientific value of research embryos and the potential benefits to be reaped from research? Presently, there is no comprehensive legal framework in Singapore governing research on human embryos, except for guidelines, namely, the "Guidelines for Private Healthcare Institution Providing Assisted Reproductive Services". Should not such research be effectively and efficiently monitored and regulated?

Sir, I declare my interest as a practising psychiatrist. While we may boast to have one of the best healthcare systems in the world, I am afraid that we may not say the same for our mental health service. We are about 50 years behind time in the way we treat our psychiatric patients. Sir, in the past, before effective medical treatment was found for the mental illness, patients with severe psychiatric illness were locked up in jails, or in asylums. Such a custodial approach was not only inhuman but was detrimental to the overall well-being of the patient. Many of them became, what we call, institutionalised, lost their identity and literally became a zombie. After the discovery of effective medical treatment and a better understanding of the underlying organic causes of mental illness, coupled with the realisation of the deplorable state of mental institutions, the movement to deinstitutionalise mental patients and help them reintegrate back to the communities was started in a number of developed countries in the middle of the last century. While there have been some hiccups in the process of deinstitutionalisation in some of these countries, the overall result has so far been positive. Sir, we missed the opportunities to move towards a community care model when the Woodbridge Hospital was redesigned and rebuilt in the late 1980s and 1990s. By then, much of the world already had moved on or in the process of closing down mental institutions and getting their psychiatric patients to move back to the communities. Yet, in Singapore, we continue to lock them up. Worse still, we miss another opportunity recently when the Ministry of Health started the process of, what they call, "decanting" long-stay patients from Woodbridge Hospital to the Pelangi Village Complex under MCDS, and this continues the approach of custodial care. To use the word "decanting" is what I find demeaning to the mental patients. This process, to me, I would describe it as "trans-institutionalisation", ie, moving the patient from one institution to another institution. One look at the way in which this complex is constructed, with high fencing and with patients pacing about in the complex, stuck in their catatonic state, you will know what I mean. Sir, here, I urge the Ministry to review its overall approach and philosophy towards the mental health service. I would like to suggest that the Ministry set up a Mental Health Service Committee consisting of representatives from the patients and their advocates, mental health professionals and policy makers. The Committee should be tasked to: (1) chart the long-term direction of our mental health service based on a community care model with comprehensive support for the patients, in terms of their medical care, rehabilitation, psycho-social needs, housing and employment assistance; (2) educate the public in order to destigmatise the mental illness; (3) review and revamp our mental health legislation to facilitate community care and treatment. I also suggest that the Ministry set up a Mental Health Service Directorate, with the appropriate budget, to take full charge of the implementation of this mental health service as proposed by the Committee. Sir, we are already half a century behind in the way we view this mental health service. But it is time for us to make changes. All is not lost. Because we could learn from those countries who have undertaken the process of deinstitutionalising their mental health services. We can learn from their experience, avoid their mistakes and thus shorten our learning curve. Sir, we owe this obligation to this group of our fellow citizens who are unfortunate enough to suffer from mental illness.

Sir, I want to thank Dr Lily Neo and Dr Ong Seh Hong for their questions. I begin, first, with Dr Lily Neo's question on bulk purchasing and Slim 10. With regard to bulk purchasing, the Group Purchasing Office of the two hospital clusters already bulk purchase standard drugs and commonly used non-standard drugs for the polyclinics and health institutions. As Dr Lily Neo noted, this has resulted in a lot of savings. But the institutions have also carried out some of their own purchases for non-standard drugs where smaller quantities are needed because it is more efficient and flexible in meeting their needs. The Ministry of Health has also requested that clusters should explore the extension of these services with willing partners in the private sector. With regard to Chinese proprietary medicines (CPM) and the Slim 10 incident, the regulatory controls for Chinese proprietary medicines were introduced in phases from September 1999 and were fully implemented by September 2001. All CPM importers, wholesalers, local manufacturers and repackers must be licensed by the Health Sciences Authority. Among the things that the Health Sciences Authority looks at include an assessment of the safety and quality of these medications. There are also full labelling requirements before they are allowed for local sale. But since the Slim 10 incident in 2002, MOH has further enhanced the control of CPM through additional measures. Since January 2003, all CPMs must carry an additional label on the outer sealed packs in both English and Chinese. This label says "Allowed for sale as a Chinese Proprietary Medicine". This helps consumers to better differentiate CPM from western drugs. From 1st January 2004, the test reports issued by accredited laboratories will be recognised and accepted by HSA. The existing product and quality surveillance programme carried out by HSA has been enhanced and strengthened. Also, all local and overseas CPM manufacturers will be subjected to periodic good manufacturing practice audits, in accordance with international standards. The CPM regulatory framework in Singapore has already been enhanced to a considerable extent and we now have one of the strictest framework in the world. In spite of this, no system, short of complete prohibition of products, can absolutely guarantee the prevention of deliberate adulteration, as occurred in the Slim 10 incident, and which can potentially occur in even the strictest of systems. Dr Lily Neo's next question was with regard to regulation of clinical trials. For clinical drug trials, a clinical trial certificate is required from the Health Sciences Authority by law before research can proceed. Issuance of a trial certificate is conditional on the research meeting the requirements stipulated in the Singapore Guidelines on Good Clinical Practice, which include specific requirements for proper informed consent. For other forms of clinical research involving patients or human subjects, there are ethical guidelines on research involving human subjects issued by the National Medical Ethics Committee. Under these guidelines, hospitals and institutions, where such research is carried out, have Ethics Committees to review the ethics of research projects and approval is necessary before such research can proceed. 5.15 pm Dr Neo was also concerned about human embryos. Under the guidelines for private healthcare institutions providing assisted reproduction services, Regulation 4 of the Private Hospitals and Medical Clinics Regulations, there are guidelines regulating the use of human embryos below 14 days created through in-vitro fertilisation techniques but which are not used in assisted reproduction treatments. This is permissible, provided stringent regulatory stipulations are met. With regard to donation of parts for research, no person is under any compulsion to give, nor is any person under an obligation to accept these donations. These provisions in the Medical (Therapy, Education and Research) Act ensure that patient donors are protected through having to make informed choices and are not under any financial inducement. But to further enhance our regulatory oversight over biomedical R&D areas where there are greater ethical concerns, the Ministry of Health is in the process of drafting a new Bill which will provide for the regulation of human stem cell research and human tissue research and banking, and provisions to extend the regulation to selected new types of biomedical R&D as these evolve. It will have the necessary regulatory and enforcement provisions to enable the Ministry to issue licences for biomedical R&D facilities, and monitor and control selected biomedical R&D activities. MOH intends to enact the new Act sometime this year. Dr Ong Seh Hong was concerned about insane patients being locked up in hospitals. I want to assure Dr Ong that we have come a long way since the day when all insane patients were just locked up in asylums. In fact, we have moved into the area of preventive mental healthcare. We have put in place a comprehensive range of community and institution-based programmes for the mentally disordered. These include various public health initiatives and community services, such as nursing homes, rehabilitation homes and day rehabilitation centres. Two major initiatives have been implemented in Singapore. They aim to educate the public on prevention strategies, decrease stigmatisation, and increase awareness of mental conditions and availability of treatment. The first initiative is the Mind Your Mind Programme, which is a 10-year prevention programme started by the Health Promotion Board in 2001 as part of the National Mental Programme. The second initiative is the Early Psychosis Intervention Programme, which is a comprehensive and integrated treatment programme that targets the reduction of chronic disability amongst schizophrenic patients. Woodbridge Hospital has also formulated long-term and immediate action plans to achieve a more balanced model of community and institutional psychiatric care. These plans include enhancing the quality of in-patient care and ramping up the development of community psychiatric care services in the next three to five years. But at the end of the day, whether a patient should remain in an institution or whether the patient can be sent home is a clinical decision, which we will have to leave to the competent psychiatrists at our institutions to decide.

Sir, the health of workers is a key factor in influencing their productivity. As the economy of Singapore is heavily dependent on its workforce, a healthy workforce will enhance the country's competitiveness in an increasingly global market. With about 2.1 million or 65% of Singaporeans aged 15 years or more working, the workplace is an ideal setting for the development and delivery of health promotion programmes to the workers. Workplace health promotion programmes should include a combination of educational, organisational and environmental activities designed to support behaviour that is conducive to the health of employees. Would the Ministry of Health help strategise the uptake of workplace health promotion in the private sector with the following four emphasis: 1) As management remains the main driver behind these programmes, there is need, therefore, to secure the support of a company's management with the provision of adequate support of the administrators or health facilitators, preferably facilitators with a healthcare background; 2) There should be an expansion of the local scope of occupational health and safety to include the promotion of workers' health through healthy living; 3) Financial assistance in the form of grants would be of value to help jumpstart health promotion programmes, particularly for small workplaces; and 4) Have in place guidelines on how to organise effective workplace health promotion programmes for workplaces of different workforce and industry sector to adopt. This "cookbook" approach has a place in increasing the uptake, particularly among new companies embracing the programme.

Sir, on workplace health and workers' health, I would like to support what Dr Lily Neo has raised. One other main concern that I would like to share with the House on preventive healthcare is how to help Singaporeans reduce health risk factors. What are these risks? They are the risks arising from not eating right, not exercising enough, and smoking. Let us take our diet, for example. We should reduce salt and saturated fat intake, and eat more fruits and vegetables. The World Health Report 2002 showed that three-quarters of heart disease and stroke could be attributed to tobacco use, low fruit and vegetable intake, and lack of exercise. More than half of deaths and disability from heart disease and stroke can be cut down. All it takes are national effort and individual actions to reduce health risk factors, such as smoking, high blood pressure, high cholesterol and obesity. In Singapore, we have put in much time and resources to promote and facilitate intervention programmes at the workplace. We do it at the tripartite level as a collective effort, involving the Government, union, employers and all Singaporeans. I commend the efforts of the HPB, but we have to do more. What do we need to do next? We have to "awake the giant within" Singaporeans and cultivate self-responsibility through health risk management. Today, we still see Singaporeans choosing "not to face the reality". They avoid health screening. Let us make a collaborated and structured effort to make all Singaporeans aware of their own health risk. We can start with basic health screening, followed by ways of empowering Singaporeans to take personal responsibility for their health risk factors. We can help create the "internal drive" within Singaporeans to stay healthy. In short, raise their awareness and help them to create the drive to take action. What are the actions we are talking about? It is just as easy as saying CHEERS, which stands for Cease smoking, Healthy Eating, Exercise Regularly, manage Stress! Sir, over the last two years, the NTUC Health Outreach Programme has helped 50,000 workers to start basic screening and monitoring their health risk factors. I would like to ask the Ministry of Health for an update of what it plans to do to help Singaporeans regularly assess and monitor their own health risk factors and basic health profile, and better manage all these risk factors for better health.

Sir, I propose that the Ministry of Health re-examine and explore more ways in which minority races can learn about the importance of good health in Singapore. Healthcare promotion plays an integral part in ensuring that Singaporeans are better equipped with knowledge critical to living a healthy lifestyle well into their golden years. It is important for Singaporeans to develop healthy habits through health promotion programmes. The nation-wide Community Health Screening Programme is not only a good exercise but an important one at that. It would at the very least ensure that our people are able to manage their health in a proper and educated manner. Through health screening, Singaporeans will then be able to spot the tell-tale signs warning of possible illness early and to seek treatment in time. This is especially true for cases of hypertension and diabetes. We have a variety of healthcare promotion programmes initiated by the Health Promotion Board. However, I was disappointed to learn that a significant proportion of minority races do not know enough about these health promotion programmes. I discovered that this was because the methods used to disseminate information to the general public, although widespread, could be better targeted. It is critical for us to reach out to our non-mainstream language speaking minorities. Sir, the health promotion exercise in Singapore assumes that the audience is proficient in English. It assumes this of the many elderly targeted by the Community Health Screening Programme. As many Members in this House will attest to, most of these individuals are usually conversant in dialects and speak little or no English. For example, I have come across several instances where some minority race constituents are not aware of the reasons why the Community Health Screening Programme is conducted, much less how they can go about getting a health screening done. This was primarily because it was not explained to them in a manner they could understand or, more specifically, in a language they could understand through the various media forms employed now. I urge the Minister to consider how healthcare promotions can better reach the minority races in Singapore. Perhaps, it would be helpful if the ethnic self-help groups' assistance could be enlisted. Having more promotional materials in Malay and Tamil would certainly help.

Sir, Singaporeans are reasonably health-conscious, both in terms of making sure they are healthy, and also in terms of knowing more about health matters. Our Government, especially the Ministry of Health and the medical fraternity, has done a great deal to try and enhance health promotion and dissemination of health-related knowledge. We all know that prevention is better than cure. In this connection, Sir, what more can the Ministry of Health do to bring about greater health promotion, ie, having a healthy nation of citizens, and propagate knowledge on health, diseases, etc? Would the Ministry consider stepping up the use of the mass media, eg, newspapers, TV, radio, Internet and the MOH website, and also the schools and workplaces, to promote knowledge on health matters on a higher scale? For example, there should be more TV shows and radio talks to educate our people about diseases and health care in simple language in the four major languages. A great deal can be done in our primary and secondary schools, and our tertiary institutions too, to promote health, guidance on healthy living, knowledge on health, preventive measures to avoid or reduce health problems. There should be well-organised healthcare and health knowledge classes. Health promotion may be enhanced also if there is less tension in life. In this connection, does the Ministry of Health do progressive research in and work with other Ministries, eg, the Ministry of Education, Ministry of Manpower and the Ministry of Community Development and Sports, to coordinate health promotion through education, proper lifestyle, sports and recreation?

Sir, as of October 2002, 24% of adult Singaporean residents aged 18-69 are overweight, while another 6% are obese. Weight problems are largely attributable to a less than healthy lifestyle, and we note that there are well-established relations between excessive body weight and conditions, such as diabetes, hypertension and osteoarthritis. I commend the Ministry for having embarked on large-scale programmes to combat obesity among children, such as the School Tuckshop Programme and the Trim and Fit Programme. These programmes have certainly helped to reduce obesity among children from 14% in 1992, to 10% in 1996, and having remained steady after that. Sir, the Ministry has also started the Workplace Health Promotion Grant in 2001. Its target audience is, presumably, our workers. The question is: how effective has this grant been among our workers? How many of our workers have benefited from this grant and how have they benefited? In 1998, our death rate of 76 per 100,000 from coronary heart disease is higher than the rates of 58 and 60 in Canada and Australia, respectively. Our death rate of 29 per 100,000 from stroke is also higher than the rate of 14 in Canada and Australia. Have our figures improved since then? 5.30 pm Sir, I also seek to ask whether the Ministry has conducted a detailed profiling of our adult population with medical conditions to see whether there is a relation between their cultural or ethnic backgrounds and a propensity towards certain diseases. Is educational level also a relevant factor in this relation? If so, Sir, I ask whether there are in place specific programmes that target these specific groups. Such targeted programmes would be more effective in reaching out to these groups who may speak certain languages, prefer a certain diet and subscribe to certain cultural practices. These programmes can be more culture-sensitive and should result in better buy-in. Further, a recent study in the US shows that the weight patients vary in their readiness to adopt specific weight loss behaviours. For instance, some are willing to exercise more but not reduce fat in their diet. Others are willing to eat more fruits and vegetables but are not willing to eat smaller portions of food. So if doctors can identify which behaviour patients are willing to change, they can assist in an effective weight-loss programme. But doctors are usually constrained by time and not reimbursed for obesity counselling. Will the Ministry consider studying the effectiveness of individual obesity counselling and perhaps later start a grant to encourage the same?

Sir, the promotion of healthy living, such as having a well-balanced diet, exercising regularly and not smoking, is essential to maintain a population of healthy citizens. Many diseases can be prevented by maintaining healthy lifestyles. This means that the Health Promotion Board should not just be persistent but also accelerate such promotion. The hallmark of success of such promotion is to be able to reach as many people in the community as possible. Sir, the publication of information booklets, organising of health talks and health screening may increase the level of awareness among Singaporeans on health matters but it does not make Singaporeans healthy if they do not act on this information or advice. We need to adopt a more structured approach to ensure that health promotion messages are disseminated to Singaporeans, especially the heartlanders and they adopt healthy lifestyles. Sir, in North-West CDC, we have formed the largest network of brisk walking clubs in Singapore. To-date, we have 75 clubs, comprising over 8,000 members who exercise regularly to keep healthy. I hope that the Health Promotion Board can be more proactive, to work closely with the CDCs to have more effective outreach in the community. May I ask the Minister what kind of promotion has been done to achieve the healthy lifestyle message? Has this programme been successful in reaching the community at large? Are there plans to partner with the CDCs and what are the key performance targets of the Health Promotion Board?

Sir, I want to thank Members for their interest in health promotion. We have made good progress in improving the health of Singaporeans. However, we need to reduce the prevalence of cancer, coronary heart disease and stroke, the major causes of ill health and deaths among Singaporeans. Other diseases of public health concern include myopia and osteoporosis. The Health Promotion Board was established two years ago to spearhead national health education, promotion and disease prevention programmes. The main thrusts of the Health Promotion Board (HPB) are: First, to educate the public on healthy living. The four pillars of a healthy lifestyle are regular exercise, healthy eating, no smoking and managing stress. I am glad to note that many Members mentioned all these. Second, where it is cost-effective, screen children, adults and elderly for common illnesses to detect and treat these conditions early for better outcomes. Third, collaborate with voluntary and community organisations, including CDCs, professional organisations to ensure a wide reach. Fourth, create a supportive environment for healthy living. Dr Lily Neo and Mr Yeo Guat Kwang brought up issues on workplace health promotion. HPB has been encouraging companies to implement a comprehensive workplace health promotion programme. Several strategies are used to secure management support, for example, chief executive officers and senior management are invited to sign the HEALTH charter, ie, Helping Employees Achieve Lifetime Health. And through this charter, pledge their commitment to implement Workplace Health Promotion (WHP) programmes in their workplace. There are also breakfast and lunch meetings which are organised for CEOs and senior management to inform them of the benefits of implementing WHP programmes. A booklet and a video CD targeted at CEOs have been developed and distributed to CEOs to facilitate their understanding of workplace health concepts. A matching WHP grant of up to $5,000 for each workplace was made available from 2001 to encourage workplaces to implement WHP programmes. To-date, about 200 workplaces have been awarded the grant. For a more holistic approach to workplace health, HPB has integrated occupational health and safety, productivity and worklife balance in the WHP programmes. HPB conducts training courses to equip facilitators of workplaces with skills to organise, plan and implement WHP programmes. A guidebook and a video CD on WHP for facilitators have been developed to help them plan and start WHP programmes. One of the components of a WHP programme is basic health screening. HPB, in its consultancy and training programmes for workplaces, emphasises the importance of conducting basic health screening for their workers. Workplaces are encouraged to include screening for hypertension, diabetes, high blood cholesterol and for obesity in their health screening packages. They are advised to monitor the results of screening of their workers and to organise intervention programmes for them based on the results of screening. Mr Ahmad Khalis wanted to know whether MOH has a profile of persons suffering from various diseases. He suggested that health promotion programmes be targeted at high-risk groups. The major causes of ill health and death among Singaporeans are coronary heart disease, cancer and stroke. The risk factors for coronary heart disease are smoking, high blood pressure, high cholesterol levels, obesity, physical inactivity and diabetes. The national health surveys conducted regularly by MOH provide information on the prevalence of these risk factors by age, sex and ethnic groups. The 1998 survey showed that the prevalence of these risk factors is higher among the Malays and Indians, compared with the general population. For example, the smoking habit is most prevalent among Malay men, 43%, compared with Indian men, 30%, and Chinese men, 24%. Smoking rate among Malay women aged 18-24 years is 13%, compared with 5% among Chinese women, and 2% among Indian women. Diabetes is more prevalent among Indians (16%) than Malays (11%) or Chinese (8%). Health promotion programmes are planned based on the results of the national health surveys. Special programmes targeted at the high-risk groups have been implemented. For example, a special programme known as the Ramandan programme has been implemented to address the high smoking rate among the Malay community. The programme is a collaboration between HPB, MUIS and other Malay-Muslim organisations. Mr Arthur Fong had asked about health promotion activities aimed at minority groups. In general, health promotion programmes, such as the National Healthy Lifestyle Campaign, National Smoking Control Campaign, National Myopia Prevention Programme, Breast Screen Singapore and the Osteoporosis Prevention Programme target all ethnic groups and media campaigns are carried in the four official languages through television, radio and the newspapers. In view of the higher prevalence of risk factors for chronic diseases among Malays and Indians, special media programmes have been produced. A 20-part cooking programme was aired on Suria to educate the Malay community on cooking tasty and healthy traditional dishes. In addition, "Rentak Sihat" a 13-part health programme was also telecast on Suria and focused on how Malays can keep fit and stay healthy through simple exercises. HPB also works closely with Berita Harian to publish stories on a variety of health promotion activities. With regard to the Tamil media, a 13-part health programme addressing health issues such as diabetes and hypertension, prevention and proper treatment to prevent complications was produced in Tamil for telecast on Vasantham Central. We will continue to focus our attention on high-risk groups and provide more publicity on health promotion activities in the Malay and Tamil media. Members are correct that prevention is better than cure. To achieve a healthy lifestyle, we need to change the mindset of Singaporeans. To do this, we need to incorporate the help of the community, CDCs, grassroots to bring this message to the ordinary Singaporeans.

Sir, I would like to thank the Minister of State for his answers. I would like to thank the Minister for Health for his good, comprehensive answers and, at times, even over-generous answers. Sir, I beg leave to withdraw my amendment. Amendment, by leave, withdrawn.

Amendment No. (2). Dr Lily Neo.

Sir, I beg to move, That the sum to be allocated for Head O of the Main Estimates be reduced by $10 in respect of Code OA 1500. Sir, in January this year, it was reported in the Straits Times that a doctor was jailed for two months for tax evasion by the Courts and suspended from practice for six months by the Singapore Medical Council. And, in February, a second case was reported. Again, the doctor was jailed by the Courts and suspended from practice for six months by the Singapore Medical Council. Both doctors were ordered to pay penalties of over three times the amount of unpaid taxes by the Courts. The doctors in both instances were rightly punished by the Courts for their offences but they were also penalised by the Singapore Medical Council. May I have the Minister for Health's comments on this kind of "double punishment"? Is the suspension by the Singapore Medical Council, especially the six months, not too harsh? As medical care is a very personalised service and patients under the doctors' care would be affected by the suspensions, do we take into consideration the patients' needs? Rather than suspension from practice, would it not be better to deploy them to work without pay in our public hospitals, community hospitals or VWOs? 5.45 pm Sir, the Ministry of Health has been recruiting doctors from non-traditional sources from neighbouring countries such as Myanmar whose medical degrees were recognised before. According to the Ministry of Health, this was done because there has been a shortage of junior doctors in the public hospitals. May I ask the Minister for Health whether he can assure the House that the standard of care of patients from these doctors is acceptable? Has the Ministry of Health collected data on mishaps and mistakes in public hospitals because of poor standards of care? Has there been a survey done on the causes of mistakes in the public hospitals? Is there an assessment done for the non-traditional source doctors employed from the neighbouring countries? Is there a comparison and assessment on the standards of the non-traditional sources doctors employed from each of the neighbouring countries? Sir, may I have your permission to take the cut on behalf of Mr Yeo Guat Kwang on training support for step-down services?

Yes, please proceed.

Thank you. The Ministry currently has a Health Manpower Development Programme (HMDP) to develop skills needed in specific areas of the healthcare industry. Mr Yeo Guat Kwang understands that the Ministry plans to extend the programme to providing training for staff providing step-down care services. Mr Yeo Guat Kwang would like to ask the Ministry how much will be set aside and how many training places will be provided. At the same time, Mr Yeo Guat Kwang would like to ask the Ministry, not just to provide funding, but also to provide a comprehensive training support system of assessments and monitoring for those trained to provide step-down care services. The Ministry should also consider training those without previous relevant background, but who may be keen to enter into this sector.

Dr Neo, in future, if you were to speak on behalf of a Member, you raise it as if it is your point.

Thank you.

You may proceed.

I will proceed to my next cut on breast cancer. Sir, I applaud the mammogram subsidy scheme for breast cancer by the Health Promotion Board. This scheme has been a great success in attracting a big jump in the number of women going for mammograms. However, due to the increased demand, the women have to wait much longer, almost one month, for the results of the mammogram. Sir, I am concerned, especially for those women who were told that they needed to go for a retest. There were 3,500 such women last year, as they had to wait a further six weeks for their results. The long wait, especially after retest, gave the women much mental anguish and anxiety from the suspense of whether they had breast cancer. Although the second test proved to be unnecessary for hundreds of them, they were recalled because the radiologist preferred to play safe. Last year, 8% of the women tested were recalled and all of them had to pay for the retest, and many of the less well-off found the extra cost to be a burden. May I ask the Minister for Health whether our public test centres are able to cope with the demand for mammograms? Do we have enough radiologists? What are the steps taken to minimise errors of interpretation? Could the waiting period be reduced? Why are our post-positive rates for mammograms so high? Would the Minister consider further outsourcing of mammograms to the private sector in order to tap the under-utilised private radiological centres and their radiologists?

Thank you, Sir, for allowing me to speak on myopia in children. I would like to express my concern on the high incidence of myopia amongst children in Singapore. Myopia is a common disease amongst children in Singapore. One only has to look at the photograph of an O-level class and he will see that almost all the students in that photograph wear glasses, evidencing that they are myopic. It is inconvenient to wear glasses. Girls do not like to wear glasses because it spoils their looks. As for boys, if they have to wear glasses it may affect their chances of being accepted in a sports team, especially in contact sports. Boys with acute shortsightedness may not be accepted in certain jobs, eg, a fighter pilot or to be a commando in the Armed Forces. The best situation is, of course, one who has good eyesight and does not need to wear glasses at all. Sir, I read in the papers recently that myopia can be completely cured with lasik surgery, but the cost of such a treatment is rather prohibitive. The cost of lasik surgery for one eye is almost $2,400 and, therefore, it is not possible to get every myopic person to be cured of the myopia by this form of surgery. The more practical solution would be if myopia can be prevented amongst our children. I read in the papers that in China, the schools there have a programme to engage school children in exercising and relaxing their eyes to cut down on the incidence of myopia. Sir, do we have such a programme in Singapore? I also would like to ask the Minister whether the Government has set aside a budget to do research on how to prevent our children from getting myopia.

Sir, 1 in 4 pregnancies, or 14,000 babies get aborted each year, and almost 60% of these abortions were sought by married women. The reasons given by these women were that they were not ready to start a family, or they did not want to have more children. Would the Ministry of Health consider introducing innovative ideas aimed at reducing our abortion rates? We should certainly have more programmes to teach the various methods of contraception, the responsibility of contraception and the trauma of abortion, targeting especially the married women. Married women should be persuaded to practise contraception rather than resort to abortion as a means of contraception. Could there be even more counselling mandated at the crucial time of decision making? I feel that it is time that we looked into giving these women more genuine alternatives, such as less complicated adoption choices for those who really cannot afford to have more children, and match nanny-services for working mothers to rely on. Teenage abortions are on the increase. Is our sex education in schools adequate? Are our teachers comfortable in imparting sex education to our students? Is there enough emphasis on responsible and safe sex and on the negative impact of unwanted pregnancies, especially the physical and psychological risks? Should there be more support given to teenage pregnancies? Could the Ministry of Health consider studying abortion trauma, which is not much documented?

I will begin first with Dr Neo's question on errant doctors. The Singapore Medical Council places great emphasis on the integrity and honesty of our medical practitioners, as these values are fundamental to a good doctor-patient relationship. It is important for our patients and the public to have confidence and trust in the doctors who look after them. For this reason, the SMC has the authority to look into all cases where a doctor has been convicted in a court, to assess whether there had been professional misconduct. The provision for those who have been convicted for any offence involving fraud, dishonesty or moral turpitude, to have their professional registration suspended is not unique to the medical profession. It also exists in the regulatory legislation for other professionals such as accountants, architects, engineers and lawyers. So what happens with regard to doctors is not unique to the medical profession. The SMC judges each case on its own merits and the penalties may differ according to the specific circumstances in each case. It should be noted that in one of the tax evasion cases, the SMC granted the doctor one month's deferment of his order of suspension so that he could have time to transfer his patients to other specialists for care and management. The range of penalties available to the SMC is prescribed by the Medical Registration Act. The SMC has no authority to require these doctors to perform compulsory community services, as suggested by the Member. Dr Neo was also concerned about the quality of doctors from non-traditional source countries. Non-traditional source (NTS) doctors refer to those who graduated from medical schools that have not traditionally been included in any of the previous versions of the Schedule of Registrable Basic Degrees. Such doctors may be granted temporary registration by the Singapore Medical Council to work under supervision as medical officers within the public sector. A total of 258 NTS doctors were granted temporary registration between 2001 and 2002 to fill the vacant MO positions in our public sector hospitals. These doctors graduated from medical schools in countries such as China, Indonesia, India, Myanmar and the Philippines. Another 19 doctors from medical schools that were in the pre-1993 Schedule were also granted temporary registration during this period. The performance of all temporary registered doctors is closely monitored by their supervisors who are required to submit assessment reports to the SMC in the third month of their appointment, and at six-monthly intervals thereafter, until the doctor leaves. Only doctors with satisfactory performance reports will be allowed to have their registration renewed for up to one year at a time. All doctors with poor or unsatisfactory reports will either have their contract terminated immediately, or after further monitoring, if they fail to show improvement in their performance. Only 6% of the NTS doctors registered between 2001 and 2002 had their contracts terminated. The majority were terminated by the employers for poor performance, including poor command of English. However, none of these NTS doctors have been involved in any complaint or disciplinary case investigated by the SMC. The feedback from our clusters on these NTS doctors has generally been favourable. Compared to our local MOs, they are often more experienced, having worked for at least six years, and many also possess some form of post-graduate qualification. There have been some issues relating to adjustments to a different work environment but, on the whole, the clusters have found many of these doctors to be hardworking and committed. Dr Neo, on behalf of Mr Yeo, had asked about training for step-down care personnel and how much my Ministry has allocated for this training. My Ministry has set aside $3.3 million for the next three years to provide advanced training in elderly and continuing care. Under the programme, doctors, nurses and allied health professionals, such as physiotherapists, occupational therapists, medical social workers, case managers, and others working in step-down care services, can apply for funding support to pursue training or skills attachment at local or overseas healthcare institutions in areas such as geriatric medicine, geriatric rehabilitation, dementia and mental health and palliative care. Trainees must be Singapore citizens or permanent residents. MOH will fund 75% of the approved training expenditure, while the VWOs will fund the remaining expenses of the trainees. They will be required to sign a bond to work with the VWO upon completion of training. The duration of the bond will depend on the length and location of the training. In addition, to ensure that patient care is not disrupted, my Ministry will provide financial assistance of up to 75% of the salary of temporary staff employed to cover the work of the staff who is away on training. To encourage training attachments in local healthcare institutions such as a public hospital for between 1-3 months, MOH will fund 100% of the salary of temporary staff. We estimate that a budget of $3.3 million will be adequate to provide training for 90 staff over the three years, comprising 10 medical traineeships in geriatrics, rehabilitation and palliative medicine; 12 nursing traineeships in advance gerontology; and 70 traineeships in other areas identified to be of high priority for step-down care service development. Let me assure Members that the number of traineeships only serves as an estimate to work out the budget. My Ministry is prepared to support more trainees within the budget allocated. We are also prepared to consider more funding support, if required. Our plan is to offer this as part of our overall operating subsidy to step-down care service providers. We have started inviting proposals from the VWOs for these awards for FY 2003. The deadline for submission is 31st March 2003, and the feedback has been positive so far. Dr Lily Neo also asked about standards of breast screening in Singapore. Breast Screen Singapore, the national breast cancer screening programme, was launched in January last year. A stringent quality assurance programme was implemented from the start of the programme to ensure that clinical quality and service standards are met for both mammograms and the assessment of women with abnormal mammograms. The programme has also instituted minimum service standards for waiting times for appointments for mammogram screenings and for assessments. Breast Screen Singapore is available at a total of 11 centres, ie, in 10 polyclinics and the Health Promotion Board building. To ensure that the quality assurance standards are met, the centres are audited and accredited every two years. Hands-on training and continuing education by international experts are carried out on a continuing basis for all health professionals involved in the programme. Dr Neo noted that the recall rate for assessment of women with abnormal mammograms is about 8%. This recall rate is comparable to the national breast cancer screening programmes in other countries. At present, the average waiting time is three weeks for a mammogram and two weeks for an assessment. My Ministry is prepared to use private sector services in the national breast cancer screening programme, provided they meet our clinical quality standards, and we are looking into this. Mr Chiam noted that many young people in our schools wear glasses. My Ministry recognises that myopia is a major health problem which needs to be addressed. The Health Promotion Board launched a national myopia prevention programme in August 2001. The programme aims to prevent and reduce myopia progression as well as to delay the onset of myopia in children. As the onset and development of myopia occurs mainly during childhood, the programme targets mainly children in schools, kindergartens and childcare centres. The main component of the national myopia prevention programme is public education, particularly in schools, on good eye care habits. The main message is to take vision breaks after every 30-40 minutes of near work, such as reading or using the computer. HPB has also produced updated guidelines for teachers on promotion of vision care in schools, kindergartens and childcare centres. Enhancement of existing vision screening programmes in schools is also emphasised, placing greater emphasis on follow-up of students detected to have myopia and providing more intensive counselling and education for this group. There has also been introduction of vision screening in kindergartens and childcare centres to identify children with early myopia or amblyopia, lazy eye syndrome. For the latter, early treatment can prevent the development of functional blindness in the lazy eye. Pre-school children who are detected to have defective vision through screening are referred to specific refraction clinics in polyclinics for further assessment. In 2002, about half a million students from Primary 1 to Secondary 5 and 43,000 students in kindergarten 2 were screened. In 2003, a similar number of kindergarten 1 students will also be screened for myopia. Since our programme started, three new refraction clinics have been set up in polyclinics to provide refraction and counselling services for pre-school children referred from the screening programmes. Mr Chiam asked about lasik. At the present time, lasik is an accepted treatment for treating myopia in adults. However, it is still not a standard treatment. And the day all eye surgeons give up their glasses and go for lasik, we know it is time to make it a standard treatment! The experience in lasik treatment for children is even less than adults. So, that is why we are not advocating lasik as a standard treatment at this time. Dr Lily Neo was concerned about abortions and abortion numbers in Singapore, and we share her concern. The total number of abortions performed has decreased, from 16,476 in 1993 to 12,749 in 2002. Under the Termination of Pregnancy Act, all healthcare institutions authorised to perform termination of pregnancy, are required to provide pre-abortion counselling to women seeking termination of pregnancy. In addition, 48 hours must elapse after counselling before termination of pregnancy can be performed. This is to allow the woman requesting for termination time to review the situation and decision in the light of information and counselling provided. My Ministry is also working with the Ministry of Community Development and Sports to enhance the counselling process to address the social issues faced by married women seeking abortion, and to encourage them to continue their pregnancies by providing appropriate help. We are also concerned about teenage pregnancies and we are working with the Ministry of Education on this. The Ministry of Education has implemented a sexuality education programme for upper primary and secondary students. The programme which was developed together with the Health Promotion Board aims to provide knowledge about human sexuality and the consequences of sexual activity. It is hoped that through this programme, students would develop healthy attitudes towards sexuality and be able to build responsible relationships.

Sir, the Minister has not answered my question on whether or not the Government has set aside a budget to do research to prevent myopia amongst children.

Currently, SNEC is conducting research on myopia and they have a budget for it.

Sir, may I ask the Minister of State about non-traditional source doctors. He said earlier that those doctors who showed poor performance and poor command of English had been sent back. May I ask him whether it was fair to have subjected our patients to their care before they were sent back? On mammograms, could I ask the Minister of State whether the Ministry of Health will consider waiving the charges for retests for the less well-off women?

Sir, with regard to the first question on non-traditional source doctors, during the time they were being assessed when they first came to work, they were under close supervision of the senior doctors. So there was no compromise on patient care. With regard to her second question, she can send in a request and my Ministry will study it.

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

Amendment No. (3), Dr Neo.

Sir, I beg to move, That the sum to be allocated for Head O of the Main Estimates be reduced by $10 in respect of Code OD 3600. Sir, last year, the Health Sciences Authority changed the blood donor recognition programme for all new blood donors with effect from 1st July 2002. This ruling removed the scheme that subsidises certain consultations, hospitalisation and day surgery charges for regular donors. For example, if hospitalised, there is a 50% discount on ward and meal charges for up to $200 per day. Also, all consultations at polyclinics are free. I believe this costs the Government about $1.7 million each year. The Health Sciences Authority said that the discount system was stopped to ensure that donation is truly altruistic. Nonetheless, this ruling has now created two groups of donors - the old donor group that is still enjoying the discount system and a disadvantaged new group that does not. Sir, may I ask the Ministry of Health whether other methods of encouraging altruism could have been adopted rather than taking away the discount system? May I also ask whether this ruling has caused a decrease in the number of new donors? Will this ruling further exaggerate the perpetual shortage in our blood bank.

Dr Neo, please go on to your next cut.

Sir, Singapore's birth rate today has sunk to a historic low of 1.42, way below the required replacement rate of 2.

1. It has been reported that one in five married couples in Singapore now finds it difficult to conceive. The 20% figure shows Singapore moving into the upper end of infertility rate in the developed countries, which ranges between 15-25%. The infertility rate here has risen steadily since the early 1980s when it stood at around 10%. The best productive age for men and women is in their 20s and early 30s, but more men and women are postponing marriage and procreation. The reasons are varied, and they include the emphasis on careers, choice of lifestyles and economic considerations. Couples seeking fertility treatment often undergo a lot of anguish and stress, physically, mentally as well as financially. I feel that more help should be rendered by the Ministry of Health to such couples. Apart from raising the amount of Medisave that can be used, could the limit of three treatment cycles be further increased because fertility treatments are often costly? Would the Minister for Health consider subsidising fertility procedures and drugs to ease the burden for patients at all fertility clinics in the public hospitals? Sir, is the Ministry of Health doing anything with regard to our low birth rate? Should there be more public awareness raised with regard to the various aspects of reproduction, highlighting especially the marital aspects that are detrimental and other aspects that are favourable to procreation?

Sir, with regard to Dr Neo's question on the rescinding of medical benefits scheme (MBS), it was in line with the best international practices and the latest development in blood banking that HSA rescinded the medical benefits scheme for regular blood donors and nominees prospectively for all new blood donors with effect from 1st July 2002. To be fair to donors from the past, this change does not apply to or affect regular blood donors who are already in the MBS by virtue of their previous blood donation. Blood donors are proactively informed of the change in the MBS. HSA has also continued to emphasise to all blood donors and to our public the importance of donating blood voluntarily and in the spirit of altruism without expectation of reward. If we follow Dr Neo's advice and give them something for donating blood, then it will not be altruistic any more. In line with this, HSA and our national blood donor recruiters, the Singapore Red Cross Society, have been taking steps to enhance the blood donor recognition programme in ways that do not involve significant material incentives. This has included upgrading of blood donation facilities to provide donors with a comfortable and pleasant environment and enhancing donor services to make the blood donor experience more positive and enjoyable. The Champion Blood Donor Award programme has also been improved to include special ruby and diamond awards at the 75th and 125th blood donation respectively. Special youth programmes have been introduced to encourage our youths to donate blood regularly as part of the healthy lifestyle and community spirit. Blood donors have, on the whole, responded positively to the message. The number of blood donations collected by HSA in 2002 was 74,750, compared to 66,028 in 2001, which is a 13% increase. This shows that Singaporeans respond to a call for altruistic donation. The number of new donors has increased 12%, from 13,537 in 2001 to 15,121 in 2002. HSA will continue to work with the Singapore Red Cross Society to ensure the adequacy and safety of the national blood programme. Dr Neo has also asked whether the Government could subsidise fertility procedures and drugs. The resources which we can devote to healthcare are finite and should be targeted at the majority of patients with medical conditions. Couples can already use their Medisave for assisted conception procedures and that is the current assistance that they get from the Government. But I agree with Dr Neo that the real problem is that people are postponing their marriages and having children. There is a biological clock in all women and it is ticking all the time. You are most fertile in your 20s, and that is when you should get married and try and have children. So we encourage couples to marry early and have their children early.

Sir, can I clarify? I have never suggested that we should give rewards to blood donors. In fact, it was the Ministry's policy all along. Why should the Minister of State now accuse me of suggesting this?

I am glad that we all agree that altruism should be the reason why people donate blood.

I am glad he changed his tune. I beg leave to withdraw my amendment. Amendment, by leave, withdrawn.

Amendment No. (4), Dr Neo.

Sir, I beg to move, That the sum to be allocated for Head O of the Main Estimates be reduced by $10 in respect of Code OE 3100. Sir, a recent World Health Organisation report said that depression is poised to become the second largest cause of disability worldwide after heart disease by 2020. Close to one in 10 Singaporeans suffers from depression or anxiety that is bad enough to affect his everyday tasks, such as going to work and interacting with family members. This is probably the tip of the iceberg as the stigma attached to mental conditions stops people acknowledging the conditions and seeking medical help. In Singapore, a study in 1998 showed that 9.3% of adults suffered from anxiety disorders and 7.8% suffered from depression. This incidence must have increased lately with the economic downturn and the record high unemployment in Singapore. Anxiety disorder is a condition where sufferers are excessively worried about everything all the time. Depression sufferers feel a deep sadness and lose interest, sleep and appetite for prolonged periods. Those who are depressed are often dismissed by family members as attention seekers and they are often misdiagnosed because they tend to complain to doctors about physical pains, like backache and headache, instead of saying what they really feel. Other depression cases seek treatment in hospitals; frequently doctor-hopping from one specialist to another and thus wasting a lot of personnel and public resources. Sir, may I ask the Ministry of Health whether it is about time we have more public awareness on mental illness? And what are the preventive measures taken to cushion this impending disability problem?

Sir, when times are bad, and you have lost your job, or in danger of losing your job, feeling anxious and depressed is normal. This is called reactive depression. But it is testimony to human resilience that we all recover from this after a while, as we look for ways to solving the problem. But where depression or anxiety occurs for no good reason, that is a mental illness and requires treatment and, if possible, prevention. The Ministry of Health recognises the importance of promoting mental health among Singaporeans to prevent all mental illnesses, including endogenous depression. To place greater emphasis on mental health, a mental health education programme "Mind Your Mind" was implemented in 2001 by the Health Promotion Board and the Institute of Mental Health. The programme aims to promote mental wellness and raise awareness of the importance of early detection and treatment of common mental conditions, such as stress, depression, anxiety disorders and schizophrenia. The programme is targeted at all Singaporeans - children and adolescents, adults and the elderly. A variety of strategies is used to reach the target groups. Mass media, talks, public forums and exhibitions are carried out to create public awareness. To impart skills to healthcare professionals for the early detection of these diseases, workshops and training courses are carried out. The programme focuses on stress management in 2001. We have reached out to students, adults and the elderly educating them on how to manage stress. Last year, the programme focused on the destigmatisation of mental illness. We have tried to change the public perception and attitudes towards mental illness and people suffering from mental disorders. This year, the programme will focus on depression and aims to raise public awareness of the signs and symptoms and treatment of depression.

Sir, I beg leave to withdraw my amendment. Amendment, by leave, withdrawn. The sum of $1,950,477,220 for Head O ordered to stand part of the Main Estimates. The sum of $1,593,924,500 for Head O ordered to stand part of the Development Estimates.

We have five minutes left.

With the consent of Mr Deputy Speaker, Question put, and agreed to. Resolved, "That, notwithstanding the Standing Orders, progress be reported now and leave be asked to sit again tomorrow." - [Mr Lim Hng Kiang]. Thereupon Mr Deputy Speaker left the Chair of the Committee and took the Chair of the House.

Mr Deputy Speaker, Sir, I beg to report that the Committee of Supply has made further progress on the Estimates of Expenditure for the financial year 2003/2004, and ask leave to sit again tomorrow.

So be it.

Resolved, "That Parliament do now adjourn." - [Mr Lim Hng Kiang]. Adjourned accordingly at Twenty-eight minutes past Six o'clock pm.