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17 Mar 2004
By Mr Khaw Boon Wan
Venue: Parliament
COS Part IV
DRUGS
1. Dr Chong Weng Chiew reminded our hospitals not to prescribe overly expensive medicines to subsidised chronic patients as they may not be able to afford them. I appreciate his timely reminder.
2. One practical way to help patients save money is to go for generic drugs. The savings can be considerable.
3. Use of generic drugs should be the standard operating procedure in our subsidised wards. It will help stretch the hospitals' budget, patients' savings and Government subsidy. Three-in-one. I therefore agree with him and what Dr Wang Kai Yuen said earlier about the need for an open competitive market for drugs and to facilitate entry of generic alternatives. About two-thirds of the 7,500 medicinal products registered in Singapore today are generic products, from various sources including India. We will continue to tap generic drugs where feasible.
4. At the hospitals, the pharmacists and the Hospital Pharmaceutical and Therapeutics Committee advise doctors on rational drug prescribing and the cost-effective use of drugs. With the introduction of electronic prescription systems, the clusters are now able to keep doctors informed about the costs of drugs and available alternatives. Drug utilisation reviews are regularly carried out in the large hospitals to study usage of new expensive drugs. This way, drug usage is audited and appropriate drug protocols put in place.
5. Patients themselves can play an important role and should understand that in most cases, a generic medication can do the same job as a branded drug. The Health Sciences Authority assesses generics for local registration to ensure that they are safe, efficacious and of good quality. My Ministry will step up public education to provide information on drugs to help Singaporeans make better choices.
Home therapy services
6. Dr Chong also asked my Ministry to consider subsidising the providers of home therapy services.
7. By home therapy, I presume he means sending a therapist to a patient's home to provide rehabilitation services.
8. Whether we should subsidise such services will depend on (a) the effectiveness of the service, and (b) the financial status of the patients.
9. Home therapy is not cheap. We should not subsidise just because patients are poor, especially when there are alternative services in the community.
10. We are already subsidising home medical and home nursing care.
11. For patients who need rehabilitation and therapy, there are many (27) day rehabilitation centres providing such services. Many of them are located in HDB void decks and are cheaper to run than home-therapy.
Traditional Chinese Medicine
12. Let me now discuss Traditional Chinese Medicine or TCM.
13. I grew up with TCM. As a child, I probably took more Chinese medicine than Western drugs. I don't think my experience is unusual.
14. Is there a role for TCM in modern Singapore? Of course, there is. Our data suggest that one in ten outpatient attendances are treated by TCM practitioners.
15. Will the demand grow? TCM has been able to retain its market share over the years. This is not unique to Singapore. Recently, I read a British article which noted the popularity of TCM in the West. It made an interesting observation that the TCM clientele in the West were either the lowly educated or the highly educated. The author did not explain why.
16. There are many things about TCM that we have no answers to. That is why all healthcare regulators, both in the East and the West, find it very challenging to regulate TCM and other complementary medicine. This is because the basis and approach of TCM and Western medicine are fundamentally different.
17. Members know Dr Hong Hai. He was an MP, a Western-trained English-educated engineer with a PhD in economics and a serious interest in TCM. He has just graduated from a local TCM school and is now a fully qualified TCM practitioner.
18. When I met him recently, he commented positively about my health. I asked him to substantiate his observation. He explained his observations about the colour of my face, my complexion and such esoteric stuff. I was happy with his conclusion, never mind that I could not fully comprehend his explanation.
19. Therein lies the challenge of trying to regulate TCM and integrate it into mainstream medicine.
20. In Western medicine, the operating principle is evidence-based medicine. If we say that a particular drug or a particular treatment works, it is backed by clinical trials and research findings which have been subject to international scrutiny.
21. Although TCM is increasingly subject to evidence-based tests in countries like China and Japan where leading universities teach and conduct research in TCM, the level of rigour has not reached that required by Western medicine. Should we accept a lower standard of evidence for TCM? Or should we apply the evidence-based principle strictly? A strictly conservative approach would make it difficult for the practice to continue, let alone grow. This will deprive consumers of a service which has provided much relief and comfort to generations of Singaporeans.
22. In 1995, MOH appointed a TCM Committee to look into this subject. It recommended, and MOH agreed, a cautious, step-by-step approach to the regulation of TCM.
23. That same year, we set up an acupuncture research clinic in Ang Mo Kio Community Hospital. A year later, we started to upgrade the training of TCM practitioners. In 1999, we tightened the control of Chinese proprietary medicine. In 2001, we registered acupuncturists. In 2002, we registered TCM physicians.
24. I will continue this step-by-step approach. I will particularly want to learn from others' experience. Next week, I will be in Nanjing to launch the inaugural SIA flight between our two cities. I will use the opportunity to visit the TCM University there.
25. But whatever we do, one thing is clear. This is an area where regulation will have to be light, for the simple reason that regulators do not know enough. The major focus of regulation is to ensure safety of the TCM products, such as by checking for contamination of herbs with heavy metals and the adulteration of Chinese proprietary medicines with Western pharmaceutical agents. However, regulators are unable to assess such products for efficacy as is done for Western pharmaceutical drugs. So consumers must not equate TCM with Western medicine and will have to be sensible and careful. At the same time, it is incumbent on the TCM practitioners to regulate themselves seriously and to continuously upgrade their standards of practice.
TCM practices in MOH approved facilities
26. Dr Chong Weng Chiew and Mr Chay Wai Chuen asked about the adoption of TCM treatments within our hospitals. Acupuncture is available at Ang Mo Kio Community Hospital, National University Hospital, Singapore General Hospital and Tan Tock Seng Hospital for selected medical conditions.
27. However, to make it clear to the patient that the treatment lies outside mainstream Western medicine, TCM therapy is provided in a separate clinic from the Western clinics and hospital wards.
28. I met the Western medical community recently and asked if we could now move beyond acupuncture to consider other forms of TCM therapies. They suggested that tui-na can be the next modality. My Ministry has formed an expert committee under Professor Lee Tat Leang of NUH to look into the suggestion. He is both a professor of anaesthesia and a qualified acupuncturist.
Training of TCM practitioners
29. Mr Chay asked about the training of TCM practitioners. The two local TCM training schools have recently upgraded their courses to a 6-year part-time or 3-year full-time diploma course. This is accredited by the TCM Practitioners Board. One of the schools has also linked up with Nanjing TCM University to offer a Bachelor's degree in TCM while the other offers a Master's degree in TCM jointly with Beijing TCM University.
30. As for TCM herbal dispensers, my Ministry has worked with the TCM traders' community to conduct a 4-year part-time training course in TCM herbal dispensing. This course is also accredited by the TCM Practitioners Board.
TCM Qualifying Examination
31. Dr Lily Neo asked about the Qualifying Examination for TCM Practitioners. Any person who wishes to practise as a TCM physician needs to pass the Examination. This was a decision taken several years ago, with ample notice to the TCM practitioners and much preparation involving the upgrading of TCM training at the TCM schools.
32. There are some TCM physicians who did not have the opportunity to receive formal training. The Ministry created a special transitional arrangement to grant them various exemptions based on the individual qualifications and experience. Only those who did not have sufficient qualifications or prior experience as assessed by the TCM Practitioners Board were required to enrol in the TCM Upgrading Training Course and pass the Common TCM Qualifying Examination.
33. To give all applicants sufficient opportunities to upgrade themselves, a total of 3 appraisals, 2 examinations and an upgrading training course were conducted over a 2-year period. Unfortunately, despite repeated reminders, 61 applicants did not come for the appraisals, 37 did not come for the examinations and 27 did not enrol in the upgrading training course. But they were a tiny minority. Out of the total 1,865 applicants, 86% (1,604) were eligible for registration and only 14% (261) were not.
34. The Common Examination will be conducted annually. Those who failed to be registered under the transitional arrangement can still enrol in the two local TCM schools and be registered once they have passed the examination.
PRO-FAMILY POLICIES
35. Finally, let me respond but only briefly to Mayor Yu-Foo Yee Shoon's various baby and family friendly comments.
36. Baby policies of all Ministries are now open for review. MOH will do its part in this review. I am sure Minister Lim Hng Kiang will leave no stones unturned; no diapers unchanged. But as a parent who know how to change diapers, we only change diapers when they are soiled.
37. We will re-look the pricing of IVF but off-hand, I will be very reluctant to start subsidizing IVF. Subsidy is a zero-sum game. More subsidy for unborn babies means less subsidy for the sick who are already born. Of course, if there is extra subsidy coming from Minister Lim Hng Kiang's baby budget then it is a different story.
38. As for childbirth subsidy, Medisave has made childbirth expenditure affordable. That is why more babies are now born in private hospitals than in public hospitals.
39. Are hospitals family-friendly? I think they are, but there is always room for improvement. With Dr Jennifer Lee at the helm of KKH, I know that KKH should not score too badly. And we will pass on similar policies to the other hospitals.