Mr Speaker sir, when deciding how liveable and how advanced a society is, the quality and affordability of its healthcare sector plays a key role.
In most countries, the nature of healthcare provision is highly contested and debated, because of its critical importance. In many countries, including our own, healthcare is also a vital sector for the economy, creating many jobs directly and indirectly.
Post Covid, I am hopeful that progress on constructing new facilities like the Woodlands Health campus and the integrated care hub at TTSH is picking up.
However, the main impediment, the main challenge in meeting our long-term healthcare lies not in the building of physical facilities. It lies in the recruitment and retention and raising the productivity of healthcare workers. It is this single theme that my speech will address.
In my speech, I will talk about:-
- Addressing recruitment and retention among healthcare workers
- Raising the productivity of healthcare workers
- Improving the outcomes from the healthcare system as a whole without increasing cost proportionately, by addressing sources of health problems upstream and by other means
Before I proceed, I declare my interest as the Chairman of a company that does consulting work in the healthcare space, among other verticals.
People, people, people
Sir, in preparing this speech, I raised the topic of how we can attract more Singaporeans into the healthcare sector at my family dinner table. Without a micro-second’s hesitation, my daughter said, “Give them decent working hours, respect at work and good pay.”
Indeed, this is the major long-term challenge we face. We can build the wards and clinics. We can buy the equipment. But how can we attract and retain workers in the sector such that churn is minimised, such that there is a core of professionals from whom the future leaders can be drawn, such that there is a good learning curve, a sufficient accumulation of experience and skills to elevate service and effectiveness so as to ensure good outcomes for patients?
There are media and anecdotal reports of facilities that are unused due to a lack of manpower. For example, a recent report from TODAY, citing a private doctor, said “As a matter of fact, several private hospitals have closed some hospital wards and operating theatres, due to a shortage of nurses.”
The all-important manpower challenge in healthcare unpacks itself into a few bundles of issues – one is compensation, one is working hours, one is working conditions and career laddering and one is productivity and also ensuring that work feels meaningful.
First, on compensation.
While nurses pay was increased last year and this is welcome, this was the first base salary increase in 7 years.
Junior doctor’s pay was increased as well recently. But, as per the reply to my recent PQ, the 7-13% starting salary increase applied to House Officers and first year Medical Officers. However more experienced junior doctors, namely eligible in-service MOs or Residents up to post-graduate year (PGY) 6, and Dental Officers up to PGY 4 could expect a salary adjustment based on their years in service and bond period rather than an across the board increase.
Clearly to attract and retain talent, compensation has to be competitive. Moreover, in healthcare, talent can migrate across national borders. Many countries are short of experienced healthcare staff. Many countries would like to poach our English-speaking and well-trained healthcare workers.
Hence, I would like to ask if compensation for healthcare personnel could be monitored, could be tracked based on hourly compensation – total pay per hour worked – and regularly benchmarked against other developed country locations, with the results published, so that we have a clear indicator of how we are doing and whether or not we will face choppy waters ahead that we would need to take heed of. I am aware of academic studies that are occasionally published to this effect, but I am not aware that there is a regular government publication to this effect.
Next, on managing working hours and burnout. There is no point raising pay if there is under-capacity and working hours rise such that pay per hour remains the same or actually falls.
Sir, I have raised in this House the issue of junior doctor working hours several times.
I would like to repeat my call to lessen weekly working hours for junior doctors from 80 to 70 and to step up enforcement to make sure that this is adhered to. There is evidence that the same training outcomes can be obtained with a cap of 70 hours per week versus 80 hours, as I explained in my previous COS speech. This would also require systems to be streamlined so that junior doctors, and indeed nurses, spend more time on patient care and training than in administrative tasks.
I would also repeat my calls to move towards 100% compliance with the current 10-hour intervals between duty periods and after in-house calls, up from 90% now; ensuring no under-reporting of hours; and taking concrete steps to shorten the time spent on handing over administrative and peripheral duties.
I understand that conditions for junior doctors are being reviewed in the public healthcare system now. I hope that the need to optimise working hours will be considered in that process.
Next Mr Speaker sir, on workload. Workload is, of course, a function of healthcare demand versus manpower capacity. Healthcare demand will rise steadily as our population ages. And, indeed, we are one of the fastest aging populations in the world.
Minister Ong has said that the annual intake of nursing students will rise from 2,100 to 2,300 a year. This should help with meeting demand, if nurses stay in the profession.
Right now, the proportion of Singaporeans among enrolled nurses is a little over 60%. It is important, for such a critical profession, to maintain a strong Singapore core and good career progression for nurses who can progress into more senior nurse practitioner and leadership roles.
I know that there are currently nursing scholarships, primarily awarded by the healthcare clusters. I wonder if this is sufficient to meet the needs of the future, to generate enough of a pipeline of nurses for future senior nurse practitioner, mentoring and leadership roles.
Does the Ministry review the number of nursing scholarships given with this in mind? And do such reviews extend to the awarding of a sufficient number of postgraduate scholarships in nursing, given the increasing complexity and technology dependence in the healthcare sector going forward? Currently there appears to be only one academic program which provides the Masters in Nursing requirement for advanced practice nurses.
Lastly, on the topic of workload, so as to strengthen the Singapore core in professions like nursing, we should provide preferential consideration to foreigners who are in these professions, who have lived and worked here for some years and have demonstrated a capacity to integrate well into our society, to obtain Permanent Residency and eventually citizenship. I believe some members of this House have called for this before and the government has said it is open to such an idea.
To add on to this, I would repeat my call for the giving of citizenship to be made more transparent, with the availability of an online point-based calculator similar to what you see in some other countries. This may make Singapore more attractive to healthcare professionals from other countries by providing more clarity and assurance.
Step up role of pharmacists
Next, on the role of pharmacists. To raise the productivity of our whole system, will the government consider giving pharmacists some powers to prescribe drugs for certain conditions? This is already being considered in Australia, though there has been some pushback associated with this.
Our pharmacists already make adjustments to dosing of drugs for some chronic medications and advanced practice nurses also have cooperative prescribing models in our local healthcare institutions.
I would like to suggest that the government monitor international developments and consider if and how to accord greater powers for prescription to pharmacists, depending on the emerging international evidence.
This may negatively impact GPs initially but I have some suggestions relating to GPs which I will come to in a minute.
Allied Healthcare professionals, Health Coaches and other personnel can play a key role
Next, sir, I would like to touch on the necessary role of other allied healthcare professionals and medical personnel. I note that the government has plans for a greater role for community pharmacists in promoting things like health screening and vaccinations. I spoke about the vital role of both health screening and vaccinations in my Adjournment Motion on preventive healthcare last year as well as via PQs previously.
MRNA technology is already spawning potentially revolutionary developments in medicine that could lead to radical breakthroughs in decades to come. I have raised the topic of MRNA cancer vaccines in the House previously.
But turning back to current realities, it would seem that we are lagging behind many developed countries in terms of the more routine types of vaccination, like influenza vaccines. This can limit the incidence of chronic or catastrophic conditions further downstream. Moreover, alarmingly, the National Population Health Survey 2021 showed that fewer Singapore residents participated in chronic disease and cancer screenings in 2021 compared to 2019.
There are plans to raise the number of allied healthcare professionals. Such professionals can play a critical role in community healthcare, nudging healthier lifestyles and appropriate help-seeking behaviours, including for mental health conditions as well as helping those with chronic conditions prevent the development of complications.
In the Serangoon ward of Aljunied GRC, my volunteers and I have had the honour of working with Tan Tock Seng Hospital (TTSH) Community Partners to conduct a health talk and consultation session at a rental block. We also refer cases we come across to TTSH Community Partners (TTSHCP). TTSH CP also stations nurses at the Community Care Service Singapore facility at Golden Ginger in Serangoon North at certain times, to make some screening and advice available to people who live in the area. These are commendable and beneficial interventions and I hope that these can be replicated in other areas that lack this. These should eventually be funded centrally as they do not require costly infrastructure and could also allow local nurses, physiotherapists, occupational therapists and podiatrists with families to perhaps work part-time near their homes in their own communities.
The model for deployment of such allied healthcare professionals is often to leverage events that attract people to consider health issues. However, some evidence from a survey conducted by Lifebuoy suggests that most Singaporeans take a rather passive approach to their own health and do not often or always proactively seek out information on how to improve their health. Hence it behoves us to find methods that are more in line with what, in business marketing, is referred to as “hunting”, ie direct sales, as opposed to “farming”, or attracting people to come to you.
To that end, I wonder if, once we have the health coaches in sufficient numbers, we can, as one initiative, deploy them to void decks, hawker centres and wet markets. These are areas of high footfall, particularly among older people who may benefit more from healthcare interventions. It may be helpful if personnel who are fluent in vernacular languages can approach them in these settings, in a more proactive way, to promote ideas such as vaccination and health screening, or even to perform certain basic screening activities on the spot.
For younger demographic segments, what might work better is, perhaps, strategies that rely on social media.
The role of General Practitioners (GPs)
Next, let me move onto the role of General Practitioners or GPs. Our roughly 1,800 GP clinics play an important role in our healthcare system as the first line of defence for non-emergencies. This role is set to increase with the advent of Healthier SG. When we speak of attracting and retaining good healthcare professionals in our system, we cannot neglect our GPs.
Yet there are worrying signs. In a survey of 300 GPs by NTU published in the journal BMC Primary Care in 2022, 14.4% said they plan to leave general practice permanently, 12.6% plan to take a career break, and 51.3% plan to reduce their clinical hours. Higher remuneration, recognizing general practice and family medicine as a medical specialty, and reducing the litigious pressures on medical practice were rated as the most important factors in these decisions, while there was growing dissatisfaction with the Third-Party Administrators that manage insurance arrangements.
If there are too many exits from the GP sector, this may dent our ability to achieve our primary healthcare and Healthier SG goals.
Also, a study of primary healthcare quality by the National Healthcare Group published in the journal Asis Pacific Family Medicine in 2014, which polled 85 experts, concluded that Singapore’s system suffers from several issues. “The primary care system in Singapore received an average of 10.9 out of 30 possible points….Singapore was categorized as a ‘low’ primary care country according to the experts.” The earnings of primary care physicians compared to specialists was one of several factors cited.
I have a few suggestions here to address some of these issues faced by the GP population and primary healthcare in general.
- Firstly, shouldn’t we regularly survey our population of GPs to understand their experience, their pain points, their perception of gaps in the eco-system and their suggestions to the government, insurers and other stakeholders? In my opinion, most of our GPs are thoughtful and well-informed individuals who should have good ideas for constructive policy change. The MOH does Primary Care Surveys every ten years or so to determine primarily the economic parameters around the primary care sector but much more can be done.
- Secondly, can the government explore onboarding individual GPs and corporate groups that run GP clinics onto the Government procurement system for drugs so that all parties can obtain lower prices on the basis of larger bulk purchases? Right now, drug sales representatives often sell drugs to individual GPs. And this means fragmentation and far less economies of scale. As an aside, I was once queuing to see a GP and someone behind me in the queue got in to see the GP before me. When I asked the receptionist why this was the case, she said she had deprioritised me as I was wearing a tie at the time and she thought I was a drug sales rep rather than a patient! I understand that the government is currently studying the idea of allowing private healthcare providers to tap on the government drug procurement system or ALPS and I hope the government will move on this soon to enable combined purchasing across the public and private sector to the fullest extent practicable.
- Lastly, would the government, as part of the surveying effort I referred to earlier, identify GPs who have spare capacity, meaning that there are certain times of day where they don’t see so many patients, and find ways to engage such GPs to augment the capacity in Polyclinics or other public healthcare institutions, if they are keen to do so? Anecdotally it seems that the density of GP networks has seen a long-term increase and competition has risen. One effect of this may be that some GPs (not all) have some spare capacity at certain times.
Healthcare Worker Productivity
Sir, I come to the last part of my speech – how do we raise the labour productivity of our healthcare workers?
I am reminded of an amusing conversation I had once as a young EDB officer. One of my colleagues was talking to another manager. The manager said that he could not increase output without a commensurate increase in headcount. To which the first person said “Ah yes, but that assumes zero productivity growth.” I have never forgotten this little bit of wisdom, so pithily conveyed.
Of course, as healthcare demand grows, we will need to hire more staff. But we need to manage the rate of that increase so as to manage cost as well as to manage population pressures that may arise from excessive inflows of foreign manpower, and I use the term manpower here in a gender-neutral way of course.
How can this be done?
There are advances in healthcare technology to draw upon and best practices available worldwide. For example, telemedicine can enhance staff utilization and save time for patients as well. Some survey evidence suggests that Singaporeans are open to virtual consultations. There is also robotics. For example, service robots can perform some of the functions of a healthcare concierge. Robotics devices can also play a role in rehabilitative medicine.
I am aware that some of these innovations have come to our healthcare system and more are being considered. I am also aware that this is not a new topic. In 2012, the MOH launched the Healthcare Productivity Roadmap and in 2017, the MOH announced the Healthcare Productivity Fund. There are also the National Healthcare Productivity and Innovation Awards.
However, I have a few suggestions here.
Firstly, the potential to apply cutting-edge developments in fields like AI, computing and robotics to healthcare is high. For example, a 2019 Accenture study on Singapore’s health workforce concluded that technology could free up 10% of time for doctors, 10% for pharmacists, 22% for nurses, 31% for laboratory scientists, 50% for pharmacy technicians and a whopping 68% for medical records clerks in Singapore.
My suggestion here is that the government measure healthcare labour productivity from time to time and publish the results, benchmarked against productivity standards in other global cities. There would be various types of metrics that could be considered. Ideally, we should measure public and private healthcare separately for the sake of comparison. And this data could be used to identify good outliers, where best practices and case studies can be documented and shared. If we do not know where we are at, we cannot get to where we want to go.
Secondly, and specifically for mental health care, this is an area where we are seeing challenges. Some experts speak of a youth mental health crisis, a phenomenon which may not be unique to Singapore by any means. Our ratio of clinical psychologists and psychiatrists lags behind some other developed countries.
Will the government explore using AI technology to augment capacity in mental health care? For example, a Boston-based company called OM1 recently built an AI platform called PHenOM to help psychiatrists enhance their diagnostic and treatment effectiveness and efficiency. Singapore-based company Holmusk has partnered with the UK NHS and Liverpool University to establish a mental health analytics and research hub. Holmusk’s mental health analytics platform is of a large scale. I hope the government will consider working with companies like this, particularly locally-based ones, to push the envelope.
In conclusion, Mr Speaker sir, our future is one where demands on our healthcare system will be greater, as our population ages.
But our future is also one where there will be greater opportunities to exploit technology and innovation to increase efficiency; and to enhance prevention upstream. We need to grasp the opportunities to meet those challenges.
And this will have to be done by our healthcare professionals, the people who must be at the heart of all we do in healthcare, for without them nothing is possible. At the end of the day, healthcare is and will remain a profoundly human endeavour. There is no more important goal in healthcare than attracting, retaining and bringing out the best from our great healthcare workers.