Speech By Dr Koh Poh Koon, Senior Minister Of State For Health, at the Ministry Of Health Committee Of Supply Debate 2022

                 Today, I will address the challenges faced by our healthcare workers, especially during the pandemic, and outline the Ministry of Health’s (MOH) longer term efforts to take care of our healthcare workers’ wellbeing and professional development.

2.              Even before the pandemic, an ageing population and increased burden of chronic diseases have placed an increased demand for more healthcare manpower. We factored these needs into our manpower plans and recruitment initiatives.

3.              But COVID-19 has stretched us further. We had to adjust our manpower deployment during the pandemic to meet evolving needs, such as the migrant worker dormitories outbreak, as well as swab and vaccination operations.

4.              To Mr Pritam Singh’s query about preparations for Intensive Care Unit (ICU) surges, I want to assure him that we have sufficient equipment and consumables to step up ICU beds significantly, and as of January 2022, more than 800 non-ICU nurses have been trained as a reserve to augment ICU nursing manpower by up to 57%.This would enable us to stretch our ICUs temporarily if needed. Thankfully, our ICU capacity is able to cope with the current surge and patients requiring ICU care are a fraction of what we had during the Delta wave. Nonetheless, we will continue to make the necessary contingency plans given how unpredictable the pandemic has been.

5.              But the pandemic had caused a sudden surge in workload and severely stretched our healthcare workforce. We reprioritised workload and reduced non-essential elective treatments. Absenteeism rates have stayed low, below 10% so far.

6.              Not only have we stretched the public healthcare sector, but those in the private sector stepped forward to help in so many ways, including support from nursing and other healthcare students, as well as the Singapore Armed Forces. Many have gone beyond their call of duty and we owe them a debt of gratitude.

Manpower transformation for a more resilient healthcare workforce

7.              In spite of COVID-19, we have persisted with actively recruiting for our healthcare workforce from both local and international sources. As of end-2021, the public healthcare workforce stood at about 62,500 staff, an increase of about 1,800 compared to end-2020.

8.              To address Mr Pritam Singh and Dr Shahira Abdullah’s concerns about attrition, MOH had previously shared that the average attrition rate of doctors and nurses from public acute hospitals in 2020 and 2021 combined together, was comparable with that in 2019. Specifically, the overall attrition in healthcare workforce was 9.6% in 2019, and it dipped to 6.8% in 2020, in the height of the COVID-19 pandemic. This then accumulated, resulting in a rise in 2021 with a 9.8% overall attrition, but this is rather similar to the 9.6% in 2019. Specifically, for the acute public hospitals, the average attrition in the period of 2020 to 2021 was about 7% to 9% for nurses, about 3% to 5% for doctors. So, the two-year average was quite similar to the 2019 levels.

9.              However, the 2021 attrition among foreign nurses was 14.8%, much higher than the 7.4% among local nurses. Understandably, some left due to family and personal reasons, as the COVID-19 travel restrictions had stopped them from being able to visit their loved ones. But our healthcare workers have stood their posts, they have not abandoned the fight against COVID-19, and we thank them for their commitment and their steadfast efforts.

10.           Having said that, this does not mean that we dismiss the concerns of attrition. We still need to do more to tackle our growing manpower needs.

11.           Given our low birth rate and our shrinking local workforce, there are just not enough Singaporeans to meet all our healthcare manpower needs.

12.           As many members, including Ms Mariam Jaafar, have pointed out, we will need a combination of approaches to ensure an adequate and strong healthcare workforce:

a. First, we must ensure adequate local training pipelines and continue to attract and enable more mid-career locals to enter the healthcare sector.

i.     Our intakes for healthcare programmes at the Institutes of Higher Learning have increased over the past five years. Between 2016 and 2021, intakes for medicine and nursing each increased by about 15%, while the combined intake for allied health programmes increased by about 65%.

ii.     The healthcare Career Conversion Programmes (CCPs) enables mid-career locals to acquire relevant training to join the healthcare sector as nurses and Allied Health Professionals (AHPs). An average of around 180 mid-career locals per year entered training between 2019 and 2021 amid COVID-19 itself, higher than the average of 110 candidates per year between 2016 and 2018.

b. We will regularly review remuneration, to ensure that we continue to attract and retain staff and maintain market competitiveness. We last enhanced the salaries of selected groups of doctors and dentists in 2019. Dr Tan Wu Meng asked that we do a deep review of salaries for nurses and allied health professionals. In fact, we enhanced the salaries of nurses, allied health professionals, pharmacists and admin staff in 2021, and there is a second tranche of increases for nurses this year, in 2022. We will continue to monitor, and review salary benchmarks in a timely manner.

c. But with a tightening workforce situation here in Singapore, we will have to accept that there will continue to be a need to hire foreign healthcare manpower to complement our local workforce and meet the needs of our ageing population. So I thank the Leader of the Opposition, Mr Pritam Singh, for supporting the need for us to hire more foreign manpower to support our healthcare needs. We are also working on retaining foreign nurses, including keeping their remuneration competitive. We have also worked with other agencies on factors that are important for their retention.

d. We also need to look beyond manpower to ensure our resources are optimised. This includes further leveraging technology to extend the capabilities of our healthcare workers,

e. And innovating the way we deliver care and services and redesign healthcare jobs along with training and development opportunities so that each category of staff can perform at the top of their license.

f. This includes training for digitalisation for our healthcare professionals to be prepared for the future. For example, the National University of Singapore has a Nursing Informatics course to equip nurses with knowledge on the development, analysis and evaluation of information systems augmented by technologies, that support, enhance and manage patient care.

g. We will also continue with our job redesign efforts in introducing new roles and new breeds of staff, such as care support associates, that blend clinical support, administrative and operations responsibilities.

h. We will also change our care models to ensure efficient and effective delivery of appropriate care at all care settings. This includes making sure we right-site patients to ensure that our resources are optimised.

i. But there will never be enough manpower if we do not empower ourselves to improve our own health. Hence, through  Healthier SG, which Minister Ong will address later, we will also reduce the load on our overall healthcare system. To Ms Mariam Jaafar’s point about organisational enablers, we agree that this is important and thus as part of population health, we will be aligning incentives and KPIs with the public healthcare clusters and in how we design our programmes.

13.           All these measures are in progress and will take some time to bear fruit. But there are also immediate pressures that we need to resolve and support our healthcare workers straining under the burden.

14.           The COVID-19 restrictions on healthcare workers intermingling to bond and de-stress has led to a sense of isolation among healthcare workers. I want to assure Dr Abdullah, Mr Leon Perera, Mr Abdul Samad and Dr Wan Rizal that staff well-being and morale is an important priority for us.

15.           MOH set up a cross-cluster Staff Well-being Committee in 2019 to improve the well-being of staff,and minimise burnout. All three public healthcare clusters also provide their staff with counselling services, helplines and peer support networks.

16.           MOH is working with the clusters to review and improve staff feedback channels, staff well-being, and mental health tracking and monitoring processes. There are also plans to appoint a Wellness Officer or its equivalent in every cluster to oversee and develop the system changes that are needed.

17.           We are also reviewing our staffing norms in the public healthcare system to strengthen our resilience to future shocks and better cope with fluctuations in workload. We also agree to Ms Mariam Jaafar’s feedback that clusters ought to continue to induct a diverse range of talents and skillsets in their talent development and leadership pipelines.

On Junior Doctors

18.           As highlighted by Dr Tan Wu Meng, one specific group of concern is the junior doctors who had to do long shifts on night calls.

19.           Singapore Medical Council guidelines stipulate that junior doctors may work up to 80 hours a week, including overnight duties of not more than 24 hours, with up to six hours after that for handovers and training. This is benchmarked against the USA’s Accreditation Council for Graduate Medical Education’s (ACGME) guidelines.

20.           Surveys showed that 20% of all junior doctors exceeded the stipulated 80-hour work week. This could be due to the nature of clinical work in certain departments or exigencies of service.

21.           Some have proposed night float systems.

a. This entails doctors taking turns to work night shifts for a few days at a stretch without covering the daytime work whilst others work the day shifts.

b. Doctors may feel more refreshed when they start their night shifts with a full day’s rest, although there are possible trade-offs in requiring more manpower to do a shift system, more handoffs between team members which carry some risks of omission in tasks, and possibly reduced learning experience as they may not follow through the entire care process to see how their patients progress over time.

c. It would be useful in disciplines where doctors on night duties have fewer opportunities to rest, such as Internal Medicine or General Surgery.

d. The system has been tried in two large departments. Plans to trial this in other smaller departments unfortunately were curtailed due to COVID-19.

e. When the situation allows, we intend to restart the trials.

22.           As we look at the issue of work hours, let us not lose sight of these important considerations which are inherent in the nature of our work as doctors. With shorter working hours in a week, a junior doctor may have to undergo a longer apprenticeship to acquire the necessary competencies.

23.           But we also recognise that the workload and the nature of clinical work today is different from yester-years, a point which Dr Tan Wu Meng has made. With an ageing population and higher chronic disease incidence and expectations of more collaborative and consultative care from patients and their families, the nature of clinical work has changed for our junior doctors.

24.           The stresses faced by junior doctors today are symptomatic of a wider need for transformation in the current care delivery arrangements. Whether it is 24-hour or 30-hour shifts, what is clear is that we should not stretch our junior doctors beyond what is physiologically possible and what would risk compromising patient safety, a point also highlighted by Dr Tan Wu Meng.

25.           But I want to caution that a simplistic framing of the issue as just work hours is not diagnosing the root cause of the problem.

26.           Recently, I met with junior doctors from the Singapore Medical Association’s Doctors-in-Training Committee and other groups of junior doctors from all three healthcare clusters. They were proactive in sharing best practices on the ground. We had candid discussions on the challenges they faced, particularly in this COVID-19 period, as well as the trade-offs of possible junior doctor workflow changes.

27.           I am heartened that many of them recognised the complexity and inter-linked nature of the issues pertaining to junior doctors’ working hours.

28.           Therefore, as a first step, MOH has formed the National Wellness Committee for Junior Doctors. Co-led by senior doctors from all three healthcare clusters and MOH, we aim to review and recommend changes to existing healthcare practices and guidelines to improve and ensure the well-being of junior doctors, in three main areas:

29.           First, a review of junior doctor workflow models and work hour norms. Other than the considerations I shared earlier, the review will also have to be done carefully as it will have an impact on the workflow of other healthcare workers who work alongside our junior doctors.

30.           Another area will be to look at the fundamental balance between training and service workload, and transforming our manpower model. It would not be sustainable for us to just simply increase the ‘flow’ of trainees going through the system to meet service demands, as this will eventually lead to a large ‘stock’ of doctors and cause an oversupply later on. Instead, we need to raise the importance and attractiveness of work roles that are core to service workload.

31.           The second area of focus is career development and training of our junior doctors. Traditional specialist-focused residency training programmes are not the only desirable career pathways, and there is a need for stronger broad-based generalist paths such as family medicine and hospital clinicians, which if successfully implemented, may also address the issue of care-fragmentation across multi-specialty teams.

32.           One such pathway is the Hospital Clinician track we launched in 2020, which we hope to expand significantly in the years to come.

33.           A third area of focus for this Committee, will be on working with key stakeholders to promote a more inclusive culture where junior doctors can feel safe in speaking out on matters related to their safety and wellness, and, importantly, to co-create policies and solutions at both the institutional and national level.

34.           The issues are complex and seek to change years of established practice. We aim to put forth preliminary recommendations by the middle of this year, so that some immediate measures can be implemented, with a view of completing their final recommendations by early 2023.

On Recognition of our Healthcare Workers

35.           We recognise that our healthcare workers have always gone above and beyond, especially during these trying times.

36.           Mr Abdul Samad and Dr Tan Wu Meng would be pleased to know that MOH has extended the COVID-19 Healthcare Award not just to healthcare staff in public institutions, but also to outsourced staff. These include cleaners and security officers, who were directly contracted by the public healthcare institutions and publicly funded Community Care Organisations. Paramedics under the Singapore Civil Defence Force would be recognised in their own way.

37.           But the biggest encouragement to our healthcare workers must come from the support and appreciation from Singaporeans-at-large whom they serve. We read about spontaneous ground-up actions from Singaporeans to encourage and thank our healthcare workers, examples which were cited by Mr Abdul Samad.

Combating abuse and harassment of HCWs

38.           Unfortunately, COVID-19 has also brought out some bad behaviour. We have read about the cases of abuse and harassment towards our healthcare workers. The perpetuators have been taken to task and convicted by the Courts.

39.           Sadly, the number of cases has been on the rise. At end-2021, there were about 1,500 of such cases, up from 1,080 cases in 2018.

40.           The actual number may be higher, as many healthcare workers exercise empathy and therefore do not always take a legalistic approach and report and escalate every altercation. However, their compassion should not be misconstrued as an acceptance of abuse or harassment. We need to make sure that our healthcare workers feel safe in their work environment.

41.           I agree with Dr Tan Yia Swam that we need to recognise such abuse and institute safe reporting systems and clear penalties on the offending parties.

42.           Let me unequivocally state that verbal or physical abuse of any healthcare worker will not be tolerated and offenders will be taken to task.

43.           MOH and our public healthcare institutions adopt a zero-tolerance approach towards abuse and harassment of our healthcare workers. Under the Protection from Harassment Act, public healthcare workers are accorded enhanced protections under Section 6 if abused or harassed while carrying out duties.

44.           Aside from legislation, we should look at other ways to deter abuse and harassment and move more upstream. Healthcare workers should have the assurance that their employers and the healthcare system have their back, while providing them with the training to handle situations where compassion and empathy are tested to the limits.

45.           MOH will therefore be establishing the Tripartite Workgroup for the Prevention of Abuse and Harassment of Healthcare Workers. With representatives from MOH, the Healthcare Services Employees’ Union, public healthcare clusters, community care partners and private healthcare providers, the workgroup aims to spearhead a coordinated national effort to prevent abuse and harassment of healthcare workers in the public, private and community care sectors.

46.           Our healthcare workers should feel safe, and to be able to call out abuse, to allow them to focus their energies with the right frame of mind on doing their best for their patients.

Healthcare Affordability and Private Sector Partnerships

47.           Let me address some other issues raised by members. On healthcare affordability, Dr Tan Wu Meng will be happy to know that from 1 July this year, we will expand the number of chronic conditions in the Chronic Disease Management Programme from 20 to 23. The new conditions included are allergic rhinitis, gout, and chronic hepatitis B. More than 134,000 individuals will benefit as they can now use their MediSave and CHAS subsidies for these conditions.

48.           We will strengthen our private sector partnerships to meet our growing healthcare needs. Dr Tan Yia Swam raised the need to have stronger oversight over business practices and medical middlemen.

49.           Today, Third Party Administrators (TPAs) and concierge services are not regulated under the Private Hospitals and Medical Clinics Act (PHMCA) or Healthcare Services Act (HCSA), which focuses on regulating direct service provision.

50.           Nonetheless, the Singapore Medical Council’s Ethical Code and Ethical Guidelines (SMC ECEG) guides that medical practitioners contracting with TPAs should ensure they

a. remain objective in their clinical judgment;
b. provide the required standard of care; and
c. and reflect their fees fairly and transparently to their patients.

51.           MOH will continue to monitor patient safety risk and study the evolving landscape of these TPA companies. We will examine how the TPA market will need to be reshaped as we make bigger shifts in preventive healthcare beyond Healthcare to Health.

52.           On Dr Tan Wu Meng’s concerns on Integrated Panels, we had earlier announced that Integrated Shield Plan (IP) insurers had accepted the Multilateral Healthcare Insurance Committee’s (MHIC) recommendation to expand their panels.

53.           Today, most IP insurers have at least 500 private specialists, with each insurer’s panel covering 80% to 90% of their private medical institution claims.

54.           To enable even greater patient choice and better continuity of care, the MHIC is considering if doctors who are already with an IP panel can be recognised by other IP insurers to some extent, as Dr Tan Wu Meng has suggested. We will announce more details in the coming months.

55.           Regarding access to treatments, our Free Trade Agreements  and Intellectual Property obligations provide due recognition to investments that patent proprietors make in developing pharmaceutical products. This is not only fair, but also ensures that Singapore remain an attractive location for drug manufacturing, research, and innovation. Having said that, we are working with relevant Government agencies to ensure that generic drugs are not unduly delayed or obstructed from entering the Singapore market.

56.           MOH will also continue to strengthen our position as a biomedical hub and anchor our domestic capabilities in new technologies such as cell-based therapy and strengthen the resilience of our healthcare system.
 

Conclusion

57.           Mr Chairman, in today’s speech I spoke extensively about our healthcare workers. To our healthcare fraternity: I know that many of you may have felt exhausted and demoralised, especially in the last two years. Take heart, Singaporeans are appreciative of your steadfast commitment and dedication.

58.           MOH is undertaking reviews to introduce structural changes in the healthcare system and manpower. We seek your patience as we work with the healthcare clusters to engage you on improving the situation on the ground.

59.           Let us uphold the values of the healthcare profession and provide the best care we can for our patients. Indeed, patients must be at the heart of all we do. But every healthcare worker also matters.

60.           Let us all, Singaporeans, help them take better care of us.

61.           Thank you, Sir.