Speech by Mr Chee Hong Tat, Senior Minister of State for Health at the SMC Physician's Pledge Ceremony, 30 Sep

Professor Tan Ser Kiat, President, Singapore Medical Council

Members of the Singapore Medical Council

Ladies and Gentlemen

Good Afternoon.

1.    This afternoon’s affirmation of the Physician’s Pledge is a significant milestone for our medical professionals as you progress on in your career.  I am honoured to be here to witness this important occasion. 

2.    This afternoon, I would like to touch on three issues. First, how to improve our residency training programme. Next, how to achieve the right mix of specialists to meet Singapore’s long-term healthcare needs.  And lastly, whether it is really necessary for our public healthcare institutions to go through JCI accreditation.

Residency Training Programme

3.    Let me start with the residency programme.  Before we had the current residency training system, postgraduate specialist and family medicine training was structured in an apprenticeship model with high stakes summative examinations. We had adapted this from the British system and it had served us well for many years.

4.    Several years ago, MOH was concerned that this model could result in a longer time for a junior doctor to become a specialist, as the first-time passing rate for the summative examinations was low.  The Ministry studied the training models of other countries and adopted the American residency system in 2010.  The intent behind this change was to provide a more structured framework with regular supervision and formative assessments that provided opportunities for trainees to improve their competencies progressively. It was also felt that as the annual number of doctors graduating from our medical schools increase, it would be beneficial to introduce a more structured post-grad training system.

5.    Unfortunately, intent is not always the same as outcome.  Good intent alone does not necessarily lead to good outcomes.  As the residency system was adapted from the US, there were challenges to fit its different elements into our system in Singapore during implementation.  I remember my former boss Mr Lim Siong Guan used to remind us that “implementation is policy”.  The effectiveness of a policy is not measured by how elegant it looks on paper, but how it is translated into reality during implementation. On this yardstick, we have to be honest and acknowledge that while the residency programme has its advantages and good points, some of the outcomes have not been as positive in practice as what we had originally hoped for. As with all major changes, what could have been better was a more gradual, step-wise implementation, with appropriate channels to acknowledge concerns of the medical fraternity, and to consider the impact of the changes from a holistic systems perspective.

6.    After having some years of experience with the residency programme, the time is right for MOH to now review the programme. We want to retain the positive elements of the residency programme while taking concrete steps to address the problems we have encountered and improving the outcomes for our doctors.  For this effort to succeed, we need to work closely with our professional bodies and doctors to listen to your feedback and see what we can do together to enhance the system.  We need your help to work with us to achieve better training outcomes for our doctors and deliver quality care to our patients.  I hope we can count on your support to embark on this review together.      

Right Mix of Specialists

7.    Next, I would like to touch on having the right mix of specialists to meet Singapore’s long-term healthcare needs as our population ages.  There is general agreement amongst healthcare professionals that we need to evolve our healthcare system to emphasise health promotion and upstream prevention; strengthen primary care; and improve the care integration between hospitals and community. 

8.    In my view, the key issue is not whether we want more specialists or generalists.  We need both groups of doctors to provide care for patients in different settings. Or the same patient would need generalist care at some times, with specialist care at other times. The patient will benefit from having a co-ordinating doctor, looking after his overall care needs. So we are not discouraging doctors from specialising, there remains an important need for different groups of specialists in our healthcare system.  What we want is to have the right mix of specialists, including larger numbers of doctors specialising in areas such as family medicine, internal medicine, geriatrics and palliative care, to meet the healthcare needs of our ageing population.  We also need to train doctors who can lead and work in multidisciplinary teams across boundaries and settings, to provide integrated care for patients.

9.    I understand it is a challenging task in practice to get the right balance as there are many factors at play.  The process will be an iterative one, there will likely be mistakes made along the way in some of our estimates and projections, but I believe we can move closer to our optimal target over time if we continue to work closely with our clusters, professional bodies and medical professionals on the ground, share data with one another and engage in open communication. 

JCI Accreditation

10.    The third and final issue I would like to touch on is JCI.  One of the reasons our healthcare institutions go for JCI accreditation is to regularly benchmark themselves and continually improve processes and outcomes.  I support this objective, but we have to ask ourselves if it is still necessary and desirable for our public healthcare institutions to pursue JCI accreditation, especially when some of the JCI components are US-centric and not applicable to our local context.  Over time, we may have reached a point of diminishing returns as healthcare institutions have already put in place many of the systems and processes, and also embarked on value innovation and other quality improvement initiatives as part of their core operations. 

11.    One unintended consequence of JCI is that it encourages healthcare institutions to “chase awards” in the name of quality improvement.  Different groups of healthcare professionals have told me frankly that they worry JCI has lost its original meaning.  During the audit period, institutions would operate in a way which is quite different from day-to-day practice.  This is not the true spirit of healthcare quality, which is about doing the right thing even when nobody is looking.  Furthermore, it is also a costly and time-consuming exercise to go through the preparation and audits.  

12.    If there are more relevant and less resource-intensive methods of achieving the same objective, MOH and our public healthcare institutions should be prepared to drop JCI.  We may not need to develop new initiatives, as my sense is that our institutions are already closely monitoring different safety and outcome indicators, and have developed strong organisational cultures that encourage continuous quality improvement.  So perhaps it is time to consider stopping JCI completely, so that we reduce unnecessary administrative burden for our healthcare institutions and healthcare professionals, and allow them to focus on more important outcomes like improving patient care and enhancing value for patients.   

Conclusion

13.    Today’s affirmation ceremony is a timely reminder of the ethical values and professional standards that you have pledged to uphold. Singapore society accords a high degree of respect for our doctors, based on the trust and confidence built over many generations. The bedrock of your professional practice must therefore always rest on maintaining this sacred trust through high standards of care, conduct and behaviour. Let’s continue to work together to help Singaporeans achieve better health and a better life. Thank you.