ESTIMATES OF EXPENDITURE FOR THE FINANCIAL YEAR - 1ST APRIL, 1997 TO 31ST MARCH, 1998
4.20 pm In the past, the doctors received $40 per night call for the first four duties and then $100 per night duty after that. We increased the allowance very significantly to between $110-$130 per night call. This is quite a significant increase. As a result, a medical officer today, with five years of service, will be able to earn at least $75,000 a year compared to $60,000 a year previously. This is a 25% increase in salaries. We have also reduced the number of night calls to a maximum of six to seven a month. So the change is for the better, but this also translates into a significant increase in our requirement for medical officers. Overall, the changes have been for the better. The scheme of service is now a lot more attractive and we are optimistic that it should help reduce the resignation rate in the next couple of years. We have also taken an additional approach of going abroad to recruit. As Members know, we have many medical students studying abroad. Our estimate is that over the next five years we will have about 240 students graduating abroad and we would like them to come back. Late last year, the Ministry sent a career counselling and recruitment team to Australia and UK and they managed to recruit 46 housemen and medical officers for this year. So this will help boost up our medical officers' strength. What was also encouraging is that the students, after attending the talks, felt encouraged and many of them said that they would definitely be coming back to Singapore to practise after their graduation. For the coming years, we should be able to rectify the situation. What about the second area, the specialists? The perception has been that the resignation rate of specialists, which means Registrars and above, is extremely high from the restructured hospitals. This perception is true for 1995. We had a total of 78 specialists who resigned from the restructured hospitals. This represents about 8% of the total pool of specialists that we have. I asked whether there was any significant factor that led to this resignation. My staff tells me that in 1995 Gleneagles Hospital made available new clinic space and that led to the departure of many of the specialists. In 1994 and 1996, the resignation rates were more manageable, about 5%, compared to the training rate of 7-8% of each cohort. I think there is a balance. For this year up to July, the resignation rate has been 2�%, which is again lower than the comparable period in 1996. Sir, there is a good match between the resignations and the supply in most specialties in the public sector. This is because we have a fairly well-managed and well-planned training pipeline. But shortages do occur from time to time when a particular specialist area experiences more resignations. The areas now that are facing a shortage would be anesthesia, radiology and medical oncology. Because it takes more than six years to train a specialist, the solution to these periodic shortages in specific areas is really to go abroad and recruit qualified specialists. This is an option that the restructured hospitals are now actively exploring. But we need to improve our internal system too. As Dr Michael Lim has said, we have to look at the conditions of service and make them more attractive. My Ministry is now working with HCS and the hospitals to do this. We are looking at a few things. Dr Michael Lim mentioned about teaching and medical research. Yes, we recognise it. Together with clinical practice, these are the three key pillars of institutional practice. We must recognise the efforts of doctors put into teaching and research, and recognise them in both monetary and non-monetary ways. So overall, we must make the public sector more attractive. But while we recognise that the public sector pay can never match the income in the private sector, our salaries should nonetheless be competitive. What about the long term manpower situation? Mr Lew Syn Pau has asked about that. So have Dr Michael Lim and Mr Bernard Chen. Let me give Members some background information. In 1991, the Health Review Committee on National Health Policies recommended that, first, Singapore should attain a doctor population ratio of 1:650 by the year 2000. As a comparison, the doctor to population ratio of the United Kingdom in 1993 was 1:650. So that places us fairly close to the United Kingdom with a few years' time lag, which is not bad. The Committee also realised that we need to control doctor manpower because the experience of all the developed countries has shown that an excessive supply of doctors only leads to escalation of health care expenditures. So it is a lesson that we should learn well and adopt. Projecting from the 1980 census, based on the Health Review Committee's recommendation, we would have about 6,400 doctors in the year 2010, compared to about 4,700 this year. That will be an increase of about 1,700 over the next 13 years. In order to meet this projected manpower, the NUS intake was maintained at 150 and the Singapore Medical Council reviewed the list of recognised foreign universities and reduced the list to 28 schools in the expectation that they would take in a total of no more than 40 Singapore students. So 150 Singapore students in NUS plus 40 from abroad would then leave us with more than enough to achieve the desired doctor strength of 6,400 by the year 2010. Earlier this year my Ministry reviewed the doctor projections again, because several factors have changed. Unlike what Dr Michael Lim has said that it was just a short three years ago, those projections were actually done about 7-8 years ago. First, the 1990 census revealed that our population was larger than projected from the 1980 census. That means the base we are using to calculate the doctor population based on that ratio was out by a bit. Secondly, the Government's effort to attract overseas talents will speed up population growth and the revised higher projected population in the year 2010 would mean that the projected number of elderly sick in the future years would also increase. The third factor was regional demand. Because regional economic growth is expected to remain strong in the coming years, we have also revised upwards the projected regional demand for medical services. This is in line with what Mr Bernard Chen, David Lim and the rest have talked about in terms of the regional medical centre and medical hub. Factoring all these changes, MOH revised the desired doctor population in the year 2010 from 6,400 to 7,100, ie, all these have led to an increase in the projected demand of about 700 doctors. To achieve this figure, we therefore work with NUS to increase the intake this year to 180 and to increase the intake to 200 for next year. 4.30 pm How about the list of recognised medical schools? Our study shows that in 1996, just from 11 medical schools, there are two Australian and nine medical schools under the University of London. These 11 schools alone took in 42 Singapore students, compared to our projected figure of 40 for the entire 28 schools. We understand that a few Singapore students applied for the remaining 17 medical schools in the US, UK and Australia. But this may change in the coming years as the parents in Singapore realise that there are other schools where the intake has been very low that they will get a better chance to be admitted to those schools. I think more Singapore parents would then encourage their children to enrol there. My Ministry will therefore continue to monitor and review the situation over the next few years before deciding on whether or not to increase the list. Sir, I will say that overall, our medical manpower in the public sector is manageable, although tight in some areas. We have steadily increased the staff strength over the years and will continue to do so, especially now that the medical student intake has been increased. What about nursing manpower, which Mr Bernard Chen asked about? Here the situation is more acute. We have a shortage, and the shortage is more significant. There are today about 9,000 nurses in both the public and private sectors. And the estimated shortage is about 2,200 nurses, ie, a 20% shortfall from what is required. The demand for nurses will definitely increase with an aging population and the expansion of the medical services. We must therefore find more creative and innovative approaches to solve this problem in the next few years. The problem is how to attract young school leavers to go into nursing, especially when there are so many other competing careers that are available, and that is only for the intake level. Secondly, how do we retain the trained nurses in the public sector? I know Mr Bernard Chen mentioned about nurses working in the Middle East. Yes, we know there are some. But in the context of the 9,000 nurses that we have, the proportion of nurses working abroad is actually quite small. It does add to the shortage. In terms of recruitment, we reached a peak of about 751 student nurses in 1989 and we were able to reach that peak because of the recession in the mid-eighties. Suddenly, a lot of school leavers felt that it was worth the while going into nursing. But immediately after the recessionary effects wore off, the following year 1990/1991, the intake dropped by more than half, an average of 330. 751 in one year, next year it was 330. Our target was 900 - a tremendous shortfall. But, fortunately, we have already recognised that it was going to be more difficult attracting students and we had to increasingly make the nursing profession more attractive and competitive. As a result, we were able to persuade the Ministry of Education to start a Nursing Diploma course in one of the polytechnics. Prior to that, nursing was only a certificate course in the School of Nursing. So this represents tremendous enhancement of the professional status. The Nanyang Polytechnic started a course in 1992 and I am happy to report that this has resulted in the increase in the number of applicants. Last year, the Diploma course managed to attract 590 applicants, Singaporeans and non-Singaporeans, compared to about 250 when we had the School of Nursing course. So it has proven to be attractive. We are strengthening our efforts to also recruit foreign nursing students, which is a better approach than trying to recruit trained nurses. Because if the students come here and study in the polytechnic, after three years, I think they will have become more acclimatised to the local demands and practices. But, nonetheless, I think we should not rule out recruitment of trained nurses from abroad. With such a significant shortage, even if they are not fully acquainted with our system, I think they can still contribute. So let us appreciate them for their contributions that they are making. At the same time, my Ministry will be looking into how to make the nursing career even more attractive and challenging. We will be carrying out a comprehensive review of the service in the next few months and we hope that arising from this study, we will be able to once again further improve on the attractiveness of the profession. Sir, let me move on to the next cut which is from Mr Bernard Chen on the professional standard of doctors. He is worried that the recent publicity of complaints to the SMC (the Singapore Medical Council) may indicate that things are not all that well in the medical profession, even though generally the standard of the medical profession in Singapore is very high. I think the point is correct that the standard of the profession in Singapore is high. Every year, the Singapore Medical Council receives between 40 and 60 complaints. I think the range is reasonable and the numbers are not too bad, considering that we have about 4,700 doctors in Singapore. In every profession, there will be a few black sheep. Sir, we have been focusing on ensuring that our doctors are competent and capable. However, it is equally important for doctors to maintain and uphold professional conduct to ensure that patients are given the appropriate care and treatment. Consequently, the teaching of medical ethics forms an important part of the medical curriculum. In recent years, the SMC has also introduced a physician's pledge to increase the awareness and commitment of doctors to the vocation. We will also be introducing lay representation in the disciplinary and complaints committees, as mentioned by Mr Chen. He has asked what else can we do. Sir, MOH also carries out medical audits on various procedures and treatments to identify areas which need to be improved or to deter poor medical practice. This is an important element and we are in the process of strengthening our audit capabilities. With all these, I think we should be able to maintain the professionalism in the profession, despite the many competing demands on the time of the doctors. Sir, let me move on to the next cut which is by Mr Goh Choon Kang on the impact of the cost of furniture and equipment on patients. It is prudent and sound to take into account all operating costs of providing a service. This way we will know what the true costs are, which are the areas which are out of line, which are major cost elements and how do we bring about productivity improvements and cost savings. The costs of furniture and equipment (F&E) are part of the hospital's operating cost, just are the salaries of nurses and doctors. In the case of furniture and equipment, they make up 5% of total recurrent cost. But while we account fully for the F&E cost, most patients do not bear the full amount of the cost. This is because patients in B1 get a subsidy of 20%. Those in B2 get 65% subsidy and those in class C get 80% subsidy. That means the Government bears 80% of the costs of the furniture and equipment for the class C patients. So much of what Mr Goh is asking for, I think, is already being provided by the Government. Dr Michael Lim talked about medical specialisation, that increasing specialisation may actually lead to increased cost and he also commented about the practice conventions in SGH. Sir, as medical science and technology continue to develop rapidly, I think it is inevitable for doctors to specialise and sub-specialise even more. I think Dr Michael Lim will fully appreciate that, being a specialist himself. The question is: how do we ensure that patients get the best care possible at the best value? He is correct. Specialist services, if used indiscriminately, will lead to an increase in health care cost. So how do you balance the two? Sir, rather than just focus on SGH, I think the problem is not just SGH's alone, the problem exists in all the hospitals, whether they are private or public. In fact, I have heard many horror stories of patients going to the private sector who were given a go-around and ended up, instead of seeing one specialist, seeing four or five specialists. So the problem is equally prevalent in the private sector. And it is not just restricted to the specialist area. It also applies to the whole medical service. I think it is well recognised that a person with a medical condition should first consult a generalist doctor, rather than self-referring to a specialist. Especially if he has multiple medical conditions, the generalist doctor would then be in the best position to decide whether that patient needs to see a specialist and, if so, which specialist. In some developed countries, their health insurance systems and their national health plans require patients to first consult a family practitioner or GP. In Singapore we do not do this, we do not regulate this, and many patients self-refer to specialists. This, of course, then makes it more expensive for him, especially when the GP could have looked after him and solved his medical problems. At the hospital level similarly, the general physician should be in charge of patients with multiple medical conditions. And this would mean that even if the patient had self-referred or had been referred to a specialist or a sub-specialist, and the sub-specialist found that he had multiple problems, the sub-specialist should actually make it a point to refer him to a general physician in the hospital, rather than to send him to a whole series of specialists. Dr Michael Lim Chun Leng rose ---