manpower

Tackling the healthcare manpower crunch and using healthcare technology

The world is facing a severe manpower crunch in health and social care. The CEO of the International Council of Nurses (ICN) said last year that “the scale of the worldwide nursing shortage is one of the greatest threats to health globally.” The ICN estimates that due to existing nursing shortages, the ageing of the nursing workforce and the effect of COVID-19, up to 13 million nurses will be needed to fill the global nurse shortage gap in the future. The Southeast Asia region alone is facing a shortfall of 1.9 million nurses, according to the World Health Organization.

Singapore needs another 24,000 nurses, allied health professionals and support care staff to operate hospitals, clinics and eldercare centres by 2030. Our rapidly ageing population is causing demand for health and social care to increase dramatically. Yet Singapore is facing a high attrition rate of nurses. One of the reasons why nurses in Singapore have reported to be resigning is because of their heavy workload and stress, which is caused in large part by the manpower shortage.

Boosting local healthcare manpower

Urgent measures are needed to address this manpower shortage. There are no quick fix solutions. We need to encourage more Singaporeans to choose health and social care as a career so as to boost the pipeline of future professionals in this field.

I highlighted in my speech on Singapore’s COVID-19 response in March that nurses in Singapore are often still seen as the assistants to doctors instead of being professionals in their own right. We need to boost the image of the profession and enhance societal esteem for nurses and allied healthcare workers. Nurses should be granted more autonomy and entrusted with higher level responsibilities.

Schools should highlight careers in health and social care early to students. Professional associations should come up with materials and videos highlighting the careers in this field and share these with schools to disseminate to their students. I agree with Dr Tan Yia Swam’s call just now for a repository of articles on navigating the healthcare system — and I hope she starts her blog again so that we can continue to tap on her knowledge. Career guidance should start early in secondary one. This is so that students’ interest in health and social care careers can be sparked early and they can start working towards choosing suitable subjects as they move up to secondary three.

As I mentioned in my speech on the education system in April, schools should move away from sorting students according to their grades and towards allowing students to take subject combinations based on their interests. This is how we can continue to raise up a generation of future healthcare professionals who love what they do and are passionate about their work.

IHLs (institutes of higher learning) could develop guidebooks to help local students prepare themselves for their eventual applications to these institutions. These guidebooks could include information on the subjects they need to take in school, the grades they need to obtain, and the co-curricular and extracurricular activities they need to get involved in to best prepare themselves to get admitted to the institution and major of their choice. For example, this guide could recommend that students take certain subject combinations, join the science club, find opportunities to conduct scientific research, write and publish research papers, or work as an intern in a health or social care institution during their school holidays.

It should provide guidance on how to search out these opportunities and work with professional health and social care associations to create these opportunities for students. These could all help our students focus early on pursuing their area of interest in health and social care and better prepare them for their eventual careers in this exciting field. It is too late to attempt to put together a portfolio just before applying for university or polytechnic. Yet this is often what many students do, because they go through secondary school with little idea of what they are interested in, and do not participate in activities that prepare them for their future careers.

Students from more well-resourced families, on the other hand, often obtain this guidance from their parents and are provided with opportunities for hands-on experience through their parents’ professional connections. In order to level up our society and capture a wider pool of talent in our population, we need to make this information available to every student.

However, changing public perceptions and increasing public awareness about health and social care careers takes time and requires a concerted effort from various stakeholders, including the government, the media, schools and parents. We must continue to develop targeted initiatives to address the concerns of healthcare workers, such as work-life balance, remuneration and career progression.

Technology as a force multiplier in healthcare

Having said all this, it is simply not sustainable to rely on increasing manpower supply alone to meet the health and social care needs of our nation. Considering our own ageing population in Singapore, which will require greater care needs, if we are to staff all our health and social care institutions with the doctors, nurses, allied health professionals and care workers to meet the ideal healthcare worker-to-patient ratios, the health and social care sector will likely take up a disproportionate share of Singapore’s manpower and will starve other sectors of the economy of skills and talent.

Technology can play an important role in boosting productivity and augmenting manpower. In my adjournment motion in this House in 2013 on easing the cost of healthcare, I said that technology should be used as a force multiplier in the face of limited manpower in our healthcare system. This is even more so now than it was a decade ago.

Healthcare technology — or HealthTech — is a fast-growing and promising field which must be developed further in Singapore. Transformational technologies are being developed now which will revolutionise the way healthcare is delivered in the future. These include artificial intelligence-driven diagnostics that can detect diseases early and make more accurate diagnoses more quickly than conventional means. For example, researchers at MIT have developed an AI model called Sybil that can predict a patient’s risk of lung cancer within six years using low-dose CT scans.

The emerging field of precision medicine has the potential to transform healthcare and is being used in the treatment of diseases like cancer, cardiovascular diseases and genetic disorders. It can potentially improve patient outcomes by providing more targeted and effective treatments, reducing adverse reactions to medications, and optimising disease prevention strategies. I note that there is now a Singapore Precision Medicine initiative aiming to generate precision medicine data of up to one million individuals, integrating genomic, lifestyle, health, social and environmental data. This is a very positive development.

There are also other healthcare technologies that are not as “deep tech” as what I mentioned earlier but are already in the market and can provide a boost to the productivity of healthcare workers, enhance the patient experience and improve health outcomes.

The National Electronic Health Records (NEHR) system is a major, multi-year HealthTech initiative. According to the MOH website, there are 2,231 healthcare institutions participating in the NEHR as of 5 May 2023. This list appears to be growing every day and I note there has been a marked increase in the number of participating healthcare providers since the start of this year.

The Straits Times reported on 2 May that the “private sector has been slow to participate in the NEHR since it was launched in 2011”. According to a PQ reply by Minister Ong Ye Kung to Mr Leon Perera in March 2023, only about 30% of licensed private ambulatory care institutions have view-access to the NEHR and less than 4% are contributing data.

A 2020 survey and paper by Clinical Asst Prof See Qin Yong of Changi General Hospital entitled “Attitudes and Perceptions of General Practitioners towards the NEHR in Singapore” found that solo-practising GPs who were more than 40 years old and who had practised for more than 15 years were less likely to view and contribute data onto NEHR. Doctors who regarded themselves as less computer savvy and those who perceived that an inadequate level of technical or financial support was available were also less likely to use the NEHR.

The Health Information Bill was supposed to be tabled in Parliament in 2018 to make the contribution of data to the NEHR mandatory for licensed healthcare groups after a grace period. However, this was deferred in the wake of the cyberattack and data breach of SingHealth systems in July that year, in order for technical and process enhancements to improve the security posture of the NEHR to be implemented first. Most of these security enhancements were supposed to be completed by last year, according to SMS (Health) Janil Puthucheary.

Can I ask the SMS if all the security enhancements to the NEHR have now been implemented? I understand that MOH aims to table the Health Information Bill in the second half of this year. Is MOH reaching out to doctors to address concerns they might have about the security of the patient data they will be required to contribute to the NEHR? How is MOH assisting the remaining GPs and dentists to get on board the NEHR?

Former Health Minister Gan Kim Yong said in 2017 that “patients can realise the full potential of the NEHR only if the data is comprehensive”. He added that “for NEHR data to be comprehensive, every provider and healthcare professional needs to contribute relevant data to it.”

Given the NEHR’s goals and the fact that $660 million has been spent on the system so far, it is imperative that the full roll-out is implemented without undue delay, while addressing the valid concerns of doctors.

We need to tap on the knowledge and experience of GPs who have been practising for many years, especially as we move forward into the Healthier SG initiative, which will see GPs playing a key role in promoting healthy lifestyles and providing preventive healthcare.

Technology can be used to help GPs focus on what they do best. Many private clinics find it a challenge to manage the dizzying array of IT systems that they need to manage their clinics, and connect to CHAS (Community Health Assist Scheme), Healthier SG and the NEHR. I note that there is a technology subsidy scheme available to help GPs to implement Clinic Management Systems that are compatible with Healthier SG. However, implementing these systems still requires a lot of time and effort on the part of GPs and their clinic assistants — time which they simply do not have, if they want to focus on direct patient care.

MOH should explore the possibility of offering and financing an “IT manager-as-a-service” to GPs and dental clinics. This would enable them to benefit from the expertise of IT professionals, who can assist them in resolving their healthcare IT-related issues. By providing a point of contact for IT matters, GPs and their clinic assistants can then concentrate on delivering high-quality clinical care to their patients. This solution would not only enhance the efficiency and productivity of GP clinics but also help them stay current with the latest technological advancements.

Conclusion

Urgent action is needed to tackle the shortage of manpower in health and social care institutions and grow the pipeline of Singaporeans entering this field. I have proposed some ways in my speech on how we can do so and I hope that MOH and MOE will consider them.

To boost productivity and augment manpower in the health and social care sector, we need to double down on the use of technology as a force multiplier, and assist providers to implement and use these technologies.

The world celebrates International Nurses Day this Friday May 12, which is the anniversary of Florence Nightingale’s birth. I would like to take the opportunity to say a huge thank you to all our nurses in both public and private healthcare institutions in Singapore. We appreciate your selfless service, sacrifice and care for our people!

This was a speech I delivered in Parliament on 9 May 2023 during the debate on Supporting Healthcare.

Attracting more Singaporean doctors home vs recruiting foreign doctors

Singapore is recruiting 180 foreign junior doctors, mostly from India, over three years, as part of overseas hiring to supplement local supply. Rather than rely on the recruitment of foreign doctors, it might be better to facilitate the return of Singaporean doctors who graduated from foreign universities.

The Pre-Employment Grant (PEG) was established for this purpose. According to the Minister for Health, in recent years, an average of 120 students have been awarded the PEG annually. The median grant amount is about $80,000 per student over two years. Recipients of the grant will be required to serve in the public healthcare clusters for a minimum period of between three to four years.

Are there plans to increase the number of PEGs, so as to attract more Singaporean doctors to return home to serve in the healthcare sector? This was a Parliamentary question I posed to the Minister for Health on 20 October.

The Minister did not commit to an increase in PEGs, but said that the number and percentage of successful applicants vary from year to year, depending on each year’s applicant pool and hiring demand among the public healthcare institutions.

Read the full PQ and answer below:

Applications for Pre-Employment Grant by Singaporeans studying medicine overseas (20 Oct 2022)

Mr Gerald Giam Yean Song asked the Minister for Health in each year since 2016 (a) how many Singaporean students studying medicine overseas have applied for the Pre-Employment Grant (PEG); (b) how many of these are approved; (c) what is the median grant amount; (d) what are the main reasons for the rejected applications; and (e) whether the Ministry will consider increasing the number of PEGs so as to attract more Singaporean doctors to return home after their studies to serve in the healthcare sector.

Mr Ong Ye Kung: We are encouraging Singaporeans who study medicine in recognised overseas universities to return home to contribute to our healthcare system.

The Pre-Employment Grant (PEG) was introduced in 2010 for this purpose. In recent years, an average of 120 students have been awarded the PEG annually. The median grant amount is about $80,000 per student over two years.

The number and percentage of successful applicants vary from year to year, depending on each year’s applicant pool and hiring demand among the public healthcare institutions. All applicants are assessed holistically, based on a range of factors, including their overall academic performance, professionalism, and commitment to serve in the public healthcare system.

Debate on the amendments to the Employment Act

I am glad to note the introduction of some new protections for workers and some PMEs in this Bill. I have mentioned a few concerns about salary deductions, penalties, exemptions from work hour limit protections, compensation for holiday work and the powers of inspecting officers.

This was my speech during the debate the amendments to the Employment Act in Parliament, on 12 November 2013.

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Madam Speaker,

I will focus on the amendments to the Employment Act in this Bill.

Section 30 – Deductions

I have several questions regarding the amendments to Section 30 pertaining to deductions for accommodation, amenities and services provided by employers to their workers.

First, how is the value of these deductible expenses determined? Has MOM conducted any inspections to determine if the prices charged by any employers are excessive?

Second, is the value of the accommodation based on the actual cost or the market value? If it is based on market value, these employers could potentially profit from providing accommodation to their workers, since private market rentals are very high. I note that Section 27(1)(c) allows for deductions for only the actual cost of meals, but Section 27(1)(d) does not specify “actual cost of accommodation”. Can the wording of the latter be changed so that employers are only allowed to deduct for the actual cost of accommodation?

Third, what can “amenities” and “other services” include? Unscrupulous employers could potentially throw in anything as a service or amenity, in order to deduct their workers’ salaries and reduce costs. I understand that some workers earning less than $800 per month still face deductions to their salaries. This could lead to financial hardship for them and their families, as their salaries may fall even further below subsistence levels. Would the Ministry consider prohibiting salary deductions for workers who earn below a subsistence threshold?

And fourth, I note that the protections under Section 30 are all still subject to mutual agreement between the worker and his employer. While one could argue that the worker is free not to sign the contract, in reality, most low wage workers are not in a strong bargaining position to refuse. This makes it more necessary for the law, and not just a contract, to protect the worker.

Section 34 – Penalties

Next, on penalties. This Bill specifies in Section 34 the penalties for failure to pay salary in accordance with the Act. A first-time offender will be liable to a fine of between $3,000 and $15,000 and/or six months’ jail, and a subsequent offence could double that.

Non-payment or late payment of salaries are a concern for many workers. Stiff punishment must be meted out to errant employers who fail to meet their obligations to their employees, in order to send a strong deterrent message.

However, the penalties do not guarantee that the worker will actually get paid what is owed him. While Section 134 stipulates that the court can order fines to be paid to the aggrieved worker, this is discretionary. Can the fines imposed be automatically paid to aggrieved workers, so that they receive all their salary arrears?

Section 40 – Exemptions from work hour limit protections

The amendments to Section 40 allow workers in “essential services” industries to work for more than 6 consecutive hours without a break or more than 12 hours a day, and without being paid for overtime work if it does not last for more than 3 weeks. Currently, this exemption is granted mostly for ad hoc work exigencies, like accidents, unforeseeable interruptions and urgent work, or defence and security duties.

This amendment could greatly increase the number of workers in Singapore who will not enjoy the work hour limit protections under Section 38(1). It will now include workers in broadcasting, newspaper and postal services, and even bulk distribution of fuel and lubricants, from among a list of 28 essential services listed in the Criminal Law (Temporary Provisions) Act.

What is the reason for including these new exemptions and in what way was the previous list of exemptions insufficient?

More importantly, how will the Ministry ensure that essential services workers are not made to work excessive hours without breaks, rest days or overtime pay, over an extended period of time?

Section 88 – Compensation for work during holidays

The insertion of a new subsection 4(A) in Section 88, increases flexibility for employers to compensate employees who work on holidays by granting them time-off in-lieu of overtime pay. It also specifies the number of hours of time-off in-lieu, depending on whether the employee worked a full day or half a day during the holiday.

Madam, holidays are very important for workers, as they provide them a day to spend with their families and recuperate from work. A disruption of a holiday due to work exigencies should be properly compensated by the employer.

This Bill allows the employer to grant only part of a day off to replace a full day of holiday work, “as may be agreed between the employee and his employer”.[1]

Why is it necessary to give this additional option to employers? It could give employers a way to avoid fully compensating their employees for holiday work, as the employee will find it hard to refuse a lower compensation.

Why not take away this option, so that it will be mandatory for employers to either compensate the employee with extra pay, or time-off in-lieu in proportion to the time spent working on the holiday?

Section 105 – Power to arrest

The Bill introduces a new Section 105, which gives inspecting officers the power to arrest without warrant persons suspected of committing offences under this Act. It includes powers to “use all means necessary to effect the arrest”. Section 105D provides for the inspecting officers to be armed.

Currently, Section 103 gives inspecting officers no such powers. They are allowed to examine, search and retain evidence, but not to arrest suspects.

I would like to ask the Minister why is there now a need to give inspecting officers powers to arrest and restrain people suspected of violating the Employment Act?

With these new powers, will inspecting officers be given the same level of training as police officers to ensure that they do not use excessive force when conducting the arrests or restraining suspects?

Salary thresholds

Lastly, the Bill raises the salary threshold for employees covered under the Employment Act to $2,500 for non-workmen but keeps it at $4,500 for workmen. According to MOM, this will allow the salary threshold of non-workmen to catch up gradually with workmen and, in the longer term, will allow the removal of the demarcation between these two groups of workers.

May I ask the Minister how long it will take to remove this demarcation, and what are the existing obstacles to its removal?

Summary

In summary, I am glad to note the introduction of some new protections for workers and some PMEs in this Bill. I have mentioned a few concerns about salary deductions, penalties, exemptions from work hour limit protections, compensation for holiday work and the powers of inspecting officers. I hope the Minister will address these concerns in his response.

[1] Section 4(A)(a).