A New Year brings new hopes and aspirations. And new worries and fears, unfortunately. In this new year, the hobbit wants to wish all readers of this nonsensical column a very ungratifying year and may all of you remain as ingrates.
This is because in 2024, the scariest word is gratification. Woe be unto you should any of you (especially those in the public sector) be suspected to have received gratification. Gratification can be displayed in many different forms; these include free concert and F1 tickets, or may even be just letting off a loud burp or two after a heavy meal or an upsized cup of bubble tea.
So remember, in 2024, stay ingrate.
Having dispensed with this New Year Greetings and leaving all ungratified, let us now set our eyes on this post’s question: Do we have too many or too few doctors?
As the cliché answer goes – it depends on who you ask
If you ask the public sector folks – they will say too few. The public healthcare clusters are desperately trying to recruit new doctors to fill vacancies that are created when new hospitals and polyclinics are launched. And the government are building these public health institutions (PHIs) rather quickly, in anticipation of increased healthcare needs of an aged population. The frequent complaints about waiting times and appointment times at polyclinics and specialist outpatient clinics reinforce the view that we don’t have enough doctors in the public sector, at least.
But if you look at the MOH Singapore statistics, in 2022, we have 2.8 doctors per 1000 population or about 1 doctor to 357 persons. This figure is in line with those of many developed Anglophone countries, including USA, Canada, UK, Australia etc and better than most countries in the region, including Korea and Japan. Also, Singapore is a small city-state that does not suffer from difficulty of having physical access to doctors that sparsely populated large countries may experience. In other words, even we may not have too many, we probably have enough or near enough doctors, going by national and international statistics and norms.
Then again, if you ask doctors in private practice, they will say the situation is rather saturated and we have enough or even too many doctors. Apparently, seven ENT surgeons have left or are leaving for the private sector in 2024. And we are in January. Prices and rentals for specialist clinic space in private hospitals are shooting up again, suggesting that demand far outstrips supply.
The Public Sector
But let us go back to the public sector again since the public sector employs the majority of doctors. In the latest SMC Annual Report (2022), it is stated that there are a total of 16,633 doctor in Singapore, of which 10,938 worked in the public sector and the remaining 5,695 working in the private sector. (i.e. 65.8% working in public sector or about two-thirds)
Of the 10,938 doctors in the public sector, 4,536 were specialists while 6,402 were non-specialists.
According to a recent article in the Straits Times, (9 Dec 2023), there were 624 doctors working in our polyclinics. These are in all probability not specialists registered with the Specialist Accreditation Board (SAB). That leaves about 5778 non-specialists working in the public sector less polyclinics. There were also 624 house officers in 2022 who need close supervision.
There are a relatively small number of public sector doctors who work in MOH, the statutory boards such as HSA, HPB, and agencies such as MOHH, AIC, Synapxe etc. If we ignore this small group, and take away the 642 polyclinic doctors and 624 house officers, there are 9690 doctors in the public sector. Of which the 4536 specialists would make up 46.8% of all doctors in the public sector.
In other words, there are almost as many specialists as there are medical officers working in the clusters’ hospitals and national specialty centres.
Obviously, this was not the case in our restructured centres long ago. Older doctors can all testify that specialists were a rare thing. In fact, even registrars were a rare thing. Once you pass your M.Med, you are either a Registrar or a MOS (Medical Officer Specialist), and you are given that prized object – the black name tag, which you proudly wear (if you are male) on top of your shirt pocket. You are now officially known as a “Tua Lo Kun” (Big Doctor in Hokkien) and you can now strut down the ward corridor with a spring in your step. Even senior nurses like ward sisters (aka ward managers) treat you with deference. You also get a respectable night call allowance (i.e. more than forty bucks). You gladly buy your on-call team supper. Actually, the registrar paying for supper was almost an obligatory thing, mainly because the more junior doctors were paid peanuts or nothing.
When you become a consultant, you have reached minor warlord status with your small team of registrar, medical and house officers. A consultant cannot be left alone when he or she visits the ward to see patients. A nurse and a house or medical officer will rush to the consultant’s side when he reviews his patients, to take instructions and to update the case-notes.
And finally, when one reaches the demi-god status of senior consultant, junior staff who are not in your team actually now avoid you or at least your stare while those who are, fawn over you, or least pretend to. The air thickens around you wherever you go, and now you are accompanied by the ward sister and at least a registrar when you review your patients. The ward doctors and staff hold a mini-conference before they make the decision to page you, or not. (For young readers, please be informed that there was this thing called a pager and “page” is both a verb and a noun).
Well, all that has changed with the above distribution of medical manpower currently in our restructured hospitals and national centres. As the numbers show, almost half the doctors are specialists. And this hobbit has been told that about half of the specialists are senior consultants (this hobbit has not been able to verify this claim). In other words, if this is true, then about 1 in 4 doctors are senior consultants, another 1 in 4 are either consultants and associate consultants.
There are no more entourages for senior consultants, except maybe the head of department or previous heads of departments. There just aren’t enough junior doctors to accompany every specialist that comes around in the wards. In some departments, the senior consultants outnumber the house officers.
It is therefore a “top-heavy” distribution of medical manpower. Obviously, we have to work in new ways now. But in the long run, one must ask, is this distribution of medical manpower sustainable from a cost-effectiveness point of view? Yet, at the same time, as aforesaid, we often hear of a large number of public sector specialists resigning for the private sector. One wonders, are they mainly senior consultants or more junior specialists?
It is a very complex situation but it would be nice to know what are the planning norms for medical manpower in our public healthcare clusters? E.g. what percentage of doctors should be specialists? And of these, what is the desired proportion for Associate Consultants, Consultants and Senior Consultants? Of course the tertiary hospitals and national centres could have a larger percentage of senior consultants etc.
This hobbit doesn’t know how many doctors and specialists the public sector needs as a whole, but the gut feel is that we probably either have too many senior consultants, too few junior doctors, or both.
The specialist manpower planning in our clusters is also inextricably linked with the private sector and national situation. It has been said that specialists should comprise 40% of all doctors in Singapore. This target has already attained currently with 40.3% of all doctors being specialists.
The Private Sector
This figure would include the significant number working in the private sector and especially the private hospitals. In our private hospitals, almost all doctors are specialists. But a closer look at the private sector would reveal that only about 38% of doctors in the private sector are specialists, (2163 are specialists out of 5695 private sector doctors). One would assume (wrongly) that the bulk of the remaining non-specialists would presumably be family physicians (FPs).
There are 3532 non-specialists working in the private sector of which only 1707 are registered FPs. That leaves 1805 non-specialist doctors in the private sector who are not on the family physician register. One wonders what do they do? Locums? Working in pharmaceutical companies? Resident MOs in private hospitals? Aesthetic GPs? This hobbit confesses he doesn’t know how this diverse group of doctors can come up to 1805, outnumbering the number of FPs.
Ideally, this group of “undifferentiated” non-specialist doctor in the private sector should be deployed where they are needed most. Perhaps more can be retrained as FPs through the GDFM (Graduate Diploma Family Medicine) route?
Let’s return to the specialist manpower situation again. The recent announcement by MOH (8 Jan 24) that it is interested in exploring the idea of setting up a not-for-profit private acute hospital should be supported. Another Mount Alvernia-like hospital would allow for more specialists to go into private practice without incurring the costs associated with the astronomical price for for-profit private hospital land in Singapore.
Perhaps this not-for-profit private acute hospital would address the possibility that we are having relatively too many specialists and especially senior specialists in the public sector.
But for this to happen, there needs to be a national and professional-wide consensus on the following:
- Do we have enough doctors nationally? (with a doctor-patient ratio of 1:357)
- Are we getting enough doctors every year (both locally and from overseas, ~ 600 to 700)?
- Are we training enough of these doctors to be specialists? (~40%)
- Do we have enough specialists nationally, now and going forward (in terms of percentage and in absolute numbers)?
- Do we have enough specialists in the public sector (in terms of percentage and in absolute numbers) compared to junior doctors?
- Do we have enough senior consultants in the public sector (in terms of percentage and in absolute numbers)?
In line with this New Year’s theme of avoiding any form of gratification, this post ends with more questions than answers……
hobbitsma 