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THE MANPOWER QUESTION 

The question of how many doctors should be trained is not easy to predict. The perceived shortage of doctors in Singapore today is largely applicable to the Government sector.

A survey of medical officers who left for the private sector in 1996 showed “poor pay”, “little or no career prospects” and “long hours of work” to be the top three reasons for leaving. “Poor treatment by superiors” was another reason for resigning.(1)

Both specialists and medical officers are attracted to the private sector. The relatively free market sentiment in the private sector means doctors will charge what they can so long as the patients can and are willing to pay. The result is the workload per doctor in the private sector is smaller compared to that in the public sector and yet the doctors are able to earn more. They can therefore work at a comfortable pace. Doctors in the public sector face a domino effect. With each doctor leaving the public sector, the remaining doctors need to carry an increased load per person and the desire for the remaining doctors to stay is diminished.

The focus on subspecialisation also means that as each specialist develops to a marketable value, there will be forces to induce him or her to leave for the private sector. The number of doctors who can provide training to younger doctors is thereby reduced. Without training, many medical officers in turn find that it is not useful to stay in the service.

The Ministry has instituted several measures to retain its doctors and to increase its number. The promotion exercise did not stem the tide for the public sector doctors to leave. The new norms for promotion did not go down well with many doctors. In a system short of doctors, numbers are more crucial than excellence. Also, at the medical officer level, the level of competence are not widely different from one doctor to another. By delinking qualification and pay, a new problem is also created. A less qualified but better paid doctor may be supervising one that is more qualified but lesser paid.

Perhaps there is a need to continue to link pay and promotion with qualification. It is generally correct that the more able doctors are those more likely to have higher qualifications. There are of course doctors who do not have higher qualifications but have exemplary performance. These generally are well recognised by their peers and are easily identified for promotion. What the majority in the public sector require is more a pay adjustment to narrow the differences between private and public sector rather than promotion.Hence the Minister’s recent announcement of the Ministry’s intention to narrow pay differences is a step that will be welcomed by the public sector doctors(2). 

Will foreign doctors take up the offer to join? It will not be a clear ”yes”. Foreign doctors are probably used to a less hectic workload. With the exception of Hong Kong, the number of patients seen in a session at the Government polyclinic certainly exceeds that seen in the United Kingdom and in the Australian setting. The number of in-patients per doctor may also be larger locally compared to overseas. To attract them to work in Singapore, terms may need to be generous. This may upset the local doctors. At the end of the day, it may be more workable to narrow the pay differences between the public and private sectors and look into the factors that will hold doctors in the public sector.

In the short run there is a need to see how the existing manpower could be encouraged to stay. The fragmentation into subspecialties in the hospital probably add to the number of medical officers required to keep the units running. The small units that come with subspecialisation run the risk of being poor training grounds for doctors who want to have a broad view of the specialties. Merging subspecialties together under a bigger department will be a plus in more than one way: there can be cross coverage of the medical officers and in this way, reduce the shortage of manpower; by having the subspecialties together, the learning experience of the younger doctors will be more varied and enriched; subspecialists too can become wider in their professional view and interests.

There is press announcement of bigger emphasis on training and to reward doctors for doing that. What is important is not only to reward individual doctors but also the whole unit to bring back the ambience of training as an institutional culture. Also, the efforts of senior staff to encourage and guide younger colleagues on their careers will help to reduce the pull factor into the private sector. 

There should perhaps be a larger  allocation of doctors in the polyclinics. The heavy workload makes it difficult to do a good job under the present circumstances. There is no protected time for training. Narrowing the difference between the consultation charges in the public and private sector may reduce the attraction of patients to the polyclinics. These, such as company patients can be served by the private sector.

There is a need for a systems approach. The number of doctors needed is dependent on how they are deployed. It is also dependent upon the motivation to stay. Reorganisation, revision of the pay structure, recognition of public sector doctors, good training and career guidance are some forces that may hold the doctors back in the public sector.