Underplanning is in the health ministry’s DNA

The saga of insufficient hospital beds continues. Our public hospitals are so full, they have to hire extra space from other institutions. The alternative would be to turn away emergency patients, again. Here’s a headline from the Straits Times, 30 August 2011:

The problem of insufficient public hospital capacity is a long-standing one, dating back several years. Even when the new Khoo Teck Puat Hopsital in Yishun opened (March 2010), and the Ministry of Health public relations went into dizzy-spin mode saying that the new facility should banish the problem into the dustbins of history, I was sceptical.

Sure enough, the new hospital was filled up before one could blink (see my July 2010 article Bed crunch continues even as new hospital opens) and by earlier this year, more crisis stories reappeared (see my June 2011 article Hospital bed supply trailing far behind increase in elderly numbers).

The latest news story reports that the situation is expected to be so dire,

The crunch has led Health Minister Gan Kim Yong to float the idea of bringing forward the opening of Sengkang Hospital, scheduled for 2020.

– Straits Times, 30 August 2011, Public hospitals ‘borrowing’ ward space, by Salma Khalik

This new hospital is in addition to the Ng Teng Fong Hopsital now under construction in Jurong East and expected to be ready by 2015. It had earlier been touted that these two planned hospitals should more than cope with the expected increase in need, claims repeated as recently as earlier this year. The latest news that they can’t come on stream soon enough is ample proof that the ministry’s planning process is flawed.

In Hospital bed supply trailing far behind increase in elderly numbers I had already pointed out that something about the planning projections makes no sense. The planners used the assumption that the demand for hospital beds increases about 1 percent per annum. I took a quick look at demographic data from the 2010 census and showed that the population of elderly is growing by 4 percent per year. I am sure the civil servants at the Health Ministry can see the same numbers but somewhere along the line, the implications stemming from the data might have been rejected out of hand, perhaps because they conflicted with wishful thinking. You get a glimpse of that in the same Straits Times story:

But [Health Minister Gan Kim Yong] told The Straits Times yesterday that simply adding more beds to the system alone will not be a viable solution in the long run.

It does not take into account how patients prefer to be cared for in the community instead of in hospitals, Singapore’s limited land space, and how with an ageing population, beds will simply not be enough no matter how many hospitals are built.

– ibid.

You see it? A dogmatic resistance to recognise the implications of data.

To be fair, the minister is exploring other ways:

More innovative ways to manage the health-care system must be found, he said, adding that he was reviewing the health-care masterplan.

One solution is to use general practitioners and polyclinics more intensively to keep people healthy – and out of hospitals. Another is to develop home care services, he said.

– ibid.

However, ideal though it may be, this is an untested model for healthcare delivery. Even if it eventually works, it’s going to take years to create the system and debug it. But most crucially, the concept seems to confuse keeping people healthy with coping with the ill. Keeping people healthy may prolong lives and improve the quality of lives. But ultimately, we will all get seriously ill. If we remain healthy, we postpone this from age 75 to age 85, but in the end we will still be hospitalised.

Alternative strategies may dampen demand somewhat but the rapid growth in the numbers of elderly will still mean that hospital capacity has to increase substantially and rapidly. There is no wishing this away.

* * * * *

How is it that barely a year after inaugurating a brand new hospital (Khoo Teck Puat) the public hospital system is facing a bed shortage overall? According to the long-term development plan, another hospital should not be needed until about 2015 when the Ng Teng Fong is ready. So why is there a bed crunch now?

It’s hard to know what went wrong with the planning system, but I can take a stab at it. Perhaps this was what happened:

I’ve noticed in previous news stories that the ministry refers to historical hospital admissions data when justifying its planning numbers. This suggests to me that civil servants treat historical data with respect to bed-days as indicative of demand, projecting (the blue line in the rough illustration above) into the future. It is likely that on this basis, they drew up plans for new hospitals.

In the illustration below, total planned bed capacity is the thin black line that steps up with the addition of a hypothetical New Hospital P in Year 8 and New Hospital Q around Year 13. The plan is approved, and everybody is congratulated for assuring the country of sufficient bed capacity to cope with growing demand in the years ahead.

Three years later, in Year 10, after New Hospital P has come into operation, the public is screaming again. Hospitals are operating at close to 100 percent of capacity, and patients are being turned away.

Why did the turquoise bars shoot up in Year 8 and after? — You might think it’s an important question, but I suspect it is not one that triggers much soul-searching in government. This is because there is an ideological tendency to fall back on the dictum, borne out of the government’s anathema to socialism, that when it comes to public goods, demand will always increase to fill supply. (You want evidence? See the sentence from the Straits Times report cited above and attributed to Gan Kim Yong: “beds will simply not be enough no matter how many hospitals are built”.) So the official attitude is: Nothing you can do about the constant cry for more beds. If you succumb, you’re only feeding the beast of social expectations.

In other words, the first instinct of the government is to dismiss the phenomenon of capacity crunch as no more than a symptom of the moral failure of citizens in their greed for public resources. This dismissal continues until the political price becomes unbearable, and then something is done.

While that explanation — that when it comes to public goods, demand will always increase to fill supply — may have a ring of truth about it, it is actually flawed. The dictum may be true when the public good is free or cheap, e.g. use of roads. But hospitalisation is a costly thing. Nor is it something people can choose to consume by themselves. They first need to fall ill (as if people like to be ill?) and a doctor needs to consider the illness severe enough to warrant warding.

So why did the bars shoot up?

The error came about when planners used historical bed-use data as an indicator of demand. This is only meaningful if there is surplus capacity in the system. In years when there is no surplus capacity, the bed-use data represents the supply limit, not demand.

In fact, in those years, hospitals would have been discharging patients early to make way for new incoming patients. New emergency cases would have been waiting in corridors for lack of beds, and elective surgery would  have been postponed. In other words, true demand was higher than supply.

In the graph above, unfilled demand is represented by the faint-coloured bars. As soon as a new hospital opens up, that unfilled demand has somewhere to go, and that’s how a new hospital fills up so quickly.

Thus, the blue line that had been used for planning new hospitals was inaccurate as a projection of demand growth. Instead it should have been the pink line:

Undeniably, it is very hard to “count” demand, unlike hospital admissions and bed stays. By definition they are patients turned away, or hospital stays cut short. How many extra bed-days would have been involved if they had not been turned away or discharged early? It is hard to know, and most certainly there’d be no records. Estimating demand is not a science but an art.

So, even if a civil servant had the foresight to know that the blue line projection is probably misleading, it would be extremely difficult for him to make a case for an accelerated building program based on the pink line projection. He would be asked: Where’s the hard data to support the pink line? Especially if he is faced with a political bias against unnecessary spending, and a cultural reluctance to point out to ministers that they are over-optimistically reliant on untested ideas of community-based healthcare, the civil servant’s chances of success are poor. Resistant to contrarian ideas, the ministry is institutionally programmed to lurch from crisis to crisis.

* * * * *

I am not at all underestimating how difficult it is to get planning right. Ask any corporation about to launch a new product, and they’d tell you estimating demand is often guesswork at best. Even for established products, estimating next year’s sales is hard enough.

Moreover, building forward capacity for the healthcare system is not just a matter of construction. There’s an even bigger problem of where one would find the needed doctors, nurses and other personnel. Then there is the question of costs and subsidies for patients. . . .

But the starting point must be to get the projections right. In this respect — to have a brand new hospital full within 12 months, and the whole system groaning under the weight of unforeseen demand with no new hospital for 3 – 4 more years to come — the record is rather less than sterling.

31 Responses to “Underplanning is in the health ministry’s DNA”


  1. 1 Stephanie 2 September 2011 at 12:06

    This strand of DNA is not privy to the health ministry, it also exist in the National Development ministry. Planning for housing is on a ‘if-you-place-order-then-we-build’ basis. As a matter of fact, it is most likely this strand of DNA originates from here, proliferated by MBT. It will indeed be a disaster if the planning for the number of beds is based on BTO.

  2. 2 Han 2 September 2011 at 12:45

    Wouldn’t you say that your post is about the chronic failure of a centrally planned system to allocate sufficient resources to meet the healthcare demands of the public? If that is not an indictment of socialist-style command and control, then what is it?

    • 3 jem 3 September 2011 at 11:59

      the article is about THIS centrally planned system failing to meet demands. I don’t think you can extrapolate it to tar ALL centrally planned systems, socialist or not.

      • 4 Han 3 September 2011 at 17:14

        You would be hard pressed to find a single instance of any centrally planned system that allocates resources sufficiently, efficiently and fairly. Chances are even two out of the three would be difficult.

      • 5 jem 5 September 2011 at 12:25

        Singapore’s public library system seems to be doing just fine.

      • 6 Poker Player 5 September 2011 at 13:02

        Public libraries remind me a hilarious episode from the Daily Show

        http://www.huffingtonpost.com/2010/02/23/stewart-to-glenn-beck-you_n_472826.html

      • 7 Poker Player 5 September 2011 at 13:22

        You would be hard pressed to find a single instance of any system based on XYZ that allocates resources sufficiently, efficiently and fairly. Chances are even two out of the three would be difficult.

        Where XYZ could be laissez-faire, sheep entrails…etc.

      • 8 Anonymous 6 September 2011 at 10:18

        @Poker Player

        “You would be hard pressed to find a single instance of any system based on XYZ that allocates resources sufficiently, efficiently and fairly. Chances are even two out of the three would be difficult.

        Where XYZ could be laissez-faire, sheep entrails…etc.”

        Funny, but there actually is a deeper point in what you said. Many kinds of problems faced by societies are intractable (perhaps such as sheep entrails), and there are no good solutions. My argument is that top-down approaches will often not only be unable to solve the problem, but will instead exacerbate them.

      • 9 Poker Player 6 September 2011 at 13:49

        “Funny, but there actually is a deeper point in what you said. Many kinds of problems faced by societies are intractable (perhaps such as sheep entrails), and there are no good solutions. My argument is that top-down approaches will often not only be unable to solve the problem, but will instead exacerbate them.”

        You are still chasing after your own tail:

        My argument is that XYZ approaches will often not only be unable to solve the problem, but will instead exacerbate them.

        Where XYZ could be laissez-faire, sheep entrails…etc.

    • 10 Agents Provocateur 4 September 2011 at 12:20

      I’m not necessarily a big fan of central planning, but maybe you could provide an argument for the general failings of central planning as a whole, as opposed to snarkily high-fiving yourself.

      • 11 Han 4 September 2011 at 23:11

        I think Alex has done a really good job in highlighting the failures of a system built on central planning, failures of which are endemic to such systems as a whole. I see no reason why I should attempt to replicate what Alex has written, and besides I would have done a shit poor job at it any way.

    • 12 Poker Player 5 September 2011 at 11:43

      So if you see a story of bad healthcare in say Texas, you say “if that is not an indictment of laissez-faire, then what is it”?

  3. 13 Anonymous 2 September 2011 at 17:30

    The decision to make Singapore a medical tourist hub is a big mistake which Singaporeans have to bear.

    Resistant to contrarian ideas, the ministry is institutionally programmed to lurch from crisis to crisis. Add another: from election to election.

  4. 14 K Das 2 September 2011 at 19:31

    An incisive analysis.

    You seem to be a jack of multiple trades and master of all. How do you do this? Are all these brain waves of your own mind? If it is so it is fantastic. In terms of solving acute community problem on a national basis you appear to be equal to 2-3 Ministers combined – what more with top civil servants helping out (if you are a Minister that is).

  5. 15 ILuvWiki 2 September 2011 at 20:27

    http://cables.mrkva.eu/cable.php?id=228018

    Here’s some insights on Wikileaks on SG healthcare.

  6. 16 mjuse 2 September 2011 at 23:42

    2 comments:

    Your analysis sure reminds me of Mah Bow Tan bleating about how affordable HDB flats were, based on the percentage of income new couples who bought flats were paying for their mortgages…and ignoring all those people who couldn’t afford flats and who were hence excluded from the data.

    If the underlying reasons that you have surmised for underprovisioning of public services is correct, then this is probably common across many government ministries. Woe betide us. The man who used to head the health ministry is now in charge of housing.

    Second comment, the whole argument about demand rising to meet supply lacks strength when applied to medical services. Deficit hawks and ideologically blinded economists in the US are using similar arguments against the Single Payer System. A good retort to that can be found at

    http://healthcareorganizationalethics.blogspot.com/2011/08/why-us-isnt-ready-for-single-payer-yet.html

    The punchline, “Patients who don’t need chemotherapy or appendectomy don’t ask for these services just because they’re paid for…”

    In the Singapore context, I would paraphrase this as, “Nobody checks into hospital for the food and great service just because it’s subsidized.”

  7. 17 Cher 3 September 2011 at 01:41

    As much as I agree with your analysis of the way the govt deals with projections and policy making, I have to admit grudgingly that the Health Minister made a valid point about keeping Singaporeans healthy. The point is so that we do not get critically ill frequently so that the beds can be used to house more patients.

    Also with technological advances, I believe that tele-health can potentially be the next thing will aid in this, monitoring patients from home instead.

    Regardless, I do agree that we have to ramp up bed numbers.
    But more importantly, govt contribution to healthcare as a percentage of GDP, instead of us footing the bills through the 3M’s (it is STILL our money).

  8. 18 Jog My Memory Please 3 September 2011 at 04:23

    Awesome piece of work Alex.
    If memory serves me correct, the Khoo Teck Puat Hospital or Northern Hospital (as it was known in earlier days) was a project postponed several years… Around the time of the 2001 elections it was a talking point but then due to SARS and national budget issues, the current MND and then Health Minister postponed the construction of this hospital, [correct me if I am wrong] estimated at about S$200mil…. subsequently it was a discussion point in GE2006 and then promises being promises they were really kept this time and construction commenced soon after… but Singapore ran into a boom time and the sand supply issue and the hospital was then constructed for S$400mil [please double check my figures]… under that leadership, tax payers could have paid less to get a much needed hospital earlier but we got the hospital in 2010 [perhaps taxpayers did not pay more thanks to the charitable kindness of Mr Khoo and his family].
    Now, let’s look forward a little,… if the same behaviour and thinking prevails, would there be planning shortfalls in MND which oversees HDB, URA, BCA…? Are the PA/HDB issue and the DBSS price issue early glimpses of shortsightedness carried over from the Health Ministry?
    Have a good weekend :)

    • 19 jem 3 September 2011 at 12:01

      According to wikileaks, the sand supply wasn’t that great of a problem after all.

      “Regarding the increase in cost of
      construction materials since Indonesia imposed a ban on sand
      exports to Singapore in January, Mah argued that Singapore
      has huge stockpiles of sand and supply has never been an
      issue. The ban caused sand prices to rise slightly, but that
      was the extent of the problem. ”

      http://wikileaks.org/cable/2007/09/07SINGAPORE1781.html

      I don’t know how much the boom time contributed, but a 100% increase (assuming your figures are correct) doesn’t seem ‘slight’ :/

  9. 20 Liew Kai Khiun 3 September 2011 at 10:05

    Piercing piece once again! There is a factor that also needs to be factored in the now endemic rates of dengue fever that swamps the hospital beds with patients. My wife had dengue once, and we were turned away by TTSH and CGH as their capacity was full. We had no choice but to check into a private hospital (luckily we had insurance). In this respect, aside from higher populations, if we equate dengue fever with construction and property development where worksites breed the most mosquitoes even as the state likes to blame individuals for not emptying their flower pots, this is one social cost that is imposed on the individuals and hospital provisions.

    But, perhaps we need to relook at the hierachisation of healthcare in Singapore between different types of wards in our public hospitals, especially on the question on whether resources and rooms can be freed up if we convert all single room A class wards and also the 4 bedders B1s into B2s instead of the humiliating C Class wards at the present. For me, in their drive towards greater corporatization and privatization (and a more cynical attempts to pass on the buck of healthcare to individuals in the name of family values), the state has probably forgotten the fundamental principles of the universal provision of and access to basic healthcare. It is just not right for public hospitals to appropriate so much at the expense of the larger public just to accommodate the few who can pay more.

  10. 21 PatricNoNSTan 3 September 2011 at 12:04

    I was once ill in A&E in one public hospital, and I was ‘parked’ along the corridor with several other patients because they were NO beds! After a night, I was transferred to an ICU bed because there STILL were NO beds and they needed to attend to me. Only after almost two days, I got allocated a bed, and my situation was actually quite bad and they didn’t diagnose me until I was sent to a ‘fixed’ ward. The whole experience was actually shocking in retrospect – anything could have happened during the time I was shifted around. Why is this happening in a supposed First World country?

    • 22 Han 3 September 2011 at 17:15

      Perhaps the ironic reply to your question would be, this is probably the hallmark of a First World country public healthcare system.

  11. 23 Ethan 4 September 2011 at 11:01

    Just as Transportation and Housing are major issues today, Healthcare and Education would be increasingly important issues in Singapore.

  12. 24 Leuk75 4 September 2011 at 21:57

    Part of the reasons is also our obsession with operational efficiency. Empty beds are considered “excess resources” not well used. Private enterprises all know the need for buffer stocks for contingencies. Somehow, we don’t seem to have much buffer for our healthcare facilities.

    Being from the former AH/KTPH system, trust my take on the new hospitals and KTPH before that. It is not the rising costs and sand prices or building speed that is the issue. The biggest difficulty is in the software. Building two new hospital buildings is the easy part. The tough one is finding the healthcare professionals to staff them – especially nurses.

  13. 25 siew tin 8 September 2011 at 00:26

    This letter was sent to STForum on the 17 Aug 2011 but they choose not to print it and calls made to the media were ignored. This only reinforce my belief that SPH/media are indeed controlled. I sent this letter to PM, MOH and various opposition therefore the recent reports in the Straits Times is probably in response to my feedback and I am still waiting for a reply from the ministers.

    Dear Sir/Mdm

    I am writing to express my deepest disappointment and disgust towards the treatment of patients at the National University Hospital. As a recent patient warded at NUH Ward 51 and transferred to NUH Rehab Ward 1 at the West Point Hospital, I have firsthand experience of how local B2/C class Singapore patients are being treated.

    Barely being in Ward 1 for few days, I was pressured to leave the premises. Their reason, my broken knee was not serious enough a problem for me to remain in the rehab centre and deemed fit enough to be discharged to an empty home where there is nobody around to take care of me in the day. Or I can pay for my stay in a community hospital as they have a 2 weeks stay policy and Ward 1 is only a transit lounge. Please note that there are ample hospital beds available and the Ward 1 is not overworked unlike NUH Ward 51. If it is a rehab centre, am I not supposed to remain here till my knee has healed and has full mobility? But what appals me is that foreign patients are not pressured to leave the ward with the same gusto as Singapore patients. Does it mean that full-fee bearing foreign patients are more welcome into government hospitals than Singaporeans who pay a subsidised fee? Is this hospital not built by Singaporean money? Aren’t patients considered as clients of hospital? Is the ‘bottom-line’ more important than the care, comfort, compassion and empathy? Are the duties of doctors and nurses different than before?

    When I raise these questions to the hospital staffs, they merely side-swiped the questions and gave me lots of suggestions of how I could be discharged and fend for myself with insensitive comments. Am I having free stay at the hospital or the profits do not substantiate my stay? Isn’t hospital supposed to see to the well being of patients? If I am paying for unsubsidized ward, would NUH throw me out with such gusto? Can I ask our former Health Minister, Khaw Boon Wan if he was pressured to leave so “as to discourage unnecessary hospitalisation” and he paid only $8 for a bypass? They even suggest that I move up to the private West Point Hospital as I witnessed one of the patients being forced to move there.

    If this is a First World Country with First World Medical facility and a Singaporean First policy, then why are there double standards in a government hospital? Has government hospital lost their moral compass and resort to being experts in money making rather than institutions which provide top notch medical services to the masses of First World status? Have Singaporeans become economic figures for GDP growth? Are we not as human as the ministers, the elites and the foreigners?

    I would appreciate a reply by our Prime Minister, Lee Hsien Loong who assured us of a Singaporean First policy in his National Day speech and an investigation/reply from our Minister of Health, Gan Kim Yong with regards to this matter. Thank you.

    Yours sincerely

    Siew Tin

    PS.. I am a divorcee with 3 children. I have no maids, relatives or any support at home. I’ve discharged myself as I couldn’t take the pressure any longer. I have never felt more sadden, disgusted and humiliated as I am subjected to their harassment and abuse on almost daily basis. I am also not the only Singaporean being driven out. Singaporeans must be aware of how NUH treats their patients.

  14. 26 James Tan 8 September 2011 at 01:38

    I understand the government hospitals are also taking in private oversea patient and they don’t have to wait (because they are paying full fee). Could this be another cause?

  15. 28 siew tin 8 September 2011 at 20:50

    The foreigners warded there were mainly industrial and road accident cases. The insurance will pay for their class B1 or B2 medical fees in full with no subsidy. I suspect that is the reason why singaporeans are driven out and not the foreigners with some already staying a few months.

    • 29 Leuk75 11 September 2011 at 19:41

      To be fair, let us consider the situation. For foreign workers involved in industrial accidents (IA), the law specifies that they be housed in at least B1 class. Since employers have to take up insurance for such stuff, they will be put in the paying class wards. Demand for the subsidised B2/C wards are obviously much greater among local Singaporeans who self pay (except for higher level management folks and IA). Hence, the pressure on the subsidised wards to discharge. Same thing why the appointment lead times for private outpatient clinics are much faster – the queue is far shorter.

      Now the star question / 重点 is: If the need and payment ability for the average Singaporean is for subsidised care, should not more beds and clinic sessions be reserved for these? Must the clinic sessions be solely “private” or can they not be a mix of private and subsidised? Do note that in subsidised cases, patients already accept that they cannot be choosing their physician, a sacrifice that has already been made!

      Maybe the powers to be have no balls to tell those with the $$ to pay and the power to put pressure that sorry, patients come first.

  16. 30 Teri 9 September 2011 at 14:05

    You know…the government is good enough to pioneer the state-of-the-art ERP system harnessing satellite to control traffic islandwide(I.e: more ERP charges) without the motorists even passing thru any physical gantry faster than the rest of the world, but when it comes to basic healthcare…why suddenly no brains and dun know how to solve the bed crunch problems? Are they really putting singaporeans’ interest first? Doesn’t take a rocket scientist to figure that out in a heartbeat.

  17. 31 Sin Pariah 9 September 2011 at 16:27

    MOH did not under-plan.
    MOH had a different plan.

    MOH planned for us to go to hospitals in JB, Malacca, etc, for overseas elective surgery – that was why our then Health Minister Khaw Boon Wan relaxed Medisave Withdrawal years ago.

    But then Khaw was also the driving force to turn Singapore into a Global Medical Tourism Destination – remember? So that rich foreigners now come to Singapore for their elective surgeries. If not, how to boost GDP and get Ministerial GDP Bonus which is 20% of their 47% Variable Pay Component (the other 27% is Job Perf Bonus). GDP Bonus is capped at 8 months’ salary when GDP Growth is > 10% – that’s why the ministers got such bonus windfall in 2010.


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