Bed crunch continues even as new hospital opens

Another day, another reason to be sceptical.

Sunday Times, 25 July 2010, reported “Full house at Khoo Teck Puat Hospital”. This headline should be handled with care since the details indicate that the new hospital in Yishun has so far only opened 200 beds. Nonetheless, the subheader hailed another achievement by the government: “Bed crunch at other public hospitals eased”.

In support of this claim, the newspaper reported:

The lighter burden on other hospitals is showing, [Health Minister Khaw Boon Wan] said.

In the past two to three weeks, not a single public hospital patient has had to wait more than 10 hours for a bed. “I’m hopeful that after next week, the situation will improve further.”

By then, another 350 beds will have been added.

— Straits Times, 25 July 2010, Full house at Khoo Teck Puat Hospital

Ten hours waiting for a bed, he said. All this while, ill as you may be, you wait in a cot in some corner of the emergency area while traffic accident or stabbing victims are wheeled around you, with blood dripping everywhere. If you’re lucky, you wait your ten hours in a quieter corridor.

I’ve seen it all with my own eyes, though I don’t think I’ve ever had to endure ten hours. Still, I’ve waited 6 or 7 hours, and that’s bad enough. My father, who is getting on in age, was in and out of hospitals much of last year and earlier this year. There were several occasions when we sent him to the Accident and Emergency (A&E) Department at nine or ten in the evening, and he would not be assigned a ward till three in the morning. Even then, it did not mean he got into a ward immediately. The bed number might have been issued, but the bed would not be ready for him, or the attendant would not come around till one or two more hours later.

Meanwhile, I would have spent the night in the A&E with him, sitting among injured gang fighters, or flu sufferers cough, cough, coughing away.

Ten hours is far too low a quality standard. But I guess it is better than being turned away from a hospital altogether, as happened in the last few years.

* * * * *

How much improvement does the opening of the Khoo Teck Puat Hospital represent? Here again, the rosy numbers in the news story meritted scrutiny. As mentioned above, 200 beds are now open with the balance 350 available soon.

Mr Khaw said that Singapore will not be caught out by a shortage of hospital beds again.

The building of Jurong General Hospital will start this year. The hospital, slated to have about 700 beds, should open before 2015.

Although Alexandra Hospital will then be closed and its 300 beds taken out of the system, there will still be a net increase of about 400 beds.

A site in the Sengkang-Punggol area, which has a growing population, has been reserved for yet another new hospital.

— Straits Times, 25 July 2010, Full house at Khoo Teck Puat Hospital

Already I noticed a last-minute change of plans. From what I’ve read perhaps a year ago, Alexandra Hospital was supposed to be closed once Khoo Teck Puat Hospital has fully opened. Now the former won’t be closed until the next new hospital, in Jurong, is ready. Somebody must have done his sums and realised that closing 400 beds at Alexandra, while adding 550 at Khoo Teck Puat will not represent much capacity increase.

What improvement to the overall situation do these two new hospitals represent? The table below gives a bird’s-eye view of the total number of beds in acute general hospitals in the public sector. All numbers were taken from the respective hospitals’ websites, except Alexandra whose bedcount I got from the Sunday Times story (I couldn’t find the statistic from the hospital’s website). It is arguable whether I should include KK Women’s and Children’s Hospital, but I guess it’s better to show its figures and let others who disagree with me subtract them rather than not show KK at all.

With the full opening of the Khoo Teck Puat Hospital, total bed capacity will go up about 9 percent this year. Then, assuming existing hospitals do not increase or decrease their capacities, it will go up again in 2015, when it will be about 16 percent above the figure for the start of 2010.

I am in no position to argue whether that’s enough or not enough, having no data to go on, but I thought that at least I would present the data here so that a public conversation about this matter can begin.

There is another way of evaluating sufficiency, and that is to compare Singapore’s capacity to other developed countries with similar aging populations. I made an attempt at searching the web for comparative data but quickly found the exercise too difficult for me. Perhaps others can take a stab at it.

  • The first problem I encountered was a definitional one. The totals above relate to acute general hospitals and maternity hospitals in the public sector (you will noticed I left out the bed capacity of the Institute of Mental Health, for example) but do other countries’ statistics refer to the same?
  • The second problem was the size of the public sector versus the private sector. Different countries have different economic models for health services. In the case of Singapore, I came across a mention on the website of Singapore General Hospital that private hospitals together account for only 20 percent of all acute beds in our city-state. Other countries may have a significantly larger private sector.

Nonetheless, at 6304 beds by the end of 2010, Singapore’s ratio of acute, public hospital beds per thousand population is only 1.26 (assuming a total population of 5 million as at June 2010). Surfing various websites, I see ratios for European countries in the range of 3 or 4 per thousand. For Australia, I found a government website that said it had 54,338 beds in public acute hospitals in 2008/9. Against a population of about 22 million, this gives a ratio of 2.5 beds per thousand population.

I would advise against drawing simple conclusions. Healthcare is a devilishly complex subject. What I can say is that Singapore does not have any ongoing, intelligent debate about it. We know when things become intolerable, but what we really need is a more considered discussion about what is optimal in terms of cost and moral obligation. Yet, and especially with a mainstream media that avoids broaching subjects likely to pose difficulties for the government, I’m not holding my breath that we’ll have an intelligent discussion anytime soon.

21 Responses to “Bed crunch continues even as new hospital opens”

  1. 1 Mat Alamak 28 July 2010 at 23:28

    Actually the hardware aspects of medical care, eg hospital buildings, beds, equipment etc is not an issue where quantity or quality is concerned. This can be achieved with money.

    It is the software aspects, eg doctors, nurses, other medical support professionals and staff, etc that is the issue in terms of quantity and quality.

    Firstly for years Singapore does not produce its own as many doctors as they produce engineers or other types of graduates. Why? Maybe someone can enlighten on this.

    Hence doctors as a profession seem to command more value and prestige due to being less in numbers as compared to engineers. This is unlike in other countries where a doctor is just another of the many professions in terms of quantity.

    On the other extreme, nursing is a shun job with Singaporeans and some even put it on the same level as cleaners in terms of work nature.

    As a result to cope with the demand, Singapore imports foreign doctors and nurses from Vietnam, Mynanmar, Philippines, Malaysia and China. However in this aspect the govt is more cautious in terms of quality unlike in other jobs. So even with geeting foreigners in, there may be a shortage of such people resources as a result.

    This explains why medical services here is not as desired, unless you can pay more. Yes money can buy quality medical care. And money with status will get superb medical care, but not necessarily better quality of life. And ultimately everyone, regardless of status or wealth will end up the same one day.

    • 2 Beast 28 July 2010 at 23:31

      It is not that there are not enough doctors; it is simply that doctors simply prevent [Yawningbread: do you mean ‘prefer’?] to open their own private practices because they can earn more and suffer less stress, compared to working in hospitals.

  2. 3 Beast 28 July 2010 at 23:29

    I don’t wish to blame the hospitals; I have seen what the doctors and nurses do, having seen my mum battling cancer a few years back, and it is not pretty.

    The crux of the problem is the numerous idiotic statements made by our Health Minister: Yes, there are enough beds, but oops….sorry, I haven’t really evaluated the gravity of the situation……yet.

    I remember the last elections, when this moronic minister yakked about sending the elderly to elderly homes supposedly sprouting (in his mind) all over Batam, Johore, etc. I think he should be replaced. He has lost touch with the ground level, and in fact, he has lost touch with just about everything that has got to do with health.

  3. 4 yawningbread 29 July 2010 at 00:40

    Beast wrote: “The crux of the problem is the numerous idiotic statements made by our Health Minister”

    I’m hoping we get past that. Healthcare and its provision is an important issue for us all. Fixating on statements made may be great fun but distract us from a mature, considered discussion of what we need going forward and what we can afford.

    For example, if capacity increases 16.5 percent over five years, will that be enough? Do we expect our population to also grow 16.5 percent the same period? Alternatively, even if our population numbers remain the same, would the gradually aging profile use up all 16.5 percent increase?

  4. 5 Paul 29 July 2010 at 06:57

    Thanks for highlighting this issue

    Part of the problem with acute hospital beds is the lack of long term care facillities. In many countries, smaller and fewer hospitals are being built as care moves into the communities. Unfortunately, here in SG, the subsidy framework for long term care is different from that in hospitals, so many patients are stuck in hospital while trying to work out affordable rehabilitative or long term care. There is also a paucity of home health services which have been shown in Singapore and elsewhere to provide good quality care in the patient’s own environment. These services reduce the stress on acute care hospitals and are actually popular with patients and their families

  5. 6 Anonymous 29 July 2010 at 07:32

    Interesting that this website, which takes its data from WHO, lists Singapore as having 3.2 beds per 1000 population. If private hospitals account for 20% of Singapore’s hospital beds, the calculation above points to a rate of ~1.6 beds per 1000 population. I find it hard to believe the ratio could have dropped by half in a few years, even considering the increase in population.

    The original WHO data: Table 6

  6. 7 yawningbread 29 July 2010 at 11:56

    One comment was deleted because it was one of those “shoot from the hip at the government” one-liner type of response, that adds no substance to the discussion.

  7. 8 quirkyhill 29 July 2010 at 12:06

    read this blog by doctors… which may enlighten… or not.

  8. 9 yawningbread 29 July 2010 at 12:51

    Anonymous – interesting discrepancy. What I can still see is that Singapore has a lower ratio of hospital beds to population compared to almost all developed countries, e.g. France, Germany, UK, Netherlands, NZ, Australia, Japan, S Korea.
    The WHO ranking is also misleading. Singapore is listed as #43 in the table, but due to duplicates, we are actually #67 worldwide. Rather than belong to the first world, we (and the USA) are kind of leading the third world group, in that after our rank positions in the table, there are no more first world countries.
    There are two problems with the ratios that I can immediately spot. Firstly, it doesn’t say whether it includes long-stay and hospice beds. Secondly, it doesn’t declare population base it uses for calculation. For Singapore, I have used total population of 5 million. If you use the Resident Population (i.e. citizens + Permanent Residents), then the figure is 3.7 or 3.8 million, which gives you a better ratio of beds per capita. Statisticians may tend to use Resident Population, but I think that’s wrong. If a foreign worker is ill or injured in Singapore, he too will be using one of our hospital beds, so the foreigner base should be counted.

    • 10 Anonymous 30 July 2010 at 14:09

      I tried to look up the population base for the 3.2 per 1000 value given earlier and it seems you are correct. According to Table 9 in the WHO data, the population is 4.4 million, but it turns out that is not the population base used.

      The footnotes give the original source of the data for Table 6, including the total number of hospital beds:

      I looked up the data for 2009. Immediately you notice that Singapore’s population is given as 6+ million, clearly an error. Also, if you look at Table 9 and calculate the population base for doctors and hospital beds, you get a different answer. For doctors, it seems they use total population of 4.8 million, but for hospital beds, only the resident population of 3.6 million is used. To me, this sort of discrepancy brings into question the entire set of data given by the WHO.

      I can’t figure out where the hospital bed count of 11000+ was obtained from, as MOH’s own data gives slightly smaller numbers:

      It seems the above source is where I should have gone from the start :). With this data of 8000 acute hospital beds and base of 5 million, you get exactly what you calculated: 1.6/1000!

      Of course, as you say, healthcare is a complex subject. Maybe the other countries are not as efficient in their use of hospital resources 🙂 After all, we have so much spare capacity that we can afford to promote medical tourism!

      In all seriousness, such discussion is indeed needed. Thanks for starting one on your website.

  9. 11 Beast 29 July 2010 at 16:04

    Hi Alex

    I apologize for sounding like a one-off ant-govt ranter, but the salient point I want to make is that, if the Health Minister has lost touch with the needs of the people, how then is he going to project the hospital needs of Singaporeans for the next, say, five or ten years?

  10. 12 francis 29 July 2010 at 16:51

    I believe that our public heath system is seeing crunch time also due to shortage of doctors because when i rescheduled my specalist appointment last week at SGH ENT dept, the hposital gave me a date in October, luckily i am not dying any time soon otherwise i’ll be dead before i can see the doctor in October.

  11. 13 yawningbread 29 July 2010 at 18:37

    Beast – fair enough, but that means all the more, citizens must take ownership of the issue, educate ourselves and press the ministry to (a) anticipate better future needs and (b) move in the right direction. It’s precisely the reason why I feel it is important to write posts like these. We need a better quality public conversation, rather than depend on the government getting things right without any input from citizens.

    On this note, let me say I have deleted another comment. Unusually, I am going to reveal what that comment said. It said:

    “This coming GE, u decide.
    PAP= More of the same
    Others = A chance for a change”

    Frankly, I’d rather not have any comments than comments like these. While people are entitled to their opinions, there are plenty of blogs and “alternative news sites” in which such coments are par for the course. Not Yawning Bread. I am swimming against the current trying to build a public that is aware enough to discuss public issues in depth, and not have everything reduced to simplistic answers, least of all, electioneering slogans. So, with due apologies to the writer of the above deleted comment, I do not wish to encourage that level of discourse. I would however be more than happy if you joined us here with the kind of discussion I intend for this site.

  12. 14 KiWeTO 30 July 2010 at 04:04

    Is our civic population mature enough to form independent 3rd party review organizations? Say the equivalent of the US’s Consumer Reports (which shamed Apple into immediate action); consumer associations such as bus passengers association or Public transport riders association that speak on issues relevant to their members?

    Such organizations (if sufficiently funded by its members or donations) could then offer 3rd party reviews of governmental plans. Yes, they may hold their own biases, but at least, their bias will show where the gaps they think exist. And contribute to a healthier social discussion on any said issue.

    Our current social discussion climate still consists of:

    “minister proclaims”,
    traditional supervised media exclaims
    (newmedia such as blogs “contest” statements or findings)
    And then end of discussion

    No wonder we don’t seem to know anything except that it feels more crowded, or services seem to be less effective, or things feel worse, and, and nothing is done until something drastic (ergo multiple floods) happens.
    (And even then, blame shifting, finger pointing, and self-important egos have us wondering what is actually being done to improve the situation.)

    Would a payTV consumers association have supported a minister saying “exclusive deals is good for market competition”? Or any sensible consumer association?

    When, would our strong-armed government with a very thin skin when criticized be willing to let its own citizens ask difficult questions on a regular basis?

    Or perhaps, they truly prefer – divide and conquer.

    [Unorganized masses are much easier to manage. But is organized interest group activity a better outcome?]

  13. 15 Kai 30 July 2010 at 13:54

    You might want to re-check on the number of beds for NUH. With the new construction of NUHS Tower Block and NUH Medical Centre, the number of beds for the main two hospital blocks should be slated to increase.

    Of course, the upward revision shouldn’t make much difference with the increasingly severe bed crunch.

  14. 16 yawningbread 30 July 2010 at 14:19

    Thanks Kai. Yes, I myself have seen the new blocks under construction, but I forgot about them, and NUH’s website did not make any obvious mention of them, thus not prompting my memory.

    I’m not going to be a pessimist and say that the bed crunch will definitely continue. It may be alleviated especially if our population does not continue to explode. It’s just that it would be great if the ministry and/or the Dept of Statistics would take the trouble to explain their assumptions and projections, to put the public’s mind at ease. As it is, ministers are simply saying “trust us, we know what we are doing”. . . which seems to make people only more sceptical, given the historical experience.

    Recent news about an explosion at a chemical plant in Nanjing added another angle to the problem: Is it safe to have hospitals run at maximum occupancy? In other words, even if we solve the problem of not enough beds for normal times (i.e. demand is >100% of capacity), to have just enough beds for normal times which seems to be the best case scenario from 16% increase in bed numbers (i.e. demand becomes approx = 100% capacity), is it good enough? What if we have a chemical explosion, or bomb attack or airplane crash-landing, or another, really severe, round of flu? Suddenly we may need 200 – 300 beds more in the emergency. Where are these beds going to come from? Do we send 300 patients home even when they have not yet recovered, to make space for new casualties? Shouldn’t we be planning not just to cope with straight-line projections, but allow some redundancy (i.e. normal demand to be 80 or 85% of capacity)?

  15. 17 KiWeTO 1 August 2010 at 15:55

    Organizations once believed in the 80/20 rule. Operating at 80% was the optimal area of production (be it beds, widgets, or mobile phone services). This kept production capacity available for unexpected needs.

    However, naughty people looking to squeeze more profit realized that keeping 20% capacity spare reduced the ReturnOnAsset function. So, the new mantra became 100% optimization in the allocation of resources an organization can bring to bear.

    “We know all possibilities, so we can project all demand, and thus optimize production to minimize waste”.
    (refrain often heard in “once in 50 years”, “perfect financial storm, “statistically happens only in 200 years”, etc. Humans like to believe they can control the future.)

    As to a chemical plant explosion, why not a sinkhole a la Guatamala City, or even a 9/11 incident? There are plenty of reasons why there needs spare bed capacity (no need for a 10hr wait? Thought we were an efficient society.)

    The question is – when we attempt to apply private sector desired outcomes (maximize return to shareholder) to public sector goods (betterment of society), are we confusing the desired outcomes just because they are both organizations usually measured by accounting numbers?

    It is one thing to bemoan unnecessary waste in public spending. It is another to make cost cutting (of waste) the primary focus and lose sight of the real societal objective of the public services.


    • 18 Beast 2 August 2010 at 17:16

      Apparently, “Business Continuity Planning” (or BCP) never came across the Health Minister’s mind. Pathetic.

  16. 19 medicalground 2 August 2010 at 17:14

    found this interesting site linked from singaporemd. Thanks YB for the work in digging up the statistics….

    I think Mat Alamak got it right in that the hardware aspect is but the tip of the iceberg. it’s the software that is going to sink the ship.

    if you wish to trace the origin of the current deficit in medical services, we’ll have to trace the healthcare policies and govt spending from at least 10 years back.

    for instance, I believe KTP was supposed to be built and opened in Jurong more than 5 yrs back, but this was subsequently shelved and delayed due to the 2 recessions. we’re now rushing to churn out 2 more hospitals because we are starting to feel the crunch (growing and ageing local and foreign population without any increase in service capacity). but it’s easy to build hardware, since all it takes is money.

    another more difficult example, in answer to Mat Alamak, is manpower. there was a conscious effort up til 5 years back to NOT increase training capacity of doctors in NUS. the aim was to divert people to other professions eg army, engineering etc. the quota was kept low, and NO scholarships were offered then. govt subsidy is a myth, and you can search or the debate on singaporemd. manpower policies have also not been able to retain both senior and junior doctors in public service, both in terms of pull (poor pay vs working hours and poor work hours) and push factors (poor HR and training support, high work load and poor working conditions), so there’s a constant drain of manpower out of the public service, and recruitment barely keeps up with the outflow. each time we lose a senior doctor to private service, we lose a mentor and decades of clinical experience, and a teacher who helps impart skills and quality to junior doctors.

    the story is the same for nurses, but I will not assume to comment, since I am not one.

    they are starting to play catch up now by increasing medical school intake and foreign recruitment. bearing in mind that training a doctor to be a house officer takes 5 yrs, and a consultant takes another 6-8 yrs (ie 13yrs) on average, the current policy change will ONLY start to take full effect in about a decade.

    I think it’s not helpful to point fingers, but I do remember that the current health minister was the perm sec back then. this is a worry, since I have been keeping current about the current policy changes, and from my personal perspective, I feel that they are stop-gap fast-food patch-it measures to increase staff numbers, rather than measures that will improve medical training and quality in the long term. In fact, the current changes to the training system seems catered to churning out specialists faster and in greater numbers, but I personally feel that there will be a compromise on quality.

    in essence, the current crunch is due to policy choices choosing to limit investment in medical infrastructure and manpower from many years back. I believe what we now need is a conscious political effort to increase healthcare investment in both infrastructure and software (not only doctors or nurses, but also paramedical staff like social workers and therapists), but it will take time to catch up with the accumulated deficits. Hopefully, quality will not be diluted in the process.

    I think it would be interesting if we can dig up the statistics on healthcare spending over the past decade and compare them to other comparable nations. a good comparator would be HK, which has comparable healthcare standards and a small population like ours.

  17. 20 rojakgirl 4 August 2010 at 05:02

    Seriously, the quality of healthcare is getting worse.

    Mainly, doctors in polyclinics and even hospitals are overworked and exhausted and thus, grumpy and so on.

    Note: this post focuses mainly on the polyclinics.

    And in polyclincs, the turnover of staff is really fast and every few months I go there, there seems to be new faces and few familiar ones. Same for hospitals: new staff(especially pharmacists) every now and then.

    The quality of care in polyclinics, these days… isn’t as good as before. Seriously, before… the doctors were more focused on receiving patient feedback(and knew when to cut in) and performing a thorough diagnosis and so on. These days, their workload is so heavy, they end up rushing through the diagnosis and sometimes, miss a couple of obvious symptoms(not counting the random/mysterious symptoms that take a few visits to detect). In polyclinics, I’d average waiting time between 1 to 3 hours and consultation time of 5 to 15 minutes.

    And I’m not sure why but a number tend to ignore what the patient feedbacks(inclusive of symptoms of pain/giddiness/numbness and so on) and dismiss it just ‘cos they can’t detect anything. As a result, some patients have to keep going back to the polyclinics, until they can find a doctor willing to listen and do a diagnosis. While, others simply decide to visit a private doctor.

    Also, from the polyclinic, it seems much more difficult to get an appointment with a specialist these days. The doctors tend to stonewall. Whether they’re trying to admit only serious cases or whether it’s something else entirely(like a tactic to control intake of hospital appointments), I don’t know.

    Oh well, private isn’t too bad though I dislike the type and dosage of medicine many clinics prescribe. In polyclinics and also public hospitals, the dosage is stricter and they’re less likely to prescribe medicine that’s really strong(in order to increase healing rate). Too great a dosage/too strong a medicine = greater chances of resistant to medicine.

    And finally, it’s too bad there aren’t any surveys/statistics about how many patients move from private(mainstream medicine + alternative medicine) to public healthcare(mainstream+ alternative like TCM) and vice versa. And the reasons for their switch and so on.

    • 21 rojakgirl 4 August 2010 at 05:11

      As for why so many doctors keep leaving for private care, I’ve heard many reasons. But mainly, I’ve heard nightmare stories about doctors being verbally or physically assaulted by patients. Yikes… and also, poor pay + crazy workload without any show of appreciation from patients and their superiors. Plus, there are rumours of doctors being tossed back into polyclinics just ‘cos they dared to question the system or do something that pisses off a superior.

      And correction: “a tactic to control intake of hospital appointments” should be “specialist appointments”.

      Also, if anyone can read Japanese, you might want to buy the manga series: “Say hello to black jack” that covers the Japanese medical system. Many of my friends who know Japanese are raving about it. From what I heard about that manga, Singapore system is far better than that, thank goodness.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s

%d bloggers like this: