Hospital bed supply trailing far behind increase in elderly numbers

My father came down with a urinary tract infection last week. At his age, the Emergency Department did not want to risk giving him only outpatient treatment, and decided he should be hospitalised for closer observation. That led to four hours’ waiting for a bed at the National University Hospital.

It so happened that a few days earlier, the Straits Times had a story about the shortage of beds. Again.

The newspaper reported:

It is crunch time again at some public hospitals, even with the opening of the 500-bed Khoo Teck Puat Hospital (KTPH) in Yishun less than a year ago. Of the seven public hospitals, three are particularly affected: Changi General Hospital (CGH), KTPH and Tan Tock Seng Hospital (TTSH). The last time public hospitals faced a major bed crunch was in the months leading up to the opening of KTPH in August last year. The worst-hit then was TTSH, which curtained off parts of its corridors to add more beds. It also diverted ambulances to other hospitals almost on a regular basis. The current situation is not yet that bad, but appears to be heading that way rapidly. The hard-pressed hospitals have initiated contingency plans.

[snip]

Taking all public hospitals together, the occupancy rate has ranged from 75 per cent to 85 per cent since August last year, said the Ministry of Health (MOH). A spokesman said: “We expect demand for beds to rise in tandem with a growing total population and a higher proportion of elderly residents.” In September last year, hospital bed occupancy ranged from 46 per cent at AH to 85 per cent at TTSH.

The latest figures for March this year showed occupancy ranging from 55 per cent at AH to 89 per cent at CGH. TTSH, KTPH and National University Hospital all had occupancy rates above 85 per cent in March. More recent weekly figures for April and last month showed that at midnight – the time at which bed occupancy rates are pegged – there were days when these hospitals were more than 90 per cent full. As empty beds include those in intensive care – which must always have some empty beds for emergencies – and isolation wards, there could be very few ward beds available for patients arriving early the next day.

While MOH said the median waiting times for a bed “remained at the range of one to 1.5 hours with the occasional spike”, these spikes are happening more often. In the week of May 15, TTSH had three days when the median waiting time was three hours or more – so only half the patients got a bed within three hours.

— Straits Times, 4 June 2011, Bed crunch time again at some public hospitals, by Salma Khalik

My father must have been caught up in one of those spikes, waiting four hours.

A follow-up article a week later showed the situation to be persisting, but also added that the increase in the number of patients seemed quite sudden:

Industry watchers attribute the high bed demand to the rapidly ageing population. What is surprising is that this appears to have happened overnight.

Inpatient increases in both 2008 and 2009 were less than 1 per cent a year.

[snip]

Statistics for last week showed four of the six hospitals had more than 85 per cent of their beds occupied at midnight – when counts are taken – on most days.

The exceptions were Singapore General Hospital (SGH), with occupancy rates hovering at 84 per cent, and Alexandra Hospital (AH), where more than one in four beds remained empty.

At Changi General Hospital (CGH), the worst-hit of the six, bed occupancy topped 90 per cent on three days and 95 per cent on three other days last week.

KTPH had occupancy at or above 90 per cent on five of the seven days last week.

Former health minister Khaw Boon Wan had said he wanted public hospitals to have average occupancy rates of 85 per cent for maximum mileage.

Private hospitals generally prefer lower rates of 70 per cent, as anything above that could mean having to turn away patients on peak days.

— Straits Times, 10 June 2011, Jump in number of inpatients at hospitals, by Salma Khalik

The problem is more than adequately described. The question is, how did things get to be like this?

This second report was accompanied by a table showing the number of in-patient admissions from 2005 to 2010, which you can see at right. The total for 2010 was 9.7 percent higher than 2005, representing an increase of about 2 percent per annum.

9.7 percent had a familiar ring. This was because last July, in the post Bed crunch continues even as new hospital opens, I presented a table in which I showed that the new hospital would increase bed capacity by 9.6 percent, the first increase of any kind since Changi General Hospital in Simei opened in 1998. In other words, the growth in in-patient admissions have fully taken up the extra capacity afforded by the new Khoo Teck Puat Hospital. That we are facing a bed shortage again is thus easily explained.

That the government added 9.6 percent more beds a  long 12 years after Changi General Hospital, with a further 6.9 percent more (to make 16.5 percent increase) by 2015 when the new hospital in Jurong is slated to open indicates that they are planning a gradual increase in capacity of 1 percent per annum. The year 2015 would be 17 years after Changi Hospital’s opening in 1998.

On the face of it, this ties in with the statement in the second Straits Times report that “Inpatient increases in both 2008 and 2009 were less than 1 per cent a year.” But was this rate of increase because the numbers of ill people increased 1 percent a year, or because we could only admit 1 percent more per year, with the additional sick ones refused admission?

I decided to test this, especially in view of the clue given in the first Straits Times report, that  “We expect demand for beds to rise in tandem with a growing total population and a higher proportion of elderly residents,” attributed to an unnamed spokesman from the Ministry of Health. This suggests that bureaucrats are (in theory) planning increases with demographic data in mind.

Now, it so happened that we had a census in 2010, and the Statistics Department even published a neat little table titled “Elderly population” (see Link). There was a similar table from Census 2000, enabling me to calculate the percentage increase of elderly Residents (i.e. citizens + Permanent Residents):

As you can see, the total number of elderly persons grew 48.7 percent over the decade, or about 4 percent per year on a compounded rate. The number of the very elderly (i.e. over 75 years old) grew even faster, at about 5.5 percent per year, to total about 70 percent over ten years.

How is it that the ministry can plan for 1 percent per annum growth when data so easily available produces a figure several times faster?

20 Responses to “Hospital bed supply trailing far behind increase in elderly numbers”


  1. 1 Chanel 14 June 2011 at 16:17

    This explains why S’pore has the lowest healthcare spending as a % of GDP amongst developed countries. And the sad part is that our ministers seem to be very proud of this “achievement”!!

  2. 2 Ben 14 June 2011 at 17:26

    Besides the shortage of beds, I think, MOH should also look at the shortage of manpower. It is good to have more beds if there is a corresponding increase in manpower. MOH can post the real-time occupancy level for each hospital on its website so that the public can know which hospitals to avoid, similar to the live traffic information provided by LTA.

  3. 3 stanley 14 June 2011 at 17:41

    given that the govt is positioning Singapore to be a medical hub and that the public hospitals accept private foreign patients too, any idea why they aren’t increasing hospital beds at a higher rate or why they aren’t planning to add more hospital beds than the current 1% per annum growth rate?

  4. 4 Fast and Accurate Diagnosis - The Cheapest Option 14 June 2011 at 18:15

    Dear Alex
    I look after my elderly parents myself.

    I use a private sector specialist for UTI infections.

    It’s actually cheaper because he is experienced and confident enough to decide whether to hospitalize or not t hospitalize.

    Over time.
    I’ve found that a competent doctor in private practice.
    Able to arrive at the correct diagnosis at the first consultation.
    Is far cheaper (in total cost for cure) than our “subsidized” public sector medical industry.

    Just food for thought for your consideration.

  5. 5 Jake 14 June 2011 at 19:59

    Enjoyed your article a lot🙂

    Perhaps the mismatch of the hospital bed expansion plan with the rate of elderly population increase is another case of wishful thinking coupled with the pitfalls of corporatising public service.

    This seems to fit into the pattern of what’s happening with the public transportation and housing. The fear of being saddled with redundant capacity and being accused of not being efficient is what had been ailing our planners this past decade or so.

    Planners then would have to hope that Singaporeans would all adopt healthier lifestyles and be less in need of public healthcare. I’m not sure whether Singaporeans are generally taking care of their healths better and exercising regularly. However, if hospital bed growth rate stays the same, that could be all that we can hope for to stave off a healthcare crisis.

  6. 6 jem 14 June 2011 at 21:01

    “Former health minister Khaw Boon Wan had said he wanted public hospitals to have average occupancy rates of 85 per cent for maximum mileage.

    Private hospitals generally prefer lower rates of 70 per cent, as anything above that could mean having to turn away patients on peak days.”

    I guess it says so much that even profit-maximizing private entities care more about meeting their customers’ needs that the public sector which supposedly supports the common good.

    Also, does anyone else find the euphemism ‘maximum mileage’ really, really disgusting? It’s obvious Khaw was referring to money. And no journalist at that time or now, had the spine to probe deeper.

  7. 7 virus 14 June 2011 at 21:35

    Looking at the numbers & concentrating on the population above 80 which is the most vulnerable, it is going to be more than doubled by 2020. That is very alarming.

  8. 8 Anonymous 14 June 2011 at 21:35

    A friend had posted these stats from the Yearbook of Statistics 2010 on his FB page, and they are strange, if you look at the number of hospital beds:

    1. in 1999 compared to 2009
    (20.1 on pg 274 of http://www.singstat.gov.sg/pubn/reference/yos10/yos2010.pdf)

    2. in 2003 compared to 2008 (http://4.bp.blogspot.com/_97gTacH4hNg/S5dST9qLajI/AAAAAAAAAac/aq_DUu0QKuQ/s1600-h/Healthcare+stats0001.JPG)

    Not sure if I’ve missed something along the way… extended care (community hospitals) beds are included.

    • 9 yawningbread 14 June 2011 at 22:32

      The stats are strange indeed. The first reference (Table 20.1) shows that the total number of beds in the public sector DECLINED from 1999 to 2009.

      1999:
      Public acute: 6,268 beds
      Public extended care: 3,292 beds
      Public total: 9,560 beds.

      2009:
      Public acute: 6,416 beds
      Public extended care: 2,040 beds
      Public total: 8,456 beds.

  9. 10 Leuk75 15 June 2011 at 00:06

    Singapore’s health landscape is now largely driven by chronic diseases. Gone are the days where you get warded for infectious diseases only, treated, cured, discharged and case close.

    Chronic disease = long term control + patient managed selfcare +/- occasional hospitalisation for exacerbations. You never really get “cured” of say diabetes or a stroke. The aim here is to overhaul yourself well enough to function independently and take medicines to prevent worsening or need for hospitalisation. Since the patient spends like 99% of time at home and barely 1% interacting with the doctors, clearly the disease management requires a huge input and discipline on the individual with healthcare professionals primarily acting as facilitators.

    Currently, there is almost nil integration of care between the acute public sector specialists and private family physicians / GPs to better distribute the care delivery load required for chronic disease management. Polyclinics are bursting with long wait times. Not surprisingly, those with low socioeconomic status are poorest equipped to self manage, least aware of avenues of help and get the most hospitalisations -> bad outcomes, more costs. Being a worker in the public sector emergency department, I have seen enough of such cases to be able to generalise that the least educated and least well off are always the least able to cope with their own health management, thus requiring frequent admissions for body overhaul.

    I am not convinced that increasing more acute beds in the public sector such as the new Jurong hospital is really the way to go. What we need is a system of intermediate community hospitals and to improve the reach of public outpatient services by partnering GPs. This is also the era where various paramedical disciplines can step in to address the needs of older patients stricken with multiple chronic health issues. Increasing acute care beds only solves the exacerbations of chronic diseases in the short term and does not deal with the underlying problem – that Singapore is now in the chronic disease and ageing stage and that needs a more integrated, community driven multidisciplinary approach to empower folks to better self manage.

    Easier said than done, but then that is what our million dollar ministers are elected to provide necessary political will and leadership. On the individual, us Singaporeans have to stop being apathetic and get more curious and proactive in learning how to keep healthy and steady.

  10. 12 lcl 15 June 2011 at 02:08

    dear alex,
    I work in the said hospital, and I’m sorry your father had to wait so long for a bed. i hope he’s better now.

    you are right in your stats, that the number of chronic care beds have declined over the years. there’s actually a decline in the number of nursing home beds since the last census according to the MOH stats recently released to us. you might wish to look it up.

    the simple fact of it is that nursing homes aren’t really profitable, and having spare bed capacity on ‘standby’ is unprofitable. conversely, using public health resources to court private class patients from overseas is, and that’s exactly what MOH has been doing over the past 5 yrs… using scarce public health resources meant for local singaporeans who need subsidised healthcare on private patients from overseas.

    unfortunately, until our government is willing to pour much more resources into public healthcare and stop treating it as a money making enterprise, these problems will continue to the detriment of our people.

    I hope you and your readers will be able to help dig out statistics and figures which will hopefully sway public opinion in this issue.

    also. thanks for your many articles which have been very objective and informative. I really do appreciate all the research you’ve done.

  11. 13 lcl 15 June 2011 at 02:17

    also, I would like to point out that your figures on AH/JGH are misleading. this is because AH/JGH is frankly not fully operational, lacking staff and specialists in many areas. Hence, admissions to them have been restricted… for example, seriously ill patients are not sent to AH by SCDF, in view of their limited intensive care capabilities and ICU bed numbers.

    if you were to remove the JGH/AH figures, I suspect that the average occupancy rates for our public hospitals will all be clustered above 80 or even 85%. woe be to us if there were to be a mass casualty event or epidemic…. we don’t have the capacity to deal with that.

    • 14 yawningbread 15 June 2011 at 13:50

      I assume you’re acquired the “Singapore disease” where you use acronyms and initials liberally without bothering to explain them🙂

      But, on a more substantial point, if your “JGH” is Jurong General Hospital, then you may want to look carefully at one of the tables, wherein you will notice that it hasn’t been built yet. Wouldn’t that make a hash of your argument?

  12. 15 53891 15 June 2011 at 10:38

    There is nothing mysterious about the limited increase (or decrease) in the number of hospital beds. Has everyone forgotten about Malaysia? That is where you are supposed to go to, if you are poor. Singapore hospitals are for the rich and medical tourists.

  13. 16 Kojakbt 15 June 2011 at 12:24

    Bro, good article. Alright for me to publish this on other sites? (of course, will always credit the source)….🙂

    • 17 yawningbread 15 June 2011 at 13:46

      Actually, not alright. You can pick up the first 200 words or so, and then add a link to the rest of the article. Taking the article wholesale, even with credit, is not good practice.

      • 18 Calculon 15 June 2011 at 16:41

        …But you didn’t link to the said article on your post on exploratory way of teaching children, a la magic school bus (^_^). I wanted to read it as your snippet was confusing….

  14. 19 lcl 15 June 2011 at 15:17

    apologies… was actually referring to the the Straits Times’ figures, not yours. my mistake from scanning thru an article too quickly.

    the ST said:
    “In September last year, hospital bed occupancy ranged from 46 per cent at AH to 85 per cent at TTSH.
    The latest figures for March this year showed occupancy ranging from 55 per cent at AH to 89 per cent at CGH. TTSH, KTPH and National University Hospital all had occupancy rates above 85 per cent in March.”
    I feel this gives an incorrect impression that our bed situation isn’t as dire as it really is. removing AH, the occupancy rate is likely to be >80%.

    also, I mentioned AH/JGH together, as the current AH staff will supposedly be transplanted to JGH once that is built, and AH will be closed down… so they’re one and the same to me. there’s always a chance that MOH might keep AH open to increase public hospital capacity though… how we’re going to find enough staff though, is gonna be another big problem.

  15. 20 Max Emeritus 15 June 2011 at 21:38

    We need more hospital. Hope another $125million come by to name another hospital after another rich man.


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