Long Waiting Times at Accident and Emergency Departments of Restructured Hospitals

Ms Joan Pereira asked the Minister for Health (a) what is being done to reduce the waiting time for (i) consultation at the accident and emergency departments of public hospitals and (ii) ward beds at public hospitals; (b) whether the waiting time has reduced; and (c) if so, by how much.

Mr Yip Hon Weng asked the Minister for Health (a) whether an in-depth analysis is being done to identify the underlying causes of the hospital bed crunch problem; (b) how will hospitals ensure that care for patients in holding spaces, including those with non-critical issues, will not be compromised; (c) what mechanism is in place for the different healthcare clusters to forecast and raise the alarm about possible upward demand at emergency departments to make necessary arrangements in advance; and (d) when is the bed crunch expected to ease.

Mr Yip Hon Weng asked the Minister for Health (a) with the activation of inpatient teams to help at emergency departments, whether this will cause other healthcare teams to be overworked; (b) where will the manpower for transitional care facilities (TCFs), particularly the TCF with 364 beds, come from; (c) how well-equipped are healthcare workers and aides in the step-down facilities to care for transferred patients; and (d) what are the immediate measures to expand our healthcare teams, considering that some services cannot be automated in the short term.

Mr Gerald Giam Yean Song asked the Minister for Health (a) what are the main reasons behind the long waiting times for admission at some restructured hospitals' emergency departments in recent weeks; and (b) what are the measures the Ministry is taking to reduce waiting time especially for patients with higher acuity conditions.

Dr Lim Wee Kiak asked the Minister for Health in light of the current hospital bed crunch (a) whether non-urgent elective surgeries in public hospitals will be postponed; (b) if so, whether this will once more result in a backlog after the current bed crunch is alleviated; and (c) how will the Ministry prevent the occurrences of deferring non-urgent treatments from turning into a vicious cycle of care backlog.

Miss Cheryl Chan Wei Ling asked the Minister for Health (a) what are the critical bottlenecks in hospitals resulting in patients being held for long periods of time at emergency departments; (b) whether this has resulted in ambulances being unable to be deployed for other emergencies; and (c) what steps is the Ministry taking to more permanently resolve the lack of bed spaces in public hospitals.

Mr Murali Pillai asked the Minister for Health (a) whether the risk of suffering from pressure injuries amongst bedridden patients who are kept for significant lengths of time at the accident and emergency departments of acute hospitals before being admitted to the wards is being monitored; and (b) whether such patients may be screened in advance for their susceptibility to develop pressure injuries and treated accordingly.

Ms Ng Ling Ling asked the Minister for Health whether the Ministry will consider developing a gatekeeping role and process at the polyclinics and GP clinics to reduce the number of patients whose conditions do not require emergency care at hospital emergency departments.

Sir, during the Delta wave last year, our Intensive Care Unit (ICU) wards came under immense pressure. This year, as we encountered the Omicron infection waves – and we have had three so far – the pressure shifted from the ICU to the regular hospital wards, and by extension, the Emergency Departments, or EDs. This is because Omicron is a less dangerous variant, and our population has become more resilient due to vaccinations and safe recovery from the infections.

Hence, over the past year, I have reported to this House on several occasions that although we did not let the virus overwhelm our healthcare system, our hospitals and, especially, the EDs, have been very busy.

Why are the hospitals still experiencing heavy workload, given that life has gone back to pre-COVID-19 normal?

The simple and fundamental reason is that the pandemic is not over. It may feel like it is over for most of us, but it certainly is not over for hospitals and our healthcare workers. We are learning to live with the virus, as an endemic disease. As I have explained to the House before, endemicity does not mean the virus disappears from our lives. On the contrary, it means that it is a permanent feature of our lives, circulating amongst us and we have to take personal precautions and implement public health measures in order to manage and live with it.

What are these public health measures? Essentially, there are three. First, the safe management measures (SMMs) to restrict social interactions and, therefore, reduce viral transmission. Two, transmission still happens and, therefore, we do vaccinations, so that infections do not translate into many cases of severe illnesses and deaths.

When these two cannot prevent cases, the third lever – which is our healthcare system – will then have to manage; it has to catch the problem and then, manage it by treating and caring for infected patients who become severely ill.

Let us take stock of the three measures. For SMMs, we have removed almost all restrictions, so that life goes back to the pre-COVID-19 normal. This is what all Singaporeans wish for and the whole point of treating COVID-19 as an endemic disease. Therefore, the Multi-Ministry Taskforce (MTF) has been very reluctant to re-impose SMMs, unless it is absolutely necessary.

The second public measure, vaccinations. We have already covered the great majority – over 90% – of our population. Our vaccination exercise is ongoing, but this is largely to extend our coverage at the margins, namely, now, infants and very young children, and to keep vaccinations up-to-date for the others. So, we are just maintaining our immunity and resilience, now no longer able to achieve the kind of quantum improvement in resilience that we could achieve when we first started our national vaccination programme.

That means that the burden of endemicity will fall disproportionately on the last public health measure – which is our healthcare system. That is why our wards and EDs have been very busy over the past year. The media highlighted it only recently, but really, our hospitals have been experiencing it for the whole year.

I hope that as we enjoy our hard-fought freedom from COVID-19, we remember the toil and sacrifice of our healthcare workers – doctors, nurses, social care workers and so on. They are sacrificing and toiling away, in order to secure freedom and the state of endemicity for the rest of society. So, COVID-19 may feel like it is over for many of us; it is not over for them.

In the hospitals and EDs, therefore, service levels may drop and waiting times become longer. Out of frustration, we understand that there will be public complaints, but I sincerely hope that our hospitals and healthcare workers will continue to receive the appreciation, understanding and support of all Singaporeans.

Sir, let me now describe what exactly is the situation at the EDs today. First, I want to assure the House, that for critically ill patients, they are attended to almost immediately at the EDs, due to the way that we triage patients and allocate resources. So, priority always goes to them.

For non-life-threatening but emergency cases, the median waiting times for consultation across all our EDs are averaged to about 20 minutes from January to September this year. It is not a very long wait, and it is important for this group of patients to be attended to quickly, so that they are evaluated and then can be discharged promptly.

For emergency cases that require hospital admission – this is where the bottleneck is – the median waiting times for wards is about seven hours, from January to September. It is a few hours longer than 2019. What I quoted, "seven hours", that is the median. There are variations. So, when we have an infection wave, like recently, waiting times can spike up sharply – to the reported 50 hours – for certain hospitals that are busier.

Despite the heavy workload, our hospitals will not compromise the safety of patients. As mentioned earlier, life-threatening cases will be attended to immediately. If surgery is required, it will be carried out promptly and beds will be there for the patients.

For non-life-threatening patients who are waiting for admission, medical teams will continue to monitor them and institute appropriate investigations and treatments.

For bedridden patients who are at higher risk of developing pressure injuries, hospitals will implement preventive nursing interventions. This includes the use of thicker mattresses or air mattresses, turning of the patients periodically and changing of diapers and drawsheets for bedridden patients.

Sir, I will now address the most pertinent question, which is what can we do about crowded EDs, to alleviate the problem?

The current situation, make no mistake, is not sustainable, and we need to resolve it. But it has not been easy to solve the problem as we are still in the middle of a pandemic. Each time a wave subsides and we started dealing with the problem, another wave would come, and attention and resources will be diverted to fight fire again.

With the XBB wave subsiding earlier than expected, we hope that this time round, we will have the time and space to deal with the problem properly and decisively. To do so, we need to diagnose where exactly is the operational bottleneck.

The issue actually is not the ED. It is really about matching the demand and supply of hospital beds. The crowdedness and long waiting times for patients at the EDs in some hospitals, especially during a wave, is a manifestation of the problem, a mismatch of demand and supply of hospital beds.

Let us look at the demand for hospital beds. If we look at average monthly ED attendances, which translate into demand for hospital beds – from 2019, before COVID-19 started – to 2022, there is a reduction from 75,000 patients per month to 63,000 patients per month. So, translated to daily attendances, it was about 2,500 patients a day in 2019 to 2,100 patients a day in 2022. This is a 16% decrease.

Hence, it would appear that all of our measures to educate the public to not go to EDs unless absolutely necessary, the GPFirst initiative and the setting up Urgent Care Centres in the heartlands as an alternative – they have all worked. Or there can be a simple reason – that during a pandemic, people actually do not like to go to EDs; that is also a possible reason.

However, while the overall number dropped, if you look at all ED attendances, the proportion of patients with highest acuity – this means they have the most serious conditions and need the most attention and probably need hospital beds – had increased from about 8% in 2019 to 11% in 2022. In absolute numbers, this is an increase of a few hundred patients per month. It is not huge but it does add to the operational burden of hospitals.

More importantly, I think, is this point, we are again looking at averages. While the average number has come down, during a pandemic, that number is a lot more volatile. So, during an infection wave, many more infected people and recovered patients go to EDs.

For example, at the peak of the mid-year Omicron wave and the recent XBB wave, COVID-19 infected patients added another 600 ED visits every day. This is 30% more workload at the ED, which is very significant.

I should mention a separate problem that we now encounter at KK Women's and Children's Hospital (KKH). The ED has been experiencing very high visits every day – at levels that they used to experience only during Chinese New Year, when all other clinics are closed. So, come Chinese New Year this round, I do not know what kind of numbers they are going to get.

This is a separate problem, due to what we call an "immunity debt" in children. It means that for the past two years, SMMs – including mask wearing – has shielded children from many forms of viral infection, and not just COVID-19. Now that life is back to normal, viral infections are making a strong comeback and demanding payback – with interest!

Let us look at the supply side of the hospital beds. There are a few factors constraining the supply and slowing down the process of warding ED patients.

First, due to our ageing population, there is a secular trend of rising numbers of patients with long stays and that reduces the turnover of hospital beds. To illustrate, the percentage of patients who stay longer than 21 days has doubled from 1.6% of all hospitalised patients in 2019 to 3.8% in 2022.

Second, the pandemic caused construction disruptions which delayed the opening of healthcare facilities, namely the Woodlands Health Campus and the Integrated Care Hub at Tan Tock Seng Hospital. If these facilities had opened as originally planned in 2022 without the COVID-19-related delays, they would have added at least a few hundred beds to our system and would have alleviated the problem.

Similarly, construction delays due to the pandemic have also postponed the opening of several nursing homes and community day care facilities, and that also constrained the ability of hospitals to discharge less acute patients and free up hospital beds.

Third, supply constraints. As part of our emergency planning, hospitals are required now to set aside, or ringfence, beds for the care of COVID-19 patients. Members of the House may recall at the height of the pandemic – and at that time we were imposing SMMs to preserve healthcare capacity – many Parliamentary Questions were filed, asking the Ministry of Health (MOH) if we had planned for adequate healthcare capacity in such emergency scenarios.

Well, ringfencing hospital beds for COVID-19 patients is part of that planning effort. However, we inject flexibility into the plan, raising or lowering the number of ringfenced beds according to the pandemic situation. So, for example, again, at the peak of the recent XBB wave, we set aside 800 beds for COVID-19 patients, as ringfence. About 80% were occupied at the peak of the wave, which meant we still had 160 beds unoccupied for contingency purposes. Not a big number, but nevertheless, constrains hospital operations and impedes the clearing of patients waiting at EDs.

Whether due to demand or supply factors, we need to recognise this – that is, we run a very high throughput hospital system. In such a system, even a very small mismatch of demand and supply, a couple of hundred beds, will cause waiting times to spike up very significantly. You think of it that way – it is not very different from an expressway with very heavy traffic flow. All it needs is for one branch to fall on one lane or half a lane, and you will have a massive traffic jam. We have a similar situation in a very high throughput hospital system.

So, how do we resolve the current problem? The hospital clusters, working with MOH, have issued a statement recently, outlining all the measures they are taking. They continue to be relevant and we will continue to pursue them.

Just to briefly recap, they include the reducing of EDs demand through primary care, alternative pre-hospital care options; educating the public to use EDs only when absolutely necessary; diverting them to nearby primary care clinics; and coordinating with the Singapore Civil Defence Force (SCDF) to divert less serious cases away to less crowded EDs.

We are also actively transferring patients in acute hospitals to step down or home care whenever possible. We are partnering private hospitals, such as Raffles Hospital, to accept patients sent by SCDF ambulances for emergency medical treatment and we also offer subsidised rates even though treatment is at Raffles Hospital.

New nursing homes are coming on stream and they are very helpful during the XBB wave. From the end of next year, Woodlands Health Campus and Tan Tock Seng Hospital Integrated Care Hub should start to open progressively. Over the next five years, we target to add about 1,900 more public hospital beds, including the aforementioned two projects, and also the expanded Singapore General Hospital Medical Campus.

But today, let me focus on two important structural adjustments that we will make which will hopefully help to alleviate the crowdedness at EDs in the short term.

Number one, we will activate more TCFs, what we call Transitional Care Facilities. Three TCFs are already in operation, with a total of 400 beds. These are operated by private providers at wards at Sengkang Community Hospital, Changi Expo Hall 10 and Crawfurd Hospital, along Farrer Road, which just opened a few days ago.

The TCFs serve a special purpose. They admit medically stable patients from public hospitals while they wait for their transfers to intermediate or long-term care facilities, or for their discharge plans to be finalised. It is, therefore, a very important step-down care facility, to free up acute beds in hospitals.

But TCFs are not just about providing beds space that is operated by private hospitals. There has to be a very firm handshake between the TCF operator and a public hospital. Because with that firm handshake, the privately operated TCF will gain confidence in admitting patients transferred by a public hospital – because they will feel assured that should they need any clinical help, in unforseen circumstances and for some complications, the public hospital will still step in. Without this understanding, TCFs will naturally be very conservative in admitting patients and there will be very little movement in stable patients.

The Sengkang Community Hospital TCF run by Thomson Medical Centre is a very good example. They have a very strong partnership now with Sengkang General Hospital.

We will replicate this, to pair up Changi General Hospital with Expo Hall 10 run by Raffles Medical Group; and Tan Tock Seng Hospital with Crawfurd Hospital. We are actively working on new TCFs in the north and in the west, to partner Khoo Teck Puat Hospital and Ng Teng Fong General Hospital respectively.

The second structural shift: our approach to living with COVID-19 needs to be extended to hospital operations as well. It is time for us adopt a more flexible and balanced approach to hospital bed assignments. We should move away from ringfencing beds just for COVID-19 patients. We had done so in the earlier stages of the pandemic, when hospitalised COVID-19 patients faced a very high chance of developing severe illnesses and numbers can spike very high during an infection wave. Hence, reserving beds – actually, we reserved wards – is the appropriate thing to do.

However, we are now at the stage when most residents have been vaccinated and boosted or recovered safely from COVID-19 and have good levels of hybrid immunity against severe illnesses. We should, therefore, allow hospitals to triage or assess their patients based on clinical severity and priority for treatment, and not manage COVID-19 patients to a different standard. This flexibility is important for our hospitals to help them optimise the use of beds. In a crunch situation, just like the expressway with very high throughput, it makes all the difference.

With this change, hospitals will no longer set aside whole wards to cohort COVID-19 positive patients as a standard pandemic practice. They will continue their current practice of using isolation beds for patients with infectious diseases, including COVID-19, if there is a risk of infection spread.

This is not a sudden change, but a transition process that has started and is ongoing. Hospitals will continue to exercise various precautionary measures on infection control to protect the vulnerable and prevent spreading of infectious diseases in hospitals. They have done so for many years, for influenza, for all kinds of infectious diseases. They will apply the same measures now for COVID-19, but without setting aside entire wards which will stall their operations.

Beyond these two structural measures, every one of us can do our part. While ED attendances have fallen compared to 2019, non-urgent cases still make up 40% of all ED attendances. We can use EDs more judiciously. Use alternatives, such a general practitioner (GP) clinic or call our family doctors.

We should exercise social responsibility, such as staying at home and self-testing when not feeling well. Most importantly, we need to continue to keep our vaccinations up-to-date and prevent ourselves from falling severely ill if we are infected by COVID-19. Today, a senior without minimum vaccination protection is still about three times more likely to end up in hospital and needing to be warded, than one with minimum vaccination protection. So, by taking another jab to keep vaccination up-to-date, you may well be freeing up an additional hospital bed.

If we can do our part, we will help healthcare workers earn back their normalcy of life, as they have sacrificed and worked hard to earn our freedom and normalcy of life.

Okay. What is the estimated backlog for elective surgeries that we are currently facing now? And what is MOH doing now about this and when we clear this backlog?

The backlog is not huge. Because ever since we started opening up, hospitals have all realised that to postpone electives and postpone non-urgent surgery, it all comes back after a while – and with interest usually. So, for the past two or three waves, we have been very reluctant to postpone these electives. In the recent wave, we postponed some, but only 5% to 10%. So, it is not a huge backlog and certainly we will want to clear it as soon as possible.

Thank you, Speaker. May I ask the Minister, what can we do to encourage more clinics to open 24-hour services. Earlier this year, my 90-year-old mother was ill and I just found it so difficult to find a 24-hour clinic. So, if MOH can encourage more clinics to open for longer hours, that will certainly help. Otherwise, my option was to send her to the emergency department.

The second question, Sir, is TCFs, will that be a difference in cost because these would be run by private clinics? So, if I am a patient going to a TCF, I would be concerned about the cost.

And finally, what is the percentage of space that is available, when you free up the number of beds for COVID-19 purposes?

I thank the Member for his questions. The short answer is we will try to encourage it, but opening for 24 hours is not easy. They will need a few doctors to cover each other. Many clinics do open to late at night and, hopefully, with something like Healthier SG, we are changing the mindset of GPs and also changing health-seeking behaviour. Hopefully, we will get more help from GPs in attending to some of these urgent cases. For your mother, if it is in the middle of the night, I think going to ED is probably justified.

Two, TCFs cost no different from public hospitals. We are running these and subsidising them in the same way.

And finally, the percentage, or number of beds that would be freed up, I gave a ballpark just now at the peak of the Omicron variant XBB wave, we were still setting aside 160 beds at the peak; sterilised it, ringfenced it, even though we had patients waiting downstairs because we were afraid of a spike of COVID-19 patients. Off-peak, the number was actually larger. So, I would say, at least 200 to 300 beds. And I think they will make a big difference to the operation of hospitals.

Thank you, Mr Speaker. I thank the Minister for his reply. I have two supplementary questions. First, I am heartened to hear that TCFs will be paired with our hospitals. Notwithstanding, would there be enough healthcare workers to run the TCFs, given the overall tightened manpower situation in our hospitals?

Second, how is MOH supporting our healthcare workers to do their work more efficiently and to prevent burnout during this period of high patient load?

We know that healthcare workers are never enough. There is a manpower crunch and intense competition between different countries trying to hire healthcare workers. Fortunately, this is something we can solve in the short term, over a few months, by recruiting, training them and putting them in place. So, this is something we are doing actively. Now that the COVID-19 situation has stabilised, borders are opening up, we have started our overseas recruitment process as well as continue to work with our local institutions to bring in more healthcare workers.

The second question on how to prevent burnout, if we solve all these jam problems, manage the pandemic and move to endemicity form of operations, I think it will go a great extent to reduce the workload.

I thank the Minister for his reply. I deeply appreciate all our healthcare workers and staff – from doctors to nurses to hospital receptionists – for their tireless efforts in caring for patients. Both they and the patients suffer tremendous stress when the queues of patients build up. So, I have two clarifications for the Minister.

First, I understand that some patients are not discharged because the downstream care facilities are not available to receive and accommodate them. The Minister said just now that there were some delays in the opening of nursing homes and daycare facilities, and transitional care facilities are being used to reduce the burden on acute care hospitals. Can the Ministry also look into providing more home support for patients to help their families care for the patients who are suitable for discharge from acute care hospitals?

And secondly, queue clearance depends, in part, on the ability to triage and diagnose arriving patients and this, in turn, is limited by the number of qualified healthcare professionals. Is the Ministry looking at giving greater responsibilities to nurses so that they can take on more of the responsibilities that are currently being done by doctors?

We are certainly looking at home discharge as well. In fact, that is a major initiative. So, in a complex system like that, it is all of the above – whether it is a nursing home, step-down care, community hospital, home discharge. We will look at all of them.

Just a point on home discharge: actually, it is quite manpower intensive. Because once you bring a patient home, a nurse does have to visit them, call them; but it frees up the bed spaces. So, it does add to the workload of nurses. So, we are managing different resources as optimally as we can. But this is a major area that, at some point, we should discuss further with Healthier SG, ageing-in-place, home nursing is a very important prong.

Second, on triage, I think nurses are already doing some of the triaging. And certainly, with our move to Healthier SG, preventive care, bringing healthcare into the community away from the hospitals, there is a lot more our nurses, allied health professionals and pharmacists can do. It is a direction we are moving towards.

Thank you, Mr Speaker. I also want to express my deep appreciation to our healthcare workers, especially the doctors, nurses and staff working in the EDs, some of whom are my personal friends and I have seen how they have persevered through these few years of COVID-19 pandemic. And I am journeying with them. I have two supplementary questions.

Pertaining to the GPFirst initiative that was piloted in Changi General Hospital back in 2014, how many of our current slate of about 1,800 GP clinics are on it?

My second supplementary question is that I have spoken to some of the GPs in my Jalan Kayu constituency about the situation in the EDs and what is the role that they can play, especially under Healthier SG to be part of the solution for the ecosystem. They have asked whether there can be more practical resources, such as a peer-to-peer call line for them to reach out to their Accident and Emergency (A&E) doctor counterparts in the public hospitals in the region so that they can triage and also assure the patients that the conditions may not warrant an ED admission.

I thank the Member. First question, I do not have the number. Maybe the Member can file another Parliamentary Question? GPs can certainly take a load off the EDs. First, open 24 hours; if not, open at night, make yourself available to telemedicine; you can assuage the concerns of many patients and avoid the ED visits. As to whether to set up a call line to EDs, I suppose the more they call, it does add to the workload of EDs as well. Notwithstanding that, I think we can approach the Agency for Intergrated Care (AIC), and AIC will help link up with the nearest EDs.

Thank you, Speaker. I have one supplementary question for the Minister. There may be elderly facing non-life-threatening cases who may not have been able to share their condition while waiting for a doctor to see them at the A&E. They may have felt nauseous, cold, scared, hungry. How then does MOH identify or how then do the nurses identify such cases and help comfort them during that waiting period?

When the queue is long and you start to have crowded EDs, the nurses do that. I think they have the skills to do that, including the language ability, because in a team, there will be multiple language skills and they would be able to comfort the elderly. I think the problem that the Member raised is probably a result of very crowded EDs, when nurses are under tremendous pressure, so the kind of attention is probably not given, compared to normal times.

So, I think we still go back to the same problem we raised earlier, that if we can resolve the crowdedness at the EDs, I think the problem that the Member raised will be addressed.

Thank you, Sir. The Minister mentioned about the non-urgent cases attended by EDs. I understand some are because the clinics could not cope and refer the patients to EDs – including some polyclinics, I understand. So, can I ask the Minister – he mentioned about TCF, whether that can also be another place? So, can clinics refer patients to a TCF instead of going to the EDs?

A TCF is not quite the place to refer ED cases to. It is more a step-down care facility. But what we are doing is setting up more Urgent Care Centres (UCCs). We have one in Admiralty and that has been very useful.

Ultimately, it goes back to how we diagnose a problem. Reducing non-emergency cases to EDs certainly will help. But that is not the main bottleneck today. The main bottleneck remains a mismatch in demand and supply of hospital beds, which leads to long waiting times at the EDs, waiting for wards and crowding the EDs. So, that remains the most urgent problem to be resolved.

Thank you, Speaker. Just a question on the situation at KKH. The Minister spoke about the heavy demand on beds there. Does the Minister have some indication as to when that demand is likely to taper or is it a case of having to stand up more beds in KKH over time?

The bed situation for paediatrics is actually quite okay. It is a different problem from the EDs of the other hospitals where there is a mismatch in demand and supply of beds. For children's beds, it is actually okay. This is more a case of ED visits, where they can be attended to, treated and discharged and go home.

When will this subside? I mentioned there is an immunity debt, which means it can be repaid over time. As to how long – I have to consult the experts in MOH, and they may have some idea.