Severe Bed Crunch at Hospitals

Madam, a combination of factors contributed to the high Bed Occupancy Rate of 87.2% early this year, higher on some days and in some hospitals. With an ageing population, there are now more old and frail patients who need hospitalisation. The proportion of public sector admissions from patients aged 65 years and above has increased from 28.6% in 2006 to 33.4% in 2013. Older patients also tend to stay longer in hospitals because it takes longer for their conditions to stabilise and for them to be eligible for discharge. The Average Length Of Stay (ALOS) for patients aged 65 and above has lengthened from 7.8 days in 2010 to 8.2 in 2013.

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In comparison, younger patients' ALOS has actually shortened during this period. With shrinking family sizes and weaker family support, over time, family members may not be ready to take the patients home in a timely manner and this will also result in a longer stay in the hospital.

We address the capacity issue from both the short-term and the long-term perspectives. In the short term, we are actively managing the capacity in two ways. First, we are managing capacity in each hospital by facilitating timely discharge of patients to appropriate care settings, including community hospitals and nursing homes, as well as the patients' own homes.

To better support our patients and their families, our hospitals are going beyond the physical confines of the hospital to provide care. Hospitals, such as Changi General Hospital, Khoo Teck Puat Hospital and Tan Tock Seng Hospital, have formed transitional care teams to support patients in their homes initially after discharge, if necessary. These multidisciplinary teams, comprising doctors, nurses and other healthcare professionals, will continue to support the patients and ensure that the caregivers are able to provide proper care for the patients. This helps to give the patients and their families greater assurance and facilitates timely discharge.

Families who need time to make permanent care arrangements at home are able to tap on the Interim Care-giver Scheme at Changi General Hospital, Tan Tock Seng Hospital and several other hospitals and community hospitals. As of December 2013, about 300 patients have benefited from this scheme.

In view of the growing healthcare needs, we have added more than 300 beds in our public hospitals over the past six months. This was done by adding more beds into existing wards, re-commissioning beds at the Communicable Disease Centre, and converting office and other non-clinical space into bed space. In addition, close to 1,000 more nursing home beds were added last year, which helped to take over from the hospitals lower acuity patients who need longer term care.

Second, we are optimising national capacity by initiating transfers from acute hospitals with a tight bed situation to others with higher bed capacity. We are also tapping on spare capacity in the private sector. For example, public-private partnerships have been forged between Changi General Hospital and Parkway East Hospital; and also between National University Hospital and Westpoint Hospital. We now have almost 50 beds from these private hospitals.

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We are exploring further collaborations with the private hospitals.

We will continue to monitor the situation closely and work with our hospitals on all fronts to ensure that patient safety and care are not compromised.

Over the medium term, the demand for acute care services is likely to continue to rise as our population ages. MOH has already put in place plans to build additional bed capacity across care settings under the Healthcare 2020 Masterplan. In 2014, 1,200 beds, including community hospitals and nursing homes beds, will be added to the healthcare sector, and 10,000 more beds will be added by the end of 2020. Besides the upcoming Ng Teng Fong General Hospital and Jurong Community Hospital which will open in 2014 and 2015 respectively. Yishun Community Hospital will open in 2016, Sengkang General Hospital and Community Hospital will open in 2018, and a new Community Hospital in Outram will open by 2020. In the intermediate and long-term care sector, we are building various eldercare facilities, including 12 new and replacement nursing homes by 2016.

Even as we add capacity, we need to also transform the model of care because a hospital-centric system is not the best in meeting the care needs of an ageing population. We need to help our senior population stay healthy and manage their chronic conditions better so that they do not need to be hospitalised frequently. We would also need to provide good support in the community to allow them to recuperate well after a hospitalisation episode.

An example of a care transformation programme is Tan Tock Seng Hospital's Virtual Hospital concept. This involves assigning a care manager to monitor frail patients who have a history of multiple admissions to hospital, and help them better manage their conditions, so that they can get better, stay healthy and not have to visit our hospitals often.

We also need to build up our primary care and intermediate and long-term care sectors and integrate them better with our acute hospitals. These transformation efforts, together with planned increases in bed capacity, will allow us to better manage our healthcare needs in the decade ahead.

I would like to thank the Minister for the very comprehensive answer. I would like to ask the Minister, while the admission rates and the duration of stays for the patients have increased in the current crunch situation, could these be also due to a relative paucity of

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downstream services, such as the intermediate as well as the long-term care sector, because there may not be a right siting of patients within the medical institution? Some patients may only require some simple kind of monitoring in the long-term healthcare sector but as a result of the paucity, they may actually end up admitting into the acute hospitals causing the current bed crunch.

The other question I would like to ask the Minister is: while building more hospitals is necessary, are we just treating the symptoms and not the cause? I would like to ask the Minister to consider taking a more holistic and systematic approach to reviewing the healthcare system and also to provide the right siting – treating the right patient at the right place for the necessary condition – and also streamlining all the work processes to minimise inefficiency and to optimise the resources, such as working with the private sector —

Madam, I am glad that Dr Lam has actually spelt out quite a lot of things that the hospitals are already doing. Many of the suggestions that Dr Lam has put forward were outlined in the Healthcare 2020 Masterplan, including streamlining our processes, ensuring better care in the community and also right siting, as well as building up capacity of the downstream, intermediate and long-term care, so that patients who do not need the care of acute hospitals can receive the necessary treatment in the community, as well as the intermediate and long-term care without having to be hospitalised.

Dr Lam also asks whether we can take a holistic approach. I think that is very important. That is why I mentioned in my reply earlier that adding hospital beds alone will not be sufficient. We will need to look at how we can transform our care model, in particular. It is important for us to take a look at our primary care sector because many of the patients who are old and frail tend to suffer from chronic diseases. If we do not manage them well, these chronic diseases will deteriorate very fast and they will end up sending the patients to the hospitals. If we are able to manage them better in the community, we can slow down the progression of these conditions. If they can stay healthy, we can minimise the frequency of hospital visits or hospitalisation. This way, we will not only free the capacity for other more urgent and more acute patients but also allow the patients to recover better in a homely environment, in their own

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home, in the community, with the support of their loved ones as well.

I want to thank Dr Lam for his many suggestions. I am not sure whether I have answered all his questions. But that is primarily the approach that the Ministry is taking and we are working very closely with the various hospitals, including the private hospitals, to look at the possibility of tapping on their expertise as well as their capacity.

I have two supplementary questions. First, have the hospitals considered converting the A and B1 class wards to C class wards, especially in this period of bed crunch, so as to free up more space for the patients? And, secondly, are the public hospitals still marketing their international patient services to foreigners because these would naturally add to the bed crunch as well?

Madam, first, let me explain that for the wards in the hospitals, the conversion has to take into account the infrastructure design. It also needs to take into account the manpower capacity as well. Some of the wards in B1 may not be able to be converted into C class wards by simply adding beds because we need to ensure that the pipes are there, the wiring is there, and the system is capable of accommodating more than the number of beds that are currently in B1. But in the hospitals, what they have done is they have taken a very practical approach for patients when the bed capacity is tight. When they need more hospital beds to cater to the demand of the patients, they would allow the patients to be uplodged. Even if they are C class patients, we allow them to be uplodged to B2 or B1 wards. So, I think all the private wards are being used as a potential capacity to cater to the need of the patient when the bed demand is high.

On the second point of foreign patients, I think I have replied in one of the Parliamentary Questions (PQs) earlier. Foreign visitors form a very small component of our hospital beds. Some of them come for day surgeries, some of them are in the emergency and treated as outpatients and they go off. From my recollection, I remember that foreign visitors in our hospitals take up less than 2% of our hospital beds and these are sometimes urgent cases and some of them are already here in the emergency department. From the hospital's point of view, these foreign visitors do not pose a significant stress on our hospital beds. If you look at the historical trends, as I mentioned earlier, I think extension of the length of stay and the rising proportion of patients aged 65 and above are key drivers of hospital bed demand. Of course, hospital bed occupancy is also a very dynamic number. It varies from day to day as you can imagine. It also varies from hospital to hospital. It depends to a very large extent

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on the number of emergency admissions and the number of discharges the hospital is able to undertake on each day. So, it depends on how many patients arrive at the A&E, how many patients we plan to discharge. On certain days, when we plan for a certain number of discharges, there could be a significant number of emergency cases that arrive at the emergency departments and we have to address them and we may have to hospitalise them.

If that situation happens, you tend to see a high bed occupancy rate for that particular day of that particular hospital. Once you admit a patient into a hospital ward, it is not just for one day. Sometimes, it takes two or three days. For an elderly, it may take a bit longer. So, even for that particular day, the occupancy rate is high because of high admissions. It will take a few days for the occupancy rate to come down even if you have low admissions because the patients will take up the bed for a couple of days, or three-four days, depending on the situation. So, it is not just a simple factor. That is why I explained in my answer that a combination of factors will contribute towards a high bed occupancy.

Mdm Speaker, I would like to ask the Minister how real is the collaboration with the private sector. If I were to run a private sector hospital, I am happy to be the landlord but I would not be prepared to take on the manpower demands. I would also not want to take the medico-legal risks. As such, how real is private sector collaboration then?

It is as real as you can get because we do have running collaboration with the private hospitals, as I mentioned, between Changi General Hospital and Parkway East. They have already been running for a year or more. What Changi General Hospital does is that it has an agreement with the Parkway East to make use of the wards. Changi's doctors are there to look after the patients and they manage the patients. They also tap on the support services and the nurses. But the doctors come from Changi General Hospital, making use of the beds, that is one collaboration.

We are also discussing collaboration in a deeper way, including the use of emergency department, building up the capability of the private hospitals to make sure that they are able to respond to emergencies. For those patients who are sent to these private hospitals, they would then be treated as if they are in the public hospitals and they would be treated by doctors in the private hospitals. So, these are some of the collaborations that we are discussing.

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What I mentioned were those that already have been in operation for some time. There are new models that we are looking at and some of these, because there are ongoing discussions with the private operators, he will understand that I will not be able to share with him more details.

There is also collaboration between NUH with Westpoint Hospital. Basically, NUH rented a ward from Westpoint and is making use of the supporting services at Westpoint Hospital. So, there are different models and we are exploring different possibilities. As the Member said, private operators may have different concerns and different considerations. But I think as far as medical risks are concerned, as a hospital, there are certain risks. The key is to ensure that we have a very strong and robust medical protocol to ensure that patients are given the necessary treatment and support. There will always be medical risks and I think, as doctors and hospitals, they accept that. We look forward to working together with some of the private operators and tap on their capacity with a win-win outcome.

Can I just ask the Minister whether it is possible to bring forward the completion date of the Sengkang General Hospital because, currently, the targeted date is 2018 which is about four years from now? We can actually add in more resources to complete the hospital earlier. Exactly whether how many more General Hospitals does the Minister envisage will be necessary to meet the needs of Singaporeans, let us say, in 2030?

Madam, beyond Sengkang, we are looking at four more General Hospitals between 2020 and 2030. This is the current projection. But 2030 is still a very long way off. We will need to continue to monitor very closely and the plan will have to remain very dynamic. And if our demography shifts, our disease pattern shifts, and the healthcare landscape changes, we will have to evolve our care model. As I mentioned just now, we should not rely on building acute hospitals as the only solution. We need to look at the entire system, transform our care model to ensure that we are efficient and it is also a good way to ensure that we are cost-effective.

He asked about bringing forward the construction of Sengkang General Hospital. I have been asked this question several times. It is not just about the physical construction. We have broken ground on the Sengkang project. It will take a while for us to complete the project. The current schedule is 2018. Bringing forward the construction has several risks. We want to make sure that the project is well built because it is a very complex project. This morning, I was at the Ng Teng Fong Hospital's topping-out ceremony, and you can see that the hospital is taking shape. But it also reminds all of us it is a very complex and

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big project. It is not just a physical infrastructure. It is also important, even as we build the infrastructure, to ensure we also develop the manpower capacity. For Ng Teng Fong Hospital, for example, currently we are building the capacity of manpower and they are operating in Alexandra Hospital, undergoing training and trying to build a team together so that when Ng Teng Fong Hospital is ready to open by the end of the year, the team is ready to move across. So, it involves building manpower as well.

The manpower development cannot be accelerated at will because we need time for people to train, and to acquire the necessary skills and experience. I would say this, we would try to build the Sengkang General Hospital as fast as practically possible, but I would not want to accelerate it beyond a point where it actually poses a risk to the project as well as to the patients.

Madam, as the Minister pointed out, the bulk of the beds are taken up by elderly patients. Can I ask the Minister to have a laser light focus on the healthcare for the elderly and the entire ecosystem that supports them because many families tell me that they do not want their elderly parents to be discharged because they cannot have the care for them at home? Can I ask the Minister to look at the nursing home situation, into day-care for the elderly, into step-down care for the elderly, so that there is a support system for them, so that they can be discharged with peace of mind and also with subsidies that can support them?

Madam, I can empathise with the Member's concerns reflecting the concerns of many of our elderly. I met many elderly patients in my own constituency and I can understand their concerns. But it is also important for us to look at this issue of caring for the elderly in a more holistic way.

First, we want to find opportunities to reach out to them, to engage them, to encourage them to adopt a healthy lifestyle, to help them stay healthy. One important factor in helping the elderly stay healthy is to help them comply with their medication. I think many elderly, as you find out during your house visits, have a lot of medication to take because of multiple conditions. Sometimes, they forget to take the medication and, sometimes, because of side effects, they decide to stop their medication. And as a result, their conditions get worse. So, we would like to encourage them to stay on their medication. That will help manage their conditions and minimise the progression of their conditions and reduce the risks of having to be hospitalised.

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Some elderly are concerned about the cost of medication, and I would encourage Members to reach out to them and tell them they do not have to worry about the cost. If there is, indeed, a concern about financial affordability, let me know and I will take a look at them on a case-by-case basis.

This is the same for home care. If you have a need for financial support, do let us know. But I would hesitate to have a model where the bulk of the elderly are cared for in an institution, whether they are community hospitals, step-down care or a nursing home. Over the long term, we will find that it is better for our elderly to be supported and cared for by their family because the elderly themselves want to be with their family and want to stay at home. It is an environment that they are more familiar with and more conducive for their health and recovery. So, we should focus a lot more on developing home care and see what kind of support services that we can evolve over the next few years to support more elderly to be cared for at home.

We will be building a lot more day-care centres so that these elderly can come down from their flats during the day to be cared for by professionals and to do exercises to stay healthy, maybe even receive therapy. After that, at the end of the day, their family members can then come and pick them up and take them home. These senior day care centres are very important and we will be building them over the next few years. It is important for us to also develop home nursing so that for patients who need nursing care at home, we will have sufficient facilities to support them.

These are various initiatives we need to put in place as part of our Healthcare 2020 Master Plan. Each piece is linked to other pieces. We need to look at it in a holistic way.

Madam, the Minister mentioned about home-nursing care. I just want to ask the Minister what more can the Government do to encourage more home nursing care, and whether the reason why there are fewer patients considering home nursing is because the expenses are not covered under the 3M framework. Therefore, there will be an immediate cashflow impact on these patients if they are discharged and then get into the homes. Would the Government consider allowing limited usage of the 3Ms for home nursing care so that patients may consider discharging earlier because they can offset their costs with the 3M subsidies?

Madam, I want to thank Mr Liang for his points. Indeed, we want to find different strategies to develop home nursing. Financing is one.

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MOH is reviewing the financing structure for home nursing so that the financial support that we give to patients, especially needy patients, should, by and large, be set in neutral so that it does not penalise them for staying at home. Instead, today they get a higher subsidy and lower cost, lower cash upfront, when they are hospitalised. This will not incentivise or encourage them to do home nursing. These are things that we will review over the next few months. We hope to be able to share with the House in time to come our ideas on how we can encourage and develop these home nursing centres.