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.
Mr Ong Ye Kung: Sir, during the Delta wave last year, our 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 Intensive Care Unit (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 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, 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 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 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, there will be public complaints and we understand, 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, for critically ill patients, they are attended to almost immediately at the EDs, due to the way 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 averaged 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 ward 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”, is the median. There is a variation. 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 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 and 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 subsided and we started dealing with the problem, another wave would come, and attention and resources were diverted to fight fire again.
With the XBB wave subsiding earlier than expected, we hope this time round, we 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, translate to daily attendances, it is 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 our measures to educate the public not to 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 – 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 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 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 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 come back 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 number 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 (PQs) were filed, asking 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 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 demands 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 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 also, we offer subsidised rates even though it is treated 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 above 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 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, and that one 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 the unforseen circumstances and 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 is run by Thomson Medical Centre, that 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 live 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 from 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 to 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 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.
Mr Speaker: Mr Gerald Giam.
Mr Gerald Giam Yean Song (Aljunied): 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?
Mr Ong Ye Kung: 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.
Mr Speaker: Mr Pritam Singh.
Mr Pritam Singh (Aljunied): 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 there having to stand up more beds in KKH over time?
Mr Ong Ye Kung: 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 it is an immunity debt, which means it can over time be repaid. As to how long – I have to consult the experts in MOH and they may have some idea.
Ministry of Health
8 November 2022