TAN TOCK SENG HOSPITAL

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TAN TOCK SENG HOSPITAL: **(Shortage of beds and standard of care at A &E Department) **

7.

Mr Low Thia Khiang asked the Minister for Health whether there is a shortage of beds at Tan Tock Seng Hospital and, if so, (i) how long has the hospital faced a shortage of beds; and (ii) what is the solution to the situation.

8.

Mr Low Thia Khiang asked the Minister for Health whether the standard of medical care at the Accident and Emergency Department (A&E) of Tan Tock Seng Hospital is compromised since patients deserving admission are being held at the so-called observation ward of A&E for a long time waiting for beds.

9.

Mr Low Thia Khiang asked the Minister for Health (a) whether it is productive and appropriate that the first counter of the Accident and Emergency Department of Tan Tock Seng Hospital is manned by medical staff whose role is to counsel patients seeking treatment to go

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to other hospitals; and (b) what is the rationale for requiring patients who refuse to go elsewhere to sign a letter of indemnity.

The Minister for Health (Mr Khaw Boon Wan): Mr Speaker, Sir, with your permission, I would like to take all the three questions by Mr Low Thia Khiang on the over-crowding problem in Tan Tock Seng Hospital together.

Mr Speaker: Please do.

Mr Khaw Boon Wan: Sir, Tan Tock Seng Hospital is, at times, over-crowded, apparently with more patients than it can cope. But Tan Tock Seng Hospital already has over 1,100 beds. This is not a small hospital. After the Singapore General Hospital (SGH), it is now the second largest general hospital here.

The key issue is whether Singapore is overall short of public hospital beds. Here, the answer is no. Our public hospitals have an average bed occupancy of about 80%; this has been so for quite a few years. If necessary, we can expand the public hospitals by several hundred more beds in the short to medium term.

The current congestion at Tan Tock Seng Hospital arises because it is the general hospital nearest to the north. For historical reasons, all public general hospitals are located in the south. With the growing population in the north, Tan Tock Seng Hospital ends up with a patient load larger than expected.

Its accident and emergency patient load today exceeds that of the Singapore General Hospital. Traditionally, SGH has the largest emergency patient load, but, nowadays, Tan Tock Seng Hospital saw 21% more attendances than SGH's current patient load.

We are monitoring the overcrowding situation carefully. Tan Tock Seng

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Hospital had been planned with a little more room for expansion, and we can open another 150 beds in stages. However, I want to exhaust other avenues first before doing this, so that our healthcare budget can be stretched to its maximum.

First, we should spread out the patient load across the hospitals, to make maximum use of available beds. As with other hospitals, high demand for beds varies from day to day. We can try to spread the load across hospitals, because not all public hospitals experience the same high demand at the same time. Second, at any point in time, there are some 40 patients (40 beds) in Tan Tock Seng Hospital who are waiting to be transferred to community hospitals or nursing homes due to administrative delays. We are working to shorten this bureaucratic delay, so as to free up more beds for new admissions. Third, some of Tan Tock Seng Hospital's beds are clogged up by foreign workers down with chicken pox. Practically all, if not most, do not need to be hospitalised. So we are fixing this problem.

In the medium term, the thorough solution to this problem is to build a new general hospital in the north. That is why I brought forward the construction of the Northern General Hospital. Planning is underway and we hope to open Phase I of the hospital at Yishun before 2010. And if we are lucky, maybe in 2009.

Let me now address the services rendered at the Tan Tock Seng Hospital Emergency Department. All emergency patients are triaged upon arrival. This is a standard operating procedure throughout the world. The purpose of triage is to assess the severity of the medical conditions so that medical care can be suitably prioritised. This is largely done by experienced senior nurses. But during

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peak periods, Tan Tock Seng Hospital would deploy a doctor to help accelerate the screening process. This is to provide swifter preliminary diagnosis and to initiate treatment.

Mr Low also commented on the Observation Ward. The purpose of the ward is to cater to patients who are in the intermediate category, between those who clearly can be discharged and those who require immediate admission. At the Observation Ward, the patients will be rendered the necessary tests and preliminary treatment to stabilise their condition. So, they are not simply just "waiting for beds". Those who respond to treatment and get better are discharged. Those who require admission are constantly monitored and provided necessary treatment, and are admitted as soon as a bed becomes available.

Mr Low is worried that medical care for patients in the Observation Ward might be compromised. It is not. In fact, in the US and UK, many hospital emergency departments have such "Short Stay Wards" for patients whose conditions can be addressed by short and directed medical treatment.

Finally, there are patients whose conditions are not severe at all. They will have to wait their turn while we attend to the more seriously ill. In fact, most of these patients should not be in the hospital's emergency ward. As part of patient relations, Tan Tock Seng Hospital tries to keep them informed of the expected waiting time, which is likely to be long. The purpose is to give them an option of seeking medical attention at other hospitals if they wish.

For those who chose to wait, Tan Tock Seng Hospital had previously asked them to acknowledge this decision through signing an indemnity form. However, upon review, Tan Tock Seng Hospital has terminated this practice.

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Mr Low Thia Khiang (Hougang): Sir, I would like to ask the Minister for the rationale for Tan Tock Seng Hospital to ask people who refuse to go somewhere else to sign an indemnity form, which reads:

'I hereby confirm that I have chosen to seek medical attention at Tan Tock Seng Hospital despite having been informed that TTSH is currently experiencing full house situation. Therefore, I shall not hold TTSH or any of its employees, servants or agents liable in any way whatsoever for any loss, bodily injury, mishap, accident, loss of life and of property arising directly or indirectly as a result or in connection with my consultation/treatment with TTSH.'

Sir, if Tan Tock Seng Hospital is not concerned about its medical standard being compromised because of the situation, why is there a need to get patients to sign an indemnity form?

Secondly, is it fair to turn away a patient who goes to a particular hospital, especially near his home, in an emergency and is asked to go away and seek treatment somewhere else? If not, the patient has to sign an indemnity form as though he is selling his life, never mind whether he is dead or not.

Mr Khaw Boon Wan: Mr Speaker, Sir, the practice that Mr Low highlighted is a local innovation, purely within Tan Tock Seng Hospital. It is not a Ministry of Health's directive. I have run practically every public hospital in Singapore, except Tan Tock Seng Hospital. And in all those hospitals, we never have such a practice. But, like all innovations, some are good innovations and some are bad innovations. As part of a creative economy, we allow for local innovations to take place. But when it was highlighted, I myself thought that it was quite a silly innovation. So I am quite glad that, upon review, they have terminated it.

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Mr Low Thia Khiang: Sir, I would like to know from the Minister whether he was aware of the shortage of beds situation prior to the question being filed, and how the Ministry of Health supervised the hospitals since he said that it was a local innovation, bearing in mind that this local innovation, whether creative or not, can cause a lot of suffering and anxiety to patients who seek treatment. My question is: how close is the supervision? Secondly, is the Minister aware of the incident and also the bed shortages? And what has he done prior to the problem, which, I believe, is quite acute now?

Mr Khaw Boon Wan: Sir, I disagree with the intensity of the criticism. I do not think the situation was acute on a nation-wide basis. I have given a very careful and fairly comprehensive reply to the Member. What is important is that we are a little red dot. You can go anywhere within half an hour or one hour. It is not like the UK. If there are bed shortages in one corner, it means that there is a possibility of emergency patients not getting medical attention in time.

We have to look at it on a nation-wide basis. Are we short of public hospital beds? I have given the Member data to show that we are not. But, yes, there are local problems which we have to resolve them locally. So it is not because of Mr Low's parliamentary question that I suddenly wake up and discover this problem in Tan Tock Seng Hospital.

Sir, the problem, on a nation-wide basis, is not as acute as what Mr Low has tried to paint it. But I agree that there are difficulties at Tan Tock Seng Hospital.

Let me take some time on this matter, if you do not mind, Mr Speaker. Running public hospitals requires trade-offs between three objectives which are often contradictory. First, keep clinical

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standards as high as possible. This means employing top brains - doctors, nurses, and equipment. Second, keep cost as low as possible, because we want to make sure that people can afford health care. Third, keep what I call "non-clinical customer service" as best as possible and as high as possible, equivalent to a five-star hotel. And we know that all three are very difficult objectives. Any politician who promises you that he can deliver all three is a liar! But I feel that our job of running public hospitals is to try to balance these contradictory objectives. And if you ask me, my priorities are in that order - first, high clinical standards; second, keep cost as low as possible; and, third, non-clinical customer service, like waiting, as best and as high as possible. It is not possible to match all three but where we can, we try to do our job as well as we can.

So, if you want customer service to be as best as possible - meaning there is no waiting, doctors, nurses and beds waiting for customers to come in - I can do that, but it means very high cost. Our private hospitals can achieve that, but look at their average occupancy rate, it is less than 50%. So, cost is high, but they can easily pass it on to the patients. I can do so in public hospitals too, but I am quite sure Mr Low will be the first one to protest and say, "Why are fees going up?" So this is the magician's act that we have to perform daily. I am not very proud of the non-clinical customer service at Tan Tock Seng Hospital A&E Department today. But we can try to resolve some of these problems, and we will.

So, I think building the Yishun General Hospital is a major fundamental step which we will speed it up. But, in the meanwhile, I think we can try to ease the burden as much as we can.

Let us bear in mind one point. When we run heavily subsidised public hospitals,

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sometimes deliberately squeezing supply, keeping occupancy rate high is not something to sniff at. It is an important part of the strategy if we want to keep overall healthcare cost as low as possible. If we have plenty of resources or plenty of money that people are willing to pay or to subsidise, sure, we can open up as many beds. I can actually open up another 150 beds at Tan Tock Seng Hospital tomorrow. I can if I want to. But is that the right solution? If I do that, then problems like chicken pox patients who are kept in Tan Tock Seng Hospital will persist. This came out during the review in the last couple of months.

When Singaporeans are down with chicken pox, what do we do? We send them home. But now, our beds are being clogged up by foreign workers, who are being dumped at Tan Tock Seng Hospital, because, for some historical reason, we heavily subsidise these foreign workers with chicken pox, when the right solution for the employer is to vaccinate them.

Years ago, when I was running the hospitals, I know many of our beds were clogged up, and SGH too, by NS personnel with chicken pox. Then when we introduced proper transfer pricing to MINDEF, the right decision was made, ie, MINDEF started vaccinating NS personnel. So, today, no more beds are being occupied by NS personnel with chicken pox. But, obviously, we have not applied the lesson to foreign workers, who are being dumped at Tan Tock Seng Hospital, at the expense of patients who genuinely require emergency care and beds.

But I want to highlight to Mr Low that no seriously ill patients are being turned away or being sent from hospital to hospital. Those indemnity forms, which I accept were not a clever innovation, only applied to those who should not have been in Tan Tock Seng Hospital, or any hospital's Emergency Department, to begin with.

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Mr Andy Gan Lai Chiang (Marine Parade): Sir, is it true that one of the reasons for over-crowding in Tan Tock Seng Hospital is that ambulances find it convenient to send their patients there and, since it is the only hospital in the north, that problem is going to be more acute? So, in the meantime, has the Minister thought of any solution to that?

Mr Khaw Boon Wan: Certainly, it is the location of Tan Tock Seng Hospital. When I was discussing this with the CEO of Tan Tock Seng Hospital, in a light-hearted manner, he said, "Our feng shui is very good", ie, its location is best and, therefore, all patients flock there. But feng shui aside, we have to solve the problem, and the problem is really to speed up the development of the northern General Hospital. As I explained, for some historical reason, all the hospitals were built in the south, because the history of Singapore started from the south, from the mouth of the Singapore River. But in the last few years, we have not been adding new hospital beds in the other parts, definitely not in the north. It is high time we built one in the north. That was also a political promise made by Prof. Ho Peng Kee, and I shall discharge that on his behalf.

Let me illustrate this by looking at SGH. I gave the example just now that, 15 years ago, when I was running SGH, I remember the A&E Department patient load was 500 patients per day. It was the largest A&E Department in Singapore. It has dropped from 500 to 310 today. It is not even the second biggest A&E Department. The second biggest A&E Department is now at Changi General Hospital, which has 320. Tan Tock Seng Hospital - 380. What does it mean? Had we not built Changi General Hospital, SGH today would be an even madder house than Tan Tock Seng Hospital. So the same thing would be resolved in a few years' time.

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Mr Low Thia Khiang: Sir, I am afraid that the political promise made by Prof. Ho Peng Kee, delivered by the Minister for Health, is a bit too late because the promise was made in the last election. Perhaps, it is not too late because the election is coming, I believe, that is why he is speeding up the northern hospital. Sir, the Minister mentioned in his answer that there is a high cost vis-a-vis the non-clinical part of the service, like waiting time. So he is saying that perhaps the patient should tolerate and bear, otherwise the cost will be high. My question is: to what extent and at what expense should the patient pay for a relatively lower medical cost? What is deemed acceptable to the Minister? For instance, waiting time at the A&E Department may be stretched to three to five hours. Is it acceptable? Or is the waiting time for a bed from the Observation Ward of A&E Department to a normal bed of 24 hours acceptable to the Minister? Whilst the Minister says that the medical standard has not been compromised, does he not agree that those who are waiting at the Observation Ward have very little time to rest because they cannot even bathe, they do not have privacy, there are a lot of activities going on there? And does he not further agree that patients, who are kept at the Observation Ward, are attended to by doctors and nurses who are trained in emergency medicines and not so much, I understand, in internal medicines which patients really need in order to recuperate?

Mr Khaw Boon Wan: I remember, just a few months back, I published an occasional paper on waiting times in the Emergency Departments. This was maybe about five or six months ago. Regularly, I would look at those data, and I will continue to publish them. If you look at those papers, you will discover that, other than Tan Tock Seng Hospital, all the

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other Emergency Departments do not fit the description that Mr Low mentioned. Even Mr Low's description of Tan Tock Seng Hospital Emergency Department was exaggerated. So, please take a look at those data. I have to rely on data - unless data are being cooked up - and those are data faithfully taken. The situation was not as what he has described.

Mr Low Thia Khiang: Clarification, Sir. My question was not what is the fact now and whether I exaggerated and what is the situation based on an occasional paper published. My question is: to what extent and what is the standard that the Minister for Health is prepared to accept vis-a-vis cost, ie, cost and non-clinical standards, eg, waiting time, that the Minister is talking about?

Mr Khaw Boon Wan: It varies from country to country. Last night, I was a bit amused when I read a paper published on the UK NHS, and it was talking about waiting of a different kind. This was not waiting at the Emergency Department, but, just as an illustration, waiting for surgeries, and they were measuring it in terms of months but it actually means years, whereas here we are talking about days and weeks. So, everything, as we said, is relative. But I take his point that, certainly, if it is a true emergency, that patient cannot be waiting for hours. And if it is a true emergency, nobody in Singapore's public Emergency Department waits for hours. He only waits for minutes. And if you are truly on high priority, or what we call P1, immediate treatment is rendered. I do not know how Mr Low got the feedback. Was he a patient in Tan Tock Seng Hospital recently or was he a resident around there?

Mr Low Thia Khiang: Yes, I was a patient. I got some feedback, but I did not verify the feedback.

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Mr Khaw Boon Wan: So, please, take a look at our published occasional paper on waiting times in the Emergency Departments. Clinical standard, as I said, is not being compromised. Customer service, yes, I agree, is not the best.

Mr Speaker: Dr Geh Min, last question.

Dr Geh Min: Mr Speaker, Sir, the Minister has stated quite correctly that, in order to keep standards up and cost down, customer service must take a relatively lower priority. But I would like to point out that, when a patient goes to the Emergency Department, he does not know whether it is urgent or not and neither do his relatives. Could I ask the Minister whether there could be better coordination between the different hospitals and even the different hospitals in the different clusters? Perhaps, the Ministry could start a hotline, like we do for roads, so that a patient who thinks he or she has an emergency and needs to go to a hospital will be able to get quick information as to which hospital has a long waiting list or has no available beds, and better not go to that one? I think this sort of information should definitely be given to ambulance drivers, for example.

Mr Khaw Boon Wan: I suppose better coordination is something we can take a look. But having spent many years in healthcare now, a layman's understanding of what is emergency is difficult to explain. You can always try to educate. I think to educate Singaporeans to detect suspicious parcels is a lot easier. Once you are sick with fever, everything is an emergency. That is why you need triage when you come in. To do triage over the telephone is not possible. And for a real emergency, living around Tan Tock Seng Hospital, that is critical, because that is my constituency. You want immediate attention, zoom, go straight to Tan Tock Seng Hospital Emergency Department.

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And, so far, if you are a true emergency case, you will be attended to immediately.