Hospital beds crunch due to COVID or just poor planning by Singapore authorities?

In an opinion piece by Salma Khalik, Straits Times’ health correspondent, it is highlighted that the delay in securing a bed recently has been exceptionally long, with some patients having to wait several days before being moved from the emergency department (ED) to a hospital ward.

She noted that there had been a 35.8-hour median wait on 10 Oct, a Monday and questioned if it may be a record for Singapore.

Ms Salma wrote, “It is never good for patients to spend long hours – or even days – in a place specifically meant for emergency treatment and not long-term care. There are no shower facilities in the ED, for one thing, or even enough toilets when patient numbers soar to beyond capacity.”

She pointed out that doctors and nurses at the ED should also not have to provide day-to-day care for patients. But instead, they should only be focusing on emergency cases.

“Anecdotally, it seems patients sometimes remain in an ED for three or four days before being moved to a ward.”

One would wonder if there has been a new spike of COVID infections among the Singapore population causing the bed crunch at the hospitals.

Referring to the Ministry of Health (MOH)’s data, we do see a spike in admissions as a result of COVID infections.

But if we look closely, we can see that the spike resulted in 186 beds being occupied. This leads to the question of how many beds we have as buffers in the public healthcare system.

According to government data, there were 15,564 beds at hospitals in 2020. During that period, there were a recorded number of 5.69 million residents, which gives us a ratio of 2.74 (2.74 beds per 1000 pax).

Based on the information from MOH, we see that the occupancy rate for Singapore’s public hospitals is mostly at above 90 per cent occupancy.

According to United Kingdom’s National Audit Office, the bed occupancy rate is deemed efficient at 85% and recommended not to exceed 90%.

Its evidence suggested that, in general, any increase in occupancy leads to an increased risk of adverse patient outcomes including mortality (in-hospital, 7-day and 30 day), avoidable adverse events reported as hospital-acquired infections (Clostridium difficile infection), length of stay, 30-day readmission and delays in admission for patients waiting in ED.

What is suggested by the UK institute, seems to comply with the reality in Singapore’s hospitals as described by Ms Salma in her opinion piece.

At a ratio of 2.74 in 2020, Singapore fares slightly better than its neighbouring countries, Malaysia (2.01, 2020) and Indonesia (1.49, 2021) but it fares considerably worse than other Asian countries such as Japan (12.63, 2021), South Korea (12.65, 2020) and Taiwan (7.3, 2021).

It bears noting that World Health Organisation (WHO) in India highlights that global standards recommend 5 hospital beds for every 1000 people. This standard is said to be meant for district hospitals — India had 5 beds per 10,000 in 2020. At the same time, the OECD average was 5 beds per 1000 in 2018.

While there has been a mad rush to build new hospitals over the past couple of years such as Ng Teng Feng Hospital, Sengkang Hospital and Jurong Community Hospitals and others, we can see that most were built after 2011.

Priority to that, we even had hospitals such as Toa Payoh Hospital being merged to form the current Changi Hospital in 1997.

In fact, if we were to look even deeper, we will see that the ramp in hospitals (in turn beds) came after 2011 when the People’s Action Party lost its first Group Representation  Constituency (GRC) in Aljunied at the General Election. (Note that the increase in 2013 was due to a private hospital and not a public one.)

In the aftermath of the election, it is reported that voters were unhappy over the influx of immigrants, causing overcrowding in public transport and other amenities alongside the rising cost of living.

Infrastructure was simply not sufficient or built fast enough to cope with the mass increase in the population where there had been a jump of 1 million residents from 2000 to 2010.

Historically, it may also be interesting to note that the total number of hospital beds (public & private) dropped from 11,936 in 2001 to 11,394 in 2011 (Dept. of Statistics) – whilst the number of hospital admissions increased from 384,054 to 469,445 – medical tourists increased to 850,000 a year.

In 2011, the ratio was just at 2 beds per 1000.

Given that there has been an additional increase of over 600k population from 2010 to 2020, rather than building more hospitals to increase its capacity for comfort and buffer, it can be said that Singapore is catching up with its backlog due to its lack of planning.

But it is fortunate that the Singapore government seems to have learnt its lesson and has been aggressively building new hospitals to cater for its population, particularly so in light of its ageing population.

However, while hospitals can be built so long you have the money but it is a different challenge when it comes to staffing them with experienced healthcare professionals.

While this can be solved with short-term solutions by hiring foreign doctors from countries such as India, many have argued and questioned why Singapore is not bringing its citizens who have studied medicine back as doctors.

True enough, Singapore is indeed ramping up its recruitment of Singaporean medical students who are studying abroad after a high turnover of healthcare staff following the COVID pandemic.

But whether would it persist in this trajectory, resolves challenges in attracting the students back or lose its way as it did in its foreign talent policy for other industries in Singapore, is something to be examined in the future to come.