Angry Doctor

Thursday, April 26, 2007

Subsidy and Other Preoccupations 12

An interesting letter to Today today which attempts to look at the issue of means testing using statistics:

More hospital beds the remedy
Means testing: Are S'poreans abusing medical system or is capacity just insufficient?
Letter from Tony Tan Kok Tee

I read with concern recent news articles on the planned means testing in hospitals here, presumably because our lower-class hospital wards are overcrowded.

The question is, what is the root cause? Is it due to Singaporeans abusing the system, or insufficient hospital beds?

According to the World Health Organization's World Health Report 2006, the number of hospital beds ratio in Singapore (in 2004) is only 28 per 10,000 population. Countries with similar Gross National Product (GNP) per capita as Singapore have a much higher hospital beds ratio than Singapore.

In the 2007 PriceWaterHouseCoopers study on global cities, Singapore also scored badly in this area.

Among the four Asian dragons, the Republic of Korea led the way with 89 hospital beds per 10,000 population, followed by Taiwan (48 beds), Hong Kong (47 beds) and Singapore (28 beds).

Among the countries with US$20,000 ($30,200) to US$40,000 GNP per capita as indicated by the International Monetary Fund, only five countries had fewer than 30 hospital beds per 10,000 population in 2003/04. They are Kuwait (21 beds), the United Arab Emirates (22), Brunei (26), Bahrain (28) and Singapore (28).

Since Singapore has been benchmarking itself in many areas against advanced countries, I think we should do likewise in the hospital beds ratio.

If our hospitals are indeed overcrowded, then building bedrooms carved out from wards for loved ones to stay, as reported in a newspaper article, will only worsen the problem.

If there is a genuine need for such accommodation, our Government may wish to allocate nearby land for such purposes and encourage private enterprises to build and manage them to complement the hospital services.

Our Government has also done a fantastic job in marketing Singapore as a medical hub and I fully support the initiatives. But if our public hospitals are also targeting the foreign patients, will there be pressure to convert the already limited wards to better-class wards/facilities at the expense of lower-class wards?

If we have insufficient hospital beds for our current population, it will be a bigger challenge to handle the additional 1 million foreign patients without compromising on Singaporeans' increasing medical needs.

Our Health Minister mentioned that means testing is to prevent Singaporeans from abusing the system. But, is that the case?

Is the "sandwiched" middle class abusing the system if they choose to stay in lower-class wards even if their income is above average? They may have two sets of elderly parents, ailing loved ones plus school-going children to care for. I would like to think they are being prudent.

Should we force them to stay in upper-class wards and deplete their savings faster?

Compared to the lower income earners, these middle-class earners may seem "well-off", but the reality may be the opposite. Every family is unique and means testing will not be able to accurately capture the increasing financial constraints of this middle class.

Another solution to the overcrowding problem, rather than adopting means testing, is to increase the number of hospital beds — beyond the planned Jurong and Northern General hospitals.

The increased capacity will not only give all Singaporeans a choice and not deprive them of the opportunity to stay in these lower-class wards especially if they are financially constrained, but also help us service the increasing foreign patients.

Our Government will have to decide whether all Singaporeans — regardless of financial health — are entitled to basic, low cost, no-frills healthcare services.

We're not asking for free medical treatment or hospital stay like in some countries, but to have a fair system for all Singaporeans.

Comparing our bed ratio to those of the other developed Asian countries, angry doc is tempted to conclude that we do suffer from bed shortage.

But wait.

Mr Tan goes on to tell us that the countries with the lowest bed ratios include Gulf states like Kuwait, UAE, and Bahrain.

Now Kuwait, UAE and Bahrain are not exactly Third World countries, with what the oil bursting out of the ground, so why would they have bed shortages? Moreover, healthcare in Kuwait, UAE and Bahrain are actually quite good, so their low bed ratios do not seem to translate to poorer healthcare for their residents either.

So what's happening here?

Well, disease patterns and health-seeking behaviour differ from country to country. A low bed ratio does not necessarily mean that the people are sick and unable to get a bed in hospital; it might just mean that they are mostly healthy and do not need to be hospitalised. On the other hand, a high bed ratio may also not mean that everyone who needs a hospital bed will get one, if access to hospital is difficult, hospitalisation fees are high, or if the beds are 'oversubscribed'.

What we perhaps need to do in asnwering the question of whether we have a problem of bed shortage is to look at data other than bed ratios.

What is the occupancy rate of beds by ward class like?

What are the waiting times from the emergency department to the ward?

What are the waiting times for elective admissions like?

Those statistics, angry doc believes, will give a better picture of whether or not we do have a bed shortage problem here.

But even if we do have all those figures, and even if we do have a proven bed shortage, it does not answer Mr Tan's question of whether the root cause is that of a fundamental bed shortage, or whether it is that of abuse. A hospital with a high occupancy may have a high abuse rate if most of the patients in fact do not require hospitalisation, just as a hospital with low occupancy may in fact have a zero abuse rate if all the patients are there for medical reasons.

We cannot have a system that will prevent abuse unless we have a system that has the moral courage to identify abuse and to stop it. Until we do that, everything else we do is just penalising people who genuinely require healthcare.

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  • What about the fact that many of the citizens of the Gulf states seek medical treatment abroad. I think their government pays for overseas medical treatment as well, which may justify the low number of beds required locally for acute situations.

    By Anonymous Anonymous, At April 27, 2007 9:54 am  

  • Maybe. But the fact remains that by itself, bed ratio is not an indocator of whether bed shortage is present.

    By Blogger angry doc, At April 27, 2007 5:26 pm  

  • The reason why Kuwait etc have such a low bed ratio is that they have a very young population. You were on target when you commented on the differential needs of the populations. According to the World Factbook, the median age in Kuwait is 25.9 while the median age in Singapore is 36.8 by which time the first few AMIs and Ca Breasts start occuring.
    If adjusted for the median age of the popultion, the bed ratio gives a rather accurate indicator of the quality or availability of medical services in a country. This is being recognised by our leaders who are planning major new hospitals in Yishun and Orchard....

    By Anonymous Anonymous, At April 28, 2007 10:21 pm  

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