Ong Ye Kung
Singapore
“The Ministry of Health (MOH) recently enhanced the Community Health Assist Scheme (CHAS) dental subsidies, which are tiered by income, for common preventive and restorative procedures.”
“Healthier SG GP clinics may also refer their enrolled patients to Active Ageing Centres and Community Health Posts to fulfill their social prescriptions and for subsidised services, such as medication management.”
“Public hospitals, such as the National University Hospital, the Singapore General Hospital and Tan Tock Seng Hospital, have deployed robotic-assisted surgical (RAS) systems for minimally invasive soft-tissue surgeries.”
“The Health Sciences Authority (HSA) welcomes drug producers to choose Singapore as part of their first-wave filings. As long as a pharmaceutical product is approved by at least one regulatory agency, such as China's National Medical Products Administration (NMPA), it would also qualify for the abridged route.”
“A decrease in estimated glomerular filtration rate in patients with diabetes can be due to multiple reasons. Doctors will first investigate the underlying cause before determining whether the patient should be referred to a specialist. Some causes are reversible and cause transient reduction in renal function.”
“Information on the Lasting Power of Attorney (LPA) cannot be made visible on the National Electronic Health Record system as it is protected under the Mental Capacity Act. Such information may only be disclosed by the Public Guardian to specified persons upon satisfactory submission of evidence(s) required under the law.”
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“After all, the proof of the pudding is in the eating. Imported infections today account for about 5% to 10% of the total cases reported every day. Cases had fallen, so sometimes, it can be 15% to 20%. By and large, throughout the pandemic, 5% to 10% of the total cases reported every day. The four weeks running up to 1 January 2023 was probably one of the most difficult periods of the epidemic in China. During that time, that four weeks, there were about 200 travellers from China detected to be COVID-19 positive. That is a low number because every day, our total reported cases is about 1,000. So, for the whole four weeks running up to 1 January 2023, 200 travellers from China were detected to be COVID-19 positive. They accounted for less than 5% of our total imported infections. ASEAN countries accounted for over 50%, rest of Asia around 15%, Europe – 11% and the Middle East – 9%. Amongst all of our imported cases, in that four weeks, seven developed severe illnesses and had to be hospitalised. Three were from the Middle East, two from ASEAN, one from Europe, one from China. Most were Singaporeans returning from these countries and regions. And these were not large numbers, so the impact on our healthcare system was very small. Since 1 January 2023 till today, I did a further check. There have also been no severe infection cases coming from China. Why is it that travellers from China accounted for a very small percentage of imported infections and severe cases, when China is experiencing such a huge infection wave? And there are two main reasons. It is due to the measures we put in place, and it is backed up by our high vaccination coverage which is being kept up-to-date. What are the measures? What are the reasons?”
“Mr Speaker, Sir, since yesterday, 8 January 2023, China has started resuming outbound leisure travel and removed quarantine requirements for returning travellers into China. Singaporeans are naturally worried that this will lead to more people here, especially the vulnerable, falling severely ill. Further, there are concerns that this will trigger a fresh infection wave that can bring back social restrictions and undo what we have painstakingly achieved over the past three years. The Government, and certainly, the Multi-Ministry Task Force (MTF) and the Ministry of Health (MOH), are acutely aware of these concerns because protecting Singaporeans and maintaining our freedom and normal lives have been our primary objectives throughout this pandemic journey. As I have said a few times publicly over the past months, the pandemic is not over and we need to be especially mindful that when China opens up, there will be risks and uncertainties because the virus would be sweeping through a population of 1.4 billion, mostly COVID-19 naive, and that is now happening. In addition, we have also anticipated that there would be a "winter wave" of infections across countries in the Northern hemisphere. This has also happened in many countries, such as the US, Europe, Japan and South Korea. Prior to this, many countries have dismantled all their border measures. A few have now reinstated the measures and announced new measures. As for Singapore, we have never dismantled all of our border measures and have kept relevant measures, precisely because we anticipated these risks. Today, I will explain why we decided on our current measures and why they are appropriate, given our current context and circumstances. But before that, let me report on the outcomes of the measures.”
“Mr Speaker, Sir, may I have your permission to answer Question Nos 1 to 3 in my Ministerial Statement, to be delivered later at today's Sitting? Mr Speaker, my response will also cover the matters raised in the questions by Ms Foo Mee Har1 and Mr Zhulkarnain Abdul Rahim2, which are scheduled for a subsequent Sitting. I invite these Members to also seek clarifications if they wish to, at the end of my Ministerial Statement.”
“Eight new tobacco import and wholesale licences have been issued in the past three years – six in 2020, two in 2021 and none in 2022 – as of 28 November 2022.”
“The list of registrable basic medical qualifications is governed by the Singapore Medical Council (SMC), which reviews the list from time to time to meet the changing healthcare needs of the Singapore population. The last review was completed in 2019, where basic medical qualifications from 103 universities globally are recognised by SMC. MOH and SMC will continue to monitor and assess if the list of registrable basic medical qualifications should be reviewed and expanded. To the Member's second question on facilitating Singaporeans with non-registrable qualifications to practise here, there is already such a system in place. They can register with SMC to take a Qualifying Examination. Individuals who pass the examination can be registered with SMC to practise in Singapore. This ensures the quality of overseas-trained doctors practising in Singapore, while ensuring that their aspirations to return home and practise are met.”
“There will be a centralised system for residents to sign up for Healthier SG. To facilitate residents in their choice of a general practitioner, clinics frequented recently or near their home will be prioritised in their options. The preferred mode of enrolment is for residents to take responsibility and make a conscious decision to embark on a journey towards better health instead of automatic enrolment. We are working with the Agency for Integrated Care and grassroots organisations to reach out to eligible residents to encourage them to enrol in Healthier SG.”
“The data requested is not readily available as the existing employment data among public healthcare institutions does not track the specific movement of Permanent Resident nurses who have switched employers but remained in the public healthcare sector. Based on anecdotal feedback, nurses who have obtained Permanent Resident status are likely to stay in service longer.”
“There has been significant efforts in palliative care training for healthcare workers over the years. The National Outcomes Framework for Medical Graduates, introduced in December 2018, guides medical schools in developing their curricula and specifies core learning outcomes on palliative care. Over 100 physicians have undergone the Graduate Diploma in Palliative Medicine programme. Our local nursing schools provide palliative care training to all nurses. Most recently, the Palliative Nursing Competency Framework was rolled out in October 2022. In addition, MOH is working with partners, such as the Singapore Hospice Council and the Agency for Integrated Care, to increase awareness of palliative care and end-of-life issues amongst healthcare professionals through training courses, seminars and conferences.”
“MOH has funded several studies on using technology to enhance care for seniors at home. Under the National Innovation Challenge (NIC) on Active and Confident Ageing, we launched the Care-at-Home Innovation Grant in 2015 to enhance the efficiency and quality of care for seniors at home through technology. One project was NTU’s Homecare and Caregiving Model for Optimising Services for the Elderly. They developed a web-based health management system integrating technology and various home care services, such as smart home sensors, medication adherence and meal planning and delivery. With the sensors, seniors felt reassured that their caregivers could be contacted immediately during emergencies. The system improved the productivity of care staff and led to better care outcomes like increased medical adherence and reduced hospital admissions. We have also funded another study by Tan Tock Seng Hospital titled "Project Carer Matters 2" via NIC. One of the study objectives is to leverage technology to create a safe home environment for seniors, by developing an automated sensor-enabled fall detection and rescue system. The study is, currently, ongoing. The Government will continue to explore how promising research projects can be scaled up and deployed.”
“From 2019 to 2021, around 1,300 medical clinic licences per year have been granted under the Private Hospitals and Medical Clinics Act. The main objective of the Act is to safeguard patient safety and welfare. To grant a medical clinic licence, MOH key considerations are the character and fitness of the licensee, the ability of the licensee to operate a medical clinic in accordance with prescribed regulatory requirements and the suitability of the premises. Participation in Government schemes, such as Healthier SG or the Community and Health Assist Scheme, are encourage and welcomed, but is not a prerequisite, as clinics may have different business considerations.”
“Individuals can appeal to tap on their MediSave account to pay for their family member’s monthly renal dialysis treatment if their family member has insufficient MediSave balances, up to prevailing withdrawal limits. MOH assesses these appeals on a case-by-case basis, taking into account the affordability of the bill and expected impact of the withdrawals on the CPF member’s MediSave balances.”
“There was a similar Parliamentary Question before and I showed some of the data. The Member should be able to find it in the Hansard. Essentially, for the non-mRNA vaccine, we mostly use Sinovac. Sinovac is effective if you take three or more shots, preferably four shots. It does protect you against severe illness. I remember the protection rate is about 70-plus percent. But if you use mRNA, it is even more effective, at 80-plus, almost 90%. So, both are effective, with mRNA vaccines having an edge over Sinovac.”
“Can the Member repeat that? I was not too clear.”
“The initial data from clinical trials of the bivalent vaccine and now, empirical data based on our actual lived experience, show that it has been effective in reducing severe illnesses. Today, when you compare, especially for the aged, those who have gotten full protection and up-to-date vaccination, versus those who have not, it still shows a significant difference between the prevalence of severe illness if they get infected. I do not have the data with me, but it is at least four to five times more likely to fall severely ill if you are not fully vaccinated or not update-to-date with the vaccination. Today, we are administering healthy numbers of vaccines – about 20,000 a day in uptake; it is quite good. This includes both mono-valent and bivalent. I do not have the breakdown, but the take-up has been encouraging for people keeping their vaccination up-to-date. We will continue to put out public messages to encourage people to take their vaccine, keep it up-to-date, because the pandemic is not over. We will be stepping up our mobile vaccination teams into the heartlands so that, especially for the seniors, they will find that it is more accessible to getting their vaccination up-to-date with the mobile vaccination teams in place.”
“Sir, the Member has referred to a US research paper, which according to media reports, found that second COVID-19 infections are more severe compared to first infections. I am afraid the media reports have not been clear or accurate. The paper cited by the Member does not compare the severity between first-time infections and reinfections. Instead, it compares the outcomes of those who had a first COVID-19 infection, versus those with two or more infections. And therefore, not surprisingly, the study found it is more likely for persons to develop adverse health outcomes after two or more episodes of COVID-19 infection, compared to people who had only one infection episode. Put it simply: getting sick twice is worse than getting sick once; but getting sick for the second time is not worse than getting sick the first time. In fact, from September to mid-November 2022, the mortality rate of reinfection cases in Singapore was four per 100,000 cases, lower than that for first-time infection cases at 35 per 100,000 cases. The rate of severe illness – those requiring oxygen supplementation, intensive care or death – was also lower for reinfections at 232 per 100,000 cases, compared to first-time infections at 282 per 100,000 cases. Our data also shows that achieving minimum vaccination protection – in other words, three doses of mRNA or four doses of Sinovac – lowers the risk of severe illness, whether it is a first infection or re-infection.”
“MOH and partner agencies do leverage smart home technologies to enhance care and support for seniors in their homes. For example, under the Lift Improvement and Facilities Enhancement for the elderly project, a wireless Alert Alarm System was jointly developed by HDB, MOH and GovTech. This is implemented at selected 1-room rental blocks with relatively high concentrations of seniors. Seniors in distress can call for help by pressing alert buttons. This will alert a nearby Active Ageing Centre or Careline's 24/7 helpline. Service providers have also been partnering the private sector to trial smart technologies that best suit their seniors' needs. These include enabling remote monitoring of vitals, assessment of mental and emotional well-being, and reminders for events and appointments. We also support the development of innovative technology for senior care at home. MOH launched the Care-At-Home Innovation Grant in 2015 under the National Innovation Challenge on Active and Confident Ageing, to fund research on enhancing the efficiency and quality of home care services. For example, one project developed a web-based health management system integrating technology and various home care services, such as smart home sensors, medication adherence and meal planning and delivery. The system improved productivity of care staff and led to better care outcomes like increased medical adherence and reduced hospital admissions. The Government will continue to explore how promising research projects can be scaled up and deployed.”
“As reported in the media, the Health Promotion Board (HPB) launched a public education campaign on sodium reduction in October 2022, to inform the public about health concerns associated with high sodium intake and encourage consumers to switch to lower-sodium alternatives labelled with the Healthier Choice Symbol. As announced in the Committee of Supply 2022, HPB's Healthier Ingredient Development Scheme provides grants for salt, sauces and seasoning suppliers to develop lower-sodium ingredients and promote their adoption among F&B businesses. We target to reduce Singaporeans' daily sodium intake by about 15% over five years, from 3,600 milligrams in 2022 to 3,100 milligrams in 2026.”
“As we move towards living with COVID-19, we have ceased mandatory testing of admissions and staff surveillance testing since March 2022 and comprehensive contact tracing efforts since April 2022. Without epidemiological investigations for each case, we are not able to tell where individuals who have tested positive for COVID-19 in hospitals and nursing homes were infected. Nevertheless, through infection prevention and control measures, our healthcare institutions reduce the risk of patient-to-patient or staff-to-patient transmission as much as possible.”
“Several of our healthcare projects have been delayed due to supply chain disruption and manpower shortages in the construction sector. The construction of the new National Skin Centre (NSC) building is now scheduled for completion by 2023, instead of 2022. NSC would still continue its services from the existing National Skin Centre till the completion of their new building. Beside NSC, the new polyclinics in Sembawang and Khatib will be delayed by a year, to open in 2023 and 2024 respectively. The integrated development of the redeveloped Jurong Polyclinic and a new Nursing Home will also be delayed by two years to 2027.”
“The electronic Health Declaration remains necessary to support public health surveillance efforts at the borders for existing and emerging infectious diseases of concern, such as Yellow Fever, Middle East Respiratory Syndrome (MERS) and Ebola. Before the COVID-19 pandemic, we used a paper-based declaration system, which has since been simplified and digitised into the electronic Health Declaration.”
“MOH has been working on several fronts to interest and encourage our doctors and medical students to take up family medicine. Firstly, we have included more topics on family medicine in the curriculum of local medical schools. The Joint Committee of Family Medicine Singapore also runs outreach activities to raise awareness of family medicine training among medical students. Secondly, MOH Holdings conducts regular recruitment drives and engagements to encourage Singaporeans studying in recognised overseas medical schools to return home to practise. Through these platforms, these medical students are updated on the latest developments in Singapore, including plans for HealthierSG, as well as the importance of family physicians. Thirdly, MOH has been working with healthcare institutions and relevant professional bodies to develop more pathways and places for family medicine training.”
“Individual healthcare institutions manage the training of their own healthcare staff, including in areas, such as customer service, for staff in patient-facing roles. SIA is renowned for their customer service and I am sure healthcare institutions will benefit from learning from SIA’s approach to training. As part of MOH’s ongoing work to evolve the role of healthcare workers, we have been coordinating with the various healthcare clusters to review and develop relevant training programmes, including areas, such as effective communication and customer service.”
“MOH does not have data on the number of seniors who have discontinued rehabilitation sessions despite not attaining the rehabilitation goals. Seniors who face difficulties in paying their rehabilitation bills may seek their healthcare provider’s assistance in applying for discretionary financial assistance, including MediFund assistance. This ensures that seniors can receive the care they require, regardless of their financial circumstances. It is important for seniors to complete their rehabilitation care. Members of Parliament may wish to extend help or direct seniors who may be facing difficulties to MOH for further follow-up.”
“This question has been addressed in my reply to Question No 46 for oral answer on the Order Paper for 8 November 2022. [Please refer to "Vacancies at Healthcare Institutions Created by Employees Returning to Aviation Sector", Official Report, 8 November 2022, Vol 95, Issue No 74, Written Answers to Questions for Oral Answer Not Answered by End of Question Time section.]”
“This question has been addressed in my reply to Question Nos 2 to 10 for Oral Answer on the Order Paper for 8 November 2022.”
“Between 2018 and 2021, the annual net new arrears incurred by patients and write-offs at the restructured hospitals were around 2.5% and 0.8% of total bills issued respectively. About $50 million to $70 million of bad debts were written off every year, mainly incurred by patients with financial difficulties. Data prior to 2018 is not readily available.”
“In fact, the admin and support care tasks performed by the aviation crew are performed by existing healthcare staff, such as Patient Service Associates and Patient Care Assistants, but there is a limit to how many we can recruit. MOH is thus working with the public healthcare institutions to further redesign healthcare support roles, including blending clinical support, administrative and operations responsibilities on a more permanent basis.”
“This response will also address the question filed by Mr Louis Ng which is scheduled for the Sitting on 9 November 2022. [Please refer to "Government Expenditure in Support of Hospitals' Care Ambassador Positions Filled by Aviation Flight Crew", Official Report, 9 November 2022, Vol 95, Issue 75, Written Answers to Questions for Oral Answer not Answered by End of Question Time section.] Aviation crews were temporarily redeployed to augment healthcare manpower as Care Ambassadors amidst the COVID-19 pandemic. The Government had supported up to 90% of the salaries of the redeployed aviation crew at about $16 million in total. This was funded through the Jobs Support Scheme, Aviation Workforce Retention Grant and direct funding from the Ministry of Health (MOH). To leverage their experience in service excellence, a unique combination of tasks was put together for the Care Ambassadors. Hence, the Care Ambassadors took up tasks in administration, service operations and support care, such as assisting patients with activities of daily living. The Care Ambassadors provided a short-term manpower boost to allow our nurses and other healthcare staff to focus on more complex clinical and care-related work at the height of the COVID-19 pandemic. We greatly appreciate the 900-aviation crew who stepped forward at various points in time across the past two years to support our healthcare workers. We are happy that most of them have since returned to resume their careers in the aviation sector. It is worthwhile making these roles permanent through job redesign.”
“Over the past five years, the Health Sciences Authority (HSA) received an average of about three complaints per year on the online sale of counterfeit health products. Anyone caught selling counterfeit health products online can be fined up to $100,000 and/or jailed for up to three years. Buyers of counterfeit health products can also seek recourse by lodging a complaint with the Consumer Association of Singapore (CASE) or taking a civil legal action against the seller in the Small Claims Tribunals or Singapore Courts.”
“For now, we will continue to monitor the situation and work towards expanding the scope of RDF treatments that can be supported. We also encourage members of the public to support the RDF with donations so that more medicines and conditions can be listed, and more patients can be supported.”
“The Rare Disease Fund (RDF) operates as an endowed fund to ensure that beneficiaries can be supported for life, as rare disease patients generally require high-cost medicines on a lifelong basis. The RDF Committee which oversees the fund adopts a 'listing' approach, which means that a medicine can only be listed for support after it assesses that the medicine is able to meaningfully extend life expectancy and improve patient's quality of life. Currently, the RDF has listed seven medicines for five conditions. The support is reviewed annually for each beneficiary, to factor in changes in their clinical condition and financial situation. Since April 2021, the RDF has received applications from six patients, all of whom are currently supported by the fund. There are sufficient funds to support these patients. We recognise that there are other rare disease patients requiring non-listed medications, which the RDF currently does not support. Medicines for rare disease patients can exceed $200,000 per patient annually, with varying efficacies, and our healthcare financing system is not designed to support such high-cost treatments. Instead, society and the Government collectively support the financial needs of Singapore citizens with rare diseases through the RDF, with the Government providing $3 of matching grant for every dollar of donation. We have also seen how some patients are able to obtain support from the community through crowdsourcing or other charity funds, which is heartening. There remains the broader question as to whether the Government should support treatments regardless of their cost, particularly if the efficacy is uncertain. This is a position that needs to be carefully reviewed and must not be taken lightly.”
“The enforcement activities are also complemented by public education efforts to deter the public from vaping. HSA engages the media to remind the public that the sale, use, possession for sale, importation or distribution of electronic vaporisers are strictly prohibited in Singapore and strongly advises the public against engaging in such activities. A digital campaign on staying vape-free will be rolled out in early 2023 to raise awareness on the negative health effects of vaping and to address misconceptions. We share the concern about vaping amongst minors. The Ministry of Health (MOH) works closely with the Ministry of Education (MOE) to raise awareness among children and youths about the harms of vaping and encourage them to lead a nicotine-free lifestyle. Schools take a serious view of vaping and school-based disciplinary action is also taken for students caught using or possessing e-cigarettes and other types of vaporisers, including suspension or caning for boys. We will work with education institutions and schools to step up efforts to control access of vaporisers and its accessories to minors and the young.”
“This response will also address the Question for Oral Answer filed by Mr Yip Hon Weng1 for a Sitting on or after 28 November 2022 and written questions filed by Mr Desmond Choo and Mr Shawn Huang for the Sittings on 20 October 2022 and 7 November 2022, respectively. Currently, there is no direct prevalence data on the use of vaporisers as these are illegal products and reliable self-reported data is difficult to obtain. The number of offenders caught for purchase, use or possession of vaporisers in 2022 is 3,691, up to September 2022, as compared to 4,697 in 2021. About one-fifth of these offenders were under-18. The Health Sciences Authority (HSA) monitors and gathers intelligence on illicit sales of e-cigarettes via social media and messaging platforms, and regularly carries out operations targeting sales of e-cigarettes on online platforms. The HSA also collaborates with platforms such as Instagram, Facebook and Carousell to remove postings on the illegal sales of such products. In 2020 and 2021, 3,573 and 6,940 postings have been removed respectively. And in 2022, up to September 2022, 3,923 postings have been removed. In year 2021 and 2022, up to September, 32 and 25 online e-vaporiser peddlers have been prosecuted respectively. Concurrently, the illegal importation of e-cigarettes is monitored at Singapore's borders and intercepted as necessary to prevent entry of these e-cigarettes into the local market. There is already a dedicated reporting channel for members of the public who have information on the illegal import, distribution, sale or offer for sale of prohibited tobacco products. They can submit an online form at go.gov.sg/reporttobaccooffences. Alternatively, they can contact HSA's Tobacco Regulation Branch at 6684 2036 or 6684 2037 during office hours.”
“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 there is an immunity debt, which means it can be repaid over time. As to how long – I have to consult the experts in MOH, and they may have some idea.”
“A TCF is not quite the place to refer ED cases to. It is more a step-down care facility. But what we are doing is setting up more Urgent Care Centres (UCCs). We have one in Admiralty and that has been very useful. Ultimately, it goes back to how we diagnose a problem. Reducing non-emergency cases to EDs certainly will help. But that is not the main bottleneck today. The main bottleneck remains a mismatch in demand and supply of hospital beds, which leads to long waiting times at the EDs, waiting for wards and crowding the EDs. So, that remains the most urgent problem to be resolved.”
“When the queue is long and you start to have crowded EDs, the nurses do that. I think they have the skills to do that, including the language ability, because in a team, there will be multiple language skills and they would be able to comfort the elderly. I think the problem that the Member raised is probably a result of very crowded EDs, when nurses are under tremendous pressure, so the kind of attention is probably not given, compared to normal times. So, I think we still go back to the same problem we raised earlier, that if we can resolve the crowdedness at the EDs, I think the problem that the Member raised will be addressed.”
“I thank the Member. First question, I do not have the number. Maybe the Member can file another Parliamentary Question? GPs can certainly take a load off the EDs. First, open 24 hours; if not, open at night, make yourself available to telemedicine; you can assuage the concerns of many patients and avoid the ED visits. As to whether to set up a call line to EDs, I suppose the more they call, it does add to the workload of EDs as well. Notwithstanding that, I think we can approach the Agency for Intergrated Care (AIC), and AIC will help link up with the nearest EDs.”
“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.”
“We know that healthcare workers are never enough. There is a manpower crunch and intense competition between different countries trying to hire healthcare workers. Fortunately, this is something we can solve in the short term, over a few months, by recruiting, training them and putting them in place. So, this is something we are doing actively. Now that the COVID-19 situation has stabilised, borders are opening up, we have started our overseas recruitment process as well as continue to work with our local institutions to bring in more healthcare workers. The second question on how to prevent burnout, if we solve all these jam problems, manage the pandemic and move to endemicity form of operations, I think it will go a great extent to reduce the workload.”
“I thank the Member for his questions. The short answer is we will try to encourage it, but opening for 24 hours is not easy. They will need a few doctors to cover each other. Many clinics do open to late at night and, hopefully, with something like Healthier SG, we are changing the mindset of GPs and also changing health-seeking behaviour. Hopefully, we will get more help from GPs in attending to some of these urgent cases. For your mother, if it is in the middle of the night, I think going to ED is probably justified. Two, TCFs cost no different from public hospitals. We are running these and subsidising them in the same way. And finally, the percentage, or number of beds that would be freed up, I gave a ballpark just now at the peak of the Omicron variant XBB wave, we were still setting aside 160 beds at the peak; sterilised it, ringfenced it, even though we had patients waiting downstairs because we were afraid of a spike of COVID-19 patients. Off-peak, the number was actually larger. So, I would say, at least 200 to 300 beds. And I think they will make a big difference to the operation of hospitals.”
“The backlog is not huge. Because ever since we started opening up, hospitals have all realised that to postpone electives and postpone non-urgent surgery, it all comes back after a while – and with interest usually. So, for the past two or three waves, we have been very reluctant to postpone these electives. In the recent wave, we postponed some, but only 5% to 10%. So, it is not a huge backlog and certainly we will want to clear it as soon as possible.”
“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.”
“However, we are now at the stage when most residents have been vaccinated and boosted or recovered 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 for 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 general practitioner (GP) clinic or call our family doctors. We should exercise social responsibility, such as staying at home and self-testing when not feeling well.”
“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 unforseen circumstances and for 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 run by Thomson Medical Centre 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 living 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.”
“Just to briefly recap, they include the reducing of EDs demand 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 the Singapore Civil Defence Force (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 we also offer subsidised rates even though treatment is 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 aforementioned 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 to 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, which 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.”
“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 were filed, asking the Ministry of Health (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 will 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.”
“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 comeback 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 numbers 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.”
“So, translated to daily attendances, it was 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 of our measures to educate the public to not 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 – that 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 it 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 the 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 KK Women's and Children's Hospital (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.”
“For non-life-threatening patients who are 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, to 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 subsides and we started dealing with the problem, another wave would come, and attention and resources will be diverted to fight fire again. With the XBB wave subsiding earlier than expected, we hope that this time round, we will 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, 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, we understand that there will be public complaints, 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, that for critically ill patients, they are attended to almost immediately at the EDs, due to the way that 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 are averaged to 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 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", that is the median. There are variations. 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.”