Monday 7 November 2011

Public hospitals 'borrow' space

The solution to the perennial lack of hospital beds could be to tap into private resources, reports Melissa Pang
The Straits Times, 6 Nov 2011

On one side are public hospitals facing a bed and doctor crunch. On the other are private hospitals with spare capacity.

Would it not make sense for patients from the former to be seen in the latter?

That could well happen, marking yet another milestone in Singapore's health-care system.

One sentence in the Health Ministry's recent addenda to the President's Address read: 'Private acute hospitals will have a greater role in serving the subsidised health-care needs of Singaporeans.'

It was not the first time the Government had raised the idea of public-private sector collaboration.

At Raffles Medical Group's 35th anniversary dinner in July, Deputy Prime Minister Tharman Shanmugaratnam said the Government was studying a plan to let private health-care providers train doctors and treat subsidised patients.

He noted that a growing number of doctors have moved into private practice, and for the vast majority who do so, 'it is like crossing the Rubicon - there is no turning back'.

'We have to find systemic solutions to avoid this being a zero-sum game,' he said.

Doctors, health economists and other observers noted that there is already collaboration at the general practitioner level, under the Primary Care Partnership Scheme.

If this was widened so that private hospitals take on subsidised patients, it would be a matter of necessity rather than choice.

Chiefly, public hospitals are facing a serious shortage of beds and doctors. Many hospitals are running at more than 90 per cent capacity, whereas most private hospitals have surplus space.

It makes sense for the public sector to turn to the private, if only as a short-term measure, till the Ng Teng Fong General Hospital in Jurong comes on board in 2014, and the Sengkang hospital by 2020.

Observers said public-private hospital collaboration could take various forms:
- Public hospitals could lease private hospitals' beds. This is already being done in a small way, between the National University Hospital and privately-run West Point Hospital.
- Block contracting of services, where the public sector subcontracts certain services such as elective procedures to the private sector.
- Allowing government-subsidised patients to seek treatment at private hospitals.
On their part, the private hospitals seem keen on collaboration, and are waiting for details.

Dr Lim Suet Wun, executive vice-president for Singapore operations of health-care group Parkway Pantai, said it has met the heads of some public hospitals to discuss possible tie-ups, but there has been 'no signing on the dotted line yet'.

'But I think we are optimistic that we can come to some conclusion,' said Dr Lim, who was chief of the National Healthcare Group and Tan Tock Seng Hospital before he moved to the private sector in March.

Parkway Pantai's group chief executive and managing director, Dr Tan See Leng, said its hospitals could collaborate in areas such as day surgery facilities and procedures like endoscopies.

A spokesman for Raffles Hospital said the hospital has expressed interest in working with public hospitals.

This could be done in areas where the public sector load is particularly heavy, such as in serving subsidised patients.

Dr Chong Yeh Woei, president of the Singapore Medical Association (SMA), which represents 5,300 doctors in the public and private sectors, said the body 'fully supports' public-private collaboration.

But he added that this would be a 'significant task that would require the alignment and reconciliation of the mission and objectives of public and private hospitals'.

Dr Jeremy Lim, vice-president of special projects at Fortis Healthcare International, an Indian health- care group with 74 hospitals across Asia, said there was no reason for the private sector not to be interested in such collaborations as they make economic sense.

'Government subsidies are not to be laughed at,' he said. 'Caring for subsidised patients means utilising otherwise unproductive time as private specialists tend to have substantially fewer patients.'

Health care in numbers

There are seven private acute hospitals - Parkway Pantai's Mount Elizabeth Hospital, Parkway East Hospital, and Gleneagles Hospital; Raffles Hospital; Mount Alvernia Hospital; Thomson Medical Centre and; Johns Hopkins Singapore International Medical Centre.

These seven have 1,466 beds altogether.

When Parkway Pantai's Parkway Novena Hospital opens in July next year, it will add another 333 beds, and when Singapore HealthPartners' Farrer Park Hospital opens in 2013, it will add 228 beds.

The public sector's seven acute care hospitals have 6,871 beds among them, said the Health Ministry. When the Ng Teng Fong General Hospital in Jurong is ready in 2014, it will add a further 700 beds.

The current 6,871 beds include the 550 added when the Khoo Teck Puat Hospital opened last year. While those beds alleviated the shortage for a while, they were not enough, and health players say public hospitals have been bursting at the seams for the past decade due to poor planning.

In August, for example, The Straits Times reported how Tan Tock Seng Hospital, National University Hospital and Changi General Hospital had to borrow bed space from nearby community hospitals.

The situation led Health Minister Gan Kim Yong to say he would consider bringing forward the opening of the Sengkang hospital, scheduled for 2020. The number of beds has not been decided.

Singapore Medical Council figures show that by the end of last year, about 60 per cent of the 9,030 doctors - or 5,278 - here were in the public sector, and 3,752 in the private sector.

But, as an indication of their high work load, public sector doctors provide care for up to 80 per cent of the country's health-care needs, noted Dr Fatimah Lateef, the vice-chairman of the Government Parliamentary Committee (GPC) for health and a public sector emergency medicine specialist.

Dr Chia Shi-Lu, an MP for Tanjong Pagar GRC and an orthopaedic surgeon in a public hospital, said occupancy rates for many public hospitals are above 90 per cent, whereas private hospitals may not be operating at full capacity.

Parkway Pantai's three hospitals, for example, have average occupancy rates of 70 per cent to 80 per cent.

Private hospitals, he said, 'represent medical infrastructure that can be used to meet the short-term shortages in terms of bed space and clinics, until current infrastructure projects are completed'.

It would make sense for private health-care providers to do so as the excess capacity would not be returning any revenue anyway, he added.

One way this can be done is for the public sector to 'buy' beds and doctors from the private hospitals, suggested Dr Lam Pin Min, chairman of the GPC for health.

As the main crunch comes from the pool of subsidised patients, this group can be admitted into, be operated on, and recuperate there, then discharged and returned to clinics in public hospitals for further outpatient follow-ups, he said.

Dr Lam, who is an opthalmologist in the public sector, said the ministry can also allow patients who have to put up with long waiting times at public hospital specialist clinics to see private doctors at subsidised rates.

The subvention would go directly to the health-care provider, similar to the Primary Care Partnership Scheme for private GPs.

Dr Fatimah suggested that the decanting of public sector outpatient patients be done by sub-contracting specialist services to the private sector.

SMA's Dr Chong said private hospitals could even help teach undergraduate medical students. Training of post-graduate students is also possible, but would involve steeper costs as they would involve clinic space and extra hours of supervision.

Public-private balance

Assistant Professor Tomoki Fujii of the Singapore Management University said that for a start, the public and private sectors should share information about excess capacity and waiting times, as some patients may choose to go to private hospitals if queues there are shorter.

If private hospitals are made more accessible, for example, by giving subsidies, it may help cut waiting times at public hospitals, said the health economist.

He also suggested private hospitals look after government-subsidised non-acute patients during off-peak hours, so these patients would be able to enjoy better treatment at a discount, or enjoy shorter waiting times.

Dr Ranjiv Sivanandan, vice- chairman of the Chapter of General Surgeons, said the group is studying possible ways that private surgeons can contribute to the public health-care system.

'Not all doctors in private practice have the time or inclination to involve themselves in public care... But there are others who may be keen but are unable to do so. Having a formalised process... opens up new avenues for this untapped resource,' he said.

Echoing a point raised by DPM Tharman, Fortis Healthcare's Dr Lim added that the challenges facing Singapore's public health-care system have to be viewed from a broader perspective of the outflow of doctors into the private sector.

He described the growing number of specialists leaving the public sector, put in the context of private sector growth over the next one to two years, as being a cause for deep concern.

Indeed, it was reported last July that the public sector faced its largest exodus of doctors ever last year, with 310 doctors, including 103 specialists, leaving for private practice.

Dr Fatimah pointed out that Singapore's doctor to patient ratio - 1.7 doctors to 1,000 patients - is low compared to a range of 2.14 to 4.49 per 1,000 in North America and Europe.

But the real ratio is much less than the national ratio because doctors in the private sector provide just 20 per cent of care, she said.

Private-public collaboration can fill the gaps in the provision of care, she said.

While those interviewed agreed that it would be a win-win solution for both parties from a business point of view, some cautioned against overcrowding at private hospitals and even an over-reliance on them.

Associate Professor Phua Kai Hong of the Lee Kuan Yew School of Public Policy said the public sector must always remain the dominant player.

Failure to do so would result in Singapore's health-care system going the way of that in the United States, where top doctors leave the public sector for better pay and working hours in the private sector, the health policy and management specialist said.


The Primary Care Partnership Scheme allows eligible chronically ill patients to visit private GP clinics near their homes. The Government foots part of their bill. From next year, the scheme will be expanded to benefit half the population aged 40 and above.

The National University Hospital (NUH) earlier this year signed an agreement for diabetic patients, whose conditions are stable, to be referred to private GP group Frontier Healthcare for co-management. The patients pay the same rates for their consultation, screening tests and medications as they would at NUH.

A community health centre at Tampines run by the Government's Eastern Regional Health System provides GP clinics in the area with diabetes support services.
GPs can refer their patients to the centre for foot and eye checks and lifestyle counselling. The Government intends to set up more such centres.

Privately-run West Point Hospital in Jurong West has been providing bed space and meals for patients at the NUH since 2009.

The private hospital also provides support for ancillary services such as X-ray and laboratory services. The patients pay NUH rates and are cared for by NUH doctors and nurses.

No comments:

Post a Comment