Breathe new life into wards

The old rules that forbid air-conditioning and en suite toilets in subsidised hospital wards are out of date. There is an urgent need for a new framework for subsidised hospitals.

SINGAPORE will be doubling the number of public general hospitals over the next 16 years - from the current six to a total of 12 by 2030 - so it is timely to re-examine the thinking behind the way public hospitals are configured.

The questions to ask: Is it still necessary to have more than one subsidised ward class? And are the deliberate discomforts built into them still relevant today?

Most of the rationale behind the way public hospitals are set up is based on the 1993 White Paper on Affordable Healthcare.

That paper has served the country well, but 20 years down the line, some of the premises on which decisions were made no longer hold true.

It was felt then that people would always select the cheapest option if living conditions were roughly similar. So to discourage over-consumption of heavily subsidised C-class wards, they were built with minimum comforts.

Or as the Paper put it: "The ambiance in the more heavily subsidised wards should be kept simple, with only those creature comforts which are absolutely necessary."

This would also keep costs down, it said.

Ward classes were differentiated by the minimum number of beds they must have, maximum floor area per patient, whether air-conditioning was allowed and whether patients could choose their specialists.

At that time, large dormitory- style wards and communal toilets were fine. But we now know this could lead to an outbreak of infection.

Such ways of differentiating the different classes was needed in lieu of means testing - which it foresaw would come one day. That day has arrived. There is now means testing to help allocate subsidies to the most needy.

Another thing that has visibly changed is the make-up of patients.

From a relatively young society in the 1990s, Singapore is now a rapidly ageing one. By 2030, when all the proposed new hospitals are built, Singapore will have close to one million people aged 65 years and older.

Even today, a significant proportion of public hospital beds are occupied by elderly patients, many of whom are frail and unsteady on their feet.

One of the discomforts built into subsidised wards are the communal bathrooms and toilets along the corridor, a fair distance from the patient's bed. Only private wards could have en suite toilets and showers.

This may have made sense when the majority of patients were young and able, aside from their illness.

But these days, making old patients walk long distances to the toilet - especially at night, since older people often frequent the loo more than once a night - is counter-intuitive to good health. There is the risk of them slipping and falling - leading to far longer hospital stays and much suffering.

Of course, they could ring the bell for assistance, but most who could, would prefer to manage on their own. Having the toilet within a few metres of their bed would make this possible.

It thus makes more sense to build subsidised wards with en suite toilets and bathrooms. This also leads to better infection control.

And this is also the reason for doing away with dormitory-style wards with eight to 12 patients sharing a room.

Since the outbreak of the Sars virus in 2003, health-care workers have become very conscious of how easily bugs can spread between patients. Having fewer people per room, say just four or five, would help to contain such a spread.

So would having proper walls between rooms. Today, dormitory-style rooms in C-class wards are separated by chest-high walls. Any airborne infection would be quickly spread from room to room, especially with ceiling fans switched on.

B2-class rooms, which are also subsidised, have normal walls. The same should apply to C-class rooms.

Then there is the issue of air-conditioning.

Having air-conditioning only in private wards was one distinct way of separating rich patients able and willing to pay for creature comforts, and poorer ones depending on government handouts.

It was also true that many older patients were not used to air-conditioning and would prefer naturally ventilated wards anyway.

What Tan Tock Seng Hospital (TTSH) is doing for its subsidised wards is a good compromise.

It has put air-conditioning in the subsidised wards, but keeps the temperature at 28 deg C. Patients who want it cooler turn on their fans.

To most people used to air-conditioned comfort, 28 deg C is still too warm.

But to patients who used to soak their bedsheets with sweat because of the heat and humidity when the temperature goes up to the 30s, 28 deg C is heaven.

According to both doctors and nurses, the cooler ward temperature and dryer air are also better for patients' health.

Hot, damp wards promote infection. The "spot cooling" measures taken by TTSH brings down not only the temperature, but also humidity levels in the subsidised wards, thereby reducing rates of infection.

Patients also suffer from fewer bedsores and scabs formed by constant scratching of itches caused by the heat and humidity.

Today, hospitals do strange things just to find a way around the old rules forbidding too many creature comforts in subsidised wards.

TTSH keeps the room windows in its subsidised wards open, even with the air coolers on, since they are allowed only natural ventilation.

This is a sheer waste of electricity to conform to a rule that should have been scrapped long ago.

The National University Hospital (NUH) air-conditions the corridors in its wards - technically correct since it is not in the rooms - so some of the cooler air would flow into the rooms and reduce the heat there.

As Singapore is now preparing for the silver tsunami, subsidised beds in new hospitals should take the condition and needs of elderly patients into account.

With the introduction of means testing in hospitals more than four years ago, the subsidy that patients are entitled to is now decided by their income or housing type.

There is no need, therefore, for such a crude way to sieve out demand for subsidised wards.

Right now, there are two subsidised ward classes: a B2 class where patients get 50-65 per cent subsidy and a C-class where the subsidy is higher at 65-80 per cent. It would be better to streamline this into one comfortable C-class with a wider subsidy range.

Whether the subsidy given should span the current 50-80 per cent, or be narrowed to 65-80 per cent, is something the Health Ministry can decide on, in line with the health-care financing review it is currently undertaking.

The Government should straighten out its thinking on the matter before embarking on the planning parameters for the new hospitals to be built by 2030. Preferably, it should do so before the next new hospital, in Jurong, opens at the end of next year.

This story was first published in The Straits Times on March 16, 2013

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