If providing air-conditioning in Class C and B2 wards in public hospitals does not increase costs significantly – why are we not doing it?
I refer to the article “Review ‘no air-conditioning’ norm for subsidised wards?” (Straits Times, Aug 17).
It states that “Singapore has progressed significantly in the past decades. Yet, when it comes to hospital care, it is still sticking to some principles set out 25 years ago.
Some have been discarded, but on an ad hoc basis. It is time to review the proposals in the White Paper On Affordable Healthcare, published in 1993, to see if they are still relevant.
In particular, it would be good to relook the deliberate discomfort built into subsidised wards to discourage overuse, and whether there is still a need for two subsidised ward classes.
RATIONING BY DISCOMFORT
It’s tough to be poor. It’s bad enough that being poor means these people cannot afford many things that others can.
Beds in subsidised wards in the hospital are in a room that is not air-conditioned, but ventilated with fans. On hot, humid days, the temperature goes up to 30 deg C or more. Meanwhile, nurses have an air-conditioned nurses station built within the ward, where they do administrative tasks as they monitor the patients. There is a glass wall between the nurses and patients.
It is hard to see how a hospital can justify providing staff with a cool environment to work in when not providing direct care for patients, while leaving patients – the very reason for having a hospital in the first place – to suffer the humid midday heat.
The decision not to provide a controlled, cool environment for subsidised patients goes beyond the Sengkang hospital.
It is a stipulation set out in the 1993 White Paper On Affordable Healthcare. It was decided then that subsidised patients should be given only a “basic package”, otherwise “there is no limit to the amount of medical care which patients might want, and which the State will have to subsidise”.
So only private patients are entitled to air-conditioned comfort, since they pay much more for their stay.
But that was 25 years ago. What made sense then may no longer apply today. And yet, several new hospitals have been built based on the parameters set out in the White Paper, a number of which are, frankly, obsolete.
Several directives in the White Paper no longer apply. For example, the White Paper states that “treatments which do not belong to the basic package” for subsidised patients include “heart, lung, liver and bone marrow transplants”.
But these life-saving treatments are now available to subsidised patients.
Similarly, it said no to subsidies for in vitro-fertilisation or IVF treatments. But Singapore needs more babies and hefty subsidies now encourage more couples to try for a child.
Obviously, the basic package for subsidised patients that was applicable in 1993 may no longer be suitable today. Just like certain treatments that were once considered extras are now being offered to subsidised patients, there is a need to relook criteria such as no air-conditioning in subsidised wards.
While air-con wards may add to utilities bills for hospitals, studies show that cooler, less humid wards aid in recovery and reduce the risk of infections, rash and bed sores, especially in bed-bound patients.
These hospital-acquired problems can cause a lot of pain and result in a longer stay in hospital, which could then end up pushing up the cost of care.
KEEPING THINGS COOL, NOT COLD
Subsidised wards do not need to be cold. In fact, many elderly patients might find low air-con temperatures too cold for their comfort. But temperatures of between 26 deg C and 28 deg C would be more comfortable for patients.
Such controlled temperatures are no longer the luxury they were 25 years ago. Today, even public transport and bus interchanges are air-conditioned.
Several older hospitals have overcome the no air-con for subsidised patients rule by offering what they call “spot cooling”. They push in cool air from the corridors into the wards to maintain a decent temperature of below 28 deg C. Patients who still find it warm can use the fans found in each cubicle.
The hospitals do this because it helps both patients and staff in those wards. But in order to follow the rules, they need to keep the windows in these wards open, to allow for natural ventilation. This makes the whole exercise more costly.
Keeping ward doors open to allow cool air in may also not be ideal, in terms of infection control.
It would be far better for MOH to officially allow such cooling measures, so that newer hospitals can be built with this in mind, and older hospitals can do it openly.
Many other changes for the better have already occurred in subsidised wards. The White Paper said there should be a minimum number of beds per ward and a maximum floor area per bed.
So C-class wards used to have at least 10 beds. They also had half-height walls between wards to differentiate them from the B2 subsidised wards.
But these no longer apply.
After the outbreak of the severe acute respiratory syndrome or Sars in 2003 – which saw the deadly bug spread within hospitals – ward sizes have come down as part of infection control.
The half-height walls that allowed air to freely flow across wards, possibly carrying airborne bugs, have also quietly made way for full-height walls as older wards are renovated.
The space between beds has also increased, giving patients more privacy in the shared ward.
B2 AND C WARDS
Today, the newer C-class wards house only five to six patients, and have en suite toilets and showers.
Gone are the days when subsidised patients had to get out of the ward and walk down the corridor to go to the toilet.
With older patients, this could increase their risk of falls. Also, many of them might have difficulty managing such a long trek, especially when they need to go to the toilet at night.
So at the new SKH, the C-class ward is almost identical to its B2 version.
The only difference is that in the subsidised B2 ward, the toilet and shower are separate, but they are together in the C-class ward, so no one can use the toilet if someone is having a shower.
Given the cost of the hospital, the additional cost of having separate toilets and showers in C-class wards would have been negligible. As cost could not have been the reason, one can only conclude that it was a deliberate move to make C-class wards less convenient for differentiation.
C-class patients who get the maximum subsidy pay 20 per cent of the bill. The same patient in B2 pays 35 per cent of the bill. My advice to those going to Sengkang is: forget the B2 ward. If you want subsidised care, choose the C-class ward. Why pay so much more just to have a separate toilet and shower in the ward?
Aside from that, there are no visible differences between the two ward classes, as both of them house five patients in each ward, get the same food, and the same level of medical care.
That raises the question of whether there is any reason to offer two subsidised ward classes.
If the problem is the amount of subsidy that would be needed if everyone chooses the cheaper C-class ward, then the subsidy quantum can be adjusted.
Now, based on means testing, C-class patients get a subsidy of between 65 and 80 per cent, and B2 patients get 50 to 65 per cent.
This could be combined to a 50 to 80 per cent subsidy, so the poor continue getting the maximum while those who can afford more pay more.
That is not only fair, but also ensures that the maximum help goes to those who need it the most.
After 25 years, it is surely time to update the healthcare norms spelt out in the 1993 White Paper.
A good place to start is to relook the need to discourage consumption with deliberate discomfort. Subsidised patients need not be made to sweat it out in hot and humid wards but can be allowed to rest in cooler comfort while they recover.”
In this connection, according to MOH’s web site – “They (public hospitals) are to be managed like not-for-profit organisations. The public hospitals are subject to broad policy guidance by the Government through the Ministry of Health.”
In this regard, according to the National Healthcare Group’s (NHG) annual report – it has profits of $14 million in FY2016.
According to Singhealth Group’s (SHG) latest annual report on its web site – it had profits of $2 million in FY2017.
I am unable to find the financial statements of the National University Hospital System in its web site.
So, what are the combined profits of NHG, SHG and NUHS for last year?
From a financial perspective – surely the public hospitals can afford to provide air-conditioning for Class C and B2 wards, as I understand that it makes no significant difference in costs, because all large facilities like hospitals use central air-conditioning systems.
Leong Sze Hian