Private Hospitals - Is the status quo acceptable?

A recent letter in the Straits Times Forum Page caught my attention because it addresses a chronic issue which has no solution in sight.

The Health Ministry and Singapore Civil Defence's diplomatic reply is reproduced below.

Madam Shirley Woon asked why the victims in the recent three-way Bugis crash were not taken to Raffles Hospital, but to the Singapore General Hospital (SGH) and Tan Tock Seng Hospital (TTSH), which are farther away ('Why weren't crash victims taken to nearest hospital?'; last Tuesday).

For severe and multiple trauma patients, the Singapore Civil Defence Force (SCDF) emergency ambulance will take them to the nearest accident and emergency department that is equipped to deal with such complexities of care.

In the accident referred to by Madam Woon, while Raffles Hospital is located close to the accident site, it is not equipped to deal with multiple trauma cases, and thus the SCDF had to take the patients to SGH and TTSH, which were the nearest fully equipped facilities to deal with such emergencies.


Bey Mui Leng (Ms)
Director
Corporate Communications
Ministry of Health

Colonel Yazid Abdullah
Director, Public Affairs Department
Singapore Civil Defence Force


Even more interesting is Raffles Hospital's reply today.

It is an established procedure that Singapore Civil Defence Force (SCDF) 995 ambulances currently take patients only to designated public hospitals ('Raffles Hospital not for multiple trauma cases' by the Ministry of Health and SCDF, Monday; in reply to 'Why weren't crash victims taken to nearest hospital?' by Madam Shirley Woon, May 15).

This was explained by the ministry and SCDF in last Saturday's report in The New Paper ('Why victims not sent to nearer hospital?').

However, Raffles Hospital receives emergency cases on a daily basis brought in by private ambulances and vehicles, and air ambulances.

Such emergency cases include victims of industrial and construction accidents, as well as overseas patients with traumatic injuries evacuated to the hospital by medical assistance and evacuation companies.

We manage such trauma cases as a matter of normal and regular practice.
In the past several years, our 24-hour emergency centre has received and treated casualties of road traffic accidents that had occurred in the vicinity of the hospital, and who were brought in by passers-by.

Such patients are resuscitated and stabilised by the duty doctors, and admitted for surgery or procedures and further treatment as required.

Our priority in all such circumstances is always to put the patients' needs first and to save lives.


Dr Prem Kumar Nair
General Manager
Raffles Hospital


And since I never read The New Paper, here's a link for those who are curious.

To help shed some light on the issue, one must define the term "MOH-designated".

There is a reason SCDF ambulances transport their patients exclusively to public hospitals, and this reason comes in the form of a service agreement, i.e. a contract of sorts where specific terms and conditions are stipulated, and which the hospitals MUST adhere to, or be found in serious breach of their obligations.
Terms include in-house ( i.e. on-site ) 24/7 specialist coverage, proper resuscitation equipment, and recognized qualifications of the frontline staff ( i.e. emergency room doctors and nurses ).

Suffice to say, to date, no private hospital is known to have signed this contract, which therefore prevents SCDF ambulances from depositing any of their patients at their doorsteps, regardless of how seriously ill or injured they may be.

So the next logical question is: should we allow this arrangement to continue? What are the predominant obstacles preventing the MOH-private-hospital agreement from becoming a reality?

Personally speaking, I don't know why the MOH isn't putting its foot down and forcing it down the private institutions' throats. Singapore is an urban, densely populated country with its fair share of healthcare problems, but much can be done to improve outcomes, especially in time-sensitive conditions such as certain types of heart attacks and strokes, which benefit from early diagnosis and intervention.

Any transport delay can result in fatal complications if the heart attack becomes a cardiac arrest, or if the stroke goes beyond the window period for therapy and the patient ends up debilitated for life.

In major trauma, the first "golden hour" is often quoted, but its validity has been questioned.

And while the SCDF reports that one of the crash victims was sent to TTSH within 8 minutes, if the accident had occurred in the midst of peak hour traffic, the poor patient would've probably expired en route.

Perhaps one of the reasons private hospitals can't fulfill the terms of the agreement is the fact that none of them has 24/7 emergency physician (EP) coverage. This is clearly indicated as a requisite, but is practically impossible in the foreseeable future.

First, there aren't enough EPs to go around the public sector, never mind the private side. Second, EPs aren't interested in better lifestyles and higher pay. Third, EPs enjoy the challenge public sector work - no matter how exhausting or frustrating - provides.

Perhaps it's time for MOH to address the issue with a greater sense of urgency, either by modifying the agreement's terms ( possible ), or by finding a way to boost their EP coverage ( unlikely ).

In any case, I don't appreciate Raffles Hospital's Dr. Nair's "established procedure" quote, which appears to absolve them of any form of accountability for the current state of affairs.