Private Hospitals Part 3 - Show Me The Money

I was waiting for someone to bring this up, and my wish came true. :)

Printed in the Forum Page today:

I am heartened to read that private hospitals are appropriately staffed and equipped to handle all manner of emergencies around the clock ('Raffles Hospital well-equipped to handle multiple trauma cases round the clock'; last Thursday).

I am, however, less certain that the majority of patients picked up by the Singapore Civil Defence Force (SCDF) can afford to pay for this level of care at private hospitals.

The existing policy of taking them to the nearest public restructured hospital probably serves the needs of most patients well, given Singapore's small size, well-placed public hospitals and good road transport infrastructure.

SCDF ambulances may be abused if patients can decide where they want to be taken. Having said that, there are medical emergencies where a delay of mere minutes can mean the difference between life and death. We thus have a situation where the resources are available and lives can be saved, but cost is an issue. Yet, there is no possibility of means testing or financial counselling.

Are private hospitals willing to take on a good Samaritan role and possibly even make small financial sacrifices by charging public rates when they receive critical patients from the SCDF?

If they agree, perhaps SCDF officers can be given the option of calling the nearest private emergency department when patients fulfil certain clinical criteria, so the hospital can decide whether to accept them or not.

Patients can then choose to be transferred back to public hospitals when their conditions have stabilised. Patients with the means can choose to stay on to complete treatment.

I hope the Ministry of Health, SCDF and private hospitals can work together to ensure that no lives are lost simply because of the adherence to rigid outdated protocols or the inability to pay.

Aaron Lee


First, a few misconceptions must be clarified.

Mr. Lee did not mention the feature article printed in the Straits Times last Saturday, so it appears that he's unaware of the local emergency medicine community's rebuttal regarding Raffles Hospital's emergency department capabilities.

Second, patients transported by SCDF ambulances cannot choose which hospital to go to. That's only allowed with private ambulances.

Third, even if one day, SCDF ambulances can go to private hospitals, expecting the paramedics to call the nearest ED to see if the patient "fulfils certain clinical criteria" would be so time-consuming it would make things a lot easier to just go straight to the public institution, which doesn't ask long-winded questions.

And honestly, in a real emergency, the ambulance usually arrives at the ED's doorstep within minutes. Who has time for a Q&A en route, especially during a collapse?


Cost is a massive obstacle, but don't expect any solutions in the near future unless the key players are somehow motivated enough to shove this through all the red tape.

On paper, it sounds simple. Private hospital EDs may be able to manage lower-income patients if the MOH extends subvention to the private sector, which is what's practised with public institutions.

However, the same subsidy is unlikely to cover private hospital ED fees because their investigations and specialist referrals cost more, and their management protocols may be extremely different ( i.e. CT vs MRI? what drugs do they prescribe? do they advocate admission rather than outpatient workup? ). All these factors can potentially result in hefty bills.

MOH should increase the subsidy amount for private hospitals, you say? Sure, but someone has to pay eventually. Higher taxes, anyone?

If you expect the private sector to - as Mr. Lee put it so idealistically - "take on a good Samaritan role and possibly even make small financial sacrifices by charging public rates when they receive critical patients from the SCDF", you should check into IMH immediately. It will not happen.

Besides, receiving SCDF cases is just the tip of the iceberg. As already highlighted in Saturday's article, private hospital EDs currently do not employ emergency physicians, i.e. emergency medicine specialists, who are senior, experienced in resuscitation and trained to manage a wide range of illnesses of varying severity.

Also, if there's a surge in the number of ambulance cases to the private sector, can their EDs handle the load? Do they have enough resuscitation facilities and equipment? Do they have sufficient staff? Are specialists from the key disciplines (cardiology, general surgery, anaesthesia ) available on-site if urgently needed?

If private hospitals can't step up to the plate, nothing will change.

Utter Idiocy

Another ignoramus rears his ugly head.

And unfortunately, posts like these don't do anything to reduce the patient loads.

Private Hospitals Part 2 - The Plot Thickens

( I think Raffles Hospital should've "clarified" from the very beginning, in their first Forum letter. )

Transcribed from Stomp Online:

It was right to send injured from Ferrari-taxi crash to TTSH , say specialists

STOMPers questioned the SCDF's decision to send the injured from the fatal Ferrari-taxi crash on May 12 to Tan Tock Seng Hospital and not the nearby Raffles Hospital. Well, they 'made the right call', say a group of top emergency medicine specialists.


Tan Tock Seng Hospital and the Singapore General Hospital were further away from the crash site than Raffles Hospital, which is privately run, but they are better equipped and staffed to handle such cases, said the group of five specialists.

The public hospitals are also part of the Ministry of Health's 'national emergency and trauma system', and as a requirement, they have the facilities, equipment and specialists available all the time to handle multiple emergency and trauma victims.

The group of specialists who issued the joint statement on Friday, May 25, are: Associate Professor Mohan Tiru, chairman of the Singapore Residency Advisory Committee of Emergency Medicine; Professor V. Anatharaman, chairman of the Chapter of Emergency Physicians at the Academy of Medicine; Associate Professor Lim Swee Han, president of the Singapore Society of Emergency Medicine; Associate Professor Goh Siang Hong, chairman of the Medical Advisory Committee of the Singapore Civil Defence Force (SCDF) and Dr Chiu Ming Terk, chairman of the National Trauma Committee at the Ministry of Health (MOH).

General manager for Raffles Hospital, Prem Kumar Nair, clarified that the hospital's specialists are not on site at all times, while those in SGH and TTSH had emergency-medicine specialists, surgeons, anaesthetists and radiologists on site, round the clock as minutes matter in emergencies.

Raffles Hospital's doctors were trained in emergency medicine and managed trauma cases regularly around the clock, said a spokesperson, but confirmed it did not have specialists trained in emergency medicine.

"Proximity is important, but more important is the degree and level of care available around the clock," said Dr Chia Shi-Lu, an SGH orthopaedic surgeon and member of the Government Parliamentary Committee for Health.

Said STOMPer Henry, after reading the report:
"I'm glad the specialists and the hospitals came out to answer our queries and to ease our concerns.

"I'm glad that we have such a good healthcare system here, but I also wish that not just the public hospitals but the private hospitals can also have an across-the-board medical approach so that in times of emergency, there are more options available to send the patients to."

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.