How close is Singapore’s healthcare system to its breaking point?

Six months ago, Indian hospitals turned away Covid-19 patients and pleaded for oxygen as supplies ran desperately low.

A year before that, exhausted Italian doctors were forced to choose who to save among the many who needed intensive care.

These scenes have played out in hospitals all over the world, whenever a new wave of infections threatens to swamp a country’s healthcare system.

Singapore’s healthcare system is world-class. But now it, too, is being stretched to its limit. On Wednesday, the multi-ministerial task force tackling the pandemic said Covid-19 restrictions will be extended until Nov 21, as the system faces a “considerable risk of… being overwhelmed”.

Already, hospitals have postponed follow-up visits and elective operations to accommodate the rising number of Covid-19 patients, creating a backlog that will take months to clear. How close is Singapore’s healthcare system to its breaking point?

Singapore has chosen to maintain its stance rather than reverting to stricter measures, and that is one indication of where the country stands, said Professor Teo Yik Ying, dean of the Saw Swee Hock School of Public Health.

“I would say the healthcare system is under pressure,” he added. “But we are not at the stage where our doctors have to make hard decisions on ring-fencing hospital resources for some patients, and to give up on other patients.”

Professor Paul Tambyah, a senior consultant at the National University Hospital’s (NUH) infectious diseases division, said that public hospitals in Singapore have relatively high bed occupancy rates compared with other high-income countries.

In a way, this means doctors are “used to” making hard decisions about which patients can afford to wait, he said. “Most clinicians are taking the current surge in our stride, although it is challenging.”

Even so, the pressure is great. A commentary published last December in the Annals – the official journal of Singapore’s Academy of Medicine – sheds some light on what local hospitals face.

The Singapore General Hospital is the country’s largest. It has 58 intensive care unit (ICU) beds in peacetime, although this can be increased to 120 beds if the need arises, the paper’s authors observed.

To do so, critically ill patients would have to be warded in high-dependency units, operating rooms and post-anaesthesia care units. Elective operations would have to be postponed.

The authors added that the lack of skilled manpower is the “main bottleneck” for ICUs, where hospitals tend to maintain a very high 1:1 nurse to patient ratio.

“Staffing for ICUs has traditionally been labour-intensive and this baseline shortage is compounded by the prolonged training required to achieve competency,” they wrote.

Although the number of Covid-19 patients who need critical care forms a tiny proportion of all cases, the demands they make on the hospital system are disproportionately large.

In July, Health Minister Ong Ye Kung said Singapore can open 1,000 ICU beds for Covid-19 patients. It was an ambitious target: Two months later, there were only around 100 such beds.

Now, it still has fewer than 300 ICU beds. To ramp up capacity to the 300-bed mark, the country will have to stomach “further degradation of normal service”.

Singapore has 1,650 isolation beds for Covid-19 patients, 89 per cent of which were full as at Wednesday. It also has 200 dedicated ICU beds, which were taken up by 71 people on ventilators and another 75 who were admitted for closer monitoring.

This is why the extension of Covid-19 measures has been deemed necessary, especially since the number of new cases shows no sign of falling yet.

As Prof Teo put it: Each additional week that the rules are in place means more people getting booster shots or natural infections, giving them immunity against the virus and preventing numbers from shooting up when the rules are relaxed.

It also gives front-line healthcare workers – who have been fighting this battle for nearly two years – a chance at a respite. Healthcare workers will be rostered for leave towards the end of this year, and have been given the green light to travel to countries with which Singapore has Vaccinated Travel Lane (VTL) arrangements.

At the same time, each additional week of restrictions means money lost for businesses, and further dents the morale of a population that is chafing under rules that seem to have no clear end in sight.

It has been emphasised that Singapore’s current position is different from that of other developed countries, where infection ran rampant and lives were lost before vaccination became widespread.

Here, infections in the wider community were kept low. This is the first major wave that the country is experiencing, and vaccination has not quite managed to prevent the spread of the virus, even though it stops severe illness.

But knowing this context does not make it any easier when one sees people in many other developed countries going about life as usual, with masks – the most visible symbol of the pandemic – noticeably absent in outdoor spaces.

Could there be a middle-of-the-road solution? Professor Dale Fisher, also a senior consultant at NUH’s infectious diseases division, believes so. The differentiated policies for unvaccinated people, which are already in place, could enable more opening-up, he suggested.

If people who are not vaccinated are not allowed to join large groups in malls and hawker centres, fewer will fall ill and require ICU care. This means those who are vaccinated can be afforded more freedom.

Singapore could also consider other easing measures, such as establishing more VTLs with other countries or even removing outdoor mask rules, Prof Fisher said.

He suggested that curbs could focus on large indoor gatherings and other such indoor settings, while allowing more freedom outdoors.

This is unlikely to lead to a big spike in infections but it would benefit people. “People should be allowed to walk their dogs without a mask,” said Prof Fisher.

In other words, more elbow room for vaccinated people – who tend not to fall too ill – is not likely to lead to a rise in hospitalisations. Already, nearly three-quarters of infected people recover at home, and facilities have been set up outside hospitals to care for those who need closer watching.

It is a very fine balance that is difficult to get right.

But Singapore cannot stay in this limbo forever, and the solution cannot simply be more VTLs because Singaporeans need more than a temporary reprieve.

What is needed is a concrete step forward – a move that impacts day-to-day life and reintroduces a sense of normalcy. Singapore may have to start small, but it has to start moving. The Straits Times