新加坡衛生部長王乙康國會答複議員：到2030年，公立醫院床位将達1.5萬張

2024年3月6日，新加坡衛生部部長王乙康在國會答複議員關于公立醫院擴容、醫療成本的問題，并通報了正在醫療系統中推行的重大改革。

以下内容為新加坡眼根據國會英文資料翻譯整理：

衛生部長（王乙康先生）：謝謝主席。我将在大部分演講時間用來談談醫療方面的兩個緊迫問題：一個是醫院床位緊缺問題，另一個是醫療成本。然後，我将談談我們正在醫療系統中推行的重大改革，這将進一步解決這兩個問題。

畢丹星先生、洪維能先生和林志蔚副教授提出了綜合診所和醫院的容量和候診時間的問題。确實，在新冠疫情後，許多國家的情況都是如此。世界各地醫院的候診時間都在延長。

在新加坡，推高醫院床位占用率的原因是，新冠疫情後，病情複雜的老年人數量在增加，我們看到這一數字在激增。我此前向議會報告過，新冠疫情前後的住院平均天數從大約六天增加到七天，僅此一項，患者就增加了15%。這發生在人口快速老齡化的背景下，是以問題愈加複雜，并将成為長期挑戰。

畢丹星先生建議我們實時公開各醫院急診科的動态候診時間。這是可行的，但我們一直不願意這樣做，也是有原因的。目前，救護車緊急救治已經有一個流程，即将需要緊急救治的患者送往最近的醫院進行治療。然而，在急診室，40%的情況并非危及生命或并不緊急，但他們最終還是去到了醫院急診室。是以，我們擔心提供動态候診資訊可能會适得其返地促使更多非急診病人前到醫院，使整體情況更加惡化。

我知道，對于一個病情嚴重的患者來說，要輪候多個小時才能獲得床位是非常不舒服和令人不安的。但請放心，即使病人正在輪候病床，醫院也會在患者到達後迅速進行分診，并對緊急情況開始治療。

洪維能先生提出了關于樟宜綜合醫院的問題，該問題也在《海峽時報》的一篇文章中有所報道。樟宜綜合醫院是一座老建築，隻有四個救護車停靠位。是以，排隊等候的速度會相當快。【請參閱《衛生部長澄清》，官方報告，2024年3月6日，第95卷，第131期，書面聲明更正部分。】

但實際上，這并不是限制因素。我們可以在救護車上進行分診。這隻是什麼大問題。我們需要關注的是重症監護室（ICU）的使用率、複蘇室的使用率。如果這些科室滿了，我們會轉移救護車。救護車停靠位滿了，我們可以處理。表面上看起來很糟糕，但實際上，從營運角度來看，這并不是一個難以克服的大問題。

林志蔚副教授建議增設更多的緊急護理中心（UCCs）。急診護理中心已經被證明是有用且有效的。我們還一直在使用“家庭醫生首選”計劃（GPFirst），尤其是在樟宜地區，這也是有用的，我們将繼續采取一切方法來緩解急診室患者的負擔。

為了更根本地應對這個挑戰，我們需要擴大醫療能力，彌補因新冠疫情而失去的時間。

自去年6月以來，我們新增了大約640張急診和社群醫院床位。這些病床構成了我們今天擁有的超過11,000張公立醫院床位。這就是我們的存量醫療資源 – 11,000張床位。我們計劃到2030年再增加4,000張床位。從現在到2030年，每年都會有新增的床位投入使用。

從今年到2025年，兀蘭醫療園将投入使用多達700張床位。2026年，盛港綜合醫院和歐南社群醫院預計将把非臨床區域改建成病房，預計将增加約350張床位。2027年，新加坡中央醫院的集合門診服務大樓将投入使用，預計擁有300張床位。2028年和2029年，重建後的亞曆山大醫院将逐漸開放。2029年和2030年，新的東部綜合醫院園區預計将逐漸開放。到2030年代初，屆時将會看到一家新的區域公立醫院竣工，我們已經着手開始這項工作。

我們剛剛在北部完成了一個項目，兀蘭醫療園。我們正在在東部建設另一個項目。我們也在中央地區擴建新加坡中央醫院。是以下一個新的公立醫院應該是在西部。我們計劃将其選址在新興的人口中心——登加鎮。它将與西部地區現有的醫院形成最佳互補。登加的新醫院将由國立大學醫學院衛生系統叢集營運。

盡管有擴大醫療容量的計劃，但在考慮容量時，我們不應陷入“建設醫院”的思維定勢。我們有潛力在醫院之外，在社群中提供更好的醫療服務。

并非所有患者在治療過程中都需要在醫院接受重症監護和持續監測。許多病人需要的療養和康複，并能保證就近獲得醫療幫助。是以，我們為亞急性和康複病人建設了更多的社群醫院，為等待長期護理安排的病人提供過渡護理設施。

通過我們的努力，長期住院患者的數量有所下降。這些患者被界定為病情穩定可以出院，但是他們在等待長期護理期間一直住在醫院，并且住院時間超過21天。這就是我們所說的長期住院患者。兩年前，在我們醫院系統中，每次大約有300名這樣的患者。現在，每次不足200名，但仍有改進的空間。

為了友善患者從急診醫院适當轉到社群醫院，我們還将進行以下政策調整，具體如下：

一、為社群醫院提供更多資金。急診醫院把合适的患者轉移到社群醫院遇到了一些阻力。為什麼呢？例如，某些診斷服務，如計算機斷層掃描（CT）和磁共振成像（MRI）以及某些更昂貴的藥物，如今在社群醫院得不到補貼。這是基于這樣的考慮，即這些患者正在康複，可能不需要這些幹預措施。不幸的是，這意味着将患者轉移到社群醫院時出現了操作上的延誤。有些患者在醫學上已準備好轉移，但卻在等待複診掃描檢查。他們應該立即轉移到社群醫院，并在那裡進行掃描。

患者或許會擔心，在轉移後，如果出現意外情況需要掃描，該怎麼辦？是以，他們堅持留在急診醫院，以防萬一。為了消除這種阻力，從今年第四季度開始，我們将允許更多診斷服務（如CT和MRI掃描）以及相關藥物在社群醫院得到資助。

更廣泛地說，我們還将社群醫院補貼架構與急診醫院的補貼架構統一起來。過去兩者是不同的。這樣，患者在住院期間，無論在哪種醫療環境下，都将鋒利相同的補貼，即50%至80%。通過這個改進，大多數社群醫院的患者住院賬單将會減少。

二、将居家病房（MIC@Home）作為主流服務。什麼是MIC@Home？這是一個試點項目，我們在患者家中設定虛拟病床，并邀請醫生和護士定期探訪他們，就像他們在醫院一樣。陳有明醫生、畢丹星先生、黃玲玲女士和佳馥梅女士已經提出或談論過這樣的計劃。

截止去年年底，已有2,000多名患者從這項計劃中受益。這相當于節省了約9,000個醫院床位的使用天數。經過幾個月的實施，我們确信這項計劃對患者很有幫助，并在緩解醫院壓力方面潛力極大。

是以，從今年4月起，MIC@Home将成為我們公立醫療機構的主流護理模式。是以，患者大可放心，他們在MIC@Home所支付的費用不會超過在公立醫院接受急診住院護理的費用。我們所有的醫院都打算将居家病房的價格定在與普通醫院病房相當或更低的水準。患者将得到補貼、醫保和醫藥儲蓄金的支援，這與實際住院治療并沒有差別。

對于林志蔚副教授的建議，我認為我們現在不需要為過渡到家庭護理提供激勵措施。更好的辦法，是将居家病房發展成一個被廣泛接受的急性住院護理的主流模式。作為第一步，我們還将進一步擴大居家病房的服務能力，從2023年的100人擴大到2024年的300人，并有可能進一步擴大規模。

三、鼓勵遠端醫療。一個典型的綜合診所就診者中，有40%是因為慢性疾病管理。去年，我們擴大了補貼範圍，并允許使用醫藥儲蓄金進行遠端醫療，用于慢性病管理。到今年下半年，我們還将把醫藥儲蓄金的覆寫範圍擴大到預防性保健服務的遠端醫療咨詢，如定期健康檢查後的随訪複查。這項措施涵蓋了綜合診所就診者的另外10%。

有了這項變化，在資金支援方面，遠端醫療與實體咨詢的待遇幾乎相同。唯一的差別是針對常見疾病的遠端醫療，即患者出現症狀，如咳嗽、感冒和發燒時。患者仍然不能使用保健儲蓄支付此類常見疾病的遠端咨詢。我們暫時擱置了這一點，因為許多人濫用這種遠端咨詢以擷取病假證明書，我們在這方面有所保留。是以，在我們考慮這一最終舉措之前，需要加強簽發病假證明書的紀律性。

以下是英文質詢内容：

The Minister for Health (Mr Ong Ye Kung): Thank you, Chairman. I will devote a large part of my speech to address two pressing issues for healthcare: one is the hospital capacity crunch; the other is healthcare cost. Then, I will talk about the major transformation that we are bringing about in our healthcare system which will further address these two concerns.

Mr Pritam Singh, Mr Ang Wei Neng and Assoc Prof Jamus Lim raised the issue of capacity and waiting times at polyclinics and hospitals. Post-COVID-19, indeed, this is the experience of many countries around the world. Waiting times have gone up all around the world.

In Singapore, what is driving up hospital bed occupancy is the increased number of seniors with complex conditions post-COVID-19, and we saw a surge in the numbers. I have reported to the House earlier that average stay in hospital went up from about six days to seven days pre- and post-COVID-19, and that alone represents a 15% increase in patient load. This is happening against the backdrop of a rapidly ageing population, which compounds the problem and makes it a long-term challenge.

Mr Singh suggested that we provide dynamic waiting times of emergency departments (EDs) across hospitals publicly, in real time. It is possible, but we have been reluctant to do so, I think for a good reason. Ambulances today already have a process in place to ferry patients needing urgent care to the nearest appropriate hospital for priority treatment. However, at the EDs, 40% of cases are not life-threatening or urgent, but they ended up there anyway. So, our worry is that giving dynamic information may perversely drive more non-urgent cases to hospitals and worsen the overall situation.

I know it is very uncomfortable, very unsettling for a patient who is quite unwell to have to wait many hours for a bed. But please be assured that hospitals will triage patients quickly upon arrival and start treatment for urgent cases, even if the patient is waiting for a bed.

Mr Ang Wei Neng raised the issue of Changi General Hospital which was also reported in a Straits Times article. Changi is an old structure. It only has four ambulance bays. [Please refer to “Clarification by Minister for Health“, Official Report, 6 March 2024, Vol 95, Issue 131, Correction By Written Statement section.] So, the queue will build up quite fast.

But actually, that is not the limiting factor. We can always triage in the ambulances. It is a small problem. What we need to watch out for are Intensive Care Unit (ICU) occupancy, resuscitation occupancy. If those are full, we divert the ambulances. Ambulance bays are full, we can handle. On the surface, it looks bad; but actually, operationally, it is not a huge problem to overcome.

Assoc Prof Jamus Lim suggested using more Urgent Care Centres (UCCs). UCCs have been useful and effective. We have also been using the General Practitioner First (GPFirst) scheme, especially around Changi area, and that is also useful, and we will continue to deploy all possible methods to alleviate patient loads at the EDs.

To tackle the challenge more fundamentally, we need to expand capacity and catch up with the time lost, due to the COVID-19 pandemic.

We opened about 640 new acute and community hospital beds since June last year. They make up the over 11,000 public hospital beds that we have today. That is the stock we have – 11,000. We intend to add another 4,000 beds by 2030. And we should see new capacity coming on stream every year, from now to 2030.

Starting this year, and next, in 2024 and 2025, Woodlands Health will commission up to 700 beds. In 2026, Sengkang General Hospital and Outram Community Hospital are expected to expand by about 350 beds by converting non-clinical areas into hospital wards. Then in 2027, the Elective Care Centre at Singapore General Hospital (SGH) is expected to open; that has 300 beds. In 2028 and 2029, the redeveloped Alexandra Hospital is expected to open progressively. Then in 2029 and 2030, the new Eastern General Hospital Campus is expected to open progressively. Then we move into the early 2030s, that is when we hope to see the completion of a new regional public hospital that we have started work on.

We have just completed one in the North, Woodlands Health. We are building another one in the East. We are expanding SGH in the central region. So, the next new public hospital should be in the West. We are planning to site it in Tengah Town, which is an emerging population centre. It will best complement current hospitals in the West. The new hospital in Tengah will be run by the National University Health System cluster. Mr Ang Wei Neng is nodding his head.

Notwithstanding this plan to expand capacity, we should not be trapped in the mindset of “building hospitals” when thinking about capacity. There is potential to better anchor care outside of hospitals, in the community.

Not all patients require high acuity care and constant monitoring in a hospital throughout their treatment course. Many need convalescent care and rehabilitation, with the assurance that medical help is readily available nearby. That is why we have built more community hospitals for sub-acute and rehabilitation patients, and Transitional Care Facilities for patients who are waiting for longer-term care arrangements.

With our efforts, the number of long-staying patients have come down, and these are patients defined as medically stable for discharge but they have been staying in the hospitals while waiting for longer-term care and they have been staying for longer than 21 days. This is what we refer to as long-staying patients. Two years ago, it was about 300 such patients at any one time in our hospital system. Now, it is under 200 patients at any one time and there is still room for improvement.

To facilitate appropriate transfers from acute hospitals to community settings, we will also be making a few policy changes, as follows.

One, more funding for community hospitals. Acute hospitals have experienced friction in transferring suitable patients to community hospitals. Why? For example, certain diagnostic services, such as computed tomography (CT) and magnetic resonance imaging (MRI) scans and certain more expensive drugs, are not subsidised in community hospitals today. This is based on the consideration that these are recovering patients and they may not need these interventions. Unfortunately, this means operational delays in transferring patients to community hospitals. There are patients who are medically ready to be transferred, but they are just waiting for a follow-up scan. They should be transferred without delay and do the scan at the community hospitals.

Others worry that after transfer, what if, unexpectedly, I need a scan for some reason. Hence, they insist on staying in the acute hospital, just in case. To remove this friction, from the last quarter of this year, we will allow more diagnostic services like CT and MRI scans and relevant drugs to be subsidised at community hospitals.

More broadly, we will also align the community hospital subsidy framework to the acute hospital subsidy framework. It used to be different. That way, patients receive the same subsidy rate, which is 50% to 80% throughout their inpatient stay, regardless of settings. With this enhancement, most community hospital patients will see smaller hospital bills.

The second change is to make Mobile Inpatient Care at Home (MIC@Home) a mainstream service. What is MIC@Home? This is a pilot project where we set up virtual hospital beds at the homes of patients, and have doctors and nurses visit them, as if they are in the hospital. Dr Tan Wu Meng, Mr Pritam Singh, Ms Ng Ling Ling and Ms Mariam Jaafar have asked or talked about such a scheme.

11.30 am

At the end of last year, more than 2,000 patients have benefited from the scheme. This translates to around 9,000 hospital bed days saved. Having done this for several months, we are convinced that the scheme works well for the patients and has great potential to relieve stress at hospitals.

Hence, from April this year, MIC@Home will become a mainstream model of care in our public healthcare institutions. As a result, patients can be assured that they will not pay any more for MIC@Home than they do for acute inpatient care in a public hospital. All our hospitals intend to price MIC@Home similar to, or lower than, a normal hospital ward. Patients will be supported by subsidies, MediShield Life and MediSave, no different from a physical inpatient stay.

In response to Assoc Prof Jamus Lim’s suggestion, I do not think we therefore need to give an incentive for transition to home care now. It will be better to develop MIC@Home into a well-accepted mainstream mode for acute inpatient care. We will also further expand the capacity of MIC@Home, as a first step, from 100 in 2023, to 300 in 2024, with the potential to scale up further.

The third change is to encourage telehealth. Sir, 40% of attendances in a typical polyclinic are for chronic care management. Last year, we extended subsidies and allowed the use of MediSave for the use of telehealth, for chronic care. By the second half of this year, we will also expand MediSave coverage to telehealth consults for preventive care services, such as follow-up reviews after regular health screening. This represents another 10% of polyclinic attendances.

With this change, telehealth is treated almost the same way as physical consultations in terms of financial support. The only difference is telehealth for common illnesses, that is, when patients experience symptoms, like cough, cold and fever. Patients still cannot use MediSave for such consults for common illnesses. Also for a good reason. We are holding this back as many people have been using such teleconsults as an easy way to get medical certificates (MCs). So, there will need to be greater discipline in issuing MCs before we consider this final move.

CF丨編輯

CF丨編審

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