Sunday, December 5, 2010

Just one class of wards will do

Dec 4, 2010
With means testing, we don't need many classes of subsidised wards
By Salma Khalik

HEALTH-CARE standards evolve over time, and the latest example is in the C class ward of the new Khoo Teck Puat Hospital (KTPH) in Yishun.

The traditional C class hospital ward has rows of beds lined up dormitory style in a long room, with toilets and shower areas along common corridors outside.

In contrast, the new C class ward, while housing 10 patients per room, groups five patients in an enclosed area with en suite toilet and shower facilities. The ward is laid out so each bed has a window to allow light and ventilation.

The new C class ward at KTPH is to be replicated in the Jurong General Hospital, due to be ready by 2014.

The new C wards prompt the question of just why there is even a need to have C class wards, and why there is a need to differentiate between the B and C classes of subsidised wards.

The quick answer is contained in the 1993 White Paper on Affordable Health Care. This suggested differentiating hospital wards by 'ambience and creature comfort', with different number of beds per room and different amount of floor space per bed.

The idea was to reduce creature comforts in C class wards to curb demand for these highly-subsidised beds, without compromising on medical care. In other words, rationing by discomfort.

But now that means testing has been introduced, there is a better way to ration demand for subsidised beds. It is timely to rethink the need for different classes of subsidised wards.

The current system of hospital bed classes is complicated, to say the least.

Today, most public hospitals have six ward classes. The three private wards are: A+ with one patient per room and a sitting room attached; A with one or two patients per room; B1 which houses four patients per air-conditioned room.

There are three subsidised wards:
  • B2+ which has five people sharing an air-conditioned room and 50 per cent subsidy.
  • B2 with six people sharing a non air-conditioned room with 50-65 per cent subsidy.
  • C with eight to 12 people in a dormitory-style ward with no air-conditioning. The ward is open-concept and separated from other wards by a waist-high wall. They are subsidised 65-80 per cent.
It looks, and is, confusing.

No wonder patients today need financial counselling to understand their choices and likely bills. Hospitals also have to set up a complex administrative procedure to handle the different ward classes.

The system of having multiple subsidised ward classes is likely to become less relevant in future.

For one thing, new hospitals in Yishun and Jurong are building C and B2 class wards that resemble private B1 class wards - with ensuite toilets and bathrooms, much more space between beds, and fewer beds per ward. The only physical difference is air-conditioning.

The change came about for a very practical - and vital - reason.

There was a major rethink on ward sizes following Sars in 2003, when the severe acute respiratory syndrome bug spread within large hospital wards.

Administrators realised the virtues of smaller, self-contained wards to ring-fence or quarantine a disease. It was harder to introduce infection control in open-concept C class wards.

Today, infection control remains a critical issue. Smaller wards with fewer patients reduce the risk of cross-infection and make it easier to isolate affected patients. This is the key reason wards in new hospitals like the KTPH and the new Jurong General will have fewer patients per ward, even in C class.

If having fewer patients share a room and bathroom facilities helps keep hospital-acquired infections to a minimum, then that should be the type of wards built. And if most new subsidised wards built in future will be self-contained rooms with ensuite facilities, there is a need to rethink the old model of having so many subsidised ward classes.

Instead, the Ministry of Health can streamline the hospital bed system by doing away with the B2 wards and having just one C class of subsidised ward.

The strongest argument for this is that the old justification of rationing demand for hospital beds by discomfort is no longer needed, as patients now undergo means testing, and subsidy rates vary according to their income levels.

Patients need not fear ending up paying more with a single subsidised class as the rates they pay will be determined by their income levels, not by ward class. So a patient earning $5,000 a month pays more for the same subsidised ward than a patient earning $1,000 a month.

In fact, the 1993 White Paper acknowledged that rationing by discomfort was not optimal, saying: 'The direct way to manage demand, which may eventually become necessary, is to use a means test.' At that time, means testing was an 'expensive and administratively clumsy procedure'. But it has become practical with today's technology and is already in place.

The next step is obvious: It is no longer necessary to impose levels of discomfort to distinguish wards with various levels of subsidy. Instead, one class of subsidised ward is all that is needed.

This would make for easier hospital construction. It is unlikely to add much to the building cost. Standard ward sizes and features make it easier for the nursing staff to carry out their duties.

It would also be administratively easier as hospitals will no longer need to explain the different features of a C, B2 or B2+ class ward. Instead, they need only tell patients the level of subsidy they are entitled to.

To be sure, the change from several to one subsidised class of hospital ward is a major move. It will take years, not least because existing wards will need to be reconfigured.

New hospitals can start doing this on a pilot basis. There will be difficulties and confusion during the transition, and patients will need to be re-educated.

But the effort will be worth it. Over time, wards will be smaller and self-contained. Subsidised patients will have access to hospital wards within their means that are also great from an infection control point of view.

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