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MANAGEMENT OF THE SICK HEALTHCARE SYSTEM
( By Dr.S.V.Nadkarni, M.S. )

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Accreditation

First let us look at the system of accreditation of the medical service centers. Today any doctor can admit and treat or perform any kind of operation in any nursing home or hospital without any regulations about the needed facilities. Some doctors perform procedures even in their own dispensaries. There are no rules laid down in this respect. Many patients have suffered serious consequences due to the inadequate facilities compared to the severity of the procedure. Sometimes there do occur sudden deaths but very often the patients develope grave complications
in these inadequate nursing homes and they are then hurriedly transferred to some higher center for further management. It is possible that a lot of damage has already been done before the patient eaches the better center. The results are disastrous or the expenses unbearable. This definitely amounts to negligence but it is difficult to prove negligence as no rules are laid down and most consultants and hospitals would plead that the case was not, in fact, so difficult; it was manageable in their hospital even though facilities were a ‘little’ inadequate, and the complication was unexpected.

In order to prevent such incidents, a system of a accreditation has been established in developed countries. Accreditation means that each dispensary, diagnostic center, nursing home or hospital is graded depending on various factors like space available per patient, investigative facilities, emergency facilities including Intensive care unit (ICU), the caliber and proportion of nursing staff, technical staff, menial workers compared to the total number of beds, the qualification of all the staff including the specialists and so on. It is like designating hotels as 3 star hotel, 5star hotel etc. Unless specific facilities are available, the hotel cannot be designated as 5 star hotel. Similarly unless full facilities and fully qualified staff in adequate proportion and fully qualified consultants are available for the patients that hospital cannot be termed as 5 star hospital. Officially there is no such designation as 5 star hospital but general public itself uses this nomenclature for many of the top class hospitals in the city. Under the system of accreditation, they may be termed as ‘A’ grade hospitals or some such term. It is not necessary that every health care service center be ‘A’ grade only. Under accreditation there will be official designation of the grade of each hospital or nursing home or a diagnostic centre or even a dispensary. The idea of accrediting the health care institutions has been mooted several times in the last 20 years but it has not been effectively implemented. One reason of course, is the total apathy of the government which is extremely reluctant to increase its own workload and apathy of the general public who do not realize the importance of accreditation for their own health. On the other and, the health care professional as well as the managers of heath care centers are also scared of the accreditation system, though this fear is not openly expressed. One fear amongst the health care providers is that after accreditation system is introduced, those with lesser facilities might be derecognized or banned and thus they will be thrown out of the profession. This fear is totally unfounded. The aim of accreditation is not to derecognize any institution but to grade it so that people at large would clearly know about the adequacy or the inadequacy of the facilities in the hospital or nursing home where they seek medical
assistance. Of course, not all the consultants and medical centers have this fear. In fact, most of them will be very happy not to accept any risk, even when the patients in blind faith try to compel the consultants to treat them at their own centre–despite inadequate facilities. Today such conscentious doctors are put under great pressure by some patients, who want to get treated there either because of faith or because these centers offer low cost treatment. But the very same patients turn around to abuse the doctors and the hospital for the inadequacy of the hospital and sue them for medical negligence under the consumer protection act, if the result is not satisfactory. So for most of these
conscientious doctors accreditation would be a boon as they will be able to refuse such high risk ases or take consent of the patient and relatives in writingthat they are willing to take their treatment here despite knowing the inadequacies of the center.Thus, only a few of the unscrupulous consultants or hospitals would be unable to continue their unscrupulous practices. The hidden fear in the minds of institutions or consultants in these medical centers which do not have full facilities is that they will no longer be able to treat all the major or serious cases as they are doing at present. There will be a natural restriction on their accepting each and every case that comes to their centers. They do not appreciare transperancy due to their greed. Thus grading of all the medical centers would be beneficial to the doctors, to the health-care centres and will also benefit the public at large.
They would now know where they are going and the relative limitations at that centre and will, therefore, be able to choose right type of hospital for themselves. Similarly very small centers like dispensary, OPD polyclinics and diagnostic centers will now be compelled to keep certain minimum facilities like oxygen and emergency kits ready at their centers for the unexpected complications that can arise during the management of the simplest of the diseases. They will have to keep adequate paramedical staff also as per the standard prescribed. Therefore, all in all, the chance of negligence will be greatly minimized if each and every center is graded and it is made compulsory that hospital or medical center must display their grade prominently at their centre.

Define the role of each category of doctors

The role of different doctors is also not properly defined. As mentioned earlier there are non-allopathic doctors as also some old-styled diploma holders (RMPs) who practice allopathy. Their exposure to allopathic training is poor. Therefore, I compared them to the bare foot doctors in China. I am sure this comparison will not be liked by all the non-allopathic faculties but the fact remains that they are not adequately trained compared to their MBBS counter parts who can be called as ‘basic’ doctors, fit to be family physicians or general practitioners or assistants in hospitals under different consultants. hen there are specialists and super specialists. In addition there are some paramedical professionals who are now–a–days claiming to be doctors and are in fact officially allowed to treat patients in their own speciality. There are physio therapists, dietitians, clinical psychologists and so on who can independently practice in their own special field.

The role of each of them is not well defined and it is extremely common to see each of them intruding into the sphere of the others. Several non–allopathic as well as MBBS doctors ask for investigations like C.T. Scan, M.R.I., Angiography and multitude of costly specialized blood tests as they proudly equate themselves with higher categories in knowledge and ‘experience’. They are also seen prescribing the costliest of the rugs or the latest of the drugs with total impunity. Their only training in the use of the new drugs is the talk of the medical representative of the company which markets these drugs. All this needs to be curbed and the role of each strata of health-care professionals must be properly defined. I realize that there will have to be a grey zone and that gray zone may be fairly wide where junior consultants will be competing with the professionals in the next upper strata. But at least beyond this grey zone, the role of every strata will be more clearly defined. Thus, if it is presumed that non–allopathic doctors are needed to cater to the poorer section of the society, then their practice should be limited only to the villages and semi-urban areas and in slums in urban areas if they were to practice allopathy.Of course, they are free to practice in their own speciality i.e. Ayurvedic, Homeopathic and Unani, anywhere as they are fully qualified in their own branch. Similarly it should be imperative that they must refer the case to higher centre if the patient is not relieved within two weeks. Similarly the M.B.B.S. basic doctors should be allowed to practice anywhere as family physician or as Assistant to any of the consultants in nursing homes or hospitals or in their private clinics. But here again they should be allowed to order only simple investigation and prescribe only established drugs. General practioners (allopathic or others) should be strictly prohibited from ordering high tech investigation and prescribing treatment with costlier drugs or drugs which have come into existence only in the last one or two years. If, in their opinion, such investigation or treatment is needed, they must refer the case to the consultant or to a hospital and take their opinion. It is only the consultant or the hospital which should be allowed to prescribe these higher investigation or costlier lines of treatment.The consultant was not basically supposed to treat any patient directly nor was he supposed to ontinue treating the patient for the entire period of the patient’s illness. Therefore, it should be ethical that the consultants should see only the patients who are referred to them by the basic doctors or, at best, could see those patients who have initially taken treatment with basic doctor and are not satisfied with the treatment given.Seeing those records should be mandatory. Seeing any patient directly without the patient being first seen by a G.P. should be considered unethical. Similarly, once he has investigated the case and advised the treatment or performed an operation, he ought to refer the case back to the family physician for continuing the treatment on the line of advice that he has given and call him for follow-up after certain period of treatment is over. It is absolutely necessary that the consultant and the general practitioner remain in touch with each other throughout the process of the treatment. The role of super specialist and the specialist is not yet properly defined, wherein the former seems to be competing with the specialist and both the specialist as well as super specialist seem to treat the same type of patient. There has to be some distinction and the super specialist must leave simple cases for treatment by the specialist and accept only the patients who require high tech management or more intense management. But in practice, this appears difficult to implement. The overlap appears inevitable, at least at present. If the role of each of the strata of health care professionals is defined to some extent, the chance of unnecessary investigation, costly drugs and incompetent treatment will be reduced to a large extent. Accreditation along with the definition of role of the doctors together would improve the health care management to such a degree that complaints of medical negligence will become near zero and may be the consumer protection act may become redundant.

Strict implementation

Rules are made irrespective of whether they can be properly implemented or not and all aberrations and all excuses for not properly following rules are accepted with ease. If rules cannot be implemented, we have a tendency in India to overlook irregularities and ‘adjust’ so that there is least headache to the administration. This is the biggest bane of the country. Thus, making rules and regulations is a meaningless farce. In the health-care sector, this is seen very conspicuously. The Healthcare system is divided into health-care provided by government/ municipality or by health-care system created by private sector. Large corporate bodies also create their own health-care system for their own employees or for general public. For example, railway employees are catered to by railway hospitals. Tata steel and Reliance have their own hospitals. In most of these hospitals full time paid doctors are appointed in all the branches of medicine. The general rule is that employed doctors are prohibited from entering into private practice. Similarly Employees State Insurance Corporation SIS) appointed doctors to treat the labour (this fact has been referred to earlier). These doctors were paid per family that registered under them for medical service, but the payment turned out to be very insufficient and the system failed. But no steps were taken to improve the pattern of payment to these doctors. Instead rules were allowed to be violated. Another section of full time paid doctors and consultants is medical teachers employed in medical colleges. The task was considered important enough so that these consultants were also prohibited from entering into private practice. However, most of the full time paid doctors are highly dissatisfied with the salary and perquisites given to them. Though often this dissatisfaction is justifiable, there are equal number of occasions where this dissatisfaction is totally unjustifiable. Normally it should have been the duty of the administrator to straighten out the problems and evolve pattern of payment and rules compatible with the expected services from their employed doctors. This rarely happens – mostly because employed doctors form such a small un influential group that both politicians and administrators in industuries can easily afford to ignore them and their grievances. Also because the administrators are equally apathetic towards their primary duty to cater to the health care needs of their employees or of the people at large. Strangely this is equally true of all the corporate bodies. Multi-nationals or big corporate houses are happy to allocate sufficient funds to satisfy their employees but are not at all particular to see that the money is well spent and that their employees get medical service worth
the amount paid for it. The employees are also happy as long as their medical bills – true or false – are reimbursed and, therefore, often indulge in procuring inflated bills from their doctors and share the booty with them. The management knows about it but prefers to ignore it. This is one of the reasons for ample corruption among professionals in these hospitals. But the bigger disadvantage of the apathy of the administration is that most of these employed doctors indulge in private
practice. Some of them do justice to their duties and also do private practice but there are more number of doctors who ignore their primary duty in favour of private practice. For them the fixed pay is merely a ‘stand by’ or ‘a support’ while they earn their main income from private practice. Public sector administration and even the corporate administration to some extent are most reluctant to increase their headache by properly implementing the health-care system. They are not bothered if the doctors indulge in private practice and earn their additional income because this stops them from complaining about inadequate salary. That reduces their own headache of administration. Thus, almost everyone tries to enter the field of private practice, irrespective of the compartments in which they work, because there is 'money in private practice’. Indirectly private practice is considered synonymous with the right of the doctors to exploit the patients. This increases the competition in the field of private practice and leads to gross malpractices. This, in turn, brings the private practice into great disrepute.

Actually the division of labour is quite clear. It is reported that about 25% to 27% of the population is covered for their health needs under the organized health care services provided by the government, railways or by private companies and corporates. The doctors who are employed in these hospitals, therefore, must be strictly prohibited from entering into private practice. As mentioned again and again earlier, incentive practice for the affording class of patients in their same section can be allowed to all these doctors, so that they will earn their additional income in the same institution if they prove to be more meritorious. The same thing should be true of the medical teachers in all medical colleges and of the doctors employed by government at the district hospitals or primary health care centers. They cannot have the cake and eat it to. There are obvious advantages in the full time service. The hours of service are fixed, long term benefits amount to nearly 30% to 40% of their salary and they have facilities of leave, traveling allowance, provident fund and pensions after retirement etc. If these full time doctors are forced to have a choice and are thus strictly prohibited from entering into private practice, the number of doctors in the private practice will be reduced. That in itself will help in reducing the malpractices in private practice to some extent. There is a second population group comprising the poorest section of the society of nearly 40% of the total population who are helpless. They are incapable of getting medical assistance with their own income and, therefore, are totally dependent on the government, municipalities, zilha parishads and the state and central governments who have set up large infrastructure starting from dispensary, primary health centers, upgraded dispensaries, taluka level hospitals to district hospitals to highly specialized medical college hospitals or other specialized hospitals. Ideally twenty five per cent to thirty per cent of the medical personnel ought to be absorbed in this section. But at present only a small percentage of doctors are working in this public sector serving poor people. Their apathy and the laxity of the government machinery makes it easy for these doctors to break the rules and enter into private practice. As mentioned earlier these doctors could be paid adequately but their performance must be assessed by the charges collected or the number of patients treated, so that sincere doctors will be better rewarded than their colleague counter parts by early promotion. This was discussed in more details earlier. But under no circumstances should they be allowed to enter into private practice. That leaves only a small section of about 25% people who are not covered by either their own organization or by government machinery but could afford to spend for their health. A certain percentage of patients from organized sector and from the poor section who are dissatisfied with the services offered to them in their respective hospitals would prefer to take treatment in this private sector. The total number may, therefore, go to 35% to 40% of the population. With the controls mentioned earlier namely accreditation of the hospitals, specific duties for each suggested by Indian Medical Council and the over-all control of the Health Council, the private sector also would become more disciplined. The charges would be more regulated and malpractices would be minimized.
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