This column in the Telegraph of 4 November 2003 was written after Susmita Biswas, a college student, died while waiting to be treated in SSKM hospital, Calcutta. i argued for autonomy and financial independence for the surgeon general of West Bengal.
A case of
incongruent expectations
I read about the tragic death of Susmita
Biswas lying at the doorstep of the SSKM hospital, and of the subsequent
transfer of the four top officers heading it. My first reaction was outrage at
the callousness of the people running the hospital, and despair at the
unalterable mediocrity of the government-run services. But my next thought was:
I would hate to be a doctor working at this hospital.
Especially now
that the SSKM hospital has become notorious. Every time a doctor from it has to
introduce himself, he will cringe. He will burst into a long explanation of the
tragic incident – that the operation room was being used, that there were no
beds available, that they phoned so many other hospitals and they all refused.
Or launch into statistics of how many patients the hospital has treated and how
many operations it has done. Or descend into a dirge about how overworked he
is, how little sleep he gets, how the government starves him of equipment, etc.
Or, if he has been properly educated, launch upon the iniquities of the
capitalist system and the malignity of his quesioner. It is bad enough not to
be recognized for the good work one does; it is infinitely worse to be branded
by association with a crime that one did not commit.
If this is how
doctors react, then it will become even more difficult for the hospital to
attract good doctors than it was; and it could not have been easy even earlier,
given the working conditions. Refusal to admit a patient is a symptom of
something – of lack of capacity in some form or another. Maybe the right
specialist was not available, maybe beds were not available, maybe the hospital
was having a crisis of one sort or another. All of them would be symptoms of
poor working conditions; all would put off good doctors. So the adverse
publicity would only make this hospital worse.
With the
transfer of the responsible officials, the government has replaced the
managerial team; the new managerial team will find its job even harder. Will it
do it better? This must depend on whether it is more competent – and whether it
has better means to do a better job.
What is the job?
And what are the means the management needs to do it? It is the public
expectation that government hospitals must treat those who cannot afford the
treatment. That ensures that they invariably get more demand for services than
they can provide. How do they cope with it?
First, they make
people wait. Anyone who wants to be treated must go and queue before a doctor
on duty; it may take hours to see him. If he is not there – or if one is
unlucky enough to be taken ill when there is no one on duty – one waits that
much longer. If one cannot afford to wait – if one dies before one gets to the
doctor, or can afford to go to a private one – one will not go to SSKM
hospital. Thus by restricting access to primary health care, the hospital
matches supply to demand.
Second, they
give unattractive service. They keep the hospital dirty. They make people share
beds, or make them lie on the floor, in corridors. They mix critically ill and
less desperate patients, so that the latter will be scared away by screams.
They have rude nurses and janitors. They make service unattractive to put off
as many patients as possible.
Third, they make
service unreliable. They do not repair equipment that breaks down. They do
substandard tests. They give spurious drugs. They increase the hazards of
treatment.
These are the
ways in which the inevitably excessive demand for public hospital services is
tailored to the fixed supply. The change of management cannot change those
ways, because the management does not fully control them. It cannot make staff
work beyond their hours of duty – or indeed make some of them work at all, if
the staff have political power. It cannot increase the area of the hospital. It
cannot police the quality of drugs. In other words, the management of the SSKM
hospital is doing an impossible job, and will therefore fail to do it however
often the government changes it. The chief minister must know this – he must
know that transfers are only a palliative to ward off public anger, that they
are not even the beginning of a solution.
Is there a
solution? No; but there is a better way of doing things. At the level of the
hospital, the new surgeon general should ask the government for three things.
First, he should be given an annual subsidy, to be deposited in the hospital’s
account on the first day of the financial year, and should have full freedom to
use it as he sees fit, without interference from Writer’s Building. He should
be allowed to appoint an internal auditor, and should receive neither visitors
nor phone calls from the government. Second, he should be free to hire and fire
staff. He should have six months to judge the capacity and willingness of the
existing staff; at the end of the six months, anybody whom he finds substandard
should be “transferred” out of the hospital by the government. And finally, the
government should immediately remove all “encroachments” – all employees, businesses,
and occupiers of space who do not serve the basic functions of
the hospital in his opinion. In brief, this hospital cannot be set right unless someone takes
charge, and has the authority to set it right.
Next, he should
decide what is the hospital’s mission. It would seem that its function is to
provide the highest medical services – services other hospitals cannot provide.
In addition, it would seem that the public expects it never to refuse a serious
case like Susmita’s. In that case he would have to concentrate on three things.
First, he must expand his outpatient services to ensure that all who approach
get quick, reliable and high-quality diagnosis – and that they are immediately
segregated into those few whom the hospital would treat and others who would
get only outpatient service or have to got elsewhere. Second, he must ensure
that his specialist services work flawlessly. He must see that all the
machines, operation theatres and instruments work, and keep working with the
minimum downtime. To this end he must line up maintenance services, and he must
engage specialist consultants to make sure someone is available on demand all
the time. And finally, he must ensure nurses that would give patients adequate
service and make sure the beds are vacated as fast as possible. This is not the
job of nurses alone; he would need counselors who would talk to patients and
their relatives from the time of admission, help them find accommodation
outside and make sure that patients have a safe place to go to once they cease
to be critical. But rapid turnaround of patients is the key; without it the
hospital cannot ensure that every emergency patient is admitted without delay.
That is his
task; to accomplish it he would need much tact, hard work, mental toughness,
and leadership qualities. But all those would be wasted if he could not get a
free hand. And because no one gets a free hand in West Bengal, it gets mice
instead of men as managers.
