Struggles Ahead

The total number of doctors in the country is estimated to be 6,70,000 to 7,00,000, the doctor : population ratio being 6.7 per 10,000 population, against a desirable 10. But the distribution is skewed and the rural population has only 2 doctors per 10,000.  The government, therefore, wants to increase the number of doctors by increasing the number of students in existing medical colleges, by a whopping 50% without increasing the bed strength.  There will be 250 students where earlier there were 150, and 3 post graduate students per unit instead of 2 as at present.  Quality will be sacrificed for quantity in the hope that flooding will send doctors to rural areas.  More likely, they will flood urban areas even more.

  Mumbai is already having 22 doctors per 10,000 population, equal to the ratio in U.K.  It has 20 beds against the national average of 9, and has most number of specialists, super-specialists and the most advanced technology.  Yet a Mumbaikar lives an average life of 56.8 years 11 years less than a Maharashtrian, who lives 68 years.  Too much commercialization or too much incompetence?  Obviously doctors sell health-products, not health-services. The same picture is seen internationally. Despite poor infrastructure a Sri-Lankan has a much better average life span than a Russian who has one of the highest medical manpower in the world.

And who are the buyers?  40% people below poverty line or poor have to depend on public sector and 30% upper class plus those who are well covered for their health needs prefer high-tech major hospitals. So, we sell our product mainly to the middle 30% people only. But the income of 50% people is shrinking while the number of specialists is increasing.

WHAT IS THE STRUGGLE AHEAD?

1)      Increasing over crowding of specialists in cities has to be reduced.

2)      The expenses are becoming unmanageable even to upper middle class, while the quality is declining. This results in shrinkage of the medical field.

3)      There is no referral system, no functional demarcation-compartmentalization, if I may call it. The resulting insecurity and confusion explains the morbidly increasing heart attacks among young doctors.

4)      We are totally neglecting primary health care and the public sector at our own peril. It is in our own interest that primary care improves and public sector expands. That will absorb more G.P.s and specialists, that will help expand the medical field, and that will reduce assaults on doctors, if public unrest is subdued.

5)      The concept of free treatment for the poor is creating havoc not only for doctors but also for the very poor who are supposed to benefit by free treatment.

The most important challenge ahead is to offer improved services at reduced cost. A report by D.H.S. in 2005 indicates inadequacies. Inadequate space, untrained staff and gross under utilization of space, O.T.s, I.C.U.s equipments and personnel along with increasing regulations and rising public expectations are making most nursing homes non-viable. But what we refuse to even mention is the conflict of interest between the owner and the freelance consultants who have no stakes in the place and who can and do shift their allegiance elsewhere, easily, for personal gains. The only remedy is Group Practice. A small hospital of 50 beds by 10 or more specialists will bind them together. The hospital will afford to employ good staff and up-date equipments. Specialists will be interested in training the staff & R.M.Os, so infra-structure will improve. The flow of patients from all partners will guaranty full utilization of space, equipment & staff and the freelance consultants will lose their importance. Group practice is the answer for the future.

A linkage with major tertiary hospitals on well-defined terms can become mutually beneficial. The offer of fortis recently, is a step in the right direction. It has offered to take up difficult cases, treat and re-transfer the patients from Nursing Homes and help with Para-medical assistance. In turn, Nursing Homes ought to demand that Fortis reduces its economy and general ward beds and admit only major cases therein.

Simultaneously, the general specialists will have to assert their separate importance in treating the middle class. The biggest task is to fight the high-tech market and maintain our biggest asset namely stress on appropriate, cost-effective technology, early decisions, short-stay and thereby reduced costs. We need to denounce loudly the misuse or overuse of costly technology and costly therapies. It will be necessary to flood the press and medical journals with articles to show where and when patients can be treated successfully without them. I believe patients can be persuaded to accept such protocols. However, maintaining meticulous records is a must, for this. It is possible that insurance companies and foreign funds from U.K. & U.S.A. would strongly support such an approach.

The central government has passed the clinical establishment Bill-2010 and accreditation is on the card soon. The association along with F.E.Q.H of Mr. Gadgil is already on the job. Accrediation will be good for us, but it can spell disaster if we remain careless and ignore the aggressive high-tech high-cost market. The insistence of costly equipments with unproven merits can result in many nursing-homes being declared “inadequate” for major cases. Planum ventilation, HEPA; 6 channel monitor etc. are but a few examples. We will have to insist that well maintained records showing adequate results for the patients treated at the centre should be an equally important criterion of adequacy.

Compartmentalization and frontal attack on the concept of free Treatment are the other important struggles ahead. Strict compartmentalization between private and public sector is as much our need as that of the government.

Senior service doctors are quite well off-could be much better off than many of us. We must not only strongly advocate a total ban on private practice by all full-time doctors/specialists but also actively assist the authorities to implement the ban. Similarly, we must continuously attack the concept of Free Treatment. The first step would be to denounce Free Medical Camps as an unethical practice and an insult to our brethren in service, except in disasters. Also, working as an Honarary, without per case minimum payment or free health check-ups ought to be condemned outright.

Even in public sector professional services must be charged. Even for the common man, these work out to be only 5% to 12% of the charges in private. But evaders must be fully charged. That will widen the net, and expand the public sector and offer work-based incentive payment to service doctors. For example, government and municipal servants treated in public sector do not pay at all, if they are treated in their respective hospitals. If they were to be treated in approved hospitals, the govt. pays even if the patient does not. But here nobody pays. Collectively, the medical fraternity is the looser. Please realize, these families make upto 15% of the total population. Other evaders are

1)      Accident victims-despite third party insurance. The public hospital fails to collect the money; the insurance company gains and both the hospital and the doctors lose.

2)      Foreigners- sometimes they do get admitted to public hospital; yet they are treated free of charge. An Australian lady was charged Rs. 300/- for fracture radius, ulna treated with Elizarov method.

3)      My study in Goa indicated that atleast 40% of the patients who attend public hospitals for emergencies belong to be affording class. Infact, they don’t mind paying but there is no provision to collect the charges.

4)      Politicians, MLA’s, Corporators etc.-less said about them the better.

Despite poverty, 80% of the people are reported to utilize private services for their primary health needs. It is a pity, we have donated this field to AYUSH doctors. This is mainly because everyone who wants to specialize gets training and experience in the teaching hospitals. But there is not a single day’s training for someone who wishes to become a general practitioner. We must demand that there should be a two year diploma course in general practice in every medical college and atleast 20% of the M.B.B.S graduates be absorbed therein. Similarly there is need to define the roles of G.P.s and consultants. In my opinion, G.P.s should be prohibited from prescribing very costly antibiotics and other drugs or advise very costly investigations. Such cases must be referred to the specialists. F.D.A. can easily prepare a schedule of such drugs and investigations. Specialists, in turn, must not see any patient unless he is referred by or was atleast treated first by a general practitioner. Compartmentalization will make clinical practice more peaceful. 

I believe we have a strong case to make C.P.A. non applicable to health services, because it is contract based on faith-and not just a contract. (Visit my website for the full high-court judgement) Suffice it to say we should anticipate problems and advise the policy makers or the authorities to correct their policies before rules are framed. If we do not do it-others do-mostly the envious elements or the market. We ought to talk both to masses as well as authorities a lot more.

On my part, I have written a book, in which I have analyzed the present scenario and given my blue-print for action. It is priced Rs.100/-.

I have also created a website and a forum within it. We need to discuss a lot on these issues, I request you to buy my book and discuss or add your comments on the website and forum.

MANAGEMENT OF THE

SICK HELTH-CARE SYSTEM

(What is Wrong - What Can the Done)

By

Dr. S.V.Nadkarni

Former Dean, L.T.Med.College, Sion,

Tel :- 9320044525

sadanadkarni@gmail.com.

Available with

Vora Medical Publication

Near J.J.Hospital , Signal Trafic Byculla,

Tel- 23754161, Telfax-23704073

E-mail : voramedpub@yahoo.co.in

Website : www.healthandsociety.in

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Social Need for Cost Effective CLinical Practice

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