Introduction:
The government has recently announced a plan to spend Bds$800m on building a new hospital. But, like most things it has done since unexpectedly coming to power, it is in danger of putting the horse before the cart.

In principle, as many of you would have known, I am all in favour of a stimulus to keep the economy moving, in fact I am on record as calling for the central bank to print Bds$1bn to feed in to the economy. I believe that this would allow the disgraceful case of Al Barrack to be settled by allowing the businessman a central bank drawdown – of about $250000 a month – better that than nothing.

The only real danger from this liquidity is inflationary, and this can be managed. In any case, it is an issue that should be publicly debated by the central bank, the minister of finance and interested parties. Typically, all we get is silence.

Rising Costs:
All over the world healthcare officials are facing a cascading increasing in healthcare costs. People are living longer, but not necessarily healthier, medical science is advancing by leaps and bounds, and new diseases are being discovered as lifestyles and food and farming practices combine to impact on our health.

Yet, despite this worldwide phenomenon, Barbadian policymakers are reluctant to put in place a sustainable healthcare strategy, apart from that unspecific promise to build a new hospital. It seems as if money does grow on trees. At the core of a proper and viable health care strategy must be nutrition and exercise, from the cradle to the grave. And we all know that the basic Barbadian lifestyle diet is a short cut to an early grave: black pudding and souse, sweet bread, and all the other life-shortening foods, washed down with over-sugared pop drinks and too much alcohol. This is an issue that must be dealt with in the homes, at school and through the medium of public bodies, including the chief medical officer’s department.

What should also be considered, apart from updating the existing polyclinics, is establishing a district hospital on the East of the country to cover any such emergencies as heart attacks or serious vehicular accidents; along with this, an air ambulance would also make those on the periphery of the island feel that medical assistance would be at hand in cases of emergencies.

Professions:
However, a central part of healthcare reform is getting doctors to jettison their old-fashioned and pompous manner and behave as if they are a part of a healthcare team, even if the most important part. Senior officials must also understand that nurses are not assistants or domestics to doctors, but fellow professionals working in partnership. It is only by respecting their colleagues that doctors and administrators will get the best out of nurses. This must be made clear by restructuring the line management authority in the wards: doctors are in charge of the medical care, nurses in charge of the treatment and ward care.

It also means restructuring the professional grades of nurses. Most people would, sensibly, prefer to be seen by an experienced casualty nurse than by a young man or woman just out of medical school. To recognise this experience, there is need for a nursing practitioner grade who will be the first person to see new patients at accident and emergency. This senior nurse will then decide in the first instance how to distribute the patient: to see a registrar or consultant, to admit on ward or to provide basic treatment and refer to the registered family doctor.

In other words, the ward sister is the manager of the ward and the primary manager in accident and emergency is the nurse practitioner. With such widespread reforms, government should contract with a number of private doctors to provide primary care to families, which will ease the burden on the hospital’s accident and emergency department for non-urgent cases. Those cases that family doctors believe are serious, or at least cannot be dealt with in a local and under-equipped surgery, would be referred to a hospital-based consultant on an appointment basis. Those doctors not contracted to the health service would be free to develop a private market with the support of wealthy individuals and insurance companies. The only state involvement would be in terms of regulation.

Hospital Care:
What is immediately badly needed in terms of hospital care in Barbados is not a new monstrosity of a hospital, but a building in which the patients (consumers) come first and not doctors, nurses or even more so, those who walk around with bits of paper in their hands describing themselves as ‘management.’ Treating patients with courtesy and kindness must be a priority, and this includes not only how patients are spoken to, but the bedside manner of doctors and nurses. It is now part of the story of the QEH that patients could be shouting from pain and in need of assistance and nurses will simply ignore them while gossiping about some trivial matter with colleagues. That sort of behaviour should be a disciplinary offence.

Private Health Insurance:
But reforms do not just go one way. It is clear that in Barbados, as is the case all over the world, individuals must take more responsibility for their health care. The financial problems facing the QE Hospital, and health care in general in Barbados, is not unique. It is a global problem and government must draw a line in the sand somewhere. What is unique, or exceptionally rare, is the lack of proper management and guidance from the politicians and the senior policymakers. The current situation has also created new opportunities for local business people. Government has first got to realise the limitations of what it can realistically do, given these circumstances. It cannot be all things to all men and women.

It must first determine the extent of the present and future pressures on the system: an epidemic of lifestyle diabetics and a higher than normal HIV/Aids infectivity rate for under 25-year-olds and the other problems of age, including dementia, mental illness, etc. For example, we already know what are the secondary diseases that develop from type-2 diabetes – eye problems, kidneys, circulatory, tuberculosis; we also know the outcomes from HIV – full blown Aids, TB, and so on and just need to plan for them over ten, fifteen, thirty years. Therefore, this may mean the main emphasis of the hospital should be on accidents and emergencies and trauma, with a discretionary approach to long-term medical needs. This has created an opportunity for the moribund insurance companies to up their game and offer private health insurance.

Analysis and Conclusion:
The key challenge for government in reforming the healthcare system, is not only updating the technology and improving the patient care, including a higher standard of training, but equally as important with rising costs and growing demands, improving productivity must me a key factor.

A few years ago Sir Richard Haynes carried out an extensive inquiry at the QEH during which, I understand, he asked for a full copy of the payroll which he apparently did not get or was late in getting. The important point is that it looked as if some unscrupulous politicians had placed the names of supporters on the payroll even though many of these people were not employed by the hospital. Whether this is apocryphal or not, the point is that the hospital and its management is held in such low public esteem that people are prepared to believe anything negative said about its treatment of patients or the general management of the institution. We need to get this right.

The other point, which is relevant in this context, is that the medical profession has a professional pride which is totally excessive and out of place in a less deferential age. This can be a hindrance to good patient care. They need to be told that people see them and respect them as professionals, but they are no longer the secular gods of the village. They are just another group of educated people in a country where an increasing number of people are equally as educated, if only in other disciplines. In outlining these proposals for reform, I am not asking to re-invent the wheel. President Obama realised the centrality of technology in healthcare when he backed the US$19bn five-year programme in his first year on health care information technology. The scale of investment in Barbados will clearly be smaller, but the important will be the same.

By introducing new technology right across government, we will not have the ridiculous situation in which parents registering the birth of newly born babies go in to the Bds$70m white elephant of a new court building, queue for ages, then go through to see a clerk who then registers all the details in a book – similar to what they did in the early 19th century. With integrated technology, right across government, that new-born baby would have a computerised file from birth to death, and everything in between. The hospital would have the birth details, including DNA, on file; the registration will add to the file, all health problems would be added by the family doctors (private and public), school performance would also be on file, work records, travel, etc.

In short, although I am a huge critic of big Brother Government, it would make it more difficult for people to forge their state records, including the so-called identity cards, and lead to better overall management by the state. But, first, government must spell out its strategy. A proper strategy would include the procurement and distribution of drugs, home care, a network of community nurses, home helps (domestics who come in to elderly people’s homes to assist), and community transport to get them out and about.

In simple terms, the idea of spending Bds$800m on a health programme is not a bad one, but it is if the money is to be spent casually on building another hospital, while ignoring the quality of staff and equipment working within the system. From state of the art X-rays, dialysis machines, ophthalmic equipment to whatever new that comes on stream, QEH should first be a centre of excellence for Barbadian people, and then a regional centre for the entire Eastern Caribbean, either on contract with other Caricom governments or at a sound commercial price for individuals. This excellence should not only be centred around the treatment of patients, but, over a period of time, should be a world-class centre for research in tropical diseases and nutrition.

Finally, it must not be forgotten that patients must be at the heart of any healthcare reforms and this can best be demonstrated by placing a publicly-funded patients’ advocacy organisation, complete with a team made up of a director and secretarial assistance on the executive floor of the hospital, so aggrieved patients could have direct access to a supporter. This is the opportunity for a root and branch change and the government must not rush in and mess it up.