Notes From a Native Son: Physician Heal Thyself

Hal Austin

Recently, the British intellectual and journalist, Will Hutton, asked the question: “How do you successfully break a mistaken and destructive intellectual consensus?” It set me off immediately thinking of the cosy social world and the mental processes in which the political, professional and academic elites in Barbados conspire to converge on the same ideas, which are implemented in much the same way, often by the same people – and, no matter which party is in control, they all expect different results.

Two ideas come to mind: the break of the consensus by the attorney general on the silly and ill-advised decision to plant taxpayers’ money in to the Four Seasons project, which he rightly sees as a private investment which should be let to private investors. The other is equally as irresponsible, the decision to build a spanking new Bds$800m hospital in Kingsland. Both ideas are loopy and reveal the poverty of our policy-making, especially when it comes to major capital projects.

First, there is nothing fundamentally wrong with the Queen Elizabeth Hospital, opened to the public in 1963, which competent and firm management cannot sort out. What patients are complaining about are issues such as time-wasting, spending hours before being seen by a doctor in Accidents and Emergencies, of under-productive nurses spending time on the wards talking to each other while surgical patients are in pain and crying out for help, over-paid and arrogant, sometimes even questionably competent, doctors being on the public payroll while spending their time looking after their private patients. The list goes on. So, to the ordinary man and woman in the street, the real problem at the QEH is not the building, although that us falling apart, but what goes on inside the building.

Barbados does need a second general hospital with accident and emergencies facilities, but not the one that has been proposed. What is need is a well-equipped hospital situated in the North-East of the country, so that un emergencies people from St Lucy, St Andrew, St Peter, St Joseph and St John would not have to wait until an ambulance arrived from Bridgetown then to take them to a hospital in town or Kingsland. So strategically, the location is the wrong one.

As to the idea that businesses would develop in the surrounding area, pharmacists, shops, rum shops and so on, this is a nonsense. How many businesses have grown up around the QEH or the old general hospital? One question that ought to be asked is if the new private hospital in St Joseph is contractually obliged to treat accidents and emergencies occurring in the vicinity? If not, what we will see developing is a segregated health service, a hospital for the rich while the poor have to travel to Christ Church or Bridgetown to be treated. In other words, what we have seen destroyed in South Africa and the American Deep South, rich white people going to a well-equipped hospital while poor native Barbadians go to the less well equipped hospital, will be transplanted to our island.

Healthcare as Social Policy:
The first task of any committee or sub-group structuring a healthcare policy must to look at the demographic and geographical needs of the community and to project forward these needs a further twenty or thirty years. In Barbados, the task is much simpler than it is in many other countries. First, Barbados has one of the highest infectivity rates for HIV/Aids for under thirty-year-olds in the world. This will put a number strains on taxpayers and, in particular the health care bill: retroviral drugs, a negative impact on the work force, and the risk of spreading the virus. Then there are the existing and future problems as a result of the lifestyle of the majority of people: alcohol abuse, poor diet, over-us of saturated fats, sugar and salt in meals, lack of exercise, over-dependence on private motor vehicles, etc. All these will lead in time to serious chronic diseases such as diabetes and its secondary problems, cancers, and so on.

A proper well-discussed health policy is more than just a hospital building; in fact, a hospital building is not even the most important part. A good healthcare policy is about prevention, regular exercise, eating well and in small portions, and the use of technology to manage the life-long care of patients. If well thought out, it would also include proper contractual arrangements with doctors, nurses and ancillary staff.

The QEH has fallen in to the trap that has plagued organisations, both public and private, since the 1960s, but in particular since the expansion of so-called business schools in the 1980s and 90s. There is a belief that to be a good manager one must be armed with an MBA degree, even those with an emphasis in marketing. The net result is that poor generalist managers are often planted on to organisations which depend on specialist skills, which the managers often do not have any knowledge of. Quite often, having these men (and often they are men) in suits walking around the office or factory |(or even hospital) interfering with the day-to-day work of the experts, and trying to instruct them in how to carry out their tasks can lead to resentment.

The way round this for a well-managed hospital is to put the clinicians, in spite of their collective arrogance and silliness, in charge on the basis that it is much easier to train a doctor to be a manager than a generalist manager to be a manager of doctors. Once that reporting line has been clarified, it must also be made clear that nurses and other ancillary are not doctors’ assistants, but professionals in their own right there to provide a service to patients. In many ways, medicine in Barbados is in the 20th century, and not even at the end, as most patients can testify. I remember a few years ago having a terrible pain in my back and went to a St Lucia-born doctor based on the rim of the Garrison. I remember the surgery well because years ago it was occupied by a dentist called Jimmy Smith. The young make doctor prescribed me some pain killers which, at the time, I did not realised were cutting a hole in my stomach. On returning to London (it was either a Sunday or bank holiday) I went to St Mary’s Hospital in Paddington and the first thing the young registrar did was to dump my tablets in the bin and tell me that they were the cause of my pain, that they were too strong. I do not know which doctor was right. All I can say is that the pain subsided after my visit to St Mary’s.  I remember that because a couple weeks ago I met a Barbadian friend who is now a so-called returnee who was in London for a medical check-up. His story was similar to mine.

We were both lucky because we could both get a second opinion, from totally professional and cultural practitioners. But what about those people who would find it prohibitively expensive to do so? Over-prescription, misdiagnosis and general malpractice are concerns all over the world and Barbados is no exception.

But looking ahead, medical science has moved on by leaps and bounds, and so does the delivery of that service. Doctors based on one country can now carry out diagnoses of patients in another, examine X-rays and make prescriptions from ten thousand miles away. Genetic science has moved on to such a level that medicine can be personalised and drugs can be developed for individuals with chronic diseases, rather than giving the same medicines to every Tom, Dick and Harry.

Contracts of Employment:
Contracts of employment should be comprehensive documents which set out all the duties and obligations of employer and employee, including productivity, behaviour, customer service and proper job descriptions, including time keeping, and am enforceable disciplinary code.

Healthcare Economics:
The big economic issues around health care are loss of working days, the development of chronic diseases and their impact on healthcare costs. Apart from lifestyle changes suggested above, the major healthcare costs are long-term and develop because of the misuse of alcohol, sweets and carbonated drinks, and the abuse of the health service by motor insurers through injured drivers, passengers and the general public, all costs that should be passed on to the motor insurers. In fact, instead of any additional taxes going in to the Consolidated Fund, only to be abused by ministers, it should go in to a hypothecated fund to be used exclusively on healthcare. Over the years, however, the biggest portion of the healthcare budget will be spent on care in the community, looking after the elderly, infirmed and mentally ill in their own homes.

Analysis and Conclusion:
In the final analysis, it is care in the community, looking after the ageing community, that will be the source of the big healthcare spend, not another hospital. And with the development of medical science, most Barbadians will not have to leave the comfort of their own sitting rooms to be treated by the leading medical practitioners in the world. Skype is just an example of a conversion, but so are the facilities for more intimate cross-border medical examinations.

The other major short-term problem is the lack of staff discipline and the general ill-treatment of patients. Employee capability is at the centre of performance and productivity. And, Barbadians are no different to other people; it is just that when employed in the public sector they believe that they do not have to exert themselves. This is an abuse of  taxpayers that should be made a serious disciplinary offence, even to the extent of having an all-out battle with the often irresponsible trade unions. (An example of this trade union madness is the claim for a ten per cent pay rise, at a time when the country is insolvent. It is stupidity bordering on madness).

Lazy and apathetic employees should be sacked on the spot, no matter what union representatives say; those that are incapable through lack of training should be provided with that training; and those whose performance is affected through external pressures, such as family problems, should be provided with the welfare support and time-off as necessary.

The public sector must be a model employer.

0 thoughts on “Notes From a Native Son: Physician Heal Thyself

  1. “Two ideas come to mind: the break of the consensus by the attorney general on the silly and ill-advised decision to plant taxpayers’ money in to the Four Seasons project, which he rightly sees as a private investment which should be let to private investors. The other is equally as irresponsible, the decision to build a spanking new Bds$800m hospital in Kingsland. Both ideas are loopy and reveal the poverty of our policy-making, especially when it comes to major capital projects.”

    Note that the AG has recanted and now says that he is fully onboard with the Cabinet’s decision.

  2. “The public sector must be a model employer.” Good luck with that buddy, maybe the gov’t-funded intellectuals could devise a ‘model’ that suits our crowd. The Bajan snivel service has become the equivalent of the UK’s Dole, except it gives ‘benefit recipients’ somewhere to go for 1 or 2 hours a day while drawing unemployment benefits for life. It stems from the fundamental problem that we have no export market for our most valuable resource: educated people. Well-educated school leavers end up in the civil service by default where they are corrupted by lazy veterans and thereby become forever useless to the private sector. I always found it funny that when Tom Adams spoke of the ‘unemployable’ he was actually the largest employer of same. Until CARICOM is adjusted so that we can export people we will not solve this problem unless these is another World War or Panama Canal.

  3. Question.

    What would happen if two prominent businessmen, showed that they needed NIS money to get the project jump started.

    Supposing Port St.Charles or the like needed $50Million of NIS money.

    Who would agree to invest this?

    Alternately, supposing a well known small hotelier, on the South Coast, showed plans and an agreement to build a 200 room hotel, with a name brand.

    Would the NIS & Government agree to part with 50Million?

  4. After reading this piece, I’m now feeling somewhat vindicated, whilst I’ve
    never been an in patient or ever sought medical treatment from the QEH I’ve on a number of occasion visited with others, on every occasion I came away with a strong desire to slap the crap out of someone there. This desire does not abate upon leaving, but grows even more as I relate my experience to a bunch of people who after so many years and money wasted on education only know what medication they’re taking based on the color of the pills.
    It’s going to be interesting how many shoot the messenger of the above article.

    I met a decent young Barbadian man at Downstate medical center in Brooklyn quite recently, actually, he’s Dr. Andrea Philips. I invited him to look up this blog; and I also promised him when next I submit some comment I’ll mention to readers the fine work he’s doing in NY, good luck to you Dr. Philips
    Now, you also promised me, when and if you come back to Barbados; you’ll not behave like some of the schmucks at the QEH

  5. Part of the problem is that we feel criticism and or feedback must be taken as negative.

    We feel that to make changes to systems/practices which have served us well cannot be critique or changed.

    Our unions believe that to operate in the irrelevant field class 60s mode is as applicable now as it was then.

    The list continues.

  6. Hal Austin’s precis of challenges presented in healthcare is quite balanced. His forecast of the increased spending associated with longevity and added challenges of unattended and ignored conditions are being seen today. Granny dumping at the QEH and high amputation rates did not happen overnight. The article suggests that putting more resources into hospital care will do nothing to prevent the development of conditions which we seem to find acceptable. Obesity, hypertension, Diabetes and the many associated cardiovascular diseases are some that come to mind. Other local media occasionally brings some of these public health challenges to the surface. Prevention in aforementioned areas get trumped by news of the advent of profiteering schools for doctor creation and more attention to the development of North American type hospital activity. As an isolated activity that’s not bad but when it is packaged with a blind eye to primary and preventive care it becomes detestable. If leadership is serious about healthcare they need to be honest about our realities. It may involve taking a bull by the horns. We can help.

    • @Francis

      Yet this issue is kicked around like a political football when none of the political parties have been able to solve the issue of improving health care through the years. What happen to all those action items coming out of the Nation Talk BAck Forums?

  7. Is Rev Al Sharpton still available to The Famlies First Foundation? Oh Lord it would be such an honest ,moral and decent act if he would provide some moral and religious guidance to families first that should help to dispense justice to poor suffering families in Barbados. I am hoping that Rev AL would intercede on their behalf.
    This is a call for HELP in the name of Justice and hoping that Rev AL can help since I can still see his picture up front at the big inaguration with The First Family.

  8. @David
    Most leaders are bullhorn grabbers. Taking a bull by the horns involves a totally different approach which may not always guarantee a number of things including immediate financial gain and re-election. Strong evidence of a need for radical change is there.

  9. I totally agree with Hal, the problem is not the hospital per se’ but the doctors and nurses. Depending on who you are, you can get good treatment.

    I recently had a experience with the hospital and i felt like a quinea pig with all the young trainees and no consultants on hand to correct these interns.

  10. We have created a system where doctors are expected to be wealthy, and to drive Mercedes, and we have given them license to sell drugs, and to earn money from unhealthy citizens.

    What do we expect as a result? ….a focus on keeping us healthy and drug free?
    Bushie fully expects to see a disdain for poor patients (who are in no position to enhance the doctors’ wealth) and a lack of focus on proactive health issues – which tend to keep paying patients away.

    We are reaping EXACTLY what has been sown.

  11. It’s not long ago that the term Public Health referred to the eradication of diseases like typhoid and other communicable conditions. This involved management of sewage, mosquitoes and the vaccination of our population. Issues such as maternal and infant episodes were helped by area clinics and hospitals. The expanding importance of Social and Preventive medicine was assisted by the devotion of many West Indians including more than a few Barbadians. Much of this function was assisted by an expanding University College later named the UWI. The hospital based evolution of practice was impelled by many Barbadians some of whom were schooled here and specialty trained abroad. An increased proportion now seem to be schooled, trained and subspecialty trained within the region. This is a good thing if we recognize that inbreeding is not desireable for good growth.
    The problem is what seems to be an isolation of Social and Preventive medicine in favor of the Tertiary aspect of practice. There are significant advantages to individuals whom are able to receive timely and competent tertiary care. No question. Much has also been written about the advantages which accrue only to the providers of such an approach. The number of people who lose from this preferred narrowly focused policy is a multiple of the tally of beneficiaries. Therein lie unnecessary costs that are described better by others beyond my grade.
    The issues we attempt to discuss are much more than may fit into a nutshell and the oxen that will be gored are many.

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