Friday 30 May 2014

Who Pays?


Late on a Sunday afternoon as I wasted time negotiating how much of the hospital bill the relatives of a deteriorating critically unwell young man should pay before they could take their brother/son/nephew to another hospital, I felt a slightly younger, more idealistic version of myself, perhaps the one acknowledging the Hippocratic oath at his graduation, sitting on my shoulder, appalled at what I had become. How did I become the doctor discussing financial matters whilst my patient’s breathing problem worsened behind me? Albeit that the money would not be coming anywhere near my pockets, the picture does not sit well. Naturally the instinctive and immediately compassionate action is to say ‘Don’t worry about the bill, just get the patient as quickly as possible to wherever their chances of survival are highest’. And yet in a hospital whose primary source of income, and therefore long term survival for the benefit of its community, is dependent on the minimal fees its patients pay, non-payment of the bill may mean the hospital cannot afford to purchase the necessary medicines to treat, and pay its staff to care for, the next unwell patient who arrives. I have been witness to the reality of empty drug cupboards and have been aware of times when the staff were not paid their salaries for 3 months. The acceptance of absconding patients or part-payment of bills, whilst beneficial for individual patients and families, can have significant wider consequences for the hospital and its ability to fulfil its basic role. Very quickly the assessment of a plea not to pay the bill becomes less than straight forward (especially when your instincts tell you that a particular family probably does have the means to pay.) But how far do you go? I felt ashamed enough negotiating how much of the bill would be an acceptable amount; physically preventing them from leaving was inconceivable.
Some of the most unsettling conversations I’ve been part of, which usually occur in the night for some reasons, happen after a patient has died and relatives of the deceased begin to negotiate how much of the hospital bill should be paid before the hospital will release the body. To an outsider it may seem barbaric to have such pragmatic conversations in the moments after a relative’s death; a time we feel which should perhaps be reserved for grieving. However, the reality is that somehow, someway, healthcare provision has to be funded.  If society is not set up to pay collectively through taxation or insurance schemes and the government does not subsidise the hospital, sadly, in that moment, it appears that the financial burden rests with the father who has just lost their daughter in the middle of the night.
When I first arrived, I found the crude interface between money and treatment very difficult, somehow offended as money changed hands on the way to the operating theatre or before an intra-venous drip would be set up. Initially I tried to remain separated from the issue with the line of ‘I’m sorry, I’m only a visiting doctor, you’ll need to speak to someone else about the cost and the bill’ or ‘I don’t deal with the money, I just treat patients’. However, the clinical condition and care of a patient cannot be separated so easily from their financial state. This is seen in the daily collision of these two spheres: the dehydrated patient who can only afford one litre of intravenous fluids, the man with abdominal pain who can’t afford his stool test, the mother who puts off bringing her child to the hospital until it is too late for fear of the hospital bill (just over £7 for a child admission).  Aside from any ethical wish to withdraw from the battle lines of cash and treatment, when you find yourself alone on the ward in the night and being looked to by the nurse in charge to make an executive decision about whether a patient has paid enough to leave, very practically it becomes almost impossible not to engage with economic matters. Unfortunately, the equation of how to balance the need for hospital income against a grieving father’s request for his daughter’s body isn’t taught in medical school.
The hospital, quite rightly, has a policy of treating patients who need emergency care regardless of their immediate financial resources. Although this reduces delays and ensures the most unwell patients get treatment urgently, defining what constitutes an emergency case can be difficult. Illness is a spectrum not a discrete entity; a case of malaria treated early can often be resolved readily with tablets for 3 days, but if untreated can progress to severe malaria with coma and convulsions. At what point do we intervene? Do we have to let our patients become unconscious before we treat them?
Patients usually stay at the hospital until their hospital bill is paid. Collection of any monies after a patient has left is neither feasible nor practical. As a result patients may end up staying for prolonged periods of time at the hospital after they have recovered or, in the case of the maternity ward, delivered their baby, whilst they await their families to come to settle the bill. Yet, often this does not make economic or clinical sense. On Tuesday morning I sat with the midwife as we debated whether it was time to send one of the long stay maternity patients home. Although only a negligible amount of the bill had been settled, the longer she and her baby stayed in hospital, the more recurrent episodes of infection they developed, caught from other, less well, patients; a situation detrimental to both their health and the hospital’s budget with a steady depletion of antibiotic supplies in the pharmacy store. After a logical assessment, naturally she went home that afternoon. In retrospect perhaps we should have sent her home sooner but it sets a difficult precedent.   
A recent visitor to the hospital raved about an MSF (Medicin Sans Frontiers) hospital he had visited in another part of the country and how wonderful it was that the treatment was entirely free. Whilst the removal of such a financial burden unquestionably improves access to medical care for that specific local population, such interventions are only sustainable for the future if there is recognition by the community (whether small village, town or country) that they will need to invest in health facilities and staff. They can also exacerbate geographical inequalities. Although its humanitarian benefit is not in doubt, completely “free” treatment from NGOs (non-governmental organisations) may not help change the perception about the need for society to invest, at least in some capacity, in clinics and hospitals.
Notably, often it is not large sums of money that can make significant differences to the standard of care the hospital can provide. The start of the rainy season has brought with it an influx of young children with malaria and pneumonia to the paediatric ward. When combined with a relatively new cohort of inexperienced first year nursing students who provide most of the nursing care, not unsurprisingly, there has been episodic chaos. One of the most worrying concerns was that children did not appear to be getting the right medicine at the right time. Undoubtedly contributing to this problem was the fact that the medicines collected for each child were stored in old plastic boxes with cracked lids with the bed number written on a piece of tape stuck to the detachable lid (think ice-cream tub but given the climate I doubt this was their initial purpose). As a result, medicines often fell out, became misplaced, or worse still, the wrong lid got placed on the wrong tub and therefore the medicine for one patient was apparently allocated to a different bed. The solution, bought at the local market, was 20 new coloured plastic boxes with hinged lids and a permanent marker to label them. The cost: approximately 50 pence a box. The result: significantly less confusion and significantly more children getting the right medicine at the right dose and the right time.
Although the relationship between money and healthcare is undoubtedly less direct in the UK, with an excessively and unjustifiably over priced car park ticket probably causing the most financial irritation during a visit to an NHS hospital, many questions remain over the future of our health service, by whom it will be delivered and how it will be paid for. From my experience, front-line medical treatment and hard cash are a frightening combination and do not belong together at a patient’s bed side.  Our options appear to be to cherish and fund the NHS or get ready with your credit card details or insurance policy next time you need an ambulance.
The patient on that Sunday afternoon did travel on to another hospital, although I do not know his outcome. His family paid 80,000 Leones of his 250,000 Leones bill (£12 of a £38 bill) and the hospital made a loss; the money not even covering the cost of medicines used. The most difficult question for healthcare in the 21st century is as relevant in a small mission hospital as it is in government offices; Who pays?
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·         http://www.workingabroad.com/database/medical-doctor-nixon-memorial-hospital-segbwema-sierra-leone