Docs not to blame

Jamaica Gleaner - - OPINION & COMMENTARY - Myr­ton Smith GUEST COLUM­NIST Myr­ton Smith is con­sul­tant ENT and head and neck sur­geon, as­so­ciate lec­turer, and for­mer pres­i­dent of the Med­i­cal As­so­ci­a­tion of Ja­maica. Email feed­back to col­umns@glean­ and myr­ton­smith@hot­

THE GLEANER by­line on Wed­nes­day, Novem­ber 2, 2016 ti­tled ‘Docs bleed the State’ is mis­lead­ing and er­ro­neous in its im­pli­ca­tion. The state­ments made in the ar­ti­cle sug­gest a lack of knowl­edge and/or un­der­stand­ing of the Gov­ern­ment’s pri­vate prac­tice guide­lines.

Un­der the cur­rent guide­lines, cer­tain cat­e­gories of med­i­cal doc­tors, namely con­sul­tants, are al­lowed to ad­mit pri­vate pa­tients in the pub­lic health fa­cil­i­ties for med­i­cal or sur­gi­cal care. In these in­stances, the con­sul­tant MUST in­di­cate to the reg­is­tra­tion staff that the pa­tient is pri­vate. Al­ter­na­tively, if a pa­tient goes on his/her own vo­li­tion to seek care at a pub­lic health fa­cil­ity, he/she can in­di­cate to the nurs­ing or ad­min­is­tra­tive staff his/her de­sire to be treated pri­vately. Even af­ter pa­tients are ad­mit­ted as pub­lic pa­tients, they may in­di­cate at any time that they wish to be­come a pri­vate pa­tient. The pa­tient in­di­cates his/her physi­cian of choice or the con­sul­tant on call is con­tacted to de­ter­mine whether they will ac­cept the pa­tient for pri­vate care.

No doc­tor should ini­ti­ate the trans­fer of a pub­lic pa­tient to pri­vate care. In any case, the pa­tient is reg­is­tered as a pri­vate pa­tient of the hos­pi­tal with the chart or the front sheet clearly la­belled as ‘PRI­VATE’ for all to see.

At the end of their stay (or at in­ter­vals dur­ing a long stay), the hos­pi­tal’s billing of­fi­cers will present a bill to the pa­tient for the use of the hos­pi­tal fa­cil­i­ties which in­cludes room and board, drugs and mis­cel­la­neous dis­pos­able items, pay­ment for pri­vate nurs­ing care, and use of theatre (if re­quired). The doc­tor is NOT re­spon­si­ble for pay­ing the hos­pi­tal. It is the re­spon­si­bil­ity of the hos­pi­tal to col­lect from the pa­tient in this ar­range­ment.

The Gov­ern­ment and its agents recog­nised the need to put mea­sures in place to pre­vent abuse of the sys­tem, and so sev­eral strate­gies are em­ployed. At the Univer­sity Hos­pi­tal of the West Indies (UHWI), for ex­am­ple, a com­pletely sep­a­rate fa­cil­ity (the Tony Th­waites’ Wing) was es­tab­lished as the place to ad­mit pri­vate pa­tients. The guide­lines also limit the pro­por­tion of time that can be al­lo­cated to pri­vate pa­tients ver­sus pub­lic pa­tients. For ex­am­ple, for sur­gi­cal cases, for ev­ery three pub­lic pa­tients that are op­er­ated on, each con­sul­tant may op­er­ate on one pri­vate pa­tient.

An­other mech­a­nism is to con­struct a sep­a­rate op­er­at­ing theatre with sep­a­rate staff ded­i­cated to pri­vate pa­tients, such as has oc­curred at the UHWI. At other hos­pi­tals, pri­vate sur­gi­cal pro­ce­dures are done out­side of nor­mal work­ing hours, such as evenings and week­ends. These mea­sures min­imise the com­pe­ti­tion be­tween pub­lic and pri­vate pa­tients for ser­vices and re­sources.


The sys­tem also has built-in mea­sures to mon­i­tor the prac­tice. The hos­pi­tal CEOs, se­nior med­i­cal of­fi­cers and par­ish man­agers have a duty to mon­i­tor the sys­tem and to en­sure that all doc­tors and other mem­bers of staff are aware of the guide­lines through in­ter­nal memos and other meth­ods. The in­sti­tu­tions also have a pa­tient com­plaint mech­a­nism to al­low pa­tients or their rel­a­tives to high­light sus­pected breaches.

Where hos­pi­tal ad­min­is­tra­tors ob­tain al­le­ga­tions of breaches by doc­tors, they are usu­ally in­ves­ti­gated and ac­tion taken. This in­cludes hold­ing dis­ci­plinary hear­ings and im­pos­ing sanc­tions in keeping with the Pub­lic Sec­tor Staff Or­ders.

The tone of the com­ments cap­tured in the ar­ti­cle would give the im­pres­sion that pri­vate prac­tice in pub­lic hos­pi­tals is bad for the pub­lic health sys­tem. In fact, this is a prac­tice that is main­tained right across the world be­cause it of­fers sev­eral ben­e­fits. 1 . In a sys­tem such as ours where the health sec­tor is woe­fully un­der­funded, the fees col­lected from pri­vate pa­tients can sig­nif­i­cantly off­set the cost as­so­ci­ated with treat­ing pub­lic pa­tients, in­clud­ing those who can­not pay. This has even greater po­ten­tial im­pact in an en­vi­ron­ment where there are no user fees. The ad­di­tional in­come helps to pur­chase much-needed equip­ment and sup­plies.

2 . The pol­icy al­lows ANY pa­tient to have the op­por­tu­nity to choose pri­vate care if they so de­sire.

3 . The pol­icy al­lows pa­tients to be able to choose which physi­cian will treat them, giv­ing those pa­tients greater com­fort and peace of mind.

4 . Al­low­ing spe­cial­ist med­i­cal prac­ti­tion­ers to en­gage in pri­vate prac­tice has been used as an im­por­tant re­cruit­ment tool to en­sure that the pub­lic health sys­tem at­tracts and re­tains the ser­vices of a highly skilled med­i­cal work­force. This is prac­tised not only in Ja­maica and other Com­mon­wealth coun­tries, but all over the world.

In re­al­ity, the prac­tice with its po­ten­tial ben­e­fits has been ham­pered by sev­eral lim­i­ta­tions. These in­clude the state of dis­re­pair of the pub­lic fa­cil­i­ties. The back­log in cer­tain lab­o­ra­tory ser­vices af­fects pri­vate pa­tients in the pub­lic hos­pi­tals as well. Many fa­cil­i­ties are im­pacted by the re­duced avail­abil­ity of drugs and other sun­dries to be used on pri­vate pa­tients. These fac­tors will al­ways im­pact on pri­vate care be­cause in the pub­lic ealth fa­cil­i­ties, the pri­or­ity re­mains the treat­ment of pub­lic pa­tients. Many pri­vate pa­tients, there­fore, opt to go to pri­vate health-care fa­cil­i­ties.

It is dif­fi­cult to see how doc­tors could be blamed for bleed­ing the State, the im­pli­ca­tion be­ing that the pri­vate prac­tice of doc­tors is re­spon­si­ble for the di­min­ished re­sources within these fa­cil­i­ties. The prac­tice is de­signed to ben­e­fit the pub­lic sec­tor, not hurt it.

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