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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rural Sierra Leone please click on the either of the links below for details
about an exciting opportunity (Bursary available):
·
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