Things that Matter: Health Care: Part 4
(Continuing an edited synopsis of the opening of the DLP Lecture Series: “Celebrating Fifty Years of Independence”, June 29th, 2016, at Almond Bay.)
How do we go forward to achieve a healthy future Barbados? Eight years ago, opening the Chronic Disease Conference, the late Prime Minister David Thompson said: “If left to chance, all the gains achieved in the Caribbean during the march from poverty to relative affluence since Independence can be wiped out by the NCDs.”
Several decades ago, WHO set the Utopian target of Health for all … this is truly Utopian, and as I have constantly pointed out, the more achievable goal is health CARE for all. But 30 plus years later, even this goal is receding across the world.
In Barbados we MUST strive for appropriate health care for all … in the words of Sir George Alleyne, Director Emeritus of PAHO and Chancellor of the UWI, our unceasing goal must be Equity in Health Care, although even this is perhaps Utopian except perhaps for more wealthy countries, such as Sweden and Holland. But we MUST ALSO strive for health for as many as possible, through PREVENTION. And here we need new understandings, new methods and new partnerships. It’s common knowledge that the five key factors for good health are: regular physical activity, healthy eating, avoidance of smoking, avoidance of alcohol abuse, and avoidance of stress and all that that implies.
But how do we change behaviour? I submit that we need three approaches:
Current knowledge must be applied by a major strengthening of our Health Promotion Unit. I lobbied and wrote proposals for its expansion some 20 years ago. As a result, the unit was doubled – from one person to two!
Secondly, we need a major research effort on changing behaviour. People are knowingly “eating themselves to death”, literally, causing huge challenges and tragedies for their families – bankrupting both families and government. Too many follow the dictum: “Whenever the impulse to exercise comes over me, I lie down until it goes away”.
Thirdly, until we have a better understanding of how to change behaviour, one method is clearly successful. Taxes on alcohol and cigarettes have a significant impact on use, and could be further increased … and it’s now been shown for sugary drinks. But not a 5 or 10 per cent tax – which is hardly noticed – but 20 per cent or more. Taxes on unhealthy foods and drinks - sugar drinks, oily and salty food (fast foods like French fries), and no VAT on healthy foods. This is a “no brainer”.
But how do we pay for the way forward? We have “champagne desires and mauby pockets”. The carefully iterated suggestions of the Barbados Association of Medical Practitioners (BAMP) included:
1) Health care financing must be part of the national vision – like tourism – both tourism and health are everyone’s business!
2) The public must clearly understand that the current method of health financing is unsustainable. (And so must government!)
3) The goal is sustainable healthcare for ALL members of society and the most vulnerable must ALWAYS be protected, with no fee-for-service. (As Sir George Alleyne says over and over again – Equity, equity, equity!)
4) A healthcare fund, managed in a similar manner to the National Insurance Scheme, should be instituted in which employed persons contribute to the health of the nation according to their means. (This worked wonderfully well for the Drug Service, with no complaints, because the benefits were so obvious! Likewise, the tiny, token prescription charge works well.)
5) More attention should be paid to the primary care services at the polyclinics – a systems review is needed.
6) The elderly should be protected from abandonment at the QEH and it should be an offence punishable by law for anyone to do so. (We need to increase support, through nursing and welfare services, for families to look after the elderly at home. And I emphasise the obvious benefits of day care centres for the elderly … the St. Barnabas centre is a model, saving families and government a small fortune. Every church should have one.)
7) Encouragement must be given to members of society who can do so, to look after themselves, through incentives for taking up health insurance for example.
8) Health care costs in the private sector can be decreased by capping malpractice insurance claims and allowing duty-free concessions for equipment to medical practices, saving costs that are passed on to the public. (This is especially important in dentistry, where equipment and conservative treatment materials are extremely expensive. I weep for public patients with pain who have to settle for extraction.)
9) Consideration could be given to having the QEH run on a public-private model, where government is the main shareholder of a healthcare corporation that employs contractors to ensure efficient 24 hour functioning. The management and efficiency of the staff would be answerable to shareholders. (I gather that idea has been wrongly interpreted as pay for service, which I don’t think it was, but it merits discussion.)
Other suggestions from doctors I consulted include: a token attendance fee for visits to the polyclinic, but waived for emergencies or cases of need; increasing taxes on alcohol, tobacco, sugary drinks and fast foods - strongly urged; insured patients should pay a contribution for use of Drug Benefit Service and polyclinic services; health care credits, to be cashed in on using the services, as in one Scandinavian country - but those with chronic diseases would need far more credits, so a challenge to the goal of equity, and perhaps complex to manage.
An important point, made by one of our most experienced doctors, is the huge and growing problem of unnecessary testing. We are victims of cultural penetration from the USA, through television, with patients expecting and often demanding a CAT scan for every headache. Our medical teaching emphasises clinical skills in diagnosis, but the pressure of patients on young doctors can be overwhelming. The American emphasis on technology instead of common sense, history taking, examination and sympathetic listening is winning, with huge, spiralling costs. And the vast cost of intensive care technology at the end of life, with loss of dignity and family distress, calls for doctor and public education, and the practice of living wills.
Similarly, pressure for sick leave for minor problems comes at huge cost to society. Samuel Butler wrote, 150 years ago, “I reckon being ill is one of the greatest pleasures of life, provided one is not too ill, and is not obliged to work until one is better.”
Finally, a health levy, similar to the Drug Service Levy of the ’80s, which was readily accepted by the population, but it must not go into the Consolidated Fund. It must be managed like the National Insurance scheme.
These proposals make sense and are based on evidence. But health care comprises several levels – Prevention, Primary care, Secondary (specialist) care, and Tertiary (Hospital) care. Most resources are spent on Tertiary care, increasing amounts on Primary care and little on Prevention. This is where effort, including research, must go. Grannies taught us “An ounce of prevention is worth a pound of cure”.
However, tertiary care is a potential revenue earner for us. Sir George Alleyne, Ms. Walters (Chief Records Officer) and I reported in 1993 on the extensive use of QEH by both Caribbean patients and tourists. But we haven’t learnt the lesson of Dr. Bayley’s Diagnostic Clinic. We could serve the many OECS patients who travel to North America for cardiac, orthopaedic and neuro-surgery, if we have the vision. I have spoken for 30 years of my vision for the QEH as the Mayo Clinic of the Caribbean. But where there is no vision, the people perish. Literally. And the controversial political pipe dream of a new hospital and the St. Joseph Hospital opportunity will need another discussion.
Bouquet: To Mr. Charles Herbert, Chairman of the Board of Goddards, for accepting the challenging role of Chairman of the Barbados Private Sector Association.
(Professor Fraser is past Dean of Medical Sciences, UWI and Professor Emeritus of Medicine. Website: profhenryfraser.com)