Mumbai’s health authorities are currently in the throes of an intense response to the pandemic. But even as they fight the battle, hospitals run by the Brihanmumbai Municipal Corporation could use the crisis to think about the future.
The unfortunate reality is that government hospitals in Mumbai almost exclusively cater to patients who are too poor to afford private care. However, Mumbai’s elite must realise that publicly funded municipal hospitals have an advantage: they provide multidisciplinary , holistic medical care under one roof. Besides, since many of them are attached to medical colleges, they can draw in the latest academic research. This cannot be achieved by small stand-alone privately funded clinics and hospitals
As a doctor who has trained in Mumbai’s prestigious municipal hospitals and who now works in the United Kingdom, it seems that Britain’s National Health Service offers a useful model for change. Despite many weaknesses, the NHS continues to provide publicly funded quality healthcare for Britain’s citizens. Regardless of the alarming mortality rate during Covid-19 crisis, the UK never lacked infrastructural or human capacity.
Early in April, the first NHS Nightingale hospital, a temporary Covid centre, was rapidly planned and constructed over a few days at the ExCel centre in London. It had a potential capacity of 4,000 intensive care beds.
On a per capita basis, the UK spends nearly 80 times more on the health of approximately 9 million Londoners than the Mumbai municipal corporation does on its residents. Of the 152 billion pounds (approximately Rs 1459,000 crore) of the total NHS budget in 2019-’20, the allocation for London was about 17 billion pounds (roughly Rs 158,000 crore).
If this seems like an unfair comparison, consider that the meagre Rs Rs 4,000 crore allocated for the health of Mumbai’s 20 million residents in the 2019-’20 budget is only around 7% of the corporation’s total revenue. On the other hand, traffic and road operations were allocated 19 % of the revenue. Mumbai is run by the richest municipal corporation in the country: it had revenues of more than Rs 30,000 crore in 2019-’20).
Here are a few pointers Mumbai’s public hospitals could take from Britain’s National Health Service.
- · Data-driven decision making: In an era of artificial intelligence and big data, Mumbai’s public hospitals must embrace new technologies. It desperately needs more computers, a dedicated information technology cell for maintaining and updating software, electronic medical record training for staff, paperless out-patient department consultations and digitalising data. For perspective, the NHS spends nearly 300 million pounds on its digital services plus 552 million pounds on tech infrastructure. Indian start-ups or the IITs could help set this up at a fraction of the cost.
- · Employ managers: Doctors rarely make good managers. Recruiting healthcare MBA graduates for administrative jobs would be a better strategy than thrusting this load on unwilling clinicians. They could be entrusted with restructuring clinics, optimising resource efficiency, scheduling appointments instead of accepting walk-in patients, organising hospital supplies, patient data management and similar tasks.
- · Build organisations: A board of directors in each hospital with clinical, non clinical stakeholders, public representatives and union leaders is a good working committee structure. It is better that these members rotate every year rather than fixed posts for deans and deputy deans. Horizontal hierarchy and an open door policy would help cut red tape and bureaucracy.
- · Billing non-essential services and insurance tie ups: Covid-19 has forced us to delineate essential vs non -essential services. The former includes emergency care. Follow-up visits for stable chronic conditions, cosmetic procedures and elective surgery are among those deemed non essential. Hospitals should consider billing those patients who can afford to pay for non essential procedures. Partnering with the government and private insurance parties means that patients would not need to pay upfront. The extra revenue could then be rerouted for non-affording patients.
- Increasing revenue: Paid observership programs for national, international students and live streaming online departmental academic programmes for a subscription are just some ideas to counter increasing health costs. There is no dearth of wealthy private and institutional donors willing to chip in. Research grants and industry partnerships are other revenue sources.
- Ramping up human capacity: Filling chronically vacant posts by doctors and nurses alone is ineffective. To truly increase capacity, we need more lab technicians, office personnel, phlebotomists, cleaners, theatre runners. Create good teams that centre on senior clinicians, where they have the autonomy to cherry-pick talent according to their needs.
- Create a specialty nursing cadre: Developing specialty-based nursing roles would decongest out-patient departments and theatre lists. Nurse practitioners, operating department practitioners, and midwives are just some of the roles our nurses could take on.
- Structured out-patient clinics: Mumbai hospitals should schedule appointments for non-urgent cases instead of accepting walk-in patients.Mobile phones would help dedicated clinic managers reach patients easily. This would result in better quality clinician-patient interaction with time for documentation, data entry and academic exchanges.
- Engage the private sector: Employing honorary clinicians who do sessions in both the public and private sector is a way to bridge the public-private divide. They could train municipal doctors or design and execute newer services within their specialty.
- Upgrading the research framework: Generating indigenous reliable data instead of basing clinical decisions on foreign statistics is imperative. Digitalising data and allotting protected research time for clinicians will enable this. Employ dedicated research staff like statisticians, trial fellows, and PhD students.
- Do regular audits: Promoting a culture of transparency with minimal red tape and bureaucracy, needs regular non partisan audits. Tendering and purchasing expensive equipment without using it for patient benefit is unacceptable. Auditing usage and patient outcomes would rectify this.
- Incentivise staff: Paying healthcare workers handsomely to lure them into Covid-19 service while offering them a pittance otherwise is sheer manipulation. Decent pay with benefits would reduce lure for “lucrative” private/corporate practice. Let’s aim to retain and nurture talent within public sector.
Some of these measures may seem drastic. But cynicism and a laissez faire attitude will leave us crippled in the post-Covid world. Mumbai should pave the way forward.
Dr Eesha Gokhale is an ophthalmologist at London’s Moorfields Eye Hospital, Londo. She graduated from Mumbai’s KEM hospital, did a post-graduate degree at Nair Hospital, and worked at the Municipal Eye Hospital in Kamathipura
Data analysis and statistical inputs courtesy Sushant Gokhale, B.Tech, IIT-B.