Thursday, January 26, 2012

If doctors and politicians want to attract medical tourism to The Bahamas, they need first to inspire confidence in Bahamian medical services among Bahamians themselves... ...Putting the legislation that already exists to work on behalf of the public interest by providing quality assurance and oversight of healthcare delivery is the obvious place to start

A question of medical trust

Tough Call - tribune242

IN a recent Tribune article, heart specialist Dr Conville Brown complained about Bahamians spending millions of dollars in the US for medical care that could easily be obtained at home.
He was arguing in favour of local healthcare providers building a large-scale medical tourism industry.

"The same things that all tourists do," he said, "the medical tourist has to do. (And) if the ownership is Bahamian, then the economy really wins because those funds will stay here."
But at the same time, he felt constrained to point out that Bahamians were offsetting the income from foreigners by flying off to get treatment in the US.

"We boost their economy big time. We are reverse medical tourists. Several hospitals in South Florida say their biggest international clientele is from the Bahamas."

Medical tourism is a multi-billion-dollar growth industry that hospitals, doctors and tourism marketers around the world are eager to tap into. By some accounts, more than half a million Americans travel to other countries for medical treatment - partly for cost reasons and partly to take advantage of procedures not yet approved in the US.

There can be no disagreement with Dr Brown's position in terms of the Bahamian economy. And for patients, the benefits are equally obvious and compelling. If Bahamians obtained their medical treatment at home, they would significantly reduce the logistics, expense and stress of being treated abroad.

Why then, do so many of us spend so much money overseas for treatments that are available right here at home? We can answer that question fairly confidently - given a choice, patients will seek medical care from the doctors, hospitals and clinics they trust the most.

This is a personal decision, and it is usually an informed decision. Patients must feel assured that the doctors and facilities they choose are both accountable and able to provide the best quality care they can afford.

So what processes do we have in place to convey such assurances to Bahamians?
Well, there are three statutory bodies that are capable of providing quality assurance and oversight to the Bahamian healthcare sector.

The Public Health Authority has managed government hospitals and clinics since 1999, under the direction of the Minister of Health. As an independent public body, the Authority is responsible for planning, policy, monitoring, evaluation, and management, as well as programme development and oversight.

However, the PHA's legislation has no provision for the investigation of complaints about the healthcare facilities managed by the Authority. Instead, PHA patients are advised to contact the "patient representative" to discuss any concerns they may have.

The Hospital and Health Care Facilities Board was created by Parliament in 1998 to license private hospitals and clinics. This legislation does include a specific mandate to investigate complaints into the "diagnosis, management and treatment" of any patient.

Physicians are the primary providers of healthcare, whether in the public or private sector, and since 1974 they have been licensed and regulated by the Medical Council. According to its website, the council was established "to regulate the medical profession, to upgrade doctors through continuing education requirements, and to safeguard the public through receiving and disposing of complaints".
However, despite the fact that it represents one of the richest professions, the council is made up of a handful of volunteers with virtually no administrative staff. Their website, for example, includes dead and departed physicians on its registry.

So do the records of these three bodies help to inspire confidence and trust in the delivery of healthcare services in the Bahamas?

Well, it would be useful to know how many complaints have been processed by the PHA's "patient representative" and how they were resolved, but unfortunately that information is not publicly available. As for the Hospital Board and the Medical Council, a summary of the case history of one complaint to these bodies over the past decade is instructive.

In 2004, a complaint was made to the Hospital Board concerning the treatment of a 42-year-old man who unexpectedly died in 2002 in a licensed Bahamian healthcare facility.

The board initially refused to deal with the complaint. But after several board members were replaced in 2005 by then Health Minister Dr Marcus Bethel, he ordered that the complaint be investigated. This order by Dr Bethel more than six years ago is the high-point of the case.

The 2005 board met with the complainant's legal and medical representatives in 2006. Afterwards, the Board chairman advised that "since the patient was dead, the file should be closed."

The board did, however, reconsider, and an investigatory panel was to be formed. However, the government changed before this happened.

The new government reinstated the 2004 board chairman, and other members. This chairman reported to a Rotary Club meeting in 2008 that the board didn't want to investigate any complaints, or "be involved in that detailed level of work".

The board said it would seek to have its enabling legislation amended, to remove the investigative requirements, and also to remove the requirement for licensed facilities to report deaths occurring on their premises - a legal mandate never complied with, and never enforced, over the board's entire lifetime.

(It should also be noted that over the past 14 years the board has issued only two "annual" reports to Parliament, something which it is required to do by law every year. And even obtaining copies of those two reports presents enormous challenges).

At a public meeting in 2008, Health Minister Dr Hubert Minnis also promised to investigate the 2004 complaint. But it is now 2012 and the board has taken no action whatsoever. Neither has it ever responded to the complainant.

As for the Medical Council, it received a complaint about the same patient's treatment and care in 2008. The disciplinary committee of the Medical Council met twice on the matter, and three years ago, then council chairman Dr Duane Sands assured Tough Call that: "There is no stonewalling. We take this very, very seriously because we want to ensure that the public will be well-served at the end of the day by this groundbreaking precedent."

He also told me that the medical act (which has been stalled for almost a decade now) was being strengthened to deal with "a finite group of people who are discrediting the profession without any real repercussions - from charging extortionary fees to providing less than appropriate care".
However, in December of last year, the Medical Council's disciplinary committee suspended the 2004 complaint investigation indefinitely.

The council decided it could not proceed because of an ex-parte injunction granted by a Supreme Court judge against the disciplinary committee in 2009, on the application of a doctor concerned in the matter. Since then, the Medical Council has taken no steps either to have the injunction removed or to proceed with the investigation.

The injunction itself is a curious feature in this story. It is perhaps "the one and only" injunction to be granted by one Supreme Court judge against another Supreme Court judge (who sits in his judicial capacity as a member of the statutory disciplinary committee).

Kerzner's branding of the Ocean Club as the "One and Only" has given a high profile to the Bahamas as an attractive destination, but the "one and only" injunction against a Supreme Court judge could have a converse affect on the Bahamas as a destination for medical tourism - quite apart from the collateral damage inflicted on the public oversight function of the Medical Council.

If doctors and politicians want to attract medical tourism to the Bahamas, they need first to inspire confidence in Bahamian medical services among Bahamians themselves. Putting the legislation that already exists to work on behalf of the public interest by providing quality assurance and oversight of healthcare delivery is the obvious place to start.

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January 25, 2012