Healthcare Quality – A Systems Issue

Covid is dramatic and important – but no less so are the myriads of other problems that health services face 24/7, non-stop

By Dr R Neerunjun Gopee

There is no health system anywhere in the world that hasn’t at some stage been overwhelmed by the tsunami of the Covid-19 pandemic. Naturally, the focus has been on dealing with the risks and challenges it has posed, which continue to receive the greatest attention. However, while all this has been going on, it must be underlined that besides coping with Covid, health systems had to also handle all the non-Covid medical and health conditions that form part of their daily routine, and that by far exceeded the Covid load. Covid is dramatic and important – but no less so are the myriads of other problems that health services face 24/7, non-stop and that are equally demanding as well as deserving of as much if not more attention.

Public Health. Pic – cisa.gov

For example, the Washington Post reports: ‘In 2019, nearly 72,000 people died from drug overdoses. In 2020, amid the coronavirus pandemic, more than 93,000 people died from overdoses, according to National Center for Health Statistics’ provisional data. That horrifying figure represents a record year-over-year increase of 30 percent. Public-health crises converged as the pandemic stretched health-care resources, and illegal fentanyl and other opioid drugs continued to drive a high death toll.’

In fact, the US has been facing an ‘opioid’ crisis for several years, and a company producing opioids and coercing or inducing medical practitioners to overprescribe them has been heavily fined by the courts. Doctors deemed to have ‘colluded’ have not escaped chastisement either. One condition of interest to me is low backache, and I have been appalled to read about the overuse of opioids in its management, contributing significantly to the crisis and mortality. This is a medication that I personally use in very specific circumstances and for limited periods for that problem, there being other more effective options of treatment.

On the other hand, in the UK, a joint investigation by Channel 4 News and The Independent has revealed what has been termed the ‘Nottingham maternity units scandal,’ reporting that ‘dozens of babies have died or been left with brain damage at a maternity service accused of bad care and neglect. From 2010 to 2020, at least 46 babies have suffered brain damage and 19 have been stillborn at Nottingham University Hospitals NHS trust maternity units. There have also been 15 deaths at the units involving mothers and babies.’

‘Poor record keeping,’ a ‘culture of fear,’ a ‘warning notice’ issued by the Clinical Quality Commission (CQC) whose recommendations were only partially implemented – the outcomes were the resultant of several factors, as is to be expected and is usually the case in such complex medical issues. There was ‘evidence of poor care of both mothers and babies and of repeated failures to investigate deaths of babies,’ with accusations of a ‘failure or delay to treatment’ and of a ‘failure to recognise complications’ as well as ‘inadequate nursing care.’ Further, ‘vacancies were allowed to build up which meant staff were stretched and a lack of beds meant at-risk women would face delays for treatment.’ At the same time, though, there was praise for ‘many of the staff for working hard to maintain safety.’

Reading this was painful for me. This may not be the National Health System (NHS) where I had trained for several years over 40 years ago, but in spite of all these shortcomings, it still remains in my view one of the best health systems of the world. What has spoilt it, according to what I learn from my contacts in the UK, is excessive and overzealous bureaucratese, but also shortcomings in training and continuity of care.

Childbirth and maternal health have been a major focus of medicine throughout the ages. I do not envy my obstetrician-gynaecologist colleagues. Obstetrics is one of the most exacting specialties to practise, and I do not relish the thought of my experiences during my posting in that department as a junior resident!

The death of a newborn is a tragedy for both health staff and the parents and family, and it is not always avoidable. The same logic applies to all other cases across the whole medical spectrum. But what is important is to be prepared to the best of one’s ability and resources, and here qualifications, training and experience are crucial. This is a very broad and complicated matter, but there are basic principles that can guide one. The approach and solution(s) can only be at systems level, and that mean at all levels of the system of healthcare.

Specifically as regards maternity, for example, there must be qualified and trained midwives who, by definition, can only gain experience under the supervision of experienced and dedicated midwives. To start with of course they must be qualified nurses, which locally means obtaining a diploma in nursing after following a 3-year course at the Central School of Nursing, after which they must follow a course of training in midwifery. The former one-year course had been abolished some years back (for reasons that I need not go into here), and replaced much later by a two-year course. However, for the past two years this course has not been run. Covid or no Covid, this ought not to have happened. Unless this issue is taken up with the urgency it deserves, and all related matters too are analysed and viable solutions worked out by clear-headed minds focused on bringing improvements rather than finding heads to chop, the risk of tragedies will remain.

But it is not only Obs-Gynae that is concerned, the same approach must inform all other specialties, clinical and non-clinical, on a proactive, ongoing basis. Only one policy innovation has been brought about for the overall improvement of healthcare quality in the past decade, and that was the introduction of Continuing Medical Education through the Finance Bill in 2011. CME too has faced difficulties in the Covid period, and here also there is a need to revisit the conduct of this programme from a systems perspective. There will always been a long way to go and millions to do – but it’s up to the country to make a good start in the hope of a sound finish.   

* Published in print edition on 16 July 2021