Livingstone Hospital … a case study worth analysing

A recent media report revealed that some patients admitted to Livingstone Hospital a large provincial hospital located in Gqeberha, Eastern Cape are apparently given a letter which reads as follows:

You have been admitted to Livingstone Hospital because you require emergency/urgent treatment for an orthopaedic condition.

Unfortunately, the implants (metal devices used to fix broken/deformed bones) needed to best treat you are not currently available in the hospital. Depending on your injury and the delay the implant unavailability causes, you might not be able to be treated surgically and have a poor result/outcome. Your doctors have not been informed when implants will again be available nor given any alternative hospitals to which to transfer you.

This follows a recent response to the Eastern Cape Legislature by the Head of the Health Department that procurement processes were underway to obtain the required implants. She indicated that patients “whose employment depended on successful surgeries were provided with sick notes, support from a social worker and facilitated referral for a temporary social grant”. The problem is not new as from the middle of 2022 it was reported that suppliers had stopped providing orthopaedic implants to the department due to the failure to pay outstanding invoices, some allegedly dating back as far as 2019.

From a medical perspective delayed treatment particularly in the case compound fractures, other than the emotional trauma that it causes, can result in an increased risk of infection and even permanent disability. Therefore the lack of implants as reflected in the “letter to patients” quoted above is a matter of serious concern particularly since the situation appears to have persisted for a prolonged period which cannot alone be attributed to “the requirement to approve tenders and adhere to supply chain management regulations”.

What is at stake in this case is whether in terms of the South African Constitution, the basic human rights of citizens are being infringed. The Bill of Rights states that “no-one may be refused emergency medical treatment” and if the patients who received the letter referred to above had been admitted having suffered acute trauma, it is reasonable to assume from the failure to be able to operate due to the lack of appropriate implants that they are indeed being refused emergency medical treatment. There may be some legal argument, that since they have been stabilised and provided with interim treatment, that this is not the case, but in my opinion this is a moot point.

One can throw one’s hands in the air in desperation that the performance of a health service can sink to such levels. However, it is worthwhile to utilise this as a case study of the challenges that face South Africa in being able to provide quality healthcare to the majority of its citizens who are dependent on the public health service. The convenient explanation is that the funding of healthcare is inadequate and what has occurred at the Livingstone Hospital is a consequence of solely a budgetary problem.

Notwithstanding this, it is useful to further analyse why this situation has arisen. In several responses from the Eastern Cape Health Department, the budget challenges are attributed to an extent to the large amounts that the department has been obliged to pay out due to medico-legal claims against the department for “medical negligence” in health facilities in the province. While some of the claims appear to be either have been gratuitous or even fraudulent, the quantum of claims against the department suggests that there is an inherent challenge of poor quality of public health facilities in the province, as highlighted by what has happened at the Livingstone Hospital.

Accepting that the demand for healthcare in most countries will outstrip the available resources, the challenge is to determine whether there is an alternative to what has occurred at the Livingstone Hospital. It seems pointless to me to employ staff capable of performing the surgical interventions required by patients presenting to the Livingstone Hospital but not providing the medical staff wherewithal to do so. Much emphasis is placed in national health policy on the need to develop primary health care, but for patients requiring specialised surgical procedures, competent skilled and staff in a well resourced secondary or tertiary level hospital are required.

To achieve this the department is required to ensure that (1) the facility is adequately resourced to provide the level of care required; (2) the available funds are prioritised and utilised to provide essential and emergency medical treatment; (3) the facility is effectively managed and that the all funds available are most effectively utilised; (4) all the staff within the facility are both gainfully employed and essential to the provision of healthcare; (5) procurement processes, both within the facility and at provincial level, for essential medical and surgical supplies are undertaken in a timely manner; and (6) contracts once in place are effectively managed

In my experience both heading two provincial health departments and subsequent to my retirement as a member of various task teams adherence to these six points is the key to the ability to provide specifically essential and emergency medical treatment when required. I have encountered health departments where staff have been employed both in a full-time and contractual capacity without taking into account the fact that by doing so, the remaining budget is inadequate to enable the department to procure the goods and services required to provide quality healthcare. Often the response to this recommendation is a knee jerk reaction that more rather than less staff are required. This ignores the fact that additional or even the current staff  numbers are unaffordable if an adequate quantum of the budget is to be allocated to the procurement of the required goods and services. These are difficult managerial decisions which must be based on accurate determinations of staff numbers and their cost, where they are deployed and whether all are essential for service delivery. I have encountered departments where the staff database is of such a nature that this data is not readily available.

Having determined the affordable staff complement and the funding necessary to procure the required goods and services, it is essential that procurement processes are efficiently managed to ensure that the necessary tenders and contracts are always in place. Only goods and services essential to provide healthcare should be procured. It is further essential that invoices are effectively managed to ensure payment within the required 30 days as prescribed by National Treasury directives. It should be obvious that if a department procures goods and services knowing that funds are not available to pay for these services, that this is both unethical and irregular. In many provincial health departments, the accumulation year-on-year of what are euphemistically termed “accruals” but are more correctly “unpaid accounts” is a reality, which leads suppliers to refuse to deliver goods and services until such accounts are settled.

The consequence of adhering strictly to the allocated budget, is that it may be necessary to limit what can be delivered which is a sensitive issue particularly difficult for politicians and communities to accept. In making these decisions I would have difficulty in excluding emergency orthopaedic procedures but as I was forced to do, when heading the Western Cape Department of Health, I would consider limiting the number of non life-threatening procedures, such as a hip or knee replacements. I accept that this is an emotive issue even more so when failure to provide a procedure, such as renal dialysis or transplantation is life threatening but without an unlimited public health budget it is unavoidable.

Managing healthcare is a challenging endeavour and not for the fainthearted. I do not have enough information on which to make a final determination on the situation that exists at the Livingstone Hospital, but from my experience in various provincial health departments, I am left wondering whether, if the steps outlined above had been adopted, what prompted the medical staff at the hospital to provide a letter to patients of the nature reported, could have been been avoided.