Healthcare Regulation

First Published: 2005-01-20

The current debate over medical malpractice lawsuits in the United States contrasts dramatically with the situation in the Bahamas.

American doctors face soaring costs for malpractice insurance coverage and want to cap legal claims. The Bush administration says lawyers are filing frivolous suits that make treatment more costly while forcing doctors to curtail vital care.

This threat of potentially bankrupting litigation causes American doctors to engage in defensive medicine, analysts say, which wastes billions of dollars a year by directing money to unnecessary drugs and tests.

But in the Bahamas, the position is almost exactly the reverse. Patients have little recourse in cases of medical negligence, regulatory supervision is almost nonexistent, and doctors are free to ignore complaints about the care they provide.

To make matters worse, we have no publicly available statistics on issues of safety, timeliness and competence in the Bahamian healthcare industry…data that is urgently needed to drive quality and efficiency among service providers.

As crazy as it seems, doctors are the third leading cause of death in the US (after heart disease and cancer) killing nearly a quarter million people a year, according to the July 26, 2000 issue of the Journal of the American Medical Association. This estimate does not include negative effects associated with disability or discomfort. Evidence from other studies indicates that as many as 30 per cent of patients receive inappropriate care in the US.

If that is what happens in the world's most advanced and litigious healthcare industry, what shortcomings must we face in the Bahamas? The short answer is – no-one knows.

Critics say that when it comes to safety, the healthcare sector should borrow a page from the airline industry. When aviation accidents occur, the industry can analyze important data to help prevent future errors. In healthcare, no such universal information system exists.

According to Leandra Esfakis, an attorney whose late father was a well-known Nassau GP: "We have the benefit of some very good medical practitioners here. But many of us also have grave reservations (no pun intended) about local healthcare facilities, which may have problems that are never brought to light, and never addressed."

Parliament set up the Hospital & Health Care Facilities Board in 1998 to inspect and license the private healthcare sector in the Bahamas. One of its chief responsibilities is to investigate complaints from the public.

However, it has no record of doing so. Last June, for instance, a complaint was made to the board over the death of a patient at a private hospital and it has yet to respond. Two more complaints have since been submitted concerning inadequate care at the same hospital. In all three cases, the patients died.

At first, the board said it had no idea how to undertake an investigation. So it asked the Attorney General's office for advice, but it still won't say when or if an inquiry will be launched. The board's chairman, Dr Kirkland Culmer, did not respond to faxed questions on this subject.

One has to ask why, seven years after it was set up and six months after a complaint was made, this statutory body is either unable to hold an inquiry, or refuses to do so. Complicating matters is the fact that some board members are intimately connected to the private facilities they are supposed to be regulating. Critics say they need to either do the job the law requires or resign.

From the public's point of view, the only leverage in these circumstances is the possibility that a complaint will affect the bottom line of the facilities involved. At the very least this would mean suspending licenses until improvements are made.

There is no point in setting up a statutory body to inspect hospitals and clinics without the capability to ensure that proper standards are met and legitimate complaints addressed. After all, these are matters of life and death. If the health standards legislation is not implemented, it leaves the survival of patients at risk.

Why create meaningless statutes in the first place? We are currently being inundated with so-called "consumer protection" legislation by the Ministry of Trade & Industry. Will these regulations have any more impact than the laws currently in force to govern the medical profession?

And why aren't death records from private hospitals collected and analyzed…for comparison with similar rates in similar-sized hospitals elsewhere? If this were done, perhaps it might move those responsible to address the root causes of deficiencies, instead of running for cover.

In Britain a special commission undertakes independent investigations into complaints about both the National Health Service and the private healthcare sector. These investigations are normally completed within six months – information is published on a Web site.

The UK commission says it aims to be "an authoritative and trusted source of information" and wants to ensure that this information is used to drive improvement in the industry. Complainants who are unhappy with the outcome of a review by the commission can take the matter further, to an independent health ombudsman.

In the Bahamas, the Hospital Board is supposed to protect the public from sub-standard healthcare. But the big question is whether the law works well enough in a small, incestuous, accountablity free society like ours to allow basic safeguards to be enforced.

As part of the effort to achieve an acceptable standard of patient safety, all healthcare facilities should establish comprehensive patient safety programmes operated by trained personnel, experts say. They must establish a culture in which patient safety is a top priority.

In the meantime, the automatic licensing of private hospitals, whether or not they meet proper standards, can be construed as putting lives at risk,. And the position is very similar for the elite medical fraternity itself.

A medical council was established by statute in 1975 to license physicians in the country. There are currently over 600 doctors licensed here, about half working full-time in government service. Under the Act, doctors can theoretically be disciplined for negligence or incompetence, for disclosing confidential patient information, or for serious professional misconduct.

Written complaints are supposed to be evaluated by the council, which may then appoint a disciplinary committee that includes a supreme court justice. Penalties can include a one-year suspension of license, a fine of $1000 and payment towards the cost of the proceedings.

The council consists of seven members, including the chief medical officer (currently Dr Vernell Allen) who acts as registrar. Members are appointed by the minister of health in conjunction with the Bahamas Medical Association.

Their chief responsibility is "to ensure that proper standards of professional conduct in the practice of medicine and proper standards of general fitness to practice medicine are maintained."

However, since the council was created, it is believed that only one Bahamian doctor has ever been suspended – and that was for drug abuse. Although formal complaints have been lodged over the years (one as recently as last December), Dr Baldwin Carey, the council chairman, would not respond to calls or faxes on this matter.

This leads us once again to the vexing issue of why there is so little accountability, or rule of law, among practitioners of three of the nation's most prestigious and rewarding professions – the law, medicine and politics.

Of the three, it seems that healthcare providers have the highest degree of immunity (or impunity)…perhaps because of the greater respect which their profession, for obvious reasons, usually commands.

But as the late Indian sage Krishnamurti once said: "It is no measure of health to be well-adjusted to a profoundly sick society."

The column 'Tough Call' by Larry Smith is published in The Tribune every Thursday and is reprinted here as a courtesy. Mr. Smith founded and successfully grew an advertising agency over 20 years. Under his direction Media Enterprises diversified into short-run commercial printing and publishing, and is now the largest non-fiction book wholesaler in the Bahamas. He has 30 years experience as a journalist and publicist and has contributed numerous articles and columns to the Bahamian press. A former reporter at the Nassau Guardian, local correspondent for Reuters and editor at the Bahamas News Bureau, he conceived and edited the Bahama Almanac (published 2000 by Media Enterprises), wrote the commentary for Mike Toogood's Portrait of an Archipelago (published 2004 by Macmillan Caribbean), and edited the Bahamas Environmental Handbook (published 2002 by the government). In 2003 he took a year's leave of absence from Media Enterprises to lead a transition management team at the Nassau Guardian after the paper was acquired by local investors. After leaving the Guardian he was contracted by the Tribune as online manager/editor and columnist. He has a degree in political science and journalism from the University of Miami. Mr. Smith can be contacted at: larry@tribunemedia.net

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