Many patients and their relatives are frequently turned away from public hospitals because of the lack of bed space for admission. Many emergency cases are turned away from the emergency rooms and left to wander, travelling from one hospital to another. Sadly, since the patient has not been seen or evaluated by a doctor or a competent nurse, many with life-threatening conditions are not identified and so patients die in transit or at the gates of the next hospital.
There are two main issues related to this. First is the lack of care and lack of empathy from poorly trained and poorly equipped frontline staff in many of our hospitals. Stressed staff who feel no more compassion as they turn away patients from the gates of the hospital. Some are even so rude and unconscionable as they shout, ‘Go away, we have no beds’ or as one said recently, ‘Will I turn myself into a bed for you?
I once heard that a well-respected consultant in one of our public hospitals was first turned away from his own hospital until the Chief Medical Director (CMD) intervened. He was eventually admitted and managed on the floor in the emergency room. Oh, and this is good. Sometime earlier, the staff had complained to the CMD about the perennial shortage of beds in the hospital and he had been unconcerned!
So the real questions are, why do Nigerian hospitals fail to make adequate preparations for fresh admissions? Why are there shortages of bed spaces in our hospitals? How do we calculate the exact number of available beds? How do we free more bed spaces daily and how can we create more beds in our hospitals?
There are many reasons why bed spaces are a premium in Nigerian Public Hospitals. These include factors related to the hospital, doctors, nurses, patients and relatives. It also includes issues related to health care financing and the poor economic situation in the country.
Let us take the later first.
The government and the health budget
It had been agreed internationally that nations should budget up to 15% of the GDP on health. However, the data for health spending as a share of GDP showed that in 2014, Nigeria (at 3.7%) outperformed lowly Angola (3.3%) and South Sudan (2.7%). Further, the majority of public health spending in Nigeria is from out of pocket expenses. This means that Nigerians pay for almost 99% of their own health care and the majority of the care (75%) occurs through private health care rather than public hospitals.
So let us understand this clearly: Most of the health provided for Nigerians is through the private health facilities, perhaps even through traditional medical practitioners, herbalists and pastors. The public hospitals in Nigeria are providing only about 25-30% of health care and still doing so badly! The question remains why and what can be done to decrease the burden?
The government has perennially underfunded health. It is simply not a priority for successive governments since the major players have enough money to fly out for medical tourism. This has recently been exemplified by the President of the Federation himself when he flew out to the United Kingdom following his health challenges.
Our leaders simply do not understand that health is wealth and you cannot buy good health with cash. You cannot also cheat death! Because what happens before your ‘untimely death’ in a Nigerian hospital matter in terms of dignity. You cannot arrive at the emergency room of a hospital you have not shown interest in expecting top-notch quality care. This has also been exemplified by the recent demise of the Ex-Governor Isiaka Adeleke.
Hospitals can work more efficiently and effectively in delivering more bed spaces and better care if motivated. The motivation is financial. The motivation required is also simple. The motivation required is simply to cut off the supply of ready monetary allocations to the hospitals. If hospitals are forced to generate their funding and resources, they would utilize bed spaces more efficiently.
The first option would be for hospitals to be creative by introducing protocols and programs for managing conditions. Protocols will ensure that care is standardized and follows laid down guidelines. This will improve service delivery and improve patient outcomes. It will reduce delays in care and the indecisions that trail care in many of our hospitals ultimately resulting in poor outcomes.
The lack of multidisciplinary teamwork in many hospitals is a huge denigration of the standard of care. Multidisciplinary team efforts must be encouraged in our hospitals in a climate of cooperation and camaraderie. Many doctors who have no clue how to treat a patient will be able to get help or be stimulated to transfer the patient to another unit in a spirit of cooperation.
Secondly, hospitals can introduce day care and domiciliary services as part of ways to decongest beds freeing up loads of spaces for new patients daily. Daycare services and especially planned and well-executed daycare surgical services with domiciliary support will create spaces in the emergency rooms and on the wards. Empty beds make money!
Thirdly, the practice of public hospitals not referring patients to specialist private hospitals is also a huge detriment to the health of the patient in many circumstances. Often, one poorly equipped public hospital refer patients to another poorly equipped public hospital without verification of the capacity to manage the patient.
Private and public hospitals should work better together with integration that benefits the patient. The suspicious climate, lack of trust and frank hatred that exists between public and private hospitals is inimical to the provision of quality health care in Nigeria. Public hospitals can have a list of close-by private specialist hospitals with capacity and bed spaces to expand their limitations. A culture of openness and accountability will help in removing the shroud limiting closer cooperation.
Better working relationship, especially under the auspices of the National Health Insurance Scheme, will help reduce the issue of beds while still offering affordable quality health care. Of course, this may not be totally palatable for high-end private hospitals but most will perhaps appreciate the volume of work and small margins than turning down the opportunity to help a fellow human being.
The Guild of Medical Directors (GMD); owners of private hospitals, would value the opportunity for closer working relationships and collaborations between private and public hospitals in Nigeria. The GMD through its members deliver the 75% of care in Nigeria in any case.
There are frequent cases of poor and delayed decision making in many cases in our hospitals. Patients are not discharged on time because of systemic failures ranging from absent consultants and inexperienced junior staff. When doctors are not available, patients are often forced to beg to be allowed home!
This is different from what happens in private hospitals where patients beg to be allowed to stay an extra day: even offering to pay for the assent. In truth, the quality of care and the ambience is better in our private hospitals, but the overriding factor is the accessibility to the doctor and timely care.
Nurses have a major role to play in discharges and rely on effective communication between all the members of the multidisciplinary team to ensure that the conditions for discharge have been met and all is well with the patient. They can facilitate or hinder the discharge of a patient from the hospital.
Often the final decision maker, nurses ensure that the bills have been paid and the patient fully satisfies the conditions for discharge. Therefore, they can plan ahead and facilitate early and efficient discharges that free up the bed spaces each morning. Slow, recalcitrant nurses can frustrate efforts to generate fresh clean beds for the hospital.
Patients and relatives
In many situations, patients and relatives fail to pay their bills and this leads to delayed discharge from hospitals. We have many reported cases of hospitals keeping patients for weeks and months following discharge because of non-settlement of bills. Hidden charges and exorbitant pricing especially in acute situations can lead to mounting bills that delay discharge. Even our public mortuaries are full of bodies that cannot be removed for burial due to failure to settle bills.
The economic situation does not help and yet care should not be withheld due to failure to settle the bill. A compromise must, therefore, be reached for hospitals to remain dutiful but efficient in service delivery. The solution is not easy to come by.
In conclusion, we have tried to explore the problems with inadequate bed spaces in our hospitals and proffer solutions that may be useful for various hospitals. Do you have any ideas to share, before you need a bed! Link me up and email solutions.
This ‘bed’ is in your court!