I read about the tragic death of Susmita Biswas lying at the doorstep of the SSKM hospital, and of the subsequent transfer of the four top officers heading it. My first reaction was outrage at the callousness of the people running the hospital, and despair at the unalterable mediocrity of the government-run services. But my next thought was: I would hate to be a doctor working at this hospital.
Especially now that the SSKM hospital has become notorious. Every time a doctor from it has to introduce himself, he will cringe. He will burst into a long explanation of the tragic incident — that the operation room was being used, that there were no beds available, that they phoned so many other hospitals and they all refused. Or launch into statistics of how many patients the hospital has treated and how many operations it has done. Or descend into a dirge about how overworked he is, how little sleep he gets, how the government starves him of equipment, etc. Or, if he has been properly educated, launch upon the iniquities of the capitalist system and the malignity of his questioner. It is bad enough not to be recognized for the good work one does; it is infinitely worse to be branded by association with a crime that one did not commit.
If this is how doctors react, then it will become even more difficult for the hospital to attract good doctors than it was; and it could not have been easy even earlier, given the working conditions. Refusal to admit a patient is a symptom of something — of lack of capacity in some form or another. Maybe the right specialist was not available, maybe beds were not available, maybe the hospital was having a crisis of one sort or another. All of them would be symptoms of poor working conditions; all would put off good doctors. So the adverse publicity would only make this hospital worse.
With the transfer of the responsible officials, the government has replaced the managerial team; the new managerial team will find its job even harder. Will it do it better' This must depend on whether it is more competent — and whether it has better means to do the job.
What is the job' And what are the means the management needs to do it' It is the public expectation that government hospitals must treat those who cannot afford the treatment. That ensures that they invariably get more demand for services than they can provide. How do they cope with it'
First, they make people wait. Anyone who wants to be treated must go and queue before a doctor on duty; it may take hours to see him. If he is not there — or if one is unlucky enough to be taken ill when there is no one on duty — one waits that much longer. If one cannot afford to wait — if one dies before one gets to the doctor, or can afford to go to a private one — one will not go to SSKM hospital. Thus by restricting access to primary health care, the hospital matches supply to demand.
Second, they give unattractive service. They keep the hospital dirty. They make people share beds, or make them lie on the floor, in corridors. They mix critically ill and less desperate patients, so that the latter will be scared away by screams. They have rude nurses and janitors. They make service unattractive to put off as many patients as possible.
Third, they make service unreliable. They do not repair equipment that breaks down. They do substandard tests. They give spurious drugs. They increase the hazards of treatment.
These are the ways in which the inevitably excessive demand for public hospital services is tailored to the fixed supply. The change of management cannot change those ways, because the management does not fully control them. It cannot make staff work beyond their hours of duty — or indeed make some of them work at all, if the staff have political power. They cannot increase the area of the hospital. They cannot police the quality of drugs.
In other words, the management of the SSKM hospital is doing an impossible job, and will therefore fail to do it however often the government changes it. The chief minister must know this — he must know that transfers are only a palliative to ward off public anger, that they are not even the beginning of a solution.
Is there a solution' No; but there is a better way of doing things. At the level of the hospital, the new surgeon general should ask the government for three things. First, he should be given an annual subsidy, to be deposited in the hospital’s account on the first day of the financial year, and should have full freedom to use it as he sees fit, without interference from Writers’ Buildings. He should be allowed to appoint an internal auditor, and should receive neither visitors nor phone calls from the government. Second, he should be free to hire and fire staff, and pay them what they deserve. He should have six months to judge the capacity and willingness of the existing staff; at the end of the six months, anybody whom he finds substandard should be “transferred” out of the hospital by the government. And finally, the government should immediately remove all “encroachments” — all employees, businesses, and occupiers of space whom he does not think they serve the basic functions of the hospital. In brief, this hospital cannot be set right unless someone takes charge, and has the authority to set it right.
Next, he should decide what is the hospital’s mission. It would seem that its function is to provide the highest medical services — services other hospitals cannot provide. In addition, it would seem that the public expects it never to refuse a serious case like Susmita’s. In that case, he would have to concentrate on three things. First, he must expand his outpatient services to ensure that all who approach get quick, reliable and high-quality diagnosis — and that they are immediately segregated into those few whom the hospital would treat and others who would get only outpatient service or have to got elsewhere. Second, he must ensure that his specialist services work flawlessly. He must see that all the machines, operation theatres and instruments work, and keep working with the minimum downtime.
To this end he must line up maintenance services, and he must engage specialist consultants to make sure someone is available on demand all the time. And finally, he must ensure nursing services that would give patients adequate service and make sure the beds are vacated as fast as possible. This is not the job of nurses alone; he would need counsellors who would talk to patients and their relatives from the time of admission, help them find accommodation outside and make sure that patients have a safe place to go to once they cease to be critical. But rapid turnaround of patients is the key; without it the hospital cannot ensure that every emergency patient is admitted without delay.
That is his task; to accomplish it he would need much tact, hard work, mental toughness, and leadership qualities. But all those would be wasted if he could not get a free hand. And because no one gets a free hand in West Bengal, it gets mice instead of men as managers.