Accountability in Healthcare: A Barbados example.

David Dean Ellis LL.M MBA BA

In the context of the current social and political climate, how can organizations be held accountable for the quality of care?

“Declare the past, diagnose the present, and foretell the future.”

― Hippocrates

This quote by the “father of medicine” is not only applicable to the practice of medicine but has ramifications for health services in any context and territory. In this paper I will attempt to establish a model for accountability in health services based on co-operation and resource harmonisation, through a discussion of the concept of Clinical governance as a foundation for improving the quality of care. For the sake of comparison I will examine the development of health services in the territory of Barbados making special references to the operation of this framework in the United Kingdom.

Declaring the Past

The health services of Barbados have undergone an interesting developmental process much like that of health services in the United Kingdom. E. R Walrond in his essay entitled Health in Barbados in the 20th Century states

“At the beginning of the 20th century, Barbados was described as the unhealthiest place in the British Empire; at the end of the century, it is considered amongst the healthiest of developing countries.”

This process has been a slow but steady development of the health services of the island spanning several decades and constitutes a continuous revision of practice and structure for the health agencies of the island. Barbados’ medical services prior to its 1966 independence from Britain was patterned along the lines of the mother country in that medical services were funded and supported by grants from Britain as well as private funds from charities and private citizens.

Accountability was not established as a staple aspect of health services as the island first started its training and education of Doctors in 1967 and there was no formal infrastructure in place.

It was not until after the establishment of an independent government that the island received its first official health body.  As stated on its website the Ministry of health became the sole

“…executing agency for the delivery of health care in the public sector and has responsibility for planning, regulation and evaluation across the public, private and NGO sectors. It is headed by a Minister who has overall responsibility for policy-making and political direction. Decision-making is centralized and there are no local authorities.” (www.health.gov.bb)

Accountability therefore was established, directed by the central authority and in this context accountability connotes something entirely different from the United Kingdom with an established NHS and the subsidiary bodies, The National Institute for health and Clinical Excellence (NICE) and the Care Quality Commission CQC who are responsible for ensuring the best level of clinical care from all aspects of the health service and institutions in the UK.

In a Barbadian context accountability to a central authority has more to do with ownership of responsibility of particular functions delegated by that central authority. The island’s health infrastructure comprises two major hospitals with a combined capacity of 623 beds, a 600-bed psychiatric hospital and 8 supporting free polyclinics providing free services for minor ailments and a number of private facilities for citizens who can afford to pay for healthcare. This of course is a big step from the island having opened its first public health centre in 1953.

In 1969 an act in Parliament now entitled the Health Services act (CAP. 44) was passed giving the Minister of Health complete power and authority over the administration of Health in Barbados and although the act has undergone several amendments to its body, sole authority over health matters still rest with the Minister of Health and his appointed ministry.

In 2002, the Queen Elizabeth Hospital Act was introduced and passed in parliament making the island’s major hospital and health facility a statutory independent institution governed by an independent board of management and responsible for the managing of the affairs of the hospital. Ultimate accountability still rested with the Government of Barbados however who still subsidizes the hospital but as an autonomous statutory body rather than as an official government department.

Diagnosing the present

Health Care services in Barbados like the UK and other territories have always been affected by the prevailing social and macro economic factors of the environment in which they operate. In Barbados specifically, the island is currently experiencing a recession and its macro-economic climate has seen a GDP real growth rate of 0% (2012 est.). The Barbadian government’s debt to GDP ratio reached 94% in September 2013. This is largely due to the global financial crises of 2008 that saw the island’s main source of income (tourism) dwindle by an unprecedented 8.7% the following year. This economic challenge has had a huge impact on the island’s economy forcing local government to adjust public spending.

In 2013, the local government announced a budget cut of 35 million dollars to public health spending and an additional 3 million dollar cut from the Barbados Drug service. The result of these, “health cuts” has been dramatic. In an article titled “Health cuts may prove costly”, the local Nation newspaper quoted the former Minister of Health Dr. Jerome Walcott as saying that the cuts came with cost

“…to human life and morbidity” (The Nation Newspaper Tuesday March 25th 2014)

This opinion has all but become a reality for the quality of care at the island’s main hospital. On July 9, 2014, the Jamaican Observer reported that the Queen Elizabeth Hospital was,

“performing only emergency medical  procedures owing to  a shortage of supplies”

Jamaican Observer. July 09, 2014

The economic reality of the budget cuts to this facility therefore has directly impacted on the level of care to which the facility is capable.

Social factors and Public awareness and involvement

There has been an increase in Public awareness on the island which is due largely to the efforts of the island’s health related NGO’s, which include the Barbados Heart and Stroke Foundation and the Barbados Cancer society. These NGO’s have worked assiduously to keep the public informed of their options with regard to care and have been marginally successful in raising the awareness of the public in terms of the health challenges which the nation faces. This has been done through the use of sponsored activities such as walks and awareness campaigns.

The Ministry of Health, realizing the value of these organizations to its on-going efforts to educate the public to their role in Health care has sought to enable these organizations with grants and concessions for their continued operation. In 2001 for instance the government leased 15000 square feet of property to the Barbados Cancer society for 50 years in order to establish a headquarters, Diagnostic and services Centre. Despite these efforts however public involvement is lacking. In a population of 288,000 the Barbados Heart and stroke foundation has received only 466 likes on its Facebook social media page, The Barbados Cancer Association follows with 185 likes and the Barbados Diabetes foundation 149 likes.

While these figures do not in themselves indicate the effectiveness of these foundations in affecting public involvement and awareness, it does indicate that a lot more work needs to be done with regard to the promotion of these causes. In a technological world where social media and smartphones allow the average citizen choice of what to support or reject, public participation on an organization’s Facebook page for instance is a sound reflection of whether the promotion of that organization is as effective as it should be.     

A large part of the problem may lie in the fact that there is no centralizing structure to the efforts of these organizations. In an island roughly 166 square miles, the effectiveness of many autonomous organizations clambering for public support and involvement may in fact constitute a case of “too many cooks spoiling the broth”.

The NHS in the UK acts as a centralizing force which directs and promotes public involvement for all aspects of health and determines funding and research for the best overall results of health care. This is not the case in Barbados and this lack of co-ordination between the various NGO’s and private health facilities may be counterproductive to the overall effectiveness of health care in the island.

The Ministry of Health, which currently has only 209 followers on its Facebook page, has indeed attempted to raise awareness and garner support from the public in terms of hosting and producing several events. In 2002 the Ministry was responsible for hosting a symposium which saw the participation of 115 stakeholders from within the public health sector as well as private organizations and facilities, civil societies and local and international financial institutions in order to formulate a Barbadian Strategic plan for health.

Also in 2008, the ministry approved the establishment of an NGO desk in the Ministry of health to act as a co-coordinating instrument for the various activities of these organizations. This however did not remove the autonomy from these organizations that still act as independent agents both in the public and private sector. The initiative also did not include the private (paid health facilities on the island

The politics of Health Care: Structure and regulation

Healthcare is a business just as much as it is a facility and like any other business, management and leadership along with teamwork represents the key to success.

Barbados as a political entity came into being in 1966 with its independence and the formulation of the various Ministries responsible for the managing of different aspects of the island’s society was part of this process. The Ministry of Health under the 1969 Health services act maintains full executive responsibility on all matters pertaining to health care. These functions under the act are centralized and the minister maintains full responsibility of the health affairs of the nation as stated,

“….the minister shall generally be responsible for the promotion and preservation of the health of the inhabitants of Barbados, and for this purpose may divide Barbados into such areas as he may determine, establish such health or sanitation districts within any such area and assign duties to such officers in relation thereto as he thinks necessary.” (Barbados health services act 1969, Cap44)

Financing

The Ministry currently shares its resources with other government ministries, which regulate the Barbadian society. Public funding for the ministry is provided through taxation. Public revenue is shared between these different agencies through an annual fiscal budget. A 35 million dollar reduction on national health spending, combined with the declining world economy has forced health facilities on the island to rethink their choices of procedures and services offered.

The Ministry’s current budget allocation for non-statutory spending is $258,945,232.00 BBD (Barbados Estimates 2013-2014), which represents the majority of its total estimated $342,381,895 annual budget for the same period.  This figure represents a drastic reduction from its actual expenditure in 2012-2013 period of $347,808,351.

In an effort to reduce government spending in a difficult economy all public services have been asked to cut back. The end result is inevitably a decline in the level of overall care in the local health industry as these facilities attempt to decide which services are expendable

Foretelling the Future

Clinical Governance and accountability in health care in Barbados

The quality of healthcare in Barbados has always been associated with provision of the necessities for maintaining an adequate health service and this has largely been determined by statistical data not necessarily relating to the patient or the public interest. Indeed the annual report from the Queen Elizabeth Hospital, the island’s main medical and nursing facility, site a range of systemic inefficiencies none of which relate to patient satisfaction with the service. There is ample statistical data on reduced mortality rates which does not in essence indicate an improvement in the health service overall, however there have been a number of promising developments over the last decade aimed at improving the island’s healthcare system.

The Barbados Medical Council

The 2010 passing of the Barbados Medical Profession act represented one of the first serious efforts to reform health care in the country through an act of parliament. This act replaced the Barbados Medical Registration act of 1971 (cap. 371), which was essentially a register for medical professionals in the island.

The Medical Profession Act however saw the creation of the Barbados Medical Council, which has as its responsibilities the registration of medical professionals on the island as well as the discipline and control of health related professions in terms of parameters and quality of service. The act conferred upon the council the power to determine the responsibilities and levels of education required for all health related professions and also the right to adjudicate if necessary in matters of medical malpractice, making the Council Barbados’ centralized health authority answerable only to the Minister of health.

The Act constituted a major step towards regulation of health services on the island and its powers extend to both private and public sector organizations. The overall objective has been to raise the standard of healthcare by creating uniformity in the standards of acceptable training by medical and health professionals.

The Sixth schedule of the act specifically confers to the council the right to test and evaluate the training and expertise of medical professionals wishing to practice in the island in order to ensure a high standard in terms of professional training.

The Barbados Association of Medical Practitioners

The creation of the Barbados Association of medical practitioners in 2009 under the Trade Union Act (Cap 361) represented a significant step on the part of the medical professionals on the island to improve the standard of medical service in Barbados.

Incorporated into its original constitution, “BAMP” states as part of its objectives;

“3.7 To obtain for the medical profession the opportunity to participate actively at all levels in the formulation of national medical health policies in Barbados.

3.8 To co-operate with Governments, Universities, Foundations and any organization in any endeavour designed to improve the health standards of Barbados.

3.9 To establish and strengthen ties between the BAMP and other Medical Associations and to establish and maintain facilities for continuing medical education research and other such activities.

(BAMP constitution Articles 3.7- 3.9)

These articles indicate that BAMP’s intention has always been to play a pivotal role in the determination of healthcare services in Barbados both in terms of quality as well as policy. This notion was given legitimacy in the 2010 Medical Profession Act, which states in Schedule 1,

“ The council shall consult with the Barbados Association of Medical Practitioners before formulating any codes and standards referred to in paragraph (e) of subsection 4”. (Barbados Medical Professions act. Schedule 1 subsection 7

In which paragraph (e) refers to the setting of standards for the medical professions.

BAMP’s overall aim has been to safeguard the integrity of the medical professions in the island through the promotion of high standards of operation.

The Barbados Nursing Association

Founded under an act in Parliament on February 15th 1943 (BRNA act 1943- 146. cap 354.), this association achieved trade union status in 1990. Stated on its website the BRNA (Now BNA) was founded,

“……when there was growing restlessness and discontent among nurses at the Barbados General Hospital, due to appalling conditions of service at the time.” BNA website. http://barbadosnursesassociation.webs.com/

The BNA’s aim is to improve healthcare standards through the establishment of a fraternity of professionals and maintaining a register of qualified nurses and volunteers. The association has been heavily involved in the promotion of health seminars and events held on the island.

The BNA however has been faced with a problem of severe shortages of trained nurses on the island. The association’s website itself lists only 25 active members and in an article entitled “Need For Nurses” on January 4, 2013, Mrs Blondell Mullin, President of the Barbados Nursing Association was quoted as saying,

“I will continue to lobby Government to increase the number of nurses to improve the delivery of health care in all institutions.” (Barbados Today Jan, 4, 2013)

The shortage of nurses has been largely attributed to the number of nurses leaving the profession. Another main factor for this shortage could be the economic realities, which have prompted trained health professionals to migrate to foreign countries to seek higher remuneration for their skills. In a paper entitled, Migration and Its Implication for Nursing Education and Training Programs: The Case of Barbados, Wendy Sealy, PhD. RN notes,

” The Barbados Digest of Statistics (2004) edition demonstrated further that there were notable decreases in registered nurses in Barbados from 701 in 2002, to 570 in 2003, and then 551 in 2004. This showed an overall decrease of 378 nurses between 2002 and 2004. Similar trends were noted for psychiatric nurses and midwives which was reduced from 291 in 2002 to 205 in 2004 and 393 in 2002 to 215 in 2004, respectively”

This pattern shows a disturbing reality for health care in Barbados and a concern for the island’s health authority. This development however is inextricably linked to the prevailing economic health of the country and its fiscal policies.

Overall impact on the quality of health Care in Barbados

Unlike the NHS in the UK, Barbados does not have an established and consistent framework for improving Health Care Quality although there have been steps taken in this direction by the Queen Elizabeth hospital in the form of training seminars on the subject. Courses on the subject area have also recently been introduced by the local Barbados Institute of Management and Productivity.

In pursuing a framework for increased quality of care, the island has had to adapt it’s approach to the subject by making incremental improvements due largely to limited resources and personnel.

Within the UK’s framework for Clinical Governance, the concepts of Education and training and research and development as a pillar to the improvement of health services is being accomplished in a Barbadian context through the Barbados Medical Council in co-operation with the Barbados Association of Medical Practitioners and the Barbados Nursing Association.

These associations, apart from insisting on high standards of Practice and training as a registration requirement have made alliances with the regional University of the West Indies to develop training programs in order to raise the competence level of regional Physicians to acceptable standards. BAMP has also created its own Continuing Medical Education (CME) program, which ensures Doctors are up to date with the most recent advancements in their fields. These CME conferences are held from May to November and offer health professionals an opportunity to continue to grow within their careers.

Clinical Audit and Effectiveness is affected determined by the Barbados Medical Council.  This however proves to be a difficult task, as the Council currently does not have the personnel with expertise to police all the private facilities on the island. The island’s equivalent to the Care Quality Commission for facilities is the Health Inspector’s department, which is not currently trained at assessing the specific requirements of Health related facilities. These inspectors are also tasked with the inspection of other private and public organizations as well.

The Board of Management in an effort to improve the quality of care at the Queen Elizabeth hospital has chosen to become self-regulating. The hospital publishes an annual document, which it provides to government and the public of the performance of each one of its departments.  This “Reflections on the Past and Future Directions” document lists both the institution’s successes but systemic inefficiencies as well. The document is accessible online in PDF format and it shows the Institution’s commitment to openness and transparency as part of its Management ethos. This “self-audit” performed by the QEH is a unique initiative which should be encouraged island wide to private and public health facilities, but this has not as yet been mandated by the Ministry of Health.

The concept of risk management has always been a concern for the Medical Professionals in Barbados and the focus has been on the conducting of training seminars to educate Health professionals in the execution of good practice. These seminars unfortunately have largely been optional and have not been implemented on a nationwide basis. Once again the Queen Elizabeth hospital has taken the lead in launching of a New Adverse Incident Policy and User-friendly form as part of the development of its Clinical Risk Management initiative.

Limitations.

Legislation

Analysis of the legislation concerning Health care in Barbados reveals a systems focus rather than a patient cantered approach to healthcare. While it is arguable that Government and the Judiciary should be concerned with structure and operation, placing of the Ministry of Health as the sole executing body with no agencies suggests a non-inclusive policy. Despite several reviews and additions to this act, (the latest being 1999) the wording remains the same and is in no way inclusive of the private sector as a source of support or counsel. This indicates a purely systemic approach to matters of health within which the clinical governance framework may not “flourish”. It also explains why private entities operate independently, all with the good intentions of improving health care in their own manner but there still exists no central coordinating agency for quality assurance on the island.

The Economic Barrier

The concept of establishing a framework of quality assurance through clinical governance on a national scale represents an initiative which will have some cost attached to it. For a government which has decreased the national allocation to the Ministry of Health by 35 million dollars, instituting such a framework may be ill timed at best and impractical. In reality, however aspects of this framework have already taken place as has been shown. What is required is a coordinating agency to harmonize the efforts of the various stakeholders and legislation to legitimize this initiative. The establishment of the National Health Service in 1948 in the UK and it’s satellite bodies the National institute for clinical excellence (1999) and the Care Quality Commission (2009) were supported by the Health and Social Care act (2008-2012). These agencies were born as a response to imminent failures in health care in the UK but were all intended to reform health care standards which would not have been possible without legislative support and the inclusion of the public and private sectors as well as the health professionals.

Public involvement and Patient focus

Public involvement in the Barbados Health service leaves much to be desired. An analysis of the constitutions and Parliamentary acts pertaining to both the local Ministry and supporting nongovernmental health agencies reveals a surprising absence of the concept of patient focus or public involvement. It should be noted here that Public awareness does in definition differ from public involvement and in this case these organizations should be credited for their efforts in raising public awareness through various initiatives and campaigns. The island’s main health facility, the Queen Elizabeth hospital, does have a patient information service on their website but to date has not published any literature aimed at encouraging patient feedback or the concept of involving the public in assisting with the formulation of policy at the hospital.  This indicates a limitation in understanding of clinical governance, where the focus still seems to be the improvement of the patient experience through the improvement of infrastructure.

This focus combined with the economic barrier and an administrative focus, which seems to be “stuck in time”, creates a problem for the very definition of clinical governance and quality improvement. If clinical governance denotes a “systematic approach” to improving the quality of care within a health system then, the absence of this approach must indeed limit the possibility of improving the quality of care.

Conclusion

A greater understanding of this concept should theoretically start with a re focus of the Ministry as being accountable to the public and the patient first at a national level and this refocus should then be filtered down through legislation to the various public and private health facilities and Nongovernmental organizations. Accountability should not stop at the Ministry as the sole controlling body in matters of health but as a co-operative effort involving the public as well as the private sector on an on-going basis.

The inclusion of these sectors of the population would not only encourage an increase in public understanding of health services options and limitations in the country but would in effect make these sections of the Barbadian society accountable to each other and the wider society.

The concept of quality improvement being the sole responsibility of the local Ministry and a few professional bodies is an out-dated and impractical concept, which should be replaced with a more modern perspective where the public and all private facilities that remain stakeholders in health care, act as a unified agency working towards the general improvement of health care in Barbados. It has been shown that the Ministry of Health not only lacks the resources and personnel to affect this sweeping reform of the health industry but its available resources have shrunk because of the prevailing Socio-economic climate. The 2002-2012 document entitled Barbados Strategic plan for health has as its motto,

“The health of a nation is the wealth of a nation”.

I believe that this statement is true in many respects when it comes to improving health standards in Barbadian organizations. Most important is that the word “nation” here should be inclusive of all aspects of society and the wealth should be determined by its people’s ability to change their circumstances not through the monetary wealth but through teamwork and cooperation.

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