22 July 2007
I must first express my happiness about what we noticed last night when there was electricity outage in almost the whole of East London. Frere Hospital continued to function using the electricity back-up system available at this hospital. It was actually the only lit building as you drive up the Oxford Street.
The Department of Health and Eastern Cape Government are concerned about the serious allegations made with regard to health care delivery at Frere Hospital. We are determined to act with the necessary urgency to ensure that the issues undermining the integrity of the public health system are investigated and swiftly addressed.
As a result of this concern, a team comprising of the special adviser to the Minister of Health, Prof Ronnie Green-Thompson, Chief Director for Hospital Services Dr Thabo Sibeko and Dr Nat Khaole, Director for Women's Health were sent to the Eastern Cape to investigate these allegations.
In addition to making their own observations during pre-planned and unannounced visits to the hospital, the team met with the Provincial Executive Council and a number of other parties including clinical staff, representatives of organised labour and hospital management over the three days.
Their report contains several findings and recommendations. The recommendations will be implemented to improve efficiency and quality of healthcare services delivery at Frere Hospital. To the extent relevant, these recommendations may also be implemented in other hospitals such as Cecilia Makhiwane Hospital which was visited by the team.
Findings and recommendations
The team has raised concerns about maintenance of the hospital and recommended a increase of the maintenance budget. Presently is 0,5% (R3.5 million) of the total hospital budget and ideally it should around 5% (which would be about R35 million). The non-functioning electronic nurse-calling system needs to be replaced. Converting the room currently used as a storeroom into another labour ward should create extra space.
Basic equipment was available and interviews with the clinical staff and hospital management indicated that no baby has died as a result of the non-availability of equipment. Therefore, the statement that health workers "play God" and decide which patient lives or dies because of acute shortages of equipment was not found to be true.
The team recommended the replacement of six of the eighteen incubators that required frequent repair. Additional neonatal ventilators should be purchased to supplement the ones available instead of moving neonates requiring ventilation to the main hospital Intensive Care Unit.
There were some issues relating to infection control and hygiene that were raised in the report requiring installation of elbow operated taps, additional hand-washing basins and the adherence to infection control procedures. These will be attended to as a matter of urgency.
Although there is largely a commitment to service delivery amongst staff, the current levels of staff complement was the main area of concern. There is an urgent need to increase the number of porters, messengers, general assistants and clerical staff and ensure that these categories of health workers are available at all times so that clinical staff can focus on what they have been trained to do.
The current nursing staff allocated to the Maternity Unit, Neonatal Unit and Neonatal ICU is not adequate. During one unannounced night visit by the team, there was one professional nurse and one nursing assistant allocated to a 32 bed ward.
The provincial Health Department and Frere Hospital must utilize all the opportunities that are available for recruitment and retention of staff. The rotation of staff between different departments to the extent that skills are lost should be done away with.
The general complement of doctors is reasonable but can be increased. Medical Officers in the Maternity Unit must be available on site to ensure optimum supervision of interns and clinical care of patients. Consultants (specialists) must conduct scheduled night rounds and use them for teaching purposes.
Clinicians were requested by the team to provide detailed statistics of all fresh and macerated stillbirths and all neonatal deaths above 1000g. The 1000g cut off was used as it is an internationally used benchmark for reviewing perinatal outcomes.
The Saving Babies Report (which aggregates the figures for 164 sites and considers 20% of the births in South Africa) provides the perinatal mortality rate of 27.9/1000 live births. Frere Hospital's rate was 29.2 for 2005, 34.5 for 2006 and 32.9 for 2007 thus far. These figures are for the deliveries at the hospital using the denominator of all live births at the hospital. They do not include all the live births within the catchment area of Frere Hospital and therefore need to be adjusted by using (as the denominator) all the deliveries in the referral area of Frere Hospital.
The neonatal mortality rates per 1000 live births for 2005, 2006 and 2007 (to-date) were 5.5, 12.9 and 9.5 respectively. The Saving Babies report figure is 8.5/1000 live births. Adjustment also needs to be done here also.
Further review of data relating to Frere Hospital catchment area is necessary since Frere Hospital is a referral facility that receives complicated pregnancies from various lower level facilities. The national Department of Health will also be initiating a national review of peri-and neonatal mortality rate in a similar approach as Confidential Inquiry into Maternal Death.
The clinical audits meetings held every week at the hospital must be formally recorded. Issues arising from the audits should be addressed by the clinical staff and the hospital management.
The District Health System must be strengthened to reduce the number of unnecessary referrals and enable the hospital to concentrate on the high-risk patients and thereby improve the peri-natal outcomes.
The current East London complex system must be reviewed in line with a national policy of delegating powers to the hospital CEOs. The management at facility level at Frere and Cecilia Makhiwane Hospitals should be delegated the necessary authority and responsibility to manage these institutions including control over budgets, staff establishments and services rendered. The provincial Department of Health must provide the support and oversight necessary to ensure that these facilities run efficiently and provide good quality of care.
Conclusion
Reduction of maternal and infant mortality rates are among the main priorities of the Department of Health and are important indicators of the functioning of our health system. There should be deliberate efforts made to encourage mothers to attend antenatal clinics early and regularly to enable early detection of any complications.
However, it is true that both these indicators are also affected by the environment in which people live in. Government will continue to address social factors such as poverty and poor nutrition that have direct effects on birth-weight and general health condition of infants.
There have been individual cases of inappropriate care that have been reported and the provincial Health Department is committed to investigate these cases. We encourage everyone who may be aggrieved about the conduct of a nurse or doctor to lodge a complaint with the Health Department management, the Health Professions Council of SA or the SA Nursing Council. We will be able to assist in this regard and the toll free number 08000 32364.
While we accept the findings of the team, we call upon anyone, including the media, who may have other information that may be helpful in strengthening the quality of care at this hospital to make such information available to the Department of Health.
Dr Manto Tshabalala-Msimang
Minister of Health
Contact: Sibani Mngadi @ 0827720161