Despite challenges, Britain’s National Health Service (NHS) remains a pacesetter in providing a population with high-quality health-care. For less developed and much poorer South Africa, achieving this dream is more difficult, as the furore surrounding the government’s National Health Insurance (NHI) plan demonstrates.
Much of the controversy relates to the fact that providing quality health-care to the whole population is unaffordable at present. But perhaps there is a lesson we can learn from the venerable NHS when it comes to how one important component of medical care, surgery, is delivered.
As surgical techniques and tools have become more sophisticated, it has become clear that many surgical procedures can be better performed in an appropriate environment, away from the pressures inherent in running a conventional hospital. Thanks to these medical and technological advances, these surgical procedures can be performed in such a way that recuperation, if required, can safely be undertaken at home, removing the necessity for overnight care.
I first encountered the same-day surgery concept in the US in 1981, and immediately saw its potential for reducing costs and improving patient outcomes. I helped introduce the concept to South Africa and subsequently Australia and the UK. Illogically, it’s been something of an uphill battle to convince the medical profession to take it on board. Why?
In considering the dynamics of the medical field, it is essential to recognise that a majority of specialists undergo training in acute academic hospitals, fostering a deep-rooted familiarity with such facilities. Embracing change within this community poses challenges, as transformation materialises only when necessitated by altered circumstances. The reluctance to deviate from traditional hospitals is accentuated by the inherent pressure from hospital managers urging surgeons to retain patient treatment within their institutions rather than supporting same-day facilities. We have to understand that patients and doctors must have a choice of where to treat their patients.
In considering the dynamics of the medical field, it is essential to recognise that a majority of specialists undergo training in acute academic hospitals, fostering a deep-rooted familiarity with such facilities
Once doctors are persuaded to visit and use a day hospital, where the benefits for both doctors and patients are clear, they usually become converts to the concept. This was clearly seen during the pandemic, when acute hospitals treated Covid patients and day hospitals opened their doors for surgeries.
Of particular relevance is the experience of the NHS. The first day hospitals proved to be such a success that the NHS pioneered the concept of building day hospitals alongside, but separate from, acute hospitals. An article in the British Medical Journal estimated that an additional 186,000 patients could be treated if all health authorities in England and Wales adopted day surgery as the norm.
In other words, the NHS’s infamous delays for elective surgery could be greatly reduced. No surprise that the concept of day surgery is now well accepted as part of the way the NHS delivers care.
Before looking at how day hospitals could assist the South African health-care system to deliver better quality care more affordably, and thus reach more citizens, let’s examine the case for day hospitals.
A day hospital has much lower overheads than a conventional hospital. It has no intensive care, maternity or emergency units, no pharmacy, wards do not require 24/7 nursing, and there is a drastically reduced need for catering and so on.
Doctors benefit by working with the same nursing team as there is no shift working, which leads to improved teamwork and faster, more efficient surgery. The cost per minute in theatre is much lower compared to an acute hospital. Our group estimates a saving in time and money in the region of 20%-25%.
Another bonus: surgery schedules are not interrupted by emergencies.
Better working conditions for doctors include the advantage associated with a compact facility, with minimal staff, linked to a relaxed and comfortable clinical working environment.
A day hospital has much lower overheads than a conventional hospital
For patients, there are many benefits beyond reduced costs. One is recuperating at home, another is that surgery is done at the scheduled time. A major bonus is that superbugs and other chronic infections are not a feature of day hospitals; this is because the number of people visiting them is tiny, and none of them are ill. Acute hospitals need to admit patients with high-risk conditions for a longer period, which can increase the risk of infections
All of these benefits translate into greatly reduced readmission rates for the same procedure. While there are no universal figures for day hospitals, I can’t recollect any readmissions in our group. By contrast, a 2019 study at Tygerberg Hospital in the Western Cape showed a readmission rate of 10.5%, with global readmission rates varying between 10% and 25%. It’s not an entirely fair comparison because an acute hospital is covering all cases while a day hospital is specialised, but the point remains valid.
Since I was involved with the introduction of day hospitals in the early 1980s in South Africa, numbers have increased to more than 100 day hospitals. Only a few medical schemes have put incentives in place to incentivise doctors and patients to use day hospitals. It remains an uphill battle, partly due to the inherent lack of knowledge of the medical profession but also because the government, via the Council for Medical Schemes, seems at best ambivalent.
This ambivalence seems to stem from a desire to “protect” the turf of the planned NHI, but I would argue that this is mistaken. As the NHS example demonstrates, day hospitals could play a significant role in making more affordable health-care available to a wider circle of South Africans, thus relieving pressure on the state health-care system. We estimate there are around 8-million South Africans who are in work but cannot afford medical scheme membership. This group could, however, afford low-cost medical plans as well as the cost-effective surgical services offered by day hospitals.
It will likely be years before the NHI is anywhere near to implementation, so day hospitals should be seen as an important way of bridging the gap between the top-quality private health-care sector and the state. And I have no doubt that, like my own group, the day hospital sector in general would be only too willing to enter into public-private partnerships to begin the process of democratising our health-care sector, something we all desire.
There is clearly a solution to a significant part of the problem of rising health-care costs. But we need to ask why the collective vision to use it wisely has not been embraced.
• Grillenberger is chair of Advanced Health
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