Readiness and responses of Public Health Facilities & Private Hospitals in the Western Cape to COVID-19

Meeting report

Hospital Association of South Africa: Private Hospital’s Response Program to the Covid-19 Pandemic
Dr Biren Valodia, Chairperson: Hospital Association of South Africa (HASA) Board, thanked the Committee for the opportunity and platform to share the work done by private hospitals in its fight against Covid-19.

Dr Valodia said the private hospital industry forms a united front under the banner of Health Facilities Response workstream of the Business for South Africa (B4SA) initiative. This is a collaboration which includes non-affiliated private hospitals. This presentation is made under this united front.

Ensuring Preparedness – Western Cape
The following points were raised:

Silver Command Council
Private hospitals are currently collaborating with the Western Cape Department of Health through participation since April. In the Western Cape, Silver Command coordinates the provincial pandemic response.

Learning Collaboration
The Western Cape Department of Health Learning Collaborative is established to enable learning from the pandemic. It is where private hospital groups presented case-studies and where academic experts participate in the process.

Joint Operational Committee
Private hospitals participate in the Western Cape Joint Operational Committee that is established to allow for discussions on operational matters within the healthcare sector.

Service Level Agreement (SLA)
The SLA establishes a mechanism for the use of private hospital beds to treat public sector patients. It enables sharing available resources for the beneficial treatment of COVID-19 patients across both sectors.

Bed Bureau
Western Cape hospitals are using the province’s bed “bureau”. Since 13 July, private hospitals upload data onto a dynamic online platform which will be available nationally. It will greatly assist during the surge when bed numbers change very quickly by indicating available demarcated Covid beds and ventilators.

Challenges
Liquidity crunch
Payment of regular staff tests
Varied provincial licensing relaxations
Nurse shortages

Dr Anban Pillay in March, speaking to the Parliamentary Health Committee said, the private sector is on board, and is training with private general practitioners to ensure everyone is aligned with how to manage the disease.

Dr Nicholas Crisp in June, speaking in an interview to Spotlight on public-private sectors working together said, from day one, players in the private sector recognise this is a national crisis, it does not want to make money out of this but needs to recover its costs.

The future: HASA believes in dialogue, collaboration, optimism, innovation, research and evidence. It believes in advancing healthcare and in accessible healthcare for all. It believes it can together overcome any challenge in front of it. In this spirit, it looks forward to continuing dialogue and collaboration. It will search to find solutions to long-standing healthcare challenges through critical healthcare reform. This includes meeting challenges of providing universal healthcare to make sure every South African has access to appropriate care.

Discussion
Ms W Philander (DA) asked if private hospitals experience delays in testing Covid-19 patients. Based on the presentation, specifically licenses, she wanted to understand what the process entails.  She asked what the response is in the private sector regarding the engagements which took place with the South African Nursing Council in April of the current year. She asked which resource shared from private to public during the pandemic is the most prominent. She wanted information regarding how the private sector deals with the shortage of nurses.

Mr C Dugmore (ANC) wanted more clarity about the actual costs for state patients who were referred for testing at the various private hospitals. He also wanted to know what the actual subsidy is to the various private hospitals who administer Covid-19 tests for non-medical aid patients referred for testing.

Mr M Xego (EFF) said there are a number of complaints coming from the private hospital, Gatesville Medical Centre Hospital, regarding the shortage of personal protective equipment (PPE). He wanted to understand the impact of the high shortage rate of PPE among private hospitals during the pandemic. Lastly, he asked what is done to address the shortage of staff members regarding the number of cases reported of staff members being infected.

Mr B Herron (GOOD) asked if testing volumes changed, specifically, if there is a reduction in the number of testing requests or patients arriving to be tested at private hospitals. He wanted to know about the pressures within the hospital facilities and if the private hospitals are under pressure regarding bed capacity.

Lastly, he wanted a run-down of the testing protocols at private hospitals, specifically, the following:
He asked what happened with a private patient who tests positive.
He asked how the private sector integrates its results with the public data systems.
He asked which protocols are put in place by private hospitals regarding advising patients about contact tracing, availability of public quarantine, isolation facilities, and the communication/connection between the two sectors.

Mr F Christians (ACDP) asked what the additional costs are for patients who through no fault of their own are referred by public hospitals to private ones because of insufficient capacity. He said many do not have access to medical care and cannot afford private hospital fees.

Secondly, he asked if the reduction of patients hospitalised is attributed to the reduction in infection rates or to capacity at hospitals being at a maximum.

Dr Anchen Laubscher, Group Director: Medical, Netcare, replied by saying, testing timeframes fluctuates throughout the pandemic. Throughout the Provinces, and specifically in the Western Cape, there was a period where time frames were quite prolonged.

Regarding respective hospital protocols for pre-admission testing requirements, it usually requires a time frame of 48 hours pre-admission for the test to be conducted. The patient remains in mandatory quarantine until admission. Currently, the turn-around time stabilised. Results are returned within 48 hours. Throughout the course of the pandemic, and as the situation unfolds and numbers increase, it reviews capacity in each hospital. Broad policy decisions were taken at the outset of the pandemic. After five weeks into the lockdown, another review was taken, looking at international literature and articles.

There was communication from various academic and clinical professional associations who represent medical professionals in the country. It is understood essential services are needed to continue despite and in spite of the pandemic. There is an acknowledgement the pandemic will not just be around for a short period. The impact on other essential services such as trauma, maternity, cardiac, neurological, surgical, pediatric and medical emergencies will continue to demand access to health care. Most of the private hospital groups implemented protocols of medically necessary and time sensitive surgeries only. It refrains from elective surgeries. Priority is given to admissions which if not dealt with within a given time frame will negatively impact the quality of the patient’s outcome. This is how it manages and continues to manage the decrease in numbers in some of the Provinces.

Mr Ahmed Chohan, Chief Operations Officer: Melomed, said there are a number of retired nurses who want to volunteer to serve during the pandemic period. To do so, the nurses must be restored onto the register and this incurs fees, along with a registration fee granted by the Nursing Council. A process is put in place via HASA.

Dr Stefan Smuts, Chief Clinical Officer: Mediclinic, said one of the key challenges it faces, both in the private and public facilities is the dire shortage of nurses. This is so specifically in the specialised units such as the medical care and intensive care units. To some extent it is also in the Emergency Centres where there are more acute cases of Covid-19. 

This is compounded by a number of the staff members who also contracted the virus and must be treated, isolated and quarantined. It embarked on a number of strategies to address this proactively. It introduced many of the disaster planning measures. The first is to make sure how many specialised nurses it has.
It will require some upscaling and must provide the training up front.

The second is a drive to recruit more of these specialised nurses to make sure it offers some employment opportunities for the nurses. A plan was developed to reallocate nurses from workloads which were not busy, such as theatre, to specialised units. Appropriate training was provided. A volunteer program for nurses was introduced where nurses can assist and contribute to the care of highly ill patients. A barrier of the volunteer program is nurses require re-institution of the licensing, along with a training update. It is looking at the re-allocation of nursing staff members who fill managerial roles in the corporate office and who are not as busy. These nurses were transported or transferred to facilities which need support, within the Western Cape.

Lastly, it looks at the concept of team nursing where an experienced specialised nurse will oversee a group of more inexperienced nurses to make sure there are always sufficient nursing hands to look after the critically ill patients. All those implemented plans led to being able to provide excellent care to the really ill patients.

Mr Matthew Prior, Funder Relations and Health Policy Executive, Life Healthcare, said it is important to highlight the actual testing does not fall under the ambit of the private hospitals. It is independent labs which perform those services. It is merely offered through private hospitals and as such it does not have full view of the information sought regarding this.

Regarding the pricing of the tests, he said there was some representation from laboratories in the network stream regarding trying to ensure the pricing for the tests significantly decreased over the pandemic period. According to his knowledge the decrease in price was achieved. However, he is not aware of any actual direct subsidy which was paid to the labs by government for those tests performed in the private sector.

Dr Laubscher said it reserved the hospitals regarding confirmed Covid-19 cases, suspected Covid-19 or non-coverage. It takes guidance at all times from the private labs regarding capacity constraints. From a risk mitigation strategy point of view, it has a universal pre-admission testing strategy from right after the lockdown was implemented across South Africa. It subsequently relaxed it progressively as the community transmissions increased to such a level the prevalence is much higher. Simultaneously, it upped the levels of PPE, along with no restrictions in its facilities.

Mr Corne Heyns, Chief Strategic Officer: Mediclinic, said regarding the additional cost to the public sector patients in private facilities, the fee is set by the National Department of Health. It is not an all-inclusive fee per day for different levels of care. This means there is no additional charge to the patient for the care provided. The fees are below cost for the private hospital sector. This is a response in solidarity with the nation and Provinces during the pandemic.

Regarding the reduction volume in private hospitals, he said there are three things to highlight. Firstly, private hospitals generally stopped elective cases even before lockdown. This volume did not come back to its current level mainly because it is only doing urgent electives, and not opening up the system completely. Secondly, medical cases saw a significant reduction and its prevailing estimate was not done. Thirdly, it saw reduced trauma because of the lockdown, and various impacts/strategies which had supposed positive effects on the health of the nation.  All these factors are still leading to the current reduction in volume across the private sector.

Dr Smuts said, while there is no agreement within the private and public sector, many of the nursing colleagues actually work in both sectors. Many of the nursing staff utilise agencies to generate shifts which accommodate work requirements. Some of the nursing college colleagues report getting more and more work within the public sector. Others actually report the opposite. There is a sharing of resources but not according to a formal agreement as such.           

Ms Melanie Da Costa, Director: Strategy & Health Policy, Netcare, said it is fair to say the process undergone helped bank a lot of lessons. The most important is, the actions of healthcare professionals serve as a testimonial that healthcare professionals are primarily interested in the best interest of the patient. Secondly, the engagement helped bridge the divide between the private and public sector. There will be much more opportunities to carve out in future. There are ways in which it can leverage the national resource. It found good ways of communicating and engagement can be more sustainable for the future.

Mr Andre Joseph, General Manager: Funder Relations, Life Healthcare, said regarding the data, all private hospital groups in South Africa submit data to the National Institute for Communicable Diseases (NICD) on a daily basis. The NICD shared this data back to the Provinces and Districts for contact tracing, which then led to isolation and quarantining.  The Districts follow up on contact tracing. In the Western Cape, the isolation and quarantine works really well. There seems to be a seamless transition from the actual contact tracing to the quarantining and isolation.

Dr Smuts said the most prominent thing exchanged between the public and private sector is leadership, knowledge, and experience. These are the most beneficial lessons learnt by everyone.

Secondly, there are specific initiatives the private healthcare sector made available, such as the availability of resources to help regarding the Western Cape Call Centre where staff members are on rotational shift 24/7 to answer calls.

Thirdly, on a national level, resources were made available full time in the procurement area. This helped to address some of the resource flow constraints. The clinical treatment guidelines and latest scientific evidence are readily shared on a daily basis. It is extremely thankful to all the academic institutions that developed great guidelines which can be implemented to both private and public sectors.

The Chairperson thanked the delegation as well as representatives for the presentation. The delegation was dismissed.

The Chairperson welcomed the Hospital Facilities Board and the Covid-19 Survivors. The Chairperson thanked these persons for being brave enough to share the experiences with not only the Committee, but the rest of the Province and South Africa.

Briefing by Chairpersons of the Hospital Boards
Mr Llwelleyn Jones, Chairperson: Victoria Hospital Facility Board, thanked the Committee for the opportunity to present what it is doing at the Victoria Hospital during the Covid-19 period.

While the Victoria Hospital is probably one of the oldest buildings in the Southern District of the Western Cape, the hospital staff and teams not only manage to provide excellent service to the community but also rose to the challenge as the pandemic hit South Africa in mid-March 2020.

It formed a team in which it discussed and planned how it will handle the pandemic and implement any plans it came up with. The Hospital Board mobilised fund-raising resources and managed to raise just over R2 million. Donations varied from R1000 to R1 million.

After interacting with the Hospital Task Team, it determined the most pressing requirements which the Hospital cannot necessarily afford by normal Department of Health procurement channels. The top priority is to supplement its equipment in a couple of areas, specifically ventilators. It managed to buy:
A pediatric ventilator
Pediatric incubation probe
Parapac portable ventilator
Two oxygen flow machines which were crucial in dealing with the most critical patients over the last few months.
Additional PPEs to the value of R1 million for all hospital staff
Installed additional WI-FI capability to make it easier for the patient community to connect to free WI-FI and communicate with families.

The Victoria Hospital ran the Abundant Life Palliative Care Program, where it cares for terminally ill patients. As such, it is extremely important to have counselling services available to the relatives of the Covid-19 patients, especially those who lost loved ones.  Unfortunately, the Hospital has a number of deaths in it. It sends its condolences to the families. It has 79 staff that tested positive for the virus. However, there are only eight cases currently amongst staff members. It has a total of just under 300 Covid-19 admission patients.

Mr D Forbes, Chairperson: Metro TB Hospital Centre (Brooklyn Chest) said the Brooklyn Chest Hospital is a tuberculosis (TB) hospital clinic. As such, when Covid-19 hit the Hospital, the Hospital received a double dose of what it has to care for. It is unique in its positioning to other hospitals.
The Chief Executive Officer (CEO) informs the relevant people on a regular basis as to what happens at the Hospital. The latest communication said there are 48 staff members who tested positive for the virus. Recoveries are at 24, and active cases currently still in isolation are 24.

It has to depend on its CEO together with its staff to assist. Before Covid-19 arrived, persons there already had to sign in and wear a mask. The people there continue to do this. However, now have to double efforts since Covid-19 appeared on the scene. Patients come from all over the country and not just the Western Cape area. There are hardly any visitors. Raising funds is often very difficult because of the community where it is situated. Often patients must be provided with identity documents and taxi fares to get home. It often provides visitation and accommodation to get paid. It caters to a slightly different kind of community.

Ms L Du Toit, Chairperson: Otto Du Plessis Hospital Board, said just before the pandemic hit, the Hospital was busy with renovations. It managed to get through it. The community supported it very well. It had Nurse’s Day, where it organised cupcakes and little cards with motivational quotes on it.  Three weeks ago, the Chairperson took a basket full of chocolates with motivational cards to the Hospital to hand out to the staff to keep staff motivated.

At the moment the staff are really motivated because of the constant motivation and support. However, in the initial stages everyone went through a difficult time, as like all other front-line workers staff were afraid and did not know what to expect. The Chairperson is also on the Committee which meets once a week to prepare plans on how it will handle everything as the situation unfolds.

Engagement with survivors of COVID-19 and their journey through the health system
Chief E Galada, COVID-19 survivor, said he was screened and tested by one of the officials from the Province. He said he was not in contact with people. He was knocking door to door to do the introduction of the screening teams to people. He did not go inside the homes even. He developed a mild headache at first at the back of his head. The second symptom was his dislike for the smell of his food which made him feel nauseous. He decided to go and get tested. After finding out he was positive, his wife and two kids went and got tested. His wife, who was alongside him in sharing a room and bed, got a negative result. His sons tested positive. He bought a TV and the parties isolated in their rooms for 14 days. During the isolation period he did a lot of exercise. His wife would bring him food. After finishing off the 14 days of isolation, he was back on track. Wherever he went he wears a mask and will continue to do so, and promote it to others also.

Mr D Olyn, COVID-19 survivor, said he started coughing after a few days. It became too much and he wanted to get tested. He got tested. The results were only given to him a week later. He said eventually he forgot about the results.  He went into a situation where he could not see what was going on around him and his eyes became an issue.

He called an ambulance and no one came. He called the afternoon and evening and still no one came. The following day the same thing happened. He called someone he knew to take him to the hospital. He was turned away from the first hospital and referred to Victoria Hospital. His friend managed to help him and took him to Victoria Hospital. He was assisted and transferred to a ward.

He awoke in the Intensive Care Unit (ICU) and could not remember how long and for how many days he was in ICU. While he was feeling a bit better, he had to get an operation on his throat to help him start breathing again properly. He remembers not being able to respond to anything despite trying his best with his own form of sign language. Once he was doing better, he was removed from the ICU ward. Eventually he was able to breathe without using the ventilators. After being discharged two weeks later, he was home for only two days before he was contacted and told he needs to go into quarantine. A taxi picked him up and took him to the quarantine site. He stayed there for a week. After a week he was able to leave and is currently feeling much better. He is thankful for the prayers.

Ms N Jacobs, COVID-19 survivor, said the reason she had to go into quarantine is because her community found out she contracted Covid-19. As a result, the community became scared she poses a threat to the community’s health. The community began shouting at her and doing things to her which made her feel uncomfortable. She decided quarantining at home is not a good idea. She decided government quarantine facilities are a better option. She said the reason she made use of the quarantine facilities is because she did not actually have any family besides her three kids.

When people within her community found out t she had Covid-19, the community treated her extremely badly. The community did not even want her children to go anywhere or play with their children. She felt as if she was treated like a criminal. The police had even put the black and yellow crime scene tape around her house. People would not even walk near her home as people thought they would get infected. She was disheartened by the fact she was made to feel like a criminal. The whole experience was extremely painful, physically, emotionally, and mentally. The ambulance fetched her, because no one wanted to help her or even look after her kids. People from the hospital had to send someone to fetch her kids.  Her kids were taken from home to the hospital facilities and had to be tested. Thankfully, results were negative.

She pleaded to the community and nation at large, no one must be treated the way the people of Langa treated her. There were people who came from other areas such as Gugulethu only to go and speak badly about her. The entire situation highlighted the stigma attached to the victims of Covid-19. The entire situation made her feel extremely bad and sad. She urged the nation to work together in supporting all victims of Covid-19 and not to torment people or laugh at them. What is needed is a solution to move forward, not laughing at the expense of others. One day the person who is laughing can become the person laughed at. It will be so much better to find a solution and just move forward together.

Discussion
Mr R Mackenzie (DA) thanked the survivors for sharing their stories. He wanted to know from the Chief if he received any support from the Department of Health.

He sympathised with Ms Jacobs. The stigma around Covid-19 and other diseases is something which needs to be dealt with.

Mr Xego said the predicament suffered by Mr Olyn is something which could have resulted in the unwarranted and unnecessary death of someone. He cannot understand how an ambulance does not show up in two days.

He said he strongly believes Ms Jacobs suffered a traumatic exercise and the Department of Health and the Department of Social Development must provide some sort of counselling. Community harassment is a serious challenge which needs to be nipped in the bud, as it is clearly a terrible experience.

Ms Philander asked if the Hospital Facility’s Board made any recommendations regarding the facility’s management. What Ms Jacobs went through is utterly shameful and disgusting. She asked as to how Ms Jacobs overcame the stigma and what the experience was, once she was out of quarantine. Lastly, she wanted to know what the overall state of the quarantine and facilities are.

Mr Christians said he believed the meeting is one which serves an exceptional purpose. It not only paints the picture of people directly affected by the pandemic, but also shows there is life after contracting Covid-19. Posing the question to Mr Olyn, he wanted to know how he psychologically got over the experience of being a Covid-19 victim, especially since he displayed such a positive personality.

Mr Jones said a WhatsApp group was created. It includes many of the Members of the Hospital Boards across the Province. Daily reports regarding both the situation in the Western Cape and nationwide are issued. Board Members did not have an opportunity to interact directly or indirectly with the Department of Health officials regarding feedback from the Department.

Ms Jacobs replied saying, regarding the living conditions, there is a big bed. However, it is strange in the beginning as she did not enjoy being isolated. She was never isolated before in her life. It is not a nice experience for her. Within five days of being there, she realised other people are being discharged. Seeing other people discharged made her think of the situation back home. Despite the place being very nice, she could not truly enjoy it as she constantly worried about the virus and what the situation back home is like.  The only right thing for her to do was to go home. Despite the fear of being attacked she convinced herself she needed to go back home as it is home. After being discharged, she went back home. Nothing happened and everything seemed to be normal again.

Mr Olyn said he managed to overcome everything with the love and support he received from his family and friends.

The Chairperson thanked the Covid-19 Survivors for being brave enough to share these stories with the Committee and for answering questions posed.

Adoption of Minutes
The Chairperson said the Committee meeting Minutes for 15 July 2020 must be adopted. The draft was circulated before via email. Members were asked to look through it and if there are no edits, to move to adopt the minutes.

Ms D Baartman (DA) moved to adopt the minutes.

Mr D Mitchell (DA) seconded the adoption.

The minutes of 15 July 2020 were adopted.

The Chairperson told the Committee the next meeting will be held on 14 August 2020, with the theme being Protection of the Vulnerable. The Committee Members and guests were thanked for their attendance.

The meeting was adjourned.