Khayelitsha Hospital challenges and successes
Meeting Summary
The Western Cape Department of Health briefed the Committee on the services rendered by the Khayelitsha District Hospital, its challenges and its successes. The Khayelitsha District Hospital Board was also supposed to brief the Committee, but due to a misunderstanding it did not prepare a presentation.
The Committee was told that Khayelitsha Hospital serves a catchment area with a population estimated at just under 500 000. A large proportion of the population is unemployed, and the Khayelitsha area is characterised by a quadruple burden of disease which includes tuberculosis (TB), HIV, diabetes and hypertension. There is also a big problem with trauma, interpersonal violence and vehicle accidents. Mfuleni has recently been added to the catchment area of the Khayelitsha Hospital.
The hospital offers the full range of services normally provided at a district hospital and also some not normally provided, such as speech therapy and audiology. The bed occupancy rate is above 100% and is steadily increasing. The average length of stay at the hospital is 4.6 days -- and 5.1 days, with the psychiatric hospitals added. The number of outpatients has increased by more than 1 000 over a year due to a conscious effort to protect the emergency centre.
The service pressures in the hospital are felt mainly in the emergency centre, and many of the complaints emanate from there. There is also pressure felt in internal medicine services, as there is a high incidence of HIV, TB and other chronic lifestyle diseases. There are more than 350 babies delivered each month, and a lot of those children are premature. The mental health services have also taken a knock due to substance abuse and social pressures. The surgical and orthopaedic services are being expanded, because that area is also under pressure.
The Chief Executive Officer (CEO) of the hospital has been moved to the Klipfontein hospital project, and there is currently an acting CEO. There are currently 617 funded posts, and 46 of those are vacant. There are shortages in specific areas, especially in specialised nursing. They also struggle to retain specialised nurses. The hospital’s budget for 2017/18 was R330 million and they overspent it by about R20 million. The budget for the 2018/19 year has been increased to R373 million.
There is fragmentation of the primary healthcare services at the provincial and city facilities, and the hospital is trying to service both structures. The community in the catchment area has also grown significantly, mainly in the informal settlements in Spine Road, Endlovini and Baden Powell. The high expectations of the hospital, and the increased scrutiny from political and social organisations, had resulted in high -- and often negative -- media coverage. This was often prevalent on social media, and had led to lowered staff morale and high turnover rates in some areas.
The Hospital had had a total of 466 000 patient contacts since January 2012. There had been 1 000 compliments and 100 complaints. They are close to achieving the National Core Standards at the hospital, and had achieved a score of 100% in the “Mother and Baby Friendly” initiative. There is an improvement plan at the hospital, which includes putting a blood bank on site. There is a mental healthcare unit in design, they have opened additional intermediate beds at the hospital, and they have implemented a Q-marshalling system to reduce waiting times, among other things.
Some Members expressed concern over the Department’s response to the stories circulating on social media and to those people who had raised complaints about the Khayelitsha hospital. They were also not satisfied with the way in which the Member of the Executive Committee (MEC) for Health had responded to some of their questions. The Committee referred to the social conditions, poverty and substance abuse prevalent in the area, which puts extra pressure on the health services. The Committee resolved to send written questions to the Department and the Hospital Board and to consider having another meeting with the same agenda,, given that the Board had not prepared a presentation.
Meeting report
Khayelitsha Hospital challenges and successes
Dr Gio Perez, Chief Director: Metro Health Services, Western Cape Department of Health said from the census, the Khayelitsha population in 2011 was estimated to be 391 749. A large proportion of this population was unemployed, and a large proportion of the population’s monthly household income was less than R3 200 at the time. If they extended the population to today, it is estimated the population has grown just under 500 000 people. However, these numbers are hotly disputed in some circles. The population quoted in the media ranges from 500 000 to 1.5 million people. The figures given by the ensus are the official StatsSA figures.
Dr Perez said the Khayelitsha area and the population of that area is characterised by a high proportion of poor households and people dependent on the public health services. That leads to a heavy quadruple burden of disease, which includes communicable diseases like tuberculosis (TB) and HIV, non-communicable diseases such as diabetes, hypertension and mental illness, and also diseases affecting women and children. There is also a big problem with trauma and violence, and vehicle accidents in the area.
The catchment population of the hospital includes facilities served by the City of Cape Town as well as facilities managed by the Province. The three biggest facilities in that area are Site B Community Health Clinic (CHC), Michael Maphungwana CHC and Nolungile CDC. Recently, Mfuleni was also added to the catchment area of Khayelitsha Hospital.
Services provided by Khayelitsha Hospital
Dr Perez said the package of services that is offered at the Hospital includes the full range of services normally provided at a District Hospital, and includes some things not normally provided at a district hospital, such as speech therapy and audiology.
They regard a hospital as being full when it is 85% full. At the moment, Khayelitsha is exceeding 100%, and it is a steady upward trend. The average length of stay is 4.6 days, but if the psychiatric hospitals are added in, it goes to 5.1 days. Usually a district hospital has an average length of stay of about 3 to 3.5 days. This longer length of stay usually indicates a higher burden of disease, or people who are sicker than average.
The outpatient numbers have increased by more than 1 000 over a period of a year because they consciously making an effort to accommodate more people in the out-patients department to protect the Emergency Centre (EC). A patient day equivalent is a mathematical concept which incorporates outpatient visits, emergency centre visits, as well as admissions to hospital. This number is also steadily increasing over time. This is painting a picture of a hospital under stress. Currently, the mortality rate for Khayelitsha Hospital is at 2.5%, which is lower than the provincial and national rates. Despite the pressure the hospital is facing, the mortality rate is still considered good.
The service pressures in Khayelitsha Hospital are mainly felt in the emergency centre, so many of the complaints will emanate from the emergency centre. There is also pressure felt in internal medicine services, as there are high incidents of HIV, TB and chronic lifestyle diseases. The number of children born in Khayelitsha Hospital is quite significant -- there are more than 350 deliveries a month and a lot of those children are premature. Mental health services have taken a knock because of substance abuse and social pressures. They are expanding their surgical and orthopaedic services, so that area is also under pressure.
Dr Perez said the CEO position is currently occupied by Dr Anwar Kharwa, but he has been moved to help to deal with infrastructure, because that is an area in which he does very well. The acting CEO is Ms Grace Mashaba. Dr Kharwa is currently kick-starting the Klipfontein Hospital project.
Regarding human resource matters, there are 617 posts that are funded at the hospital, and currently 46 of those posts are vacant. There are shortages in some specific areas, especially in the area of specialised nursing. The Department struggles to find specialised nurses, and once they have specialised nurses, they struggle to retain them. 65 appointments have been made since 1 January 2018. African females dominate the nursing profession.
From a financial perspective, the Hospital does struggle. Its budget in 2017/18 was R 330 million, and they overspent that by about R 20 million. The budget for the 2018/19 year has been increased to R373 million.
Challenges
Dr Perez said the first challenge is the burden of disease. Khayelitsha unfortunately experiences a higher burden of disease than the rest of the metro. In addition, there is fragmentation of the primary healthcare services, and the provincial and city facilities are still fragmented, but the Hospital is trying to service both of these structures. The community has grown significantly over the past six years, mainly in the area of informal settlements, in the Spine road, Endlovini and Baden Powell areas. Mfuleni has been added in the drainage area of Khayelitsha Hospital, and this has increased the service pressures. There are legitimately high expectations and increased scrutiny and pressure from political and social organisations which has resulted in high profile – and often negative -- media coverage. This is particularly prevalent on social media. This has led to a lowering of morale among staff members and high turnover rates in some areas.
Khayelitsha Hospital in Metro East has the highest number of paediatric admissions, second only to Tygerberg hospital. The deaths in there are largely due to pneumonia, sepsis and gastro. The ill-defined deaths are largely children who are dead on arrival, and children who die within hours of admission. During the gastro season and bronchitis season, the number of children surges to almost that of the Red Cross Hospital. Paediatric ward space is under pressure. They have two paediatricians working there with a team of medical officers.
Dr Perez referred to obstetrics service outcomes, and said the number of births has gone up from just over 5 000 to just over 7 000 births per year. Hypoxic-Ischemic Encephalopathy (HIE) is a condition that affects children whose brains have been deprived of oxygen during the child birth process. This number has been reducing steadily from 2012 to 2017, and they have introduced a number of safety measures at the hospital to reduce it even further. Maternal deaths and neonatal deaths are particular low in that space. They have two qualified obstetricians working in the obstetrics services.
Orthopaedic services have also increased. There is an app called the VULA app, which allows doctors and facilities to refer patients via a cellphone app. The number of referrals has virtually doubled over the period from April 2017 to June 2018. They have two orthopaedic surgeons. They have recently had a backlog in orthopaedic surgeries of about 100 people. They had put systems in place to catch up on the backlog and when they tried to contact those people, about 20% of those people had unfortunately died due to new trauma.
Most of the patients survive the EC, but they come to the EC for stab wounds, motor vehicle accidents, assaults, gunshot wounds, blunt trauma and burns. 7.8% of those people do not survive.
Service delivery achievements
Dr Perez said the Hospital has had a total of 466 000 patient contacts since January 2012. There have been more than 1 000 compliments compared to 100 complaints. Complaints are an opportunity for them to improve their services. The Hospital pharmacy received a gold award for the best functioning pharmacy in the province. They are close to achieving National Core Standards at the Hospital -- it has gone up from 78% in 2012, to 95% in 2017. There is a 100% score in the “Mother and Baby Friendly” initiative.
There have been a lot of achievements in the nursing space. A significant number of nurses have progressed from professional to speciality. They have completed training two paediatricians and one obstetrician on site. They are currently training a number of registrars in emergency medicine, paediatrics, obstetrics, orthopaedics and internal medicine. 45 diplomas in primary emergency care, child health, anaesthetics and HIV management had been achieved by medical officers who voluntarily get an additional qualification to improve the way they manage clients. They do not get paid extra for that, and the graduates pay for it themselves.
The Department has an improvement plan which has been documented, which includes putting an onsite blood bank at the facility, as currently they have to drive to Tygerberg for blood. There is a mental healthcare unit in design. They have opened additional intermediate care beds at the Hospital, as well as at Zandvliet, which is in Macassar. There are plans to initiate eye care services from January 2019, and to increase services in the breast clinic. To deal with the congestion in the emergency centre, they have implemented a Q-marshal system and strengthened the night nursing office. They have also improved their linkages to primary health care and to community-based services, and they have increased intermediate care in the area.
Dr Perez said Khayelitsha Hospital was commissioned five years ago. It was built to meet the needs of a large community. The staff, hospital management and the Board, are working within the prescripts to try to meet the community’s health needs and their priorities.
They did have a few good stories to tell. One of them was of Ms Vuyokazi MaDlomo Matanzima, whose story was provided in the presentation. They had found that focusing on people with whom the community is familiar, instead of highlighting infrastructure, yields better results from the public.
Dr Beth Engelbrecht, Head of Department (HOD): Western Cape Department of Health, said that the Khayelitsha Hospital is part of a system, and all parts of the system need to be working together. They also have an interface with Tygerberg Hospital as part of their referrals.
Hospital Board comments
The Chairperson welcomed members of the Khayelitsha District Hospital Board, and asked if the chairperson of the Board would like to add anything to the presentation.
Mr Mzwandile Feni, Chairperson: Khayelitsha Hospital Board, said he was in his second term of office, and based on their role as board members of the Hospital, the things that they hear provide a different picture altogether. The performance of the Hospital is not that which is being portrayed through social media. The hospital is doing exactly what it is supposed to be doing, and the nurses and doctors are actually doing sterling work to make sure that whoever comes to the hospital is attended to promptly and the services are provided adequately.
The disadvantage is the size of the hospital in comparison with the size of the population of Khayelitsha -- somebody has to do some miracles in order to satisfy everybody. It can never be the case that in an ever-sprawling community such as Khayelitsha they can do things that would satisfy everybody, but they do try their level best. In their tenor as Board members, they are providing advice on how best to improve the services of the hospital. Those improvements are in progress at a level that will ensure that those who are doomsayers will now have to swallow their negative comments about the hospital.
The hospital is doing very well, and they receive referrals from various other neighbourhood hospitals in Khayelitsha. People would never be seeking the services of Khayelitsha Hospital if its performance was that of what is being portrayed and circulated in social media. They are working hand in hand with nursing managers and senior management to make sure that the hospital is serving the purposes for which it was established.
Other challenges which the hospital faces include people expecting divine miracles from the hospital without looking at the fact that it can never meet all the needs of the growing population of the area, and this is serious problem they are grappling with. A shortages of staff is as a result of a lack of finances to pay them. They can only employ people when they know they have the budget to pay the staff at the end of the month. There is access control which is provided by security services at entrances. People have been complaining that even if someone from the township is stabbed and gets admitted into the hospital, that person is never safe because the same people who want to assault that person could do so in the hospital, as there are no tight security controls at all the entrances. They are working to address this shortcoming.
Disccussion
Ms P Lekker (ANC) expressed her discomfort with the choice of words used by Mr Feni in labelling people, whether they were on social media or wherever they may be, as doomsayers and in other unsavoury terms.
She asked what the plans were to address the increasingly high bed occupancy rate. She expressed concern over the presentation’s comparison between the national and provincial statistics of the mortality rate. Was not one death too many? With regards to the service pressure in internal medicine, she referred to an issue where she had a family member who went to Site C hospital and was referred to Khayelitsha District Hospital, and at 02h00 was told that there was no available medicine. The family member had to fetch medication at Bellville pharmacy.
It would be incorrect to say people are portraying negative connotations about the hospital. This is misleading the people of South Africa, and if they want to build a positive society they must start with their utterances and expectations when they speak of these matters. There are stories that some children are taken to Khayelitsha Hospital and when some of them arrive at the hospital, they are diagnosed as dead on arrival, or they die as a result of whatever the cause is. Why would children be transported to Khayelitsha Hospital when there is the Red Cross Hospital, which is dedicated to attend to children? What are the norms and standards when children are admitted to hospital?
Ms M Gillion (ANC) said she was very disappointed in the utterances of a chairperson who was supposed to be looking at the health and welfare of their communities. Using terms such as “malicious individuals” and “negative comments on social media” was incorrect, as she experienced what people are going through at Khayelitsha hospital. Even the chairperson of the ANC in the Western Cape had a bad experience two weeks ago when his brother-in-law was admitted to hospital, and for two and a half days nobody gave any attention to him, and he subsequently passed away.
Taking the health and wellbeing of people in the community into account should be the role the chairperson, and not to dabble in politics. The people in Khayelitsha are in trouble and the health services are in trouble. She asked when the Members of the Committee will have the privilege to see the 100 complaints and 1 000+ compliments of the hospital. Do these compliments and complaints have merit? When there was an unannounced visit of members of the National Council of Provinces (NCOP) to the Khayelitsha Hospital, most of the complaints came from the nursing staff who are under pressure, and the welfare of the nursing staff is not taken care of. There are malicious cases brought against staff members. Doctors should investigate that and give the Committee a report on it. There are staff members who are very unhappy with the way they are treated in the hospital.
When political parties put pressure on any government department, it is because they care about what is happening in that department. If people from a societal organisation put pressure on a government department, it is because they too care. She asked what is being put in place to address this challenge. Social media campaigns cannot have an impact on the morale of staff. Batho Pele (“People First”) was introduced in this country by a Minister who had passed on. The legacy of Batho Pele is nowhere to be found, or is very low, when it comes to health departments in South Africa.
The important thing is what is going to be done to improve the situation at Khayelitsha Hospital when it comes to service and complaints. People in the emergency centre sometimes sit on the floor for two days. When they had the G.F Jooste Hospital, the pressure was not so high. Khayelitsha Hospital was built to alleviate the pressure from other hospitals. This was not happening today. People from Mfuleni are being referred to Khayelitsha Hospital, when Tygerberg and Eersterivier hospitals are closer. Was this still the apartheid regime in play, when poor black people have to use Khayelitsha Hospital instead of the hospitals closer to them? This was not only a provincial problem, but they cannot always run away when they have to address the challenges that come their way.
Mr B Kivedo (DA) said he is more concerned about the Khayelitsha area itself and its ecological environment -- growing informal settlements, poor living conditions and the impact of this on health in general. Poverty is also a major problem in the area, which can lead to physical and mental health issues. He expressed concern over prevalence and increase in substance abuse in Khayelitsha. This was not a major problem years ago, but it has increased over the years. Substances abuse often leads to violence and abuse of women and children. Perhaps now the legalisation of the personal use of marijuana will worsen the situation, but he does not want to take a stand on that. How will the social issues be addressed first?
Ms P Makeleni (ANC) said that Khayelitsha Hospital has been an issue for a long time now. They are on a fact-finding mission and are trying to provide solutions to issues. It would be more interesting for the Committee to receive the presentation from the Khayelitsha Hospital Board in terms of their findings at the hospital and what they had done to improve them. She hoped that the Board will still take the Committee through that.
When the Hospital looks at the budget and resource allocation, does it look at the 391 749 people according to the statistics? What is the plan going forward to cope with the increasing population in the area? What informs the decision to include Mfuleni into the catchment area of the Khayelitsha hospital? When was the number of beds in the hospital increased to 340, and what has been the impact thereof? What are the monthly averages for patient day equivalents, and in patient days? Will the current Acting CEO, Ms Grace Mashaba, be appointed as the new CEO, or is it just a temporary position, and for how long will she be Acting CEO? Why was the Ward Councillor and the Sub-Council representative not included in the hospital Board? In which spaces are the 46 vacant posts, and when will these vacancies be filled? How many doctors are in the Khayelitsha Hospital, and how many people do doctors see each day? What is the allocated budget for the Mitchell’s Plain Hospital and Victoria Hospital? Does the Khayelitsha Hospital always exceed its budget? What is the form of community engagement that the hospital board is using? Does the board need any help in improving communication with the community?
Mr D Mitchell (DA) asked what pre-emptive programmes are being set in place to reduce the number of deaths from seasonal illnesses such as gastro-enteritis?
Ms D Gopie (ANC) asked why Mfuleni is in the Khayelitsha Hospital’s catchment area instead of Eersterivier. How is Khayelitsha strengthening the night nursing office? She asked for clarification of the VULA referral system.
MEC’s response
Dr Nomafrench Mbombo, MEC for Health: Western Cape, said that they generally do not want to dismiss any complaints. They do not dismiss any person’s experience. If they have done something wrong, they apologise and take lessons from it. When a Board member comes up with what they have experienced, it does not mean that the Board member is dismissing what politicians or any other person has experienced. She does not think Mr Feni was saying that those who circulate negative comments about the Khayelitsha Hospital were related to the politicians sitting here or that any person’s view is dismissed. Mr Feni was sharing his views from a community perspective where they have been dealing with the different political parties, community groups and individuals that are sharing their experiences from where they are sitting.
She wanted to highlight that the health systems for poorer communities are under pressure, and Khayelitsha is not exempted from that,. She is not dismissing that even if they have the best health outcomes, clinicians and skilled staff, the experiences of people sitting on the couches do not count. Sometimes the same issue is circulated on social media without people having seen the response. She is not dismissing what is being said by Members of the Committee, but she is saying that there is a challenge which a reflection of not only the South African health system, but also the prevailing socioeconomic environment. She did not want to lecture the Committee, but sometimes it is necessary to explain certain things to get a clear understanding.
Dr Mbombo said information on the bed occupancy rate and what the plans are, has been made available to the Committee. There are plans also to reduce the waiting times of people waiting for CAT scans, for example. She does not want to repeat what she has already said in Parliament. It needs to be understood that they can do as much as they can, but if the up-streaming factors are not addressed, there is nothing they can do more than what they are already doing. She compared what they are doing to mopping the floor, while what needed to be done is to close the tap. Interpersonal violence is a big reason for people coming to the EC, and in more than 72% of the cases the contributing factor is substance abuse, specifically alcohol. People need to reduce the risk factors related to the abuse of alcohol. The increasing bed occupancy rate can be addressed by focusing on preventative measures.
The Department does not dismiss the opinion that people are dying in Khayelitsha Hospital. Sometimes people experience the death of someone at the hospital and it becomes an emotive issue instead of a statistical reality. In most cases when people complain, she is the first person to respond to that complaint. Sometimes they will even sit with the family of a diseased person to try to understand what has happened. With regards to complaints, sometimes it becomes difficult to respond to generalisations.
Dr Mbombo said Red Cross hospital is a tertiary hospital which not only caters for the province, but caters for everywhere. Khayelitsha Hospital is a level 1 hospital, and Red Cross is level 3 hospital. Unlike other level 1 hospitals in the metro, Khayelitsha also offers some aspects of the services that are even at a level 2 hospital in terms of specialisation.
When it comes to the health system -- specifically the medical part of it, and in terms of health systems anywhere -- they have to respond to the disease profile of the population. The referral system for Khayelitsha was part of the eastern sub-structure, and they are referred to that side of the area. When she did an unannounced visit to Eersterivier Hospital, although it is a level 1 hospital, it does not have a broader health package.
In the catchment area, the only 24-hour clinic is in Delft CHC. There were too many people in the Delft CHC, and there was too much pressure on that hospital, which does not have a broader health package compared to the Khayelitsha hospital. In Khayelitsha, there is a 24 hour clinic in Site B which is supposed to reduce the pressure in the catchment area, but in fact it did not reduce the pressure. Eersterivier hospital also needs to see to most of the mental health patients in the area.
Dr Mbombo said the public health system is only for people who cannot afford private health services. She did not understand the question of Ms Lekker, which related to the apartheid system, because the referral system is related to the geographic area.
The Department had been asked once by the Committee about the issues related to the complaints and management system, and had presented on this to the Committee for more than an hour. They had various systems through which people can submit complaints and concerns.
The Department had met with the Public Service Commission (PSC) after the unannounced visit by the NCOP to Khayelitsha Hospital and heard the complaints of the nursing staff, and had engaged on issues related to labour relations. As part of their improvement plan they want to do town hall meetings where the staff can say whatever they want to say, beyond meeting with their managers.
Dr Mbombo said it should not be that just because people raise issues with the Khayelitsha Hospital, it translates into lowered staff morale. They are not saying that all of the staff members are doing as much as they can, but sometimes there are loose ends which result in issues. People should be free to raise issues with the hospital. People should also not spread stories which do not relate to their experiences at the hospital. Some of the staff members do as much as they can, but they sometimes feel demoralised when issues are circulated in the public sphere. Some stories circulate on social media for a long time after the issue has been resolved and an improvement plan is in place. If an issue is raised with a particular member of the staff, that issue must be addressed between the patient and the staff member. She reiterated the point that stories that circulate in social media are not always fully factual, but there are people who add to the problem by spreading those stories. People should try to verify what has been done by the Khayelitsha hospital in response to the stories which circulate the public sphere instead of passing on the stories without the facts. Khayelitsha Hospital and the Provincial Health Department do implement the Batho Pele values.
Dr Mbombo said that the environmental health aspects and all other social determinants of health do impact on health. Wealth and health are the same thing, and the Khayelitsha Hospital is absorbing every social ill in the communities it serves. With the gastro season, while they may not be able to control it, the deaths from gastro and pneumonia are decreasing although the incidences might not be decreasing.
It becomes difficult to talk about whether a hospital is full month on month. Beds in various wards are meant for their respective disciplines, such as paediatrics. For example, a person with a broken bone cannot be put in a bed meant for infectious diseases. Internationally, a hospital with a bed occupancy rate of 80% is considered full.
Dr Mbombo said the letter she had received was that the presentation was on Khayelitsha Hospital. She was not aware that they were going to present on any other hospitals, but differentiation needed to be done.
She said Ms Mashaba is Acting CEO. Dr Kharwa is still in the post of CEO, but because of his skills related to infrastructure, he has been assigned to a different project. The post is not vacant.
Ms Makeleni said that Dr Mbombo was not answering her exact questions directly. How long will Ms Mashaba be acting CEO? She said she is not sure whether Dr Mbombo misunderstood her questions.
Dr Mbombo said she is doing her part, but the Department would also provide answers and if clarity is required they can come back to that.
Ms Makeleni asked the Chairperson to consider the time, as they had only 10 minutes left as per the official schedule.
The Chairperson allowed Dr Mbombo to continue, and then the Department would answer their questions, and if the questions were not addressed they would take it from there.
Ms Gillion said that Dr Mbombo said many times she is not lecturing the Committee. The issue is when they are in the House and they ask questions, Dr Mbombo can answer whichever questions she wants to but in this meeting they want direct answers and not long lectures. The lectures Dr Mbombo is giving now she should give to the communities, so that they understand the situation.
The Chairperson said that Dr Mbombo is responding and as Ms Makeleni had mentioned, time was an issue.
Dr Mbombo said when she is invited to a Committee meeting, she does not ask Members to limit their questions. When she is responding, she is responding to what the Members have asked.
Some of the members made comments.
The Chairperson asked Members of the Committee to allow Dr Mbombo to respond. The Department would add on.
Ms Lekker asked to be allowed to speak.
The Chairperson said she would not allow Ms Lekker to speak right now.
Ms Lekker said a member of the Khayelitsha hospital board was fully participating in the meeting by making remarks.
The Chairperson allowed Dr Mbombo to speak again.
Dr Mbombo said she had been asked to come and respond to the questions, and had she not been present she would have been criticised. If the Members of the Committee ask questions, she has the responsibility to respond. Whether they liked the responses or not, they should let it be, because the Members had asked the questions. It is the responsibility of the Members to be conscious of the time.
Ms Gillion raised a point of order.
The Chairperson said Dr Mbombo was continuing with her response.
Ms Gillion raised a point of order again.
The Chairperson allowed Ms Gillion to raise her point.
Ms Gillion said that they as a Committee play the oversight role over the Department. If the Minister does not want to answer the questions directly she can refuse, but they as a Committee will not be undermined. This lecture needs to be given to the community who do not understand the situation.
The Chairperson asked Dr Mbombo to respond to the remaining questions.
Dr Mbombo said Ms Mashaba is acting in the post which is still occupied. There is no vacant post. The length of her tenure as Acting CEO will depend on when Dr Kharwa will be finished with the project he has been assigned to. She does not know when Dr Kharwa will be finished with that project.
HOD’s response
Dr Engelbrecht acknowledged that the hospital is under pressure and that the staff are working extremely hard. They have amazing staff and clinicians at the Khayelitsha Hospital, and negative communication and media does have a negative impact on staff morale. This is particularly the case for staff in leadership positions. There is a complaint mechanism, and if any of the Members of the Committee pick up on complaints sometimes, they should rather contact the Department instead of using other means.
There is an extensive plan with 31 elements that are being addressed at the hospital due to the fact that they have acknowledged that the hospital is under pressure. The population is growing and the Members of the Committee are also aware that despite the fact that the population in the Western Cape has grown by more than 30%, their budget has been reduced in real terms over the last three years. They have allowed the Khayelitsha hospital to spend more than their allocated budget because of the pressure and because they recognised that they should prioritise the vulnerable in communities.
When patients arrive at the emergency centre, a proportion of them come by ambulance, but the largest proportion does not come by ambulance. They can influence the ambulance transfers, and there is a very clear triage, which employs the same parameters they use in the emergency centre. When there is a patient that is serious, the patient will not be taken to Luvuyo clinic, but will be taken to the Hospital. There is a clear understanding on how the referral system works and they are governing this clearly through various systems.
There are five death review committees across the Province to look at every child death, and especially unnatural deaths, to find out what happened. Between November and May there is a heightened diarrhoeal presence, and from May to November there are higher rates of pneumonia.
Dr Engelbrecht said when she started working in this Department, the Red Cross hospital would have a bed occupancy in the diarrhoeal season of 145%. They are now down to below 100% due to the fact that they strengthened the system, and especially the preventative part of the system. The primary care facilities are preventing diarrhoeal disease getting worse, and dehydration is managed much earlier. They work with the Department of Social Development and Early Childhood Development centres in terms of where the pockets are, because they monitor what has happened by address and death. As a Department, they look across the whole system to see what is happening and where the various pressures are so that they can take decisions to deviate and redirect pressure to have it equalised according to the resources available.
Chief Director’s response
Dr Perez said many people pass away in hospital -- and everyone must pass away eventually. Many people who will pass away are going to pass away in hospital. This is a normal process. One of the issues he has personal knowledge of is the mortality rate in hospitals. He was the Medical Superintendent of G.F Jooste Hospital from 2002 to 2006. When he took over as CEO there, the mortality rate was 11%. When he left the hospital, the mortality rate was 7%. The hard measure by which hospitals are measured is the mortality rate, and it can never be 0%.
He said Eesterivier hospital, Khayelitsha hospital and Helderberg hospital are all hospitals which are in the Khayelitsha and Eastern sub-structure. The bed utilisation rate in all three hospitals is over 100%. Unfortunately, Easterivier hospital had the highest bed utilisation rate at the time. When they looked at the data, they actually found out that patients went on their own from Mfuleni to Khayelitsha hospital. The part that they could control was the dispatching of ambulances, and they had added that to Khayelitsha hospital. It was not a matter of sending people to Khayelitsha hospital without thought. From Mfuleni to Tygerberg hospital is 21km, from Mfuleni to Eesterivier is 5.6 kilometres, and from Mfuleni to Khayelitsha hospital is 7.6km.
Dr Perez said that the primary healthcare platform in Khayelitsha is fragmented because the city and the province belong to two separate organisations, and there is a challenge in that space. In the Khayelitsha community, the management of the city and the province have sat together and worked out a very detailed response plan to the diarrhoeal and respiratory surge season. That includes things like hand washing campaigns and access to fresh drinking water. This has been working very well in Khayelitsha, and the numbers reflect this in terms of the mortality rate.
He said there were a number of other questions that had been asked, and it might be better to respond to those in writing. For example, many of the 46 vacant posts are nursing posts and many of those posts at the time of operation were new posts. Khayelitsha hospital was opened with 230 beds, and it now had 340 beds.
Dr Perez said that they calculate the budget as a cost per patient day equivalent. A patient day equivalent is a mathematical construct which considers the number of admissions plus a percentage of the number of EC visits plus a percentage of the number of Out Patients Department (OPD) visits. The latest patient day equivalent figures show that for Khayelitsha hospital, they paid R2 768 per patient day equivalent; for Mitchells Plain, they paid R2 667; for Karl Bremer, they paid R2 505; and for Victoria Hospital, they paid R2 797. The Department can give the Committee access to the figures that inform this.
Further discussion
The Chairperson asked if Members of the Committee still had questions. She asked them to be mindful of the time.
Ms Gillion said she still had a lot of questions and she would not be suppressed.
The Chairperson said Ms Gillion would not be suppressed, but the Committee still had other work to do. She allowed Mr Feni to give an input.
Mr Feni said he would try to express the constraints and frustrations that they are encountering as Board members within the hospital. There were a plethora of challenges that they were grappling with and the causal factors were mainly due to the unannounced oversight visits to the Khayelitsha Hospital which tended to interrupt the healthcare services that are being provided.
Dr Mbombo asked the Chairperson to indicate how much time was left to answer questions, because they did not want to leave any questions unanswered.
The Chairperson said Ms Gillion had indicated that she still has many questions. She proposed to extend the length of the meeting.
Ms Gillion said the Committee was supposed to get a report from the Board. The verbal response by the Board does not communicate the challenge that the Board is facing. She proposed that the meeting be rescheduled, because she still has many questions remaining. She would not be silenced because this was in the best interest of the community, which was coming to the Members of the Committee with their complaints.
Dr Mbombo said they had not received any letter from the Committee that asked for a report from the Board.
The Chairperson said the meeting’s agenda was a briefing by the Department of Health and the Khayelitsha Hospital Board on the services rendered by the Khayelitsha District Hospital. The Chairperson said it meant that there was supposed to be two presentations.
Mr Feni asked if the verbal report was still relevant.
The Chairperson asked Mr Feni if they had a presentation in writing at the present moment.
Mr Feni said they did not have a presentation.
The Chairperson asked if Mr Feni would be able to furnish the Committee with a report on what the Members of the Committee had asked at another time.
Mr Feni said they would be able to do so.
Dr Keith Cloete, Chief of Operations: Western Cape Department of Health, said that when the invitation came to the Department, there was deliberation as to what the request meant. There was a decision made that there would be one presentation. If the Committee had wanted two separate presentations they should have asked for that, because the Board and the Department had met together in preparation for this presentation.
The Chairperson said the remaining questions would be put in writing.
Ms Makeleni asked the Chairperson to consider allowing the Board to give a presentation to the Committee before questions were posed to them.
Dr Mbombo asked if she could respond to one of the questions she had not answered.
Mr Mitchell said that the agenda as it stands had been completed.
Ms Gillion asked if she could ask two questions.
The Chairperson said she would get a written response to those questions.
Ms Gillion said that the Department had made it very clear that they are experiencing challenges at Khayelitsha Hospital. She asked why they had transferred the CEO, Dr Kharwa, to another project when they are experiencing challenges.
Ms Gillion that since 2004, the Health Department had introduced the amalgamation of clinics into the Department. Fragmented services was one of the reasons why they were sitting with non-service delivery, not only at Khayelitsha Hospital, but at other hospitals as well. 14 years down the line, the Department has allowed the City of Cape Town to “play games” with the provincial Department. From 2004 to 2006, all clinics had responded positively, except the City of Cape Town clinics. These problems came from the Department’s reluctance to deal with the City of Cape Town.
The Chairperson allowed Ms Lekker to provide input.
Ms Lekker proposed that a meeting of this nature needed to be reconvened. The presentation had provided only the names of the Board members. There needed to be more information about the Board, its challenges and successes.
The Chairperson asked if the meeting could continue for longer than scheduled.
Dr Mbombo said that they did indicate that there would be another meeting specifically related to the Board. This was agreed upon. She asked if the questions would be asked orally now or if the questions would be sent to them. She was unsure about the way in which the questions and responses would be structured. She had to leave the meeting soon due to another scheduled appointment.
The Chairperson said the questions would be sent to the Department, and the Committee would want a written response to those questions.
Ms Makeleni said Ms Lekker had proposed reconvening the meeting.
The Chairperson said they would look at that after the Department had left with the Parliamentary programme.
Ms Makeleni said she wanted to make it clear that they are not fighting with the Hospital Board. They are on a fact-finding mission and their role here is to find solutions so that the service delivery is carried out properly.
The Chairperson asked Members if they supported the proposal by Ms Lekker to reconvene the meeting.
The proposal was accepted by the Committee.
Ms Gillion said that one of the Board members was making remarks to her while the meeting was in progress. She wanted to make it clear that she was performing her oversight role. She was asking these questions because the Members of the Committee were the faces which defend the Department in public.
Dr Engelbrecht said once the Department received the questions, they will respond fully to them. She said they have always been very respectful of the oversight role that the Committee plays. She finds it unfortunate when a Member of the Committee points a finger at the Department across the table in a way that appears disrespectful. They would really appreciate it if the Chairperson can assist them in keeping a respectful relationship.
The Chairperson thanked the Hospital Board for having availed themselves for this meeting. She thanked the Department for their presentation.
The meeting was adjourned.
Documents
Present
-
Botha, Ms L Chairperson
DA -
Gillion, Ms M
ANC -
Gopie, Ms D
ANC -
Kivedo, Mr B
DA -
Lekker, Ms P
ANC -
Makeleni, Ms P
ANC -
Mitchell, Mr D
DA
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