Capacity of Khayelitsha District Hospital

Meeting report

Opening remarks by Chairperson

The Chairperson welcomed Members and the officials from the Western Cape Department of Health. She said a notice had been sent out for an in-person engagement, but she had received only one apology. She said the matter should be taken up with the Office of the Speaker and the relevant Chief Whips of the absent parties.

She said the management of the Khayelitsha District Hospital (KDH) was before the Committee as a result of a Committee resolution, which had come about because of various media reports.

Mr R Allen (DA) thanked the Chairperson for addressing the absence of other Members of the Committee.

Briefing by Khayelitsha District Hospital
 
Mr David Binza, Chief Executive Officer (CEO), Khayelitsha Hospital, said the hospital had been commissioned in 2012. At the time, a total of six specialists were employed at the facility. Those included three family physicians, one emergency physician, one obstetrician and one paediatrician. The hospital served a large community with a high burden of disease. Surges in various conditions occurred on a regular basis. Such surges included a weekend surge for trauma, surges in diarrhoeal disease and respiratory ailments in children at specific times of the year, as well as surges in mental health conditions (especially post COVID). Those surges were often linked to socio-economic conditions.

The facility had a functional Emergency Centre (EC) and offered the full package of care expected at a district hospital. In addition to the district hospital package of care, it also offered some care that was usually offered at a regional hospital. There were currently 14 specialists based at the hospital.

The KDH currently accepted referrals from within Khayelitsha, as well as Mfuleni. Neighbouring facilities with a similar care package included Helderberg Hospital, Karl Bremer Hospital and Eerste River Hospital. Patients from Khayelitsha requiring an advanced level of care were referred to Tygerberg Hospital.

Mr Binza said there was a tsunami of ill health created by six colliding epidemics. Those included violence and injuries; communicable diseases; non-communicable diseases; diseases affecting pregnant women, babies, and children; mental health conditions; and COVID-19.

There was pressure in the service facility areas of the emergency centre, mental health, perinatal and theatre, where there were backlogs.

There were multiple constraints experienced at KDH. The demand exceeded the supply. The official bed capacity was 340 beds. That was often exceeded, especially during times of surge. The EC and mental health ward often ran above capacity. However, despite these constraints, the mortality rate at the facility was between two and four percent. That was comparable with all the other district hospitals in the Cape Town Metro.

Mr Binza outlined the steps taken to improve service levels at the KDH. These included:

Strengthening community and primary health care facilities in the area.
Strengthening relationships with other government departments and stakeholders in the area.
Expanding bed numbers in 2017.
Commissioning of the computerised tomography (CT) scanning service in 2017.
Opening an on-site blood bank in 2019.
Commissioning of overflow psychiatry beds at Lentegeur Hospital in 2021.
Strengthening of nursing management, especially after hours.
Allocating additional agency staff to work in the EC and other pressurised areas.
Additional infrastructure for mental health clients was being planned.

Discussion

Mr Allen recalled that a few years ago, his mother had been transferred from Mitchells Plain Hospital to KDH because the former had experienced staff shortages. As a result, he always remembered how KDH helped his mother. He wanted details on the engagements that had taken place with the Department. He referred to media articles about the R100 million that was required by the hospital to address staff shortages and a lack of resources. What action had the hospital taken with the Department to address this? Had there been any feedback from the Department on its engagements with the Western Cape Department of Treasury?

He asked if there had been interaction with the local clinics, as patients who could have been assisted at the clinics turned up at the hospital. Had the different spheres of government been working together? He said communication was effective in managing crowds, so patients could be aware of the waiting times in advance. He asked for details on that.

Ms R Windvogel (ANC) was concerned about the absence from the meeting of Dr Nomafrench Mbombo, Provincial Minister of Health, and Dr Keith Cloete, Head of the Western Cape Department of Health.

The Chairperson said the invitation had been addressed specifically to the management of the KDH.

Ms Windvogel said she had sent in a request that the Department be present at the meeting as well. She felt the KDH was not being treated like a real issue. She did not want to make it a race issue.

The Chairperson confirmed that the invitation had been extended to the Minister's office, but both Dr Mbombo and Dr Cloete were in Cabinet meetings and had tendered apologies.

Ms Windvogel nevertheless expressed her concern, as she felt their presence was required in the meeting. She thanked Mr Binza and Dr Kariem for attending the important meeting and for the information given. She acknowledged the hard work that took place to run the hospital. She felt the provincial government did not give them the necessary support.

She asked questions about issues raised in the presentation. She referred to the hospital having been open for ten years, serving a large community with a high burden of diseases. She asked how the increased population in that area had affected the functioning of the hospital. Had the management and board requested an expansion of the hospital from the Department? If they had, when was the request made and what response had been received?

She asked Mr Binza about the hospital serving as a regional hospital. What regional level services were offered at the KDH? She asked if they burdened the KDH, and whether additional resources were available for those services.

Ms Windvogel also asked about the bed capacity of 340, which was often exceeded. She asked how much the capacity was exceeded and how often it happened. How much additional funding was required? She wanted to know why the Department had not given the KDH funding.

Mr G Bosman (DA) asked what community interventions were conducted to educate the community on the role of the KDH. What awareness programmes were conducted within the community to prevent alcohol and drug abuse?

Secondly, he asked Mr Binza about the lack of support the KDH received from the Department that Ms Windvogel had raised. Had the KDH received support from the Department, and was it adequate?

The Chairperson asked for context on the service pressure. Was it caused by surrounding clinics not servicing clients, which resulted in them going to the hospital? She had read that some patients went to the KDH when they had to go to the clinic. How did the hospital communicate with clinics and community members about this?

Ms N Makamba-Botya (EFF) asked Mr Binza about the hospital’s service level agreement (SLA). Was the agreement being honoured under the conditions the hospital currently operated under? There had been daily complaints about the service at the KDH, so she wanted to know what plans were in place to address the SLAs. Had there been an action plan put in place to better the service? This was beside the support received from the Department.

Department's response

Dr Saadiq Kariem, Chief Operations Officer, WC Department of Health, responded on the issue of funding and said there were regular engagements with Provincial Treasury, which was busy with budget allocation processes. The engagement process that the Department had held with Treasury on behalf of all hospitals in the province had been robust and good. He had alerted the Treasury about the needs of the Department across the board, especially in the service pressure areas. The Department had many needs especially, after the COVID-19 pandemic. It was difficult for it to accommodate all the needs across the Department and those of its institutions. There was significant pressure on all the services.

There had been interactions with local clinics and communities, informing them on which services to access and where, and there had been many radio campaigns and interactions in Khayelitsha. There was an active engagement with the members of the Khayelitsha Community Forum to inform them on what hospital and clinic services were provided. Health care in Khayelitsha and other areas was under significant pressure. The clinics worked very hard, as Members had seen the long queues, but the need was greater, and the clinics could not keep up with the demand. The same experience was true across the board.

When KDH was opened it was meant to be the equivalent of a district hospital with six specialists. Analysis had been conducted prior to its opening, and this was thought to be sufficient. However, the concept of the ‘unmet need’ became apparent, because where a service had not been provided, people would not access it. It was soon realised that the capacity was not sufficient. The specialists had to be increased from six to 14, and that was still not enough. The concept of the unmet need was real and was present across all hospitals. Indicators like life expectancy at birth, which were measures used in public health, were high in the Western Cape, which had the highest indicators across the provinces. It was an outcome of additional measures which were difficult to measure in Khayelitsha. He said communication with local clinics had taken place through many campaigns. People were informed about when to approach a clinic or a hospital for the different services. There were also difficult circumstances, as some people could afford to go only to the hospital, as it was nearer to where they lived. The same pattern took place between regional and central hospitals, where 44% of the central hospitals like Groote Schuur, Tygerberg and Red Cross War Memorial’s Children’s Hospital provided services that could be provided at the equivalent of a KDH at the regional and district level.

Dr Kariem said the population increase in Khayelitsha had exploded over the years, which added to the service pressures.

On requesting support from the Department, he said there had been a lot of communication with Mr Binza and the Department about what could be provided and what services could be offered. He repeated that the budget was limited, and the best was done to offer services within the budget.

The services offered were listed in the presentation, but a longer list could be provided to Members.

Dr Kariem said bed capacity was often exceeded in the Emergency Centre and in terms of mental health care. Those surges happened throughout the year. As a result, there was an attempt to increase the bed capacity and the services offered within the surrounding communities.

Regarding the service level agreements and the action plan, he said the additional services were mentioned in the last slide of the presentation.

Looking to the future, the Department’s perspective was concerned with mental health pressures. R30 million had been allocated for additional support for mental health. Surgical services had been allocated an additional R20 million, which had been exacerbated by the COVID-19 pandemic. There were other services as well, and the total was R114 million that the Department had reprioritised from within its budget. That had received the support of Provincial Treasury. The other services included neonatal, ICTS and palliative care, which needed additional support. Palliative care referred to people who were at the end of their lives or those with terminal illnesses that required additional care.

Mr Binza said a stakeholder engagement had been attended on 18 February 2021. It was organised by the Khayelitsha Health Forum under the leadership of Mr Mzwanywa Ndibongo, Chairperson, Khayelitsha Health Forum. There had been multiple organisations in attendance, like the Treatment Action Campaign (TAC) and the South African National Civics Organisation (SANCO). Mr Binza had also engaged Mr James Kruger, Director: Khayelitsha Eastern Substructure, Western Cape Department of Health, and Dr Vera Scott, City of Cape Town. There was a billboard that encouraged community members to first attend clinics when they fell sick.

Mr Binza also ran the Khayelitsha Community Health Centre (CHC) before being appointed as the CEO of the KDH. While at the CHC, there were over 50 000 people who attended. The CHC provided good service to the community. There was room for improvement in the relationship between the PAC and community-based services (CBS), where engagements had been ongoing. They were working towards community-oriented primary care. This was often met with challenges related to the social determinants of health, like the high crime rates. Recently, colleagues in Mfuleni who were en route to assist at a vaccination site had been robbed at gunpoint. That challenged service delivery within the community, and required intersectoral collaboration with other government departments like the South African Police Service SAPS).

Mr Binza said the Department was supportive, and Dr Mbombo had organised the billboard and was helpful in addressing the continued robbing of emergency medical services (EMS) which impacted negatively on the provision of service. The EMS had to be escorted by police, which decreased the turnaround time. A submission on the staff shortages had been submitted to Mr Kruger, who had been supportive. The submission was being worked on, and it would require R150 million to address the issue. It remained to be seen whether the support received was sufficient, but the KDH had quantified how much was required for all services, not only clinical services. Clinical services relied on other services like porters, cleaners and clerks.

Referring to the interaction with local clinics, Mr Binza said that KDH relied heavily on EMS to move patients from the hospital to the relevant clinics in terms of a clear triage and classification system. Patients classified as green and yellow had to be taken to PAC or CHC. Patients classified as red or orange were brought to the KDH. That was a way to reduce the long waiting time.

To deal with the lengthy waiting times, there was a system in place that registered patients as they entered the health system. It monitored their age and how they were triaged, and those who were elderly or disabled were prioritised. It displayed when patients had been waiting for a long time. Patients were also able to track how long they had waited via the monitor. There was a triage audit conducted each year to assess the waiting times, and improvement plans were compiled based on the findings. The emergency centre was run by over three consultants. The board worked on community engagements and since it was new, it had a lot of work to do.

The land grabs had worsened the rapid population growth situation, as shacks had appeared where there had previously been none. There were many land grabs that had taken place during the pandemic, with shacks having been erected next to the KDH. It showed that the population had increased rapidly. There were continually patients from the Eastern Cape who sought services from the KDH.

Mr Binza said the KDH provided services that could be accessed at a regional level. He mentioned services that were provided by specialists, which included internal medicine, emergency services, surgery, orthopaedics, obstetrics, gynaecology, paediatrics, psychiatry and anaesthesiology. Those services were meant to be offered at a regional level. There were additional services provided at the hospital, like physiotherapy, laboratory services and the new ophthalmology.

The additional 80 beds in wards 91 and 103 had helped with the bed capacity. It had taken the KDH to 140% of what it could manage with the little resources it had.

Regarding the service level agreement and the plan of action, Mr Binza had alluded to some actions taken in his presentation. Some of those included the expansion of beds, the opening of blood banks to speed the turnaround time of blood test results, and the commissioning of the CT scan. He said there were strategies to address the service delivery issues. Referring to staffing, he said the submission had been made as the KDH was dependent on agency work, which involved challenges like serious adverse events and patient safety incidents. KDH wanted full-time employees, as that was easier to manage.

The step down facilities had been one of the things learnt during the pandemic. The Thusong Centre had been operated as a bed expansion measure. It was close to the KDH, so the clinicians could easily walk there to attend to patients. The only intermediate care facility was in Baphumelele, which was locally accessible. Conversations were ongoing with Baphumelele to increase its accessibility by changing its admission requirements. There were others in places like Mitchells Plein. EMS had been engaged to station an ambulance at the KDH to easily transport patients between the three facilities so that the green and yellow cases could be seen at a primary healthcare level, while the red and orange could be seen at the hospital level. Those were ongoing conversations.

The Chairperson asked about the staff structure. She asked if Mr Binza was referring to current vacant positions at the KDH, or to personnel to complement the current service pressures. Dr Kariem had mentioned the additional R114 million rand that had been re-prioritised for KDH. Would the R114 million not support the staff where the pressures were experienced?

Dr Kariem said the R114 million had been allocated for the entire province. KDH would benefit from that money, and he referred to mental health as an example. R30 million of the R114 million had been re-prioritised for mental health, and of that R30 million the KDH would receive enough funds for an additional doctor to provide mental health support. R20 million of the R114 million had been allocated for the province. From that R20 million, R13 million would be prioritised for the metro and some of that would benefit the KDH.

On the staffing, Mr Binza said the posts were vacant, but they were not funded. They were not funded vacant posts, otherwise the normal recruitment and selection process would have been followed. They could not be filled because of a lack of funds. Over and above those, there were gaps that had been identified which could do with additional staffing and that was why the sub-structure within the Department had been engaged. He understood that it depended on the availability of funding.

On other ways to alleviate the pressures faced at the KDH, Mr Binza said the building of the Belhar Regional Hospital would help to lessen the workload, as patients from surrounding hospitals could be re-directed there. It was a long-term solution.

The Chairperson asked how many funded and un-funded vacancies existed.

Mr Binza said he did not have that information.

The Chairperson said she would request it in a Committee resolution.

Further discussion

Ms Windvogel asked how many full-time staff members were employed at the KDH.

She also asked for a written description of how much funding the KDH was to receive.

On the bed capacity, Ms Windvogel understood that the KDH currently had 340 beds, but asked how often this number was exceeded, and by how many patients. She also asked when KDH started accepting referrals from Mfuleni, and what challenges it had caused. Were there any additional budgetary allocations? Why were patients referred to KDH and not another hospital?

Referring to slide five, which spoke about the mental health pressures, she asked if KDH also served as a psychiatric hospital, or if that was an unfunded function. How many unfunded functions were offered at KDH, and what cost was attached to that?

On improving service levels at KDH, Ms Windvogel asked Mr Binza for his opinion on the Department's decision to close multiple clinics in Khayelitsha. How did he think it would affect the functioning of the hospital?

On the employment of agency staff, she said staff members had raised concerns about their safety.

She also asked what lessons had been learnt from the COVID-19 pandemic.

How much additional funding and infrastructure did the hospital need to operate?

Ms Makamba-Botya said the action plan referred to was a short term solution that could not address the capacity challenge which seemed to be the major issue. Mention had been made about robust engagement with Provincial Treasury for funding that would speak to redress at KDH. She asked for access to those engagements, as she could see the KDH was not coping with the demand. She felt the responses were short-term based, and asked if the stakeholder engagements were effective, as the inflow into Khayelitsha was ever increasing. Were the stakeholder engagements really effective? She also referred to the R150 million and wanted to know if that included the expansion of the KDH since there was also population growth. The R114 million that would be shared across the province would also not help the KDH, as the issue there was based on a lack of capacity.

Department's response

Responding to the hospital's capacity, Dr Kariem said that as of that morning it was at 134%, which was 34% above the official bed capacity. The patient profile revealed that a number of them were in the EC, and still had to be seen. There was one patient waiting in triage and four patients waiting to be seen by the doctor. There were patients waiting to be admitted and discharged. The occupancy figure indicated that the KDH was over its capacity. There was a surge in EC and mental health patients, but the doctors could see where the patients were, and which patients required which services. The patients would then be prioritised according to their green, yellow, orange, or red status. The system was relied upon to manage the pressures on the day.

On the vacant posts, Mr Binza said that 369 posts were required, and a breakdown had been submitted as he had previously mentioned. That number could change after engagements with the sub-structure within the Department before it would be submitted to the Chief Director. With the newly revised numbers, R50 million would be required to fill those vacancies.

On exceeding the bed capacity, Mr Binza said that the KDH often went up to 446 bed capacity instead of the 340 official bed capacity. The expansion of beds in 2019 had helped. The capacity had been exceeded by 106 more patients requiring beds. That happened during certain times of the month and included the weekends, public holidays and at the end of the month. It also happened during social activities, like big soccer matches.

The decision on patients from Mfuleni being diverted to the KDH had been taken by Dr Cloete. He had organised a walk-about in all hospitals, including KDH, to assess the service pressures in the EC. These other hospitals experienced a far greater workload, and it was decided those patients were better taken care of in KDH. That had definitely added to the workload in KDH and with the mental health patients added, it came to an additional 12% in extra load, especially with the psychiatric patients. Additional human resources and infrastructure resources were needed.

He said there was a planned extension of the psychiatric ward at KDH to take place in 2023. There were engagements to fast track that process to ensure psychiatric patients were not kept for longer than the prescribed 72 hours before being moved to a psychiatric institution. The current average stay of such patients was 22 days, or 528 hours, which far exceeded the prescribed 72 hours. There were engagements to work on the seamless movements of those patients from district hospitals to institutions. The difficulty in accessing the psychiatric services added pressure on the KDH. The services often under pressure were emergency care services and mental health care services. Patients were redirected from Eerste River Hospital (ERH) because the conditions there were extremely dire.

Mr Binza said staff morale was low, and was addressed through team building activities and by celebrating calendar holidays like Heritage Day to build team unity. Safety continued to be an issue, and it was an issue bigger than KDH, which required SAPS interventions. Staff members were often robbed at bus stops and had to cancel their shifts as a result. The psychiatrist registrar was robbed en route to work, and as a result, the EC specialists cancelled his shift for fear of his life. Mr Binza stressed the need for intersectoral collaboration to reduce the safety risk posed to staff members. The non-functioning of primary healthcare affected the KDH. It depended on the circumstances in the primary healthcare facilities that had to be monitored and evaluated to assess the number of patients seen and redirected. That engagement had been carried on various radio stations.

A lesson learnt from the pandemic was the expansion of beds to the Thusong Centre, which was close enough for clinicians to walk to and take care of patients. Patients would not tire from sitting on chairs. The banning of alcohol had also reduced the workload significantly, as there had been empty beds for the first time. A step down facility that was close to the KDH would be very helpful -- the one in Baphumelele was an example. The fact that patients in Khayelitsha faced the quadruple burden of disease required them to need more time in admission.

Mr Binza said the only current solution to the infrastructure situation was the provision of the 30 extra beds in the psychiatric ward. The KDH could have done with a bigger emergency centre, as the hospital had grown exponentially.

The Chairperson said she understood that there was an array of factors that contributed to the pressures faced by the KDH. Health was everyone’s concern. She was glad there was a functional board. The board and the various forums mentioned should play a greater role in future deliberations. Taking into consideration all the factors mentioned, like the influx from other provinces, the expansion of informal settlements, the criminality, and the social factors, it required a holistic and inter-departmental approach to address the pressures faced by the KDH.

Ms Makamba-Botya said her question on the expansion of the hospital had not been answered.

Ms Windvogel said she tried to understand how the Department operated. During the pandemic, there had been budgets to fix issues within three to six months. Why was it so difficult for the present issue to be fixed now that things had gone back to normal? The Department sent money back to Provincial Treasury, but it claimed it did not have money. It was wrong that people had to sleep on floors. She understood there were a lot of dynamics to be considered, but felt the same energy applied during the pandemic could be applied to the KDH. She was perplexed as to why things were not being done. As government representatives, they had to put things in place. She found it unacceptable.

Mr Allen thanked Mr Binza and Dr Kariem.

Mr Binza said that the board had just begun engagements which he hoped would help. The hope was that the engagements would lead to community members accessing health care services at the appropriate places, like primary health care clinics.

On the expansion of the hospital, he repeated that the KDH could do with the expansion of the emergency centre, but the only planned expansion was of the psychiatric ward. If the Belhar Regional Hospital was built, it would decrease the pressure on the KDH. There were pressures in the neonatal and childcare services.

He said the National Health Insurance (NHI) that would allow for universal coverage would help lessen the load on the public health service, which serviced 84% of the population. If that were delayed, he would welcome the expansion of the KDH. The current expansion of the psychiatric ward would also help the KDH.

The little funding received helped, as there was a fourth theatre needed and a shortage of ventilator machines, and those would be addressed through the expected funding.

The Chairperson thanked Mr Binza and Dr Kariem, and excused them.

Committee Resolutions

The Chairperson advised that the Committee should resolve to get the necessary information from the Department that would allow it to be fully informed on whether to have an oversight visit or a joint Committee meeting. The Committee needed specific details on how many funded and unfunded vacancies were present at the KDH. It also wanted to know how much of the reprioritised R114 million would be allocated to KDH. What purpose would the allocation serve?

Ms Windvogel said the Department must share the submission it received.

Mr Allen said there should be a timeline for the request for the information.  

The Committee resolved to request the KDH’s action plan, as well as a report on the discussions taking place between the hospital management and Provincial Treasury on the expansion of the KDH.

It resolved to give the Department two weeks to respond.

The meeting was adjourned.