Within less than 50 years of its operations, SKIMS – the tertiary care teaching hospital and a deemed university that sits over the healthcare pyramid in Kashmir, is showing serious stress within the institution. Whether or not it is the outcome of post-2019 decision-making, the mess is seriously impacting patient care, reports Masood Hussain
A Srinagar resident, Irfan spent three days in SKIMS after his aunt was operated upon and put on life support. “She was not put on a ventilator but I was asked to pump oxygen manually using the (ambu) bag,” Irfan said, showing his pink-red fingertips. The staff gave him absolutely no reason for why a machine was not employed instead of an ambu bag. “The doctors were apparently not sure of her condition well before the surgery. They said there are two options – one, let her die normally or we will operate upon her and there is a possibility of her death on the operation table. Thank God, she survived for three days after the operation but she was not treated well.”
Over the last few months, the small talk about the “worst situation” prevailing in the SKIMS, the major tertiary care hospital in Srinagar, is constantly making rounds. There are interesting anecdotes explaining the deterioration. “In cancer radiology, anybody who requires therapy is first marked on a machine and for this very purpose, the patients were sent to SMHS Hospital because the SKIMS machine stopped working,” one hospital insider said. “Once, they were marked there; the patient would start receiving therapies.”
Most of the MRIs are now being carried out in privately run facilities outside the 1200-bed hospital. It was after a hiatus of many weeks that the hospital managed to procure cancer markers, a vital diagnostic chemical the staff was desperate for. “I observed there are two activities with huge priority,” Irfan said. “The security of the hospital is taken care of and used almost everywhere and the hospital is adding to the parking space.”
“Not everything that you say may be correct but one thing is sure – we are in a whirlpool,” one senior doctor admitted. “We have problems almost everywhere – we have staff problems, we have infrastructure issues and off late, we are facing faculty problems as well.”
The doctor said the entire situation is the outcome of meddling by the bureaucracy that started with the undoing of institutional autonomy at the far end of Dr Ahangar’s leadership. “We are not desperate for autonomy but the administration must address the issues that are cropping up,” the doctor said. “Right now, SKIMS does not seem to be a priority for the administration and sometimes we feel as if the situation is deliberately created.” The authority to make purchases and appoint the staff has been taken away from the Director SKIMS. While a Committee is overseeing the purchases, all issues related to jobs are to be tackled by the SSB and J&KPSC.
Manpower is the biggest issue the SKIMS is facing right now. “The last recruitment of the nursing staff was done in 2013,” one senior doctor said. “The hospital administration was asked to get the staff appointed through the Subordinate Services Board (SSB). More than a year has passed since around 300 nursing positions were referred to the recruiter and they are yet to advertise these positions.” The gazetted staff has to be recruited by the JKPSC (since June 11, 2023) and the non-gazetted and class-IV by the SSB (since January 15, 2021).
In between, a number of technical staff superannuated thus adding to the staff deficit in the hospital. The hospital had hired around 70 nurses on a contractual basis. What was interesting these nurses were disengaged and sent home at a time when the hospital lacked nurses. This, insiders said was done despite repeated requests by hospital administration that they should not be disengaged. Some of these nurses have gone to the court.
“We lack nursing staff, nursing aids, dressers, laboratory technicians and a number of technologists,” one insider said. “Right now the formal SKIMS bed capacity is 1015 beds, we stretch it routinely to 1200 beds but given the staff position, it has to be 600 beds right now.”
Hospital administration insiders said they cannot go with our problem to the patients who come with their last hope of treatment. “By an average, around 1500 patients are registered in SKIMS emergency every day, 5000 patients visit are managed in the OPD on a daily basis as 250-300 patients are admitted every 24 hours,” one doctor said. “We avoid talking because it will extinguish the hope that the hospital lacks the capacity to treat the sick, which we do not want.”
The shortage of staff is impacting patient care, the doctors said. In ICU, it has to be three nurses to one bed in three shifts and a ward must have five nurses at any point in time. “We do not have staff to manage ventilators which we have and do not operate and our wards are managed by two nurses at the most,” one doctor added.
Everything is hanging because of staff issues. Immunology had 21 professionals and all retired except four. Pathology was managed by 35 staffers and now it has only seven. People in MRD, X-ray, ECG and many others are actually casual labourers who have been elevated to the status simply because there are no trained paramedics. “Engineering wing is hanging as they have been told they will be going back to the PWD department and in the confusion they have their own issues,” one official said.
There is a process underway to engage 125 Nursing Aid Grade III nurses on an academic arrangement basis for six months and it is likely to happen in a week or so, officials in the SKIMS administration said.
Insiders admit that the radio-diagnosis department is severely hit as only one CT machine is functional right now. It is catering to a huge load and it often stops functioning in between. “The big institution like SKIMS having only one CT is a shame,” one middle-aged doctor, speaking anonymously said. “We have an old MRI machine also.” Most of the machines have outlived their life span and their replacement is part of the institutional routine.
SKIMS’s radio diagnosis and imaging department is vital to almost all departments. Its emergency section has a 16-slice CT scan and a colour Doppler ultrasound. While part of the machinery it shares with the RCC, it has a 1.5 Tesla Magnetic Resonance Imaging (MRI) system, which is vital for diagnosing a number of diseases including brain, spine, joint, heart, blood vessels, liver biliary channels, gastrointestinal system, obstetric and gynaecological issues.
Since April 2007, the SKIMS’s Radiation Oncology Department-run Regional Cancer Centre (RCC) became the State Cancer Institute (SCI), making it eligible for certain funds for infrastructure. It has raised a 5-level building but it has not procured all the machines that it requires.
The department had 3D CRT and IMRT in addition to having equipment for conventional radiotherapy. Using four treatment units, almost 150 patients get therapies in the department on a daily basis. The department’s CT Simulator was not working forcing the doctors to send patients to SMHS for radiation planning for high-precision radiotherapy. For many years now, the department has been trying to acquire high-end LINAC with IGRT, SRS and SRT capabilities as well as a 4D-CT simulator for improving the standard of cancer treatment. These machines are yet to come.
“We had set the process for procuring a new CT machine (128-slice) some years back but there is no progress,” an informed officer said. “X-ray plants and ABG machines need to be procured but the extremely slow process of procurement has dealt a severe blow to the system at SKIMS.” Insiders said that the laboratory equipment has not been procured after the contract with the supplier expired in December 2022 tenders are floated and the pace is slow. However, insiders in management said the X-ray issues will be over this week as two plants have landed and are in the process of being installed.
A senior faculty at the SKIMS said that the institute, being a deemed university, has historically remained at the top of Kashmir’s healthcare pyramid. It would acquire the best equipment always. “The situation is changed now, all the new institutions that have come up in the last few years have the modern equipment as nobody decides on the pleas we have submitted,” one doctor said. “This deficit is now playing with the reputation of the SKIMS in health care.”
Off late, some members of the SKIMS faculty have started moving to other places. Surgical oncology, for instance, was being managed by four doctors and two of them – Dr Sheikh Zahoor and Azhar Jan Battoo, resigned and joined the privately run Paras Hospital in Srinagar. In Neurology, Dr Hilal A Ganai has submitted his papers and joined the private sector. A senior faculty from the Medicine department has taken the CRS route and superannuated prematurely.
The surgical Oncology department has been suffering ever since it was created by a Kashmiri specialist working in Britain. SKIMS doctors said he encouraged a number of surgeons working elsewhere and brought them to SKIMS. However, when they found an adverse work culture in which there was mudslinging and discouragement, they gradually gave up. Those who did not resign then have resigned now.
“If the administration was keen that they should not leave, they could have rejected their resignation but the fact is that it was accepted,” one doctor said. At SKIMS, the patients requiring surgery have a long waiting list that will now get delayed further.
“I think there is some kind of conspiracy. In 2024, when the AIIMS will start working in Kashmir, I have apprehensions that fifty per cent of our faculty will move there,” one concerned doctor said. “At SKIMS, doctors retire at 62 and in AIIMS they retire at 65. There are better increments.” A number of doctors admitted that the internal politics within the institute is playing a role in not offering an ideal work culture to the new talent.
The hospital has more than 115 faculty positions – of a sanctioned 295, vacant, right now.
The SKIMS crisis is being seen as an essential outcome of a series of decisions that were taken after August 5, 2019. These decisions included taking away the autonomy of the major institution, preventing it from appointing its staff and even making material purchases part of a complex web. In fact, the committee that is supposed to oversee the institution has not met even once since it was constituted. Including SKIMS with the hospitals managed by GMC in Srinagar and Jammu reduced one key step that was keeping the institution ahead.
Top doctors managing the institution said they are aware of the issues and the deficits are being addressed. “We are getting a 128-slice CT from JKMSC and the process for getting an MRI and Linear Accelerator has started,” a top officer said. “We have sent all the vacant positions to the recruiting agencies for making selections. Till they make the appointments, we have started some ad hoc arrangements to hire paramedics and the list will be out within a few days.”
Asked about the faculty resigning and joining other organisations, the top doctor said everybody has a right to go to places they think are better. “They were here for 10 years and why now, all of a sudden, have they started tracing disabling things,” he said. “It is a matter of right, some people fly abroad and some find better venues here as well. What is so new to it?”