**Abstract**

Tertiary care is the apex of health care pyramid. Usually patients with congenital or unidentified medical conditions present to the tertiary care. Rest are those after an index admission, enter into multiple unpredictable complications. Multidisciplinary approach with 'fresh' thought process is vital. Integrated skills and comprehensive knowledge are important. By the time patient presents to tertiary care patient as well as attendees will be in severe depression with added financial constraints. This contributes to compromise of host immunity. Henceforth a psychosocial support system with empathy is necessary. What went wrong is not always the relevant question, how things can be improved is the pertinent point.

**Keywords:** redefining tertiary healthcare, self-sustenance, infrastructure planning, referral system, psychosocial aspects of tertiary care

### **1. Introduction**

India is a vast country with varied geographical, cultural and economic zones. Seven and half decades after gaining independence and two years after Covid pandemic, India stands as one of the most viable healthcare delivery systems in the world. Modified universal immunization policy is a major preventive strategy of the Indian public health care system at primary level. Grass root personnel involved have done their best in delivery of Covid vaccination also. The speed and alacrity with which they took digital format of work is highly commendable.

National health policy 2017 has set the vision and tone for achieving universal health coverage. National Health Mission (NHM) adopted a primary health care program with the establishment of Health and Wellness Centers (HWCs)

Now the need of the hour is to redefine the provision of tertiary care to the general population.

### **2. Present scenario and scope of tertiary care in India**

In India the chronic and non-communicable diseases account for 53% of all deaths and 44% of disability adjusted life years [1].

Diabetes, cardiovascular, liver and kidney diseases, autoimmune diseases, blood dyscrasias, muscular and rheumatic ailments are all included in this category [2].

Added to this, is rising incidence of trauma cases due to the rise in daily journeys of the general public by road, rail and air ways.


#### **Table 1.**

*Summary cancer statistics 2020, world [3].*


#### **Table 2.**

*Summary cancer statistics 2020, India [4].*

Cancer cases have increased throughout the world due to both increased incidence and early detection combined with awareness among general public. In the year 2020 the global burden of cancer rose to an estimated 19,292 million new cases with 9958 million deaths (**Table 1**) [3].

In India in the year 2020, the number of prevalent cases (5 years) is about 2,720,251, the number of new cases 1,324,413 and the number of deaths 851,678 (**Table 2**) [4].

Each of the above category needs tertiary care and support thus elevating the need for dedicated health care delivery centres.

### **3. Overview**

By definition, 'tertiary care' program has to include complex diagnostic procedures and treatment modalities to be performed by medical specialists in state of the

#### *Redefining Tertiary Care in India DOI: http://dx.doi.org/10.5772/intechopen.112750*

art facilities. All the acute trauma, emergency cases and chronic disabling diseases need tertiary care setup.

The Government of India has taken up in 2021, the norm of establishing one medical college for every district in the country. This has created a great buzz in medical education and health-care delivery across the length and breadth of the country. It will ensure adequate training of medical students as well as availability of specialist services to the general public. But the vital role of infrastructure to diagnose, stage and treat chronic diseases cannot be taken lightly. From the inception level tertiary care needs proper planning, dedicated execution, and feedback based follow up for a successful functioning.

Hitherto in India, Tertiary Care Centers functioned in the form of institutions with autonomous protocol like the Tata Memorial Centre for cancer—Mumbai, Adayar Cancer Centre—Chennai, Aravind Eye Care—Madurai, Christian Medical Centre—Vellore, AIIMS—Delhi, PGI—Chandigarh, Jipmer—Pondicherry, Railway and Defense Hospitals, etc. In the past three decades a chain of private healthcare delivery institutions have come up with international standards in investigative facilities and top notch efficient individuals working round the clock. A syndrome based diagnosis and management have contributed to many miracles in saving the precious lives of millions of patients. Research work regarding disease pattern, innovative design in rehabilitation programs viz. Jaipur foot, low cost laparoscopic instruments, Continuous Medical Education have been pursued by these institutes rising up to international standards. Medical tourism was also a part of this.

To bring these facilities to the public at large is a tough task. With rising cases of organ compromise and failure such as kidney, liver, lung and heart even special procedures like dialysis and organ transplantation surface to the front line.

Further there is a rising incidence of congenital anomalies including autism, pediatric illnesses and cancer cases. Henceforth it is a challenge to channelize the medical personnel as well as infrastructure and make it available for the reach of an average Indian patient.

In this chapter the medical, psychosocial and environmental aspects of tertiary care are discussed along with the pertinent question why tertiary care in India needs to be redefined?

A set of proposals are also recorded herewith as a Model for Modern Tertiary Care Centre Protocol (MTCCP) for future reference and direction.

The most important principle to run a Tertiary Care Centre is to have a proper referral system. This should not be violated by any means and should be strictly adhered to.

Tertiary care means not only specialist care but also disease specific care. Hence a proper referral system will ensure targeted patient care both therapeutic and support care.

#### **3.1 Medical facilities**

The medical facilities necessary for tertiary care can be divided under three headings.

A. Infrastructure.


#### *3.1.1 Infrastructure*

Accessibility of tertiary care at district headquarters is vital. The designing, construction and maintenance of all the buildings in the facility is the responsibility of the infrastructure development wing of that State. The MTCC shall be maintained as per NABH and NMC guidelines currently in vogue. Budgetary allocations for infrastructure shall be independent of the annual budget for patient care.

Currently, the teaching hospitals affiliated to medical colleges are being regarded as Tertiary Care Centers. In reality they are not. They do not have a uniform plan either in buildings, specialist departments and super specialties departments. A wide variation in the establishment of most vital services has given place to uneven distribution of specialist care resulting in deprivation of essential services to the patients of that region.

For example, in one of the states two medical colleges each of more than five decades of existence, just 150 km away from each other, differ in departments of Cardiology, Gastroenterology, Nephrology in Medical specialty and functioning Cardiothoracic surgery in Surgical specialty even now. This discrepancy jeopardizes the patient care, treatment methods, professional skills and even the academic teaching between the two institutes.

Diseases of one zone are no less in severity than the other zone. Even the student who seeks admission after all the hardships of appearing for a National level Qualifying entrance examination is denied Learning experience grossly for no fault of his/her. The state Government, State and National medical councils along with the elected representatives of that area have no understanding of this major problem. It is always looked upon as the inefficiency and lack of resourcefulness of the concerned medical college staff, Principal and hospital administration that are responsible for this gulf. This is a sad state of affairs.

That's why, it is imperative that a National Level Modern Tertiary Care Centre Protocol (MTCCP) must be contrived and be put into practice by the Government.

redefining tertiary care means.


This needs a thorough scrutiny of available infrastructure, working conditions of the already established specialty services and correction of the gaps. Organization of Tertiary Care Centre can be modified to offer clinical research and training programs. This authenticates the function in a better way.

Usually institutes are burdened with dedicated teaching programs. Teaching includes student evaluation also. Such an academic course in progress, may compromise the attention and energies of the professionals. Indian Government Hospitals do a lot of work but lack in documentation and follow up. Many smaller countries like Japan and Arab countries have contributed to good number of activities such as clinical and treatment protocol trials and research. India lacks in standardization of work. This should be corrected.

Moreover, the existing teaching hospital buildings are terribly congested and do not have enough space for modern arrangement of wards. They are not having technical support to tackle sanitation and electricity needs for intensive care units and laboratories to perform the specific investigations. They also lack in communications

and digital networks for e-hospital administration and services. Lack of ventilation, space for attendants, facilities for differently abled personnel are gross defects to be considered.

Every time an Accreditation Team arrives the inspection is done with much compromise with regards to disposition, emergency services and many a time monitoring staff. This type of window dressing cannot be taken to be any progress or up gradation.

The NABH protocol directed Ward Carts, ICU and Operation Theater design and even sterilization measures followed presently are inadequate. So, we propose a dedicated Tertiary Care Center (TCC) to be constructed. The tertiary care system in other countries needs to be viewed at this juncture.

Hospitals and clinics can be broadly categorized by the organizations that manage them.

In the country of Japan the healthcare delivery system is a mixture of both private and governmental organizations. Corporate clinics are gaining more prominence in recent times. This resembles that of the Indian Health care delivery system. The types of hospitals operating in Japan include general hospitals, advanced treatment hospitals, regional support hospitals, clinical research hospitals, psychiatric hospitals and tuberculosis hospitals. Thus, it can be observed that a specific disease based hospital care is being practiced. Among these general hospitals will differ from the rest by the staffing pattern. Those which fulfilled the staffing pattern may be licensed to operate.

In Japan the hospital beds are classified as general psychiatric infectious disease tuberculosis and long term care beds. Thus, there is a disease specific organization of beds. Even in the number of hospital beds there are large disparities for patient's choice. For example, when studied in Kochi prefecture, the number of hospital beds is about three times higher in comparison with Kanagawa prefecture where it is the lowest [5].

The healthcare scenario in China is somewhat similar to that in India. Patients are not forced in their selection of admission in Medical Institutes, so they go to the nearest and cheaper institutes than attend a tertiary hospital. Thus in China the necessity for a tiered healthcare delivery policy to differentiate the function of hospitals is not yet implemented. A tiered healthcare delivery system seems to become a vital element of China's Healthcare reforms in the coming years. An average Chinese citizen is free to select a medical institution of their choice and they have the policy of offering various cover ratios for patients admitted to different levels of hospitals. The highest 'coverage ratio' means the lowest self payment ratio for patients in primary hospitals. The and lowest cover ratio for patients in tertiary hospitals means the highest self payment ratio.

In the majority of hospitals in other countries such as the United Kingdom and France are public facilities [6].

A well drafted research paper with inputs regarding hospital infrastructure was previously proposed by Devanshi Gaur et al. [7] and gives an innovative planning of tertiary care hospital along with the probable challenges there of.

#### **Establishment of TCC:**

**Infrastructure**: Establishment of the hospital at a pre-planned place in the vicinity of city limits will encourage the growth of a satellite township. In such a scenario various consumer services will flourish. This can be converted to a source of income generation and financial self-support. A medical hub ensures multi-specialty medical care to the target population.

An all-inclusive premise for a Tertiary Care Center is a better idea and is not impossible to plan and construct.

A well-conceived plan shall augur a better environment for future challenges in terms of changing patterns of diseases and medical emergencies.

With advancements in technology a TCC will soon emerge as the best service nodal point for the needs of the ever evolving society. Multinational company office buildings and commercial centers like shopping malls and Inox theaters are being erected in a matter of months. So, a properly planned hospital can as well be planned. A positive initiative and execution will definitely make it a reality.

In India 'Arc model' or 'U' shaped accessibility to a series of buildings is rarely followed.

Blind ends, crises-crossing of roads with unlicensed encroachments, unauthorized parking of vehicles is the major constraint even within premises.

Huge congestion of vehicles, drugs and consumables vehicles, and ambulances is a daily occurrence.

One main and common approach road with bylines for each wing of the hospital like emergency, mass casualties, and trauma etc. at the designing stage itself is preferable. Provision for airlift is important for patients brought from far off places and also for organ retrieval and donation which needs green corridor. This has been already provided in some of the state TCCs with the initiative of the local state government.

Buildings of definite standards, electrification and provision for generators or solar power plants are necessary. Recent civil construction methodology has changed by leaps and bounds to evolve into cost-effective and strong structure (**Figure 1**).

**Figure 1.** *Proposed model for Hospital Building.*

The bureaucratic delays and over shooting of time schedules is on one side while compromise in standards is on the other side to be tackled firmly. Stringent measures regarding quality control is important.

A list of diseases in order of complexity and chronicity that are referred to the TCC is to be prepared to streamline the case load.

The present Ayushman Bharat program identified the organization of healthcare service delivery with chronic illnesses follow up at Health and Wellness Centers (HWCs) on specific days of the week and referral of patients by the medical officer in charge either physically or through telephonic consultation.

This has to be very strictly followed to the tune that both physical and digital deviation is not possible. Then only the target population is eligible to visit Tertiary Care Centers for specific purposes.

Screening at the outset at the reception area will filter the patients to ensure that specialist care services and bed occupancy are not compromised or misutilised. A definite referral shall be the sole eligibility criterion for further evaluation.

Emergency & casualty for trauma with blood bank and radiology services, casualty for other than trauma cases with emergency operation theaters and 24 h laboratory, dedicated wing for MCH.

(Mother and child health care services) building and intensive care units (ICUs) are all to be planned as an arc with interconnecting walkover bridges having wheelchair or trolley friendly facilities.

Patient transport should be in the form of ramps with proper wall support. Solar/ battery driven buggy facility is very vital to ease the transport within premises.

The ground floor is ideal for emergencies, trauma, attached laboratory, basic radiology. First, second and third floors can be planned for wards. Elevator facilities like in commercial centers can be provided for staff and patients separately.

All wards need a central nursing station with emergency cart, basic laboratory, mobile X-ray plant and emergency ultrasound machine for utilization.

Resuscitation units must be provided for every section containing bed strength of 50. Protected water supply and restroom maintenance is to be taken care of. Fire safety

outlets and measures to prevent or limit spread of fire are to be installed.

Bedside oxygen supply is to be centralized and be provided with frequent safety checks. The present measures have been installed in a hasty manner during Covid pandemic and they are not being maintained and checked periodically.

Self-sufficiency in power generation and waste disposal is very vital. This self-sustenance can be ushered in by establishment of biogas plant, solar panels, wind energy as part of infrastructure. Sewage disposal, disposal of wound dressings, bed rolls and diapers is to be given paramount importance so as to prevent recycling of infected materials. Safe disposal of sharp needles and body parts has to be scientific.

We propose a Government run biomedical waste disposal unit (BMWD unit) with proper affiliation to pollution control board for every district. This shall replace the present private organizations taking advantage of the monetary benefits yet with disposal norms which are never under proper scrutiny. Bringing all the private health care delivery units under this Government run BMWD unit will have standardization of disposal with revenue generation by channelization of services. Similar to the Motor Vehicle act a BMWD act can be brought into existence and taxation of small clinics to corporate hospital units will pave the way for a healthy country.

Quality control measures with follow up and scrutiny is the need of the hour. Unfortunately, occasional news of hazards regarding disposal of blood stained linen and body parts or dead fetuses is considered sensational. But a practical solution has not been proposed or implemented. Hence a judicious daily clearance shall make a better environment.

The gap between proposals and implementation is often large and remains unbridged over decades. In fact, the proposal to make Tertiary care a public-private partnership and the challenges there of have been discussed in great detail by previous research workers also [7]. Any proposal needs a governmental initiative and strict scrutiny is a must. Institutes need leaders and leaders make institutes, thus finding a right combination is vital.

#### *3.1.2 Database*

A central operating system of registration and Health Unique Identity Number is to be developed for database registration. This UID can be developed at the primary health center to be quoted in the referral or it can be provided as personal information at the TCC. Linking Aadhar numbers is the best way to retrieve or enter health information for the individual thus every citizen is allotted a Health Unique ID for his life. Once such a system comes into vogue, Health Insurance can also be streamlined.

The internet facility of the hospital must be ensured by a central operating system with LAN connections and proper backup. Automation in filling up details will ensure data entry and retrieval becomes easy and will be having accountability with regard to services offered. This is not a big issue as such a system is already in vogue for large hotels and tourist places. The same model can be studied to apply in health care.

#### *3.1.3 Diagnostic facilities*

Doctor and nursing staff in treating a patient entirely depend upon the investigative procedures and their results. Most of the times daily monitoring and on the spot verification of blood parameters marks the key step to plan and continue treatment schedules. This is the major breakeven point of defining morbidity and mortality of a patient. Multi monitors, autoanalyzers, automatic alarms are all the paraphernalia in decision making for the correct initiation of treatment and changes thereof.

Clinical laboratories presently in Government setup are bereft of basic machinery like auto analysers. Sometimes the outsourcing services supply incompatible reagents and test kits with lacs of rupees being wasted just due to lack of knowledge regarding the machine make and version. Microbiology and Pathology investigations need more sensitive equipment with regard to sterile area and culture sensitivity test resources. This loophole has to be corrected by providing.


Follow up should be on daily stock verification and automatic supply of reagents basing on case turnover. This will correct non-availability of various investigations in the hospital premises which encourages third party encroachments with investigation mafia.

#### *Redefining Tertiary Care in India DOI: http://dx.doi.org/10.5772/intechopen.112750*

The establishment of above facilities should correlate with the bed strength similar to the doctor-patient, nurse-bed ratios.

The intensive care units for each wing need to be operational round the clock and hence strengthened by both equipment and staff adequately.

Yet another important aspect of diagnostic facilities is the procurement of radiation based investigative machinery. X-ray plants, CT & MRI machinery need to be established separately for medical and surgical patients ensuring less confusion and waiting period. Reporting of these investigations is already being outsourced by tale radiology hence will be totally comfortable for the specialists. The same principle can be followed.

In the present scenario the number of tests done usually does not match the genuine number of investigations ordered by the treating doctors. This leads to off the record exposure leading to criminal wastage of the facility and black marketing of the tests. A callous attitude with regard to siphoning of costly investigations dents the system heavily and is a painful truth to be accepted in Government hospitals. This pilferage of services is to be firmly handled with due penalties to usher in foolproof practices.

Apart from this, interventional radiology procedures are of great importance which save lives and provide minimum access methods with maximum benefit for patients for certain diseases. These are to be treated on par with ICU and emergency care. This point is to be included in the plan of the construction and establishment.

Oftentimes there is a news article about rats in ICUs and failed radiology services. It is the system which fails to function, but not the duty doctor, nurse or technician.

The investigation facilities form the core of the functionality of the TCC which needs to have a separate biotechnology wing for repairs, replacements and maintenance.

Social responsibility of large scale industries in the local area can contribute to the maintenance of this wing.

#### *3.1.4 Staff and personnel*

Staff pattern in a Tertiary Care Center will be in three tiers.

#### *3.1.4.1 Non-medical*

Maintenance staff are for cleaning and disposal, laundry, staff to deliver drugs, dressings etc., security guards, reception and registration with 'May I Help you' cubicle, pantry and bedside help.

A novel approach is to have a volunteer wing. A possible liaison with the local medical and paramedical students' wings, social service organizations will definitely go a long way to fill the gaps rather than prolonged periods of no or less attention to the needy patients.

Mechanization of cleaning and laundry is to be installed. Establishment of semiautomatic washing machines with driers is quite practicable.

#### *3.1.4.2 Nursing*

Ensuring adequate staff is of utmost importance with allowance of leave pattern for a 8 h of daily duty or 50 h per week. A proper central body has to monitor the attendance. Automatic punching systems can streamline the staff capacity.

Proper duty rooms, dress changing facility with provision of food during duty hours can encourage better efficiency. Group drills, six monthly audits will ensure more participation with assurance of workplace dignity.

One kitchen for one specialty wing is the best method to take care of the needs of patients as well as the staff. Apart from this, provision of restaurants for access to the public will encourage revenue generation.

#### *3.1.4.3 Medical specialists*

Hitherto all days in a week are taken to be working days for the professionals to look after and follow up out-patients and in-patients. However, this can be modified as weekdays (5) and weekend days (2) to have uniformity in the care. Doctors can be rotated in their weekdays and weekend duties. This will ensure a better orientation and mental readiness to discharge medical officer duties. Accountability and follow up of the cases will be definitely better by this process.

Registered medical doctors with their specialty will encourage a proper direction of the patients to the concerned specialization.

A tier system with teams for each ward will ensure each professional to work with responsibility. A service track record shall be maintained which will keep track of the number of working hours and the quality of work done. This will in a way define each doctor, nursing assistant and technician based on their work output to have bonus or elevation.

The present method of promotion to a higher cadre brings in non-functional senior staff members drawing better salary based on their number of years in service rather than work output. This must be ended.

#### **3.2 Psycho social**

The Tertiary Care Centers (TCC) is not mere treatment centers. They are evaluation and rehabilitation centers. The psycho social needs of patients who come here are completely different from those present to regular hospitals.

A terminal illness, an incapacitating neuromuscular disability, mental retardation, organ failure and cancer are some of the examples which need a lot of emotional and moral support.

Inpatients tend to develop intensive care unit psychosis, post trauma psychosis, fear of death and deformity, depression due to prolonged course of the disease, mood swings and anger towards fellow human beings. All these have been described. But, these were given no importance all these years. The appropriate role of psychologist, psychiatrist, nursing assistant, physio therapist, trainer, stoma care specialist and nutritionist has been neglected beyond measure especially in the government set up. This gap is to be filled carefully and with proper and professional planning and by team approach.

Proper suggestions for rehabilitation and reorientation of daily life are to be given to the patients. Post procedural handouts, videos, oral explanation by nursing assistants will make paramount change in the otherwise handicapped life of the physiotherapy plays an important role.

Home care in terms of nursing and medical care of patients with prolonged illnesses is to be integrated to the respective departments. For this training of attendants is vital.

Psychologists, facilitators and self-help groups are important.

The rehab team shall have an overall picture and review of the patient before discharge.

Follow up by video call or visit can be done.

It needs weeks to months or sometimes years to reach a plateau in the sinuous ups and downs in the natural history of prolonged illnesses.

#### **3.3 Environmental**

Proper ventilation and air entry is to be ensured. Stringent practices of sanitation and sterilization must be followed. Greenhouse effect by channelizing the sunlight through shades and curtains, increasing indoor plants, ensuring green zones between wards and buildings, rainwater recycling, sewage water disposal are a must.

Plastic ban with usage of native natural materials like leaves and tree bark will help reduce carbon waste. Drainage system is a far cry in the present setup which needs proper planning. Night time ventilation is defective in most of the institutions.

Rainy season is another big challenge in maintenance of sanitation and cleanliness. Smiling nursing staff who greet the patient is almost unknown in the government sector. This change in the psyche of Indian Government Service is in fact a big lacuna.

Poverty and illiteracy can no longer be the pretext for a proper provision of the above measures. Availability and enforcement is the need of the hour. Health care delivery system is to be given the status of a medium scale Industry with definite budget allocations and scrutiny.

A healthy population will contribute better for the economy growth. Quality assurance is not by too many rules. It has to follow a flow chart of diagram.

Centralized monitoring and correction of loopholes alone will ensure a fresh beginning for health care delivery.

Employee unrest with paucity of regular payment of salaries and monetary benefits is very common over all these years.

A definitive Human Resources Management needs better funds allocation.

Railways, the largest national institution under the central government has witnessed a big leap forward in standards and modern style of functionality. Similarly, a proactive approach is necessary in health care also.

### **4. Conclusions**

A new idea is never a waste. It is built upon previous failures and deficits. Like Metro facilities in Indian Cities, Modern Tertiary Care Centers (MDTCCs) a fresh thought process is necessary. A systematic review paves the way to a better version of planning.

It is always good to correct and proceed hopefully than to be silent and carry on with the old and outdated system.

We sincerely hope to have the establishment of a model and operationally practical Tertiary Care Center.
