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Newport Hospital Medical team visit to Kutaisi June 2008


Three consultant doctors from Gwent Health Trust, Dr. John Davies, Dr. Brian Stephenson, and Dr. Stephen Hunter travelled to Kutaisi Under the Auspices of the Newport Kutaisi Association. They met staff of city hospitals & clinics and were interested to see how future medical links could be established between Newport & Kutaisi. What follows is a comprehensive report of their social and professional activities during the visit. The report is divided into four parts; an account of the hospitality, a report on the state of the Health service in Georgia, a specific account of Healthcare in Kutaisi, and recommendations for action. We thank them for their generous time and effort before and after the visit.

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A report by Dr. Brian Stephen, Dr. John Davies and Dr. Stephen Hunter

June 16th-20th 2008

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1.Social Activities

Having arrived late, we were met at our differing times and transported to a perfectly adequate family guesthouse in Tbilisi.

Waking reasonably fit the next morning; we were treated to breakfast greetings by our welcome, and drank a toast with sweet Georgian red wine to the success of our visit. We were introduced to Mamuka and Zurab, a gynaecologist and anaesthetist from Kutaisi, and our guide and Koba, his translator.

In a modern Mercedes minibus, we were taken to see some of the sites of Tbilisi. Beginning with the state Chancellery and the Supreme Court, we visited the Narikala Fortress and the Church of Metekhi. We stopped for coffee, and to begin relationships, in a cafe district in the old town. This could have been Paris, or any European city. Our hosts were good-natured, talkative, welcoming, and in no way guarded in what was a convivial conversation.

We then visited the Sameba Cathedral, a relatively new construction (begun in 1995), and which is the largest religious building, and one of the largest Orthodox churches in the world, intended to celebrate 1500 years of the autocephaly of the Georgian Orthodox church. We drove to Mtsketa, one of the oldest cities in Georgia, stopping only to pick up Artor, a bar owner who had been in Tbilisi picking up tiles. He was also to become one of our guides and hosts.

 

Mtskheta was a capital of the Georgian Kingdom of Iberia during the 3rd century BC - 5th century AD. Here Georgians accepted Christianity in 317 and Mtskheta still remains the headquarters of the Georgian Orthodox and Apostolic Church.

Svetitskhoveli Cathedral (11th century, see photo) and Jvari Monastery (6th century) in Mtskheta are amongst the most significant monuments of Georgian Christian architecture. The "Historical Monuments of Mtskheta" is a UNESCO World Heritage Site, as are both Bagrati and Gelati in Kutaisi. We stopped for lunch at a roadside cafe, where they were expecting us. The food was excellent, the company more so, but the quantities were simply impossible to cope with. By now, we were somewhat behind schedule, so we were only able to swing through Gori (the birthplace of Stalin), rather than make our scheduled stop. The drive to Kutaisi was memorable for the driving rain, the unreliability of the road surface, and the driving, which would frighten any westerner. Our driver filled the bus with Diesel while smoking a cigarette, and was also arrested, charged and fined by the Police for talking on his mobile phone while driving.

We arrived in Kutaisi to be greeted by a delegation from the NKTA, and especially Madonna Megrelishvili, the chair. We were lodged in a wing of the L&J clinic, which is co-owned by Dr Zaza Lominadze. Our rooms were of a high standard, with en-suite, a small stocked fridge, air conditioning and satellite TV that included BBC World.

After a quick wash and change, we were taken to dinner at Artor’s bar, sited right next the River Rioni, which was in spate. Children bathe there in the summer, something commemorated by a wonderful statue on the bridge of a small boy holding two hats.

The following morning, we were formally received at the town hall by the Mayor. He expressed some extremely kind sentiments about us, and particularly about the value of the twinning with Newport, which is clearly seen locally as by far the most important of the 18 cities with which Kutaisi is twinned. Those are; Columbia Missouri, Gelsenkirchen, Vitoria-Gasteiz, Nikaia, Tula, Plovdiv, Ashqelon, Rasht, Samsun, Gyumri, Tianjin, Xinhua, Lyon, Bayonne, Donetsk, Kharkov and Lvov.  He made parallels between the history and culture of Kutaisi, Georgia, and the British and Welsh. Newport memorabilia features prominently in his offices. We were given a number of local gifts, including large carved wooden drinking cups.

We had not expected to have to respond, but we did, and hope our extemporisation was adequate – certainly it was well received. Kutaisi television was present, and interviewed us. They were to follow us, and interview us, on three further occasions during our brief stay.
We were then formally shown around the L&J clinic. It provides a wide range of ambulatory, outpatient and in-patient services, majoring on Cardiology, general surgery, ophthalmology and optometry. It is a modern, clean and busy facility, partnered with clinicians and insurance providers. We were able to observe surgery and cardiac investigation. We spoke with a number of clinicians, many of whom speak extremely good English, we and the others being grateful for the services of our translator, Maia Alavidze.  Television was here also.

From there, we were treated to another extensive lunch, at a rustically themed new restaurant on the edge of the city on the road to Tbilisi. This was our first introduction to the tamada toasts. Thankfully, we were prepared for this. Clearly a cherished institution, it has many similarities with undergraduate drinking games.

We were then guided around Bagrati cathedral, after taking a stroll along “Newport Street”, and visiting the church, seminary and river view at the end away from the city centre. A distinct landmark in the scenery of central Kutaisi, the cathedral rests upon the top of Uk’imerioni Hill. It was built in the early years of the 11th century, during the reign of King Bagrat III due to which it was called "Bagrati" Cathedral, i.e., Bagrat’s cathedral. An inscription on the north wall reveals that the floor was laid in "chronicon 223", i.e., 1003. In 1692, it was devastated in an explosion by the Ottoman troops, which had invaded the Kingdom of Imereti. The incident caused the cupola and ceiling to collapse leaving the cathedral in its present state. We were also taken to the Gelati Monastery, which is a few miles away. The Gelati Monastery for a long time was one of the main cultural and intellectual centres in Georgia. It had an Academy that employed some of the most celebrated Georgian scientists, theologians and philosophers, many of whom had previously been active at various orthodox monasteries abroad or at the Mangan Academy in Constantinople. Among the scientists were such celebrated scholars as Ioane Petritsi and Arsen Ikaltoeli.
 
Due to the extensive work carried out by the Gelati Academy, people of the time called it "a new Hellas" and "a second Athos". The Gelati Monastery has preserved a great number of murals and manuscripts dating back to the 12th-17th centuries. In Gelati is buried one of the greatest Georgian kings, David the Builder (Davit Agmashenebeli in Georgian Again, we just had time to wash and change before being taken to a formal reception at the offices of the NKTA, which are combined with the English Language Centre (ELC). Several young Georgian female English learners had prepared effusive speeches welcoming us, with a considerable degree of intellectual thought. Once again unprepared, we were forced to extemporise, but our efforts appeared well appreciated, and there was clearly considerable warmth towards us, and towards Newport.

Local Newport literature is a prominent feature of this facility. They were delighted when Brian and I were able to point to the guides they have to Caerwent (Brian’s home) and Caerleon (mine) amongst many others, including the most up-to-date editions of “Newport Matters”.
Television was present here too. After a substantial buffet supper, we were entertained by Georgian singing and piano playing, which was extraordinarily moving.

The following morning, we were driven to the church hospital, where we were very warmly greeted by Father Kalistrela and his team. He explained to us his vision that had led to the church taking responsibility for the institution from the state after the soviet times, and which is intensely personal, as the hospital literally saved his life. Once again, we had to extemporise our own responses, which were hopelessly inadequate, although Brian, in evoking the father’s prayers for himself, was an instant success. We were again given gifts, and television was here also.

The hospital has two major buildings, one of which is clearly very old, the other constructed during soviet times. Ironically, the newer building is completely wrecked and unusable. The older building has problems which are so fundamental it can never be made fit for purpose as a contemporary hospital, those problems including sanitation, electricity, heating and so on. There were one or two seriously ill individuals we saw there, but most of what we saw was ambulatory care, diagnostics, and the staff. They are well trained, highly competent, committed and skilled. They have basic equipment, and some modern equipment also, but they lack the capacity to perform modern ultrasound and laparoscopic surgery, which they identified as their major need. Some of the patients we saw would not have been in hospital at all in the UK. In fairness, although this hospital does provide “pro bono” services, we could not tell the difference between the clientele here in respect of dress, behaviour or apparent wealth from the ones we had seen at L&J. Several of the L&J staff used to work at the church hospital.

We were then taken to the “Beau Monde” clinic, run by Mamuka. He built this clinic as a result of a visit he had made to Newport more than 10 years ago, facilitated by Dr Robert Golding, and modelled on St Joseph’s. It was the first private clinic/hospital in Georgia. It specialises in Obstetrics, Gynaecology, Dentistry and Ophthalmology. The facilities are excellent, understandably less luxurious than the L&J, but clean, comprehensive, and with the latest technological equipment. We saw several recent deliveries. Caesarean section rates here are considerably higher than in most of the developed world. There are well-developed plans to expand, including developing tomography to a standard that would still be accepted in many UK hospitals.

We were then given a special tour of the “treasures” of Kutaisi in the museum. These are mainly iconography and other religious material that has survived the various vicissitudes that the region has had to endure throughout the ages. We regretted not having more time to spend in the museum, which is well ordered, and appears to afford considerable opportunity to learn about the depth and origin of local culture.

We had a (very) brief opportunity to purchase some souvenirs, before once again changing for a farewell dinner with the NKTA. This was a substantial affair, with many toasts, guests from the Association, all the hospitals and clinics, and the mayor. The warmth was, it is fair to say, palpable, and there was an air of fraternity and realistic optimism that is hard to encapsulate.

At 6am the following morning, we had to set off back to Tbilisi, a journey punctuated only by a brief breakfast, and a stop to rescue a man who had overturned his car four cars in front of us! It is a measure of our host, Mamuka on this occasion, that he refused to leave us in the airport (a new building on George W Bush Boulevard) until we were well through the departure gates. Our flight home was timely and uneventful.

2. Georgian Healthcare

I have spoken with the representatives of the Office of Public Management, who were engaged by the government after the Rose Revolution to advise on healthcare in Georgia. The important context is really the general economic one. It is relatively recently that a culture of high- and low-level corruption has begun to become extinct, and therefore governmental income can become both predictable and have utility. International bodies such as the World Bank have been fundamental in this respect. Tangible evidence is the reliability now of the power supply, as contracts are adhered to and people actually pay their bills.
The strategic direction is one of a separation between the state as a purchaser of care, and private enterprises as providers. The state funding will be from a combination of payroll taxes on employees, and a supplement on employees in a 3:1 ratio. Although employees and employees will pay, the benefits will be available to all. This is highly redolent of the 1911 national insurance model in the UK, albeit that was largely for pensions, sickness and other benefits rather than healthcare.

This model works perfectly well in many parts of the developed world, including several western EU countries. It can become top-heavy without investment in public health and family medicine, but the government has already begun investing in training practitioners in those areas, who should begin to come on-stream soon. The solitary medical school in Tbilisi has just begun to achieve standards of education that would have been present when most of the current doctors were trained by the soviets, where medical education was very good. Nursing education is more dispersed, and we received many accounts of exactly how it was inadequate and not fit for purpose.

These are issues for government, and unnameable to our influence. The OPM website contains much information that is informative. What they have found frustrating is frequent ministerial changes, and subsequent changes in the civil service. Nonetheless, International bodies appear to be optimistic that the Georgian Economic situation is set fair, and this can only be good for healthcare. Current GDP spend on health is around 20% per capita of what it would be in the UK, at least 50% of that personal expenditure rather than system spend.

3. Healthcare in Kutaisi

What we saw is of a technical standard that is comparable with that in the UK. In respect of facilities, L&J and Beau Monde would be the envy of many UK facilities, although they could learn from better techniques to manage waiting, and queues. The medical staffs are well trained, largely in the Soviet system, which was technically excellent. There is a missing generation of younger doctors that might pose a future problem. Clinicians work extremely hard, and with care and compassion.

There are clearly issues with family medicine (General Practice) and nursing standards were reported to us as being variable, at best. Access to knowledge bases can be problematic, and all would welcome liaison with colleagues in the West, particularly Gwent. We spoke with several colleagues who would welcome a period of clinical attachment with Gwent Consultants. None expressed a wish to emigrate.

We did not see any of the hospitals to which referral is made for high-end procedures (cardiothoracic, level 4 trauma, MRI), but were assured these were responsive and adequate.
I asked briefly about Mental Health Care. There is some basic office practice, but the seriously mentally ill are either in a state institution 25 miles away, on the streets, or dead. No one sees this as a priority.

The church hospital cannot be sustained. I asked why anyone would choose to go there, and the solitary reason is to achieve a particular expert opinion. If in-patient care is needed, they then go elsewhere in the main. Obviously we did not see business models, but in a privatised provider sector, charity will not maintain that system, and the capital required to regenerate cannot be funded. Sooner or later, what will happen is that the better staff will leave, particularly as they gain access to mobile technology, and either set up practices themselves, or, more likely, join enterprises such as L&J. Therefore, assistance to the church hospital (which is urgently needed) should be in the form of supporting human technology, or in mobile and portable technology.
 

The Immediate Way Forward

We asked repeatedly what we could best do to help. The overwhelming response was to establish professional relationships, to exchange ideas and share knowledge. Some want to come to Newport to “see for themselves”. There is a need for some basic technology, particularly for the church hospital. Mostly, this is about people, not policies, politics, or planning.

1.   We will develop a cross-speciality register of clinicians willing to share electronic dialogue with Kutaisi clinicians. We can give this to the NKTA, Mamuka and Zaza, and see how it develops.

2.   We can establish regularised clinical attachments for perhaps four Georgian clinicians for a month twice a year. We can provide accommodation, clinical supervision and education and texts. We would waive our usual administrative fees for clinical attachments. Given the price differentials, some assistance would need to be sought with living expenses, and possibly the association could look both at that, and at providing pastoral care in what would be a very alien environment.

3.   Dr Davies can provide pro-bono education for perhaps two Georgian Cardiologists/Pulmonologists once or twice a year. On return, they would need to be equipped with portable contemporary sonography machines. Initial analysis suggests that might be best arranged as personal or charitable purchase, perhaps from within the EU or US, as UK NHS prices for this kit are substantially higher than from other sources.

4.   Mr Stephenson is willing to co-ordinate the purchase of contemporary and future proof portable laparoscopic and storage kit for the church hospital. This equipment, even sourced imaginatively, is likely to cost in excess of £75,000, and might afford and opportunity for a specific project for the associations, its affiliates, the mayoral charities, and possibly WaG.

5.   Dr Hunter has agreed to host Dr & Mrs Alavidze for a period living with his family. The children (who are learning English) could attend school for short period, Dr Alavidze could have a clinical attachment in Anaesthetics/ICU, and Maia could renew her acquaintance with Newport, particularly the University.

6.   We would all be willing to join, and contribute to the workings of the NKTA.

7.   Some consideration needs to be given as to how best to approach the issue of nurse training and competence. This has deep-seated cultural, political and resource implications, and may not be amenable to our influence.


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