It would seem self-evident that curing the patient in optimum time and at optimum cost should be the main goal of any healthcare system. Yet, in many ways the patient does not seem to be the centre of most healthcare systems in this country. This is true in both, the public and private sectors. All healthcare facilities have to constantly manage a variety of conficting goals. In private facilities, the need to provide good-quality patient care sometimes goes against the need to improve footfalls, to utilize beds, to improve proft margins, and so on. In public facilities, it is not just a lack of resources that undercuts patient care; often, the need to satisfy diferent stakeholders like lawmakers, civil servants, hospital administrators, and patients, produces contrarian results. These needs may or may not be congruent with good-quality patient care. We remember arguing long ago with an insistent legislator (a doctor) that unless the stafng needs of existing facilities were fulflled, merely opening more public-sector facilities, would serve little purpose. While agreeing, he explained that his goal was to make a public announcement that a new government
423 hospital would be opened; whether it would be stafed, and if stafed, whether it could actually attract doctors and could provide services, was a secondary issue. In many states, doctors and nurses in government hospitals are assigned 12-hour shifts routinely, irrespective of the impact this might have on quality of decisionmaking and stress levels of care providers. Resource allocation in the public sector often bears little relationship with needs on the ground. In the private sector, resource crunches are just as important and to make matters worse, organizational goals do not always promote quality patient care. The result is that very often, many healthcare providers, whether doctors, nurses, or technicians, in a private healthcare facility or in a public one, are left fghting a lonely battle for the patient in the face of indiference from the management.
Managements are far more powerful than mere individuals and in the absence of any legislation or institutional requirements to put the patient frst, it is difcult to see why and how they would do so. In the circumstances, how to tweak institutional systems in a manner so as to align goals of diferent stakeholders towards providing primacy to the patient remains the major problem to be tackled. In this text we shall argue that institutional eforts to strengthen standard protocols and to collate data could be one mechanism to overhaul healthcare systems and make them patient-centric.
Why Protocols
Medicine is governed by protocols of all kinds. Whether it is the protocol on how to treat a patient with pneumonia, what kind of checks are to be conducted before declaring a patient ft for surgery, or how to take a simple blood test, there is a protocol for nearly every task. Perhaps the reason for so many protocols is the high level of complexity involved in many tasks, the fact that so many providers have to work together on a single patient, and most important of all, many decisions can mean the diference between life and death. So students in medical colleges have to internalize protocols. It is these protocols that play an important role in protecting both the patient and the care provider. For example,
patient-centric healthcare: through institutional regulation
424 any provider who sufers an inadvertent needle prick while treating a patient has to take a post-exposure treatment immediately to pre-empt infection. Doctors and nurses spend a lot of time in memorizing medicines with similar-sounding names, so as not to confuse two drugs.
or predators?
However, once they leave college and enter the real world, the healthcare provider fnds that things are very diferent from college textbooks. In India in particular, where jugaad or local innovation is prized above all, people fnd it difcult to stick to protocol. And in many settings, for a variety of reasons, protocols are simply short-circuited. The reasons may not necessarily be to make more proft. For instance, doctors are expected to use gloves while examining a patient so as to minimize the chance of passing on infection; but public-sector hospitals in India simply do not have the kind of resources needed to provide the large number of gloves required. In private-sector settings, saving on cost is just as important. But there are plenty of other factors as well, such as a dearth of trained care providers. In many government-run insurance schemes, there simply are not enough super-specialists available even in the private sector and especially outside metropolises. An MD (Doctor of Medicine) who has enough experience is often allowed to treat a patient with kidney disease. There is no DM (Doctorate of Medicine) available. The alternative is to let the patient die.
The great shortage of doctors and nurses in the country is a very signifcant factor. The result is that if intensive care units (ICUs) demand one nurse per ventilated patient and one nurse each for three non-ventilated patients, these norms are hardly ever followed. The toughest norm prescribed by health accreditation councils relates to employment of sufcient numbers of nurses and doctors as per prescribed patient–nurse ratios. So facilities often save on the numbers of doctors and nurses that are required as per norms and prefer to employ persons of lower skill. Secondary care requires a general nurse midwife (GNM), but hospitals make do with auxiliary nurse midwives (ANM) who get only part of the training of a GNM.
Another complicating factor for doctors in the private sector is the existence of managements who want to see maximum numbers
425 of patients treated. In self-owned small facilities, such proft motives matter too. Hence, over-diagnosis and over-treatment is routine. In this process, the standard protocols on diagnosing disease and treating patients are often short-circuited. Sometimes, to give just one example, the standard ftness test before surgery is done in a very cursory manner. The implication is clear: the patient is to be found ft for surgery. Or in complicated cases such as heart procedures like angioplasty, surgeons are not always available on call in case any complications arise; the services of heart surgeons, after all, come at a premium price.
Our point is simply this: all these anomalies and short-circuiting of protocols is possible because there are no laws that require these to be followed. There is no law to mandate the presence of a cardiothoracic surgeon for complicated angioplasty procedures or indeed, for any angioplasty procedure. There is not even a law that requires proper recording and reporting of key performance indicators in medical facilities. The fact is that systematic recording of adverse events like infections and errors help to save lives over time, but maintaining those kinds of records takes both time and money. Without a law, there is no compulsion on anyone to invest that kind of time and money. It is, therefore, up to the hospital manager or owner to record hospital-acquired infections, adverse events like blood transfusion reactions, etc., and it comes as no surprise that hospitals choose not to do so. It is only the most serious adverse outcome that needs to be reported to government, namely death. Even here, the medical cause of certifcation of the death form is not automated, so the information cannot be easily retrieved. It is also not necessary to enter information like the International Classifcation of the Disease or the procedure code, hence we cannot fnd out the procedure-wise risk adjusted mortality rate for any hospital.
It is this kind of data which would allow the detection of anomalies; this, in turn, would allow improvement in patientcare processes in a hospital. Currently, hospitals don’t even know the number of lives lost due to adverse events. Data empowers practitioners and protects patients. The fact of the matter is that though many facilities do maintain such data in every ward, they see no need to collate it for the entire hospital and over time. It
patient-centric healthcare: through institutional regulation
healers or predators?
426 is data collated over time for a facility which can help in the standardization of processes. International mortality rates may carry less relevance in Indian settings. We need to collect our own data and establish our own benchmarks. Today, there is a perception that this kind of patient data can only be useful for research. There may also be fears that it could be used to victimize professionals. In other countries, there is a provision for anonymous reporting of adverse events. That kind of system could always be worked out; provided there is a will to do so.
In the absence of any requirement to maintain data or to follow protocols, two kinds of things happen. Managements are simply emboldened to put pressure on doctors whom they employ, to deviate from standard patient-care norms. Those who do not conform are marked out and often isolated. Secondly, in the absence of systematic recording of data, it is not possible to identify anomalies or take any corrective action.
With the increase in the size and commercial power of hospitals and medical chains, managements have appropriated more and more power over care providers. One kind of response from the medical community to this systematic pressure has been the emergence of a movement called ‘evidence-based medicine’. Simply put, this is a concept that says that diagnosis and treatment need to be based on adequate information about the patient. Above all, the protocol is given importance.
However, we need to remember that individual or even group initiatives, howsoever well meaning and infuential, cannot be a substitute for organized action on the part of the state. The state alone has the power and authority to enforce norms of behaviour through law. Unless the government demands that protocols be followed, it is difcult to see how any kind of compliance could be ensured. Quality- control managers, adequate numbers of doctors and nurses, regular calibration of laboratory equipment—all these have a costUnless the law demands that the protocols be followed, there will be a high propensity to ignore these.
Governments in India have made an attempt to enforce some kind of order in the health care space but it is not enough. One of the major criticisms of the Rashtriya Swasthya Bima Yojana (RSBY) —a health insurance scheme for the poor that is sponsored
427 by the Government of India—has been that it hardly focuses on issues of clinical governance. Let us see what happened in one case where the government did make a systematic intervention of this kind in the healthcare market.
Case Study of How Clinical Protocols were Used to Strengthen Patient Care
In the state of Maharashtra, a health-insurance scheme was implemented for three-fourths of the population of the state from November 2013 onwards, which means about 22 million families were covered. Before this, the scheme was run in a pilot phase for less than a quarter of the population, i.e. for around 5.4 million families, from July 2012 to November 2013. Once the success of the pilot demonstrated the feasibility of the scheme, it was implemented throughout the state. This publicly funded scheme provided insurance cover of Rs 1,50,000 (about USD 2,205 at the exchange rate of say, 1 USD = 68 INR) per annum to each family covered in the scheme. The premium payable by the government was Rs 363 including taxes (this equals roughly USD 5.4). The families covered did not have to pay anything. They only needed to show one of two kinds of ration cards1 to be eligible for coverage. A public-sector insurance company, the National Insurance Company, agreed to provide the insurance cover on payment of advance premium by the government for all those covered. The insurance company would empanel hospitals and run the scheme through a third-party administrator. The budget of the scheme was around Rs 820 crore in one 12-month period in the year 20152 (roughly USD 120 million at current exchange rates).
The insurance covered a range of surgical treatments. The system of diagnosis related groups was not used for the scheme; rather, 971 specifc interventions across 30 diferent specialities were included. Some fairly common procedures included were angioplasty, hospitalization for diferent kinds of cancers, treatment of fractures, and so on. Both secondary-care and tertiarycare treatments were included.
The mechanism was as follows: patients who were covered were to present themselves in hospitals empanelled under the
428 scheme. If the treating doctor felt that any procedure was called for, he would raise a pre-authorization request, which would be sent via a software application to the insurance company. It was incumbent upon the insurance company to reply within 12 hours to the request. Once the doctor received a ‘yes’, he could go ahead with treating the patient and post treatment, send in the bill to the insurance company.
healers or predators?
After a few months of running the scheme, it was noticed that large numbers of patients treated for heart attacks, showed normal post-treatment angiograms, that is, angiograms were not indicative of signifcant coronary artery disease. After a few months of running the scheme, it was noticed that large numbers of patients treated for heart attacks using non-invasive means, showed normal post-treatment angiograms, that is, angiograms were not indicative of signifcant coronary artery disease. Data over a onemonth period showed that, in two hospitals, the fgure reached as high as 55 percent of patients treated for heart attacks using non-invasive means, showing normal angiograms post treatment. Leaving out these two outliers, in hospitals that showed anomalous data, overall 32 percent patients showed normal angiograms post-treatments. When the hospitals were asked why this was so, no reply was received.3 Normally, not more than 10 per cent patients show normal angiograms post a heart attack. It was at this point that many concerned doctors suggested that some mechanism was needed to standardize norms of diagnosis and to determine appropriateness of use. At this time, the scheme was still in its pilot phase and covered slightly less than one quarter of the population of the state or about 5.4 million families.
The state government then introduced an algorithm developed by doctors in various highly rated government institutions such as AIIMS (All-India Institute of Medical Sciences) New Delhi, PGIMER Chandigarh, Grant Medical College Mumbai etc., in an attempt to standardize the diagnosis of patient conditions. Such an algorithm was developed for a large number of the treatments covered. Each algorithm began by listing the various possible clinical indications for that procedure. The treatment provider was expected to answer the questions regarding each clinical indication identifed and send it in with his treatment request. To give one
429 example, the protocol for angioplasty for chronic stable angina was developed by a faculty member at AIIMS and was as follows:
CORONARY ANGIOPLASTY: Chronic Stable Angina4
1. Select the Procedure from drop down of various cardiology procedures available: Coronary Angioplasty
2. Select the Indication from the drop down of various indications provided under this head:
Chronic Stable Angina
Acute Coronary Syndrome, Unstable Angina
Acute Coronary Syndrome
Non-ST Elevation MI
Recent STEMI
3. Does the patient have Angina class III-IV: Yes/No
4. If the answer to question 3 is yes,
a. Does the patient have >70% diameter stenosis in <2 major coronary arteries, AND no signifcant left main disease:Yes/No (Upload Angiogram)
b. Is the patient receiving aspirin and statin AND at least 2 of the following classes of drugs: long acting nitrates, beta-blockers, calcium channel blockers: Yes/No (Attach Prescription)
5. If the answer to question 3 is No, has the patient had a stress test:Yes/No
6. If the answer to question 5 is Yes, Is the stress test moderately or strongly positive:Yes/No (Attach Stress Test Report)
7. If the answer to question 6 is Yes,
a. Does the patient have >70% diameter stenosis in <2 major coronary arteries, AND no signifcant left main disease:Yes/No (Upload Angiogram)
b. Is the patient receiving aspirin and statin AND at least 2 of the following classes of drugs: long acting nitrates, beta-blockers, calcium channel blockers: Yes/No (Attach Prescription)
430 Once an algorithm was developed by any faculty member, it was validated by another faculty member from a diferent institution. Subsequently, it was pilot tested for one to two months before being standardized and released to participating hospitals.
or predators?
In cases where the patient to be treated did not conform to the algorithm and the provider still felt he should be treated with the specifc intervention, he was asked to record the reasons for the same. In a few cases, second opinions were also taken.
In one study of the introduction of these algorithms in the scheme, scholars found that, ‘... There was a 12.3% reduction in the proportion of PCIs performed in the 1-year period after the introduction of appropriateness-based reimbursement.’ Further, the study compared these fgures with a similar scheme and noted that, ‘data from another government funded health insurance scheme in the state of Tamil Nadu (Chief Minister’s Comprehensive Health Insurance Scheme, CMCHIS), where appropriateness criteria are not in use, showed no reduction in PCIs. On the contrary, in keeping with national trends, there was an increase in the number of PCIs (as a proportion of all procedures) in the frst 6 months of 2014 (1.3% to 3.4%), compared to 2013’ (Karthikeyan 2017).
Another result of the introduction of the algorithms was some normalization of the responses of the insurance company to treatment requests. Mostly, insurance companies use a least-cost approach to treatment requests. However, the approach that is the least costly is not necessarily the appropriate one. For that, extant protocols would be a much better guide than anything else. And once the protocols are developed by care providers themselves and are in line with current treatment guidelines, the possibility of denial of care gets reduced. In this particular programme, it was found that the insurance company agreed to 96 per cent of treatment requests. There was some diference of opinion in very few cases.
Currently, the State Health Assurance Society that administers the scheme continues to use these algorithms to take a decision on many treatment requests received.5 Overall, the response to the algorithms was reasonably positive. Often, the treating hospitals did suggest improvements that were referred to a group of expert doctors for a decision. The setting up of this system began in 2013
431 and gradually began covering most of the procedures. It continues to underpin the insurance scheme till date.
With a view to further strengthening emphasis on compliance with protocols, the Maharashtra government also introduced a more rigorous accreditation mechanism for empanelling hospitals for the scheme. Till 2013, the insurance company merely looked at the infrastructure available and the numbers of doctors available for empanelling any hospital for a specifc super-speciality. This was a minimal method of verifcation. But in view of the fact that the numbers of hospitals accredited by the NABH (National Accreditation Board for Hospitals & Healthcare Providers) in Maharashtra was hardly more than 10 at the time and that the company needed 300 hospitals to service the entire state, there seemed to be little option. Hence the government developed a separate set of 85 indicators for purposes of empanelment. These indicators were a mix of infrastructure, human resource, process indicators such as hospital-acquired infections, etc. and outcome indicators like mortality rates. These indicators were grouped into nine separate chapters, namely: 1) Human Resources 2) Infrastructure and Facilities 3) Infection Control 4) Medication Monitoring 5) Patient Medical Records 6) Standard Operating Protocols 7) Quality of Patient Care 8) Transparency in Pricing and 9) Patient Satisfaction Indices. The chapter on Patient Satisfaction Indices was introduced with a view to ensuring that the facility provided forms for patient feedback, that it took patient consent before surgery, and generally informed the patient about their rights. The chapter on Transparency in Pricing was introduced with a view to persuading the facility to provide detailed prices to the patient and a list of tests and items used to treat them, at the time of discharge.6
The government instituted extensive training programmes for hospital managers and doctors about what these indices were and why they should be followed. The overall response was quite encouraging. At the time the exercise was initiated, some of the smaller hospitals openly said that these patient-care norms could only be applied to rich institutes catering to NRI tourists and these were too tough for the small nursing home. Today, such sentiments are the exception rather than the norm.
healers or predators?
432 Using such methods, the government endeavoured to build greater consciousness about the need to maintain high standards of quality when it came to patient care and to persuade hospitals to upgrade their facilities. One signifcant result that this device had was that hospitals which had achieved an ‘A’ grade in this scoring process began to use the scoring as a publicity device and to build brand value. Given that in India, hospitals mainly use the reputation of doctors rather than accreditation as a means to inform people about the quality of care, this was a signifcant step. Today, institutes like the Krishna Institute of Medical Sciences Karad in the Satara district, Pravara Medical College in the Ahmednagar district, and even ‘fve-star’ hospitals like Seven Hills in Mumbai, use the Society grading as an indicator of high quality of care.
The scoring process is mandatory for government hospitals as well. Many hospital managements in the public sector use the scoring process to put pressure on their superiors to increase their staf and to improve infrastructure. Data available was used to upgrade systems at the facility level and many facilities made serious eforts to improve their ratings.
Additionally, the availability of data in standardized formats led to research studies, which provided valuable insights for policy formulation (Duggal et al. 2016). Overall, the mere fact that there is a system of documentation and a quality check helps to ensure a more patient-centric approach in healthcare. That such approaches have a long-term impact is visible in the recent study by IIM Ahmedabad on the healthcare sector, which places Maharashtra at number one spot in the country in a matrix that relates outcomes to inputs provided (Sinha et al. 2016).
Conclusion: Asking Managements to be Accountable
Today, the Government in India funds a large part of insurancebased healthcare in the country. Of the Rs22,726 crore (US$3.34 billion) worth of premium paid for health and personal accident insurance in the country for fnancial year 2014–15,7 government-sponsored health insurance, both in the central and state governments, accounts for nearly one-third. That is a lot of money and market power. Such power can be used easily to improve
quality of care and to encourage a patient-centric approach. Even otherwise, to set up norms of clinical governance is surely part and parcel of the government’s job.
This is not to make a case for ‘big government’, merely responsible government. The idea of an Orwellian ‘big brother’ government is quite popular in public discourse. However, seen in the Indian context, it seems quite inappropriate. The government is no longer the service provider in most sectors, with the exception of public utilities like electricity, water supply, and railways. Rather, going by recent history, the quantum of services provided directly by government providers has been steadily going down. Today, the private sector is so deeply imbricated within government by way of providing services, whether in public health or education, that it is practically impossible to roll the clock back. Given their abilities and market presence, private providers should participate in providing public health services to generate a universal platform of service delivery. Leaving private providers out merely because of their location would only generate conficts and limit the scope of services provided. The point is that these services should adhere to some norms of service delivery.
In all the debates generated by the budget every year, there are vociferous demands made for an increase in public funding for health. Much of this funding does go to the private sector. What the private service providers are really saying is that they should be given more funds, but no questions should be asked about performance indicators or about how the money is utilized. That being the case, irrespective of any norm setting, funding of private service providers through public funds is very likely to go on. In the circumstances, it makes sense for the government to at least enact legislation to provide for quality checks. Interestingly, looking at the implementation of the Clinical Establishments (Registration and Regulation) Act of 2010 enacted by the Government of India, it has not been followed by setting up the kind of norms described above at the level of state governments. Few large states have followed suit, either to accept this legislation or to enact legislations of their own.
In case we hope to encourage a more patient-centric approach to healthcare services, patient data needs to be maintained,
433
434 protocols followed, and some performance indicators put in place. A system of accreditation of medical facilities, which is based on collating data on key indicators, would help generate a more patient-friendly system.
Here it is important to note that the mere fact of maintaining records accurately and consistently creates imperatives that serve to improve patient care. The ability to access patient history across institutions, and within an institution across time, can save many lives.
Secondly, it is important to recognize that norms of service delivery can only be set up by the government. No private agency has the legitimacy or the locus standi to do so. The idea of a selfregulated industry has not functioned in the past 50 years. It is high time that the government lived up to its own responsibilities.
We have already pointed out that it needs frm backing of law and the state to encourage hospital managements to put patients frst. Collation and maintenance of patient data is in the best interest both of doctors and of patients. The trouble is that individual practitioners are powerless against managements and patients even more so.
No doubt conscientious medical professionals have done a great deal to generate awareness on these issues. A movement for evidence-based medicine and a demand for inclusion of patient rights in the various state-level versions of the Clinical Establishments Act are only some examples. However, it is unfair to place the entire burden of the task of being conscience keeper on the shoulders of a few individuals. Nor is it likely to be fruitful in the long term. A few individuals or organizations, howsoever infuential, are no substitute for law.
Notes
1. A ration card is a document issued by state governments in India to facilitate access to a public distribution system which distributes food grains to people. Each family has a specifc set of entitlements. In Maharashtra this document was also linked to eligibility for the health care scheme discussed here.
2. Figures from Public Health Department, Government of Maharashtra.
3. Personal communication dated 18 March 2013.
4. From the website of the Maharashtra government.https://www. jeevandayee.gov.in/RGJAY/RGJAYDocuments/Clinical%20 data%20Form%20for%20Cardiology.pdf; accessed on 28 October 2016.
5. Henceforth the word ‘Society’ would be used to refer to the State Health Assurance Society.
6. Detailed information about the indicators and explanations are available in training documents on the government website: https://www.jeevandayee.gov.in/RGJAY/RGJAYDocuments/ NABHRGJAY.pdf
7. Indian Non-Life Insurance Industry Yearbook, 2014-15, General Insurance Council; p 52.
References
Duggal, B., S. Saunik, M. Duggal, et al., 2016, ‘Mortality Outcome in Patients Undergoing Coronary Revascularization with Drugeluting Stents versus Bare Metal Stents in India’, Poster session presented at Annual Meeting and Expo of American Preventive Health Association (APHA), Denver, Colorado, USA.
Karthikeyan, Ganesan, Umesh Shirodkar, Meeta Rajivlochan, and Stephen Birch, 2017, ‘Appropriateness-based Reimbursement of Elective Invasive Coronary Procedures in Low and Middle Income Countries: Preliminary Assessment of Feasibility in India’, National Medical Journal of India, 30: 11–14.
Sinha, Piyush Kumar, Arvind Sahay, Surabhi Koul, 2016, ‘Development of a Health Index of Indian States’, Indian Institute of Management Ahmedabad, Facilitated by OPPI (Organisation of Pharmaceutical Producers of India), p. 21.
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CHAPTER XXI
THE next afternoon as Lee was taking tea with the other guests in the library she happened to glance out of the window, and saw Lord Barnstaple returning from the moors, alone. It was an unusual occurrence, for he was an ardent and vigorous sportsman. Ten minutes later she became aware that a servant in the corridor was endeavouring to attract her attention. She went out at once and closed the door. The servant told her that Lord Barnstaple desired an interview with her in his own sitting-room; he feared interruptions in her boudoir.
Lee went rapidly to his rooms, curious and uneasy. She felt very much like running away, but Lord Barnstaple had been consistently kind to her, and was justified in demanding what return she could give him.
He was walking up and down, and his eyebrows were more perturbed than supercilious.
“I want to know if you will give me a little help,” he said abruptly.
“Of course I will do anything I can.”
“I want that bounder, Pix, put out of this house. I can’t stand him another day without insulting him, and of course I don’t want to do that. But he is Emmy’s guest and she can get rid of him—I don’t care how she does it. Of course I can’t speak to her; she would be in hysterics before I was half through; and would keep him here to spite me.”
“And you want me to speak to her?”
“I’m not asking you to undertake a very pleasant task; but you’re the only person who has the least influence over her, except Cecil—and I don’t care to speak to him about it.”
“But what am I to say to her? What excuse?”
Lord Barnstaple wheeled about sharply “Can’t you think of any?” he asked.
Lee kept her face immobile, but she turned away her eyes.
Lord Barnstaple laughed. “Unless you are blind you can see what is becoming plain enough,” he said harshly. “I’ve seen him hanging about for some time, but it never occurred to me that he might be her lover until lately. I don’t care a hang about her and her lovers, but she can’t bring that sort to the Abbey.”
“I can tell her that everybody is talking and that the women are hinting that unless she drops him she’ll be dropped herself.”
“Quite so. You’ll have a nasty scene. It is good of you to undertake it without making me argue myself hoarse.”
“I am one of you; you must know that I would willingly do anything for the family interests that I could.”
“You do belong to us,” said Lord Barnstaple with some enthusiasm. “And that is what Emmy has never done for a moment. By the way,” he hesitated, “I hate to mention it now, it looks as if I were hastening to reward you; but the fact is I had made up my mind to give you my wife’s jewels. They are very fine, and Emmy does not even know of their existence. I suppose it would have been rather decent of me to have given them to you long ago: but——”
Lee nodded to him, smiling sympathetically.
“Yes,” he said, “I hated to part with them. But I shan’t mind your having them. I’ll write to my solicitors at once to send them down; I’ve got to pass the time somehow. For Heaven’s sake come back and tell me how she takes it.”
“I don’t suppose I shall be long. I haven’t thanked you. Of course I shall be delighted to have the jewels.”
“You ought to have the Barnstaple ones, but she’s capable of outliving the whole of us.”
CHAPTER XXII
AS Lee walked along the many corridors to her mother-in-law’s rooms she reflected that she was grateful Lord Barnstaple had not refrained from mentioning the diamonds: their vision was both pleasing and sustaining. She was obliged to give serious thought to the coming interview, but they glittered in the background and poured their soothing light along her nerves.
Lady Barnstaple had but just risen from her afternoon nap and was drinking her tea. She looked cross and dishevelled.
“Do sit down,” she said, as Lee picked up a porcelain ornament from the mantel and examined it. “I hate people to stand round in spots.”
Lee took a chair opposite her mother-in-law. She was the last person to shirk a responsibility when she faced the point.
“You have seemed very nervous lately,” she said. “Is anything the matter?”
“Yes, everything is. I wish I could simply hurt some people. I’d go a long ways aside to do it. What right have these God-Almighty English to put on such airs, anyhow? One person’s exactly as good as another. I come from a free country and I like it.”
“I wonder you have deserted it for five-and-twenty years. But it is still there.”
“Oh, I don’t doubt you’d like to get rid of me. But you won’t. I’ve worn myself out getting to the top, and on the top I’ll stay. I’d be just nothing in New York. And Chicago—good Lord!”
“You’ve stepped down two or three rungs, and if you’re not careful you’ll find yourself at the foot—”
“What do you mean?” screamed Lady Barnstaple. “I’ve half a mind to throw this teacup at you.”
“Don’t you dare to throw anything at me. I should have a right to speak even if I did not consider your own interest—which I do;
please believe me. Surely you must know that Mr. Pix has hurt you.”
“I’d like to know why I can’t have a lover as well as anybody else.”
“Do you mean to acknowledge that he is your lover?”
“It’s none of your business whether he is or not! And I’m not going to be dictated to by you or anybody else.”
Lady Barnstaple was too nervous and too angry to be cowed by the cold blue blaze before her, but she asserted herself the more defiantly.
“I have no intention of dictating to you, but it certainly is my business. And it’s Lord Barnstaple’s and Cecil’s—”
“You shut up your mouth,” screamed Lady Barnstaple; her language always revealed its pristine simplicity when her nerves were fairly galloping. “The idea of a brat like you sitting up there and lecturing me. And what do you know about it, I’d like to know? You’re married to the salt of the earth and you’re such a fool you’re tired of him already. If you’d been tied up for twenty years to a cold-blooded brute like Barnstaple you might—yes, you might have a little more charity——”
“I am by no means without charity, and I know that you are not happy. I wish you were; but surely there are better ways of consoling oneself——”
“Are there? Well, I don’t know anything about them and I guess you don’t know much more. I was pretty when I married Barnstaple, and I was really in love with him, if you want to know it. He was such a real swell, and I was so ambitious, I admired him to death; and he was so indifferent he fascinated me. But he never even had the decency to pretend he hadn’t married me for my money. He’s never so much as crossed my threshold, if you want to know the truth.”
“People say he was in love with his first wife, and took her death very much to heart. Perhaps that was it.”
“That was just it. He’s got her picture hanging up in his bedroom; won’t even have it in his sitting-room for fear somebody else might look at it. I went to see him once out of pure charity, when he was ill
in bed and he shouted at me to get out before I’d crossed the threshold. But I saw her.”
“I must say I respect him more for being perfectly honest, for not pretending to love you. After all, it was a square business transaction: he sold you a good position and a prospective title. You’ve both got a good deal out of it——”
“I hate him! I hate a good many people in England, but I hate him the most. I’m biding my time, but when I do strike there won’t be one ounce of starch left in him. I’d do it this minute if it wasn’t for Cecil. What right has he got to stick his nose into my affairs and humiliate the only man that ever really loved me——”
“If you mean Mr. Pix, it seems to me that Lord Barnstaple has restrained himself as only a gentleman can. He is a very fastidious man, and you surely cannot be so blind as not to see how an underbred——”
“Don’t you dare!” shrieked Lady Barnstaple. She sprang to her feet, overturning the tea-table and ruining her pink velvet carpet. “He’s as good as anybody, I tell you, and so am I. I’m sick and tired of airs— that cad’s that’s ruined me and your ridiculous Southern nonsense. I’m not blind! I can see you look down on me because I ain’t connected with your old broken aristocracy! What does it amount to, I’d like to know? There’s only one thing that amounts to anything on the face of this earth and that’s money You can turn up your nose at Chicago but I can tell you Chicago’d turn up its nose at you if it had ever heard of you. You’re just a nonentity, with all your airs, and all your eyes too for that matter, and I’m known on two continents. I’m the Countess of Barnstaple, if I was—but it’s none of yours or anybody else’s business who I was. I’m somebody now and somebody I’m going to stay. If I’ve gone down three rungs I’ll climb up again—I will! I will! I will! And I can’t! I can’t! I can’t! I haven’t a penny left! Not a penny! Not a penny! I’m going to kill myself——”
Lee jumped up, caught her by the shoulders and literally shook the hysterics out of her. Then she sat her violently into a chair.
“Now!” she said. “You behave yourself or I’ll shake you again. I’ll stand none of your nonsense and I have several things to say to you yet. So keep quiet.”
Lady Barnstaple panted, but she looked cowed. She did not raise her eyes.
“How long have you been ruined?”
“I don’t know; a long while.”
“And you are spending Mr. Pix’s money?”
“Yes, I am.”
“Do the Abbey lands pay the taxes and other expenses?—and the expenses of the shooting season?”
“They pay next to nothing. The farms are too small. It’s all woods and moor.”
“Then Mr. Pix is running the Abbey?”
“Yes he is—and he knows it.”
“And you have no sense of responsibility to the man who has given you the position you were ready to grovel for?”
“He’s a beastly cad.”
“If he were not a gentleman he could have managed you. But that has nothing to do with it. You have no right to enter a family to disgrace it. I suppose it’s not possible to make you understand; but its honour should be your own.”
“I don’t care a hang about any such high-falutin’ nonsense. I entered this family to get what I wanted, and when it’s got no more to give me it can be the laughing-stock of England for all I care.”
“I thought you loved Cecil.”
The ugly expression which had been deepening about Lady Barnstaple’s mouth relaxed for a moment.
“I do; but I can’t help it. He’s got to go with the rest. I don’t know that I care much, though; you’re enough to make me hate him. What I
hate more than everything else put together is to give up the Abbey And you can be sure that after the way Mr. Pix has been treated ——”
“Mr. Pix will leave this house to-night. If you don’t send him I shall.”
“You’re a fool. If you knew which side your bread was buttered on you’d make such a fuss over him that everybody else would treat him decently——”
“I have fully identified myself with my husband’s family, if you have not, and I shall do nothing to add to its dishonour. There are worse things than giving up the Abbey—which can be rented; it need not be sold. The Gearys would rent it to-morrow.”
“If you think so much of this family I wonder you can make up your mind to leave it.”
Lee hesitated a moment. Then she said: “I shall never leave it so long as it needs me. And it certainly needs somebody just at present. Mr Pix must leave; that’s the first point. Lord Barnstaple and Cecil must be told just so much and no more. Don’t you dare tell them that Mr. Pix has been running the Abbey. You can have letters from Chicago to-morrow saying that you are ruined.”
“If Mr. Pix goes I follow. Unless I can keep the Abbey—and if I’ve got to drop out——”
“You can suit yourself about going or remaining. Only don’t you tell Lord Barnstaple or anybody else whose money you have been spending.”
“I’d tell him and everybody else this minute if it weren’t for Cecil. He’s the only person who’s ever really treated me decently. And as for the Abbey——”
She paused so long that Lee received a mental telegram of something still worse to come. As Lady Barnstaple raised her eyes slowly and looked at her with steady malevolence she felt her burning cheeks cool.
“He wouldn’t have the Abbey, anyhow, you know,” said Lady Barnstaple.
“What do you mean?”
“I heard you jabbering with Barnstaple and Cecil not long since about the Abbey and its traditions, but either they hadn’t told you or you hadn’t thought it worth remembering—that there is a curse on all Abbey lands and that it has worked itself out in this family with beautiful regularity.”
“I never heard of any curse.”
“Well, the priests, or monks, or whatever they were, cursed the Abbey lands when they were turned out. And this is the way the curse works.” She paused a moment longer with an evident sense of the dramatic. “They never descend in the direct line,” she added with all possible emphasis.
“I am too American for superstition,” but her voice had lost its vigour.
“That hasn’t very much to do with it. I’m merely mentioning facts. I haven’t gone into other Abbey family histories very extensively, but I know this one. Never, not in a single instance, has Maundrell Abbey descended from father to son.”
Lee looked away from her for the first time. Her eyes blazed no longer; they looked like cold blue ashes.
“It is time to break the rule,” she said.
“The rule’s not going to be broken. Either the Abbey will go to a stranger, or Cecil will die before Barnstaple is laid out in the crypt ——”
Lee rose. “It is an interesting superstition, but it will have to wait,” she said. “I am going now to speak to Mr. Pix—unless you will do it yourself.”
“I’ll do it myself if you’ll be kind enough to mind your business that far.”
“Then I shall go and tell Lord Barnstaple that you have consented ——”
“Ah! He sent you, did he? I might have known it.”
Lee bit her lip. “I am sorry—but it doesn’t matter If to-day is a sample of your usual performances, you can’t expect him to court interviews with you.”
“Oh, he’s afraid of me. I could make any man afraid of me, thank Heaven!”
CHAPTER XXIII
LEE returned to her father-in-law more slowly than she had advanced upon the enemy. She longed desperately for Cecil, but he was the last person in whom she could confide.
Lord Barnstaple opened the door for her.
“How pale you are!” he said. “I suppose I sent you to about the nastiest interview of your life.”
“Oh. I got the best of her. She was screaming about the room and I got tired of it and nearly shook the life out of her.”
Lord Barnstaple laughed with genuine delight. “I knew she’d never get the best of you,” he cried. “I knew you’d trounce her. Well, what else?”
“She promised to tell Mr. Pix he must go to-night.”
“Ah, you did manage her. How did you do it?”
“I told her I’d tell him if she didn’t.”
“Good! But of course she’ll get back at us. What’s she got up her sleeve?”
“I don’t think she knows herself. She’s too excited. I think she’s upset about a good many things. She seems to have been getting bad news from Chicago this last week or two.”
“Ah!” Lord Barnstaple walked over to the window He turned about in a moment.
“I have felt a crash in the air for a long time,” he said pinching his lips. “But this last year or two her affairs seemed to take a new start, and of course her fortune was a large one and could stand a good deal of strain. But if she goes to pieces——” he spread out his hands.
“If Cecil and I could only live here all the year round we could keep up the Abbey in a way, particularly if you rented the shootings; but
our six months in town take fully two thousand——”
“There’s no alternative, I’m afraid: we’ll all have to get out.”
“But you wouldn’t sell it?”
“I shall have to talk it over with Cecil. The rental would pay the expenses of the place; but I can’t live forever, and when I give place to him the death duties will make a large hole in his private fortune. I have a good many sins to repent of when my time comes.”
He had turned very pale, and he looked very harassed. Lee did not fling her arms round his neck as she might once have done, but she took his hand and patted it.
“You and Cecil and I can always be happy together, even without the Abbey,” she said. “If Emmy really loses her money she will run away with Mr. Pix or somebody. We three will live together, and forget all about her. And we won’t be really poor.”
Lord Barnstaple kissed her and patted her cheek, but his brow did not clear.
“I am glad Cecil has you,” he said, “the time may come when he will need you badly. He loves the Abbey—more than I have done, I suppose, or I should have taken more pains to keep it.”
Lee felt half inclined to tell him of Randolph’s promise; but sometimes she thought she knew Randolph, and sometimes she was sure she did not. She had no right to raise hopes, which converse potentialities so nicely balanced. Then she bethought herself of Emmy’s last shot, which had passed out of her memory for the moment. She must speak of it to some one.
“She said something terrible to me just before I left. I’d like to ask you about it.”
“Do. Why didn’t you give her another shaking?”
“I was knocked out: it took all my energies to keep her from seeing it. She said that Abbey lands were cursed, and never descended from father to son.”
Lord Barnstaple dropped her hand and walked to the window again.
