Patient-Centric Healthcare: Through Institutional Regulation [a chapter from "Healers or predators?: healthcare corruption in India"]
Meeta RajivlochanVisit to download the full and correct content document: https://ebookmass.com/product/patient-centric-healthcare-through-institutional-regulat ion-a-chapter-from-healers-or-predators-healthcare-corruption-in-india-meeta-rajivloc han/
CHAPTER
TWENTY FIVE Patient-Centric Healthcare: Through Institutional Regulation
Meeta and Rajivlochan
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.
healers 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
patient-centric healthcare: through institutional regulation
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
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)
429
patient-centric healthcare: through institutional regulation
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.
healers 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.
patient-centric healthcare: through institutional regulation
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,
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.
healers or predators?
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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De sorte que plus que tout, je crois le sentiment de ma dignité arrêta mon élan.
Slang achevait tranquillement sa toilette qu’il compléta par une cravate écossaise, un gilet de piqué blanc, un veston de cheviotte bleue ; il coiffa un chapeau melon en feutre gris, prit une badine de bambou puis sortit d’un tiroir une paire de gants jaunes qui n’avaient jamais été ouverts et que, précautionneusement, il garda à demi ployés dans sa main.
Cependant, il se souvint qu’il avait oublié quelque chose dans ses vêtements de travail : c’était un portefeuille en cuir fauve, tout bourré de papiers qu’il glissa furtivement dans sa poche comme s’il eût craint que je pusse apercevoir ce qu’il contenait.
Puis il consulta sa montre :
— Hurrah ! s’écria-t-il, j’ai encore le temps de prendre le train de onze heures quarante-six… Au revoir, fellow !… Va déjeuner dans le pays… tu trouveras à l’angle de Sussex-Street et de WimbledonPlace un petit restaurant pas cher où le stout est excellent… Je te dirais bien de rester ici… mais tu comprends, ce n’est pas possible… Tant que je suis là, ça va bien, mais en mon absence, Betzy pourrait trouver cela drôle… Je rentrerai probablement vers cinq heures… six heures au plus tard… Allons ! good bye ! tâche de ne pas t’enivrer…
Et Slang, après m’avoir donné une vigoureuse poignée de main, partit d’un pas rapide.
Du seuil de la grille, je le vis s’éloigner, s’engager dans l’avenue qui conduit à la gare, puis disparaître entre les arbres.
Mes yeux n’avaient pas quitté ses semelles. Il me semblait qu’avec elles cet homme emportait tout mon bien !
Ce que l’on va lire maintenant paraîtra peut-être invraisemblable à certains lecteurs. Je les supplie, ceux-là, de me faire crédit de quelque confiance ; ils verront par la suite si j’ai dénaturé ou surfait quoi que ce soit dans une affaire qui fut certainement la plus compliquée de toutes celles que j’eus à instruire, durant ma carrière déjà longue de détective amateur.
VMAUVAIS DÉPART
Sans perdre une minute, je pris, comme on dit, mes jambes à mon cou dans la direction du petit bois qui m’avait déjà servi d’asile et j’en sortis presque aussitôt transformé en parfait gentleman.
J’avais même eu la chance de retrouver mon chapeau.
Au lieu de rentrer chez moi, je me dirigeai précipitamment chez un marchand d’automobiles nommé Bloxham qui demeurait à l’entrée de la ville et je pénétrai dans son garage en hurlant :
— Bloxham !… Bloxham !…
Un petit homme aux yeux bigles sortit de derrière une auto dont il était en train de regonfler les pneus et me regarda d’un air ahuri :
— Qu’y a-t-il pour votre service, monsieur ? demanda-t-il en se découvrant.
— Voyons… avez-vous donc perdu la tête, Bloxham ? Comment ? vous ne me reconnaissez pas ?
— Non monsieur… c’est-à-dire qu’il me semble bien vous avoir déjà vu quelque part… mais…
Je songeai aussitôt à mon maquillage que je n’avais pas eu le temps d’enlever :
— Je vous dirai mon nom tout à l’heure… pour le moment contentez-vous de savoir que j’exige de vous un service… il faut que j’arrive à Melbourne avant le train qui part de Broad-West à onze heures quarante-six.
Le petit homme tressauta comme s’il eût été surpris par un courant électrique, et ses deux pupilles vinrent affleurer la racine de son nez.
— Vous n’y pensez pas ! s’écria-t-il en se retournant vers l’horloge placée dans le fond du garage… il est exactement onze heures quarante-deux ; le train va partir dans quatre minutes.
— Il le faut, vous dis-je… Je paierai ce qu’il faudra… et d’avance encore… Avez-vous une voiture prête ?
— Celle-ci… mais il faut que je regonfle un pneu…
— Faites vite alors !…
— Je vous assure, monsieur…
— M’avez-vous entendu, Bloxham ?
— Vraiment c’est impossible… oui, c’est réellement impossible… grognait le petit homme en ajustant son raccord sur la valve… il faudrait faire du quatre-vingt-dix de moyenne…
— On fera du cent s’il le faut ! m’écriai-je…
Et pendant que le pauvre Bloxham actionnait désespérément sa pompe, je pris un seau, allai le remplir à une fontaine et, me servant de mon mouchoir en guise de serviette, j’enlevai rapidement l’affreux enduit qui me barbouillait le visage.
— Eh bien ! me reconnaissez-vous maintenant ? demandai-je en m’approchant.
— Oh ! Monsieur Dickson… Quelle surprise !… Ah ! par exemple !… Si jamais j’aurais pu penser que c’était vous, ce vilain individu… pardon… je voulais dire…
— C’est bon… hâtez-vous…
— Du moment que c’est pour vous obliger, monsieur Dickson, je ferai l’impossible…
Et de fait, Bloxham se mit à pomper avec une énergie désespérée.
Cet homme me devait quelque reconnaissance, car je m’étais récemment occupé pour lui d’une affaire assez embrouillée, dans laquelle il se trouvait compromis, quoiqu’il fût tout à fait innocent, et j’avais fini par mettre la main sur les vrais coupables.
J’avais sauvé la réputation de Bloxham et j’étais sûr qu’il ferait tout pour sauvegarder la mienne.
— Vite !… vite !… activons, m’écriai-je après avoir regardé ma montre… nous n’avons plus qu’une minute…
— C’est prêt, monsieur Dickson, répondit Bloxham en dévissant son raccord… Montez, nous allons partir aussitôt.
Et il appela :
— Jarry ! Jarry !
Une figure cramoisie s’encadra dans un guichet.
— Surveillez le garage… Jarry… je m’absente pour quelques heures… et surtout si M. Sharper veut encore essayer la vingtquatre chevaux, dites qu’elle est en réparation.
— All right ! répondit l’individu qu’il avait interpellé… on aura l’œil…
Déjà, Bloxham avait donné un tour de manivelle et le moteur battait avec une trépidation sonore.
Il sauta au volant, actionna le levier de mise en marche et nous partîmes.
A ce moment même, un coup de sifflet strident nous annonçait l’arrivée en gare du rapide de onze heures quarante-six.
La distance qui sépare Melbourne de Broad-West n’est que de quarante-deux kilomètres par chemin de fer, mais on en compte cinquante-trois par la route qui décrit de nombreuses courbes et au milieu de laquelle se trouve une côte de douze cents mètres excessivement rapide.
De plus, — et là était la difficulté — le rapide qui ne s’arrête plus entre Broad-West et la capitale de l’État de Victoria met juste vingtcinq minutes pour effectuer le parcours.
Il fallait donc que nous le gagnions de vitesse.
Avec une quarante chevaux comme celle que nous montions, la chose était facile, en admettant que nous ne rencontrions sur la route aucun encombrement et que nous traversions à toute allure Long-House et Merry-Town, deux petites localités assez désertes, situées sur notre passage.
Pendant sept kilomètres environ, nous longeâmes la voie du chemin de fer et je pus constater avec un vrai bonheur que nous « semions » le rapide, mais il nous fallut bientôt nous engager dans un chemin sinueux et aborder la fameuse côte de Devil, dont la pente, d’après les cartes, est de vingt pour cent !
L’auto de Bloxham enleva la rampe en troisième et dévala ensuite vers Long-House à une allure fantastique.
Le rapide devait être à cette minute très loin derrière nous et je jubilais intérieurement, en songeant à la tranquillité de Slang, qui était à cent lieues de se douter qu’un détective allait le prendre en filature au débarcadère de Melbourne pour ne plus le lâcher d’une semelle.
Mon plan était simple.
Je m’attacherais à ses pas, ou si besoin était, je le ferais suivre par des agents secrets, ma modeste personne, quelque active qu’elle fût, n’étant pas encore parvenue à se dédoubler.
Il fallait, en effet, avant de mettre les menottes à mon « pseudocousin », recueillir certains indices qui m’étaient indispensables. L’assassin de M. Ugo Chancer pouvait avoir des complices. Je me trouverais alors avoir affaire à une bande puissamment organisée pour le cambriolage et le vol.
Si cela était, la découverte d’une association de malfaiteurs, sur d’aussi faibles indices, me classerait définitivement parmi les plus fins limiers de police et une pensée d’orgueil intime, autant que de
curiosité professionnelle, m’aiguillonnait de plus en plus à mesure que nous approchions de Melbourne.
Oui, plus je réfléchissais, plus j’arrivais à me persuader que j’allais me trouver en présence d’une sorte de Robber’s Company semblable à celle de Brisbane.
Slang paraissait trop sot pour avoir conduit seul cette affaire… Cependant il était l’instrument du meurtre, tout en témoignait et il importait d’élucider promptement ce qui restait de ténébreux dans l’exécution d’un crime aussi habilement conçu.
Et d’abord, il n’était pas admissible que le voleur-assassin s’en fût allé sans tirer aucun profit de son crime.
Nous avions trouvé dans le secrétaire de M. Ugo Chancer une forte somme en or, mais il n’était pas croyable que la fortune du vieux de Green-Park se réduisît à cent quatre-vingt-trois livres en monnaie courante.
Il devait avoir des titres déposés chez un ou plusieurs hommes d’affaires, comme l’insinuait le chief-inspector Bailey Peut-être ?
Mais cela n’expliquait pas le geste, véritablement par trop désintéressé, du cambrioleur assassin.
De toute façon, il était urgent que j’entrasse en relations avec l’homme d’affaires de la victime ; or un hasard providentiel m’avait, on le sait, livré le nom de M. R. C. Withworth, 18, Fitzroy Street, à Melbourne.
Je devais donc m’adresser à ce M. Withworth qui envoyait au défunt des plis cachetés et semblait être, sinon le confident, du moins l’intermédiaire entre M. Ugo Chancer et les différentes banques d’Australie.
Nous venions de dépasser Merry-Town et nous apercevions déjà les premières maisons de Melbourne, quand notre automobile eut soudain des ratés.
Cela se traduisit d’abord par quelques explosions rapides et bruyantes qui peu à peu s’atténuèrent pour se changer en un
pénible crachotement de valétudinaire.
C’était la panne ! l’affreuse panne devenue pourtant si rare aujourd’hui grâce aux merveilleux perfectionnements de l’industrie automobile.
J’avais pâli et Bloxham avait proféré un mot énergique que la bienséance ne me permet pas de reproduire ici…
— Voyez vite ce que c’est ! m’écriai-je en secouant mon malheureux conducteur par le bras.
Bloxham sauta sur la route, releva le capot de la voiture et se mit à examiner les quatre cylindres.
— Eh bien ? demandai-je…
— C’est l’allumage qui ne se fait plus, répondit-il, le nez sur le moteur.
— Vérifiez vite… by God !
— Les bougies sont en bon état…
— Votre huile donne bien ?
— Oui…
— Alors ?
Tout à coup, il se frappa le front d’un geste désespéré, courut au réservoir de cuivre placé à l’arrière de la voiture, en dévissa rapidement le bouchon et s’écria, après avoir jeté un coup d’œil dans l’intérieur :
— Il n’y a plus d’essence, monsieur Dickson !…
J’eus envie de sauter sur cet homme, de le prendre à la gorge et de l’étrangler comme un poulet…
Fort heureusement, je me contins et ma rage s’exhala en injures et en imprécations.
— Je croyais que nous aurions assez d’essence, monsieur Dickson, balbutiait Bloxham en se frappant la poitrine à coups redoublés comme un gorille aux abois.
— Vous croyiez ! vous croyiez !… Ah ! idiot ! crétin ! triple brute !… Vous mériteriez… A cause de vous un assassin des plus dangereux va m’échapper… Je vais être perdu de réputation… Je…
Le sifflet narquois du rapide passant à quelques mètres de la route me coupa la phrase sur les lèvres et me jeta dans un état de fureur indescriptible…
Si encore j’avais pu télégraphier, téléphoner à la gare de Melbourne… Mais non, nous étions à trois milles au moins de MerryTown et le train serait arrivé avant que j’eusse atteint le bureau de poste de cette localité.
J’étais hors de moi… Je trépignais comme un enfant à qui on a volé ses billes, et un facteur qui passait sur la route me prit sans doute pour un fou, car il s’enfuit de toute la vitesse de ses jambes.
Quant à Bloxham il s’était accroupi dans la poussière et poussait des cris déchirants.
Je regrette qu’un photographe amateur ne nous ait pas pris à ce moment avec son kodak car cela aurait fait un cliché des plus amusants pour le Great Humoristicou l’Australian Jester.
Enfin je me calmai et regardai ma montre.
Il était exactement midi dix et l’express allait entrer en gare de Melbourne…
— Tout n’est peut-être pas perdu… pensai-je. Il se peut fort bien que mon Slang revienne à la villa Crawford… Somme toute, il n’a aucune raison de se méfier… Pourquoi s’enfuirait-il ? Ce serait avouer son crime…
Et j’en arrivai presque à me persuader que je le retrouverais le soir, dans le petit pavillon dont il m’avait fait les honneurs avec une cordialité si touchante.
En tout cas, puisque je l’avais laissé échapper, il fallait que je continuasse mon enquête, que je visse M. Withworth et le chiefinspector de Melbourne. Et qui sait si je ne rencontrerais pas ce bandit de Slang dans quelque rue de la ville ? C’était un alcoolique
invétéré et il serait bien surprenant qu’il ne fît pas de nombreuses stations dans les bars de Collingswood ou de Northcote.
— Combien d’ici à Melbourne ? demandai-je à Bloxham qui se lamentait toujours dans la poussière.
— Quatre milles, monsieur Dickson… bégaya le pauvre homme en agitant ses petits bras pareils à des ailerons.
— C’est bien… je vais les faire à pied. Excusez-moi, Bloxham, si je vous ai un peu malmené tout à l’heure, mais je ne vous en veux plus… Combien vous dois-je ?
— Vous plaisantez, monsieur Dickson… D’ailleurs je n’accepterai jamais de vous quoi que ce soit… je vous dois trop pour cela… Ah ! quelle fatalité, by God ! quelle fatalité ! Pour une fois que je voulais vous être agréable !
— L’occasion se représentera, Bloxham, soyez-en sûr… Et tenez… puisque vous désirez m’obliger, il y a un moyen…
— Oh ! dites, monsieur Dickson !
— C’est d’avoir toujours dans votre garage de Broad-West une voiture prête à partir… une voiture avec de l’essence… par exemple…
— Comptez sur moi, monsieur Dickson… et veuillez encore une fois agréer toutes mes excuses…
— Vous êtes tout excusé, mon ami, répondis-je en donnant au malheureux chauffeur une tape amicale dans le dos — ce qui eut pour effet de soulever un affreux nuage de poussière — et croyez que je regrette vivement les qualificatifs un peu désobligeants dont je me suis servi à votre endroit… Allons, good bye !… J’irai probablement vous rendre visite ce soir…
Et après m’être épousseté tant bien que mal avec mon mouchoir, je me dirigeai pédestrement vers Melbourne.