SAMA Insider - 2016 July by HMPG

SAMA

INSIDER

JULY 2016

A revolution in HIV and TB testing What are Prescribed Minimum Benefits? PUBLISHED AS A SERVICE TO ALL MEMBERS OF THE SOUTH AFRICAN MEDICAL ASSOCIATION (SAMA)

SOUTH AFRICAN SOUTH AFRICAN MEDICAL ASSOCIATION MEDICAL ASSOCIATION

November 8-12, 2016

Held in conjunction with the South African Urological Association (SAUA) Meeting • November 8 – 9, 2016

Photographic competition entry

JULY 2016

CONTENTS

Diane de Kock

Simon Buthelezi

FROM THE PRESIDENT’S DESK The Minister’s health budget debate: What are the issues?

Health conference with a difference

Prof. Denise White FEATURES

EDITOR’S NOTE Keeping you informed

A revolution in HIV and TB testing

Temporary incapacity leave in public service

Dr Hlombe Makuluma

What are Prescribed Minimum Benefits?

Council for Medical Schemes

6 Unpacking plain packaging

New book brings healthcare and business together

SAMA Communications Department

of tobacco products

Bernard Mutsago

SAMA Communications Department

The cure for HIV/AIDS: Medicine, a noble calling

Dr Ayodele Aina

The importance of keeping proper medical records

Julian Botha

Ransomware: Protect your business now!

Gert Viljoen

MEDICINE AND THE LAW

Medical Protection Society

BRANCH NEWS

MEMBER BENEFITS 2016

Alexander Forbes

Herman Steyn 012 452 7121 / 083 519 3631 | steynher@aforbes.co.za Offers SAMA members a 20% discount on motor and household insurance premiums.

Automobile Association of South Africa (AA) AA Customer Care Centre 0861 000 234 |aasa@aasa.co.za

The AA offers a 12.5% discount to SAMA members across its range of AA Membership packages.

Barloworld

Lebo Matlala (External Accounts Manager: EVC) 011 052 0167 084 803 0435 | LeboM@bwmr.co.za Barloworld Retail Digital Channels offers competitive pricing on New vehicles; negotiated pricing on demo and pre-owned vehicles; Trade inâ&#x20AC;&#x2122;s; Test Drives and Vehicle Finance.

Legacy Lifestyle

Patrick Klostermann 0861 925 538 / 011 806 6800 | info@legacylifestyle.co.za SAMA members qualify for complimentary GOLD Legacy Lifestyle membership. Gold membership entitles you to earn rewards at over 250 retail stores as well as preferred rates and privileges at all Legacy Lifestyle partnered hotels and further rewards back on accommodation and extras.

Medical Practice Consulting Inge Erasmus 0861 111 335 | werner@mpconsulting.co.za

20% discount on assessment of Practice Management Applications (PMA) and Electronic Data Interchange (EDI) systems.

Mercedes-Benz South Africa (MBSA) Refilwe Makete 012 673-6608 refilwe.makete@daimler.com

17/05/2016

Mercedes-Benz offers SAMA members a special benefit through their participating dealer network in South Africa. The offer includes a minimum recommended discount of 3%. In addition SAMA members qualify for preferential service bookings and other after market benefits.

EDITOR’S NOTE

JULY 2016

Keeping you informed

Diane de Kock Editor: SAMA INSIDER

Editor: Diane de Kock Chief Operating Officer: Diane Smith Production Editor: Diane de Kock Editorial Enquiries: 083 301 8822 Advertising Enquiries: 012 481 2069 Email: dianed@hmpg.co.za

his month’s issue of SAMA Insider is packed with information which we hope will assist our members. On page 4 Prof. White gives us some background to the Minister’s health budget debate and challenges members to continue the discussion on the legalisation of cannabis. A “revolution” in HIV and TB testing is covered on page 5 and Bernard Mutsago, on page 6, unpacks the use of plain or regular packaging of tobacco products. On page 8 Julian Botha gives us valuable background on the importance of keeping proper medical records, a recommendation echoed in the learning points of the Medical Protection Society article on page 18. The Council for Medical Schemes have provided a helpful article on Prescribed Minimum Benefits and on page 17 Gert Viljoen looks at cybercrime and the impact of the King Reports on SMEs. Enjoy the read and please provide feedback in the form of a letter to the editor or a request for more information.

Design: Carl Sampson Published by the Health and Medical Publishing Group (Pty) Ltd Block F, Castle Walk Corporate Park, Nossob Street Erasmuskloof Ext. 3, Pretoria Email: publishing@hmpg.co.za | www.samainsider.org.za | Tel. 012 481 2069 Printed by Tandym Print (Pty) Ltd

DISCLAIMER Opinions, statements, of whatever nature, are published in SAMA Insider under the authority of the submitting author, and should not be taken to present the official policy of the South African Medical Association (SAMA) unless an express statement accompanies the item in question. The publication of advertisements promoting materials or services does not imply an endorsement by SAMA, unless such endorsement has been granted. SAMA does not guarantee any claims made for products by its manufacturers. SAMA accepts no responsibility for any advertisement or inserts that are published and inserted into SAMA Insider. All advertisements and inserts are published on behalf of and paid for by advertisers. LEGAL ADVICE The information contained in SAMA Insider is for informational purposes and does not constitute legal advice or give rise to any legal relationship between SAMA or the receiver of the information and should not be acted upon until confirmed by a legal specialist.

FROM THE PRESIDENT’S DESK

The Minister’s health budget debate: What are the issues? • the successful implementation of National Health Insurance (NHI) • the outcomes of the Competition Commission’s public market inquiry into the cost of private healthcare • issues pertaining to the explosion of medico-legal litigation.

Prof. Denise White, SAMA President

he debate on the Minister of Health’s Budget 2016 was held in parliament on Tuesday 10 May 2016. Representatives from the stakeholders in our health system attended en masse, filling the gallery in the Old Assembly Chamber to capacity. Prior to the debate the Speaker cautioned enthu siastic invitees to refrain from participation in the proceedings in any way; no comment or applause was permitted. And so we sat, a bank of silent witnesses, to the (mostly) dignified proceedings that took place between the political groupings in the chamber. Minister Motsoaledi’s speech was com prehensive and realistic in its analysis of the state of the nation’s health and the challenges on the road ahead. He said: “Every vision, policy, plan, pro gramme, decision and campaign will from henceforth be based on and directed by the dictates of the National Development Plan (NDP) – without any reservation whatsoever. By 2030 the NDP for health envisages a life expectancy rate of at least 70 years for men and women, an HIV-free generation of under 20s, a radical reduction of the quadruple burden of disease, an infant mortality rate of less than 20 deaths per 1 000 live births, an under-5 mortality rate of less than 30 per 1 000, and a significant shift in equity, efficiency, effectiveness and quality of healthcare provision – with the availability of universal health coverage implemented and the risks from the social determinants of disease significantly reduced.” He warned that the determining factors of whether these noble goals can be achieved are threefold: 4

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Minister Motsoaledi is deserving of accolades for his passion and tireless commitment to improving all aspects of healthcare in the face of seemingly insuperable odds. HIV no longer bears the threat of certain death to all who test positive, and from September 2016 the CD4 count will no longer be the eligibility criterion for antiretroviral treatment. It is estimated that 3 million South Africans are now on ARVs. While supporting the budget proposals and praising the Minister for his significant achievements, speakers from the opposition parties raised certain concerns, stressing that the country has not turned the corner with respect to our burden of disease. When challenged by the Democratic Alliance to take bold action against the dys functional Health Professions Council of South Africa (HPCSA), the Minister responded that, based on the recommendations of his ministerial task team, the unbundling of the Medical and Dental Board from the existing HPCSA structures is poised to be undertaken. The Inkatha Freedom Party appealed to the Minister for the urgent enactment into law of the private member’s Bill tabled by its respected and long-standing MP Mario Oriani-Ambrosini who died on 16 August 2014 from cancer. If the Bill progresses, and is ultimately adopted by parliament, even in an amended form, it will be the first time a private member’s Bill succeeds.

Legalisation of cannabis In response to the political call for the legalisation of cannabis for medical use in South Africa (SA), SAMA has tabled a proposal for the World Medical Association (WMA)’s consideration and possible adoption. Currently it is a work in progress. The use of cannabis is an important world wide health and social issue. It is the most commonly used illicit drug in the world. The World Health Organization (WHO) estimates that about 147 million people, 2.5% of the world population use cannabis compared

with 0.2% using cocaine and 0.2% using opiates. Cannabis for medical use has been legalised in certain countries, which drew on evidence of varying strengths to develop their cannabis policy, whereas in SA and other countries it remains prohibited. The huge medical and pharmacological innovation potential of the endo-cannabinoid system has been widely recognised. It affects a variety of physiological processes, including appetite, pain sensation, mood and memory. Clinical conditions that may be relieved by treatment with marijuana, or other canna binoids, are: glaucoma; chemotherapy-indu ced nausea and vomiting; appetite, weight, mood and quality of life in patients with AIDS; chronic pain, in particular neuropathic pain; multiple sclerosis; and epilepsy. The prohibition of cannabis is seen as an impediment to scientific research and doctors find themselves in a medico-legal dilemma in striking the balance between ethical responsibility to patients who consider cannabis as effective therapy and compliance with existing legislation. In the absence of convincing scientific evidence on the therapeutic effectiveness of cannabis, SAMA has proposed to the WMA that more rigorous research involving bigger samples be implemented, before government decides to legalise it for medical use. To this end SAMA recommends that laws governing access to, and possession of, cannabis should be relaxed to allow for unhindered scientific research in order to broaden the evidence base. Strengthening scientific evidence through research is indisputably the ethical and logical way forward. But it needs to be considered that the long and protracted course of obtaining such evidence could be counterproductive, in that countless patients enduring debilitating and painful disorders will be denied the potential benefit of treatment for years to come. As a profession committed to relieving pain and suffering, is it humane to deny these patients access to a substance that has the potential to alleviate their distress for an indeterminate time? The debate must continue! Article references are available from the Editor on request.

FEATURES

A revolution in HIV and TB testing SAMA Communications Department

n the fight against HIV and TB, South Africa (SA) is one of the first countries in the world to have embraced molecular technologies, which amplify genetic code (DNA and RNA) to rapidly identify infectious organisms. Implementing rapid molecular tech nologies for TB tests that significantly reduce the time of diagnosis to 2 hours as opposed to 6 weeks, as well as molecular technologies for early infant HIV diagnosis, HIV viral load testing and CD4 testing – this is part of the work currently being carried out by the University of the Witwatersrand (Wits)’s Department of Molecular Medicine and Haematology. These life-changing technologies’ imple mentation in SA and impact as a whole on global HIV and TB health were discussed by Prof. Wendy Stevens and Prof. Lesley Scott at the Wits Faculty of Health Sciences 13th Prestigious Research Lecture on 14 June 2016. Prof. Stevens is the Head of Department of Molecular Medicine and Haematology in the School of Pathology at Wits. She is also the Head of the National Priority Programme (NPP) of the National Health Laboratory Services (NHLS). Together with the National Department of Health, the NHLS and clinical stakeholders, Prof. Stevens put together the policy for the use of molecular technologies in SA – the first country to roll this out to scale. Prof. Lesley Scott is the Head of Research and Development for the NPP. In the policy titled Unlocking Access to Global HIV and TB Care through Molecular Diagnostics, the professors shed light on the simple, quick, ingenious molecular technologies their teams have tirelessly worked on to use molecular technologies to improve patient care. Given the HIV and TB co-epidemic in SA, where our TB infected population has up to 65% co-infection with HIV, this is a revolution in patient healthcare that could save millions of lives.

Prof. Wendy Stevens, Head of Department of Molecular Medicine and Haematology in the School of Pathology at Wits University and Head of the NPP of the NHLS. “As a result of the use of an automated molecular diagnostic machine for TB called GeneXpert, for example, over 80% of individuals with multidrugresistant TB, which is highly infectious and 60% fatal, can immediately be identified. The quick turnaround for results means that patients don’t go missing or infect others or die, as happened previously. In 2014, for example, approximately 9.6 million people developed TB and 1.5 million died globally,” said Prof. Stevens. TB diagnosis using the GeneXpert is now done at the patient’s bedside, irrespective of whether they are in a rural clinic or city hospital. However, before such testing can be done on the machines, they must be checked to see if the technology is working properly. This process was almost impossible to do. “Not only would it take several weeks, it also posed a severe biosafety risk because it meant transporting live organisms, sometimes over great distances,” explains Prof. Scott. “This is no longer necessary with the introd uction of a method, developed by this research and development team called SmartSpot Tbcheck, which checks, in situ, whether the GeneXpert machine is working properly before you test a TB patient.”

Prof. Lesley Scott, Head of Research and Deve lopment for the NPP. Molecular technologies are also being used in HIV early infant diagnosis (EID) to determine whether the HIV virus DNA is present, and these technologies are also being used to test HIV viral loads and CD4 counts. “It is all about choosing the right technology and getting it to the right patient at the right time,” says Prof. Stevens, whose team has been using molecular technologies since the 1990s to test HIV viral loads and CD4 counts. Today, this approach is recommended globally as the single best indicator as to whether a person is taking their HIV medication or not, or whether they have become resistant to their treatment. “With molecular technologies we can now implement highly centralised, highthroughput testing and decentralised, lowthroughput testing in clinics and hospitals all over the country,” adds Prof. Scott. “This will considerably reduce the money spent on these tests while at the same time advancing faster, simpler, more accurate testing and diagnostics in the future, potentially for any kind of disease.” “It’s been a tough, hard road and a huge team effort to get where we are now,” con cluded Prof. Stevens.

The Wits Faculty of Health Sciences The Wits Faculty of Health Sciences offers world-class training in medicine, dentistry, nursing, pharmacy, pathology, physiotherapy, occupational therapy and public health. In conjunction with the Gauteng Department of Health, over 1 000 medical and dental consultants are involved in teaching undergraduate and postgraduate students. Practical experience is offered in five major hospitals in Johannesburg as well as several rural hospitals, the state-of-the-art Wits Donald Gordon Medical Centre and various clinics. Research at the Faculty of Health Sciences ranges from basic medical science to highly sophisticated molecular biosciences, in noncommunicable diseases and in infectious diseases such as HIV/AIDS, TB and malaria. Wits has a proven record of achievement in all aspects of health sciences and, in addition to the many hundreds of individuals who conduct research in the Faculty, 20 research entities are gathered under the umbrella of the Faculty Research Office and the Schools of the Faculty.

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JULY 2016

FEATURES

Unpacking plain packaging of tobacco products Bernard Mutsago, SAMA Health Policy Researcher and Analyst

he world is paying a high price for the tobacco epidemic. The monetary, health and social toll of tobacco is staggering, and there is unanimity in much of the world (including South Africa (SA)) that far more drastic interventions are needed, despite pockets of resistance from the tobacco industry. Why does packaging matter in the tobacco arena? Because the package is a significant marketing tool engineered to communicate powerful messages that unconsciously trigger the urge to smoke for potential and current smokers. In direct proportion, this same immense power of the package has been positively rerouted to counter the global nicotine epidemic and its associated deadly effects. Plain packaging or stan dardised packaging has emerged as one of the latest tobacco control measures globally, because of compelling evidence of its effectiveness. Crudely defined, plain packaging of tobacco products – as opposed to regular packaging – is a fresher and stricter demandreducing intervention, whereby all tobacco products are required to no longer have attractive colours, logos, trademarks, and pictures. Instead the package should contain large pictorial and textual health warnings highlighting tobacco smoking’s worst manifestations. Promoted by the World Health Organization ( WHO)’s Framework Convention on Tobacco Control (FCTC), the intervention requires FCTC signatory countries to display only brand names, product names and critical product information on the package, in a standard colour (dull) as well as specific font size (large). The packaging specifics are to be defined by a national authority. In 2012 Australia became the first country to fully implement plain packaging through its Tobacco Plain Packaging Act. This saw tobacco consumption among Australians dropping by about 13% within 2 years of the introduction of plain packaging. A few other countries – Ireland, the UK, Northern Ireland and France – also passed laws to implement plain packaging, starting in 2016. Various other WHO member countries are at various stages of the legislative and policy processes towards plain packaging. SA, against fierce opposition from the tobacco industry, has

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announced that it is seriously considering the introduction of plain packaging; a draft Bill is under consideration. Local organisations such as the Cancer Association of SA have fully backed this intervention.

The monetary, health and social toll of tobacco is staggering, and there is unanimity in much of the world that far more drastic interventions are needed, despite pockets of resistance from the tobacco industry Experimental and qualitative studies cond ucted around the globe provide strong evidence that regular packaging promotes the uptake of smoking and suppresses quitting, while inversely plain packaging is found to be effective in decreasing the attractiveness of tobacco products and evoking negative feelings about smok ing, leading to increased smoking cessation rates. Plain packaging interventions were also found to decrease the tobacco package’s function as a form of tobacco advertising and promotion. The large, confronting, graphic and colourful health warnings that are an element of plain packaging were found to be more noticeable and easily remembered, leading to reduced desire to use tobacco. Study participants in France and the UK described plain packaged tobacco products as “ugly”, “repelling”, “unfashionable”, “unappealing”, and “unsatisfying”.

Globally, smoking causes over USD500 billion in economic damage each year. Annually, over 5 million people die world wide due to smoking and, tragically, 600 000 of these deaths are of non-smokers who succumb to second-hand smoke. Up to 44 000 South Africans die every year due to smoke-related diseases. The tobacco industry’s resistance to plain packaging laws across the world, in spite of the above statistics, is troubling to the public health community and the contest has not been shy of litigation. The WHO asserts that plain packaging is in compliance with intern ational trade and intellectual property law since it only regulates the use of logos or colours for public health purposes. On the basis of evidence, the WHO dismisses the tobacco industry’s objections to plain packaging, namely that plain packaging will: • increase illicit trade • decrease tobacco prices, thus promoting consumption • prevent tobacco companies from using their trademarks. Governments have the moral duty to pro tect their citizens’ health. The WHO FCTC gives governments the latitude to define specific details of plain packaging law or policy to suit their country environm ents, but urges flexible legislation to permit amendm ents, in preparation for the almost guaranteed offensive by tobacco lobbyists. As SA, a signatory of the FCTC, observed Anti-Tobacco Campaign Month in May 2016 and joined the whole world in commemorating World No Tobacco Day on 31 May, pro-health citizens celeb rated SA’s anti-tobacco campaign that began more than a decade ago and is intensifying under the current Minister of Health, Dr Aaron Motsoaledi. The WHO underscores that plain packaging is more effective if implemented as par t of a suite of comprehensive multisectoral anti-tobacco measures. Appreciably, Motsoaledi has affirmed and practically demonstrated his commitment to implementing all such approaches, namely: • tobacco pricing and taxation • restriction of smoking in public places • regulation of content of tobacco products

FEATURES

• regulation of tobacco advertising, pro motion and sponsorship • regulation of tobacco product dis closures.

The WHO’s avid message to the world, in the form of the theme for the 2016 World No Tobacco Day, was Get Ready for Plain Packaging!. For the SA government and the

public health fraternity, it would seem, the WHO’s warning is off the pace. But for the 7 million tobacco-smoking South Africans, the warning should not go unnoticed.

Plain packaging • • • • • • • •

Dull and “uncool” package no logos, trademarks or pictures salient graphic health warnings large, visible health warning text warning message should be 50% or more of the principal display area brand and variant names in standard positions on pack unattractive no adverts inside pack.

Regular packaging • • • • • • •

Seen as “cool” colourful evokes positive perceptions of smoking warning labels in small print misleading claims, e.g. “mild”, “lite” colours, shapes and sizes of pack influence consumers, especially youth and women promotional material in pack.

The cure for HIV/AIDS: Medicine, a noble calling Dr Ayodele Aina, SEDASA National Chairperson

edical practitioners live in a world that, although divided by borders, is limitless. We can travel anywhere, see anything, experience every feeling that ever existed, but we need to be satisfied. We should not impose borders on ourselves or hunger to be recognised as not belonging to a community, or be labelled as part of another group. Medical researchers now seem to join hands and invest in research for new smartphones and the cure for baldness rather than finding the cure for HIV/AIDS and feeding the world. There is no cure for HIV and AIDS, yet treatment can control HIV and enable people to live a long and healthy life. Functional cures are difficult to achieve because HIV hides just out of reach in hidden reservoirs.

Destroying the reservoirs may be the key to curing HIV. Medical practitioners live in a world that has invented the telephone, internet, and social media, which makes communication easier. But we have never felt so alone and out of touch as we do now. Hidden behind the screens of our computers, tablets and smartphones, we feel alienated from what the world has to offer. Medical doctors in various specialities live in a limitless world, which grants the right to be free and equal and has given us the opportunity to learn from one another. The world tells the differences between us and the fact that they make us equal, and do not tear us apart. It also teaches the importance of destroying the hidden reservoirs that may be the key to curing HIV and other cankerworms of our day.

While technology and democracy gives some the power to fast forward the world in which we live, it has also created unfor tunate circumstances and given us the sense of absolute power and knowledge that often make us feel like a god. No, we are not gods and we cannot decide on the fate of others. Only they have that right. But we can and we must change ourselves by making knowledgeable decisions, the right choices in life and not letting others decide for us. If the medical profession is not a noble calling, I doubt if the world will continue to depend on medicine for the treatment and cure of HIV. Medical practitioners should be delight ed to be in a noble calling and constantly uphold it.

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FEATURES

The importance of keeping proper medical records Julian Botha, Strategic Accounts Manager: SAMA Private Practice Department

he importance of keeping proper, comprehensive and organised medical records cannot be overstated. Such records are often the only defence avai lable when a doctor answers complaints or allegations by patients, medical schemes or even other doctors. This is even more important as South African (SA) society is becoming ever more litigious and doctors are increasingly in the firing line of such litigation. With the imminent arrival of the Protection of Personal Information (POPI) Bill, dealing with the personal information of patients in a medical practice will be even more strictly regulated and the mishandling of such information may result in criminal sanction. In this article we will deal with the current regulation of medical records in terms of the existing legislation and guidelines. In our next article we will provide information on the POPI requirements and how they relate to medical records. In order to continue we must first understand what is meant by the concept “medical records”. The medical record of a patient is the umbrella term for any documentation or other media form that relates to the diagnosis, treatment and care of the patient. It therefore includes clinical notes (irrespective if these are handwritten or electronic), reports from laboratories, radiological images and reports, sonograms, audiovisual material (e.g. photographs and video or voice recordings) and printed readings from medical devices. Medical records are sometimes referred to as the health record of the patient. The Health Professions Council of South Africa (HPCSA) utilises health records in their guideline document, Guidelines on the Keeping of Patient Records (2nd ed. 2008). This document provides the following definitions of a health record: “A health record may be defined as any rele vant record made by a health care practitioner at the time of or subsequent to a consultation and/or examination or the application of health management. A health record contains the information about the health of an identifiable individual recorded by a health care professional, either personally or at his or her direction.” These guidelines further give information regarding what would form part of the health record: “1. Hand-written contemporaneous notes taken by the health care practitioner.

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2. Notes taken by previous practitioners attending health care or other health care practitioners, including a typed patient discharge summary or summaries. 3. Referral letters to and from other health care practitioners. 4. Laboratory reports and other laboratory evidence such as histology sections, cytology slides and printouts from automated analysers, X-ray films and reports, ECGs, race, etc. 5. Audiovisual records such as photographs, videos and tape-recordings. 6. Clinical research forms and clinical trial data. 7. Other forms completed during the health interaction such as insurance forms, disability assessments and documentation of injury on duty. 8. Death certificates and autopsy reports.”

Ownership There is often confusion and subsequent disputes regarding the ownership of medical records in private practices. Simply stated, the general principle is that the private practitioner is the owner of the medical records. However, there are certain important factors which must be borne in mind. The medical record of the patient belongs to the doctor, but the patient should not be prevented from accessing these records or obtaining copies of the records. The doctor can charge a reasonable fee for requested copies. In the event that the doctor refuses access to the records or declines to make copies available, the patient has the remedy of formally requesting same in terms of the Promotion of Access to Information Act (No. 2 of 2000). It is clearly preferable to provide the access and/or copies when the patient asks for them in the first place as this will reduce acrimony and possible litigation. Where a patient has paid for a portion of the record, for example X-rays or CT scans, then the patient should retain these records unless it is agreed with the patient that the records be retained by the doctor for monitoring purposes. As the patient has paid for these particular records, they would enjoy ownership of them. The ownership of the medical record does not vest in a doctor who is an employee of a private practice, as a professional assistant, but rather in the private practice itself. However, it

would be unreasonable for the private practice to withhold copies of the medical records in the event that there is any compliant or claim against the professional assistant concerned, and should therefore make such copies available to allow that doctor to mount his defence.

Retention All practitioners have an obligation to retain the medical records of their patients. This obligation exists for a variety of reasons. These reasons include ensuring the continuity of care of the patient and to serve as evidentiary record in the event of any litigious or professional dispute or complaint. Because medical records contain confidential information of a patient’s health status, they fall under section 14 of the National Health Act (No. 61 of 2003): “14. Confidentiality 1. All information concerning a user, including information relating to his or her health status, treatment or stay in a health establishment is confidential. 2. Subject to section 15, no person may disclose any information contemplated in subsection (1) unless: (a) the user consents to that disclosure in writing; (b) a court order or any law requires that disclosure; or (c) non-disclosure of the information represents a serious threat to public health.” This means that over and above the obligation on the practitioner to retain the health record, there is a statutory obligation to ensure that the confidentiality of the medical records is preserved. These records must be kept in a safe place where they can be accessed only by persons who are authorised to have such access. Questions are, however, often posed to us relating to the length of time records should be kept and the keeping of electronic records. The HPCSA has published helpful guide lines in respect of the retention of medical records, Guidelines on the Keeping of Patient Records (2nd ed. 2008) at paragraph 9 quoted below: “9.1 Health records should be stored in a safe place and if they are in electronic format, safeguarded by passwords. Practitioners should satisfy themselves that they understand the HPCSA’s guidelines with

FEATURES regard to the retention of patient records on computer compact discs. 9.2 Health records should be stored for a period of not less than six (6) years as from the date they became dormant. 9.3 In the case of minors and those patients who are mentally incompetent, health care practitioners should keep the records for a longer period: 9.3.1 For minors under the age of 18 years health records should be kept until the minor’s 21st birthday because legally minors have up to three years after they reach the age of 18 years to bring a claim. This would apply equally for obstetric records. 9.3.2 For mentally incompetent patients the records should be kept for the duration of the patient’s lifetime. 9.4 In terms of the Occupational Health and Safety Act (No. 85 of 1993) health records must be kept for a period of 20 years after treatment. 9.5 Notwithstanding the provisions in paras 9.3 and 9.4 above, the health records kept in a provincial hospital or clinic shall only be destroyed if such destruction is authorised by the Deputy Director-General concerned.

9.6 In addition to the time periods men tioned above there are a number of other factors that may require health records to be kept for longer periods, but no clearcut rules exist in this regard. For instance, certain health conditions take a long period to manifest themselves, (e.g. asbestosis), and records of patients who may have been exposed to such conditions, should be kept for a sufficient period of time. The HPCSA recommends that this should not be less than 25 years. 9.7 A balance must be reached between the costs of (indefinite) retention of records (in terms of space, equipment, etc.) and the occasional case where the practitioners’ defence of a case of negligence is handi capped by the absence of records. The value of the record for academic or research purposes, and the risks resulting from the handling or complications of the case, are additional considerations. 9.8 Where there are statutory obligations that prescribe the period for which patient records should be kept, a practitioner must comply with these obligations.”

As we move ever further into the digital age, the storage of records and documents electronically is becoming more and more prevalent. It is clear that there are continuous tech nological advances in the field of electronic data storage and that the above guidelines do not reflect these advancements. It is therefore important to extract the underlying principles and apply them to the practice of electronic storage: • The system should be secure and not accessible to any other person. • It should also ensure that no subsequent modifications can be made to the stored data. • There should be separate back-up storage of the medical records. The retention of the medical records is the responsibility of the practitioner and therefore that practitioner must personally ensure that the medical records are secure, irrespective of any promises made by any service provider, and would be ultimately responsible should those records be lost.

Temporary incapacity leave in public service Simon Buthelezi, Industrial Relations Advisor

nce in a while it happens that one needs to take sick leave for legitimate reasons, only to find that the sick leave days are exhausted due to previous sick leave one has taken in the same leave cycle. Our members usually call our offices in complete frustration as they don’t know what to do in this situation. First of all there is a need to differentiate between two types of incapacity leave as indicated in Determination and Directive on Leave of Absence in Public Service, namely temporary and permanent. Permanent leave occurs when there is no hope that an employee will ever be able to render services again due to illness. This should not be thumb-sucked but backed by verifiable medical assessment. This article will only focus on the issues pertaining to temporary incapacity leave. Temporary leave occurs when an employee has exhausted his/her normal sick leave during the prescribed period, but according to his/her doctor requires to be absent from work due to temporary incapacity. In this situation it is incumbent upon the employee

to submit adequate proof that she/he is ill or injured and unable to perform her/his duties satisfactorily. A doctor’s report is then required and this type of leave is granted with full pay.

The process The human resources department in all insti tutions are the custodians of this process and have forms available solely for such a purpose. It is therefore necessary that members approach their respective human resources departments for advice and any other requirement for administrative purposes. The completed forms should be accompanied by a relevant doctor’s report, which is more than an ordinary sick note, as the report should include comprehensive information on the condition that led to tem porary incapacity, and indicate employee consent. The nature and extent of illness or injury should also be included. In line with item 10(1) of Schedule 8 to Labour Relations Act 1995, an employee should also provide any medical evidence related to his/her condition, e.g. medical reports from a specialist, blood test results, X-ray results or scan

results obtained at the employee’s expense and any other additional written motivation sup porting his/her application. It is also expected that the employee will give consent that her/ his information or record can be given to the employer and will be willing to undergo further medical examination, should the employer so require at the expense of the employer.

Approval The temporary leave approval or denial is the sole responsibility of the Head of Department, however it may not be denied without valid reasons. If the temporary leave is not approved due to understandable reasons, e.g. lack of relevant documents, the period of absenteeism will have to be covered by unpaid leave as the result of the leave days being exhausted. If the Head of Department refuses to approve the application for temporary leave incapacity, the employee may lodge a grie vance in line with the Grievance Procedure in Public Service. Forms are available in the office of the Labour Relations Officer and SAMA will assist members in this regard.

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FEATURES

A health conference with a difference Dr Hlombe Makuluma

his year marks 20 years since our MEDUNSA, no, the University of Limp opo, oh no, Sefako Makgatho Health Sciences University class graduated. For simplicity’s sake please allow me, for the purposes of this article, to just say the MEDUNSA class of 1996. What started as a WhatsApp group discussion in April 2014 to discuss relevant issues resulted in a very successful health conference that was held at Saint George Hotel on 20 and 21 May 2016. The conference was initially dubbed as a reunion of the 1996 class; however the feeling was that reunions are useless if not structured. They tend to be meetings where former classmates get together to brag to each other that “mine is bigger than yours” and end up with no value to the participants. Taking that into consideration the class of 1996 decided that they would meet and have a formal accredited conference and open attendance to all health practitioners. Without falling into the trap that “ours is bigger than yours” please allow me to just say this is a class of pathfinders – it is the only class that has produced three provincial heads of health departments (KwaZulu-Natal, Free State and Gauteng). This includes national heroes such as an ophthalmologist of note who is currently serving as the first African president of the World Ophthalmologist Congress 2020, the first black female urologist and an extraordinary number of specialists, such as chemical pathologists, oncologists, nuclear medicine physicians, radiologists, neurosurgeons, etc. At the conference one of the doctors who qualified in 1996 and who is currently practising as a business coach released for the first time, pre-publication copies of a book he has authored: The Business of Health Care: Managing Your Private Prac tice (see page 16). The published version contains a foreword by an eminent ENT surgeon in South Africa, a leader and an author who writes: “In The Business of Healthcare the author gives us his blueprint – a strategy which when properly executed will eliminate flaws in private health practice, unravel the myster y behind success, and lead to victory. The genius of

JULY 2016

SAMA INSIDER

Panel discussion on quality health delivery. From left: Dr R Khanyile, Dr E Moshokoa, Dr K Legodi and Dr H Makuluma.

Dr H Makuluma, conference chairperson, opens proceedings and welcomes delegates.

Delegates listen attentively.

his plan is the sheer simplicity of its pre cepts. The author readily confronts the complexities of running a medical practice with carefully thought out principles, and also with simple but deliberate language.” Back to the conference, which was the first organised via social media and by an informal structure: the name of the conference was “Health Conference by Health Practitioners for Health Practitioners”. The theme of the conference was: “Mending the Gap between Quality Healthcare Provision and Quality of Life of the Healthcare Practitioner” and it was attended by more than 80 health practitioners who robustly participated in the carefully structured presentations and panel discussions. For the first time sponsors were given an opportunity to participate in the conference proceedings rather than just to exhibit. The conclusion of the conference was that there is a need for such a platform

in the future. It was agreed that this kind of conference will be an annual event. The conference tackled issues that were pertinent in the sustainability of health prac tice, such as: • challenges facing health practitioners • medical aid issues • impact of NHI • economic sustainability of the practitioner. What characterised the conference were robust panel discussions where the dele gates participated and aired their views and suggestions on how to balance clinical practice and economic sustainability. It was clear that there is a need for health prac titioners to take control and be active in influencing the trajectory of healthcare into the future. The conference concluded with a relaxed and entertaining gala dinner.

SAMA eMDCM

Zandile Dube 012 481 2057 | coding@samedical.org 67% discount on the first copy of the electronic Medical Doctors Coding Manual (previously known as the electronic Doctor’s Billing Manual).

SAMA CCSA

Leonie Maritz 012 481 2073 | leoniem@samedical.org CCSA: 50% discount of the first copy of the Complete CPT® for South Africa book.

Tempest Car Hire

Corinne Grobler 083 463 0882 | cgrobler@tempestcarhire.co.za SAMA members can enjoy discounted car hire rates with Tempest Car Hire.

V Professional Services

Gert Viljoen 012 348 3567 | gert@vprof.co.za 10% discount on medical practice bureau service through V Professional Services.

Hugh Kannenberg +27 72 6257619 Sales - 087 805 0003 / Technical - 087 805 0530 | sales@voxtelecom.co.za/ help@voxtelecom.co.za Provide email and internet services to members. Through this agreement, SAMA members may enjoy use of the samedical.co.za email domain, which is reserved exclusively for doctors.

Xpedient

Andre Pronk +27 83 555 2885 Sales – 086 1973 343 | andre@xpedient.co.za Xpedient’s goal is to enable Medical Specialists to focus on their core competencies and allow us to assist them in making their business a success. As a SAMA member you qualify for a complimentary preliminary business assessment specific to your practice to the value of R 5000

17/05/2016

MEMBER BENEFITS 2016

Vox Telecom

FEATURES

What are Prescribed Minimum Benefits? Council for Medical Schemes

rescribed Minimum Benefits (PMBs) are a set of benefits that must be covered by every medical scheme as mandated by Section 29(1) (o) and (p) of the Medical Schemes Act (No. 131 of 1998). Medical schemes must fund the diagnosis, treatment and care of PMB conditions in full, without imposing co-payments or using deductibles from a risk pool. The medical savings account may not be used to fund PMBs as mandated by Regulation 10(6). Entitlement to PMBs is not subject to patient plan options or benefit types.

What is covered under PMBs? PMBs cover the following most serious and often life-threatening conditions: • Any emergency medical condition as per the definition in the Regulations • 270 diagnostic treatment pairs (DTPs) • 26 chronic conditions on the chronic diseases list (CDL). Although PMBs must be funded in full, the Medical Schemes Act allows medical schemes to use certain measures to manage their finan cial risks that are often associated with the unpredictable health needs of their members. It is extremely important to understand the implications of these measures to avoid co-payments being imposed on members.

Financial measures allowed to manage costs related to PMBs Designated service providers Designated service providers (DSPs) are health care providers, such as doctors, specialists and hospitals, who have entered into agreements with medical schemes to provide their services to the members of such medical schemes at a negotiated price. Each medical scheme has its own DSPs and using the correct DSP for PMBs guarantees members that their scheme will cover PMB conditions in full (at cost). In cases where a DSP is accessible and available but voluntarily not utilised by the member, the medical scheme may charge a co-payment as specified in the particular medical scheme’s rules.

Medicine formulary A medicine formulary is a list of medica tions that the scheme is willing to fund 14

JULY 2016

SAMA INSIDER

for the treatment of PMB conditions. These formulary lists must be developed using evidence-based medicine and costeffectiveness. Formularies are often plan or benefit specific and must be accessible to the members of the scheme at request. If a member voluntarily chooses to use medicines not listed on the formulary, the medical scheme may charge a co-payment as specified in the medical scheme’s rules. In instances where the formulary medicine has proven to be ineffective or causes harm or an adverse reaction to a member, provision must be made for appropriate exceptions or substitution without any penalty to the member (Regulation 15I (c)).

Managed healthcare protocols Managed healthcare protocols must be developed using evidence-based medicine and must take into consideration costeffectiveness and affordability. Medical schemes must provide their protocols to healthcare providers, beneficiaries and members of the public on request. In instances where the formulary medicine has proven to be ineffective or causes harm or an adverse reaction to a member, provision must be made for appropriate exceptions or substitution without any penalty to the member (Regulation 15H (c)).

What doctors can do to ensure access to PMBs is not delayed Doctors must adhere to clinical guidelines and protocols, as well as formularies in the management of medical conditions. • They need to write comprehensive, clear and legible clinical notes and dis charge summaries. A good clinical record is a valuable asset that assists in the adjudication of complaints and other medico-legal matters. This includes letters of motivation, discharge summaries and prescriptions. • They need to understand the coding systems and adhere to appropriate use of ICD-10 and procedure codes and modifier codes. SAMA provides coding courses from which providers and administration companies can benefit. The course should be based on the National Reference Price List (NRPL) of 2006.

What are the common mistakes committed by doctors in motivating for PMBs? • Not documenting a full clinical history and findings at examination and treatment with the appropriate codes. • Non-adherence to clinical guidelines and protocols, bearing in mind costeffectiveness, affordability and scientifi cally sound and prevailing level of care in the public healthcare sector.

Complaints process Within a medical scheme The Council for Medical Schemes (CMS) governs the medical schemes industry and therefore member complaints should be related to the member’s medical scheme. Any beneficiary or any person who is aggrieved with the conduct decision of a medical scheme can submit a complaint. It is very important to note that a prospective complainant should always first seek to resolve complaints through the complaints mechanisms in place at the respective medical scheme before approaching the CMS for assistance. Members can contact their scheme by phone or, if not satisfied with the outcome, in writing to the principal officer of the scheme, giving her/him full details of their complaint. If they are not satisfied with the response from the principal officer, they can ask for the matter to be referred to the Disputes Committee of their scheme. If members are not satisfied with the decision of the Disputes Committee, they can appeal against the decision within 3 months of the date of the decision to the CMS. The appeal should be in the form of an affidavit directed to the CMS.

Complaints to the CMS Complaints against medical schemes can be submitted by letter, fax, email or in person at the CMS office from Mondays to Fridays (08h00 - 17h00). The complaint form is available from www.medicalschemes.com Complaints should be in writing, detailing the following: • full names • membership number • benefit option

FEATURES

• contact details • full details of the complaint with any docu ments or information that substantiate the complaint. The CMS Customer Care Centre and Com plaints Adjudication Unit also provide tele phonic advice and personal consultations, when required. The CMS aim is to provide a transparent, equitable, accessible, expeditious, as well as a reasonable and procedurally fair dispute resolution process. Hence, the CMS will send written acknowledgement of a complaint within 3 working days of receipt, providing the name, reference number and contact details of the person dealing with a complaint. In terms of Section 47 of the Act, a written complaint received in relation to any matter provided for in this Act will be referred to the medical scheme. The medical scheme is obliged to provide a written response to the CMS within 30 days. The CMS shall within 4 days of receiving the complaint from the scheme or its administrator, analyse the complaint and refer the complaint to the relevant medical scheme for comments.

Upon receipt of the response from the medical scheme, the CMS will analyse the response in order to make a decision or ruling. Decisions and/or rulings will be made within 120 days of the date of referral of a complaint and communicated to the parties.

The registrar’s ruling and appeal to Council Section 49 of the Act makes provision for any party who is aggrieved with the decision of the registrar to appeal such a decision.This appeal is at no cost to either of the parties. An appeal must be lodged within 30 days of the date of the decision. The operation of the decision shall be suspended, pending review of the matter by the Council’s Appeals Committee. The secretariat of the Appeals Committee will inform all parties involved of the date and time of the hearing. This notice should be provided no less than 14 days before the date of the hearing. The parties may appear before the Committee and tender evidence or submit written arguments or explanations in person or through a representative. The Appeals Committee may, after the hearing, confirm or vary the decision or

rescind it and give another decision as they deem just.

The Section 50 appeal’s process Any party that is aggrieved with the decision of the Appeals Committee may appeal to the Appeal Board. The aggrieved party has 60 days within which to appeal the decision and must submit written arguments or explanation of the grounds of his or her appeal. The Appeal Board shall determine the date, time and venue for the hearing and all parties will be notified in writing. Appeal Board hearings shall be heard in public unless the chairperson decides otherwise. The Appeal Board shall have the powers which the High Court has to summon witnesses, to cause an oath or affirmation to be administered by them, to examine them, and to call for the production of books, documents and objects. The decisions of the Appeal Board are in writing and a copy thereof shall be furnished to parties. The prescribed fee of R2 000 is payable for Section 50 appeals. CMS Customer Care Centre: 0861 123 267 or

0861 123 CMS

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FEATURES

New book brings healthcare and business together SAMA Communications Department

new book by Dr Hlombe Makuluma – a medical practitioner and life and business effectiveness coach – is set to transform the way many healthcare practitioners setup and manage their health care practices. The Business of Healthcare: Managing your own Private Practice by Dr Hlombe Makuluma is a book that seeks to bridge the gap between health training and business training for all healthcare professionals operating a private practice or those intending to open one. “ What challenged me to write this book was a desire to help others start their practices or improve on what they had. I presented many seminars on the subject and what was intriguing was that many doctors, especially older doctors, would come to me afterwards and say ‘I wish we had heard this years ago because our practices would be more successful than they are now’,” says Dr Makuluma. After spending years studying medicine, many health practitioners decide to start private practices but find the process of getting the business off the ground daunting and frustrating. The business aspects of operating a private practice do not form part of the training curriculum for health practitioners and they start their own businesses through trial and error.

In the book, Dr Makuluma explores the life stages of a private practice, from concep tualisation through to the stage where it can operate without the daily inputs of the practice owner. “I believe that through this book, I dispel the myth that operating a health practice as a business denigrates the professionalism of the health practitioner. I think it shows how one can balance professionalism with the delivery of quality healthcare, and business interests,” explains Dr Makuluma.

JULY 2016

SAMA INSIDER

• How to increase the value of the practice through the development of systems that enhance the saleability of the business.

Dr Hlombe Makuluma The Business of Healthcare is written in eight chapters and covers a range of issues: • The business of health practice • The foundation • Growing your practice into a business • Monitoring and measuring practice per formance • Promoting a health practice • Health practice business systems • Leadership for a health practice • Positioning for the future. “I’ve really tried offer a step-by-step guide to practitioners to ensure the sustainability of their businesses, not only in the short term but into the future as well,” says Dr Makuluma. He says that through the book he hopes to help practitioners learn and understand important principles that will guide them through opening a practice. These include: • The importance of setting up a practice as a registered business and the pros and cons of different business structures. • Strategies for promoting a healthcare practice into profitability. • Various approaches to create more time for the practitioner without losing revenue from the practice. • How to manage the financial and human resources of a practice. • Leadership approaches that will lead to the business generating passive income for the owner.

“So far the feedback from the seminars I have presented, that are based on the book, has been phenomenal. I want to help practitioners out there maximise their business potential and I believe through this book they will gain the knowledge to take their practices to the next level,” Dr Makuluma concludes. Dr Hlombe Makuluma obtained his BSc in Biochemistry and Microbiology from the University of Fort Hare in 1991. In 1996 he completed his MB ChB at MEDUNSA. In 2001 he completed the Advanced Management Programme from the Manchester Business School and 10 years later obtained his MPhil (Sustainable Development Planning and Management) from Stellenbosch University.

A book that seeks to bridge the gap between health training and business training In 2013 Dr Makuluma obtained two certificates in coaching; the first a certificate in Business Coaching, and the second a certificate in Executive Coaching. Currently Dr Makuluma operates his own business in Pretoria offering coaching services where he specialises in working with health practitioners operating their own private practices. Apart from this, Dr Makuluma conducts seminars and workshops on the different aspects of operating and managing a health practice, which was the seed from which his book grew. For more information on The Business of Healthcare: Managing your own Private Practice by Dr Makaluma, send an email to healthpracticebook@gmail.com, or call Dr Makuluma directly at 082 853 7823. The book sells for R200, excluding postage.

FEATURES

Ransomware: Protect your business now! Gert Viljoen, VPROF

ybercrime is always in the news these days, mainly because more and more companies are affected by it. Lately, ran somware has been the preferred weapon of scammers.

How does it work? Typically, one of your employees gets an email with an attachment and as soon as the attachment is opened ransomware begins encrypting files and shuts down your computer systems, or a crucial part of your business. Emails aren’t the only threat – increasingly, infected popups and links to fake websites are being used. You then receive a ransom email demanding payment in either bitcoins or via an EFT within 48 hours. If the amount is not paid immediately, then the amounts are escalated by the cyber criminals. As regards the quantum of the ransom, in two recent cases R25 000 was demanded. Sometimes a nominal payment will be requested at first, followed by further (and larger) demands once you pay up. When the ransom is paid, you are supposedly given passwords to restore your computer operations. In many cases, however, you are not given passwords even after you cough up the cash, and you are then open to continuing extortion – making it inadvisable to pay the ransom. Businesses have responded to this by instructing all staff to delete any unfamiliar emails that contain attachments. In response, cyber criminals upped the ante by getting profiles of senior executives and

sending “management emails” to staff instructing them to follow what is contained in the attachment. Thinking the email came from a senior executive, the staff member would open the attachment. Immediately, the ransomware kicks in.

How to protect your business Using up-to-date antivirus software with a firewall is a must and many businesses have encrypted their sensitive information. Educate and instruct staff not to open links in emails or email attachments, not to visit suspicious websites, to keep antivirus software fully updated, and to disconnect from the internet immediately if anything suspicious happens. There are also reports of scammers using popups so make sure everyone uses a reliable popup blocker. Circulate the FBI’s latest eight-point protection list in FBI warns the public about ransomware internet scam on their website: https://www.fbi.gov/sanjuan/pressreleases/2016/fbi-warns-the-public-about-ransomware-internet-scam. Most important is to do daily backups. If you get infected then the most you can lose is a day’s worth of transactions, which can be quickly recaptured. In the above cases where R25 000 was demanded by cyber criminals, the businesses used backups to restore their systems and didn’t pay ransom. Be vigilant, back up and use the latest antivirus software. Remem ber, technology keeps changing and so will cyber criminals.

King IV corporate governance code may apply to you

he King reports over the last 2 decades have become locally and globally synonymous with good governance. To date, the King Codes have had limited impact on small and medium enterprises (SMEs). It is important to note that the King Codes are voluntary. In terms of the latest King IV Report (it has been released for comment and will only be final once all comments have been considered), supplements have been released for various types of organisations to report on corporate governance. One of these supplements applies to SMEs.

How does King IV define an SME? A company with at least 350 points in terms of the Companies Act’s Public Interest Score calculation is considered an SME. The points are a combination of turnover (1 point per R1 million), employees (1 point per employee), third-party liabilities (1 point per R1 million) and shareholders (1 point for each shareholder). Therefore King IV seems to be looking more at medium-sized entities than at smaller ones.

Why adopt these codes if they are voluntary? Over the long term there is a strong link between sustainability and good gover nance. For example, good governance can help with getting access to finance and a well-governed organisation will outperform the market in the long term.

What do the codes require? The starting point is good ethical leadership – if an organisation has this, it invariably practises good governance – and thus the board of directors must lead in a responsible, transparent and fair way. This foundation should apply to all busi nesses as the ethos of a business is usually defined from its early beginnings. The composition of the board of directors should ensure it has the skills and indepen dence of thought to effectively manage, control and report on its performance. In order to ensure adequate control, the codes envisage that the board will govern: • risk and opportunity • technology and information • compliance with all laws

• fair remuneration policies • good stakeholder relationships • assurance that adequate control and reporting integrity are in place.

Proportionality When implementing practices to comply with the King IV Report, the size of the organisation will dictate the resources to allocate to the codes. Therefore while a large company will have, for example an audit and risk committee, your medium-sized company may allocate say 25% of a director’s time to meeting the requirements set out in the Report. It is up to each organisation to use its judgement.

Disclosure In your organisation’s annual report, there should be a section on how it is implementing the Report. Some templates are provided for in the King IV Report but these are not prescriptive. Good governance makes commercial sense in the long run, so it is worth taking stock of where your business stands on this issue. SAMA INSIDER

JULY 2016

MEDICINE AND THE LAW

Patient confusion: Patient claim Medical Protection Society

rs S, a 77-year-old woman whose past medical history consisted of a previous hysterectomy for benign fibroid disease, presented to her general practitioner (GP) with a history of intermittent haematuria. Her GP recognised the potential seriousness of this symptom and made an urgent referral to a consultant urologist, Dr F. Dr F arranged an intravenous urogram followed by a CT scan, which suggested a tumour in the left distal ureter. Mrs S was advised that this was highly suggestive of carcinoma and required surgical removal. However, Dr F arranged a biopsy of this mass via an ureteroscopy, which was reported as inconclusive, containing insufficient material to make a definitive diagnosis. A repeat biopsy was recommended by histology. There was nothing documented within the records to show that the implications of the same were discussed with Mrs S.

All medical practitioners must make time to ensure their patients fully understand all aspects of their management Dr F proceeded with left radical nephro ureterectomy, a decision supported by the local colleagues after a clinical review

meeting. During surgery Mrs S was found to have a 5 cm tumour and a sigmoid colon adherent to the pelvic side wall due to multiple adhesions from her prior surgery. The histology of the nephro-ureterectomy specimen showed no evidence of malignancy with endometriosis in the ureteral wall and lumen. This was communicated to Mrs S who felt that she had been misinformed as to the purpose of the surgery (as she had never had cancer). Unfortunately the postoperative recovery was complicated by a colovaginal fistula, and Mrs S had to go back to theatre for an emergency laparotomy and Hartmann’s procedure. After this, Mrs S developed an incisional hernia, which was repaired along with a reversal of the Hartmann’s 1 year later. Mrs S indicated an intention to bring a claim stating that she had undergone surgery based on a false premise. She alleged that she would have requested a repeat biopsy (as recommended on the biopsy findings within the records), which would have come back negative for malignancy and thus she would never have agreed to surgery. The expert opinion on the case indicated that it was reasonable for Dr F to perform an initial ureteral biopsy, but that it must be recognised (and should have been made clear to the patient) that often such biopsies are not diagnostic. Therefore repeating the biopsy may not have revealed any further information. The expert was also of the view that the clinical review meeting’s decision to proceed to radical nephro-ureterectomy was justifiable, even if the true diagnosis of endometriosis had been made. Due to the location and size

of the mass radical surgery would still have been warranted. Medical Protection set out their expert evidence and indicated they would defend Dr F in the event a formal claim was commenced. The case was not subsequently pursued.

Learning points • Communication and documentation is vital. Had the specific purpose and limitations of the biopsy been explained clearly to Mrs S at the outset, and the options for further management discussed thoroughly, she might not have brought the claim. • As with many claims, the claimant did not sue based on the outcome of the surgery but rather because of lack of communication and correct information. • All medical practitioners must make time to ensure their patients fully understand all aspects of their management.

Letters to the Editor

he Letters to the Editor page aims to give members the opportunity to comment on, query, complain or compliment on any matter, topic, incident, event or issue in their particular field or with regard to general healthcare, which you feel should be shared with your colleagues and fellow readers. Please note that letters: • should be no longer than 300 words • can be published anonymously, but writer details must be submitted to the editor in confidence • must be on subjects pertinent to healthcare delivery • should be submitted before the tenth of the month in order to be published in the next issue of SAMA Insider. Please email contributions to: Diane de Kock, dianed@hmpg.co.za

JULY 2016

SAMA INSIDER

BRANCH NEWS

Ask the sexperts SAMA Communications Department

he SAMA Gauteng Branch, in partnership with Bayer Health, held a very informative and educational CPD workshop on Saturday 11 June 2016 from 09h00 to 16h00 at Discovery Health Head Office in Sandton. The event was entitled a “Sexual Health Work shop” and was well attended by 54 general practitioners and specialists. Practical case studies kept the speakers engaged. The programme began with a talk on male sexual dysfunction by Dr Etienne Kok which was followed by specialist urologist Mr Corne van Graan on benign prostatic hyperplasia, prostate cancer and robotic surgery. A very informative presentation was given by Prof. Riana Bornman on endocrine disrupters and the effect on the human reproductive system. Dr Elna Rudolph enlightened the audience about menopause and hormone replacement therapy. After a nutritious and delicious lunch Marli Smit from SAMA Head Office discussed the ethical dilemmas relating to doctors and social media. Always quite controversial, the topic of testosterone replacement therapy was addressed by Dr Bhana. Glenn de Swardt from

Raffle prize winners reminding practitioners about the importance of the digital rectal examination.

Workshop delegates. Anova ended the programme by providing practitioners with some useful tips to make their practices lesbian, gay, bisexual, transgender and intersex friendly. The day ended with an exciting raffle with giveaway tickets to the SAMA conference, the GP Specialist Indaba, Sexpo, Body World Exhibition, movies and some hampers.

Kalli Spencer (Branch Chairperson), Marli Smit (SAMA Legal Advisor), Shirleen van Zyl (Bayer Brand Manager) and conference speakers Riana Bornman and Etienne Kok.

SAMA Gauteng AGM 2016

he SAMA Gauteng branch held its AGM on 25 May 2016. The event, held at the Department of Surgery at the University of the Witwatersrand Medical School, was well attended by branch members. It presented a great opportunity to reflect on the happenings of the past year. Prof. Lionel Green-Thompson was inaugurated as the branch president for 2016. The AGM is an opportunity to honour the branch’s life members. The Life Members recognised were: Dr Davis, Dr Friedland, Dr Garb, Dr Greenblatt, Dr Gritzman, Dr John, Dr Katz, Dr Mistry, and Dr Skudowitz. Drs Davis, Friedland and Mistry were present to receive their certificates. The evening concluded with two speakers: Mr Connie Bezuidenhout did a presentation on Customer Centricity which focused on what patients expect from their doctors; this was followed by Dr Kgosi Letlape, the President of the Health Professions Council of South Africa (HPCSA) who presented on “The Future of the HPCSA”.

Prof. Green-Thompson, Dr Spencer, Dr Letlape, Prof. Dhai.

Life Members: Dr Davis, Dr Mistry, Dr Friedland.

Dr Kalli Spencer and Prof. Lionel Green-Thompson.

SAMA INSIDER

JULY 2016

BRANCH NEWS

Health Minister Aaron Motsoaledi joins Eastern Province branch for NHI workshop Dr James Burger

ational Health Insurance (NHI) is not a concept without its fair share of controversy among doctors. While a large number of doctors acknowledge the extensive flaws in our current system, many have expressed their concerns about South Africa (SA) taking on such large-scale reform in its health system, either publically or in the pseudo privacy of their tea rooms. On 19 May, the SAMA Eastern Province Branch held a workshop on the NHI with Health Minister Dr Aaron Motsoaledi. Despite the airlines trying their best to put a spanner in the works, the minister managed the trip to the Bay to engage with our members on the future of SA healthcare. It is no easy feat to keep a full house of doc tors in their seats for the best part of 3 hours, but the audience remained captivated by the impressive orator, many of us taken with both his ability to deliver the crux of the extensive information, as well as his healthy sense of humour. The talk covered the most pertinent information on the NHI plan, discussing our current situation, a background to the solution, and general plans for moving forward. The SA healthcare system is an outlier in its design. Modelled very similarly to the American system, we have found ourselves in a very expensive and unsustainable position. The minister noted different but extensive problems in both private and public sectors, with a marked needs-benefit mismatch and exorbitant costs in health necessitating a shift in our system. Often referred to as the third global health transition, universal health coverage is not a new concept; a point emphasised by the Minister while he was providing background to the NHI. The NHI is a health financing system that pools funds to provide access to quality health services for all South Africans based on their health needs and irrespective of their socioeconomic status. This redesigning of the system is the only way for us to guarantee universal health coverage, which is one of the Sustainable Development Goals. He pointed out four key areas in the public sector where improvement is imperative: human resources, financial management, procurement/supply chain, and infrastructure. While acknowledging these problems, the Minister showed selected results from studies 20 JULY 2016

SAMA INSIDER

Minister Motsoaledi speaking to a captivated audience. Photograph courtesy Die Burger.

From left: Prof. C Grobler, Dr L Pepeta, Mariana Johnstone and Dr K P Tabata. auditing the NHI pilot districts that were analysed with the Infrastructure Optimisation Tool Kit. His understanding of the problems on the ground and willingness to provide practical and appropriate solutions were refreshing to see. Work streams of the NHI have been allocated various task teams of professionals in order to develop a strategy appropriate and affordable for SA. The NHI will, therefore, be tailored to our unique requirements, while remaining cognisant of our limited resource availability. One must commend the Minister on the way in which he left the audience feeling calmer and more confident about our way forward. The notion that there is a plan in place and that these teams of competent individuals are being formed in order to ensure success was well received by the audience.

Back row, left to right: Dr M M Tebelele, Dr J Basson, Dr J Burger, Dr O A Olubiyi, Dr F Khan. Front row: Dr L Pepeta, Minister of Health Dr P A Motsoaledi, Dr K P Tabata, Dr S Pillay and Prof. C Grobler. We thank the Minister for his time and for the renewed confidence that he instilled in our members. Thanks too for the hard work by our ever impressive branch secretary, Mariana Johnstone, in organising such a smooth and beneficial evening.

News from Free State branch

t is with regret that we accept the resignation of Dr E Motloung as honor ary secretary of the Branch Council. We wish him good luck with his studies and hope all will go well.

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HOW TWO SURGEONS ARE SAVING NOT JUST LIVES, BUT AN ENTIRE SPECIES.

2012: Two equine surgeons, Doctors Johan Marais and Gerhard Steenkamp, are called upon to use their training and skills to save the lives of rhino that have been horrifically mutilated by poachers. They realise that their expertise could bring new hope to the rhino poaching crisis. And so the Saving the Survivors project is born. It is a project that saves between 80 and 120 rhino every year. Johan and Gerhard are PPS members whose compelling story reveals once again just how unique a breed, graduate professionals are, and how much value they bring to the world. Thatâ&#x20AC;&#x2122;s why at PPS we pride ourselves on understanding the world, needs and wants of graduate professionals, and tailoring solutions to their needs. And why weâ&#x20AC;&#x2122;ve excelled at it for 75 years.

For more inspirational stories like this, visit pps.co.za

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