SAMA Insider - 2015 Mar by HMPG

SAMA

INSIDER

MARCH 2015

Steve Biko auction: SAMA weighs in SARA AGM 2015

PUBLISHED AS A SERVICE TO ALL MEMBERS OF THE SOUTH AFRICAN MEDICAL ASSOCIATION (SAMA)

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SHORT COURSE IN CLINICAL MANAGEMENT OF HYPOTHYROIDISM Hypothyroidism can affect a patient in several aspects and should be treated appropriately once it has been diagnosed. Symptoms of hypothyroidism are non-specific or the patient may even be asymptomatic, it is thus important to make a correct diagnosis before treatment is started as it will be chronic medication. It can also be dangerous if thyroid medications are taken when not needed. COURSE CONTENT This course covers the following modules: » » Epidemiology of thyroid » diseases; » » Thyroid anatomy; » Thyroid physiology; » » Thyroid hormones synthesis, metabolism and secretion; » » Etiology of hypothyroidism; » Risk factors for thyroid disease; » » Clinical presentation of hypothyroidism;

Diagnosis of hypothyroidism; Treatment of hypothyroidism; Complications associated with untreated hypothyroidism; Other conditions associated with hypothyroidism; Screening of patients for hypothyroidism and Aim of treatment for hypothyroidism.

SHORT COURSE IN FERTILITY MANAGEMENT This training manual is part of the FPD online training programme for doctors. It is based on the Merck Training Programme and is designed to assist doctors with understanding Fertility and also to know when to refer for fertility problems. COURSE CONTENT

SHORT COURSE IN ICD 10 CODING (DISTANCE) The implementation of the ICD-10 diagnostic coding in the healthcare environment took effect on 1 January 2005. The National Department of Health and the Council for Medical Schemes support this implementation of ICD-10 in the public and private health sector. It is a diagnostic standard that is accepted by all the parties as the diagnostic coding standard of choice for South Africa. As per the regulations of the Medical Scheme Act (published in Government Gazette No 20556 on 20 October 1999), all providers of healthcare such as hospitals, doctors, allied professionals, etc is required to make use of ICD-10 codes. ICD-10 has become the international standard for the generation of health statistics, allowing relative comparison across countries. This publication comprises of three volumes, which provide the basic tools for coding. Each volume has rules and guidelines to assist the user in reporting conditions in a standard an uniform format. ICD-10 operates in conjunction with other procedural and billing coding systems and replaces the “traditional” diagnosis with a code. WHO SHOULD ENROLL? All healthcare practitioners working in the clinical field. CONTENT The course is offered as a distance learning programme. Participants who enrol will receive a customised manual specially developed for distance learning. The comprehensive and user-friendly manual was developed by experts in the field. It includes practical exercises and all course content can be used as a reference source for coding queries. This manual is to be used in conjunction with International Statistical Classification of Diseases and Related Health Problems Tenth Revision (ICD-10) – Volumes 1, 2 and 3. (© Copyright World Health Organisation) This course will cover the following modules: » Background to ICD-10 coding » Benefits of clinical coding » Basic structure and principles of ICD-10 coding » Rules and conventions of ICD-10 coding » Accuracy in coding » Practical applications

This manual is divided into 4 Sub-modules: » Anatomy of Male and Female » Fertility Overview; Reproductive System; » Infertility Cause and » Physiology of Human Reproduction; Treatment Option ACCREDITATION Accredited according to the HPCSA CPD Guidelines for Health Professionals - November 2006, for 3 CEUs. COURSE FEE

ACCREDITATION Accredited according to the HPCSA CPD Guidelines for Health Professionals - November 2006, for 27 CEUs on level 2.

Access to this course is free for SAMA members. Non SAMA members: R456.00 Inclusive of all VAT & Taxes where applicable. This includes all study material & assessment.

COURSE FEES R 880.00 This amount is inclusive of all vat and taxes where applicable.

REGISTRATION

Tshepo Gaofetoge Tel: 012 816 9100/9101 Fax: 086 558 5433 Email: melanym@foundation.co.za Address: P.O. Box 75324, Lynnwood Ridge, 0040 Website: www.foundation.co.za

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SHORT COURSE

SHORT COURSE IN THE CLINICAL MANAGEMENT OF ALLERGIES The prevalence of allergy is increasing worldwide, particularly in urbanised communities. Asthma is thought to occur in at least 1 in 10 people, and allergic rhinitis may occur in 1 in 5, irrespective of race or socio-economic status. Therefore, all family practitioners, irrespective of which communities they serve, will probably see patients with hay fever every working day. In many instances the diagnosis is made easily, but sometimes the diagnosis is difficult to make and investigations will help to confirm the diagnosis of allergy and the attendant inflammatory airway disease. The wide range of allergy tests available requires a logical approach to selecting the most cost effective and appropriate test for each individual.

ACCREDITATION

DATE 14 – 15 March 2015 5 – 6 June 2015 25 – 26 July 2015

VENUE Pretoria Port Elizabeth Durban

COURSE CONTENT

COURSE FEE Pretoria Durban Port Elizabeth

Tshego Mathabathe / Zelvodean Lowting Tel: 012 816 9094 Fax: 086 502 5688 Email: tshegofatsom@foundation.co.za zelvodeanl@foundation.co.za

R 3 990 (VAT incl.) R 4 900 (VAT incl.) R 4 900 (VAT incl.)

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This course covers the following modules: » Allergic disease; » Systemic allergy and » Respiratory allergy; » Food allergy and intolerance. » Skin allergy; A member of SAIHCM

Accredited according to the HPCSA CPD Guidelines for Health Professionals November 2006, for 30 CEUs on level 2. (Workshop: 12 CEUs, Assessment: 18 CEUs)

Foundation for Professional Development (Pty) Ltd, Registration number 2000/002641/07 Registered with the Department of Education as a Private Institution of Higher Education under the higher education act, 1997. Registration number 2002/HE07/013

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A member of the SAMA Group

MARCH 2015

CONTENTS

“In Flight” – Dr Riaz Ismail

EDITOR’S NOTE An elephant called Race

Compensation for injuries and diseases contracted at the workplace

Conrad Strydom

Mpotlana Daniel Madiba

FROM THE PRESIDENT’S DESK Transforming our academic health service complexes

Things we need to know about unfair suspension

Wandile Mphahlele

Prof. Lizo Mazwai

FEATURES 6 Steve Biko: Selling a post mortem, or a legacy?

Marli Smit

SAMA GPPPC proposes solution to Discovery’s forensic investigations

SAMA Private Practice Department

SARA AGM calls for changes in higher education

Conrad Strydom

Latest development in public service salary negotiations for 2015/16

Mpotlana Daniel Madiba

The progress of the ‘Ideal Clinic’ project in South Africa

Bernard Mutsago

Tips for running a successful journal club

SAMA Governance and Legal Department

MEDICINE AND THE LAW The elusive diagnosis

Medical Protection Society

GENERAL NEWS

Alexander Forbes

Herman Steyn 012 452 7121 / 083 389 6935 | steynher@aforbes.co.za Oﬀers SAMA members a 20% discount on motor and household insurance premiums.

Automobile Associa6on of South Africa (AA)

AA Customer Care Centre 0861 000 234 | kdeyzel@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 LeboM@bwmr.co.za Barloworld Retail Digital Channels oﬀers compeRRve pricing on New vehicles; negoRated pricing on demo and pre-‐owned vehicles; Trade in’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 enRtles 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 accommodaRon and extras. Claim your membership at www.legacylifestyle.co.za/SAMA, all you need is your mobile number to earn or redeem rewards. Travelling SAMA members can book their travel online or speak with our concierge service at Travel By Lifestyle (www.travelbylifestyle.co.za) Legacy Lifestyle, the rewards you’ve earned will pay for the Lifestyle you deserve.

Medical Prac6ce Consul6ng

Werner Swanepoel 0861 111 335 | werner@mpconsulRng.co.za 20% discount on assessment of PracRce Management ApplicaRons (PMA) and Electronic Data Interchange (EDI) systems. SAMA and Merck Serono are offering SAMA members a first-‐of-‐a-‐kind and FREE FPD online CPD courses on FerRlity and Hyperthyroidism on www.mpconsulRng.co.za. Each course is worth 3 CPD points. The benefit is a saving of R465.00 per member per course.

Medport

Shelly van Dyk

087 550 1715 | support@sosit.co.za A personalised portal website; an opRonal public webpage to make their services known (Private PracRce); access to a HPCSA accepted CPD Manager; a consolidated e-‐ mail account; online data storage space; unique applicaRons to manage their medical career; addiRonal applicaRons to download onto your portal page; easier and user friendly access to the internet; lisRng of your Private PracRce on the SAMA Geomap Directory.

EDITOR’S NOTE

MARCH 2015

An elephant called Race

T Conrad Strydom Editor: SAMA INSIDER

Editor: Conrad Strydom Head of Sales and Marketing: Diane Smith Production Editor: Diane de Kock Editorial Enquiries: 012 481 2041 Advertising Enquiries: 012 481 2069 Email: conrads@samedical.org

here’s an elephant in the room and it is getting restless. It is never quite missing from the corners of one’s eyes, yet the medical profession has so far managed a masterclass in ignoring it. The large-bodied pachyderm in question is none other than the racial divisions that continue to exist in South African medicine. At the recent annual general meeting of the South African Registrars Association (covered on pages 9 and 10 of this issue), a frequent topic was the issue of black registrars being intentionally failed during oral exams. The topic has been discussed regularly at every meeting of SARA that I have ever attended and seems to indicate a persistent legacy of racism at some of our country’s most renowned medical schools. With every single black registrar being failed at certain institutions, isn’t it time for the Colleges of Medicine or the Health Professions Council of South Africa to take these allegations seriously? While places like Tuks, Wits, UFS and Stellenbosch have done a good job of transforming themselves during the last 20 years of democracy, they were pillars of the establishment during apartheid and elements of rot necessarily remain. This issue also focuses on the troubling recent fiasco surrounding an auction of Steve Biko’s post-mortem report (page 6) as well as helpful information for doctors in the public sector courtesy of SAMATU’s Daniel Madiba and Wandile Mphahlele (pages 12 to 14). Our resident health policy researcher, Bernard Mutsago, also takes a look at the health department’s recent ‘Ideal Clinics’ initiative on page 16.

Design: Health & Medical Publishing Group (HMPG) Block F, Castle Walk Corporate Park, Nossob Street, Erasmuskloof Ext 3, Pretoria Published by the Health & Medical Publishing Group (HMPG) www.hmpg.co.za | publishing@hmpg.co.za | Printed by Creda Communications

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.

Mercedes-‐Benz South Africa (MBSA)

Lebo Selumane 012 677-‐1855/082 412 7229 Lebogang.matlhare@daimler.com Mercedes-‐Benz offers SAMA members a special benefit through their parRcipaRng dealer network in South Africa. The offer includes a minimum recommended discount of 3%. In addiRon SAMA members qualify for preferenRal service bookings and other aeer market benefits.

MTN Service Provider

Oswin LoPering Melissa Adriaanse 083 222 1954 083 212 3905 Lofer_o@mtn.co.za Adriaa_m@mtn.co.za We are pleased to oﬀer SAMA members 18% discount. The discount however only applies to new addiRonal contracts and also when the user is due for upgrade. Discount will not apply to InternaRonal Roaming and Dialling, SMS’ and Data packages. Please note that this is extended out to the family and the discount is on VOICE packages only as well. Monthly Service Charge: less 18% (eighteen percent) discount. Usage Charge: less 18% (eighteen percent) discount (excluding internaRonal calls, internaRonal roaming, SMS, MMS and data Usage Charges).

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.

SOSiT

Shelly van Dyk 087 550 1715 | support@sosit.co.za 20% discount on InformaRon Technology support and a 24/7 callout service.

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 083 2764 317 | gert@vprof.co.za 10% discount on medical pracRce bureau service through V Professional Services.

Vox Telecom

DJ Viergever 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.

FROM THE PRESIDENT’S DESK

Transforming academic health service complexes “Cognizant of the emphasis on primary health care and community-based education, the training of medical professionals in South Africa should take place at all levels of healthcare, not just at tertiary training hospitals”

Prof. Lizo Mazwai, President, SAMA

he concept and definition of an Academic Health Service Complex (AHSC) came about in 1997, after a National Health Commission committee chaired by Prof Jagidesh (Jack) Moodley (on which I served) looked at some of the implications of the transformation in healthcare going pari-passu with reforms in education for health professionals. A m o n g t h e c o m m i t t e e ’s m a n y recommendations was that, cognizant of the emphasis on primary healthcare and community-based education (CBE), the training of medical professionals in South Africa should take place at all levels of healthcare and not just at the tertiary training hospitals as had been the practice for decades. Hence each of the country’s eight medical schools had to establish their own academic health science centres (AHSCs) based in their provinces and were also obligated to support adjacent ones without medical schools. The challenges brought about by problembased learning (PBL) and CBE had implications on the model and mode of delivery of education and training in the respective medical schools who, with the exception of Unitra (the former University of Transkei, currently Walter Sisulu University), were still following the old traditional curriculum. Chief among these were structural changes to make accommodation for small group tutorials, new audio-visual aids and more seminar rooms to replace the oldfashioned lecture theatre. Furthermore, there was a need for the introduction of more staff as tutors and facilitators. It was determined

that the academic staff also needed more contact time with their students, not only to facilitate teaching but also for the frequent formative and summaries assessments. Overall, this transformation turned out to be extremely labour-intensive and a very expensive drain on institutional funds. Consequently many of the medical schools were slow on the uptake. Part of the reason for the slow uptake was just the inherent inertia at the prospect of changing from the timehonoured centurial didactic lecture mode and model of delivery. When the University of Cape Town (UCT) finally adopted the new approach it was widely considered that Cape Town was going to produce a “new breed of doctors”. Yet this was the same mould of “Five-Star Doctor” that Charles Boelen from the World Health Organization ( WHO) had referred to in response to the Alma Ata Declaration of Health for All by the Year 2000 (for more information on this, refer to the Vol 23, December 2004 newsletter of The Network: Towards Unity for Health, a global health improvement collective). This doctor of the future, the so-called “Five-Star Doctor”, needed to fulfill at least

five essential functions. In short, these were: • To assess and improve quality of care in a comprehensive and integrated fashion • To make optimal use of new technologies in a cost-effective, ethical way for the benefit of the client • To promote healthy lifestyles and empower the community through skillful communication • To reconcile individual expectations and community needs, both in the short and long term • To engage in efficient team work in the health sector and socio-economic sectors influencing health. These projected functions have implications for the Department of Health (DOH) and any university who has to work closely in sharing their Service Delivery Platform as a teaching platform as well. This can only be realised through Joint Establishment Agreements with other institutions, hence the AHSCs have to be modified in their design structure to serve this dual function. The staff working at these centres will also have to serve a dual function as part of our contribution to the Alma Ata Declaration.

SA’s health education system (from the website www.southafrica.info) • About 1 200 medical students graduate annually. In some communities, medical students provide health services at clinics under supervision. Newly graduating doctors and pharmacists complete a year of compulsory community service in understaffed hospitals and clinics. • In an attempt to boost the number of doctors in the country, South Africa signed a co-operation agreement with Cuba in 1995. South Africa has since recruited hundreds of Cuban doctors to practise here, while South Africa is able to send medical students to Cuba to study. • South Africa believes the Cuban opportunity will help train the doctors it so desperately needs for the implementation of the National Health Insurance Scheme. • Other agreements exist with Tunisia and Iran, as well as between Johannesburg Hospital and Maputo Central Hospital. • The government has also made it easier for other foreign doctors to register here. • The Allied Health Professions Council of South Africa had 3 773 registered ‘complementary health’ practitioners in 2012.

SAMA INSIDER

MARCH 2015

FEATURES

Steve Biko: Selling a post mortem, or a legacy? Marli Smit, Legal Advisor at SAMA on behalf of the Human Rights, Law and Ethics Committee “The amnesty hearings revealed that the trouble started, not because Biko was confronted by affidavits implicating him or because he had confessed to any wrongdoing, but because he insisted on sitting on a chair.”[1] Adv George Bizos

mortem report will reduce the principles this great man lived by to a mere sale transaction awarding the highest bidder a delicate piece of our South African heritage. The information which was intended for dissemination, holds great value to South Africans and more so, to the family members of Mr Biko. In order to understand the injustice surrounding the sale of this post mortem report, we need to address a few key issues:

n December 2014 it was reported that the post mortem report of Steve Biko was put up for sale by an auction house. As can be reasonably expected, distress spanned from the family to the larger community. Although the High Court halted the sale of the report, this brought an untested area in ethics to the fore that will be discussed and debated by academics. After it became known that the Biko family had not been involved in the sale of the post mortem report, the frank and impersonal manner in which this sensitive document was made available for sale resulted in anger and disbelief. The questions that resounded around South Africa were passionate. Who were the people infringing the rights of Biko and his family? How could they justify their attempt to sell the post mortem report of one of South Africa’s most important freedom fighters? How could his struggle and legacy be demeaned to a mere advertisement by an auctioneer? Where was the dignity? Where was the respect? Where was the social conscience? Stephen Bantu Biko was a man who understood the principles of equality and mutual respect. He wanted his fellow countrymen to appreciate their own unique qualities and stand firm in the belief that each man is entitled to be treated equal, irrespective of his race, gender, age or class. Auctioning off his post

MARCH 2015

SAMA INSIDER

Who was Steve Biko and what importance does his post mortem report hold for South Africa and its people? Stephen Bantu Biko was born on 18 December 1946 in Ginsberg Township, Eastern Cape.[2] He was an activist who wanted to empower black people to look at themselves in a different light. His use of the famous slogan “black is beautiful” resonated with millions and gave rise to what would later be known as the Black Consciousness Movement. Through his actions, his defiance of the injustices of the apartheid regime and the belief that he instilled in his fellow black South Africans, Steve Biko became a beacon of hope to many. He believed in a future, brighter than anything which could be imagined at the time, where all South Africans would walk side-by-side on an equal basis towards a single goal… equality. How did the post mortem report fall into hands of non-family members? Biko’s post mortem was attended by Prof. Johan Loubser (then Chief State Pathologist) Prof. I W Simpson, Department of Anatomical Pathology at the University of Pretoria; Dr Jonathan Gluckman, Pathologist appointed by the Biko family; Prof. Neville Sydney Proctor, Anatomical Pathologist of the University of the Witwatersrand (at the request of Dr Gluckman) and Prof. LS de Villiers.[3] Dr Jonathan Gluckman handed the post mortem report to his then secretary, Ms Maureen Steele for safekeeping, since it was suspected that his offices had been bugged. He had also received numerous death threats at the time. When Ms Steele passed away, the report came

into the possession of her children. Whether they in turn sold the post mortem to the auction house or merely provided it to the auction house to sell on their behalf, is unknown.[4] Is it ethical to commodify and commercialise human data? Commodifying and commercialising human data by making it available to the highest bidder is not only unethical, it’s morally reprehensible.[5] When dealing with human data, we are presented with a scenario where a person’s Right to Human Dignity as contained in Section 10 of the South African Constitution, as well as their Right to Privacy as protected by Section 14 of the Bill of Rights, can be protected when infringed upon, provided that the person is alive and able to exert his/her rights in this regard.[6] However the extent to which these rights are applicable insofar as information of the deceased is concerned, has not yet been established. Is it ethical to deny someone and/or their family these rights in death? Human data applies to the individual, but should also extend to the dignitas of the individual’s family. Can we objectively commodify and commercialise a post mortem report without infringing the rights of the deceased and his family? It is imperative that we understand the extent to which these basic human rights envelop and protect not only data of living beings, but also those of the family of deceased persons. The fact that the Law of Persons in South Africa deems a deceased to have no legal rights or duties and thus, no capacities, creates a grey area pertaining to the highly personal information of the deceased. [7] However, certain protective measures do exist in the South African Law, in consideration of public health and out of respect for the dead and the deceased’s relatives. Among others, the handling and disposal of human detritus is regulated and the violation of a grave is considered a criminal offence. Under Roman-Dutch Common Law a deceased person’s heirs could institute an action for defamation of the deceased. Recognition of this principle in modern South

FEATURES

What is the effect of such commodification and commercialisation of human data? Family members of Mr Biko have strongly opposed the sale of his post mortem report, especially because it is being done for private gain by third parties. Nkosinathi Biko, CEO of the Steve Biko Foundation and son of the late Steve Biko, made the following statement: “The autopsy report of any deceased person is central to the dignity of the deceased. An action by an unrelated party that amounts to auctioning off national history for private commercial reasons fails the nation at the level of morality and decency, and certainly fails at honouring the memory of those who laid their lives down for that very nation.”[9]

The Steve Biko family and Foundation have confirmed that they want to preserve and display the post mortem report for all South Africans to further the legacy of the late activist. The Biko family is of the view that they have the right to display the post mortem report as a whole, or select appropriate sections thereof to be made available to the public. The fact remains that the only reason the report exists at all must be contributed to the decision by the Biko family to have their own pathologist present when the post mortem was conducted. It can therefore not be contested that they are, in fact, the true owners of this valuable document. Should the sale of this piece of South African heritage be allowed to proceed, we as a nation stand the risk of again failing to stand up for the rights which we obtained at such a high cost in human lives. Commodifying and commercialising human data in any shape or form should be

condemned and criminalised. In death, it is the memory of our lost loved ones that we cherish most. It is disrespectful, hurtful and immoral to take away the Biko family’s choice on how they want their loved one to be remembered. In essence, we should allow Mr Steve Biko to sit on a chair.

1. Google Cultural Institute accessed at https://www.google.com/culturalinstitute/ exhibit/steve-biko-the-inquest/AQqnVp5h?hl=en on 29/01/2015. 2. Steve Biko Foundation Press Release accessed at http://sbf.org.za/ resources/PRESS%20RELEASE%20- %20Update%20on%20the%20 Steve%20Biko%20Autopsy%20Report%20on%20Auction%20-%20 Legal%20Action.pdf on 29/01/2015.. 3. Steve Biko Foundation Press Release accessed at http://sbf.org.za/ resources/PRESS%20RELEASE%20- %20Update%20on%20the%20

Steve%20Biko%20Autopsy%20Report%20on%20Auction%20-%20 Legal%20Action.pdf on 29/01/2015. 4. “High Court halts auction of Steve Biko’s autopsy report” accessed at http://mg.co.za/article/2014-12-02-biko-family-files-interdict-to-stopauction-of-slain-activists-autopsy on 29/01/2015. 5. Steve Biko Foundation Press Release accessed at http://sbf.org.za/ resources/PRESS%20RELEASE%20-%20Update%20on%20the%20 Steve%20Biko%20Autopsy%20Report%20on%20Auction%20-%20

Legal%20Action.pdf on 29/01/2015. 6. The South African Constituttion, Act No. 108 of 1996. 7. Heaton J. The South African Law of Persons 4th Edition. 2012. 8. McKerron RG. Law of Delict. 7th ed. Cape Town: Juta & Co, 1972:183. 9. Steve Biko Foundation Press Release accessed at http://sbf.org.za/ resources/PRESS%20RELEASE%20-%20Update%20on%20the%20 Steve%20Biko%20Autopsy%20Report%20on%20Auction%20-%20 Legal%20Action.pdf on 29/01/2015.

African Law is however unlikely – the right to sue for defamation would be considered to have died with the deceased.[8]

Acknowledgements: I gratefully acknowledge the support, advice, time and willingness of Prof. Ames Dhai (Director: Steve Biko Centre for Bioethics, Adjunct Professor and HoD: Bioethics, Wits and Co-Chair: HREC, Editor: South African Journal of Bioethics and Law, Immediate Past President: SAMA) to collaborate with me on this article. Thanks go to Mr Gert Steyn (General Manager, SAMA) for his insight, suggestions and additions to the article. I also thank Adv. Yolande Lemmer (Company Secretary, SAMA) for editing the article and providing advice and support.

SAMA GPPPC proposes solution to Discovery’s forensic investigations SAMA Private Practice Department

he South African Medical Association (SAMA) remains concerned by the perpetual forensic investigations into the practice of some of our colleagues in General Private Practice. This occurrence has also led to a group of GPs in the province of Mpumalanga resolving to boycott servicing patients who are members of Discovery Health. SAMA’s national General Practitioners in Private Practice Committee (GPPPC) wishes to state categorically that the organisation distances itself from any form of corruption, or irregularities in the processing of medical aid claims and intentional criminal conduct. We are of the sentiment that the medical profession is a noble and reputable industry with the highest order of ethics and commitment. For this reason we encourage our members to observe at all times the prerequisite demands of effectively and efficiently managing their successful practices.

Following consultation with the affected parties the following salient points and facts were acknowledged: • The GPs expressed dissatisfaction with the methods and instruments used to investigate suspicious claims. • GPs regret being coerced to enter into agreements under duress by the signing of Acknowledgements of Debt (AOD). • GPS were not given sufficient time to assess information before committing to the AODs.

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• A number of meetings were held between the GPPPC and Discovery Health. As part of a solution moving forward the following agreedupon resolution is being implemented and doctors are advised to consider these points in their daily practices. • Discovery will be establishing a mediation process to deal with fraud-related matters. • The mediation process is aimed at creating an avenue for doctors who signed an AOD, and who feel that they were made to sign under

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duress, and those that feel they have been wrongly accused or overcharged. The affected doctors are advised to follow the mediation and arbitration process to have their matters reviewed. The review, mediation and arbitration process will be dealt with on a case by case basis. Arbitrators used will be independent mediation and arbitration professionals and will be nominated by the Association for Mediators and Arbitrators. This is to ensure that the process is both fair and transparent. The cost of arbitration will be carried by the party found to have been at fault as per the outcome of the arbitration process. Members are advised to use the SAMA legal team for advice when dealing with Discovery or other medical schemes when confronted with challenges of this nature. We would like to reiterate that the option is open to our members without any form of impositions.

SAMA INSIDER

MARCH 2015

FEATURES

SARA AGM calls for changes in higher education Conrad Strydom

Delegates to the SARA AGM addressed a number of issues related to the treatment of registrars at higher education institutions

he South African Registrars Association (SARA) held its annual general meeting at the Irene Country Lodge in Centurion on the weekend of 7 and 8 February. The occasion served as an opportunity for the association’s national executive committee members to report back on their activities during the past year and to elect new leaders for the 2015/16 term. SARA represents medical graduates who are training to become specialist doctors in the ever-unstable South African public health sector and is an interest group of the SAMA Trade Union. Outgoing SARA president Dr Ntsaki Masinga outlined many of the challenges facing registrars in South Africa in her chairperson’s report, citing an environment in which “the teaching landscape is unequal and academic excellence is the exception rather than the norm.” While SARA has provided input at most meetings of the Health Professions Council of South Africa’s (HPCSA) Post-Graduate Education and Training Committee, according to Dr Masinga the rate of change in medical higher learning institutions has been incremental at best. She also noted SARA’s eagerness to be a part of the exciting changes that the Department of Health has envisioned for the health service in terms of the National Development Plan 2030, but worried that registrars’ needs are often lost among the other challenges facing the public health sector. To effectively represent registrars,

some form of representation on university councils should be sought. Among the most potent challenges faced by SARA are the unacceptably high failure rates among specialists at both primary, intermediate and final exams; the discrepancy between the official higher education policies of the HPCSA and the actual policies of numerous universities; the lack of an independent complaints and standards body for the medical education sector; and the fact that examinations are often conducted with only one moderator. Another recurring gripe was the fact there is no standardised logbook method for registrars. Electronic logbooks were suggested as a possible solution since they will prevent a loss of documentation, although it was unclear how these logbooks could be procured. There was a general consensus that SARA’s new leadership should do its utmost to strengthen the association internally in order to maximise its effectiveness when negotiating with influential bodies such as the HPCSA and Colleges of Medicine of South Africa (CMSA). According to the SARA leadership in attendance, there has been little or no progress of late on issues of pressing relevance to registrars, such as installing cameras to monitor oral examinations, because provincial health departments and universities believe registrars have no real capacity to implement these measures.

“We must demand the transformation of the Colleges of Medicine, sooner rather than later”

After the NEC’s reports had been delivered, the meeting was addressed by SAMATU president Dr Phophi Ramathuba, who was accompanied by HPCSA ombudsman Dr Munyadziwa Kwinda. Dr Ramathuba elucidated the numerous issues facing registrars and the profession as a whole, citing the increasing frenzy for medical malpractice litigation. She assured the registrars that they were not the only segment of the health sector that was being taken advantage of, citing the need for increased advocacy on the part of doctors. According to Dr Ramathuba, the pass rates among black medical registrars demonstrate a clear bias on the part of examining bodies. “It is clear that these pass rates are being racially defined,” she said, “since not even a single black person is being passed in certain departments. How can it be that a black learner can get eight distinctions in high school and pass medical school but suddenly can’t pass registrar training? Obviously something fishy is going on at some of these institutions.” Dr Ramathuba urged the young doctors present to use the power of collective action to effect change in their environment. “We must demand the transformation of the Colleges of Medicine, sooner rather than later,” she said. “Who is supposed to regulate the Colleges of Medicine?” she asked HPCSA ombudsman Dr Kwinda. “On paper it is supposed to be the HPCSA, but no one seems to be able to provide clarity on this matter. Meanwhile, the CMSA make rash decisions without anyone holding them accountable.” SARA awards After a long day of reports and debates, the SARA delegates made their way to the library of the Irene Country Lodge for a gala dinner and awards function. The occasion served as an opportunity to present awards to new SAMA president Prof.

Dr Munyadziwa Kwinda, Dr Ntsaki Masinga, Dr Tebatso Boshomane SAMA INSIDER

MARCH 2015

FEATURES

New SARA leadership elected

SAMATU president Dr Phophi Ramathuba addressing the SARA AGM Lizo Mazwai and one of our country’s most respected research scientists, Prof. Mike Sathekge of Tuks’ Nuclear Medicine Department. Prof. Mazwai received an award for his outstanding contribution to health education in South Africa, which has included a long history of service in academia, while Prof. Sathekge’s contribution as one of the most well-known researchers in his

The South African Registrars Association (SARA) elected a new leadership corps at a recent AGM in Centurion. Outgoing chairperson Dr Ntsaki Masinga wished the incoming leaders luck with their duties and urged them to commit themselves fully to resolving the challenges faced by registrars in the country. After a brief round of voting, SARA’s vice-chairperson Dr Elliot Motloung was elected chairperson for the 2015/16 term. The full list of new leaders is: • Chairperson: Dr Elliot Motloung (UFS) • Vice-chairperson: Dr Emmanuel Ati (UKZN) • Treasurer and marketing: Dr Tebatso Boshomane (UP) • Secretary: Dr Edward Ngwenya (UP) • National coordinator: Dr Gabsile Phala (WITS) field internationally was recognised as a shining example to underprivileged youth who wish to become doctors. In his address to the registrars, Prof. M az wai stressed the impor tance of leadership qualities in doctors. “You might

not realise it, but the mere fact that the word ‘doctor’ is appended to your name makes you a leader in the eyes of everyone,” he said. “Your challenge is to be the best possible leader you can be whenever you practise medicine.”

Latest development in public service salary negotiations for 2015/16 Advocate Mpotlana Daniel Madiba and Polelo Ndala, SAMA Organising and Collective Bargaining Officer

n 30 September 2014 labour at the Public Service Coordinating Bargaining Council (PSCBC) tabled demands which included an adjustment in public servants’ salaries and improvement in the conditions of service. The tabling of these demands has been prompted by the fact that the multi-term agreement that was signed in 2012, that is the PSCBC Resolution 1 of 2012 (an agreement on salary adjustments and improvements on conditions of service in the public service for the period 2012/13-2014/15) lapsed during the 2014/2015 financial year. Labour’s demands included but were not limited to the following: Cost of living adjustment (COLA) • A 15% increase across the board for all public servants. Term of agreement • A single term Housing • An increase of the current housing allowance from R900 to R3 000 for all employees in the absence of the Government Employees Housing Scheme (GEHS). • An annual adjustment of the housing allowance with effect from 1 April every year with the same percentage as the salary adjustment. 10

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Government Employees Medical Aid Schemes (GEMS) • A 28.5% increase in subsidies including public servants who are on open schemes and ensuring parity in respect of open schemes subsidy-wise. • Annual adjustments must be based on the average medical inflation of the previous year and must be administered by government as opposed to what is happening currently. Leave • Family responsibility leave to include assistance to immediate family and in-laws. • Six months paid maternity leave and two weeks paternity leave outside of the family responsibility leave. • Ten days special leave for employees with children with disabilities. Outstanding matters • All outstanding matters emanating from previous resolutions to be finalised on or before 15December 2014. On 11 December 2014, during the last Council (PSCBC) sitting, the following draft agreements were produced for circulation: • Draft agreement on the review of the Per formance Management and Development System (PMDS). • Draft review of Resolution 3 of 2009 (pay progression for employees not covered

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• • •

by the revised Occupational Specific Dispensation. Draft agreement on the review of the danger allowance (PSCBC agreed that the identification of occupational categories to benefit from this dispensation will be done by Sector Councils and this process will take at least a period of six months to complete after the date of signing the agreement). Draft review on decent work and outsourcing. Draft agreement on minimum service level agreement. Draft agreement on the Government Employees Housing Scheme (GEHS).

On 14 January 2015 PSCBC resumed negotiations and the employer’s offer in terms of what they have tabled as a response to our demands was still at 5.8% across the board for all public servants and further proposed a three years multi-term agreement which will be Consumer Price Index (CPI) based. It is our hope that the current round of wage negotiations will be concluded before the end of the financial year. For more information contact: Mr Polelo Ndala at 012 481 2160 or email polelon@samedical. org, or Advocate Mpotlana D Madiba at 012 481 2075, or via email at danielm@samedical.org.

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Compensation for injuries and diseases contracted at the workplace Adv Mpotlana Daniel Madiba, SAMA Trade Union

if deceased, their dependants. In this case, the Act expressly includes casual employees, directors or members of body corporates who have concluded contracts of service with the company or body corporate, and if they are working within the scope of their contracts.

When is compensation payable

he employer has, in common law, a duty to ensure the provision of a safe, healthy and hazard-free employment environment. In common law, if an employee is injured or contracts a disease through the negligence of his or her employer, the employer shall be liable in delict for the losses suffered by such an employee. Such claims must be instituted in the civil courts, and the employee shall bear the evidentiary burden to prove that the employer was negligent, that the harm was caused by the negligence, and the extent of the damages. In many instances, this duty on the employee was difficult to prove, and employees had to bear the cost of litigation against wealthy employers, who may be expected to defend such actions with vigour.

The compensation regime in South Africa Given the situation outlined above, in South Africa as in most countries of the world, the state accepts some responsibility for employees who are injured in the workplace, or fall ill because of unhealthy working conditions. In South Africa, the occupational injuries and disease regime that provides for the compensation of employees for injuries and diseases contracted at the workplace is codified under the Occupational Injuries and Diseases Act 130 of 1993 (COIDA). COIDA established the office of the compensation commissioner, who has the responsibility to administer the social insurance scheme established by an Act of Parliament (COIDA), and financed from a fund into which levies of contributing employers are paid. COIDA applies to all employees and,

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The Act gives every employee or their dependents a right to compensation from the fund if the employee has met with an accident resulting in disablement or death, or if the employee contracts an ‘occupational disease’ that arose out of and in the course and scope of employment. Accident In terms of the Act, the word ‘accident’ bears its ordinary meaning. Generally, an accident denotes an “unlooked for mishap or an untoward event which is not expected or designed”, but our courts have accepted that it can include an intentionally inflicted injury – Langeberg Foods and another v. Tokwe [1997] 3 All SA 43 (E). An accident in this regard may, however, not extend to cover the intentional and wilful (self induced) misconduct on the part of the employee. An accident normally consists of a single event, but the courts have accepted that a series of events that have a cumulative effect resulting in an ultimate injury constitutes an ‘accident’ for purposes of COIDA. So, for example, the repeated lifting of heavy objects that ultimately results in backache and the exposure to repeated distressing incidents resulting in post-traumatic stress were regarded as ‘continuing accidents’. Occupational disease An occupational disease is said to be any illness arising from employee’s employment. The Act provides a list of occupational diseases identified by their causes in schedule 3 and goes further to recognise that any other illness, not listed in the schedule, shall constitute an occupational disease if it arises out of employment. Employees are, however, not covered by the fund in respect of diseases contracted outside, or unconnected with, their employment, even if the habit which possibly caused the disease was practised at work. John Grogan provides an example of lung

cancer caused by smoking as one example of a disease that will not be covered. (John Grogan, Employment Rights, p. 276). If an employee has contracted any disease mentioned in schedule 3, it is presumed, unless the contrary is proved, that such a disease arose out of and in the course of his employment [Section 66]. Arising out of and in the course and scope of employment This requirement of the act had proved to be the most controversial of all the requirements for asserting a claim under COIDA. As a result, there has been extensive analysis of the requirement in many judgments in various contexts, including cases involving claims against employers based on their vicarious liability for delicts committed by employees. The courts preferred to give a wide interpretation of the phrase in many instances, for example, a policeman who fired a shot that injured a colleague while fooling around with a service revolver was held to have been acting within the course and scope of his duties, and to have caused an accident arising out of the victim’s employment [Minister of Justice v. Khoza 1966 (1) SA 410 (A)]. However, where another policeman intentionally shot a colleague who taunted him about the relationship that he (the victim) was having with his wife, the shooting was found not to have occurred within the course and scope of the victim’s duties, even though he was on duty at the time – Twalo v. Minister of Safety and Security and another (2009) 30 ILJ 1578 (Ck). Employer’s liability for occupational injuries and diseases In common law, employees have an action against employers if they (employers) negligently fail to discharge their obligation to keep the workplace safe and healthy, and the employee contracts an illness or has an accident as a result. Simply put, an employee would have a civil claim against an employer who failed to provide or ensure a safe and healthy working environment is provided. In this case, the employee would have recourse based in delict. However with the enactment of COIDA, aimed to provide for social insurance for employees, the employers are now relieved in terms of Section 35 (1) of any claim that may arise in delict for injuries or diseases sustained or contracted by

FEATURES

employees that arise in the course and scope of their employment. This statutory compensation scheme therefore provides complete indemnity to employers for all injuries sustained or illnesses contracted in circumstances covered by COIDA. Our courts have, however, recently accepted that an employee may still have a claim in delict against an employer for illness or injuries sustained in the workplace if such injury or illness does not arise out of and in the course and scope of employment. A case in point in this regard is the decision of the Supreme Court of Appeal in MEC for Department of Health (FS) v. De Necker (924/2013) [2014] ZASCA 167 (8 October 2014). This decision of the Supreme Court of Appeal re-emphasised the principle that an employee may still found a claim in delict for injuries or illness sustained or contracted at the workplace, if such illness or injury does not arise out of or in the course and scope of the employee employment. Therefore a sufficient causal connection between the accident and the employee’s employment or work must exist before the provisions of COIDA may apply. The brief facts of the De Necker (the doctor) case were that, the doctor was employed by the

Free State provincial department in one of its health facilities as a registrar training to become a paediatrician. The female doctor sought to institute a claim for damages sustained as a result of being raped, at approximately 02h00 on 30 October 2010, by an intruder who gained access to the hospital premises. The incident occurred at a time when the respondent was discharging her duties as a registrar in the hospital. At the time of the incident there was building construction work being carried out at the hospital, a portion of the parameter fence was under temporary repair, and the light in the building where the incident took place was not working. The Department of Health claimed that the doctor could not sustain a claim in common law (delict) because such a claim was barred by the provisions of Section 35 (1) of COIDA, in that such an accident arose out of or in the course and scope of the employee’s employment. In this regard the court queried whether the injury sustained bore a connection to the employee’s employment. Put differently, the question that might rightly be asked is whether the act causing the injury was a risk incidental to the employment. The court then concluded that it

was unable to see how a rape perpetrated by an outsider on a doctor on duty at a hospital arises out of the doctor’s employment. The court could not conceive of the risk of rape being incidental to such employment. Consequently the SCA confirmed that the doctor may have a claim for damages in common law of delict. The COIDA compensation regime is an important social insurance scheme that ensures that employees who meet accidents at workplaces and arise out of or in the course and scope of their employment are justly compensated on the no fault regime and without unduly long and costly litigation process. However, according to the Supreme Court of Appeal decision on the De Necker case, employers should consider themselves warned that they may not be able to hide behind COIDA, if they are negligent in not providing adequate protection for their employees at work, particularly those in potentially hazardous circumstances or late at night. Safety and security at the workplace is a matter of great importance that the employer may not afford neglect for another day lest a flood of civil claims are to flow.

Things we need to know about unfair suspension Wandile Mphahlele, Legal Advisor: SAMATU suspension (suspension pending a DC) and punitive suspension (suspension as a penalty). Both these are covered by section 186 (2) of the LRA.

Cases:

ection 186 (2) (b) LRA: Unfair labour practice means any unfair act or omission that arises between an employer and an employee involving the unfair suspension of an employee or unfair disciplinary action short of dismissal in respect of an employee. Suspension is defined as temporary prohibition of an employee from rendering his/her services to the employer. It is normally during an investigation against the employee. During the suspension period the employment relationship still continues. There is preventive

Mokgotle v. Premier of North West and another (2009) 30 ILJ 605 (LC) Issues on display: Suspension and audi partem Facts: The employee, a Director General in the office of the premier was suspended after allegations of corruption surfaced in the media. On 17 November 2008 he was suspended and auditors were tasked to investigate. He was to report back on 1 December 2008. Due to political reasons the auditors’ mandate was terminated and the Auditor General was tasked to take over. This led to a delay in the investigation and when the employee returned to work on 1 December 2008 his suspension was extended. It is this suspension that provoked this urgent application. One of the three grounds raised by the employee in this application was that he was not given an opportunity to be heard before the suspension. The employee relied on common

law and not LRA in these proceedings, and the employer tried to object to the jurisdiction of the court on the grounds that the employee didn’t follow the LRA procedures. Analysis: The court was of the view that case law affirms the principle that common law contracts of employment should be developed in the light of the constitution, specifically to include the contractual right to a pre-dismissal hearing. The court felt bound by the Supreme Court of Appeal jurisprudence that states that contract of employment embody an obligation of fair dealings between the parties in a contract. In determining the principle of fair dealing, one must have regard to the jurisprudence of unfair dismissal and unfair labour practice. Substantively, this principle relates to the reason of suspension; the alleged misconduct must be grave. Suspension is said to be the equivalent of arrest. Employees must only be suspended in exceptional cases. Procedurally, the court was of the view that in the interest of fairness the employee must given an opportunity to state his side of the story before being suspended.

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FEATURES Held: Court held that there was no evidence that the employee was going to interfere with the investigation and that he was supposed to be heard before suspension. The decision to suspend the employee was set aside. South African Post Office Ltd v. Jansen Van Vuuren (2008) 29 ILJ 2793 (LC) Issues on display: substantive grounds of suspension and compensation Facts: Employee was a Senior Systems Programmer and was responsible for computer servers. On 1 December 2005 the employer experienced a power outage. The employee was accused of being responsible for the outage. He was asked to provide an explanation on what occurred. The employer was dissatisfied with explanation and suspended the employee. The reason for the suspension was that he made unauthorised changes in the production environment. Analysis: The court agreed with the Commissioner’s view that suspension prejudiced the alleged offender psychologically and in terms of further job prospects. Commissioner also stated that suspension must be in exceptional circumstances. Court also emphasised the fact that employers must refrain from hastily resorting to suspending employees when there are no valid reasons to do so. There must be a sound reason for suspending someone. Suspension must be based on serious substantive reasons. Held: Employer was ordered to pay employee one month’s salary for the unfair suspension. Masinga v. Minister of Justice, KwaZulu-Natal Government (1995) 16 ILJ 823 (A) Issues on display: Contracts governed by statutes, right to be heard Facts: Employee was a public prosecutor in the employ of the Department of Justice. His employment relationship is governed by KwaZulu Public Service Act 18 of 1995. This Act among other things provides for suspension without pay when charged with misconduct. The Act also provides that an employee under suspension who resigns or assumes other employment before his charge has been finalised shall be deemed to have been discharged on the account of the alleged misconduct. During his suspension, the employee was engaged in another job at the Community Law Centre, University of KwaZulu-Natal. The employer (Department of Justice) became aware of this and dismissed

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the employee. Employee referred the matter to the High Court and the court found in his favour; on appeal (High Court, three judges) the appeal court found against him and the matter went to the Appellate Division. Analysis: The issue for determination was whether the employee was engaged full time (permanent job) which would prevent him from resuming his employment with an employer if his suspension was lifted. Court found that the employment contract with the Community Law Centre was casual and could not prevent him from going back to work on instruction. Held: The employer decision to discharge the employee was set aside. On relief the employee wanted his suspension to be declared unlawful as he was not given a chance to be heard before he was suspended. The court held that the audi partem rule will not apply in the case where discharge is in terms of statute and not discretion of his seniors. The employer has a contractual duty to pay the employee unless suspension without pay is contracted. This was evident in the Masinga case, where the employment relationship was governed by an Act which had a section allowing suspension without pay. Constitutionality of such clauses in contracts or sections in legislation has not been tested. I doubt that they will pass the constitutional test considering the development of the audi partem rule in labour law and the right to be presumed innocent in cases of misconduct. An employer must have substantive grounds and apply procedural fairness when deciding to suspend an employee because wrongful and unfair suspension could cause the employer to be liable for damages. The case of Mokgotle and Jansen are points of reference in this regard. In the case of Jansen, the court was not satisfied with the substantive reason of suspending the employee and damages were awarded. Courts are generally worried about the manner in which employers are so quick to suspend employees. Normally the courts are reluctant to grant urgent applications on suspension issues but of late they seem to grant them as in the case of Mokgotle. In all the cases discussed above it is evident that the audi partem rule is paramount and that failure to afford an employee a chance to state his case before suspending him/her might lead to the suspension being unfair. A matter for debate is the constitutionality of contracts that are governed by statutes as in the case of Masinga. This is in a case where suspension is effected without a hearing. In the Masinga case, the court held that the

audi partem principle does not apply since the suspension is mandated by statute. This is not the only case, in the matter of Jacobs v. Minister of Justice (1992( 13 ILJ ( C ), the court held that the audi partem rule didn’t apply in the case of suspension in terms of section 15 (10) of the Prison Act 8 of 1959, the employees were suspended without pay and without a hearing in terms of the Act. In its conclusion, the court reasoned that the legislature did not include or does not in any way indicate that there be a pre hearing before dismissal. Brassey suggests that such decision goes against laws of natural justice, especially considering the fact that suspension is without pay. He argues that it is not in the interests of justice to suspend an employee without a hearing. A suspension imposed for an unreasonable period has been determined to be unfair by the Labour Court, in the matter of Ngwenya v. Premier of KwaZulu-Natal (2001) 22 ILJ 1667 (LC), the court held that suspension for an indefinite period is not only not in the interests of the employee but also against public interest. The fact that the employee is paid during that suspension does not ease the infringement on the right to dignity and the damage to one’s reputation. An employer must or can only suspend the employee in exceptional circumstances; this for example will be in cases where the employee’s presence in the workplace will interfere with the investigation. In the case of Mokgotle, the court found that the employee failed to prove that the continued presence of the employee in the work place will jeopardise the investigation. The test for suspending the employee is whether the employee’s continued presence in the workplace is desirable or not. In conclusion, it is critical to have a hearing before suspending an employee. Courts consider the effects of suspension to be detrimental to the employee, thus the employer must prove exceptional circumstance to justify suspension. Suspension of the employee must be for a reasonable period; this means that the employer must be able to conclude its investigations within a reasonable period. Indefinite suspension of the employee will render the suspension unfair. Further, suspension of the employee without pay can only be effected in cases where there is an agreement to that effect. In some cases the statute governs the relationship and might allow suspension without pay. Ordinarily, the employer has a duty to remunerate the employee during suspension. Remunerating the employee during suspension does not give the employer the right to suspend the employee indefinitely or for an unreasonable period.

Health Awareness Days 2015 JAN FEB

Sunsmart Skin Cancer Awareness Month

Mental Illness Awareness Month

Healthy Lifestyle Awareness Month Reproductive Health Month Environmental Health Awareness Month

Bone Marrow Stem Cell Donation and Leukaemia Awareness Month (spans 15 August to 15 October) National Women’s Month Organ Donor Month

1 4 27

New Year’s Day World Braille Day World Leprosy Day

4 9 10-16 10-16 22

World Cancer Day International Epilepsy Day STI/Condom Week Pregnancy Awareness Week Healthy Lifestyle Awareness Day

TB Awareness Month

MAR

4- 8 8 8-14 16-22 12 20 21 21 23

School Health Week International Women’s Day World Glaucoma Week World Salt Awareness Week World Kidney Day World Head Injury Awareness Day Human Rights Day World Down Syndrome Day World TB Day

1-5 11 18 28

Corporate Wellness Week World Population Day International Mandela Day World Hepatitis Day

1-7 1-7 3-28 6-12 4-10 9 12 15

World Breastfeeding Week CANSA Care Week HPV Vaccination Campaign Polio Awareness Week Rheumatic Fever and Rheumatic Heart Desease National Women’s Day International Youth Day Commencement of Bone Marrow Stem Cell Donation and Leukaemia Awareness Months 26-31 African Traditional Medicine Week 31 African Traditional Medicine Day

JUL AUG

Albinism Awareness Month Bone Marrow Stem Cell Donation and Leukaemia Awareness Month (spans 15 August to 15 October) Cervical Cancer Awareness Month Childhood Cancer Awareness Month Eye Care Awareness Month (spans 23 September to 20 October) Muscular Dystrophy Awareness Month National Heart Awareness Month National Month of Deaf People National Oral Health Month

1-8 2-6 2-6 9 10 11 12 14 21 21-27 23 24 26 26 28 29

Pharmacy Week Back Week Kidney Awareness Week International Foetal Alcohol Syndrome Day International Gynaecological Health Day World Hospice and Palliative Care Day World Oral Health Day National Attention Deficit Hyperactivity Disorder Day(ADHD) World Alzheimer’s Day World Retina Week Commencement of Eye Care Awareness Month Heritage Day World Environmental Health Day World Retina Day World Rabies Day World Heart Day

SEP

Bone Marrow Stem Cell Donation and Leukaemia Awareness Month (spans 15 August to 15 October) Breast Cancer Awareness Month Eye Care Awareness Month (spans 23 September to 20 October) Mental Health Awareness Month

Health Awareness Month

APR

2 7 17 18 24-30 25 29-17

World Autism Day World Health Day World Haemophilia Day Good Friday Global / African Vaccination Week World Malaria Day May National Polio (1st Round) and Measles Immunisation Campaign

Anti-Tobacco Campaign Month Burns Awareness Month International Multiple Sclerosis Month

MAY

3-10 6-12 8 10 12 12 15-15 17 17 27-2 28 31

Hospice Week Burns Awareness Week World Red Cross World Move for Health Day World Chronic Fatigue and Immune Dysfunction Syndrome International Nurses Day June Go Torquise for the Eldery World Hypertension Day International Candlelight Memorial Day June Child Protection Week International Day of Action for Women’s Health World No Tobacco Day

Men’s Health Month National Blood Donor Month National Youth Month

JUN

1 2 3-9 4 5 14 15 16 15-21 17-28 21 24-30 24-28 26

International Children’s Day International Cancer Survivor’s Day World Heart Rhythm Week International Day of Innocent Children - Victims of Aggression World Environmental Day World Blood Donor Day World Elder Abuse Awareness Day Youth Day National Epilepsy Week National Polio (2nd Round) Immunisation Campaign National Epilepsy Day National Youth Health Indaba SANCA Drug Awareness Week International Day Against Drug Abuse and Illicit Drug Trafficking

1 1 8 9 9 9-15 10 9 11- 17 12 12 10 12-20 15 15-19 15 16 16 17 17 20 20 20-26 23 24 28-3 29 30

International Day for Older Persons National Inherited Disorder Day World Sight Day Partnership Against AIDS Anniversary International Day for Natural Disaster Reduction National Nutrition Week World Mental Health Day World Sight Day Case Manager Week World Athritis Day National Bandana Day World Hospice and Pallative Care Day World Bone and Joint Week National Foetal Alcohol Syndrome Day National Obesity Week Global Hand Wash Day World Food Day World Spine Day World Trauma Day International Day for the Eradiction of Poverty National Down Syndrome Day World Osteoporosis Day International Lead Poisoning Prevention Week National Iodine Deficiency Disorder Day World Polio Day November World Stroke Week World Stroke Day Commemoration of African Food and Nutrition Security Day

Quality Month Red Ribbon Month Sunsmart Skin Cancer Awareness Month 2 4-10 2- 6 6 9 14 25 25-10

National Children’s Day National Cardiopulmonary Resuscitation (CPR) Week SADC Malaria Week SADC Malaria Day World Quality Day World Diabetes Day International Day for the Elimination of Violence Against Women Dec 16 Days of Activism on No Violence Against Women & Children

Prevention of Injuries Month Sunsmart Skin Cancer Awareness Month

1 3 5 9 10

National Department of Health

World AIDS Day International Day of Persons with Disability International Volunteers Day World Patient Safety Day International Human Rights Day

Postal Adress: Private Bag x 828 / Pretoria / 0001 / Physical Address: Civitas Building 242 Struben Street / Pretoria / 0001 / Tel: 012 395 8000 / www.health.gov.za

OCT

NOV DEC

FEATURES

The progress of the ‘Ideal Clinic’ project in South Africa Bernard Mutsago: SAMA Health Policy Researcher

n the face of government’s historic failure to implement delivery promises over the decades – particularly improving public sector health facilities – plus the ongoing misleading pledges of better services to the masses, to gain electoral strength, few will take seriously any new government announcements of yet another “improvement” project or operation with a different name. At the end of 2014, President Jacob Zuma launched the Scaling up Ideal Clinic Realisation and Maintenance Programme, a government project aimed at improving the quality of services in state-run primary care clinics. The project forms part of Operation Phakisa, a government initiative to address priority issues in the National Development Plan (NDP) 2030, which envisions“a health system that works for everyone, produces positive health outcomes, and is not out of reach.” ‘Phakisa’is a Sesotho word for‘hurry up’. For a start, the Phakisa initiative is being implemented in two sectors: the Ocean economy and the Health sector (focusing on clinics). The project mimics the Malaysian government’s Big Fast Results model that was successfully applied in Malaysia’s economic transformation programme. So far 10 clinics across South Africa have been identified for initial implementation of the project. Details are still sketchy since the project has not yet got off the ground (Joe Maila; DoH spokesperson, personal communication, February 2015). No new clinics will be built under the project; only a revamp of existing clinics will be done. The Ideal Clinics Initiative is organised into eight work streams, namely: service delivery, waiting times, human resources, infrastructure, financial management,

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SAMA INSIDER

supply chain management, scaling up and sustainability and institutional arrangements. The dream clinic will be characterised by: • Better facility management • Better cleanliness and hygiene • Fast patient queues • Constant availability of medication • Friendly staff.

“If the government is currently buckling under the heavy weight of an enormous vacant post backlog and staff shortages, how can this dream be fulfilled?” The quest for quality in our health system has a long history. Quality improvement initiatives in this country date as far back as 1993 when hospital and later primary health care (PHC) clinic accreditation was introduced. Today, there are multiple government instruments, structures or frameworks that collectively distil towards the goal of quality healthcare, some of them shown in the figure above. The Ideal Clinic project was instituted following the findings of the national health facilities audit that was conducted between

May 2011 and May 2012. Conducted on every public sector health facility in the country, the audit found that primary care facilities on average scored lower than hospitals in all priority areas. Based on some derisive public expressions following the announcement of this project, there appears to be little marked zest for the initiative. So what is causing this seeming public despair? Firstly, there is erosion of trust in government’s promises and ability to speedily mend the public health system. Secondly, with 3 500 primary care facilities in the country, everyone is wondering where the money to fix all these facilities will come from. Thirdly, if the government is currently buckling under the heavy weight of an enormous vacant post backlog and current staff shortages, how will this new dream be fulfilled? Fourthly, will this pipe dream ‘quality’ be availed across the board? For example, will rural clinics have the same quality as urban facilities? Fifthly, the time frame is ridiculous by some accounts; some ‘ideal’ quality standards do not need five years to implement. Doubtless, there are some merits in the initiative; there are opportunities for publicprivate partnerships, and nobody disputes the significance of a strong primary care system that offers quality health services and broadens access. However, the government seems to set the bar too high for itself. So, until tangible results appear and the root problems bedevilling the public health system (managerial incompetence, bureaucracy, corruption, etc) are dealt with, the cancer will continue to spread and the initiative remains just a preposterous fantasy.

FEATURES

Tips for running a successful journal club SAMA Governance and Legal Department

here are many ways to accumulate the CPD points you need to continue practising as a doctor. Most doctors read articles and complete questionnaires in publications such as the South African Medical Journal or attend any of the numerous CPD meetings SAMA arranges for its members. A very effective strategy is for multiple doctors to form a journal club, a small group that studies the latest literature together and meets to discuss issues of importance in their field. Running a successful journal club In order to run a successful club, the club must have a clear set of goals. The first objective of any journal club should be to acquire continuing professional development points for its members. This is done by keeping up-to-date with the latest literature, often by perusing medical journals. Journal clubs also serve as the perfect venue for disseminating information on and building up debate about good practice. This includes an emphasis on ensuring that professional practice is evidence based. A good journal club should also aim

to sharpen the learning and practising critical appraisal skills.

timetable for the year, all made clear well in advance.

Tips for setting up a journal club Each member’s roles and responsibilities should be clearly defined and accreditation obtained in advance from the South African Medical Association (see contact details at end of article). All meetings should have a chair or facilitator and one person should be responsible for coordinating the club’s meetings. All members should be encouraged to contribute their views. Each member should commit to reading the articles that the club will be discussing before attending a meeting. It is also essential that a training needs assessment for the group should be carried out so that the format for the meetings can be decided in response to the needs of the members. Training in specific skills should be provided as and when needed (critical appraisal, presentation skills, etc). It is important to have an environment of shared learning and to establish clear boundaries regarding start and finish times, as well as a

Content of the meetings The meetings can be topic based or can focus on an article of interest. One person in the group should attempt to present and discuss a paper or topic. Alternatively, the club can discuss the article as a group. If one person is presenting, you can use this as an opportunity to practise and give feedback on presentation skills. You can follow the format of a critical appraisal journal club, choosing an article on a topic of interest or a recently published paper and appraise it using a checklist. An evidencebased journal club starts with a real clinical question, proceeds to a search of available literature, selects and reads the most relevant paper and then appraises it at the next session, followed by a decision on whether or how to put the given paper’s proposals into practice. For further information on CPD accreditation please contact SAMA’s Lisa Reid on 012 481 2082 or email cpd@samedical.org.

MEDICINE AND THE LAW

The elusive diagnosis The Medical Protection Society shares a case report from their files

r M, 50 years old, suffered chronic ill-health due to a spinal fusion, chronic bronchitis and asthma. He was a regular attendee at the surgery of Drs C and D, with sinusitis. In March 2005, Mr M saw Dr D with a similar complaint and she administered him with a flu jab, particularly as Mr M often failed to attend chronic monitoring clinics. The notes from the consultation said: “Upper respiratory tract infection NOS. Catarrh following URTI 2/52 ago is well. O/E ENT NAD chest flu jab given.” A year later, Mr M saw Dr D and the notes said: “Acute sinusitis chest clear. Prescription for doxycycline 100 mg (8).” Dr D advised Mr M how to take the doxycycline and told him to return if the symptoms did not resolve. Three months later, in June 2006, Mr M attended the surgery again, this time as an emergency, and saw Dr C. Dr C’s notes said: “[SO] penis. Cough. EM-Cough prod of green sputum and sore scratch of L-side of corona of penis ? infected. Chest clear. RV PRN.” Dr C prescribed Mr M some antibiotics to cover the possibility of both skin and chest infections, and asked Mr M to return if either problem did not clear up. Three months later, Mr M was again seen by Dr C as an emergency appointment. Mr M presented with a productive cough and a high temperature, and, on examination,

MARCH 2015

SAMA INSIDER

“With Mr M’s previous presentations with chest infections in mind, Dr C prescribed an antibiotic suitable for respiratory tract infections” there were signs of chest infection at the base of the right lung. Mr M was prescribed antibiotics for a lower respiratory tract infection. Six months later, in February 2007, Mr M saw Dr C with a rash on his glans penis and also on his left hand. Dr C considered that the rash looked like a bacterial infection rather than a fungal infection. He prescribed an antibacterial steroid cream. Five months later, Mr M consulted Dr C over the phone. Mr M said he was coughing up phlegm and that his ears felt blocked. With Mr M’s previous presentations with chest infections in mind, Dr C prescribed an antibiotic suitable for respiratory tract infections. Six months later, in January 2008, M r M suffered a strok e. Upon admission to hospital, diabetes was diagnosed. Mr M remained in hospital for three months and afterwards continued to suffer pain and restrictions to his mobility. Mr M made a claim against Dr C and Dr D, alleging that over the course of his numerous consultations, they had failed to diagnose, treat and monitor his diabetes; failed to diagnose, treat and monitor his hypercholesterolaemia; and failed to monitor his blood pressure. Expert opinion MPS instructed GP expert Dr K to report on breach of duty. Dr K raised no criticisms of the care provided by either Dr C or Dr D, and did not consider either to be in breach of duty. However, Dr K did warn that a lack of a screening programme at the surgery, to screen for diabetes in at-risk patients, posed a litigation risk. Professor V, a consultant physician, reported on causation for MPS. He

said that had the diabetes been diagnosed and controlled, together with treatment of his blood pressure and cholesterol, on the balance of probabilities Mr M’s stroke would have been prevented or, at least, delayed for a few years. Professor V deferred to Dr K’s view that there had been no breach in the duty of care. Due to supportive expert evidence, MPS resolved to defend the case; Mr M’s legal team discontinued the claim and MPS was able to recover some of its costs.

Learning points: • The NICE guidelines Preventing Type 2 Diabetes: Risk Identification and Interventions for Individuals at High Risk (2012) are aimed at identifying people at a potential high risk of developing the condition; assessing their individual risk with testing; and, if necessary, offering lifestyle advice (such as advice on diet and exercise), to help prevent the condition in people who are at high risk. The guidelines are available at www.nice.org.uk/guidance/ PH38 • It is important to listen to patients who reattend with recurring problems. Doctors must not let an element of ‘crying wolf ’ blind their judgment. Maintain an open mind and be willing to revise an initial diagnosis. • A long-running scenario such as this one is ideal for discussion at a ‘significant event’ meeting, to identify whether anything could have been done differently at each stage of Mr M’s treatment.

GENERAL NEWS

WMA condemns use of doctors in Saudi Arabia flogging World Medical Association

he use of doctors to assess prisoners’ fitness for being flogged in Saudi Arabia has been strongly condemned by the World Medical Association (WMA). In a letter to the King of Saudi Arabia, the WMA President Dr Xavier Deau calls for a halt to the flogging of Raif Badawi and his immediate release. He adds: “Our attention was also drawn on a standard procedure in Saudi Arabia whereby doctors are required to assess prisoners’ fitness before they are flogged. By doing so, doctors are required to participate in the enabling of the sentence and therefore in acts of torture and other

cruel, inhuman or degrading treatments. This is a flagrant violation of a fundamental principle of medical ethics, ‘do no harm’. We therefore condemn unreservedly this standard practice and are determined to fully support doctors who refuse to participate in it.” Dr Deau says the WMA is very concerned by the sentence imposed on Mr Badawi of 10 years in prison and 1 000 lashes. He said Mr Badawi is a prisoner of conscience detained solely for exercising his right to freedom of expression. “The flogging imposed on Mr Badawi constitutes a form of grave, cruel, inhuman

“By doing so, doctors are required to participate in the enabling of the sentence and therefore in acts of torture”

and degrading treatment that the WMA condemns strongly as a blatant violation of human dignity and human rights. It cannot be justified under any political, military, religious or other cause.” Dr Deau concludes: “We are therefore calling on you to put an immediate stop to any further flogging of Raif Badawi and to release him immediately and unconditionally, as he is a prisoner of conscience.”

SAMA saddened by passing of Prof. Sam Ross Dr Mergan Naidoo, Chairman: SAMA KZN Coastal Branch

AMA is sad to report the recent passing of Professor Sam Ross. Prof. Ross joined the Department of Obstetrics and

Gynaecology at the University of Natal in the late 1980s after working in various countries in Africa. He was the pioneer of Community Obstetrics in South Africa and established support for midwives in Umlazi, KwaMashu and KwaDabeka PHC clinics. He co-authored the textbook Obstetrics, Family Planning and Paediatrics (University of Natal Press, 1986) which was used extensively by medical and midwifery students. His research on nutrition during pregnancy was published in Early Human Development. He started a programme for training in advanced midwifery in Durban, which spread all over the country. He retired in the early 1990s but remained active in strengthening the health systems around midwifery and women’s health in South Africa. He was a supporter of the Student Christian Fellowship at the Alan Taylor

Residence for medical students, where he regularly rendered spiritual support, guardianship and mentorship. Later, he took in some students who needed accommodation, and despite harassment from the authorities he defied the Group Areas Act by having black students stay with him in a white suburb. He also established the KwaMashu Christian Care Home for the elderly. Professor Ross’ drive and commitment to improving care for vulnerable populations will be sorely missed. Professor Ross is survived by his wife, Dr Morag Ross, children Fiona, Andrew, Sue and Alison, and grandchildren Michael, Jonty, Ben, Joel, Sarah, Justin, Tayla and Kiera. The South African Medical Association mourns this loss and extends its condolences to his family.

SAMA INSIDER

MARCH 2015

GENERAL NEWS

Increased generic competition signals turning point in health reform Brigitte Taim

hile the Department of Health’s new strategy to contain medicine prices continues to dominate the media spotlight, a far quieter healthcare evolution is underway behind your local pharmacy counter, where medicine prices in South Africa are undergoing a dramatic change. As patents expire on a generation of traditional pharmaceuticals, competition has exploded among manufacturers of generic equivalents, which is driving the cost of generics so low, that some are practically available for free. The price squeeze is being felt even by brand name products still protected by patents. Although annual price increases are granted, the effect of generic competition

in the market prevents originator companies that manufacture brand name products from taking advantage of these increases. “According to the latest IMS data, private sector drug prices on average only increased by 2.1% last year, despite the health department providing an increase of 5.8%,” said Paul Anley, the CEO of a top generics firm. “This is further evidenced by the originator market only growing at 2.1% by value and 1.2% by volume, which reflects a tight 0.9% price increase for originators.” While the growth of generics is almost five times faster at 10.4% by value and 4.8% by volume, which indicates that the generics sector did take advantage of the price increase,

Anley notes that this is largely necessitated by the fact that the industry operates at much lower margins. Generics’ increased local market share now accounts for more than 50% by volume, although much smaller by value due to the price differential between brand name drugs and generic equivalents. The cost variance between the two is now as much as 72%, which is a tremendous saving. “More than one out of every two drugs dispensed in South Africa are generic at this point,” Anley said, “so even if a brand name doesn’t have a generic equivalent, there may be a generic in that same therapeutic category.”

UNIVERSITY OF OXFORD, ENGLAND

OXFORD NUFFIELD MEDICAL FELLOWSHIP 2015/16 Applications are invited for an award under the Scheme for Oxford Nuffield Medical Fellowships normally to be held in a department within the Medical Science Division of the University. This prestigious fellowship carries an allowance of £41 564 (plus any cost of living increases). This allowance is subject to UK tax. The Trustees will also pay direct, economy class return air fares for the appointee, his/her spouse and children up to the age of 18 years. A generous baggage allowance is also provided. Applicants should have graduated from one of the universities listed below and should either hold a medical qualification or have appropriate research experience. There is no limit as to age or status. The fellowship is tenable for two years in the first instance, with the possibility of an extension for a third year. Fellows are expected to return to South Africa at the end of the fellowship to continue to do work of a similar nature. The award is available from 1 October 2015 or, subject to consultation with the University’s Medical Sciences Office and the department concerned, from such other later date as may be agreed. The next round of Nuffield Medical Fellowship for South Africa will be in 2016/17. If the fellow requires a visa to come to the UK, a Tier 5 Temporary Worker Visa (http://www.admin.ox.ac.uk/personnel/permits/tier5/ temporaryworkers/) will be sponsored by the University to allow the fellow to undertake collaborative research (only). Supplementary employment (such as clinical work) might be permitted only if the specialty is listed by the UKBA as a shortage occupation (Medical practitioners – 2211) (see http://www.ukba.homeoffice.gov.uk/sitecontent/documents/workingintheuk/shortageoccupationlistnov11.pdf). Please note that the visa regulations are constantly updated by the UK Border Agency.

Participating universities University of Cape Town, University of Limpopo, University of KwaZulu-Natal, University of the Free State, University of Pretoria, Stellenbosch University, University of the Witwatersrand. Further information may be obtained from Ms Nandie Makatesi (nandie.makatesi@uct.ac.za). Details of the research interests of those departments in which the fellowship may be held may be obtained at the website http://www.ox.ac.uk/divisions/medical_sciences.html

Candidates must provide a letter describing their plans and proposed work at the University of Oxford (prior contact with suitable academic hosts at the University is highly recommended), as well as a full curriculum vitae and the names of at least three contactable referees. These should be sent, only via email, to Ms Nandie Makatesi at nandie.makatesi@uct.ac.za

by no later than 31 May 2015.

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