SAMA Insider - 2015 Apr

SAMA

INSIDER

APRIL 2015

Medical malpractice: SAMA responds

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

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APRIL 2015

CONTENTS

“Excitement” – Dr Leonie Scholtz

3

EDITOR’S NOTE Double whammy Conrad Strydom

5

FEATURES Medical malpractice lawsuits – too little too late

Dr Mahlane Phalane

6

SAMA helps victims of medical negligence

SAMA Communications Department

7

SAMATU holds NEC meeting

Conrad Strydom

SAMATU responds to minister’s budget speech

SAMA Trade Union

7

9

The GP re-emerges as the care co-ordinator

SAMA Private Practice Department

10

Doctors call for lawyers to get out of hospitals

SAMA Trade Union

10

GEMS network agreement – balanced billing

SAMA Private Practice Department

SAMA Trade Union

12

State of public health update – early 2015

13

SAMATU president Dr Phophi Ramathuba and team win award

SAMA Trade Union

14

NDoH’s new ICD-10 circulars relevant to private and public healthcare

SAMA Private Practice Department

16

Management in health: the new frontier for the public health service

Dr Shailendra Sham

19

MEDICINE AND THE LAW High expectations

Medical Protection Society

20

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

APRIL 2015

Double whammy

I 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

n the span of one memorable week in March, health minister Dr Aaron Motsoaledi publicly tackled two of our country’s biggest healthcare issues – medical malpractice litigation and efficiency concerns at the HPCSA. The former issue, in particular, garnered considerable media attention and a surprising amount of backlash from the legal profession. While medical malpractice legislation protects patients from unscrupulous or incompetent practitioners, the tremendous spike in malpractice suits over the last six years did suspiciously coincide with caps imposed on claims from the Road Accident Fund, until then the major source of income for litigators.

There have also been reports of lawyers who pay hospital staff to inform on doctors or sabotage procedures to ensure that malpractice suits occur. While such instances are certainly the exception, not the rule, they do indicate a level of corruption that mandates the Department of Health’s (DoH) involvement.

Regarding the HPCSA matter, I have been told that SAMA and the South African Dental Association’s plan to establish an independent regulatory body is neither gone nor forgotten – perhaps the minister’s inquiry might even give it some impetus?

In this issue we examine SAMA’s response to the increased national focus on malpractice litigation, including a look at the association’s new programme aimed at assisting the victims of medical negligence (see page 6). We also look at SAMATU’s recent NEC meeting at the SAMA Head Office in Pretoria (page 7), get briefed on the DoH’s new ICD-10 circulars and look at the improving state of public sector hospital managers, courtesy of the Health Policy Committee’s Dr Shailendra Sham (pages 16 and 17).

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

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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.

FEATURES

Medical malpractice lawsuits – too little too late Dr Mahlane Phalane, General Secretary: SAMA Trade Union

T

he South African Medical Association Trade Union (SAMATU) would like to put it on record that we will always put the patient first. Our mission is to unite doctors for the health of the nation, while our vision is to achieve quality healthcare for all in our lifetime. We agree fully with the Black Lawyers Association (BLA) that section 27 of our constitution guarantees the people of South Africa the right to have access to healthcare. Our utterances and actions are based on that noble provision in our constitution. Our profession is based on the principle that prevention is better than cure.

Medical malpractice does not guarantee access to healthcare, it merely reacts to an act or omission that often can never be corrected legally or financially. How much money can ever be enough to compensate a mother with a child with cerebral palsy or a parent who has lost a child?

Let us see [lawyers] take legal actions against government or health professionals for failing to live up to the prescripts of section 27 of the constitution for a change SAMATU respects and accepts the rights of lawyers and any other profession to practise their trade, the same way we advocate for ourselves to practise the art of medicine.

However, what we condemn is the practice of touting, a phenomenon shunned by the legal profession itself. It cannot be correct to have some lawyers or their agents snooping for any case of medical malpractice that a lawsuit must be instituted against government or medical doctors at all costs. We respect and advocate for the rights of patients to have access to justice and recourse, if they have suffered in the hands of the medical profession or healthcare system.

We want to put it on record that we are unapologetic and tireless in our pursuit of quality

Dr Mahlane Phalane healthcare services for all. Diseases, disabilities and death do not know race, gender, status or economic class. All of us without exception, our lives and our health status remain precious, unconditionally. We are on record pushing and supporting the minister and the Department of Health to turn the great plans in their Ten Point Plan into a Ten Point Action. If we correctly implement this plan, consequential things such as medical malpractice lawsuits will indeed become extinct. Our primary role remains to be the noble advocates for patients, our failure to do so has dire consequences. Hospitals should be centres of excellence, reliable sources of compassion, caring and comfort for all. None of us should profit from the misery of patients.

SAMATU devotes itself and calls upon our colleagues in the nursing profession and the public at large to lead a practical campaign to improve the quality of healthcare services in our clinics and hospitals. We do this because we ourselves will one day become patients, and our loved ones also depend on public healthcare services. Our working environment is characterised by diseases, disabilities and death. This is a serious call for service that requires the support of everyone, the BLA and the legal profession at large also included.

If the genuine interests of the BLA and the legal profession at large is about protecting the patients’ right to access to healthcare, then their focus should change and deal with real healthcare issues. For a change, let us see the BLA take legal actions against government or

health professionals for failing to live up to the prescripts of section 27 of the constitution. We will join and support the BLA if they will help us to use legal means to ensure that life-saving equipment is available in all hospitals and clinics. Let us see the BLA taking community cases where there is no access to clinics or hospitals, let us see BLA taking legal action to prevent drug stock outs in our clinics and hospitals. There can never be enough money received through a medical malpractice lawsuit that can soothe the hurting heart of a mother who has lost her newly born child, or has given birth to a child with cerebral palsy, and no amount of money can replace a lost life, no matter the circumstances.

What we condemn is the practice of touting, a phenomenon shunned by the legal profession itself Prevention is better than cure, the BLA, SAMATU and nurses should join hands in advocating for the human rights of patients, not to profit from their misery or to protect the system that is failing all of us. Focusing only on medical malpractice lawsuits as a means to advance patient rights of access to healthcare is a case of too little too late.

SAMA INSIDER

APRIL 2015

5

FEATURES

SAMA helps victims of medical negligence SAMA Communications Department

T

he South African Medical Association (SAMA) is investigating setting up a fund to compensate patients who fall victim to unavoidable adverse events (through no fault of their treating physician), while working with government to improve the overall quality of care in both public and private sectors.

SAMA Chairperson, Dr Mzukisi Grootboom, emphasised that this would in no way affect legitimate medical negli­ gence claims but form part of an overall strategy to address a crisis that threatened the very existence of higher-risk specialist care in South Africa – something that would negatively impact on patients. Identifying and compassionately addressing genuinely unavoidable accidents and adverse outcomes, while teaching doctors to communicate openly and honestly with their patients, would help reduce the expensive - and rising tide - of pending claims. South Africa, while severely short of specialists, nevertheless had some of the best and most sought-after practitioners in the world with ground-breaking and/or life-saving procedures an almost everyday occurrence. He cited Dr Graham Howarth, Africa representative for the global Medical Protection Society (MPS) (to which most doctors in South Africa belong), recently saying an extrapolation of the annual indemnity fee hikes necessary to counter rising claims over the next five to 10 years ‘begs the question of whether anyone will be left in the private sector to deliver babies, (for example), at all’. Grootboom said private obstetricians would this year pay the highest annual indemnity subscriptions at R450 000 per annum, which came on top of their equipment, office and administration overheads.

The ‘very real danger ’ existed that this could induce them and other high-risk consultants to avoid certain procedures and/or move to the public sector (where the State pays for their indemnity cover), which he described as, ‘simply shifting the problem elsewhere,’ hiking the taxpayerfooted legal bill which could potentially cripple or at least severely curtail overall public healthcare deliver y. The rising curve in MPS settlements involving local obstetricians graphically illustrates the problem; the pay-out in 2013 was R13 6

APRIL 2015

SAMA INSIDER

million, up from R2 million in 2003, (the latter involving a single claim).

Echoing what National Health Minister, Dr Aaron Motsoaledi said in Gauteng at an early March medico-legal summit called to address the escalating crisis, Grootboom said the local explosion in medico-legal claims was not in keeping with generally known trends of negligence. Recent amendments to the Road Accident Fund (RAF) legislation made damages claims due to personal injury sustained in motor vehicle accidents now a far less lucrative source of income for lawyers, who had shifted their target to physicians and hospitals. Another legal ‘driver’ was the Contingency Fees Act (of 1997), which permits attorneys to offer clients ‘free’ legal help in pursuing a suit against a medical practitioner, (actually 25% of the settlement or double their usual fee, whichever is the lesser).

Motsoaledi accused some (unnamed) chief health executives at his public hospitals of being in cahoots with lawyers to cash in on the lucrative litigation. ‘They and others in the health sector are members of syndicates which have permeated our hospitals, sharing information which leads to the looting of funds meant for members of the public,’ he charged at the indemnity summit. Gauteng, KwaZulu-Natal and the Eastern Cape currently have claims against them worth billions. Gauteng alone faces medical negligence claims estimated at R1.268 billion. The Black Lawyers Association strongly attacked Motsoaledi’s ‘finger-pointing,’ saying he should be more introspective and examine the true cause of the massive lawsuits channeled against his department. It bemoaned SAMA’s apparent support for the minister at the medico-legal summit, saying it amounted to ‘an orchestrated assault on the rights of the downtrodden and victims of malpractice in public healthcare’ and said both the BLA and SAMA should campaign for higher professional standards among their members when treating members of the public.

Over the past 13 years the overall indemnity insurance paid by private doctors to protect themselves against medical negligence claims has risen by 573%, pushing up their fees and encouraging those not contemplating the financially safer haven of the State sector to look overseas for opportunities – or to simply give up their practices. The annual MPS subscription for a private neurosurgeon in South Africa will this year reach R338 520, while plastic, bariatric, orthopaedic, non-spinal and fertility surgeons

will pay R140 860 per annum. The greatest number of claims, with the highest damages paid, are in obstetrics, neurosurgery, spinal surgery, trauma and orthopaedics; all highly sought-after and understaffed disciplines with severe work pressure. Grootboom said it was entirely possible that newly qualified doctors would steer clear of such specialisation unless the situation was quickly mitigated or corrected, further undermining the government’s ability to deliver universal healthcare via the National Health Insurance (NHI) scheme. He said he was fully aware there were other drivers behind the rising litigation (such as diminished supervision of juniors, a lack of necessary nursing skills, equipment and drugs, and insufficient and thinly spread medical expertise, (especially in more rural areas). However, while increasing best practice skills, straightforward communication with patients and by working with government to diminish risk to patients, SAMA hoped doctors could better live up to their dictum of, ‘first do no harm’ and avoid having to practise defensively, in a hostile, pressurised and uncertain climate. A ‘no fault’ compensation scheme has already been suggested by top health science academics in order to limit the costs of medical negligence and its impact on the NHI. This would limit legal costs for provincial health departments and private practitioners by reducing the number of court cases. Such a system does not rule out court action for those dissatisfied with their compensation, but rather creates a short-cut for patients who prefer not to go through protracted and expensive legal battles.

Motsoaledi said at the medico-legal summit that unless something was done about the increasing rates of medical negligence claims, ‘the whole system will suffer immeasurable damage’. He recently appointed an independent ombudsman to look into patient complaints while the Office for HealthCare Standards Compliance, tasked with setting and monitoring minimum standards for all hospitals (public and private) in advance of the NHI, is also expected to have some impact on the crisis. Howarth of the MPS commented in an article published recently in the SA Medical Journal; ‘I think it points to the kind of future we’d have if people are not very careful. Private patients, providers, public patients and providers, politicians and policy pundits all have a vested interest in solving the problem – there is not a medical answer – it has to enter public debate’.

FEATURES

SAMATU holds NEC 2015 meeting Conrad Strydom

T

he National Executive Committee of the South African Medical Association Trade Union (SAMATU) met on 26 February 2015 at the SAMA head office in Erasmuskloof, Pretoria. The NEC met to discuss both the long and short term policies that SAMATU will be implementing during the 2015/16 period, including policies on such vital public health issues as commuted overtime, RWOPS and the looming rollout of the NHI programme.

In her opening address, SAMATU president Dr Phophi Ramathuba congratulated the provincial health departments who had begun to turn their acts around. “In the past, not even the minister of health could guarantee that doctors would be paid on time, despite all of SAMA’s efforts,” Dr Ramathuba said. “Lately, however, the situation has shown signs of being remedied and we are very grateful for that change.”She welcomed the

increased spending on health and education that had been announced in Finance Minister Nhlanhla Nene’s recent budget speech, but worried that the money might not be allocated properly or could be lost due to corruption.

She welcomed the increased funding for the National Institute for Communicable Diseases, a vital part of South Africa’s public health sector. She cited the example of the cholera outbreak in Limpopo in 2009 and noted that it was an outbreak that could have easily been handled had the NICD been equipped with the proper funding. SAMATU was also impressed with the increase in ARV roll-outs that had been announced by the minister of health.

However, concerns were raised about the lack of prominence given to prevention campaigns.

“ARV programmes are prioritised because they are funded by pharmaceutical companies,”

Dr Ramathuba noted. “Unfortunately, preven­ tion campaigns are not as lucrative.” The SAMATU President did not hold back on the subject of NHI rollout, citing the long overdue white paper on NHI as deeply disappointing.

The NEC members called on SAMATU mem­ bers to overcome their apathy and become serious about effecting change in the public health sector.

Issues such as RWOPS and commuted overtime were simply being ignored by provincial health departments, implying that doctors will have to embark on an aggressive advocacy approach to resolve these issues, a situation that only SAMATU is in a position to help them with.

Finally, the NEC decided to push as many of its resources as possible into developing and strengthening the trade union’s provincial executive councils (PECs), these being a prerequisite for any successful local trade union.

SAMATU responds to minister’s budget speech SAMA Trade Union

I

n her opening address to the annual National Executive Committee meeting of the South African Medical Association Trade Union (SAMATU), the union’s president Dr Phophi Ramathuba acknowledged Minister of Finance Nhlanhla Nene on the budget speech he delivered on 25 February 2015. Dr Ramathuba welcomed the 2015 budget’s increase in health and education spending, citing both as essential for the creation of a functioning healthcare system in South Africa. However, she hopes that the increase in spending will result in a great improvement on the quality of healthcare at medical facilities. “Ordinary people are still complaining about shortages of medicine, medical equipment and healthcare professionals,” Dr Ramathuba said. “We therefore call upon the Departments of Health and Treasury to find solutions to this crisis and indicate whether more funding or better management is needed.”

Members of SAMATU’s National Executive Committee met at SAMA HQ in Pretoria on 26 February to discuss public health issues

In Mpumulanga there is a huge backlog of orthopaedic cases due to the province functioning with only one orthopaedic surgeon SAMATU also welcomed the R1.5 billion that has been taken from provinces and allocated to the National Institute for Communicable Diseases (NICD). This will greatly improve the country’s ability to cope with infectious disease outbreaks such as TB and cholera. SAMATU also appreciates the final commitment on the release of the NHI White Paper, which is long overdue. However, the union is worried about nothing being said on funding towards the increased training of doctors, especially medical specialists. The current crisis in Mpumulanga is a prime example of the need for more doctors. “In Mpumulanga there is a huge backlog of orthopaedic cases due to the province functioning with only one orthopaedic surgeon,” Dr Ramathuba indicated.

SAMATU noted that South Africa has been consistent in producing 1 200 medical doctors a year while the country’s population and burden of diseases has done nothing but increase. Doctors can’t cope with the growing disease burden, terrible working conditions and unfair labour prac­tices, resulting in record numbers of doctors emigrating. On a positive note, SAMATU is encouraged by the final registration of the Office of Health Standards and Compliance (OHSC) and the R120 million budget allocation it has been afforded. “We hope the structure will now have no reasons to stop functioning. Our members on the ground have been patiently waiting for OHSC inspectors to visit our facilities and assist in making sure hospitals and clinics meet the required standards to operate.”

SAMA INSIDER

APRIL 2015

7

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FEATURES

The GP re-emerges as the care co-ordinator SAMA Private Practice Department 12,00% 10,00% 8,00% 6,00% 4,00%

Important initiatives and developments Care co-ordination Most medical schemes have made a conscious decision to entrust the GPs as principal co-ordinators of care and gatekeepers in the value chain. They have declared 2015 as the year that will see the GPs reclaim their rightful places in the healthcare continuum. The care co-ordination campaign will therefore put the GP firmly in the driver’s seat. This initiative should be embraced by the GP community.

A vast majority of major schemes (GEMS, DISCOVERY, and POLMED, etc.) are behind this initiative and have already incorporated the associated networks into their offerings. The motivation behind having patients choose their care co-ordinators is predicated on saving on costs associated with doctor-hopping, as depicted in the graph below.

It is therefore imperative that SAMA members should familiarise themselves with the rules of various schemes and to raise their concerns or dissatisfaction if any, with SAMA. According to GEMS: “Beneficiaries who consult with multiple family practitioners or only with specialists have higher costs after adjusting for disease mix.”

Patient screening The need to have all patients screened on an annual basis cannot be overemphasised. It is only through the screening campaign that most chronic illnesses can be picked up early to allow for early interventions.

The current set-up is that a significant number of chronic patients are first picked up once they experience complications and end up in hospital; some of them with irreparable and irreversible complications.

Early intervention will therefore translate into huge savings in downline expenses. Annual screening will drastically reduce costs related to hospitalisation, with the concomitant reduction in the percentage of the healthcare rand that hospitals currently enjoy. This will in turn translate into a commensurate increase in the GPs and specialists’ components of the healthcare rand.

5GPs

4GPs

3GPs

2GPs

-4,00%

1GP

0,00% -2,00%

Background For many years, the GP has been directly and indirectly responsible for up to 70% of the healthcare rand, tasked with kick-starting every healthcare rand spent. For the record, when GPs refer a patient to a specialist, pharmacist, hospital, physiotherapist etc, they are indirectly instructing their patients to go and spend money with the service providers that the patient is being referred to. This is because they are the first line of call for all patients and are generally regarded as gatekeepers.

Despite their undisputed roles as primary care-givers and catalysts in the healthcare value chain, only 6% of the healthcare rand ends up with GPs. They remain the poor cousins in the value chain and very much lower down in the pecking order. That is all about to change.

Care Co-ordination Motivation Costs

2,00%

Specialists only

T

he general practice landscape has changed considerably in recent times. Most GPs are now experiencing the ‘laws of diminishing returns’ – the more they put into their practices the less they get per effort expended. This is largely due to a maze of rules, statutory requirements and stumbling blocks that they now have to navigate through, all in the name of managed care.

The discussion that follows is aimed at creating a propitious environment for the evolution and survival of the present day GP.

Source: GEMS – The transition to the ‘the activist healthcare payer’ in South Africa – Dr Guni Goolab, principal officer, GEMS Regulation 8 of the Medical Schemes Act No 131 of 1998 This Act makes provision for Prescribed Minimum Benefits (PMBs), in terms of which: “any benefit option that is offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions”. This is provided they are obtained from a designated service provider (DSP) – 270 treatment pairs (DTPs) and 25 Chronic Disease Lists (CDLs) together constitute the PMBs. For members with chronic conditions to access and enjoy this benefit, they are required to register on the chronic disease management programmes offered by medical aids and their appointed service providers. Members, once registered, are allocated care plans. Care plans are normally developed by medical advisors employed by medical schemes, based on their registered protocols and guidelines. However, they may be jointly developed and modified to suit individual patient requirements.

For example, a care plan for a hypertensive patient will require at least four related GP visits for the condition, coupled with two specialist visits, one ECG, FBC, U&E, a diet plan, etc. All these will be covered as PMBs. GPs should ensure that there are care plans in place for all their chronic patients and should actively manage that. This process will, on its own, guarantee an additional number of consultations in any given year. However, the GP has to take an active role in co-ordinating this, thereby ensuring that the patient is less likely to experience complications or to be hospitalised.

In summary • Medical aids have wisened up to the pivotal role that the GP plays and have embraced the GP as the gatekeeper, care co-ordinator and driver of care.

• SAMA members should direct their energies at driving care co-ordination, patient screening and management of chronic ailments.

• SAMA members should only participate on networks that are aimed at entrusting them as care co-ordinators. Again, it should only be after they have been approved by legal department.

• All members should familiarise themselves with the rules of all (major) schemes and should not hesitate to contact SAMA to raise concerns or to seek clarification.

Let us make 2015 the year of the GP and in so doing re-establish GPs as vital cogs in the delivery machinery.

SAMA INSIDER

APRIL 2015

9

FEATURES

Doctors call for lawyers to get out of hospitals South African Medical Association Trade Union

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he South African Medical Association Trade Union (SAMA TU) would like to join the health minister Dr Aaron Motsoaledi in calling for “lawyers to get out of hospital and go back to court, and for doctors to get out of courts and go back to hospital”. The increasing frequency and value of medical malpractice claims threatens delivery of health services to the nation, especially the poor. We also agree that access to justice for those who have genuinely suffered at the hands of the healthcare system should never be compromised. However, prevention is better than cure and as stakeholders in health we need to improve the access to and quality of our services.

We would like to declare our support and dedicated participation in the minister’s

The impact of medico-legal cases has dire consequences for everyone medico-legal summit. We hope this summit will come up with tangible resolutions and an action plan that will put patients first, protect the interests of the nation, and regulate the healthcare system in a just way.

The impact of medico-legal cases has dire consequences for everyone; the limited resources are diverted from life-saving activities, while there is a risk of extinction of critical medical specialties such as gynaecology, neurosurgery, anaesthesiology, neonatology and others. As SAMATU we will embark on a nationwide programme to educate doctors on medico-legal issues, and

put more emphasis on improving the quality and access to healthcare.

Doctors are being held hostage by unscrupulous individuals who are fleecing the medical profession. We call on patients not to be lulled into unscrupulous malpractice claims by lawyers who are out to make a quick buck, since they are contributing not only to the decline of the medical profession in this country but also sabotaging the very health system they depend on when they are in need. Something must be done to remedy this sorry state of affairs and realign patients, doctors and the legal system in a new relationship of mutual trust and benefit.

GEMS network agreement – balanced billing SAMA Private Practice Department

W

e have been inundated with a plethora of complaints regarding the GEMS Network agreement.

Complaints regarding the debarring of balanced billing have now reached fever pitch and need to be addressed on an urgent basis.

At our last GPPPC meeting, a task team was established to investigate the workings and the applicability of balance billing in the present day GP practice, with the view of making an informed decision on how the matter can be best dealt with.

For the record, balance billing entails billing patients for the remaining balance after a medical aid fund/third party administrator had paid a portion of the fee charged.

With balance-billing, the provider submits one account for a service to either the scheme or member, or both. For example, the GP charges R500 for a consultation and submits the account for R500 to either the scheme, or the member, or both, but keeps both in the

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loop and ensures there is transparency in the dealing. The account specifies how much the scheme must pay and the amount that the member must pay.

Split billing is illegal and balance billing is not Split-billing occurs when a provider divides the total service charge into two or more accounts. For example, a GP charges R500 for a consultation and submits one account for R300 to the scheme for the portion that is covered by the member’s benefits, and another account for the remaining R200 to the member for the part which the scheme does not cover. The provider does not discuss this openly, and each party therefore remains

in the dark as to how much the other party is paying.

Given the above explanation, split billing is illegal and balance billing is not.

GEMS, on their website, clearly differentiate between the two and confirm that balance billing is legal and that split billing is not.

However, they also contend that the GP, once contracted to them, is debarred from practising balance billing.

Whilst we understand the cost containment drive and the need to make healthcare affordable, we are of the view that such a decision should at least have been preceded by practice cost studies and a more appropriate consultation should have been negotiated and proffered.

To this end, we are now investigating the most workable arrangement, given the material conditions and will advise on the next steps. We will also engage with GEMS to see if we can come to a more workable solution.

HIGHER CERTIFICATE IN MANAGEMENT (Distance) INTRODUCTION

COURSE CONTENT

The Higher Certificate in Management is an entry level management programme that successfully develops the skills of young potential managers, supervisors, and team leaders.

FPD's approach is to combine excellent theory and personal experience which results in a management programme that is inspiring and practical.

• • • • • • • • • • • • • •

WHO SHOULD ENROLL?

Study Material

The Higher Certificate in Management is targeted at: • Young managers with potential, first line managers, supervisors, team leaders and other candidates who require management development.

• Graduate trainees (university and technicon) and succession planning nominees.

• Grade 12 graduates who have just completed their tertiary education and who are in need of developing a broad range of managerial skills.

Your course material with assessment guide will be posted/couriered to you after we have received your deposit. All course material and videos of each module will also be available on the support website.

Students that enroll on this programme are exposed to complex business environments and are challenged to think differently through self-assessment and reflection. Through examining a range of management concepts, students discover winning techniques that improve their ability to manage in an ever changing world. The most relevant management subjects have been weaved together to form a solid educational foundation for the emerging manager.

COURSE DESIGN

Self Management and Presenting Yourself Perfectly Relationship Management Your Role as Supervisor Leadership that gets results Strength in team work Labour Law Diversity Management Operations Management Project Management Financial Management Customer Services Thriving & Surviving change Knowledge Management Human Resource Management

CERTIFICATION The Higher Certificate in Management is a registered and accredited South African qualification on the NQF Level 5 (120 credits).

Successful delegates will receive a Higher Certificate in Management for this course if they fully attended the workshops and successfully completed the assessment process.

The course is offered using participatory methods and building on the shared knowledge of the participants. The course is skills-based and allows participants the opportunity to find solutions to problems they may identify as managers.

Admission requirements

Pre-course work: Each module is supported with customised precourse materials. The pre-course material is user-friendly and afford delegates the opportunity to apply key learning concepts to their own jobs within their own working environment. Delegates are expected to complete these modules prior to attending the workshops.

Cost and Dates

These components have been designed to ensure: • acquisition of knowledge • application of such knowledge in a simulated learning opportunity • the development of a frame of reference on the subject • assimilation of skills

The admission requirement is a Grade 12 National Senior Certificate OR a NQF Level 4 qualification.

Now open for DISTANCE ENROLMENT PRICE R8 500 (incl VAT) Deposit: R4 250 Payable with Registration

FOR MORE INFO PLEASE CONTACT CHANTAL ODENDAAL / CHANTEL HIRA Tel: 012 816 9103 / 9110 Fax: 086 567 2243 Email: chantalo@foundation.co.za chantelh@foundation.co.za Address: P.O. Box 75324,Lynnwood Ridge,0040 Website: www.foundation.co.za

Foundation for Professional Development (Pty) Ltd, Registration number 2000/002641/07

FEATURES

State of public health update – early 2015 South African Medical Association Trade Union

T

he South African Medical Association Trade Union (SAMATU) would like to thank you dearly for choosing this noble profession, and for choosing to be a member of SAMA and its Trade Union. We would like to tell you that your selfless efforts to provide high quality health services are both noble and admirable. There is no reward or remuneration that can ever be enough for your life-saving services. We strive to unite doctors for the health of this nation. It must never be the case that key health issues like National Health Insurance happen without our active participation and knowledge. We cannot be called essential workers if we are not treated like essential workers.

SAMATU has identified the following key priorities to make your life better: • Push the health minister to finalise the RWOPS policy. Doctors are being unfairly discriminated against and they are being denied an opportunity to make an honest and much needed extra income.

• All doctors should sign performance agreements before the end of April 2015 and all doctors must submit their PMDS which must be processed.

• We demand a common and consistent national policy and implementation of Commuted Overtime.

• All hospitals, community healthcare centres and clinics should have elected shop stewards that we will train and empower to deal effectively with challenges doctors face.

• We all need to start recruiting our colleagues and friends. Our immediate target is 2 000 new members so that we can have our own seat at the bargaining chamber. We are dealing with serious issues affecting doctors at the bargaining chamber, issues like OSD. Currently our demand for danger allowance for doctors is one of the issues we are pushing for your sake.

• We should revive and improve our level of professionalism, and host several CPD programmes to train and up-skill ourselves.

• Advocate for the return of a healthcare system and dislodge the current crippling tender care system. We should be an authority on healthcare issues. We should host a pragmatic trade union convention as soon as possible, one that will devise an action plan towards realising a better healthcare for all.

• We should always remember that the medical profession is a caring profession, 12

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one that requires our participation in community upliftment projects in education, health and other spheres of our lives. You are invited to share your ideas for activities in this regard with the SAMATU General Secretary’s office.

SAMATU will provide you with brief monthly updates to inform and empower you on bread and butter issues. The medical profession has and will continue to suffer because of a lack of knowledge around health policies, and poor understanding of a doctor’s rights and responsibilities as enshrined in the Labour Relations Act. It is our lack of unity, apathy and individualism that is killing our once noble profession. We often get a raw deal from our managers and employers because we are not united, informed or active. When last did you complete your performance assessment and get the bonus you deserved? Do you know that failure to do your PMDS disadvantages you on your OSD progression? Did you ever sign a performance contract? How then are you going to be assessed for your PMDS if you do not know which targets to aim for?

The SAMATU leadership can never make any progress without your support, guidance and active participation. It is time we become the change we want to see. Be proactive in dealing with your problems – establish a workplace forum and elect shop stewards to deal with your issues. Our failure to do such a simple but effective task makes us the worst profession when it comes to dealing with labour challenges. Cleaners and other department of health employees enjoy all the benefits due to them because of this, but we reduce ourselves to ineffective automated ectopic beats. Unity is power. Below are some of the benefits that are due to you as a doctor in the public service: • Annual salary adjustments as determined and agreed to by SAMA and other trade unions together with the State in the PSCBC effective from 1 April.

• A once off payment equal to ten per cent (10%) of the first notch of salary level 8 for the improved qualification that members obtain effective from 1 January 2013.

However, this bonus is limited to one additional qualification only and excludes government-funded studies.

• A push for the inclusion of medical doctors to be covered in terms of a danger allowance.

• Benefit from the services and support of the proposed Government Employees Housing Scheme.

Junior Doctors Association of South Africa (JUDASA) JUDASA is a SAMATU structure that deals with issues affecting junior doctors. They have representatives in hospitals, both provincial and national. Below are key issues they dealt with in January: • Accommodation challenges for interns and community service doctors.

• Working conditions; long working hours and a lack of equipment.

• A recruitment and outreach programme; they have visited hospitals in Limpopo and Gauteng.

• JUDASA will be hosting its AGM in KZN on 18-19 April 2015.

Senior Doctors Association of South Africa (SEDASA) SEDASA is an association of SAMATU dealing with challenges facing the senior doctors. Below are key issues they deal with: • RWOPS issues.

• South African Military Health Services challenges.

• Hosting their AGM on 10 April, 2015 at SAMA HQ in Pretoria.

South African Registrars Association (SARA) SARA represents registrars and has a presence on most campuses. They had their AGM on 7-8 February 2015 in Pretoria. They focus on the following issues: • They conduct registrars’ research workshops to help registrars with their research projects.

• Pre-final examination symposia to help with preparations for final year exams.

• Community Responsibility projects, including: • Refurbishment of Holy Trinity High School in Atteridgeville.

• Distributed scientific calculators and other goodies at Bazindlovu Seconday School in Mthatha, Eastern Cape.

We invite you to contact us directly and guide us on issues or projects we need to embark on. It will take your personal participation to effect the changes you want to see.

FEATURES

SAMATU president Dr Phophi Ramathuba and team win award SAMA Trade Union

Dr Phophi Ramathuba

S

AMA congratulates its Trade Union president, Dr Phophi Ramathuba, after her team was awarded a platinum award as best service delivery team during the Limpopo Premier’s Awards. Her hard work and innovative leadership was also acknowledged in parliament by the official opposition, the Democratic Alliance, in 2014.

‘Walk the talk’ are words befitting a description of our president. We believe that leaders must practise what they preach.

Dr Ramathuba is employed at Voortrekker Hospital as a senior clinical manager and she is currently heading the institution. She has often shared her memories during one of their

morning meetings as doctors and other health professionals when they raised concerns on the re-emergence of malnutrition in Mokopane extensions 14, 19 and 20. Doctors shared their frustrations that on Monday you could admit a child and discharge him/her on Wednesday, only for the child to be re-admitted on Friday.

This vicious cycle would continue as the same child would be discharged on Monday to come back again on Thursday. Unfortunately, some children would even die from this condition. After discussions an initiative was taken to establish a team that will look at the cause of this and come up with turn-around strategies. This was in the spirit of the ancient wisdom that says prevention is better than cure.

The team was composed of doctors, nurses, dieticians, social workers, pharmacists, and community liaison officers. Home visits were conducted and many challenges emanating from ignorance and lack of knowledge were identified. The team agreed on mobilising hospital staff, joined by members of SAPS, Home Affairs, SASSA and a number of NGOs. A door to door campaign on malnutrition was conducted. Children with no birth certificates were provided with this lifechanging document, while those without social support grants were also assisted.

Dieticians educated the community on how to spend their grant money on foods rich in nutritional content. The campaign

was duplicated in all the affected areas. The hospital started to see reduction in admissions of children with malnutrition. The under five mortality was reduced drastically.

The team also has a relationship with the local radio station, Mokopane FM. Every Wednesday, between 14:00 and 15:00, they present topics and interview each other as a means of educating the public. The program is sustainable and it’s used in line with the Department of Health’s health calendar. The team identified a group of elderly retired senior citizens who meet every first Wednesday of the month to help them by giving lectures on health-related issues, and our physiotherapist helps them with exercises that allow them to live a long, healthy life. In recent months, having noted many of them are on chronic medication and often stand in long queues in hospital to collect chronic medication, or go to the clinic where they will be told medication is out of stock, the team is now packaging medication to dispense to the senior citizens monthly during their meetings. This has made the lives of our elderly easy and is about bringing services to our people.

The project taught the staff that selfless hard work without expecting rewards and fame is worth more than silver and gold. We would like to congratulate the excellent team spirit that prevails at Voortrekker Hospital, and urge them to continue serving our people.

FEATURES

NDOH’s new ICD-10 circulars relevant to private and public healthcare SAMA Private Practice Department

T

he National Department of Health (NDoH) has published new circulars on their website dated 26 January 2015. These are of great importance to South African healthcare practitioners.

Circular No 05 of 2014: Inclusion of ICD-10 codes on prescriptions The ICD-10 Ministerial Task Team has received enquiries and complaints from pharmacists with regard to the implementation of ICD-10 Phases 3 and 4.1. Their main concern is that medical schemes reject accounts in cases where the relevant ICD-10 code is not in­cluded on the account. The pharmacists report that legally they may not add their own ICD-10 codes to these accounts. As a result, they need to contact the prescribing practitioner to obtain the relevant information.

They experience immense delays and difficulties in obtaining said information before submitting their accounts. Most of the time they end up using default ICD-10 codes which are clinically not meaningful. The ICD-10 Ministerial Task Team requests that all prescribing healthcare providers add the clinically correct ICD-10 codes to their prescriptions.

Circular No 06 of 2014: Validation of secondary ICD-10 codes All healthcare stakeholders are reminded that full ICD-10 coding validation applies to the primary and secondary ICD-10 codes as well.

This means that all secondary codes will be checked for: • Validity of the code according to the start and end dates as indicated on the ICD-10 Master Industry Table (MIT).

• Maximum level of specificity.

• Correct sequencing.

Circular No 03 of 2014: Generic dictionary – the ICD-10 dictionary The ICD-10 MIT is used as the national standard for ICD-10 coding in South Africa and has been updated in accordance with the corrigenda published by the World Health

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Organization (WHO). The MIT was published on the National Department of Health’s website on 1 January 2014.

The ICD-10 Dictionary published by the Generic Dictionary is not up to date and contains codes that are no longer valid or relevant.

Utilisation of these codes could result in rejections.

The ICD-10 Ministerial Task Team informs all healthcare practitioners, medical schemes, administrators and managed care companies that this list should not be used for coding of clinical conditions or as a PMB identifier.

For example, code A09: The code description has been changed and a fourth digit (A09.0; A09.9) was added to provide more clinical information on the specific condition, therefore A09 is no longer a valid code.

The ICD-10 MIT is available on: www.health. gov.za Notices/ICD 10 Documents/1 January 2014/ICD-10 MIT 2014 EXCEL 1 January 2014.

Circular No 04 of 2014: Errata ICD-10 MIT 1 January 2014: Code Z09.0; reporting of errata The current description of ICD-10 code Z09.0 on the ICD-10 MIT is incorrect. The words

‘malignant neoplasms’ should not be part of the full WHO description.

Reporting of errata on the ICD-10 MIT There could be other corrections that need to be carried out to the current ICD-10 MIT that have been published on the website of the NDoH and implemented on 1 July 2014.

The ICD-10 task team will make such corrections in the next published version of the MIT. The ICD-10 task team requests medical schemes, administrators and managed healthcare companies: • not to reject claims when a code is correct but the description is not; • to report identified errors to the ICD-10 email address: icd10@health.gov.za.

Please refer to the National Department of Health’s website for more information on these new and other circulars as well as additional information about ICD-10 at http://www.health. gov.za/icddoc.php or contact SAMA’s Medical Coding Unit on 012 481 2073 or coding@ samedical.org.

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

Management in health: the new frontier for the public health service Dr Shailendra Sham, Health Policy Committee: SAMA

M

uch has been written about the options for management of healthcare institutions with an ongoing debate as to whether the ideal manager is a healthcare worker with managerial expertise or a management expert with some knowledge of the healthcare environment.

Many in the private healthcare sector have argued for the latter, contending that a private healthcare institution is ultimately a business and its management primarily requires the skills of a good business administrator, allowing the doctors to focus on being clinicians. This is feasible in a private environment where the management of the institution is largely operational and the clinicians are autonomous entities who independently interact with the institution. It becomes more complicated in the public sector where clinicians are employees of the institution and the institution is directly responsible for the management and clinical oversight of its clinician workforce, as well as responsible for their clinical performance and the consequences.

The South African public sector health service has survived a destabilising period where the appointment of public sector hospital CEOs with no medical background and/or questionable administrative skills has been described as a“freefor-all”. Although this practice was subsequently reversed by the current health administration, many institutions are still recovering from this legacy. Even with policies in place to ensure the appointment of institutional managers with appropriate healthcare backgrounds, the public sector still experiences widespread challenges with the administrative capacity of individuals in management positions at all levels in the system.

Like most other public service domains, there is a wide range of individuals at every level in the system, each with their own strengths and weaknesses, personalities and interests. Just as there is a wide range of medical students in each medical school class, interns in each clinical rotation and registrars in each clinical department, there is a wide range of clinician-managers in district hospitals, heads of clinical units and departments in regional and tertiary hospitals, academic heads in teaching units, medical managers and CEOs at larger institutions, district and area managers, DDGs, HoDs and political leadership at provincial and national levels, with

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varying degrees of administrative skills, ranging from exceptional to virtually non-existent. In recent years, a number of strategies have been introduced that have sought to improve the capacity of management at various levels in the system; however while there has been clear improvement or maintenance of effective management systems in many areas, there remain significant challenges in others, ranging from unavailability of competent individuals with key management posts being vacant, to abundant availability of incompetent individuals who have negative impacts on the functioning of their respective systems.

The South African public health service has survived a destabilising period [involving] the appointment of hospital CEOs with no medical background The Occupation-Specific Dispensation (OSD) relevant to medical practitioners is often erroneously reduced to a mere salary adjustment, whereas a key component of the dispensation is the formal differentiation of career streams into clinical, academic and administrative categories.

This introduced a more substantial midlevel administrative function into the clinical domains and departments of institutions, which, although previously present in the key responsibility areas of senior and principal medical officers and specialists on paper, was in the past largely restricted in practice to institutional and departmental managements.

This change, in theory, should better devolve administrative powers, functions and responsibilities throughout the workforce and

result in a more empowered and capacitated workforce overall. Unfortunately, this concept has been variably applied in various institutions and clinical departments.

There are fundamental differences between chronological seniority, clinical seniority, academic seniority and administrative capacity; the first three are often assumed to inherently imply the fourth but this is not necessarily true.

The criteria for appointment to senior, principle and chief posts prior to OSD was highly variable with more senior posts in some cases being used to attract doctors to areas that required more staff, or doctors in some cases being promoted because of duration of service rather than administrative experience or ability. Of course, there were many individuals appointed to these posts who were or are excellent managers, but this association was not guaranteed. Challenges with the understanding and implementation of OSD by existing managements and human resource practitioners resulted in the initial direct translation of posts without a process that established whether the candidate was suitably qualified or experienced. Even now, almost six years after medical OSD was implemented, there is great variability in the administrative capacity of clinicians appointed to administrative posts at all levels.

Another initiative that has been slowly influencing change in public sector health structure administration is the progressive trend by the current National Department of Health leadership and other political leadership to call for and in increasing areas insist on formal training and qualification in administrative areas for candidates applying for management posts.

The Academy for Leadership and Management in Healthcare was launched in 2010 as “a virtual structure that will set standards and accredit programmes”. There are also ongoing programmes of varying quality and depth being arranged for public sector health managers or potential managers, presented by management consultants, the Public Administration Leadership and Management Academy and others. Courses on areas of management such as project management have been presented to doctors facilitated by their institutions and are often covered financially by various training and development grants.

FEATURES

There is a host of administrative courses available for either contact or distant study in South Africa, with varying degrees of focus on healthcare management; of note, SAMA’s Foundation for Professional Development offers an excellent range of management courses tailored for the South African healthcare environment, with the flagship Advanced Health Management Programme being co-accredited by Yale University. For those interested in a broader understanding of the healthcare environment, there are a number of post-graduate courses and degrees in Public Health available, some of which are accessible on a part-time basis.

There are also a number of home-grown publications by leading South African academics available which focus on issues related to the administrative aspects of healthcare.

The incorporation of basic administrative concepts into undergraduate medical curricula is an area that seems to have been neglected. Many junior doctors emerge from undergraduate training being competent clinicians, but yet are unprepared for functioning in a work environment that requires interaction with colleagues, working within a structured hierarchy, engaging with other disciplines

Many junior doctors emerge from undergraduate training as competent clinicians, but unprepared for the work environment and professions, and dealing with the stress of a resource-constrained environment.

Junior doctors often take their interactive and engagement cues from the seniors that they work with, and where that capacity is limited, the foundation may be laid for the development of habits that lead to at best frustration, and at worst, labour relations difficulties. SAMA should play an active role in contributing to the education of junior doctors on basic managerial, labour relations and professional conduct, proactively from undergraduate level, which will undoubtedly not only improve job satisfaction and promote a healthier work environment, but is likely to decrease the downstream labour relations issues that SAMA deals with on a regular basis.

It is inevitable that for the public sector health service to function effectively there needs to be

optimisation of, and innovative approaches to, healthcare management at all levels, from national and provincial, to institutional, departmental, and intra-departmental levels.

Managerial skills should not be seen as the domain of institutional and departmental heads only; doctors at every level should be empowered and skilled to understand and deal with administrative issues at their own levels, and escalate them appropriately and efficiently. The development of a clinicianmanager cadre of doctors should be seen as the next phase in the public sector health revolution that will empower us, improve our workplace satisfaction, and undoubtedly positively impact on clinical outcomes.

If you have any queries regarding this article, please forward your correspondence to Shailendra.Sham@gmail.com.

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 h, 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 e-mail, to Ms Nandie Makatesi at nandie.makatesi@uct.ac.za by

no later than 31 May 2015.

SAMA INSIDER

APRIL 2015

17

SAMAREC/CPD SERVICES AVAILABLE: 타

South Africa Medical Association Research and Ethics Committee SAMAREC

타

타

WHAT WE ARE ABOUT SAMAREC:

CPD:

Evaluating the ethics of research

Assisting health professionals to

protocols developed for clinical

maintain and acquire new and

South African Medical Association

trials conducted in the private

updated levels of knowledge, skills

Continued Professional

healthcare sector. Ensuring the

and ethical attitudes that will be of

Development Accreditation

protection and respect of rights,

measurable benefit in professional

safety and well-being of

practice and to enhance and

participants involved in clinical

promote professional integrity. The

trials and to provide public

SA Medical Association is one of

health to the nation

assurance of the protection by

the institutions that have been

o

Excellent Service

reviewing, approving and providing

appointed by the Medical and

o

Quick Turnaround

comment on clinical trial protocols,

Dental Professions Board of the

o

Efficiency

the suitability of investigators,

Health Professions Council of SA

facilities, methods and procedures

to review and approve CPD

used to obtain informed consent.

applications.

Our Mission: o

Empowering Doctors to bring

For further information please contact the SAMAREC/CPD Secretariat on 012 481 2000 OR email us on samarec@samedical.org or cpd@samedical.org

MEDICINE AND THE LAW

High expectations The Medical Protection Society shares a case report from their files

M

r O was a 24-year-old man who h a d j u s t e n j oye d a h o l i d ay overseas. On the return journey he started vomiting. The nausea and vomiting continued after he arrived home and he began to lose weight because of it. When his symptoms did not abate he made an appointment with his GP. H is GP documented a four-week history of nausea and vomiting and, after reviewing normal blood tests, referred him to gastroenterology. The gastroenterologist wrote back concluding that he had found no significant pathology on endoscopy or ultrasound, and that he thought that anxiety was contributing to his ongoing symptoms.

Irritable bowel syndrome was also considered to be a factor.

Mr O asked his GP for a private referral to neurology, which he agreed to. The neurologist arranged an MRI scan, which was normal, and felt that Mr O was suffering from a significant depressive illness from which he had partly recovered. Mr O did not agree with this diagnosis and felt that his symptoms had a physical rather than a psychological cause. He did, however, agree to see a psychiatrist, who concurred that his symptoms were due to anxiety and depression. He prescribed venlafaxine and arranged CBT. Mr O was struggling with fatigue in addition to the nausea and was not coping at work, so he visited his GP again. His GP referred him to a specialist in chronic fatigue who wondered if he might be suffering with post-viral fatigue syndrome.

Mr O was convinced that there was a physical cause for his symptoms and demanded a second neurological opinion.

This was sought but nothing abnormal was found on examination, repeat MRI or lumbar puncture. He had mentioned some dizziness and had an audiometric assessment showing abnormal canal paresis to the right. The neurologist concluded in a letter to the GP that “the only abnormality found in spite of extensive investigations was a mild peripheral vestibular disorder”. The letter detailed that he had been seen by a physiotherapist who had instructed him in Cawthorne-Cooksey

exercises and that he had been asked to continue these at home.

Despite doing the vestibular rehabilitation exercises at home, Mr O failed to improve.

He still felt weak and light-headed and had moved back in with his parents who were worried about him. They made him another appointment with his GP who referred him for an ENT opinion.

The ENT consultant took a detailed history and noted the absence of tinnitus, vertigo or deafness. She could not find anything abnormal on examination and thought that a labyrinthine problem was unlikely to be the problem. She repeated the balance tests, which were normal.

Years went by and Mr O became very focused on his symptoms, feeling sure that a diagnosis had been missed. Opinions were sought from an endocrinologist, a professor in tropical diseases and a private GP. Nothing abnormal could be found and no firm diagnosis was made. A neuro-otologist thought that his symptoms were due to a combination of “anxiety with an associated breathing pattern disorder, a migraine variant and physical de-conditioning”. A joint neurootology/psychiatry clinic concluded that it was “a confusing story with nebulous symptoms but it was probably a variant of fatigue disorder with a depressive element and derealisation”.

Mr O was very frustrated at the lack of diagnosis or improvement in his symptoms. He felt that the sole cause of his symptoms was a peripheral vestibular disorder. He made a claim against his GP, alleging that he had failed to make the diagnosis and that he had also failed to arrange vestibular rehabilitation.

MPS instructed expert opinion from a GP and a professor in audiovestibular medicine.

The experts felt that Mr O’s GP had not been at fault.

The professor in audiovestibular medicine was sceptical regarding the diagnosis of a vestibular disorder. He noted that repeat audiograms and tympanograms had been normal and felt there was no robust evidence that he had a peripheral vestibular disorder.

He stated that there was no clinical history suggestive of vestibular pathology at the onset of Mr O’s illness. He also commented

that there had been no consensus amongst various specialists as to the true cause of Mr O’s symptoms and that to claim that a peripheral vestibular disorder was the sole cause was an overly simplistic view.

The GP expert noted that the neurologist’s letter to the GP referred to Mr O having been instructed by the physiotherapists in Cawthorne-Cooksey exercises. These are vestibular rehabilitation exercises so it was wrong to say that there had been a failure to arrange the exercises or that this was the responsibility of the GP. The expert explained that GPs are not trained to instruct a patient in vestibular rehabilitation exercises and are not likely to have direct access to specialist physiotherapists who could arrange these. The expert noted that a large number of specialists saw Mr O over a prolonged period, all of whom failed to reach a consensus on the cause of his symptoms. The expert’s view was that the treatment provided was reasonable and that the standard that the claimant sought to apply was too high.

Mr O withdrew his claim before it went to court.

Learning points • The defence of this claim was helped by the contents of the correspondence to and from specialists, which were relied upon to disprove some of the allegations made. It is important to take the time to write comprehensive referral letters and to read letters from specialists carefully. Correspondence is an important part of the medical record, as well as being important communication between clinicians.

• Mr O clearly had a very difficult time.

There had been a protracted period of time with no clear diagnosis. However, in the circumstances of this case, this did not equate to negligence.

• This case highlights the standard doctors must meet in order to refute negligence claims – that of a responsible body of their peers (GPs in this case), rather than a specialist in the condition in question.

SAMA INSIDER

APRIL 2015

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GENERAL NEWS

Involvement of physicians in inhuman state punishment condemned by WMA World Medical Association

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he World Medical Association (WMA) has condemned unreservedly the practice in Iran of involving physicians in applying punishment to convicted people.

Following the recent case of an Iranian man who was deliberately blinded after being convicted of pouring acid on another man’s face, the WMA has written to Iran’s supreme leader, Ayatollah Khamenei, condemning both the inhuman punishment and the involvement of physicians.

WMA president Dr Xavier Deau writes: “We condemn strongly such inhuman punishment.

This cruelty is not justice, but a form of torture prohibited by international law. There is no value or gain from this action, only further suffering.

“We are also particularly concerned by the involvement of physicians, as they are asked to cooperate with the Iranian authorities in the application of this punishment. By doing so, physicians are required to participate in the enabling of the sentence. They participate in unacceptable acts of torture and other cruel, inhuman or degrading treatments. This is a flagrant violation of a fundamental principle of

medical ethics “First do no harm”. We condemn unreservedly this abhorrent practice.

“We urge the Iranian authorities to immediately stop carrying out these inhuman punishments and only implement sentences in line with international human rights law.”

Dr Deau also called on Ayatollah Khamenei to promptly take all necessary steps to address the WMA’s concerns and demands concerning the sentence of flogging imposed on the jailed Iranian cleric Sayed Hossein Kazemeyni Boroujerdi, serving an 11-year prison sentence and in urgent need of medical treatment.

WMA calls for official investigation into ISIS organ harvesting World Medical Association

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he World Medical Association (WMA) has joined the international call for the United Nations to investigate reports that the Islamic State of Iraq and al-Sham (ISIS) is involved in harvesting human organs to raise funds for its terrorist activities.

The WMA’s demand follows comments earlier this week from the Iraqi ambassador to the UN that the terrorist organisation was forcing doctors to remove human organs and executing those doctors who refused to participate.

WMA president Dr Xavier Deau said: “If these reports are correct it means there is a horrifying trade in human organs on an almost

industrial scale being carried out by these terrorists. The reported involvement of doctors in this activity must be investigated, as well as claims that those doctors who refuse to take part are being executed.

“We urge the United Nations to intervene as soon as possible to investigate officially whether there is any truth in these reports and the claims that mass graves have been discovered full of bodies with surgical scars and missing kidneys. We also need to know what role transplant surgeons are playing in using these organs and where necessary take action.”

SEDASA AGM coming up

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ll senior employed doctors are cordially invited to attend the 2015 Annual General Meeting (AGM) of the Senior Employed Doctors Association of South Africa (SEDASA). The theme of the AGM will be ‘Moving Towards Action for Doctor’s Issues’.

Join us in tackling the issues doctors face at the coalface everyday, including: • Expanding support for members • Industrial relations

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APRIL 2015

SAMA INSIDER

• Overtime • RWOPS • Training and standards compliance SAMA and SEDASA will sponsor delegates on a first come first serve basis (we can accommodate five delegates per province).

Venue: SAMA Head Office, Erasmuskloof, Pretoria

Date: 10 April 2015 Time: 09H00 (registration starts at 08H00) Please contact Ms Girly Moseki, committee co-ordinator, on 012 4812092 or email girlym@samedical.org. Please supply the co-ordinator with dietary requirements upon confirmation of attendance and indicate whether you will be driving or flying to the venue.

KEYNOTE SPEAKERS

ASSA Prof Walter Biffl (USA) SAGES Dr Nageshwar Reddy (India) Dr Ailsa Hart (UK) Prof Chris Mulder (Netherlands)

SASES Prof Didier Mutter (France) VASSA Prof Iris Baumgartner (Switzerland) Dr Nils Kucher (Switzerland)

TSSA Prof Herman du Plessis (SA)