THE SOUTH AFRICAN SOCIETY OF OTORHINOLARYNGOLOGY HEAD AND NECK SURGERY
PRESIDENT’S REPORT 2013
- STATUS OF THE ACADEMIC INSTITUTIONS
The SA Society for ORL- HNS is extremely grateful for the work being done by the Heads of Departments (HOD’s) and consultants at the various training institutions nationwide. Training of pregraduate and postgraduate students is increasingly challenged due to limited resources at governmental hospitals, shortage of consultants (also in other departments such as Anaesthesiology), long waiting lists, antiquated or dysfunctional equipment, limited theatre time and declining nursing standards. A recent survey completed by the HOD’s highlighted the shortcomings in terms of the staffing, equipment, waiting times and facilities at the various institutions. The EXCO is concerned however about the availability of consultants at the training institutions which probably results from a combination of factors such as a lack of applications to vacant positions, working conditions, and time spent by some consultants who has already been appointed away from the institutions so that they can attend to their private practices. Pertaining to the issue of RWOPS (Remunerative work outside of the Public Service) the EXCO expressed their viewpoint as follows:
- It is illegal for a full time surgeon to conduct private practice outside the times determined by the RWOPS agreement, it in essence implies that the surgeon would be contravening the employment contract.
- It is unethical for a full time surgeon to neglect his/her responsibilities to training registrars and care for provincial patients when contravening the RWOPS.
- It is unfair and immoral for a full time surgeon to charge less than colleagues in private practice as the surgeon is already earning a salary from an employer, in fact, the full timer should actually charge more.
- It is unfair and immoral for a full time surgeon to sign DSP or payment arrangements with funders which pay the same to all levels of experience and expertise, particularly when the surgeon is in a senior position in the province or has a superspeciality.
- It is immoral (corporate governance issue) for a funder eg Discovery Health to agree to pay a surgeon (the payment arrangement) when the surgeon works in contravention of the employment contract with the province.
The ongoing inability of the University of Kwazulu-Natal to appoint a Head of the ORL Department during the past four years still remains of concern and will hopefully be resolved in due time.
We would also like to welcome the newly established Department of ORL-HNS at the University of Limpopo campus in Polokwane and congratulate Prof Omoding as the new Head of the Department. The evaluation process that was followed by the Departments of Health and Higher Education in terms of the decision process to establish an ORL-HNS department in Polokwane, remains of concern, as no independent otolaryngologists were involved.
- REGISTRAR’S ASSOCIATION
The Society would like to congratulate the Registrar’s Association in the way the association is functioning to improve and manage issues pertaining to ENT registrars. We particularly would like to commend Dr Gavin Quail and his committee for the ongoing effort in maintaining the National Registrar Quality of Training Survey project where facilities and tuition at the various training institutions are anonymously being evaluated, in an attempt to identify areas where affected institutions should improve.
It was decided by the EXCO two years ago to ring fence the grant allocated to registrars so that it can be administered by an appointed registrars committee. Registrars are therefore encouraged to communicate with the registrars committee to familiarize themselves with the requirements when they apply for funds.
- SAMA and SAPPF
The Society’s relation to SAMA and SAPPF appears to be a contentious issue from time to time. The issue has been discussed at the last EXCO meeting and a written formulated standpoint will be issued shortly. It remains the view of the EXCO that the Society is an independent association that will side with an institution who will to the highest standard promote and benefit the values, principles and goals of the Society and it’s members. We appreciate that Government employed members may find membership to SAMA beneficial as they are obliged to belong to a representative union where SAMA may fulfill that role, as SAMA is affiliated to COSATU. SAMA in recent years however failed dismally to act benevolently on behalf of private practitioners, a role that has efficiently been fulfilled by SAPPF.
- DESIGNATED SERVICE PROVIDERS (DSP’s)
Various medical funders, specifically GEMS, are attempting to negotiate contracts with individual doctors to establish DSP’s. When they realized that they were unsuccessful in their negotiations with SAPPF or the various Societies, they changed their strategy to include individual doctors, which conforms to the simple principle of divide and rule.
The ENT Society’s viewpoint is that engagement in talks will take place when the following conditions are met and placed on the agenda:
- Establishment of tiered consultation fees.
- Establishment of equal rand unit conversion rates for both surgery and consultations.
Considering the ethical implication of signing as DSP’s we would like to reiterate SAPPF’s viewpoint, which was also submitted to the HPCSA earlier this year. SAPPF believes that payment arrangements and DSP contracts are unethical for the following reasons:
- It contravenes the Hippocratic principles of “non-nocere”, justice and autonomy. Contracts interfere directly with the patients’ right to choose and the autonomy of the doctor-patient relationship. Dual loyalties arise which affect choice of management e.g. medicine in restrictive formularies that will cause a sense of obligation amongst signed doctors or enforce prescription of formulary medication. Patients are unjustly exposed to third party profits overriding care. Absence or lack of quality assurance/controls exposes patients to signed up networks which are based on the fees charged only, rather than quality or availability of service. There are no checks on service by signed up doctors nor guarantees of emergency or holiday/weekend cover from contracted doctors.
- Unforeseen consequences such as poorer care/outcome may result from restricted investigations or medication, which a signed up doctor is obliged to follow. No attempt is made towards cost effective care. The arrangements target cost reduction only.
- They are counter altruistic e.g. 50% of patients on the Discovery Health (DH) payment arrangement are on losing (financially) plans. This results in cross-subsidization from patients on lower plans (mostly lower income patients). The CEO of DH has previously stated (in a report to shareholders) that the payment arrangement with doctors had increased profits for DH. It is therefore clear that profits, and not cost effective care, drives payment arrangements. There is no independently verified research demonstrating positive outcomes from payment arrangements other than increased profits to third parties. By signing these arrangements doctors participate in diverting funds meant for healthcare to third parties.
- Payment arrangement doctors or DSPs charge fees based on the particular fund plan. Therefore patients paying higher premiums pay more for the same evaluation/surgery (with payment arrangement doctor/DSP) than those paying lower premiums, which is an unjust practice. It remains unprofessional as the contracted doctors adjust their fees according to the payment plan, and not on experience or quality of service. Traditional referral principles based on peer review is replaced with referrals based on fees charged under the payment arrangements. This undermines any quality controls practiced by referring doctors.
- Patients with PMB conditions may be exposed to inferior care, as payment doctors/DSPs are not quality assured. If these patients seek care at better centres or with peer reviewed doctors, they are not protected by the Act on PMBs and will be exposed to co-payments or payment in full (e.g. Discovery Health members). Doctors signing payment arrangements that do not ensure equal care for patients are responsible for the added stress on patients seeking peer reviewed care, as they are not covered in full. This constitutes unethical behaviour.
EXCO believes that payment arrangements and DSP contracts must have the following to meet ethical requirements:
- Quality assurance and peer review is essential.
- Conditions should meet the patient’s need for time, respect and compassionate treatment.
- Arrangements should recognize professional expertise, experience and training.
- Arrangements should not undermine the Act regarding PMB payment and co-payments.
- Formularies should be based on best practice and peer review, which cover unusual circumstances and responses.
- Arrangements should benefit the patient and not the third party administrators.
Please note that none of the current payment arrangement/DSP contract meets these requirements. We would therefore like to urge colleagues not to consider becoming part of DSP’s or payment arrangements.
- HOSPITAL CONTRACTS NETCARE
Hospital Groups increasingly demand from members of our Society to engage in the signing of contracts, or the completion of questionnaires that incorporates irrelevant personal data. Through the services of Webber Wentzel legal consultants a concept contract was drafted to assist our members in negotiations with their respective hospitals, and should be used by our members.
Netcare recently issued contracts and questionnaires to our members requiring them to complete and supply irrelevant detailed personal information. A meeting was subsequently held between Netcare and Mr Casper Venter from Healthman upon which it was resolved that no further contracts or questionnaires have to be signed or completed by our members. The management company (MANCO) or Healthman should be consulted if members are required to engage in future negotiations.
EXCO continuously receives requests to grants and we would like to urge members to familiarize themselves with the requirements to grants which are available on the website.
HOD’s are also reminded about the requirements and deadlines for departmental grants. EXCO would like to reiterate that departmental grants will only be issued to departments that fully complied with the requirements, which in essence means that each member of the department (consultants and registrars) should be paid up members of the Society.
The EXCO constantly receives requests from members to be sponsored for fellowships, especially to fund fellowships abroad. The EXCO is investigating the possibility of establishing funded fellowships locally. It is unfortunately impossible to consider sponsoring and funding fellowships abroad.
- FUTURE CONGRESSES
The way in which future congresses will be hosted will have to be evaluated and the model that served us well for many years will probably have to be revised. A questionnaire requiring your participation will be distributed electronically and your opinion and cooperation is highly valued.
It remains the sentiment of the EXCO to encourage the establishment of Specialist interest groups such as The Cochlear Implant Society, SA Association for Facial Plastic and Reconstructive Surgery (SAAFARS), etc. We would like to remind the Societies that a constitution needs to be submitted and would urge existing groups to revise their constitutions and resubmit.
- HISTORY OF THE SOCIETY
The EXCO wishes to compile a history of the Society and we urge members to submit photographic material and even record and submit events in which they participated that they think may contribute to the history of the Society.
A membership card of the Society for ORL-HNS will be issued and posted in due time. Membership cards will be valid for a year and issued annually to paid up members. New Society ties have been designed and will hopefully be available at the next congress.
- BUSSINESS ASSOCIATIONS WITH AUDIOLOGISTS
We want to remind members that it is illegal to engage in official business partnerships with audiologists.
- CONE BEAM SCANNERS
Several requests about ownership and operation of cone beam scanners have been received. It is unlikely that otolaryngologists will be enabled to own and operate cone beam scanners due to the following reasons:
- Doctors have to be licensed to own radiologic equipment, which can only be done with accredited training. The Radiology Society already indicated that they will not endorse such training for obvious reasons, which will render licensure impossible.
- Operation of such a scanner poses medico-legal implications if operators miss underlying pathological conditions.
- It may be possible to own a scanner in association with radiologists.
- FUTURE LEADERSHIP
It is most important to identify members in your respective communities displaying the willingness, ability and diligence to be involved with matters concerning the well-being of the Society. We urge members to identify those colleagues and encourage them to become active in activities of their respective regional societies, learning about the structure and culture of the Society in preparation for service at national levels.
- NEW WEBSITE
A brand new website has been launched today which sports a new look and will hopefully make navigating through the site more user friendly.
DR JACQUES VILJOEN
PRESIDENT: SOCIETY OF ORL-HNS
29 September 2013