The Voice For South African Private Practitioners

The South African Private Practitioners Forum (SAPPF)

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The South African Private Practitioners Forum (SAPPF) was established to protect and defend the role of the private sector in what has become an extremely hostile and volatile environment, and respond to the competing challenges facing the medical profession. Dr Chris Archer, CEO, discusses the challenges, their highlights and the importance of obstetrics

Please tell us about your background, experience and rise through the ranks.

I was born in Johannesburg but grew up and was schooled in what was then Rhodesia, now Zimbabwe. I attended the University of Cape Town (UCT) where I obtained a B.Sc. (Med) and an MBChB.

Following a stint in the Rhodesian Army and General Practice, I returned to UCT to train as an Obstetrician and Gynaecologist. I moved to Johannesburg in 1990 and have been in private practice in Johannesburg since then.

Who were some of your mentors growing up and for you, what does good leadership entail?

I studied medicine at UCT at the time when Chris Barnard performed his first heart transplant and his influence was profound on all impressionable medical students at the time. His courage to enter uncharted waters and his dedication and professionalism made a great impression. These characteristics together with a vision for the future and a desire to make a difference are, I believe, important characteristics of a leader. Reading, learning and being a lifelong student but, ultimately, understanding yourself and being your own man are also important attributes.

What are some of the challenges facing specialist private practitioners?

Being a doctor is enormously rewarding. It offers unique opportunities to any human who is attracted to it as a career, whether that career is working in the public service or in private practice. Many doctors working in the private sector today are drawn to private medicine because of a desire to be their own boss. Others find themselves in the sector because of a growing dissatisfaction with the work conditions in the public service, or simply because of the government policy that prioritised primary healthcare.

Medicine, like most professions, is constantly changing and the need to continuously adjust your sights and adapt is an ongoing challenge. Charles Handy in his book The Second Curve- Thoughts on Reinventing Society says that all things human follow a trajectory that resembles a Sigmoid Curve—a mathematical concept but one that is often metaphorically used in phrases such as ‘a learning curve’, or ‘being ahead of the curve’, a phrase used by many businesses when projecting the future.

Today, that future is uncertain. The state’s intention to introduce the National Health Insurance (NHI) suggests the private sector’s future role is unclear. Whether the private sector will be able to co-exist with the state in a single-payer system or be consumed in its entirety by the NHI is unknown. What is clear, however, is that if the private sector is to survive it will have to adapt—to enter a trajectory described by Handy as a Second Curve. For Second Curves to be successful, however, Handy believes they need to start before the first curve peaks. That is the challenge facing the private sector in South Africa today, we are seeking our Second Curve.

Why do some specialists need to pay enormous monthly insurance fees?

We are living in an increasingly litigious world, added to which there is an unrealistic expectation regarding the ability of modern medicine to solve all of mankind’s health challenges. Certain disciplines, such as my own of OBGYN, are amongst the most at risk. There are a number of reasons for this; chief of which is that obstetricians deal with a new life, and with all the joy and excitement and expectation associated therewith, so when something goes wrong, not only are the parents and families understandably devastated, but there are enormous potential damages claims for loss of income and ongoing medical expenses.

How do we compare to other countries and what solutions do you propose?

Overall, we do not compare well. Our private sector is similar to that of other first world countries except for an unacceptably high caesarean section rate where we compete with Brazil in having the highest in the world, but our public sector performs very poorly in relation to our peers.

In the public sector, the training of nurses and improvements in managerial skills of public institutions need urgent attention. In the private sector, emphasis on quality rather than price through the reorganisation of solo practices into integrated care units and the introduction of performance matrices are needed urgently.

What is the biggest lesson you learnt as an obstetrician?

Man is living longer and more productively through the introduction, not of medical breakthroughs, but through the provision of cleaner air and water, together with better sanitation and nutrition. However, life’s most perilous journey is the one we take through our mother’s birth canal and here, the application of science and medicine has dramatically reduced the maternal and neonatal mortality and morbidity figures. When things go wrong during labour, women need urgent attention and those who insist on having their babies at home place their children’s futures in jeopardy.

The modern obstetric practice conducted in a suitably equipped hospital with trained staff available to deal with all obstetric emergencies, despite its undoubted deficiencies, trumps home deliveries from a safety perspective.

What is the ethos of the SAPPF and social responsibility?

The ethos of SAPPF is simply to provide the best care possible for our patients. Our vision is the achievement of an integrated, appropriately funded, affordable quality healthcare service, accessible to all who live in South Africa, and in which the private sector is able to co-exist in a symbiotic relationship with the state.

What is the extent of claims faced by private specialists when negligence is a factor, and are there any fraudulent claims?

Both true, negligence and fraud are, I believe, relatively small issues involving private specialists, although both exist and we are working hard to lessen the impact of both on society.

With respect to negligence, I believe that no health professional knowingly and deliberately starts his or her day with the intention of doing someone harm but as Atul Gawande points out in his book The Checklist Manifesto: How to Get Things Right, modern medicine is an extremely complex enterprise and has become the art of managing extreme complexity. The Ninth Edition of the World Health Organization’s (WHO) International Classification of Diseases lists 13 000 different ways that the body can fail and today, clinicians have at their disposal more than 6 000 drugs and 4 000 medical and surgical procedures, each with different requirements, risks and considerations. It is as Gawande points outs, a lot to get right.

Fraud is a criminal act and the law should make no exceptions just because the perpetrator is a medical professional. SAPPF is working closely with the medical schemes industry to try to stamp out these activities.

What are some of the highlights that SAPPF has enjoyed?

Since its formation in 2008, SAPPF has grown from a few dedicated individuals to one with 23 affiliated disciplines and about 3 000 members. Although our membership is largely specialist based, recent requests by general practitioner groups and The Association of Physiotherapists have been favourably considered, which will double the membership.

This growth in membership has undoubtedly followed the SAPPF success in protecting the rights of private sector professionals from unwarranted or ill-considered attempts to curtail private sector influence.

SAPPF has participated and made representations to the NDOH on NHI, the CMS on the Prescribed Minimum Benefit Review process as well as the Private Sector Health Market Inquiry (HMI). SAPPF has proposed the establishment of a South African Classification of Healthcare Interventions—which the HMI team describes as a ‘really positive proposal.’

SAPPF successfully opposed an attempt by the NDOH to introduce a Certificate of Need (CON) and participated with the HPCSA in proposing an ethical tariff for the medical profession.

Why does the cost of private birth continue to rocket? Are there any solutions?

Cost drivers in obstetrics are multiple and complex but reflect the current cost of providing a quality obstetric service. Structural changes to the way in which the service is provided are being implemented although the current fee for service/solo practice model still predominates. The cost of liability insurance has been driving the cost of care in recent years and the introduction of the South African Society of Obstetricians and Gynaecologists (SASOG) BetterObs Programme and other initiatives are attempting to reduce the risk of adverse events occurring in childbirth. Experience from other countries has shown that this crisis in obstetric litigation that is driving recent cost escalations can be brought under control.

What are your views on the proposed National Health Insurance (NHI)?

My personal view is that the current model of universal healthcare being proposed by the government is, given the current economic circumstances, unaffordable, unattainable and not sustainable. However, having said that, I do believe it is imperative that South Africa moves towards a more just and accessible system than the current two-tier system. WHO believes that every country needs to find its own unique solution and South Africa is no different. The challenge should be not to implement failed doctrinaire ideologies but to marshal all our available resources to provide an accessible, affordable and sustainable quality service for all South Africans.

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