Voices

Poor governance has disempowered doctors, put patients at risk

2017-08-21 23:13

The primary patient advocate is the doctor. Even when the regulator fails, the doctor remains beholden to the patient’s best interests.

However, insufficient governance, especially regarding key medical players such as medical scheme administrators and hospital groups, has resulted in power imbalances that are interfering with the doctor’s role in patient care.

Not all role-players in the healthcare sector are beholden by law or by implementation to protect the patient. Doctors have the closest relationship with the patient and are bound by both the Health Professions Council of South Africa (HPCSA) rules and the Health Act, but more specifically by their own oaths as caregivers to first and foremost protect the patient.

This means that while medical scheme administrators view the patient in aggregate – calculating risks, costs of treatment, diagnosis, probability of recovery and future healthcare – the doctors view their patients as individuals, mainly concerned with the best treatment for the patient and they sometimes don’t take cognisance of the costs.

That’s the only kind of doctor that is safest for the patient, one whose primary focus is the patient’s wellbeing. However, the manner in which doctors treat their patients is now under threat.

There is immense pressure on healthcare providers to contain costs but continue to deliver world-class medical care.

But all the power around costs, protocols and type of care lies with the strong, consolidated medical scheme administrators and hospital groups.

Medical practitioners are not allowed to negotiate collectively, but, for example, medical schemes are able to use the power of their membership base to dictate terms that are not always based on a desire for optimal individual patient outcomes.

This means that good ideas to help enhance patient care and reduce patient costs, such as alternative reimbursement models, often bring with them the risk of patient “disservice”.

The tension between containing costs and providing the safest treatment for patients is a good and valid one, and important in balancing all the needs of the healthcare sector, but that this can only be done effectively if all role-players have an equal voice.

The direct employment of doctors by private hospitals in this environment also adds risk.

The mere fact that the doctor is now an employee of a particular business or establishment, usually a large corporate entity in the case of the current consolidated private hospital groups, puts the doctor in a vulnerable position.

As an employee they now have to answer to their employers, most of whom are answerable to shareholders, even if they would like to hold the patient’s best interests as central.

The inability of doctors to have clinical autonomy in this environment is the reason the direct employment of doctors is not permitted by the HPCSA, but this is under threat with permissions being sought, and even sometimes granted by the HPCSA, for exemptions.

While an anaesthesiologist often is not a patient’s primary contact and the patient may not have the same relationship with them as they will with their surgeon, for example, their primary and overriding responsibility is to the safety of the patient.

It is the anaesthesiologist’s responsibility to ensure the patient is fit for surgery, remains safe throughout the procedure, and that their pain and experience is managed with the best possible care.

As such, these doctors, who are specialised in this field, have a deep commitment to the wellbeing of the patient.

This role extends to advocating with funders and other healthcare providers such as hospitals, nurses, allied health workers) for the needs of their patient.

The power imbalance in the advocacy of patient rights is exacerbated by a lack of resources to enable effective monitoring by the country’s regulators.

All regulators, from medical schemes and hospitals to practitioners, are under-resourced and insufficiently empowered to enforce regulations.

For example, the Council for Medical Schemes is so underpowered and under resourced that its backlog of complaints is almost unmanageable, with years sometimes passing before specific cases are heard.

The council not have the budget or personnel to effectively regulate the medical schemes and administrators.

The Office of Health Standards Compliance, tasked with inspecting health establishments such as clinics and hospitals to determine if they comply with current regulations, is a new and severely under-resourced entity that does not even yet have clear regulatory power over private hospitals, let alone the capacity to enforce any regulations.

It is critical that doctors be allowed to continue in the role of patient advocate, beholden only to the patient’s best care, and the government needs to ensure that nobody, medical scheme administrators or otherwise, interferes in your best healthcare as the patient.

It’s your doctor that’s looking after your best interests as the patient, and the doctor needs to be empowered to continue to oversee your care.

The government needs to support entities such as the Office of Health Standards Compliance and the Council for Medical Schemes. The checks and balances are missing, making for an incredibly dangerous environment for patients,” she adds.

Natalie Zimmelman is chief executive of the South African Society of Anaesthesiologists

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December 10 2017