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Doctors and hospital CEOs: bridging the communication divide

By David A Steynberg

Miscommunication between doctors and hospital management are many times to blame for a deterioration in services in the public sector. This is according to Junior Doctors' Association of South Africa (JUDASA) president, Dr Kgopotso Pege, who says that even when things like IV lines or oxygen masks are in short supply, doctors don't elevate the issue to management.

“You tell doctors to call their CEOs and ask them how they're supposed to work when they don't even have the equipment to resuscitate a patient and, no, doctors will make a plan,” Dr Pege says. “They'll borrow and improvise and when their hours are completed for the day they drive home and it's not their issue anymore. So, in the long run, we as doctors don't apply the pressure for things to get fixed quick enough.”
There are two reasons for this behaviour, according to Dr Pege: one is that doctors don't like to ring alarm bells and be called out as a troublemaker, choosing to work below the radar; and two, doctors are too passive and don't take the time to fix their working environment.
“Doctors just sort of do their bit and say that's where their responsibility stops. They don't go beyond that line,” she tells us. “But that's where the issue is: a lot of problems that happen in hospitals start off small and they just get progressively worse because no one makes management aware that there is something they need to think about or keep an eye on. It then gets to a point where things have fallen apart and it's not something that doctors can hide anymore.”

Dr Pege elaborates, using the example where there will be no water in theatre despite the other wards having water.
“People would go and collect water with buckets and this would just continue,” she says, adding that doctors do tend to improvise too much. “While there is no disruption to services, services have deteriorated. In theatre water is important – it's supposed to be a sterile environment. When someone is scrubbing it's supposed to be with running water and not water from a jug.”
It is due to this behaviour where doctors improvise so much and ensure that services are not disrupted, that causes management to not have the urgency to fix the problems.
“You go to places like casualty and you don't have things to strap a drip, so you end up using all sorts of things to put a drip in place and strap it down,” Dr Pege says. “Services are running normally up until a point where you really are in trouble. It starts small and doctors don't make hospital management aware in time so it can come up with contingency plans.”

Back in 2011, JUDASA embarked on a project to get doctors much more active in the management and running of their hospitals. And while it had good intentions, the response was disappointing.
“It was a kind of 'heal our hospitals' survey aimed at asking doctors what equipment they had and what their issues with HR or management was,” Dr Pege says. “Doctors are very passive and don't take part in things like this because they'll tell you they don't have the time. Yet, things fall apart around them. They don't make the time to get involved, yet ultimately it would have been for their own benefit. If we are able to mop up the system, it will be a better working environment for them. We wanted to get an idea of all the stories being circulated in the media, but there was little we could do if we did not have the facts.
“We were trying to establish factors like how many boilers their hospital had compared to how many there were supposed to be. How many were broken and when did maintenance get done. Issues like consumables: what did the supply chain look like and how did the depot supply equipment? Questions like: why do people go without medication? These needed to be answered.”

Back to the present day, Dr Pege says that her organisation is in full support of Health Minister Aaron Motsoaledi's implementation that hospital CEOs need to health professionals. She says that it makes more sense because these are CEOs who understand the system.
“Someone who has no insight into the needs of the hospital is just useless,” she says, boldly. “You have someone who goes and orders a fancy antibiotic yet the hospital doesn't have Panado! You'll have instances where someone order a 20-mil syringe instead of a 2-mil because they believe a bigger syringe is better. You need someone who has better insight into the running of the hospital and what makes it work.”
Dr Pege also believes that the problem of non- as well as miscommunication between doctors and management could be solved by having hospitals run by medical professionals.
“Hospital CEOs need to be people who understand; people who can come down from the office and walk through a casualty ward, a clinic or an outpatient area and see the issues, and how many doctors are there to run a full clinic with 120 patients on a daily basis,” she says. “People don't understand and when stories break in the media communities start blaming doctors. If we could transform the image and have people who understand what the health needs are, I think it would do us a world of wonders. There is a lot of mismanagement in hospitals and a lot of focusing on the wrong things.”
JUDASA's mission to embrace the minister's plan to have health workers as managers because they believe these kinds of managers will really identify with the needs of the hospital.

interview

Intercare: a model for healthcare

By David A Steynberg

Each year more and more South Africans are joining private healthcare due to medical schemes offering increasingly affordable insurance packages. The National Health Insurance scheme will also, in the long term, cast the net wider in order to provide residents with quality basic healthcare.
At the same time, the public hospital system is not going to have the beds, doctors and correct infrastructure to cater for this influx of patients requiring medical care. This is where the private sector will play a big role. And more specifically, the day and sub-acute hospital market.
Well, that is if Dr Hendrik Hanekom is right. Years ago, Dr Hanekom, in his role as CEO of the South African Medical Association (SAMA), was viewed as a visionary and often presented to his peers the future of global healthcare. Looking at what was happening internationally, Dr Hanekom said that the status quo of the time was not going to remain for long. He predicted that economic and cost pressures around the world were going to see solo practice making way for group practice. Traditional fee for services were going to move to alternative reimbursement methods; fixed fees would be the order of the day as would per diem rates for certain services.

The birth of SAMA
Many of his words have come to pass, and his own endeavours have quite literally put his money where his mouth is.
After graduating with an MBChB from the University of Pretoria in 1978, Dr Hanekom was stationed at an old mission hospital in Kgapane, outside Tzaneen, for his two-year military service. It was there, watching two experienced general practitioners, Drs Sarel Spies and Noel Pharoah, that Dr Hanekom developed his skills, practicing as a GP for the seven years from 1980 to 1987. He was presented with the opportunity of joining the Medical Association of South Africa, assuming the role of chief executive in 1990. He would spend nine years transforming the representative body into a knowledge-based service organisation and integrating the disparate medical professional organisations into a new, inclusive organisation, SAMA.

Changing the landscape
On the cusp of a new millenium, Dr Hanekom and his business partner, Dr George Veliotes, founded NovaHealth, the holding company for one of South Africa’s most innovative and fastest-growing healthcare companies, Intercare.
It is this space that Dr Hanekom says will go a very long way to ensuring more affordable, accessible healthcare to South Africans.
“What costs medical schemes a lot of money are the high-risk patients (those with a single chronic disease, those more complicated with two to three chronic diseases and those who are functionally impaired as result of a condition such as stroke),” says Dr Hanekom from his Lynnwood offices. “Those high-risk patients consume 60% of the healthcare rand, and due to a lack of coordination these people repeatedly land in hospital.”

Locking the revolving door
The revolving door syndrome - repeat patients - is something Dr Hanekom says can be halted through proper rehabilitation and care coordination treatment programmes offered by groups such as Intercare.
“On the medical side, Intercare caters for routine care, urgent care and chronic care,” he says. “Our integrated Centres for Lifestyle Management focus heavily on chronic lifestyle conditions such as diabetes and hypertension. By focusing on urgent and chronic conditions, we try to ensure patients don’t end up in acute hospitals. But if they have been in an acute hospital for a condition such as stroke, then they can come to us for rehabilitation in our sub-acute and rehabilitation hospitals.”
Sub-acute care has been instrumental in making healthcare more affordable and accessible, simultaneously yielding a high quality of care with quantifiable metrics to demonstrate the impact of interventions.

Sub-acute: a growing sector
As an industry, sub-acute hospitals have evolved into a recognised niche, with its continued growth due to two factors: a clear demonstration of its cost-saving potential; and patient outcomes demonstrate that sub-acute treatment interventions have long-term benefits of keeping patients out of expensive acute hospitals.
Complementary to Intercare’s medical and dental centres, lifestyle management centres, and sub-acute and rehabilitation hospitals, is its day surgery hospitals. Day surgery is quickly becoming a norm in the delivery of healthcare internationally, with 80% of all surgical procedures performed in day hospitals in Canada, 70% in the UK and 60% in Australia. South Africa, however, lags behind at only 15%, with studies proving that costs are 25% to 68% cheaper for day surgery than the same inpatient procedure.
With two day hospitals already operational, Dr Hanekom believes Intercare is well positioned for the anticipated increase in patients nationally.
“We have a risk-sharing platform and have doctors, dentists, nurses and various other professionals” says Dr Hanekom. “Our model lends itself to the NHI which we will embrace as a collaborative partner. It’s another funder of healthcare to provide more care to more people.”

interview

The rural retention

By David A Steynberg

Each year South Africa’s eight medical schools produce around 1300 doctors, of which around half (650) leave the country. Some 75% get employed in private healthcare, which leaves about 160 medical professionals to be absorbed into the urban public healthcare system. Only about 40 are employed in rural public healthcare.
This is according to Retha Grobbelaar, communications head at Africa Health Placements - a donor-funded organisation which facilitates attracting and retaining foreign-qualified doctors in our rural public health system.
With high population proportions to medical professionals in our rural settings, quality of care is negatively affected and burinout is high, according to Grobbelaar. “Morale is low and they often don’t feel supported,”she says. “This causes doctors to leave the rural healthcare system, as well as the country.”
While numbers are hard to come by, Grobbelaar says that from her organisation’s own records, some 23000 South African health professionals are scattered around the world - mostly in Australia, New Zealand, Canada, the US and the UK.
According to a 2011 report entitled The HRH Strategy for the Health Sector: Human Resources for Health South Africa, countrywide there is a shortage of over 80000 healthcare professionals. The report states that is is possible to close this gap in the next 20 to 25 years.
This is why organisations like Africa Health Placements are vital. Grobbelaar explains the work they do: “We study the disease profile of the rural population, look at the human resources of the hospital as well as which services are needed and then place the doctors where they are needed most,” she tells us. “We also do logistical orientation such as set up insurance, banking and accommodation, as well as provide workforce support.”
So far, AHP has been successful in attracting and retaining foreign-qualified doctors to rural hospitals, but there still exists a shortage in trained medical staff as well as competent and motivated management.
The first issue is multi-faceted: is it solvable by simply increasing the number of medical universities and, in turn, graduates?
According to Grobbelaar, this is not the solution. “There are no guarantees that these graduates will work in the public healthcare system, never mind in rural hospitals,” she explains, adding that worldwide there exisits a shortage in medical professionals.
The HRH report states that since 2002, the number of health professionals in the public sector has grown: between 2002 and 2010, 4373 more doctors were employed. In fact, overall numbers of workers in the public healthcare sector increased from 153383 to 280511 between 2004 and 2010. While this is a positive step in the right direction, the report paints an even more distressing reality.
“It is evident that the growth of output of graduates significantly exceeds the growth in employment in the public sector,” the HRH report states. “Seventy percent of new graduates produced in the key professions over 10 years were not absorbed into the public sector. Over a ten year time frame, for example, 11700 MBChBs were trained yet only 4403 medical practitioners were employed over the same time in the public sector. In the same period 2104 dentists were trained and only 248 employed in the public sector. Over 80% of physiotherapists and occupational therapists were not retained in the public sector.”
In the rural context, which is home to around 44% of the total population, only 12% of doctors and 19% of nurses practise in this area. Compared with their urban counterparts, only 5.4% of rural dwellers belong to a medical aid and infant mortality sits at 52.6 per 10000 births (the Eastern Cape is as high as 70).
Grobbelaar says that according to their research, the lack of retention in rural public hospitals is mainly due to a lack of good management and support by the hospital and district management.
Positively, the National Department of Health last year launched the Academy for Leadership and Management in Health Care which seeks to address and redress the lack of quality management and leadership, as well as to address skills gaps at all levels, including clinical and hospital management. “It is so important like never before to speak out about the skills, experience and vital role that this profession plays and sharing that with those who want to further improve the country’s health and wealth - and outcomes for patients and the public,” health minister Dr Aaron Motsoaledi said at the launch.
Although there are other ways of increasing the access of populations living in remote and rural areas to adequate health services, for example through different models of service delivery, or through internationally recruited health workers, these recommendations focus only on interventions that are within the remit of human resources planning and management. The four main categories of interventions include education, regulation, financial incentives, and personal and professional support, such as improved living conditions and personal safety.
Grobbelaar says one of the main reasons for foreign-qualified doctors choosing to live and work in rural South Africa is dissolusionment with their own health systems, displacement due to political instability and civil war, as well as their interest and desire to gain valuable knowledge in our diseases and trauma.
“Many admit to being bored treating stomach bugs and flu,” Grobbelaar says. “Working in a rural hospital gives them a sense of making a difference while practising interesting medicine.”
With such a shortage of healthcare professionals in our rural hospitals, where a great need exists, it’s encouraging to know that non-governmental organisations are working together with government to ensure a steady flow of qualified doctors are sent to these institutions where, hopefully, better resource planning and inspired leadership will ensure they continue to be served well into the future.

interview