South African Society of Anaesthesiologists (SASA)

South African Society of Anaesthesiologists (SASA) SUBMISSION ON THE OFFICE OF HEALTH STANDARDS COMPLIANCE MARCH 2012 1

1. WHO SASA IS AND ITS RELEVANCE IN A TRANSITIONING HEALTHCARE SECTOR SASA welcomes the opportunity to comment on the National Health Act Amendment Bill, as a key preparatory step for a better healthcare system. SASA is the South African Society of Anaesthesiologists, a professional association dedicated to the furtherance of the discipline of anaesthesia at both an academic and a clinical level and is devoted to the welfare of its members. SASA provides members with many services including free access to the official Journal of the society, numerous CPD activities, support and advice from experts, the production of practice guidelines as well as guidance and assistance over issues such as ethical billing practice, generic substitution and informed consent for anaesthesia. SASA comprises five business units, which are all relevant to various aspects of the envisaged NHI and the reforms leading up to it, viz.: Unit Scope Relevance for OHSC Education Medical schools; awards endorsed by the Society, guidelines & standards for anaesthesiological practice; 1 CPD (Continuing Professional Development); society publications, such as the South African Journal of Anaesthesia and Analgesia OHSC norms & standards; Clinical Governance ( Evidence- Based Medicine and related to the National Coordinating Centre for Clinical Excellence). Regulation SASA Constitution; Peer Review; Practice guidelines Congress & AGM; regulatory bodies (HPCSA, etc.). OHSC ombud; scope of practice, ethical behavior; quality of care Public sector Labour relations; OSD; Registrars HRH Strategy; OSD; health facility management Private Practice Private practice matters; coding; Billing guidelines; medical schemes; contracting Reimbursement levels; DRGs, co- payments; coding (as possible OHSC standards) Special interest groups RAPSA (Regional Anaesthesia and Pain Society of SA); PACSA (Paediatric Anaesthesia); SOSPOSA (Society of Sedationist Practitioners of SA) which include non- anaesthetists with a special interest in the utilization of and training in sedation techniques; Cardiothoracic Anaesthesia Society of South Africa (CASSA), which promote the science and practice of cardiac and thoracic anaesthesia and formally develop echocardiography training for anaesthesiologists All of these Special Interest Groups would have a key role to play in the delivery of services which would be subject to the OHSC, but also subject to the HPCSA s rules on scope of practice and specialization and sub- specialities. SASA currently has a membership comprising of members in the following categories: SASA membership Private 814 Full time public 65 Full time limited private practice 138 1 Current Guidelines include Procedural sedation guidelines: SASA Guidelines for Procedural Sedation and 2

Honorary life members (some retired) 111 Trainees 294 Associates (non- specialists) 112 TOTAL MEMBERSHIP 1534 SASA is the largest specialist grouping in South Africa. It is, however, also a vulnerable group of specialists, identified as such by the HPCSA in its May 2011 Bulletin and the HRH Strategy 2011. The training of anaesthesiologists also takes a long time (13 years as a minimum from starting out one s medical studies). As a much sought after skill, competition for anaesthesiologists is global, i.e. the South African health sector competes with international markets for its crop of anaesthesiologists. 2. SASA S CONTRIBUTION TO- AND INVOLVEMENT IN THE SA HEALTH SECTOR Members of SASA play key roles in healthcare delivery, from primary care level to the high technology settings in central hospitals. SASA plays an active role in education. It also ensures that it is active in giving guidance to its members (as can be seen from the Guidelines it issues), of which Peer Review is part. SASA has, for example, simplified the coding structure it uses to prevent code proliferation and to simplify and clarify the basis for its billing. SASA has been and is involved in the discussions that led to the decision to deploy specialist district clinical support teams (DCSTs). It is also involved in the evaluation and compilation of the Essential Equipment List (EEL). It has also met with relevant staff members in the National Department of Health (DoH) in relation to the envisaged Office of Health Standards Compliance and the HRH Strategy. Whereas private practice matters are concerned, SASA made the decision to not take part in the RPL court case, as it believes that differences have to be addressed through active engagement and dialogue from all parties concerned. SASA wants to remain in the loop on all NHI developments and wishes to ensure that there is interaction, authorized by laws such as the Amendment Bill currently before the Honourable Members of the Portfolio Committee, on the areas within which its members are trained and experienced. 3. THE IMPORTANCE OF A STRUCTURED PROCESS OF ENGAGEMENTS AND PRESERVATION OF INDEPENDENCE OF THE OHCS Although SASA was marginally informed about the OHSC, it remains concerned that, whereas the current persons involved in the process have a clear understanding of the limitations of their powers, and have taken an open approach, these factors have to be written into the law explicitly, to ensure its protection in spite of staff- or political changes. The independence of the OHSC has to be preserved beyond it merely being mentioned. This independence has to be preserved by, amongst others: Ensuring that technical areas of standard- setting, such as those affecting the practice of anaesthesiology, are set by experts in the field, and not merely, as the Bill currently reads, promulgated by the Minister of Health, with the possibility that the CEO may appoint committees to advise him or her. All draft standards must, by this law, be published for comment prior to its finalization. SASA 3

understands that publication in the Government Gazette may be time- consuming, but proposes that publication to affected stakeholders in media and by means generally accessed by such stakeholders, should be sufficient. The CEO on behalf of the OHSC can approach, or be called to account, by Parliament directly and that the reporting via the Minister of Health, be changed to a direct line to Parliament. Such formalized processes should go beyond sessions in which professionals are just informed about intended changes, and should be participatory and build on the collective knowledge and on information- and experience sharing exercises. SASA members are at the coalface and have much to contribute. This will not only give effect to the constitutional mandate of government of participatory governance, but will also ensure better buy- in and outcomes that are responsive to the needs of both the professionals and patients in the health system. SASA proposes that standards that affect the following fields that relate to standard- setting should directly involve its membership: Academic medicine and training standards in tertiary and central facilities that are subject to accreditation; Private practice standards; Facility and equipment upgrades and maintenance; Clinical governance and national treatment guidelines; Peer review, ethics and professional matters (incl. HPCSA issues) Formularies, guidelines, protocols and scope of practice. In relation to the above, it should be borne in mind that only professionals authorized in terms of the Health Professions Act of 1974 and the regulations thereto, are able to pronounce of what would be appropriate quality of care in the fields in which our members are active. SASA believes that the Amendment Bill should recognize this aspect, in order to prevent possible conflicts in standards and standard- setting. 4. COMMENTS ON FURTHER ASPECTS RELATING TO THE ESTABLISHMENT OF THE OFFICE OF HEALTH STANDARDS COMPLIANCE AS PER THE AMENDMENT BILL TO THE NATIONAL HEALTH ACT, 2011 SASA has interacted with staff in the DoH responsible for the quality oversight and the production of documents such as the Core Standards for Health Facilities and the Fast- Track to Quality. SASA welcomes the initiative to have mechanisms in place to ensure that quality of care is increased within health facilities and regards the published documents as steps in the right direction. What is lacking, however, is - A clear programme in terms of which private facilities will be accredited; A public tracking of facilities already accredited or being accredited. The involvement of anaesthesiologists in such accreditation processes (inspections, interviews, etc.). The view of SASA members working in such facilities during accreditation visits will offer key insights into some of the quality elements found in the two documents referred to above and must be included in accreditation processes. For example, the safety of equipment and its correct use (including training) is some of the criteria. Another is the clinical efficiency management systems that are necessary to ensure patients receive adequate, safe, quality health care. These assessments, and the implementation of these 4

systems, cannot take place without the professional involvement of societies such as ours on a macro- level and the participation of individual members at facility level. Guidance on the establishment of quality systems (i.e. implementation), in cases where such systems do not exist or do not exist to the extent envisaged by the OHSC. SASA propose a formalization of such systems with the formal involvement of professionals, e.g. in the form of a Quality Assurance Committee (comprising professionals and other stakeholders, i.e. not only employees) at facility level, to ensure implementation of the envisaged standards. World- wide anaesthesiologists are at the forefront of systems to ensure patient safety, for example and SASA will gladly continue to interact with the NDOH on the implementation of these systems. One example that could be implemented easily is the WHO Safe Surgery Checklist. 2 SASA members have already played a leading role in implementing this system at various sites in the country and, as part of the NHI pilot projects, would be happy to facilitate the implementation of this system within facilities in pilot districts. SASA endorses the WHO Safe Surgical Checklist and it has been implemented in several hospitals in both the Public and Private Sector. Individual accountability of employees and management of facilities. The OHSC Bill only envisages fines and criminal prosecution. However, it must be made clear that non- adherence to standards and norms should render the employee liable for disciplinary action by the employer (including dismissal). A further prime example of the involvement of SASA in responding to the pertinent healthcare needs of South Africa, is its ESMOE (Essential Steps in Managing Obstetric Emergencies) training programme, undertaken with the Medical Research Council s Maternal and Infant Care Strategies Research Unit. ESMOE aims to improve the emergency management of pregnant women and their infants by using a training package for emergency obstetric care that is taught to undergraduate students, both medical and nursing, taught to all interns and which must be signed off prior to registration as a doctor, serves as a basis for fire- drills (simulation exercises) for both doctors and midwives in all institutions performing deliveries, which training exercises are documented and that they occur is part of the institutions CEOs key performance areas Some of our members also point to organisational aspects that affect quality of care. For example, an anaesthesiologist reports that a door to a theatre has fallen off six months ago and has not been repaired yet, presumably as this falls within the work to be undertaken by the Department of Infrastructure Development. The hospital manager cannot simply obtain quotations and have this repaired by an outside (or contacted in) repair service. This could be seen as an example of how a centralized system does not work. SASA members have for example, expressed the need to see the standards checklist for revamped / upgrade facilities, and to provide input into this. SASA also received reports from members that pharmaceutical- and equipment supply systems (one of the quality elements referred to in the two quality documents referred to above) have not improved. For the sake of transparency and accountability, SASA proposes that the outcomes of facilities accredited against the Core Standards be published, so that our members, and the public at large, can see and evaluate the impact of these quality assessments and improvements. As set out above, the process of standard- setting as is envisaged by the amendment Bill is not adequate it leaves this process to the OHSC, with no legislative parameters within which these standards must be set (e.g. with professional input if professional standards are at stake), or 2 http://www.who.int/patientsafety/safesurgery/en/. 5

structures that must be involved, in such standard- setting processes. It should be noted that standards already exist in relation to equipment and medical devices, and that professional standards in relation to quality of care exist within the various professional bodies, under the ultimate oversight of the HPCSA. SASA urges alignment, and an active pursuit to identify, and avoid duplication in standard- setting and implementation (enforcement). Moreoever, SASA urges the establishment of Advisory Boards, comprising relevant specialists and specialities to set these norms and standards. Legislation must provide for the constitution, roles and functions of such Boards. Lastly, private practice in anaesthesiology is different to private practice in other specialities, and many of the accreditation criteria may not be applicable at all to SASA s members. Hence a one- size- fits- all OHSC accreditation in view of participation in an NHI would not be rational. NATIONAL CO- ORDINATING CENTRE FOR CLINICAL EXCELLENCE: SASA is concerned that this particular Centre, never mooted before, will be implemented as part of the Human Resource for Health Strategy 2012-2017. Apart from the overlap with the Clinical governance Standard set in the Core Standards Document, it could also conflict with the powers afforded to trained and experienced professionals in terms of the Health Professions Act. Professional societies, as is the practice world- wide, already set treatment guidelines and standards of care, and there should be no need to duplicate efforts. These societies do include academics and others referred to in the HRH Strategy document. SASA suggests that adopted guidelines could be published by the NDOH under the auspices of the OHSC. Insofar as this particular Centre proposes that cost- effectiveness studies are undertaken, it is assumed that a structure similar to the UK NICE 3 is envisaged. For such a mammoth task, SASA proposes careful interrogation of models to ensure a model that is appropriate for a developing country, in light of the severe shortages of health economists, and the absence of frameworks to set monetary thresholds and QALY s in South Africa. The purpose of such a structure, e.g. to guide District Health Authorities in deciding to procure goods and services or not, or as a price regulatory mechanism (as is the case with the reference to cost- effectiveness in the medicines pricing regulations of 2005), must be clear. LICENSING OF PRACTICES: Another conflict that arises from the HRH Strategy is the assertion that healthcare practices are not licenced or registered. This is also relevant where OHSC accreditation is concerned. It must be noted that all healthcare professionals who wish to be in active practice, and also those not in active practice, but who may wish to occasionally practice their profession, MUST at ALL TIMES maintain their registration at the HPCSA. This is indeed a form of licencing and to be on the register literally means compliance with ALL of the numerous standards set, which include, amongst others: Levels of fees and billing practices; One s scope of practice; Appropriateness of care delivered in general or in specific cases; Whether one has been trained and sufficiently experienced to provide certain healthcare services; Control over under- graduate and post- graduation training; Control over sustained professional self- development through a CPD system; 3 National Institute for Clinical Excellence. 6

Mandatory internships and community service; Mandatory compliance with ethical rules, many of which relates to exactly how a practice must be run (e.g. on advertisements, interactions with patients, record- keeping, relationships with private hospitals and medical schemes, etc.). In addition to the above, healthcare professionals belong to professional societies with oversight over them in relation to peer review and compliance with clinical guidelines and protocols. Lastly, SASA requires confirmation as to whether this refers to attempts to bring the Certificate of Need (included in the National Health Act, but not being implemented, back into the discussions of a re- organised health system. If this is the case, SASA calls for an urgent meeting with the DoH on this matter and urges the Honourable Portfolio Committee to interrogate this matter. 5. CONCLUSION SASA remains committed to assist in its areas of expertise in the planning and implementation of initiatives aimed in increasing access and quality of care. SASA outlined in this submission areas where its members can get involved, e.g. at pilot sites and in expert committees of the OHSC, in evaluating draft standards and on specific projects, such as the WHO Safe Surgery Checklist and a further roll- out of the EMOE programme. SASA remains convinced that consultative processes, and with that buy- in and ownership of health transformation objectives can be optimized by means of the establishment of standing consultative work teams or forums. Certain areas of competence are within easy reach of many of the specialist disciplines, and can be effectively utilized in many of the NHI- related initiatives, including the implementation of the OHSC and the legislative framework which should cater for its effective creation and maintenance, irrespective of changes in staff and political leadership. CONTACT DETAILS: Dr Hyla Klyts Vice- President, SASA Email: Hyla.Kluyts@up.ac.za P O Box 1105 CRAMERVIEW 2060 SASA office: Tel: 011 463 0684 / 086 010 3137 Telefax: 011 463 1041 Email: sasa@uiplay.com 7