Allowing public sector doctors to work in the private sector as part of the Department of Health’s (DoH) so-called RWOPS (remunerated work outside of the public sector) policy is causing increased tension between administrators of state hospitals and doctors who are accused of abusing the system to the detriment of their state patients. Some hospital managers are now urging government to stop the practice or urgently review the current policy before the implementation of the proposed National Health Insurance (NHI) system.
Prof Joe Veriava of the school of clinical medicine at the University of the Witwatersrand (Wits), and an outspoken critic of the policy, said RWOPS affects both service delivery at public sector hospitals as well as academic teaching and research, aggravating the gross inequities between the public and private sectors.
Another problem is that many doctors who are involved in RWOPS claim commuted overtime, despite the fact that they had not fulfilled the number of hours required of them.
He appealed to the DoH to revise the policy in the interests of both public and private sector patients.
No monitoring system
Health ombudsman, Mboneni Bhekiswayo, said the public sector bears the brunt of the RWOPS policy and there is clear evidence that doctors are abusing the system.
“The policy clearly stipulates the number of hours (16 hours a week) that doctors are allowed to work in the private sector and that they have to apply for permission to do it. The weakness in the system is that no one monitors compliance and adherence.”
To curb the practise, the DoH introduced the occupation-specific dispensation (OSD) process in 2009, which was aimed at ensuring adequate remuneration, particularly for very senior specialists. However, Bhekiswayo said this didn’t make any difference as the practice is still continuing unabated.
Dr Ernest Kenoshi, CEO of the Steve Biko Academic Hospital (SBAH) in Pretoria, said it is estimated that between 70%-80% of doctors in the public sector are involved in RWOPS. However, he added, it is extremely difficult to determine exact figures, because not all apply for official approval.
“A large number of doctors do RWOPS in a clandestine way without informing any of their superiors and hospital managers,” he said, but admitted that there were no proper systems in place to monitor the time doctors spend in private practice.
“I don’t think this will ever be possible because a lot of doctors are unfortunately not honest enough to cooperate if requested to record this for us.”
Putting an immediate stop to RWOPS will improve the quality of care of patients in the public sector and will also have a positive effect on the waiting times both in out-patient clinics and in the wards in public hospitals, Dr Kenoshi said.
RWOPS should be abolished with immediate effect, not only because of the negative effects it has on patient care, but also because public doctors’ salaries have doubled in the last three years and will continue to increase annually at a high rate because of the implementation of the grading system introduced by the OSD resolution, he said.
“I am of the opinion that the net income of specialists in the public sector is currently at the same level as that of their counterparts in the private sector and will surpass those of private sector specialists when the last phase of the OSD process is implemented.”
Doctors’ contention that they have to augment their salaries therefore no longer holds water, he said.
Poor service delivery
Prof Ken Boffard, head of the department of surgery at Wits denies that RWOPS has contributed to poor service delivery at the Charlotte Maxeke Hospital Johannesburg Hospital (CMJAH).
“The reduced surgical throughput at the CMJAH – compared to five years ago – is due to a 50% reduction in available theatre time and a reduction in the number of beds available. So, even though surgeons are available, there is a limit on what there is to do.”
Prof Allan Taylor from the department of neurosurgery at the University of Cape Town, agrees. According to him, the levels of care in public hospitals are appropriate, and often exceptional, given their allocated budgets and the number of patients they have to see. He added that waiting lists primarily exist because of limited operating time and that these pressures have existed long before the policy was introduced.
Prof Boffard conceded there is no official monitoring system in place at the CMJAH. However, he added that it is extremely difficult to monitor doctors because they are not allowed an office or work area in the hospital. As a result, they use their private rooms for academic work. To monitor their presence in a private hospital is even more difficult.
In a bid to deal with potential problems, Prof Boffard requires doctors to submit a timetable detailing when they will be at the hospital, and their overtime call rosters. “I can then check that they are in the theatre, with outpatients or where they are supposed to be at the time they are supposed to be there.”
Prof Taylor said they have a strict monitoring system in place and doctors have to apply on an annual basis for permission to work in private practice. Part of the application is a detailed work plan accounting for all hours spent in public service, including normal and overtime hours. Private practice hours must also be documented.
This work plan is enforced by department heads and random audits are performed by the province to ensure compliance. Some departments, such as surgery, also perform internal reviews of working hours and work outputs, including teaching and research.
Prof Brian Warren, executive head of the department of surgical sciences at Stellenbosch University, said he believes monitoring should not be based on how much time is spent in the public sector, but on whether the staff member meets all of his/her full-time commitments including teaching and research.
“I keep a close eye on this and turn a blind eye to the actual time spent on RWOPS,” he added.
Training of junior doctors
In terms of the surgical training of junior doctors, Prof Boffard said that although there is some validity to claims that this is being neglected at some hospitals, it has nothing to do with RWOPS.
“Because of the reduced number of lists, and therefore cases, the trainees are receiving less surgical training. There is an interesting ‘knock-on’ in that the senior registrars (within a year of finishing their training) have to do more surgery to try and increase their exposure, further reducing training for their juniors.”
In response to allegations that some doctors are defrauding government by claiming for overtime for hours they worked in private practise, Prof Taylor said these statements are made by those who don’t understand the system.
“Public service doctors are contractually primarily obligated to provide a service at public institutions. Duties are planned in advance and academic meetings take place at planned times during normal working hours. Overtime is payment for duties on public patients outside of normal working hours and, again, these working hours are often scheduled. Call lists are drawn up for the following month and duties are allocated to specific individuals. Being absent or late for public hospital duties because of private work would not be acceptable.”
Prof Boffard added that full-time surgeons at the CMJAH are paid a fixed amount for overtime (16 hours) or one night on call per week.
In terms of salaries, Prof Warren disagreed with Dr Kenoshi’s statement that public sector surgeons are earning the same salaries as their counterparts in the private sector, pointing out that surgeons in the private sector earn as much as R4m per annum.
According to Prof Boffard, most surgeons are junior or senior specialists and earn between R400 000 and R600 000 per annum. Only a few unit heads or chief surgeons earn R1m or more, he said.
The reason that many work in the private sector is because of limited progression up the ladder and they therefore try to establish a private practice before province ‘forces’ them to leave. In addition, they get exposure to procedures that are not done in the public sector, he added.
According to Prof Taylor, allowing doctors to work in both systems offers a balance that enhances clinical practice. “We should be striving towards equal health access for all and an awareness of the necessary limitations in a public system and the occasional excesses and efficiencies in a private system is a step towards this.”
“In the ideal world, there would be no need for RWOPS. Salaries would be appropriate, equipment and supplies in government would be adequate and administration would be competent,” said Prof Boffard.
But he agreed that the policy should be ‘revisited’- especially in light of government’s proposed NHI. In his view, RWOPS will no longer be affordable once the NHI is implemented.