RWOPS clampdown – a crisis in the offing

State-employed consultants are beginning to resign in numbers at two top Gauteng hospitals – and many of their Free State counterparts may soon follow – as a clumsy and sweeping nationwide crackdown on the Remunerative Work Outside Public Service (RWOPS) and overtime begins.

As of the start of June, Charlotte Maxeke Academic Hospital’s anaesthesia department will have halved from 24 to 12 posts, while Chris Hani/Baragwanath’s Radiology Department will have shrunk from 20 to 13 posts, double the attrition rate of the past several years. At Charlotte Maxeke 10 anaesthetists walked out last month. At the core of the angry, disillusioned resignations, plus the threatened closure of two Medi-Clinic private hospitals linked to Bloemfontein’s two academic hospitals, is a heavy-handed political crackdown on RWOPS. Free State Health MEC Dr Benny Malakoane issued a sudden memo banning all private work inside of official State hours (7:30 am to 4 pm). A Public Servants Association (PSA) court interdict overturned the memo, but Malakoane has vowed to fight back.

In Gauteng, Charlotte Maxeke’s clinical chief executive, Dr Mamorena Mofokeng, told anaesthetic department chief Dr Eddie Oosthuizen that resigning consultants were ‘RWOPS criminals’, in whose departure she would rejoice. Oosthuizen said his departmental turmoil began with RWOPS, but soon expanded to commuted overtime when several anaesthetists were not paid overtime in mid-April and others were paid far less than they had worked for, all without any warning or consultation.

‘We got mixed signals (answers) from management, ranging from untrue assertions that overtime contracts were not handed in, to demanding a copy of our on-call roster or a work plan proving we’re doing the core hours prior to overtime,’ he said. ‘There’s also a huge element of maltreatment of doctors – the attitude is so negative. Other departments don’t seem to be part of this and we don’t really know why. Different rules seem to apply for different people.’

Head of Radiology at Chris Hani/Baragwanath Hospital, Dr Emtias Nagdee, says he’s lost seven of his 20-post staff over the past six months and believes the Maxeke conflict influenced some of his colleague’s most recent resignations. His attrition rate has gone from 20% to 40%.

Surgery chiefs alarmed

Professor Martin Veller, Head of Vascular Surgery at Wits University and President of the South African Medical Association (SAMA) Gauteng branch, said the biggest factor in Charlotte Maxeke Hospital’s sudden exodus was junior consultants’ belief that they were being ‘treated like cannon fodder’. He cited ‘poor communication, disrespect and the juniors’ inability to earn additional income in commuted overtime and RWOPS’. He characterised Mofokeng’s attitude as ‘bombastic and alienating’, saying her (mistaken) view on the RWOPS ban and resignations is that it will ‘create’ the daily equivalent of five more consultants available for daily State work.

‘She obviously plans not to replace them, which will have a massive impact on service, with operating lists being cut. However, one positive from all our meetings with management and the province is that we’ve secured an undertaking to meet regularly with them in future on labour matters,’ he added.

Professor Martin Veller, head of Vascular Surgery at Wits University.

Professor Martin Smith, Surgery Chief at Chris Hani/Baragwanath and the new Head of Surgery at Wits University, said a ‘crisis of leadership’ had developed, as downstream managers took ‘a sledgehammer to a nail’ to deal with a small group of state doctors abusing private practice.

‘This is not benefiting anyone, least of all the patients. Somebody needs to rescue the situation fast. It’s smoke and mirrors hiding the real dysfunctionality of the system and helluva shortsighted. There are problems on both sides and I can’t even see a medium-term solution while this antagonism goes on. We need to find middle ground very quickly.’

Alienation threatens successful NHI

In the Free State, Malakoane banned all RWOPS work in official hours on 5 April, a month into his tenure, brooking specialist resignations and thus potentially derailing intern and registrar training – and threatening the closure of two Bloemfontein Netcare hospitals. While Malakoane’s sudden, unheralded move is part of the nationwide official crackdown on unregulated RWOPS,1 his controversial memo and apparent ignorance of a 14-year old public private partnership (PPP) between Netcare and 90 State specialists at Bloemfontein’s Pelonomi and Universitas Tertiary Hospitals fuelled scepticism about impending universal health coverage.

Netcare has two private facilities attached to the Pelonomi and Universitas tertiary hospitals and uses state specialists under the terms of a 1999 agreement between the province, the PSA and the University of the Free State. The contract has three group practices (consisting of state doctors) sharing rooms, equipment, facilities and billing to meet patient demand at both sites.

‘This is a long-standing example of how government can work with the private sector towards a National Health Insurance system, you could even call it a pilot, yet at one stroke an unaware MEC nearly brought it all tumbling down,’ a doctor with government links observed, on condition of anonymity.

Izindaba has learned that several state consultants in Bloemfontein who work with Netcare have begun scaling down private admissions and long-term private theatre lists. Some are considering moving out of the state sector altogether. They legitimately fear that they will be rendered powerless to attend to any complications or provide continuity of care (e.g. chemotherapy). This is despite the PSA’s successful court interdict preventing Malakoane’s edict from taking effect until 6 June.

Any shedding of scarce specialists by the state sector would severely compromise service delivery at both tertiary and regional hospitals, where training accreditation for interns depends on specialist supervision and registrars require on-the-job teaching. It would also leave medical officers adrift in multiple, often single-consultant departments.

Wrecking a crop for a few bad apples

Several overworked and under-resourced specialists blame the province for historical and professional neglect forcing them into RWOPS, ‘to somehow begin making up for the overtime and round the clock on-call work we do for the state’, according to Dr Edson Mafana, the only general surgeon at Bongani Regional Hospital in Welkom.

Added Mafana: ‘The agreement is that since we know that government cannot possibly pay me for all the hours of standby that I do, they allow me to do RWOPS to make up for it. If my juniors call me and I’m on leave at home in Welkom, I come running, because there’s simply no-one else. Even less can I leave my juniors or ICU patients in favour of RWOPS – that would be irresponsible. I think management are defaulting on their RWOPS monitoring duty; if you know of someone not seeing patients, confront them – don’t make it a blanket thing – that’s what management are paid for!’

In his interim interdict ruling against the provincial health department, Judge A J P Hancke found that the RWOPS system had been in place so long (21 years) that the MEC would ‘suffer no prejudice’ if it was extended another month. Judge Hancke said that if the present system was terminated, ‘for example if it is being abused or impractical, it can only be done over a period of time and after proper consultation and investigation’. The PSA had testified that the MEC’s decision was ‘arbitrary and impulsive’.

Private hospitals already affected

Sydney Masalla, Manager of the Pelonomi Netcare Hospital, said their PPP was built on the RWOPS principle: ‘If doctors can’t do RWOPS, then the PPP is unworkable.’ The biggest impact on his hospital would be on gynaecological cases (e.g. babies being delivered and fertility treatment, where waiting lists can run to four months). His emergency department would also be compromised and other services ‘made more complex’.

His Universitas (private hospital) counterpart, T J Ramanamane, was more tight-lipped, saying his Netcare regional manager, Billy van der Merwe, had instructed him not to speak to the press, but adding, ‘Until he meets with the MEC, we’d rather be cautious.’ Both managers declined to confirm that Netcare lawyers were hastily preparing an interdict against the province or that Universitas stood to be even more heavily impacted than Pelonomi, especially in the cardiology and emergency care departments. (Professor Danie Marx, of Universitas, told Izindaba he is one of only two cardiologists in the entire Free State and Northern Cape, illustrating the dire human resource specialist crisis driving such arrangements.)

Impeccable Izindaba sources said a Netcare court case against the province was ‘guaranteed if they can’t come to some sort of arrangement – huge investments are at stake – but pushing the wrong buttons now could worsen their relationship’. Netcare national spokesperson Kerishnie Naicker said her CEO, Jacque du Plessis, would not comment. ‘It’s at a very sensitive stage,’ she said.

Free State to fight doctors’ interdict

Mondli Mvambi, a spokesperson for the Free State Health Department, said their lawyers were preparing to robustly contest the existing court interdict. ‘The MEC’s position has not changed. People travel 500 km to see these doctors and then wait hours and hours before being told the doctor is not available. We’re simply applying the law – we need doctors in peak hours between 7:30 am and 4 pm. That’s what they’re being paid for – let them do their job. Why do they want to go to the courts? The MEC’s door is always open.’

Doctors are supposed to fill in a request form stating how many RWOPS hours they want to work, times and dates, and at which specific private facilities. ‘As far as we know, nobody has applied for RWOPS in the entire province so far this year,’ said Mvambi.

Asked about the Netcare PPP, Mvambi said the provincial executive committee had decided that the MEC ‘should have a discussion with them because this is an exceptional case – but they [all state doctors] cannot have blanket permission for RWOPS.’ He denied that Malakoane had only learnt of the Netcare PPP after his clampdown. Asked why, if that was so, Malakoane did not approach the 90 specialists before issuing the edict, thus saving an expensive, time-consuming and alienating court interdict, Mvambi replied: ‘The issue at hand is getting doctors to be where they’re supposed to be in official working hours. If there are exceptions we’ll deal with them. That’s a matter for the lawyers to argue.’

When it was put to Mvambi that some specialists argued they could ‘retire without RWOPS’ if they were to claim – and be paid – for the overtime they worked in the doctor-starved state sector, he replied: ‘Overtime is an arrangement with management. If they need overtime let them claim it, we’re open to that. We pay commuted overtime and for sessions they do. Let them come forward so we know what we’re dealing with. They’re not employed by the media, they’re employed by the state.’

Confronted with the spectre of specialist resignations, he said: ‘Every policy has its unintended consequences. We need them to come to the negotiating table to look at the matter afresh. I’m sure the policy makers are mature enough to come to the table and mend the relationships. This [RWOPS] policy is not meant to pin anyone down, it’s meant to get the best out of everyone; if we can’t get that, we must renegotiate and look at our options’.

He confirmed that Malakoane was keeping his national counterpart, Dr Aaron Motsoaledi, fully briefed.

How some Free State specialists work

One Free State family medicine consultant said many specialists used what he termed ‘dead time’, between 7 am and 9 am, to check patient files and do private ward rounds before starting their state clinic shifts. From about 3 pm they usually ‘finished up’ some of the work. ‘It’s not like they’re not rendering services; no patient is left unattended. If the RWOPS edict is enforced by the MEC, that “dead” time will no longer be used productively or effectively. People are anxious and considering whether to go fully private or cancel private practice altogether and focus on public.’ He said Universitas Hospital, which has 50 State specialists involved in the Netcare PPP, was relatively well staffed – appropriate, considering it is a referral hospital for the Free State, Northern Cape and part of the Eastern Cape.

One medical officer (MO), who has put in several years’ service at Bongani Regional Hospital, said all specialists at his hospital have private consultancies either at Medi-Clinic or at the mine hospitals, and two of them have ‘substantial’ Medi-Clinic practices. One of them, solo paediatrician, Dr Mubarik Saleem, told Izindaba that if he were not permanently on call at Bongani hospital. ‘there would be mass deaths’. ‘We are incredibly busy. Not just me but all the others are also single consultants (except for internal medicine), and they are just as busy.’

The MO said that to fall ‘within overtime contract’, each department would need six or seven full time specialists to cover the after-hours call roster for each month. ‘This has been going on for three or more years with no end in sight.’ Motsoaledi has contended that he’d rather have a post officially vacant than one filled by a specialist who was ‘never there’. This was put to the MO, who countered that such a generalised statement was ‘totally untrue’ when it came to Bongani Hospital. ‘They are there if you need them for anything. Twice last month we had specialists on leave come in to help with a case.’

Dr Edson Mafana at Bongani Hospital said Motsoaledi’s statement ‘beggars belief’. ‘There may be areas where he gets away with that being true if there are enough specialists there. If they want me, I drop everything and go back to the state hospital. If we’re really not interested in working, then why are we always fighting with admin, the MEC or the minister for more equipment and ICU beds and theatre time? It doesn’t make sense to me.’

Mafana said he works with four MOs, running four and a half wards of 135 patients. His trauma and general surgical units are full and, with winter setting in, his burns unit is already overflowing. If he and one of his MOs were in theatre, that left three MOs to do ward rounds, run the clinic and attend to emergencies (one of whom will have just completed 24 hours on call, and another on call that day).

‘When they complain about a patient waiting period, I don’t know what we’re expected to do. Those patients coming to casualty and surgical outpatients have to wait for the other three doctors to finish ward rounds. If we have an emergency and another elective, then we have four doctors in theatre and only one outside. How then do we do RWOPS?’ He accused the politicians of ‘trading on our Hippocratic Oath’ and said that for the past decade they ‘hadn’t bothered’ to appoint another specialist to his department.

Mafana and several other specialists could not understand why their MEC was behaving in a manner which could aggravate the state specialist shortage instead of pressing management to take full responsibility for RWOPS and ‘tackle individual problems where they find them’. Better policing would enable many of the original goals of RWOPS to be achieved, including training/skills building and skills retention.

Wrecking a working PPP

Dr Deon Menge, a general surgeon at Pelonomi Hospital (and Free State SAMA chairperson), said Malakoane admitted to a group of worried doctors who approached him that he did not know about the PPP in advance of his edict and had promised to look at each individual case. He said removing RWOPS would collapse Bloemfontein’s Netcare hospitals, which are connected to their state counterparts by corridors and which share vital equipment. ‘They have their own theatres, systems, staff and finances, but if we run out of ICU beds in government we borrow from them and they look after our patients – it’s all built on the RWOPS principle.’

He said the few doctors who abused the system were ‘a drop in the ocean’. Of the 1 300 doctor posts in the Free State public sector, only 700 are filled, ‘something they may do well to remember’. Menge added that in other provinces, particularly KwaZulu-Natal, interns, community service doctors and registrars are doing illegal RWOPS, but not in the Free State.

He was ‘particularly upset’ when Malakoane alleged both illegal RWOPS and that ‘we were stealing equipment and consumables to treat our own patients’. ‘We use the Netcare equipment and billing system – there’s no ways we’d allow that.’

The Free State and Charlotte Maxeke debacles are being keenly followed by consultants nationwide. How they are handled could prove a ‘tipping point’ for better or for worse – with long-term implications for NHI.

A Charlotte Maxeke Hospital spokesman could not be reached for comment.

Chris Bateman

chrisb@hmpg.co.za

1. Bateman C. RWOPS abuse: Government’s had enough. S Afr Med J 2012;102(12): 899-901

1. Bateman C. RWOPS abuse: Government’s had enough. S Afr Med J 2012;102(12): 899-901

S Afr Med J 2013;103(6):361-364. DOI:10.7196/SAMJ.7029