South African Medical Journal - Volume 102, Issue 10, October 2012

CPD Questions October 2012

The South African private health care sector is rightly well regarded for its quality of care, including centres of excellence and hotel-style creature comforts. Much is made of the foibles of the public health system, but private care is in no less an efficiency and sustainability crisis.

Getting back to where it all started - the patient

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Poor maternal outcomes

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Sexuality and disability

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Point-of-care diagnosis of TB

I respond as head of one of the units 'studied' in Peer and Fagan's 'descriptive audit'.

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I support strongly the maintenance of the highest standards of training, patient care and self- and peer-reviewed critical evaluation. The valuation of my unit does not threaten me. Although no heads anywhere in the world should think that their unit is perfect, as there are always challenges and room for improvement, I am confident that my trainees at Tygerberg Hospital/Stellenbosch University receive a good and balanced training, comparable to most first-world countries. Ironically, the above-mentioned paper found exactly this of some units - but, as written, discredits all ENT training units in this country; perhaps the authors think that readers will assume that their authorship implies that theirs is exempt?

With their retirement from their present roles in the SAMJ, Professors Dan Ncayiyana (Editor-in-Chief for 20 years) and JP van Niekerk (Managing Editor for 11 years) are pleased to announce that Professor Janet Seggie has been appointed as Editor-in-Chief of the SAMJ.

I would like to make some comments on the issue of domestic violence. My understanding of this problem is that it is primarily a social problem that can lead to ill-health risks (physical, mental, emotional and even spiritual) and that it has three components : the perpetrator, the effect on women, and the effect on children.

'Thieves of the state' - what a marvellous turn of phrase, damning and straight to the point. Dr Goldstein must be commended on her excellent letter. She has done what so many of us, her colleagues, have not had the courage or energy to do : stick out our necks and expose this shameful blot on South Africa's medical landscape.

South Africa's private healthcare sector had 'gone overboard' commercially, resulting in deep distrust between funders and providers in an opaque environment that had lost sight of the best interests of the patient, Dr Humphrey Zokufa, CEO of the Board of Healthcare Funders (BHF) admitted last month.

South African sunscreen manufacturers are hastily reformulating their products following confidential tests commissioned by the National Cancer Association of South Africa (CANSA) which show that most offer sub-optimal protection. This means that outdoor lovers (especially those in the Western Cape, where the incidence of malignant melanoma has trebled over the past 20 years), will face at least another summer using mostly below-par sunblock creams. Those who don't know that most locally sold creams don't offer decent protection beyond two hours of exposure to sunlight, will remain vulnerable.

Unless there is speedy and decisive political leadership regulating the current 'tide of profiteering' in private healthcare,the much-acclaimed National Health Insurance (NHI) will merely entrench current private sector turmoil and prolong court battles over aberrant laws.

Making medical scheme member contributions mandatory is less important than properly regulating prescribed minimum benefits (PMBs) which pose the biggest, most imminent threat to medical schemes' viability, Board of Healthcare Funders (BHF) CEO Dr Humphrey Zokufa claims.

The medical fraternity of Cape Town has been bereft of an exceptional physician and respected colleague. Abraham Leib Maresky, popularly and affectionately known as Lampy by one and all, died of postoperative complications on 2 July 2012.

Kalvyn van Eeden died on 12 April 2012 at the age of 82 of cancer that he bravely faced with dignity, but also with a realistic and scientific approach. He was a legend in his lifetime and contributed immensely to the community and medical profession, especially in the Limpopo Province (formerly Northern Transvaal).

The carefully chosen account of the five epidemics that emerged in South Africa over a few centuries following European conquests makes for fascinating reading. The book is rich with detail, eminently readable and entertaining, the seriousness of the subject matter notwithstanding. It is well written, concise and covers complex, often unappreciated, historical events.

South Africa is struggling to improve maternal and perinatal outcomes, resulting in failure to achieve the Millennium Goal for maternal health. Staff attitudes and skills have been identified as a factor affecting deaths and adverse outcomes in mothers. Huge training efforts are required from health departments to ensure that staff have the required skills to provide the services.

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The integrated approach to training of nurse professionals, which includes midwifery as a part of undergraduate training, has a devastating effect on the quality of midwifery. Training of midwifery is unfocused and forced upon those who have no interest in improving maternal outcomes. Maternal care is provided in professional silos by professionals who are not equipped with appropriate skills. Unless this systems design error is corrected, and a single-output training model introduced to professionals providing maternal care, we are unlikely to see a a major change in our maternal outcomes. New models based on inter-professional training and task sharing need to be developed for the country, including redefining of professional accountability for maternal care.

Schoon and Motlolometsi draw timely attention to the failure of the current health system to reduce the unacceptably high numbers of maternal and perinatal deaths in South Africa.

In the South African health care system patients/consumers are divided into those who can afford private care and those who rely on state medical assistance. The system is under pressure to fund delivery of medical care to its beneficiaries. We consider the effects of different funding models on medicolegal liability of health professionals serving the private sector. Medical reasons should determine the service rendered. However, financial implications of services rendered and defensive practice of medicine also contribute to treatment received by a patient and its remuneration. Practitioners who commit to delivering a predetermined set of services within a particular time for a predetermined 'lump sum' are only paid for the service specifically requested. Should disease be found other than those contracted for, we argue that inaction with regard to that disease would be deemed to be negligent or unethical according to legal and ethical considerations.

A 27-year-old neurologically disabled but fully conscious malezolpidem-responder patient was investigated for blood-brain barrier (BBB) dysfunction 5 years after a traumatic brain injury. A baseline single-photon emission computed tomography (SPECT) technetium-99m-labelled hexamethylpropylene amine oxime (^99mTcHMPAO) brain scan was performed and the patient was administered 10 mg zolpidem daily. The patient was rescanned 2 weeks later when ^99mTcHMPAO was injected 1 hour after zolpidem application. SPECT technetium-99m-labelled diethylene-triaminepentacetic acid (^99mTcDTPA) BBB scans were also performed before and after zolpidem treatment. There was decreased uptake of ^99mTcHMPAO in the left frontoparietal brain region, left temporal region and left thalamus on baseline scanning; this improved within 1 hour after zolpidem treatment at the follow-up scan. The^99mTcDTPA scan remained within normal limits before and after zolpidem treatment. The patient's neurological disabilities, especially coordination, speech and gait, improved markedly. The Barthel index remained normal, but the Tinetti falls efficacy scale improved from 21/100 to 15/100. The results implied that the underlying cause for the patient's long-term neurological disability and brain suppression was not due to a long-term dysfunctional BBB.

The World Report on Disability by the World Health Organization and the World Bank marks a watershed in the history of how disability should be understood by healthcare practitioners. Along with a special issue of the Lancet, this report marks recognition by organised healthcare that healthcare practitioners acted paternalistically towards disabled people, often deciding on their behalf what is in their best interests. South Africa favours a human rights approach to disability, where the Constitution mentions non-discrimination on the grounds of disability, and globally through the promulgation of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). Historically, health practitioners have underestimated the capacities of disabled people and from clinical encounters view disability as an illness, whereas in reality most disabled people are not ill.

Background. The introduction of national health insurance (NHI) is an important debate in South Africa, with affordability and institutional capacity being the key issues. NHI costing has been dominated by estimates of exorbitant cost. However, capitation is not only a different payment system but also a different service delivery model, and as a result there are opportunities for risk management and efficiencies.

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Objective.This study explores how private general practitioners (GPs) may choose to embrace these service delivery concepts and deal with the cost implications to meet NHI requirements.

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Methods. Data were collected from 598 solo private GPs through a self-administered online questionnaire survey across South Africa.

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Results. In spite of poor engagement with the public sector, and some challenges in costing and organisation, GPs appear to have an affordable and pro-active response to NHI capitation costing and fee setting. On average, they would accept a minimum global fee of R4.03 million to look after a population of 10 000 people for personal healthcare services.

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Conclusion. At a total cost to the country of R16.9 billion, government could affordably use GPs to develop the primary healthcare part of NHI to cover the entire South African uninsured population. It is anticipated that a similar approach would be successful in other developing countries.