market inquiry into the private healthcare sector public hearing 6 … · 2020-03-24 · market...

Market Inquiry into the Private Healthcare Sector

Public Hearing 6

Day 2

held at

Olive Convention Centre, Durban

KwaZulu Natal

on

18th

May 2016

Panel:

Chairperson: Chief Justice Sandile Ngcobo

Professor Sharon Fonn

Dr Lungiswa Nkonki

Dr Ntuthuko Bhengu

Drs Cees van Gent

Stakeholders/ Presenters:

Department of health Free State. Pg. 3 – 129.

Department of health Limpopo. Pg. 130 – 185.

National pathology group. Pg.186 – 428.

Ground Level Enterprises (Pty) Ltd

www.groundlevel.co.za

Transcriber’s Certificate

I, the undersigned, hereby declare that this document is a true and

just transcription, in as far as it is audible, of the mechanically

recorded proceedings in the matter of:

Health Market Inquiry Public Hearings

18th

May 2016

.................................................... Date: 18th

May 2016

Transcriptionist:

Editor’s Certificate

I, the undersigned, hereby declare that this document is a true

reflection, in as far as it is audible, of the mechanically recorded

proceedings in the matter of:

Health Market Inquiry Public Hearings

.................................................... Date: 18th

May 2016

Editor: Godfrey Malgas

Health Market Inquiry 18th

May 2016

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SESSION 1: PRESENTATION BY DEPARTMENT OF HEALTH

FREESTATE.

CHAIRPERSON Everyone is here, we can begin. Good morning

everyone and welcome to the second day of the series of public

hearings. Today we are going to listen to three presentations, the

first one will be offered by the Free State Provincial Government

and the second will be offered by the Limpopo Provincial

government, and the third presentation will be made by the

National Pathology Group. Is the Free State ready? Good, do you

want to come forward?

Once again good morning, I apologise for you know starting this

late. If there is anyone to blame you must blame the National

Pathology Group, they prevented me from coming here on time

because they insisted they wanted to see me before we start. It is a


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pity I did not see you before we started, but anyway you are here

now. I wonder would you want to place yourself on record and

indicate to us who is with you and who is going to make the

presentation?

MARCUS MOLOKOMME Good morning chairperson and panel

members. My name is Dr Marcus Molokomme, I will be presenting

on behalf of the provincial Department of Health, Free State. With

me today to my left is Advocate Justice Finger who is head of legal

services in the Department of Health Free State. Immediately to

my right, the fair lady is Mrs Pinky Berlot, she is head of the

licensing unit in the Free State Department of Health, the private

facilities side and the far right is Mr Reuben Ruiters who is head of

emergency medical services in the Free State. I wil l be making the

presentation. facilities side and the far right is Mr Reuben Ruiters


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who is head of emergency medical services in the Free State. I will

be making the presentation.

CHAIRPERSON What language are you going to speak? SeSotho?

MARCUS MOLOKOMME I would have loved to use my mother

tongue which is Sepedi, I am a traveller, I am originally from

Limpopo so and with me here I have Reuben Ruiters, hy praat die

taal, and then two of us are just around here. So we will use

English Chairperson, if you allow.

CHAIRPERSON Because you come from Limpopo you cannot

speak what they speak in Free State, you have to speak in Limpopo,

but they speak in Limpopo. Okay, very well. Again just place

yourself on record and then if you are ready to start t hen we can go


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ahead. First of all let us make sure that we have all the

documentation that you sent to us. Okay, you can go ahead.

MARCUS MOLOKOMME Thank you very much to the panel for

the opportunity. I am representing the Free State Department of

Health. Our approach with the documents which we have already

delivered are going to focus on the summarised version of our

PowerPoint presentation so I will be talking to the slides as we go

along. I will make the presentation to the end. The colleagues

around me as introduced will then be of assistance i f there are any

questions or clarity or discussions at the end of the presentation.

Our intention as the Free State is to stick within the hour or even

less if you allow Judge or chairperson.


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CHAIRPERSON Can we do this? Ja, sure. I think what would be

very helpful to us would be if you can just summarise your

presentation so that at least we have sufficient time for

engagement, okay. But of course I cannot stop you from you know

reading your presentation. Thank you.

MARCUS MOLOKOMME Thank you very much chairperson. We

were here yesterday for, we just missed the Medscheme

presentation at the end, just to get the sense of our approach so that

we can save you time, so we are committed to that. It wi ll not be

10pm again. Thank you, we will basically almost stay on these

content slides because we want to just give a narration of the

summary that you already have and in that way I am sure we will be

able to save time. We will not go verbatim what is o n the slides.


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The Free State in a nutshell as being in the middle of the country

faces different complications or implications in terms of its

geography. It is a primarily rural province, divided into five

Municipal districts; Xhariep district which is more towards the

south close to the Orange river, close to the Vaal is Fezile Dabi, to

the north west we have Lejweleputswa, to the east is Thabo

Mofutsanyana close to where we are now and central is the

Mangaung Metro which covers area from Thano, Botshub elo and

Bloemfontein city. So that is the only metro we have. Our

population size is according to Statistics SA around 2, 6 million for

the entire province.

In your presentations you will look at the distributions of the

private sector beds, with all their differentials but what is of note

when you look at them you will see that MediClinic Group in the


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Free State dominates the number of beds in their different

configurations, albeit acute, sub-acute and even some of the day

beds or mental health beds that they have. Another thing that is

clear it is how Bloemfontein is dominating the number of beds in

the Free State. The Health System Trust in 2010 had a little study

and per capita we are showing that we are really competing with

Gauteng in terms of pr ivate beds against the population, but the

issue in the Free State is the distribution of those beds and what we

are trying to show there is that we are having the rural areas like

Xhariep district where there is not even a single private sector bed,

Thabo Mofutsanyana is the biggest district, but it is the poorest of

all the districts. It is only now that they are starting to have a

second private hospital being built in that district. So as the

committee, as a private facility licensing committee th ese are some

of the mandates in our regulations; this is one of the areas that we


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are looking at – the distribution of the beds. It is an area that

became highly contested two years ago in 2014 when we Gazetted

the Free State Private Facilities licensing beca use there were

groups, especially Hospital Association of South Africa, which the

document we have included that were challenging us that we are

instituting section 36, certificate of need indirectly by declaring

that this committee or the committee should be looking at where

these beds should be placed in terms of need.

And it is at this point that I want to touch on a point that briefly

was touched yesterday, that the complication of the health sector is

when need and demand are mixed together, or the two terms are

used interchangeably because demand can be created and I can give

you examples. Many of us we are parents here or grandparents for

some chairperson you would find that many of our children are


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exposed to psychometric tests ; we have now psychologists who are

education specialists. In my case my own daughter is going

through occupational therapy just because of the way she holds the

pen and because she writes 8 not flowing, she writes two zeroes put

together. So that is demand, the demand is created and we can go

on and on about the attention deficit diseases that all our kids are

on now. That is demand to us, it is an economical concept which

can be created, it is linked to want which can be religious, political

and so forth.

We are talking need and to us need means we look at burden of

disease, we look at what do we need to do to get people healthy and

what is available to get them to that. The difficulty with that

approach that we have found in the Free State which was maybe

touched even yesterday, was that because we do not measure and


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some of these things do not have signal s, we end up having a

problem of what is healthy – how do we define a healthy society?

What is this outcome we are talking about? Is i t based on usage?

Is it based on headcount? How many people contact or use our

services? Or is there a more community based measurement in

terms of what is healthy?

So the need in i tself sometimes is not an exact science. So when

we talk about the need for beds, in the Free Sta te if you look at the

statistics that we have given you in terms of the numbers, you will

see that in Bloemfontein because it is urban in relation to the rest

of the districts as a metro, you will find that the demand is higher

than the need. So invariably you are continuously having

oversupply of services because it is informed by the economy of the

area, but if you go to districts like Xhariep, Thabo Mofutsanyana


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you will find that those are the poorly serviced areas in terms of

private healthcare because the demand is lower than the need. You

have this juncture between urban and rural areas and applications

for private facil ities follow the markets. So you end up having

everybody applying for Bloemfontein which is what the slides will

show you that you have in terms of the numbers we have shown.

Now what we have done in 2014 was to try and reverse that by

looking at what joint ventures are possible with the private sector

to make sure that we service the population not based on demand,

based on need. The examples for demand and need can go on and

on. I sometimes watch TV and I listen to somebody called the

Wallet Doctor where you can get doctor for being admitted, so that

in itself creates a demand for a bed in private sector because I can

get money whilst I am lying there . So demand can be tampered

with and we should then focus on need and in the Free Stat we


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maintain that that is where we should be going with our regulation

in terms of the private facilities.

I am going to skip the other areas, I t hink they are quite

straightforward in terms of what we regulate. It is not too different

from other provinces, but what we did add given that all the

information was telling us was inclusion of a need for a business

plan by the applicant to be included. What we had realised in the

past without having business plans people were just supplying

based on demand or need, we have gone past that, but then what we

ended up having at the end was that people were getting approvals,

not necessarily l icenses. The way it works in the Free State we

give an approval, you get a license when you have finished building

and we have inspected. So you have an approval to build and then


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you get a license at the end of the time, which is according to our

regulations, in three years.

Now, what used to happen is that people would get this approval

but never got things off the ground because they then had financial

difficulties because the planning was not what it was supposed to

be. So what we had said we now include a request for a business

plan, but what we are struggling with to be upfront with the panel

and the commission is that chairperson we do not have stringent

financial instruments that we can use to measure this business

plans. As you know business plans now can be produced by the

internet, you Google it , you get a template, you populate it , it looks

good on paper but sometimes it is never practical and this is why

you will find in many of the sl ides people who got approval in


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2012, 2013 many of them are still in process and many of them are

struggling partly because of the finances.

In another scenario that really woke us up as a province was that

we will sometimes then approve sub-acute bits for a particular area

based on need. That supplier would go and turn th e soil, make

foundations pay about R7 – 8 million, when they go to Standard

Bank for example in this case for more funding, Standard Bank says

we have done our own study, there is no way you can have sub -

acute bits in that area, they should be acute bits, that is the only

time we are going to give you the money. Then the supplier then

re-applies for amendments of the application, so it becomes a

vicious cycle where now the need is tampered with, informed by the

finances. So we are maintaining that we need a proper business


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plan from day 1 that we can adhere to as something that is

sustainable.

Secondly what we introduced is this community involvement, social

responsibility. It used to be quite loose in terms of the way it was

penned in the regulations and many of these hospital groups would

just provide CPD training for doctors and say that is our community

involvement. What we have done since 2014 was that we want an

annual plan, that annual plan must include things that we can

measure because if you cannot measure it it is not going to be done

and the community involvement should be clearly defined and also

the social responsibility. Not in general terms, but it should be

drilled down and customised to the communities that these hospital

groups find themselves in. It needs to go beyond just CPD training,

or continued professional development. I apologise for the


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abbreviation. It needs to be proper social development linked to

the needs in that area. We even are asking for them to set

milestones so that these things are time bound in terms of the social

responsibility. So the way we are interrogating applications now

going forward will be that and we want to make a humble request

chairperson that municipalities maybe through SALGA should be

engage maybe in this process because many of the delays in the

Free State are caused at that level, in terms of private facilities.

We give approval, part of the process is that you must submit your

plans to the Department, or to the municipality. The municipalit y

must then okay the plans and give an approval. Secondly the

purchasing of the sites or the land becomes a huge delay for many

of the applications – so many of them give up at that level and

when they give up, the panel should appreciate that we give this

based on need so when things do not happen it means we are


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denying people services in that area because then for three years

nothing happens and then after three years only then do we realise

okay this is not going to happen, then we restart the process. So it

means it is three years of people not getting a particular services, it

be sub-acute, acute or mental health, and for a province

disadvantaged like the Free State with its own geographic that we

are sharing soft borders with everybody, except Limpop o it

becomes quite difficult. So we propose humbly that municipalities

maybe if there is time can be engaged, maybe broadly through

SALGA just to check what issues are in terms of allowing people to

get land, what are the issues, is it contested lands, is it farms that

are green land and not brown, all those kind of issues, or in terms

of special planning. Sometimes the two departments, because we

do not have those interactions will approve and find that there is

another plan from the municipality to do s omething else in that


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area. So I think it will be another area to complete that loop in

terms of. . .

CHAIRPERSON Has the provincial government engaged the

municipalities on the issue of the delays?

MARCUS MOLOKOMME Thank you Chairperson for the

question. Not at the moment, I think we are engaging them on

other matters but when it comes to this facility licensing since 2014

when we came on and changed the regulations we still have not.

The other area that we know we are struggling and we as a province

have not moved forward is the quality assurance wing in terms of

assessing these facilities. You will see in the documents there are

different kinds of assessments and the first assessment is that we

said we will only inspect at completion of the constru ction and we


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found problems with that approach because then if some people

build an infection or what do you call a sluice room, a dirty room,

and you find that dirty room is built without an exit so the dirty

things are going to walk through the clean are as and the reception.

It is difficult when you come and you discover that opening, that no

you need to open this door, there must be a door here and

sometimes that is on the third floor, there is no way they are going

to break that wall and create a staircase for them to be compliant.

So what we are opting for going forward in reviewing our

regulations is to make sure that we identify key levels in those

building where we coming to inspect. Currently our regulations are

saying those kind of inspections a re done by invitation, meaning

the group must then invite us to inspect. So we want to stop

making it voluntary, it must be mandatory visits by our units,

maybe a foundation level, window level and so forth, depending on


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how infrastructure engineers will advise us. To make sure that we

correct things because variation orders at the end are quite

expensive to get people to be compliant. Also it is sharing the

information with the public. We do share the office of Health

Standards Compliance or National Core Standards what used to be

through our governance bodies for public sector facilities. So we

have clean committees, hospital boards, we have provincial and

district health councils – that is where all these CEO’s and district

managers are held to account to the public in terms of our

compliance. But with private facilities we still have not shared our

findings, for example MediClinic Group would score 72%, that

information invariably had always remained in the department, we

would not go out and publish that MediClinic compared to Life,

Rosepark compared to Netcare, this is their scoring; compared to

Ernst Oppenheimer this is their scoring – that we have not done and


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I want to declare that upfront. That is an area that we are willing

to go and look at .

We also need to review the penalties.

CHAIRPERSON That has not been done?

MARCUS MOLOKOMME No particular reason chairperson. I

think there has been an oversight and it is informed by I think in

the past where we approached private and public sector it is only

now I think in the past five years that even the department itself is

starting to call i tself Free State Health, not Free State Department

of Health because once you do that you are already suggesting that

demarcation between private sector and the public sector. Whereas

the Minister always says he is not the Minister of Public Health, he


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is the Minister of Health in the country and even our MEC should

start approaching as we are doing in the Free State Health to

approach that we are responsible for the entire system of health,

not public and private. So we have been rigorous in assessing,

even if you look at our outcomes in terms of mortality rates, you

will find that we are willing to publish number of maternal deaths

that happens in a particular facil ity in Bloemfontein, but you will

not find us doing the same about MediClinic down the road in

Bloemfontein. So it is only now that we are starting to engage them

– our legal department actually next week has a meeting where we

are starting that platform so that we are able to report to the public.

CHAIRPERSON Is that required by the regulations?

MARCUS MOLOKOMME No.


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CHAIRPERSON That would require public institutions to report

on these matters but does not deal with the private sector?

MARCUS MOLOKOMME Yes, our regulation and our Act is

focussed primarily on public sector. We are mandated, but what we

have done as districts you will find in Lejweleputswa you will find

when we report mortality rates, we report maternal deaths for

example from all facilities including our private sector. So it has

been sporadic, it is not something that had been structured and that

is what we are saying as the unit that leads for licensing we need to

start on that platform to make sure there is that collaborat ion, but

there is nothing stopping us, it is just something that was not done

in reporting in the public sector and the data.


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I will just give a quick example – when we had that campaign by

the Minister in the country for HIV counselling and testing, HC T,

that was the first time since I have been in the system that we have

had interaction in sharing data with the private sector proper

because when we did the mop-up we went to the National Health

Laboratory Services, NHLS, to get their data. We physicall y went

to every practit ioner to get their data on HIV counselling and

testing, including Male Medical Circumcisions. We went to all

private hospital groups to get their data as part of the mop -up

process so that is why maybe the end people claim we perfor med

well as a country because we for once had an eagle view of what

the system is doing in terms of strategies for HIV and AIDS and

those are the initiatives that I am talking about, but we have not

built on them going forward. Up to now, but going forwar d that is

what we intend doing.


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Chairperson, should we continue?

CHAIRPERSON Yes, please by all means.

MARCUS MOLOKOMME Let me get Adv Finger to just make one

point, if you allow chairperson?

ADV FINGER I just wanted to bring to the panels attentio n that

the new regulations it is compulsory for private sector to provide us

with data, so we have made it compulsory. If you look at

regulation 31 in the new regulations. Thanks.

CHAIRPERSON Previously it was not, was it? So you had to

focus on public institutions, and who was responsible for gathering


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this information, was it the district council or was it the provincial

government?

MARCUS MOLOKOMME Provincial government, yes thank you.

Lastly we want to now in terms of our assessment, I have spo ken

about penalties, penalties are R100 000,00 or five years

imprisonment for non-compliance. We think that is too light. I

think going forward in the way we want to take quality assurance

seriously we need to review those penalties. It is quite easy I am

sure for some of these hospital groups to budget R100 000,00 just

for compliance, it would be quite easy to budget for that. So we

need to look at how we are going to enforce and make that heavier.

Lastly we want to look at our assessment tools.


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I think our assessment tools are designed based on national core

standards and national core standards for their purposes are quite

brilliant, but they measure the basic, they look at the floor, they

look at how clean things are, we want to upgrade that to st art

looking at governance issues, to start looking at clinical

governance issues. As you would have heard yesterday that

sometimes even clinical notes are not what they are supposed to

me. We need to start measuring those and lastly we need to start

measuring outcomes – i t be patient satisfaction and so forth. So the

tool needs to be redeveloped to move beyond just the core basics.

CHAIRPERSON Is there any reason why this was not done

previously?


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MARCUS MOLOKOMME I think the reason is that our system is

still growing, I will not say it is still you know immaturity, it is

still growing because even in the public sector i tself we are still

using national core standards to assess ourselves and those

standards are quite basic. So if you were to just dep ose our tools

against other developed countries or even some other countries in

the continent, their measurements are more advanced than what we

are measuring. For example we would come to a facility and just

measure if there is a policy, so we have not tr anspollated that or

moved that into the private sector. So what we actually even did,

we did not even have a tool – you will find many provinces have

developed their tools based on the national core standards that we

use to assess our clinics or hospitals in the public sector. It is only

now that we are starting to now come up with better tools for

emergency medical services, mental health institutions because we


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were using just generic terms to measure as you will have seen in

our submission to you. So i t was not happening because even

ourselves we are still learning from these tools within the public

sector. The ways of standard compliance itself has now as

independent group, as I will say upped the game in a way in terms

of what they are measuring with their triangulation approach, not

only where there is a policy, they will then go and check if the

policy is applied at the production side.

I want to move to the second section that we have – I think just

finally because we have not been approving fac ilities, almost all

our facilities that we have standing were regulated with regulation

158 so you will find that going forward we will then have some

legal battles with some of the groups in terms of applying our


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current regulations. Like we have submitted the HASA document

indicating areas of concern that we are raising.

I am moving chairperson if you allow to the second section that

[inaudible].

CHAIRPERSON Is someone going to speak to those issues – the

litigation – at some point? Yes, thank you.

MARCUS MOLOKOMME Adv Finger will talk to that ones, I just

finish the summary then we will just touch on those areas. Thank

you.

The Free State in its uniqueness back in 2000 to 2002 entered into

PPP, a public private partnership, with the hospital group Netcare.

The contract is included in one of your folders there. Now the


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intention of this firstly was to look at, we define the concession

period to be 16 years which would have meant 2018 will have been

the last year of this PPP, but right from its ince ption it took longer

than anticipated to finish the bricks and mortar building of the

private wings, so there was a concession between the department

and Netcare groups through CHM to move that concession period

by an extra four years so now it will end in 2022, not 2018. I

wanted to just clarify the way that concession came from, but the

principles that were on the table from the beginning were we need

to have a shares services model with Netcare and this was at two

facilities – [inaudible] tertiary hospi tal and Universitas Academic

Hospital, with different bits. There will be facility fees, we needed

to look at the model of improved revenue collection from both sides

but primarily we needed to redirect that revenue to improve the

patient experience of care in the public sector. So we needed to


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improve revenue collection, but that revenue collection must be

translated into patient experience in the public sector. We needed

to also look at efficiencies in terms of management and clinical

care, but the most important one was the risk bearing – the risk

needed to be transferred to the Netcare group. So those were the

principles.

In 2010 as shown in the document we realised an Exco took a

resolution, provincial executive committee took a resolution that

we need to interrogate this contract because we are not realising

any of those principles and this was eight, nine years into it . We

then engaged KPMG to come and be the arbitrator and also

continue with their audit and interrogation of this contract. The

document is included in the Word document that we sent as a

narrative to our presentation – what we have done there in detail


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chairperson, we have included the milestones right from day one,

month by month in the Word document what has been happening to

date. What we had found was that this partnership, the risk burden

rested with the Department, there were disagreements with almost

all the fees, we could not see how revenue streams were re -directed

to the public sector for patients to benefit and there a re many of us

who were of the opinion, even though we have not provided the

evidence, that Netcare was in this partnership primarily as a

comfort zone to get a license because primarily it means they have

a license until 2022, in essence. It is a partners hip that we have

and if we want to exit the partnership there are legal fees and we

could be sued. So basically Netcare is in this space, they are

guaranteed a license until the concession period ends. So we are

all agreed that could not be, we needed to go back to the principles

of the PPP, but the most important part to raise here is that this was


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before regulation 16. So this was happening without any legal

framework in the country, so the country was not ready for any

partnership of any sort, especia lly of this kind, but it happened. So

what we are trying to do because we cannot apply the law

retrospectively and I am in your hands here Judge, I am not a legal

eagle but that is my understanding of the law. Now the issue then

that we have is that we needed to then interrogate and go through

arbitration as in our contract, have some agreements, have some

concessions and at the moment as we speak one of the biggest

problems that we realised was firstly we needed to make sure we

have what we call a management unit for this PPP because of the

nature of the PPP and the amount of capital or investment that we

are talking about, but also we looked at the revenue streams and we

looked at the problems. Because even data collection was not what

it was supposed to be, we could not measure things in terms of this


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contract and there are those who are of the opinion that this

contract really has introduced other complications. And one

complication I want to touch on is the Radiology Building or

radiology revenue stream that also became as part of this contract.

I know the RSSA, the Radiology Society of South Africa has

already presented in Pretoria and I know they also use that popular

term price takers, but in the Free State we have a different notion

or concept and experience from radiologists. Radiologists formed a

group and through that group they entered this PPP space to bill for

radiology services on behalf of the Department. So there is a

contract that we have included in the pile there, in the folder, but

the funny thing about this contract is that it entitled the department

right from the beginning to only 33,3% of the net collections and

when we did this assessment we all felt that this could not be and I

do not want to make this a legacy issue and blame p eople in the


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past, it is a matter that we needed to deal with. Because firstly it

meant all the risks rests with the Department of Health – we own

the equipment, we maintain the equipment, we have the personnel,

this is all the administrative people and th e radiologists and the

radiographers, people who are all in the company are actually our

employees, but they are making 76% for just providing a practice

number and claiming on our behalf – that is exactly what that

contract entails and we needed to put a stop to that. So what we

did, actually then issued which is included in your archives there to

terminate and then go properly on to tender if there is a need for

billing for radiology services. So I just wanted to touch on that in

terms of part of the PPP – i t is not in essence legally part of the

PPP, but the PPP platform created an environment where such

practice could happen.


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CHAIRPERSON Just tell me, you know, is there a policy now that

governs these PPP’s?

MARCUS MOLOKOMME Yes, there is now, regulation 16 I am

referring to in the Treasury and also the PFMA, but back in 2000,

1999 when this was contemplated there was none, it was just an

open land where innovative people could enter the space and I must

say there are a lot of lessons that we lear ned from this PPP and I

am sure other provinces will give their experience and so forth, but

ours is quite unique and I will touch on the second section. I am

coming back to this point, on other complications that this PPP

brought.


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PROF FONN Can I just understand, so the nature of the issue with

the radiology group is that they did the billing service for the

province?

MARCUS MOLOKOMME Yes, there was a notion that somehow

our department and Netcare were made to believe that they will not

be able to charge total fees in terms of the uniform fee structure,

the UFS, so they needed a practice number from specialists to be

able to bill for 100% of the fees, so that is the arrangement. So

what they are providing as a group like you heard yesterday that it

is better to pay into groups, they made that kind of a group as

radiologists. Once they made the group they came out with an

association which had a practice number, that practice number is

the practice number that claims for all medical aid patients and

private patients that comes to the facility. So they are basically


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claiming for all the services of imaging and treatment, radiological

treatments in our facilities. So that money gets into their account

as people who have carried out the service, but that s ervice is not

only them, they report on the images, the service is done by

radiographers who are employees of the state. This people in this

group also are professors and Head of Departments who are

radiologists within the Department so that is the arrang ement – just

to paint the picture, but once those monies are there they will pay

all their costs and then 33% is due to the person or the Department

that owns the equipment, that pays salaries and maintains the

equipment.

PROF FONN So the costs that are covered by the income does not

include the Departmental costs?


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MARCUS MOLOKOMME Not at all, it is just what you pay the

people who do the electronic data interaction, the EDI, who send

the batches, their claims. Some monies was paid as bonuses to

radiographers I think they were paying them like stipend on top of

the salaries we pay. So those are the costs and maybe other

company costs that they might experience. So it is not the cost of

the State, that is why I am saying all the risks, 100% rested on th e

State, they just provided an administration and a practice number.

PROF FONN And was this contract signed between the Free State

Department of Health, Treasury was not involved at all?

MARCUS MOLOKOMME Not at that point.

CHAIRPERSON Treasury?


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MARCUS MOLOKOMME Not at all.

CHAIRPERSON And how much are we talking about here?

MARCUS MOLOKOMME I will share the figures because we had

asked for confidentiality because we wanted to be open with the

panel as much as possible because our idea is tha t we need to

correct things, we are not here to defend or hide anything because

we want things to be done in a correct framework. They were

talking turnover of up to R80, 90 million a year, that is the

turnover so we will be entitled to around 33% of that . Let me just

add chairperson that this month of May, oh sorry.

CHAIRPERSON Are you going to come back to this point at some

time, are you going to come back to this issue? Now precisely


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what is it that these radiologists did apart from supplying the

practice number?

MARCUS MOLOKOMME In terms of service these are our

employees, so basically in the daily process of giving our service

those patients that are fee paying then get bil led through that

vehicle. So all your patients that are on medical aid wh en they

interact with our service, will be billed. Let me just add where this

other stream of patients came from. In our Netcare PPP

arrangement, Netcare does not own any radiology capacity so all

the patients that are in Netcare at both Universitas Acad emic

Hospital and [inaudible] tertiary hospital are then transferred to the

public side to come and have the tests and the imaging done. So

basically all the patients that ever had an x -ray, an MRI scan, a CT-

scan or any contrast medium treatments from Ne tcare Group as part


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of the PPP were seen in the public side at Universitas and

[inaudible], but will have been billed by this group. Now Netcare

at some point also had some, I do not remember the percentages,

also had some money that was paid from the gro up to Netcare as

part of their revenue because of that arrangement, but Netcare will

tell you this arrangement was not part of them, they are pointing

the finger towards the provincial government because that is where

the contract is held. But in terms of benefits, those benefits went

both ways, we can call them benefits – I am just saying the

payments and we even had a concession chairperson, that patients

that came from Netcare would not wait when they came to the

public side. So if you find 100 poor pat ients queuing up in

radiology for a particular x-ray modality and three Netcare patients

arrived, those will be the first to be seen. And these are just some

of the things that we have been challenging because we did not


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want, and in one of our discussions it is just you know things

sometimes do not get returned, people were saying people who do

not pay do not mind waiting sometimes. And these are some of the

notions that we want addressed, that is why we are saying we are

here to open up in terms of our experience with our PPP so that we

once and for all correct what has been going on. So to answer your

question they did nothing else, they just provided practice numbers

but continued to work as they would anyway for a salary because

they would report on every image – that they would have been

doing anyway. But the issue was that the hospital on its own could

not be able to, I think we allowed thirty to thirty five percent, but

do not quote me on that, we need to cross reference, as a hospital

who could only bill for a section of the fee, but them as

radiologists could get 100%, but from that 100% we still get 30%

anyway.


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CHAIRPERSON Help me understand this – these radiologists were

employees of the provincial government and they were getting paid

a salary by the provincial government?

MARCUS MOLOKOMME Yes, they were. The second section I

am not going to come back to this, the technical part, but there is

another element that I want to touch on that informs how employees

of the State end up doing business in this manner with the

Department.

CHAIRPERSON Now in addition to the salary that they will

receive monthly, then they have a share of about 63%?

MARCUS MOLOKOMME Yes chairperson. So as the RSSA would

have presented, the Radiology Society, the ra diologists are


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basically hospital based so there is always an argument that I am a

radiologist in the State, there is no way I can go do any other work

outside. So my work needs to be done where I am at, so that is

another argument that has always been fl ighted in terms of

justifying this practice. That I am here 24/7, I am not like another

private sector radiologist who is in another hospital and getting all

this money on their own, so that is another element to this angle

which I will touch on just now.

The next concept that I want to touch on, thank you Chairperson, is

this whole concept of remunerative work outside the public service.

I am not too sure if other provinces have touched on it yet, but we

want to go deep into it because to us this is t he biggest problem we

face. And part of it is that the Free State with its PPP arrangement

has created an enabling environment, the fertile ground for this


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practice to happen. Basically as we said Chairperson now, these

are employees of the State that are now given approval to now go

do remunerative work, work where they are paid outside the public

service and outside in this case does not mean outside of his hours,

it means outside the premises. I want to be clear on that because

sometimes people think we are saying out means i t is after work so

it does not matter – in this case we are talking work that is done

just outside any of our premises. This is section 30 in the DPSA

you will find that it is by policy allowed to happen, but many

provinces have their own interpretation of how to apply this

concept of RWOP’s or remunerative work outside the public

service. Other provinces, especially in this case where we are

sitting Kwa Zulu Natal has put an end to it in 2010 and many other

provinces we are still struggling with this beast. In terms of our

arrangement Netcare is attached to our facilities, we can be sitting


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here if you go to the loo here you are already in Netcare that is

about three or four steps. Now if you have an arrangement with a

specialist who works for Netcare and works for you, you never

know where they are at. So invariably during office hours they are

able to see their own private patients and see public sector patients

and we all know Chairperson that if somebody is called by Netcare

and they are stil l seeing ten poor people we know where they are

going to go. I think we can argue about the ethics and the behaviour

the whole day, but the issue is we know that sometimes this market

is driven by income or money or revenues. Now it is a gainst that

that we then in 2013 started the process of reviewing the policy and

what we had done was that we are not going to approve any

remunerative work outside the public service where people apply to

do it during office hours or during when they are on call, that is


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overtime. This applies to all public officials in the Free State, but

we were focussing specially on clinicians.

The biggest problems that we are facing, I will tabulate them now.

Number one was service delivery – we realised that people were

leaving the public sector to go and work in their private rooms in

the hospital groups or their own private practices during peak

hours, by this we mean 10 and 2 o’clock. This is when you find

many patients in our out -patient departments, patients in the wards,

ward rounds were not done the way they should be, meaning we are

not discharging patients as we should and so forth in terms of

service delivery. The second part was supervision – we felt that

this practice was encouraging what we call thi s “juniorisation”, if

there is such a word, of the doctors sector where you find there is

no hierarchy anymore. We knew many of us when we trained we


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knew it was almost like military – there was a Head of Department,

there were consultants, there were sen ior registrars, there were

junior registrars, there were medical officers, seniors and junior

medical officers, there were comp-serv doctors and then there were

interns in that order. So that was the pecking order, but now all

that has gone murky because people are just haphazardly leaving at

any given time, not in a structured manner. So you will find

sometimes in the services, the front line person is not the most

senior. You will find a new registrar who is basically a medical

officer being the one running the services because the top

[inaudible] has left the service to go do their remunerative work.

So it “juniorise” the front line of medical care and this has led to

many litigations, especially when you find junior doctors having

mishaps because they were not supervised and we could test in

some of the cases that if the senior person was there the decisions


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taken, or the problem list that would have been drawn or the

interaction with the family or the intervention would have been

more robust in ident ifying what is wrong and doing something

about it . So this practice is now coming and showing its ugly head

in litigations because the senior was not on site. We know the

problem with this chairperson is that you will not get many

witnesses to this because as junior doctors we all want to be

promoted and qualify as specialists. We would hardly report our

seniors as they were not on site and that is the biggest problem

RWOP’s brings.

But to me the biggest one is the next one – training and teaching.

Yesterday you were told here that some of the doctors do not write

the quotes and it is our submission here that that problem starts at

the production line. The doctors we are producing now and we


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have all been saying it in corners, we are saying it here – the

doctors we are producing now in terms of quality are a far cry from

what we used to produce. The specialists we produce now are a far

cry from what we used to produce. Let me just give an example –

if you get a good intern who is produced from a par ticular

University, the f irst day they arrive you give them an A4 paper to

write clinical notes, they will complain, they will want three more

pages to write clinical notes but you meet that same intern when

they are a medical officer, they need half of th at page to write the

notes. So they will be so domesticated because the hierarchy has

lost its shape to a point that people get domesticated with the bad

cultures within the medical sector and RWOP’s is the cause of all

this in terms of training and supervision.


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Research is suffering because the Heads sometimes are not on site,

teaching is suffering because people are chasing RWOP’s and this

is in 2013 is what informed our position on RWOP’s. We got

challenged , taken to court, we were interdicted for technical bits in

terms of creating expectation because this is a privilege, it is not a

right, it is something that is applied for annually and we can say

yes or no, but later on Adv Finger can maybe touch on the legal,

technical bits if you so wish chairperson. Now...

CHAIRPERSON Okay, these doctors who are supposed to train

these young, these trainee doctors if that is their proper term, are

they attached to tertiary institutions as well where they teach?

MARCUS MOLOKOMME Yes, the biggest problem we face with

these RWOP’s is basically the academic facilities because this is


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where you find all the super -specialists and many of our specialists.

In the Free State like in many other provinces you will not find this

as a big problem in district hospital s, clinics, community health

clinics or centres or regional hospitals – that is where it starts. In

regional hospitals yes you will f ind it; your [Bongani?] regional

hospital, your [ inaudible] in Betlehem, but [inaudible] tertiary

hospital and Universitas – that is where you find the biggest

problem because most of all applicants are from those facilities and

we are focussing on this because the biggest problem we were

concerned about teaching and we had contacted the dean because

we feel in terms of what I am going to present now later, we feel

that the Universities have a key role to play because we cannot

allow teaching and research and learning to suffer whilst we are

allowing people to go and do RWOP’s. And then in between that i t

is service delivery. So that was our position. It was not to tamper


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with any autonomy of any nature, all those things that we were

accused of, but the issue we are not here to defend our position, we

just presenting the problems we experienced.

Okay, fifty specialist to date since 2013 left the services because of

this matter.

CHAIRPERSON Can I ask you this question – these professors, I

assume they are professors because they are attached to tertiary

institutions, would they go and do RWOP’s during teaching hours?

In other words absent themselves from lectures because they want

to go and do RWOP’s?

MARCUS MOLOKOMME I would not say yes, but it is something

we could not measure because our Human Resources measurements

are not that advanced because people will always giv e you a work


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plan, but whether they adhere to that work plan in terms of

measurements it becomes difficult which is why we then need the

Dean of the Medical Schools to be assessing that on their side

because we have this space called joint appointments. S o these are

people who are employed by the State, we pay 70% of their salaries

and 30% comes from higher education because they are linked to

the facilities, to the medical schools. So half the time when they

claim I am in an academic meeting, as CEO I am not too sure if I

do not collaborate with the Dean if that is so because on my

worksheet it will say 2 till 4 academic commitments. If I am a

CEO I will just assume at the University, but if I do not follow up

to say where is Professor Molokomme at this time and be told no he

is busy in lectures or sometimes you are told he is busy in his

rooms, please phone his rooms. So those kind of. . . Our HR has not

entered that space rigorously to do those measurements.


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CHAIRPERSON Are you suggesting that one of t he problems with

RWOP’s is that it is difficult to monitor? Please say that on

record.

MARCUS MOLOKOMME Yes, there is a notion that RWOP’s as a

policy if not a problem, the problem is its monitoring because we

do not have the necessary tools to do that.

PROF FONN Can I just clarify with regard to the teaching

commitments – there are two kinds of teaching as I understand it

that happens. The one kind of teaching is lectures and the other

kind of teaching is service learning. Service learning takes pla ce in

the hospitals around the beside so is it the case that if doctors are

not in the hospitals running their ward rounds, they are not doing

their teaching?


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MARCUS MOLOKOMME Yes, you are absolutely correct and to

us that is the most important teaching i n a medical school – the

academic ward round. Now many of those ward rounds will have

been given by senior registrars because the consultants invariably

would have been doing RWOP’s. That is the point that I was

making that we have “juniorised” all front s so an academic ward

round where as a junior doctor you panicked and never slept the

whole night to knowing that tomorrow is an academic ward round,

it is going to take an hour of rigorous learning with patients, now it

is done by junior officials because the seniors might have been out

doing those RWOP’s. So there are two components I agree; it is

the physical traditional lectures, standing in front of the students in

the medical school or research supervision and there is also the

most important – the textbook is the patient.


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PROF FONN Can you give us a bit more detail please on the court

case? So you were taken to court over RWOP’s and what was the

outcome?

MARCUS MOLOKOMME Okay, can I allow Justice Finger to give

that detail?

ADV FINGER The outcome was that well it was really a

procedural issue because I think they raised the issue that there was

not enough consultation. We had issued an instruction that

RWOP’s would not be allowed between 07h30 and 16h00 and you

know they went to court and brought the whole history as to where

RWOP’s came from and that you know, it is something that they are

used to and we should have allowed more time to consult with them


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and also not just stop it immediately – give them some time to

adjust and the Judge agreed with them at the time.

CHAIRPERSON So it really was that you should have consulted,

given them more time, it really was a procedural matter, the court

did not get into the merits or the demerits of the whole exercise – is

that right?

ADV FINGER That is correct.

MARCUS MOLOKOMME Thank you. Now taking it further, we

always said who are the actors in this space, obviously it is the

clinicians themselves, but hospital managers in what chairperson

has raised in terms of managing and monitoring, clini cal managers

and Heads of Clinical Departments and Clinical Units but the


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problem is that many of them are involved in the scheme so it

becomes an agency issue in terms of how it should be managed.

We also need to highlight that you know, as Adv Finger ha s

touched on, the issue of RWOP’s was really as a policy like I said

it is not a bad thing, it was to mitigate the disjuncture or the

disparity between what private sector doctors were earning and

what public sector doctors were earning. So it was the bal ancing

act to allow and also to allow some skills, sometimes there is some

equipment that we do not have in the public sector, but it is

available out there. So it exposes our clinicians to both worlds if

you like, and were supposed to benefits patients – who were

supposed to benefit from that practice, but we know it has not

happened. But in terms of monies, the specific dispensation

occupational, OSD when it came it basically closed that bridge, but

then we just continued with RWOP’s as if it was a righ t and not a


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privilege. We never assessed whether we have reached Utopia, we

reached a point where we have equalised what private sector

doctors are earning and those doctors with us in the public sector

and there are many people who would argue that we ar e paying,

even though the salaries are not what they are supposed to be in

terms of being risk based and so forth for doctors, but by far we

have bridged that gap. Because also now I will give you an

example – an obstetrician for example for indemnity wil l pay up to

R300 000,00 in private practice. The same obstetrician working at

[inaudible] institution pays nothing because we carry his liability.

So basically we, in terms of costs and benefits we have equalised

what people earn. So meaning the need for RWOP’s must be

reviewed and it is behind that background that we are going to give

a resolution.


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Deans of medical schools are the biggest player, oh.. .

CHAIRPERSON I have this question, but there is another problem

though isn’t there because you must be able to attract and retain the

specialists and for you to do that you need to offer them conditions

of service with which they will be comfortable and wasn’t RWOP’s

supposed to address that problem partly?

MARCUS MOLOKOMME Yes, partly but in the main it was to

equalise like I said that gap that existed. In terms of the our

services competing with the private sector, that is something we

need to as a province to work on, to make sure that the goods and

services are in order, the equipment is up to scratc h so that

specialists are seeing they are doing what they are trained to do.

We do not want them to venture into private sector to go experience

things. When they are sitting for tea they should be able to


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compare notes in terms of what they are treating with their

counterparts in the private sector and to many of the people even

though they are complaining about RWOP’s, the biggest thing that

we have not maybe addressed is to address the environment that we

work in to make sure that it at tracts people on its own without

having them do RWOP’s. Sometimes we do not want to paint

everybody the same batch – there are many clinicians that are

committed in the public sector, have stayed in the sector and there

are many medical officers who we even call career m edical officers

for you know maybe wrong reasons, who are those traditional

doctors who just stay there and render a service, even in this milieu

of RWOP’s and so they are not participating in that. So there are a

few people that we are focussing on who a re the ones that really are

abusing the system, but there are many committed doctors. I do not

want to leave the panel with the impression that in the Free State it


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is ‘hallo-ballo’, people are just doing RWOP’s, it is a few people

that we are dealing with but it creates a problem.

The second point that I wanted to make in terms of access is the

hospital groups themselves, after the Deans of medical schools.

Because when many of these people leave to do RWOP’s, they are

doing them in the private hospitals so it is for the benefit of the

hospitals that we allow these people to go out. For example if I am

an anaesthesiast like for theatre you will find that my theatre lists

are booked between ten and one o’clock, then the question should

be asked should you not be in the public sector hospital right now

while you are running theatres here? So in the Free State we

started with Netcare now to partner because they have biometric

systems to start monitoring movement of our doctors. So for

cardiology department I know I did not give in time, which


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cardiologists is in there at what time, which is necessary to support

are in there at what time. So there is an area there to be looked at

in partnership in controlling the movement of our clinicians.

Lastly is the medical aids, we know Gems started in 2013/2014 to

produce lists based on Persol numbers and ID numbers, lists of

clinicians that are being paid by Gems medical aid, whereas being

employed by the State. It is a l ittle measurement, even if it can

create other problems, it is at least a beginning of knowing who is

earning money from medical aids whereas in the State because we

then start, it is a proxy measurement because we can then even

measure if there are specialists what time those patients were seen.

Now the hurdle that we could not jump when Gems provided the

lists was that many people were threatening to take us to court

because they were claiming this is an employer -employee


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relationship, it cannot be entered by a third party, in this case

Gems. So I am just putting that as one of their terms that were out

there to try and curb this abuse of RWOP’s.

Lastly in our proposal we are saying we need to standardise this

practice. Many provinces have different approaches, some have

actually outright banned RWOP’s, some of us tried other means

and we struggled and we are calling that we need to standardise it

in the short term, but in the long term we need to call for a repeal

of section 30 and come up with an innovative and more inclusive

method of ins tituting another kind of RWOP’s in a way, or another

retention strategy. I have given one instance about magnet

facilities where we make sure that every specialist have got

everything they desire to treat patients in the public sector and we

pay them well because at the end this is what this is about.


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The last point that I wanted to make Chairperson then if there are

any other issues then my colleagues can come in, is. . .

CHAIRPERSON Go ahead, yes thank you.

MARCUS MOLOKOMME The last point, sorry le t me start again,

the last point I wanted to raise representing the Free State is one of

the experiences we have as a public sector divided from the private

sector is that we invariably get calls to receive patients from the

private hospital groups based on that the medical aid is exhausted

and we have had a few meetings locally to try and address this with

the hospital groups, but we are putting it here because the practice

has not stopped and we have put in confidence two cases; one from

I think last year one that was quite recent as well about a practice

where you will find a private hospital will meet a pregnant mother,


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that mother gives birth to a baby with maybe a little abnormality

needing a neo-natal ICU. Depending on the scheme, what they

cover and what they are willing to cover or how much savings they

have you will find the mother is admitted in that hospital, but the

baby is ferried to a public sector hospital, separating mother and

child right from day one based on money. And in the case that w e

are putting forward unfortunately the baby demised and we are

saying that cannot be – going forward this is the space we need to

look at. We expect our private hospital groups to nurse patients to

wellness and this is the point that was made yesterday, we are not

measuring outcomes – we are measuring price and affordability.

Whereas in the midst of all the presentations we even heard

yesterday, this point was not addressed in terms of what happens

when a patient lying in ICU runs out of funds, what is t he

obligation of the medical aid – is it a pro rata determination, do


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they have to apply for motivation or do you ship out this patient

expecting government to now take over because now there is no

money. There are many cases like this, the most other rec ent one

that we did not include was a case from a patient from Lesotho and

this is one of the challenges that we face in the Free State with the

proximities, that patient came admitted in MediClinic

Bloemfontein, got a drug reaction, a condition she did no t come

with initially, got a drug reaction, ended up in ICU, three weeks

later money runs out and the family is called from Lesotho to come

and collect. Now the family ends up at my office saying please

help, there is nowhere else to go, we feel this is a practice that

must be brought to an end.

The other part that we want to raise is the issue of protocols – the

clinical protocols that we have are not standardised so private


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sector sometimes driven by the bottom line will do renal dialysis on

a patient because the medical aid for that pensioner would allow,

but they do not plan that what happens when that money runs out

because when that same patient comes to a public sector facility,

our protocols will now dialyse the pensioner, just putting it brutall y

as it is. So you will find somebody comes with all the tubes

hanging expecting to be dialysed, and we tell them we are not going

to do it and their argument is woah is it because I am poor, but the

medical aid has been dried out elsewhere and those peop le will not

touch that patient because that patient now has no money. And we

have a lot of patients that are falling through the cracks because of

the protocols but also because of the approach from the other side.

Lastly we want to just touch we know EMS regulations are being

finalised, we are also going to form a committee to regulate our

private ambulances. The issue that we are raising it here with


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private ambulances is that we are finding and Mr Ruiters is here to

just confirm, we are finding that at an accident scene you

sometimes find that the private ambulance groups would not touch

some of our patients or our victims because they ask the question

from the side, whether you are able to pay and that is the difficulty.

We have attached a case that we have handed over to the police

where there was an accident in an area called [Poliroo] in Thabo

Mofutsanyana, next to Bethlehem and three of the victims were

speedily taken to Hoogland MediClinic because they were on

medical aid and the rest of the victims were left there for him and

his crew in public sector to arrive and we are saying these are some

of the areas that we need to look at in terms of experience of care,

right from the streets. Not only focus on the bigger facilities and

that is the case that we want to.. .


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And lastly when these patients run out of medical aid even the

ambulances in those hospital groups will not carry these patients,

we get phoned to come and pick up. So that practice must be

looked at and I know people are calling for reg ulations. Some of

these things need regulation, some of them just needs us to be more

human.

Lastly, the public EMS, maybe out of trauma from the past, if you

were to be picked up on the N1 around the Free State, before you

get to [inaudible] tertiary hospital trauma unit , you will have

driven past three private sector hospitals and our ambulances do not

even bother, they just past those with red lights wailing, high speed

to [inaudible] because they know those patients are not going to be

accepted. We do not have the evidence of how many were rejected,

because like I am saying it has become a culture of some sort that


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if those people are poor, stabbed chest around next door to

MediClinic, you drive to [inaudible], you stand more chance of

saving that l ife than going next door. And these are some of the

practices unfortunately that come and we cannot just stand here and

prove that this is what is happening, here is the evidence because

will say we have never rejected a patient but in our call centre we

do record all these calls that we get and some of the calls are such

calls where we are requested to come and pick up and people are

declaring, please come pick up because the patient has run out of

money.

Chairperson, that is almost 90% of our presentati on linking as an

oral submission and I will just check if. . . That is our oral

submission, but the panel is available to answer.


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CHAIRPERSON Yes, on this last issue may I ask you this question

– does the provincial government have a policy on emergency

medical care?

MARCUS MOLOKOMME Yes, we do Chairperson. We have an

Emergency Medical Services Unit which covers pre -hospital

transport, we have high trauma or high life support vehicles, we

have disaster vehicles and then we have the planned patient

transport – these are the ones that are used for referral of patients.

So these are the big bakkies or big Iveco busses that you will see

transporting patients within between levels of care. We also have

maternity ambulances, we are one of the provinces that i n

2010/2011 financially reduced maternal mortalities by 50% so we

were the icon of Africa at the point by just instituting skilled

attendants speedily by putting maternity ambulances where we


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should. So we have different policies for different vehicles. We

also have ICU vehicles and mental health ambulances because we

always have the opinion that mentally challenges people we usually

call the police, in our case we call an ambulance because that

person is ill , not a criminal. So we have those policies in terms of

medical care. We also have airborne medicine, so we have now in

the new contract; in the past we experienced biggest problems

because people could not fly at night because of the nature of the

configuration of our service; so we have not introdu ced 24/7

service so we can fly to clinicians, to patients at once at night with

our airborne medicine. Interaction with the private sector – we

have a contract with Buthilezi EMS for inter -facility transfers that

we have gone out on tender on people compe ted and the preferred

bidder was awarded the contract. So we have a policy on all those


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areas. All of them are underpinned by our referral policy and the

aversion policy.

CHAIRPERSON What is the attitude of the private sector to

individuals who are in need of emergency medical treatment such

as those who get involved in serious car accidents, who might

require immediate medical attention?

MARCUS MOLOKOMME What we have seen is that on arrival at

the accident scene or a call, if it is a call people will always check

before they come out if there is a method of payment. On an

accident scene when they arrive there is that triage and that triage

is no more only clinical, it is also based on their ability to pay and

the cases we are reporting here for [Poli roo] indicates just that .

But also when they pick up patients who are unable to pay, the


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same private facility ambulances that are linked to hospitals would

not go to their own facilities, they will drive to public sector

hospitals to go and deliver. So you invariably find private, and it

is not unique for Free State, you will find private ambulances

entering public facilities to drop off and this is because they get

paid from Road Accident Fund, nothing else. I might not be able to

prove it here, but we know the driver there is because they are able

to claim for the trip to go drop off, but they will not drop off that

patient in a private sector for them to be stabilised. They will drop

that patient destination is the public sector hospital, but they ar e

able to claim for that transport. So you will find many times

accident scenes have all these cars and they are willing to

transport, but they will check if you can afford the destination – so

the destination is determined by your ability to pay because t he

kilometres will already be claimed from Road Accident Fund.


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CHAIRPERSON Has the provincial government engaged the

private sector on the rendering of emergency medical care?

MARCUS MOLOKOMME Yes chairperson, can I allow Mr Reuben

to give you.. .

REUBEN RUITERS I thank you Chair. I think how operationally

it happens is the private facilities being your Netcare, your ER24,

they also have their own control centres of which they advertise

their call centre number to be called and so forth. So the call

centre or call management process is not yet in a state where we

centralise it where we have only one entity. So currently each

provider receive their own calls and they dispatch their resources

as basically how they receive the calls and based on that we do not

have control of us knowing at the go that there is an accident


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outside on the N1, we will always we informed by their call centre

talking to our call centre that we need additional resources or send

more vehicle support, but only when we arrive in s uch incidences

then we will experience that they did have capacity at the moment,

but they chose not to render services to other victims.

CHAIRPERSON Yes, thank you. Okay.

DR VAN GENT Thank you Judge. I received and read with a lot

of interest. . . I heard with a lot of interest your presentation and I

read thank you very much. I think I have two areas where I would

like a bit of clarification. I think I understood what you said the

difference between demand and need which is very interesting

statement you made, it is easy to make the statement to find a

solution to find out what really need is and also part of our job is


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finding out whether demand is really demand isn’t it – i t is part of

what we do and we both struggle in doing that. But in the

application, I am obviously talking about the licensing process, in

the application there is a number of forms and requirements and

one of them is a business plan, and I do think that is the document

in which you would like to f ind information on the need to

establish a hospital in a particular area or district whatever. And

then I see that you have a committee, I think you are chairing the

committee from the licensing committee that meets every month

and discussed the application and amongst them also the bu siness

plan and it is quite hard to really interrogate a business plan and

find out what the reality on the ground is of these behind these

sector – so do you issue requirements, your own requirements, of

this business plan. So I read that you have five d ifferent sort of

criteria by which the committee makes its call on the business plan


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and ultimately advises the Head of Department whether or not to

give the license, do you require these applicants themselves to

make a self-assessment of all these criteri a that your committee are

going to judge this on?

PINKY BERLOT Okay, thank you chair. What is required is for

the applicant to submit all the information and what we do as the

committee, we verify that information because already we would

have that information at our disposal in terms of the information

that we would be having on data, but now like the presenter said on

the issue of the business plan, they do submit but we do not have

the skill to can say is it good enough or what.

DR VAN GENT I sympathise, I myself have in my long life have

tried to find the truth behind business plans and it is not easy, but

what I was asking is have you considered they themselves to ask


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for a self-assessment on equity for example, you know on the

equitable distribut ion between districts of beds in the Free State or

by demographics or one of the other criteria, BEE of course that is

easy for them to assess it themselves, you just find out who owns

the thing. But actually what I am coming at is to do a real need

assessment themselves and put that position to you instead of you

yourselves having to do the analysis.

PINKY BERLOT No, we have not considered that.

DR VAN GENT It would make life much easier I think.

MARCUS MOLOKOMME Yes, thank you panel. What I was

presenting was that this is our biggest problem in terms of business

plan and we are looking for instruments so that we can assess, but I


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hear what you are saying that we should also create a criterion that

people can self-assess so that we can then interrogate their own

assessments. We appreciate the point.

DR VAN GENT Yes, it is, of course I should not mingle into your

affairs, but on one hand it makes life easier, but it is also more

predictable I think for parties that apply for a license to know

precisely on what criteria they will be judged upon and they can do

a self-assessment and try to.. . It would also make life for us a bit

easier because we would understand precisely what the criteria are

and how they are going to be applied, in what ways mo re and in

what ways less in this situation.

Can I go on to the second subject and that is also that the panel is

looking into the matter of quality and quality and information on


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quality provided by hospitals and then primarily of course our

mandate is to look into the private sector, but the same probably

will apply to the public sector. So your new regulation 2014 I see

under section 31 point 3 that the Head of Department may request

routine statistics and in fact the Head of Department has quite

recently in 2016 I think issued a list of statistics that he or she

requires, it is a list of about eight pages with data points that these

hospitals have to provide to you on a regular basis, on a monthly

basis even I think it is. My first question – this applies to both the

public sector and the private sector?

MARCUS MOLOKOMME Thank you. Yes, i t does. Like we

discussed with the chairperson, in the public sector almost all those

are mandatory. There are regulations set already in terms of the

clinical data sets and all the other national data sets or provincial


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data sets that must be reported on, so in the public sector we are

quite rigorous on that. We are now trying to transfer that

mandatory obligation or expectation to the private sector with that

section 31 of our regulation.

DR VAN GENT Thank you. When reading through the list of data,

for example the maternity data is about twenty items referred to

maternity data and other data, but I had the impression that these

are statistics, these are not data points that one can use to come up

with meaningful quality or outcome measures or indicators – i t is

pure statistics. How many women come in and this and this

condition and that. So a list of statistics, but you cannot derive

from that meaningful outcome measures, am I correct?


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MARCUS MOLOKOMME Yes, you are correct. Like I mentioned

we are having a meeting next week led by our legal department to

develop that section 31 further. We were meeting all the hospital

groups.

DR VAN GENT This has been postponed because I saw it was

intended to take place today, maybe it takes place today somewhere

else. I will be happy to be part of that as well, it is very

interesting. What I am getting at is this – again maybe the same

sort of basic comment or quest ion that I had before, did you ever

consider asking, and I am referring to the public and the private

hospitals – to they themselves do an assessment of their clinical

quality in the sense that you hand them let’s say fifty clinical

quality indicators which can be taken off the internet for free plus a

description how to measure them easily, you just hand them over ; it


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is a bit more complex than what I said now, but just ask them to do

a self-assessment on a number of pre -described standardised quality

indicators and do that on a continued basis. Maybe not every

month, but every half year and do that in a standardised way. First

off for all private hospitals, probably starting with new licenses as

a requirement for the license, but you would probably also be able

to extend that to already existing hospitals because you refresh

your requirements every year, don’t you.

PINKY BERLOT Not really, the only self -assessment that they do

is after we train them on the National Question then we require

them to conduct the self-assessment and we verify that, but not as a

continuous basis we do not, it is not the expectation currently from

the Department.


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DR VAN GENT It would be such a good thing to start with I think

to get the hospitals to first of all self -assess on a standardised

format and you could do that I think as a provincial authority.

Secondly to ask them to publish this information on their site

because it is very important for the public to learn of course what

the quality is that is being provided at all these private hospital and

it is a completely compliant with the National Health Act. And

thirdly to use this information as input for sort of a risk assessed

inspection. I see that you inspect these hospitals every year or

every two years, but I read a couple of these inspection reports and

they are find, but they are not risk orientated. It is not you know,

they are not. . . People do not go and the team does not go in with

prior knowledge about what the outcomes of this particular hospital

are, where the problems probably are and sort of focus in on these

problem areas. I am actually talking like a consultant to you now,


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not as a panellist asking you questions. Can I have your comments

on this?

PINKY BERLOT I think what we are saying is we have not yet

engaged into that, that is the way to after I think this consultation.

Thank you.

DR VAN GENT Thank you very much, I have no further questions,

thank you very much.

DR NKONKI Thank you very much for your interesting

presentation. My first question is around your description of I

would say mis-alignment between what you have l icensed and what

sometimes financial institutions, a bank in this instance, would say

they would lend money on. So what I would like to know is what


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would be the rationale for the bank to say you have issued a license

for an acute hospital and they would say we would rather fund a

different type of hospital - what rationale would they put forward

for that?

MARCUS MOLOKOMME Thank you. The discussion it is never

between us as a Department with the banks. The banks will discuss

with the applicant, but through suspicion when we interrogate these

applications because then we treat them as almost new applications,

when we interrogate the reasons we are finding is that they w ill just

oppose performance in that area from other institutions against the

applicants. So if the applicant has applied for day beds, I am

giving an example, and they feel there is no sustainable business

that they can fund on that model as compared to a cute for example,

I would not say they have looked at MediClinic or Netcare, but


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invariably I am sure they would compare apples with apples. So

they look at performance in Bloemfontein for acute bits against

performance maybe in other areas or even provin ces for sub-acute

beds. In this case it was approval for sub -acute beds based on our

need, but when the banks entered the frame they felt there is no

business for sub-acute beds. But I might add that in this example

that we are giving there was also another element – there was a lot

of delay in finalising from the municipalit ies in terms of the plans

so what was needed as sub-acute beds five years prior, now when

you wanted to build and get funding six years later might have

fallen off as a business model . So that was just another element.

So what we are saying is that our business plan should be so solid

as we have been advised now that whether it is tested today or in

ten years, it will still make sense because invariably if we would

build those sub-acute beds in three years it means the business


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could have collapsed two years later according to the banks. So

that lack of alignment I think we can mitigate against if we have

sound business plan interrogation; either self -assessment by the

applicants and also as a committee when we assess the business

plan.

CHAIRPERSON The problem though that you know, as a

provincial administration one assumes that your primary focus is

the provision of healthcare services, you identify that in this

particular area there is a need for healthcare services and therefore

it is appropriate to issue or to grant a license, but the bank have got

different considerations. They look at whether it is economically

viable to have a hospital there. So you have two opposing inter ests

which might not coincide and that is what they would look at.


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MARCUS MOLOKOMME Correct chairperson, that is the

dilemma. Like I am saying the only way to mitigate that is to make

sure as we assess the business plan we also have that view because

at some point nobody had R300 – R400 million lying around, they

are going to need institutions at some point. So our business plan

interrogation must reach that level so that when we approve at least

we have that strong suspicion that this is sustainable.

CHAIRPERSON But you should have different considerations

because for you it is not a question of whether or not the provision

of healthcare services in a particular area is economically viable,

for you the question is whether there is a need there because you

have a constitutional responsibili ty to provide those services. If

they cannot go to Xhariep for example you have to go there

yourself.


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MARCUS MOLOKOMME Yes chairperson that is the point, but

the point we are making is that we equally cannot be obl ivious to

those requirements by financiers, even though it is not our focus

which is why we included the business plan so that we can look at

the sustainability of what people are saying, but not use it as a

criterion because that will then create other di fficulties.

CHAIRPERSON That is going to land you into some problems.

There will be areas where you would never be able to issue a

license whereas there is a need for it simply because it is not

economically viable. And the question really is – what are the

alternatives?

MARCUS MOLOKOMME Yes, that is the experience in Thabo

Mofutsanyana and in Xhariep which is why maybe we did not cover


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it here. We talk about joint ventures, like you correctly have said

chairperson if we do not open the private fac ility we are going to

have to go there because the need exists in those areas. So we

mentioned joint ventures in that vein, that is not the PPP in its

current form, no way, but what we are talking about is joint

ventures going forward to ensure that we ad dress the need in those

areas. So joint ventures in terms of a business plan and we

currently even have new applications now, people innovators who

go, people who apply now are actually even now starting to

mentioned joint ventures, they are not applying just a single

entities, they are proposing that they are willing to partner with

government in those peripheral areas based on preventative models.

So we are start ing to see new applicants now coming because

everybody now sees that the financial instituti ons would not fund

the demand anymore in Bloemfontein so we are now forced into an


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innovative space where we need to now find those joint ventures

between the private sector and the provincial Department as well.

DR NKONKI Thank you. My second question is around your PPP

experience and I think it is widely acknowledged that public

facilities do struggle with bil ling and so I think that your

experience is useful in terms of how you tried to improve your

billing through your interaction with radiologists . So what I would

like to know, you have gone through all these different steps and

you have outlined your milestones here, but what have you learned

specifically to billing? Would you say that your capacity to bill

has improved now through this PPP expe rience and if yes, in what

ways had it improved?


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MARCUS MOLOKOMME Thank you for the question. I think our

capacity as a provincial department increased in other instances. I

will start with the latent phase – I think we have proper policies

now in terms of revenue collection. We appreciate that yes, we are

not for profit but we equally are not for losses. Now, the PFMA is

quite clear in terms of the responsibility of the accounting officers,

CEO’s and district managers in terms of revenue collection – so

that is quite clear on the latent softer side of things. In terms of

the practicalities we have now appointed case managers to be able

to, and it is a practice that we learned from our PPP experiences

and we have last year reviewed even their job desc riptions to focus

on revenue. Treasury gave us money in the past two years in a

revenue enhancement programme, so what we have learned in terms

of capacity is that we need to create an ambiance to pay. I think if

I go to Pick n Pay and there are no tills I would leave my wallet in


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the car, I am just going to collect and leave, but the presence of a

till suggests and creates that expectation to pay. So if you go to

many of our facilities, there is not even a SpeedPoint, nobody

carries cash, we expect people to pay, but we are saying they must

give us R50,00. Nobody walks around with that kind of money

anymore, so what we have done as the Free State we are even

engaging service providers to come and supply us with this

[inaudible] where you can swipe a Jet Card, a Sales House card,

there is no Sales House you are right any more, okay, but you

understand chairperson, Edgars and all those Truworths cards as

methods of payments. So we are creating expectation that even

though the service is for public we still need to pay our R20,00, we

still need to pay our R10,00. There is actually in the province a

move now even to take the model, the Cuban model where we even

though the service is free we put how much it costs so that people


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can appreciate it is free, but i t has cost the State R20,00 for me to

be here today. So sometimes when you come next time you wonder,

hey I have cost the State R100,00 already, I am not going to go. So

we are creating those expectations in terms of the practicalities of

revenue.

We are now in the process of advertising a new tender for this new

revenue services based on our experiences so the contract will be

very different from where we are at. So we are terminating the

current Radiology’s contract, it is its last month, in June we are

running the bidding processes, in July we will start with a new

service provider based on all regulations currently because now we

are in a very nice regulatory space than where we were years ago.

In terms of the PPP, in 2022 there are two options – i t is either

we.. . There are three options actually. The immediate option is


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that we pay the exit as you will have seen in that R206 million I

think and then we will be sued, litigation costs maybe another R200

million so we can pay around R400 million and e nd up with

immediately tomorrow a hospital with equipment with 210 beds. I t

costs up to R2/R3 million to build each bed in a hospital so

meaning if we wanted to build an equivalent hospital in

Bloemfontein it will cost us R2 billion. So some people argue pay

the R400 million, get out of this PPP, count your losses, you have

the equipment, you have the new hospital at half the price, that is

the one approach. There are some who are saying let us sit out the

concession to 2022, benefit without paying the R 400 million and do

not get a service provider, absorb those beds into the system and

move on. There are those who are saying the third option is to

clean up our act , get the regulatory framework, bid, get people to


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tender for those beds and move forward. So the Department still

has those decisions to make in terms of lessons learned.

In terms of the PPP beyond radiology services with revenue

streams, yes there are lessons to be learned on how we channel now

that money towards the benefit of the public wh ich is the principle

that underpinned this PPP arrangement. So we do not have capacity

for radiology yet, that is why we are going out on tender, but based

on new regulations, new set up, new contract, new monitoring and

evaluation, new data sets and so fo rth.

CHAIRPERSON As a government these are the sort of services

that you will be providing for the rest of your existence. Now it

does seem to everyone that perhaps it is high time that the

government should reconsider outsourcing these things and devel op


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the capacity to do these things itself. You have been with this

process for a sufficient time to have had a transference of skills so

that you train your own people to be able to do these things . I

mean these are not people from Mars who are doing thi s, these are

ordinary human beings and you can train them and make sure that

they perform this task rather than relying always on service

providers to come and do the job that civil servants are supposed to

be doing. Isn’t that, shouldn’t that be the long term plan?

MARCUS MOLOKOMME Thanks Chairperson. In principle yes,

but in these highly specialised areas unfortunately the principle

does not hold. What we are outsourcing is this arrangement where

we will be able to claim 100% of the radiology fees, it is just

maybe unfortunate that when the Society delivered their submission

in Pretoria maybe this point was not highlighted. We were told


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when we engaged this group that actually there are now a set of

rules that came from the Society that Adv Finger is here to

elaborate on that, which protected radiologists in terms of this kind

of claims and profit sharing mechanisms. So even when people say

they are price takers there are many other arrangements that are not

being declared in essence and in the Free State that is what we are

experiencing. So what we are outsourcing is not the revenue

collection, it is the mechanism to collect that money because that

capacity we will never have until we change our regulations in

terms of our Medical Aid Scheme Rules , in terms of who can claim

what and who can claim 100% and if we allow our public hospitals

for example in this strata of patients from age zero to age four to be

able to claim 100% from our fee structures then we would not need

to outsource anything because the capacity exists, but the challenge

becomes in the specialised areas.


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CHAIRPERSON What prevents you from doing that? It is the

rules and you made the rules?

MARCUS MOLOKOMME As government yes we make the rules.

CHAIRPERSON Then you cannot blame anyone else because you

make the rules and you change the rules if the rules do not work

out.

MARCUS MOLOKOMME I agree to the principle, the practicality

is the difficulty.

DR NKONKI So finally on this revenue, you mentioned Gems and

when Gems came to present to us on many of their options, the

State is their designated service provider for their PMB’s. So I


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would like to know if your capacity to build, how is your capacity

to build in that area?

MARCUS MOLOKOMME Our capacity to build in terms of now

the set targets for public sector patients that includes those lower

schemes in Gems and Moto-Health and Metropolitan and so forth,

like I said three years ago we started the project and we have

capacity in all facilities to claim for all those.

We also have the assistance of Medi -Credit so many of our

facilities use Medi-Tech system for batching purposes. So in terms

of claiming for patients that we see according to our structure in

terms of who pays, who does not pay and also those that are p aying

over the counter, the capacity exists in terms of meeting those

targets. In the Free State one of our challenges now that you are


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touching on revenue is those patients that are coming from Lesotho,

but we have identified the challenges, we have iden tified the

referral patterns, we have engaged three months ago with the

Lesotho Government Department of Health and of all the monies

that we are owed up to 60% already had been paid in those three

months.

DR NKONKI Okay thank you. My final question i s on the Human

Resources, how you assess them during your licensing and renewal

of licenses. So on page 6 of your written submission you have

about five criteria that you have outlined, so I would like you to

talk more on that, in particular how you deal with assessing nursing

staff for re-licensing.


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PINKY BERLOT On the issue of the HR we first look at whether

do they have the policies and procedures that guide the processes

because we believe that the facili ty cannot function well if they are

not having staff and also we will be looking into the staffing

norms, especially in the nursing areas. So they will be monitoring

what they are informing us against what we will be assessing on the

day of inspection, like to check how many personnel, the number o f

patients, because mostly they will be working on the Acuity system

to say you know they re-allocate staff accordingly to Acuity. And

also on the issue of the you know the job descriptions, the issues of

the BMS we are all looking into all those things, not only the

nursing staff personnel but the entire facility. I do not know if I

have answered.


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DR NKONKI So given the challenges you have outlined on

RWOP’s, have you explored using the opportunity for re -licensing

as one avenue to manage the challenges you have with RWOP’s?

MARCUS MOLOKOMME We have not at this juncture. What we

are doing we are engaging them outside the licensing framework

because what we had realised is that there is an opportunity there to

engage the managers of these private facili ties, hence the meeting

that we were even supposed to have today. We wanted to start from

there. I think the approach in the Free State is that we have always

tried to find common ground, if we fail then we legislate in terms

of including it as part of our protocol. But what we are finding

now going forward is that with the people who left the services

RWOP’s is starting to become more controllable because like I said

we lost up to fifty, just on the training platform, up to fifty


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specialists over the three years since we started controlling this

phase, but yes we will take the point that going forward we might

need to look at that as part of our Human Resources control in

terms of re-licensing.

DR NKONKI Thank you.

PROF FONN Thanks very much. Yesterday we heard from Dr

Ruff, he was presenting an alternative model and part of what you

have been dealing with is the licensing of hospitals and he

presented a model which suggested that in fact one could license

something that was service provision and that was not a hospital ,

that was a group of people who provide primary and referral

services. And it seems to me that part of the issue around business

plans and Standard Bank and all these things have to do with the


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viability, the economic viability, of the hospital and we have also

heard evidence of our entire health system being too hospi -centric.

So is there the space, the possibility, to meet need through a model

that is not licensing a hospital and is that something that your

provincial department could imagine?

MARCUS MOLOKOMME Thank you yes, let me give two

examples to clarify. We are currently now, we had advertised

because it is a specialised area chairperson - regenerative medicine

as an alternative to all this invasive treatments that we rende r. So

this is not a hospital, but this is a group of services providers that

are specialists in that area that we want to contract to come and

provide a service and now pay them as a group. We are one of the

provinces that started five years ago for male medical circumcision

where we said we will contract IPA’s for example, not individual


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practitioners, we needed them to organise themselves either into

companies if they could not operate as an IPA because an IPA is

more of a relationship, or create IPA’s as form of a team per area,

per region and Motusi IPA is to give an example was one of the

IPA’s that became a model for the country in terms of how we

contract for services, for male medical circumcision. They will

then place a claim and what we had attached there is all the

requirements in terms of quality assurance, adverse events

management in terms of outcomes and follow ups for patients and

then we will pay you on that basis. So we would pay it once we

have ticked all those boxes in terms of outcome s, but paying them

as an organised group.

We are now, the MEC in his budget speech this year mentioned that

we need to look at triaging service as a service that we can look at ,


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having groups to assist the department, to reduce the waiting times

in our casualties, especially for preventative care so that patients

do not wait in a tertiary hospital because patients do not honour or

respect referral l ines. You see a hospital, you come in if you are

ill . So we need to have that kind of filter to provide a service at a

low cost obviously to try and negate. So we have looked at those

mechanisms. At the moment in the Free State we are having two

groups – we have an academic group where i t is a group of

specialists that is organised themselves and those group s are the

ones that engage in terms of clinical care in the province will be

the groups. Those people who are doing RWOP’s, many of them

are participants into those groups because to get an approval for

RWOP’s you should, if you are a sole practitioner, j ust on that

basis we do not approve even if you are going to do after hours

because it means the practice out there depends on you solely. If


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there is no one else you are going to have to escape to go and see

patients but if it is a group practice, or a t eam, then we know there

are other people who are representing you. The radiologists as well

they formalise themselves into a group, even thought the model is

not what it is supposed to be, but it answers that question in terms

of there are groups already in the Free State that are interacting

with the Department, not necessarily through licensing but through

them organising themselves as specialists. What we need to then

do is to make sure that those interactions are proper.

PROF FONN So it seems to me that you have identified many of

your own problems and you have also showed stewardship in terms

of trying to move to learning from the problems, working out what

might work better and so on, and you have indicated some

interventions to us where you know that something could be of


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assistance, so for example a national approach to RWOP’s is the

one example you gave us. Now we are a panel who has to advise

on the private sector and my question to you is what else do you

need from, where could we be of assi stance to you given that we

are looking at the private sector in increasing access to quality

care, what do you need or what can we in your conception of what

we are able to do, what can we provide in addition to this example

of the national approach to RWOP’s?

MARCUS MOLOKOMME Thank you. The way the health system

has been operating obviously it has been that segregation between

private and public and I understand the principle of the NHI and

personal coverage and so forth, but currently we are working i n a

system that remains separate. I think the first thing would be to

make sure that we share data – I think that is the first thing that we


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need to address because like we heard yesterday morning, that

without that data we cannot measure things, we do no t know where

we are at, we definitely would not know the before and the after .

So I think the first thing is to share that.

The second thing is alignment in processes in terms of

predetermined objectives. Sometimes when we engage with private

facilities, for example in media liaison – I am just giving an

example – you will find that the public, the private sector will

always say hold on we do not account to you so there is already

that kind of spooky stories about who is who, there is territorialism

in terms of operating within the health system. I think one of the

things that we still have not covered here is the role of the

Universities in the Free State and I am of the opinion that there is a

lot of interaction of the health market with the Universi ties that we


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need to look at. In this case in the particular in the Free State I am

talking about all the clinical tr ials that get carried out in our

Universities, all the drug tests that gets carried out in our

Universities, and lastly as the Free State where you can assist us is

sometimes the behaviour of the pharmaceutical companies because

it is always portrayed as the Free State as a collapsed system

because there are no medications, but there are many instances even

though we have not brought the presentation or the proof but we

interrogating the systems, where you find companies are setting

credit limits; something that is unheard of in the public sector, a

credit limit of R1 million for a province. You are basically asking

that province not have medication because a credit limit of that. So

those are the kind of strategic broad issues that I feel the

commission can assist us in interrogating and correcting the way

forward.


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PROF FONN Let me understand, are you saying that the tests that

are done in clinical trials land up being to the account of the public

sector?

MARCUS MOLOKOMME The arrangements usually you will find

the University holds the account so the research monies for all

those tests or monies that come from the private sector end up a t

the Universities and in the Free State you would find the

Department of Health has no view or has no oversight over such.

So those monies remain in control of the medical faculties and that

is what I am highlighting.

PROF FONN But does the medical faculty then pay those

laboratory tests that are done in clinical trials or does the public

sector pick up the cost?


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MARCUS MOLOKOMME The public sector some of those, you

remember that some of those, not some of those, patients or

anything that happens in the medical schools, 70% of that usually

happens in the public sector – we are the ones who owns hospitals .

So the patients are in the hospitals, the professors and many of the

clinicians are on joint appointments so we are paying them. So the

activities that they do within that space, there should be that

component that comes to the public sector, that is our view as the

Free State and that is what we, within the Memorandum of

Understanding, what we are start ing to interrogate. So I am not too

sure in other provinces how this pans out, how those monies gets

treated once they are in the accounts of the Universities but in our

case those monies sometimes are used to appoint officials on behalf

of the University or sometimes a ward just gets painted from thos e

monies. So we are saying there is a scope there to be explored in


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terms of monies that are coming from the private sector, entering

the space but remain stuck at the Universities.

PROF FONN No, I do understand what you are saying, but what I

am trying to understand is – so I mean I know the way clinical

trials work, I understand the way hospitals work. A doctor is doing

a clinical trial and he is paid for that by the pharmaceutical

industry usually or whatever device industry whatever is being

tested and the patients are admitted as per protocol, I come in, I am

an ordinary patient, but I am also eligible for the trials so I am

entered in the trial. I am sitting in the hospital and I need X and Y

test so that could legitimately be charged to the publi c sector, but

for the clinical trial I also have test A, B and C. For test A, B and

C is that paid for by the University from the clinical trial funds or

is that paid for by the public sector?


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MARCUS MOLOKOMME That is the issue interrogating because

by protocol those fees should be carried by the research fund but

what we are interrogating now is to check if our own NHLS bill

does not end up on the public account. So that is why we have not

presented it here yet, because we did not want to come here with

wishy-washy, we wanted.. . But we are saying it is something to be

looked at in answering your question earlier.

PROF FONN And then just explain to me about the R1 million

credit limit. So if I understand you correctly you are saying I am a

pharmaceutical and I will say to you okay I am ready to deliver, but

you have not paid me so I am not delivering.

MARCUS MOLOKOMME Yes, even though that bill might be

fifteen days old, if it is close to R1 million we cannot order with


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you. So once you set a credit limit you are basically saying it is

C.O.D. and now R1 million for the whole province becomes a

challenge. So what I am saying is that has not happened before and

it is something that has happened from a particular company and

the engagement is that we cannot operate in that kind of space. All

our bills have thirty day turnaround time, if we pay in two days

fine, but we have thirty days. Now if you set a credit limit and one

batch of order is R920 000,00 it means for that month I will not be

receiving much from you regardless of what you supply – if it is an

essential drug or not. So we are saying that space also needs to be

looked at. Also taking it further sometimes accounts get frozen

without knowledge, even though you find we have paid for all the

ARV’s, but we owe maybe one batch for Panado, the practice has

always been the pharmaceuticals will sometimes we hold their

deliveries. So it is a space that needs to be explored and looked at


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how you know some of those scenarios do happen, but the credit

limit one is the one that stands out because it has happened just this

year and it is something we have never seen before, especially for a

province. If it is R1 million for one facility I would understand but

if you are one of the biggest suppliers and t hen you set a credit

limit of R1 million you are basically saying that province every

thirty days only has R1 million to order and that becomes a

problem.

PROF FONN So this is an interesting scenario because my sense

is that people need to sell their products and one of the biggest

consumers of ARV’s anyway is the public sector, so my feeling is

they need you more than you need them, unless they are the sole

provider. So if they are the sole provider then obviously they have

got more power than you have, but if you have got the money you


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have got more power. So how come the free market works

sometimes, but not other times when it comes to government?

MARCUS MOLOKOMME I heard yesterday a panel member

making that point, and yes it is a funny sector becau se the general

principle is that the one with the gold sets the rules, but sometimes

in health sectors that equation does not work and this is one of

those things where a sole provider who decides to set a credit limit

you are basically their hostage. But we are interrogating that, but

what we are saying is that in essence as a matter of principle this is

not how the public of private health sector should interact with

public.

DR BHENGU Thank you very much for the presentation, I just

wanted to you made reference to national core standards and you


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basically say you are proposing that they be made tougher, is that

more or less that you.. .

MARCUS MOLOKOMME Not necessarily tougher, but they need

to be escalated to look at things that are more beyond basi c.

DR BHENGU Now how have your hospitals performed in the at

least with the most recent assessment by the office of Health

Standards Compliance in public service hospitals?

MARCUS MOLOKOMME Yes, we had one worse hospital in

Diamant in Xhariep, it is a district hospital. The way the system

works it is divided in the extreme measures, those measures are the

measures that must have, you cannot fail those. So we have one

facility that failed which is almost worst in the country, Diamant


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District Hospital The other hospitals are almost there but they have

regressed like the big ones. Universitas used to be number one in

the country, in the core standards but they have regressed to around

70% in the office of health standards compliance, but the issues

that were raised are developmental issues that can be sorted out,

like old aging infrastructure that can be addressed. So in terms of

[inaudible] also regressed, so as a province we have moved from

being number 3 to number 5 with the current assessment, no w

talking broadly as the entire country. But in terms of ideal clinics

as part of those assessments, ten of the clinics that were enrolled,

all of them are doing very well, two of them are in the top five,

primary healthcare clinics.

DR BHENGU How would you sort of, what would you like to tell

us because it is public knowledge that media is usually not kind in


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reporting on the performance of health services in your province.

You have touched on the drug issue for us, but how would you

explain this – is it fair coverage or there is room to improve?

MARCUS MOLOKOMME Firstly I think let as a team here let me

be the first to declare that there is areas that we need to improve on

as a public health system, also in private. But many of the reports

that we get have really been unfair and they are targeted at a

particular individual who is our MEC, Dr Benny [inaudible]. And

many cases, both criminal and otherwise have been opened against

him by these groups that are protesting and feeding the information

to the media. So I will say many of the reports have not been

accurate and even innocent scenarios have been highlighted to

sensationalise. I mean if a lift breaks down in [inaudible] hospital ,

just as an example in Bethelehem, and a picture of EMS officials is


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taken then carrying a stretcher of patients up the stairs and it is

portrayed as the no exception to the rule, this is how things work in

the Free State, you can see the sensational. If lifts do not work we

use the stairs, it is as simple as that but unfortunately sometimes

the way it is being portrayed i t is being pitched to represent a

system that is collapsing. Yes, we face challenges. Like I said we

lost fifty specialists, I mean no system loses that as an academic

platform and does not get shaken up, but we have equally recruited

two hundred and fifty registrar and most of them are qualifying this

year. So as these problems come like in any other system we are

mitigating for. I think the biggest problem is that we have not told

our stories as well because I do not think we are in the business of

reacting to media reports, but I think we need to start telling our

stories because there are many stories from the Free State that we


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should be telling in terms of the successes as the health system,

also private and public.

DR BHENGU Just on this point, isn’t that. . . Okay I will begin to

know why the loss of so many specialists at the same time and

where did you lose them to and whether the new, I mean the

replacements you talking about will be registrars which suggests of

course these are still doctors in training, whether that does not

explain much of the generalisation you are talking about. I am

aware of the issues because I am not sort of disregarding what you

said, I am just saying does it not contribute to that as well?

MARCUS MOLOKOMME Yes it compounds the problem. I think

to start from where we started losing specialists, I think the issue

of RWOP’s, when we tackled it it created that toxic environment


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where many of the established spec ialists felt they would rather

leave the service into private practice. Many of them are now

returning to do session because now I think we have removed the

toxic part, I think we have managed to engage after the court

ruling, we have managed to share ideas on how this would work.

So many of them are returning and many have left the services, but

have entered the University frame, so part of the monies that I am

talking about is those monies that parachuted them into lectureship.

So we have not lost them totally from the service. So in terms of

lecturing and practicals and bedside teaching, many of them stil l

remained but they have left their posts as Heads of Clinical

Departments, but there are those who left and went to the Western

Cape – that was our biggest losses to Stellenbosch. There are many

who just retired, took early retirements, they felt this is too much

for them and they would rather just go and be on a farm. So those


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we have allowed as well. So in terms of genirisation yes it is

compounded by the fact that the most senior people are applying

for posts. I think the other biggest problem the Free State faces is

that when we advertise City Press and the Times, our last advert

was two weeks ago, we hardly get quality people applying, you get

a few chances but that is the problem that we have which is why we

are calling for an innovative way of looking at RWOP’s so that we

can tackle that carrot for people to come down to Mangaung and

also Cheetah’s are not doing too well so that is another prob lem.

DR BHENGU In Gauteng you said they lost a block of specialists

if I am not mistaken, the aesthetics department in particular and in

no time people started coming back again and we heard yesterday

and it has been coming up now and then that there a ctually maybe

the private sector is, there is an oversupply of specialists. Now if


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we have such an issue about RWOP’s, I am just asking here your

personal opinion, isn’t that maybe the one way to sort of clean up

and say okay those who want to go, go we w ill suffer in the short

term but the private sector cannot absorb all of those who go but

when they come back they come back on our terms – would that

work?

MARCUS MOLOKOMME That was not our plan, but invariably i t

has worked because we sometimes you have to anticipated these

unintended consequences and celebrate because we never had a

doubt. We knew when we started that anyways some of these

colleagues when you say RWOP’s they are not necessarily doing

clinical care out there, some of them are on their farms, some are

having game farms, I can give a long list so when they leave they

are not necessarily in another clinic, they are doing something else.


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So when you remove them from clinical care they are bound to

come back because what they are doing out there is not sustainable,

it is not what they are trained to do, it is not what they enjoy – i t is

leisure. So people cannot do leisure 100%, maybe at some point

you can but it has brought back a lot of people who are now not

willing to do RWOP’s anymore. They appreciate our approach and

it has in a way cleaned out the nest in a way, but there are those

few that still remains because they knew they had nowhere else to

go because it is so saturated out there that they would not survive.

But also this indemnity thing is pushing people back out of

specialities back into the system because it costs you R400 000,00

to practice even though you are part time- just to see two patients a

day you need to pay R400 000,00 a year so that you are adequately

covered, but when you work for the State, you have that comfort.

So many people are coming on that basis because out there it is


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difficult. I think lastly as the Free State our focus has always been

we have shifted to super -speciali ties and it goes back to that issue

of demand. We have created demand for super -specialities so we

train fellows almost who can compete with Gauteng just with one

University – remember we have one medical school, but we train so

many fellows and it goes back to that point of demand and nee d. Do

we really need? So we have trained people who are super -

specialists and they cannot survive out there because you will si t

there and wait for a gastro-[inaudible] patient the whole day and

hardly ever see anybody. So people are now forced, because w e

train them so much that they can only work in the services but i t

has its own negatives as well that we did not bring here.

DR BHENGU Still on RWOP’s – you say you have a system that is

working with the cardiologists in terms of biometrics, for me it


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seems like a critical step in stabil ising in the short term. Is there a

reason that it is not deployed widely and do your employment

contracts provide for that, specifically the biometrics?

MARCUS MOLOKOMME Not at the moment, it is something that

we are exploring through our IT effort as a province to look at how

we can institute beyond biometrics, all the HR measurements, not

only for doctors but for all staff. We have had a presentation

recently on lean management that showed that actually most of our

staff works in 30%, 40% on core business, the rest of the time it is

either I am visiting the next office or I am on the corridor or I am

in the loo an so forth. So we want to introduce proper human

resource measurements because if you do that RWOP’s then

becomes a component of that, we did not want to just say people

must check in and out and focus on as if it is a witch hunt for


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clinicians, we want HR measurements from security services,

cleaners up to the top specialists because Labour Relations Act is

for everybody, it does not recognise specialities.

DR BHENGU I am towards the end now, when I mean as a

preamble to this case was it you starting to take leaf out of the

KZN book to withdraw RWOP’s privileges?

MARCUS MOLOKOMME That was not our approach. We

benchmarked, we spoken to Kwa Zulu Natal with their approach

and we knew that approach would not work in the Free State for a

number of reasons. In Kwa Zulu Natal they have more specialists

per capita than us in the private and also in the public, their

production and retention is better than all provinces. What they

produce they keep because the measure the return on investment


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with registrars. We do not. So we knew that we were going to

have challenges if we approach it in that manner. We did not have

the critical numbers of the critical mass to suddenly wake up and

say no more RWOP’s. So we decided the only way we can do it is

to write to all of [inaudible] who are doing RWOP’s to say going

forward in 2013 we will not approve anybody who is a pplying to do

them during office hours, half past seven to four, we will only

approve from 4pm to the next morning unless you are on call we

will also not include RWOP’s because some of the specialists or

medical officers who have been on call that night s o we did not

want to allow that moonlighting arrangement. That was the initial

point and on that basis we were taken to court.


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DR BHENGU Thank you, I think Advocate said it was on a

technicality that you lost – what does it mean? Is it still back on

your agenda?

ADV FINGER Ja, and this is where sometimes we take forever as

government to approve. Look the mandate form the MEC is that we

still should pursue the change of the policy to reflect that we only

approve from four upwards, but I can tell you p ractically that is

what we are doing currently and I think generally being accepted,

although it is not policy as yet but that is what we are doing

currently, only approving after hours.

CHAIRPERSON How far is the litigation concerning the

regulations of 2014?


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ADV FINGER The matter is sitting in July, so that is the first

time. So we have closed all pleadings, it will be sitting in July.

CHAIRPERSON I did not get that.

ADV FINGER The matter will be heard in July, coming month.

CHAIRPERSON At the High Court or the Supreme Court of

Appeal?

ADV FINGER That is the High Court, Free State High Court.

CHAIRPERSON What are the implications for the regulations?

Does it mean you cannot apply those until the matter is resolved by

the court?


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ADV FINGER No, we have not been interdicted from applying the

regulations so we are applying them. Yes, and I just think you had

made reference to maybe just to briefly highlight what are the

issues there. I think the main issue HASA felt that you know with

regards to section 36 they thought that is where we are coming

from, that was our enabling Act but we were able to prove that

actually we have our own Hospital Act. So they were coming from

the point of view that they were able to make national department

well almost believe that section 36 is unconstitutional, that is their

view. So therefore because they were able to convince the national

department who are we to come up with our own regulations, they

also felt that two critical issues – we should not issue licenses for a

year because they were saying it is not good for business that there

is uncertainty but I mean we felt that health is a critical issue, we

should be able to assess each year and issue a license and indeed if


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you comply there should not be any uncertainty. The issue is

compliance – if you comply, there should not be uncertainly. They

also felt that when there is a change of ownership because this is

one thing that we try to avoid that you come as Justice Finger 100%

black owned, after we give you a license then you go to someone

else. So they also felt that for a change of ownership we should

just issue license once and not come when there is a change of

ownership. So currently in our regulations the license is not

transferable so as and when you dilute shares and change, you need

to come as a new application so they also did not want that. So

overall they basically accusing us of not having lis tened to all these

matters that they raised and that is why they are asking for a

review.


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CHAIRPERSON As I understand the challenge i t is that there was

not any proper consultation before these regulations were

promulgated, that is one of the challenges.

ADV FINGER Yes, and we have been able to prove that in fact

there were some changes that we made subsequent to that, it is just

that you know they felt that everything must agree with everything

but we did consult yes.

CHAIRPERSON One does not know what the court is going to say,

it may set aside the regulations in which event you have to star t the

process all over again. Okay. Now and this was in terms of the

Free State Health Act which was promulgated in 1996, is it?


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ADV FINGER Yes, it is the Free State Hospitals Act, 1996, yes.

CHAIRPERSON What is the situation with the Free State now in

relation to the licenses? You have got the Free State Act of 1996,

then you have regulation 158 which was promulgated under the

1977 Act, then you have the Free State Regulations of 2014 and

you also have the Free Stat Act of 1996 – are all these measures

responsible for the issuing of the licenses?

ADV FINGER Correct chairperson except that we no longer

applying regulation 158, we basically now using the Free State

Health Establishment 2014.

CHAIRPERSON But that only relates to the regulations tha t you

made in 2014, only relates to the facilities?


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ADV FINGER That is correct.

CHAIRPERSON So to try and rationalise this legislation so that

you have one set of regulations that govern hospital facilities, but

you still have to wait for the High Court s’ decision.

ADV FINGER Actually I think there are two Acts that you have

mentioned – i t is the Free State Health Act, but that one was in

2009, but the ones that specifically focus on hospitals is the Free

State Hospitals Act of 1996 which I can tell yo u that we are

starting to review that you know to make sure that it is modern

because it had been almost twenty years that it was, but yes the

Free State Health Act, the regulations were issued in terms of that

Act yes.


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CHAIRPERSON You are familiar with the regulations, are you?

ADV FINGER The regulations.

CHAIRPERSON Perhaps before I get there – there are two groups

of licenses that I want to talk about. The first group is the ten

licenses which were issued but where nothing has happened and

then there are nine licenses which were issues but which have since

lapsed. So you have got a total of about nineteen licenses which

have been issued between 2012 and 2014, I think between 2008 and

2014 – were any of these licenses issued under the new regulatio ns?

ADV FINGER No, all of them were issued in terms of the old

R158.


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CHAIRPERSON Now with regard to those licenses that are not

operational, what is the situation there? For how long is the

situation going to continue?

PINKY BERLOT I think those that are not functional, others they

are within their t imeframes because they would have applied for the

extension, most of the submission of the building plans based on

whether finances for the rezoning, but I think in particular there are

two that I think they have would say exceeded the t imeframes that I

think as a department we need to close that although we are saying

that automatically it lapsed but I think to make sure that they do

not come back we need to say we have not seen your movement,

just to inform them officially that their application has lapsed –

there are only two from those.


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CHAIRPERSON Does it concern you though that you have got

licenses that were granted in 2012 which in relation to which no

building has commenced?

MARCUS MOLOKOMME Thank you chairperson. Yes, it is a

concern as I covered earlier, this is where the municipalities get

into the space because many of these applicants are able to prove

that they have submitted their paperwork, it is still stuck with the

municipalities or the rezoning or the land requisition still has not

happened and that is where we are finding the challenge. We, in

the regulations, give them an extension but some of them then end

up being caught up by the regulations in terms of time. So it is a

concern yes because when we issue them like I said they are based

on need so any delay that we have means we have not created that

access.


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CHAIRPERSON Is the position that in relation to these ten

licenses, that have been issued during the period 2012/2013, all of

these licenses nothing is operational because of the need to go

through the approval system – all of them?

MARCUS MOLOKOMME Not all of them, I think in the narrative

in the Word document we have singled out one in Mangaung Metro

where we basically have previously disadvantaged owners and

those are the ones that are also struggling in terms of the financial

model. This is one of the reasons why we in the new regulations or

with the business plan interrogation we saying we need to tighten

the belt there so that we do not allow people through that will

struggle as much as those ten that are in terms of finances. If it is

the municipal then we must go an engage with the municipalities to

check what the issues are – i t is a concern.


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CHAIRPERSON I mean does it concern you though that if there

are these licenses that have been issued but where nothing is

operational, somebody else could have been issued with that license

and could have had a hospital up and running by now?

MARCUS MOLOKOMME Oh yes, we agree Chairperson which is

why the other point that we need to tighten is the penalties and also

the inspections because those regulations that issued these licenses

were quite loose in terms of when we inspect. So we are inspecting

by invitation of when you compete building. So I mean somebody

can sit with an approval until the last day of the regulations

allowing, even though they never had an intention or capacity to

build anything. So what we are doing now in terms of inspections

is to introduce site v isits to check if there is anything tangible

happening so that we are able to revoke a license or an approval on


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that basis. So we are going to set milestones to be able to check,

unlike wait until three years and only then discover that this is not

going to happen because that is another three years – so that is six

years where that need is not being fulfilled.

CHAIRPERSON For those licenses who are having difficulty

securing the approval of the building plans or the transfer of the

land – what assistance is the provincial government giving to those

individuals?

MARCUS MOLOKOMME At the moment we are not in that space,

all we do is wait for them to bring the plans according to the

regulation timeframe and then our infrastructure then interacts with

those plans. So we do not offer any assistance at the moment.


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CHAIRPERSON What space are you talking about? You say you

are not in the space – what is the space that you talk about?

MARCUS MOLOKOMME Okay, thank you. The municipal

arrangement with the applicant because the applicant submit the

plans to the municipality, they make the request to transfer the

lands with the municipality and the rezoning. So that is the space

that I am talking about. So that arrangement we are not in – we

only then receive the approvals from the municipality.

CHAIRPERSON Shouldn’t the provincial government though try

and take some steps to facilitate the process of the consideration

and the approval of the building plans so that you could fulfil your

responsibility to make sure that health services are available within

the province?


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MARCUS MOLOKOMME I agree it is something we should look

at.

CHAIRPERSON The regulations contemplate that there will be a

committee which will be dealing with some of these issues, that

committee has been set up?

MARCUS MOLOKOMME Yes, I chair that committee.

CHAIRPERSON One of the functions of this committee is among

other things, to oversee compliance with prescribed norms and

standards as well as the quality of services that it provi ded by these

facilities. Have you commenced with these duties?


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PINKY BERLOT I think it will be the inspections that we are

conducting, that is when we monitor the norms and standards where

the team will have to be determined to conduct such.

CHAIRPERSON What norms and standards are you using?

PINKY BERLOT We are referring to the private facility tool and

norms and standards it will be like the infection control, the health

and safety, all those other related policies attached to the patient

safety.

CHAIRPERSON And these norms and standards?


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PINKY BERLOT No it will be our annexure . I think it is attached,

that is being revised when there is a need to review it on an annual

basis if there is some gaps.

CHAIRPERSON When you monitor the quality of services,

precisely what is it that you are looking for? How do you do that?

PINKY BERLOT We are looking into all the processes like the

governance issues, the HR issues, the clinical issues up to the

support services, the pharmacy, all the areas, maintenance – we are

looking into all those areas – how the equipment is being

maintained under the heath care technology, so each and every

section is being allocated an assessor with a speciality attached

that they will follow what is required in the t ool.


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CHAIRPERSON Do you assess the quality of the treatment that

the patients receive at these private institutions?

PINKY BERLOT Yes, when we do the records review that is how

we monitor whether the patient you know has been appropriately

taken care of starting from the admission, that is where we will get

the challenge of the clinical records because would not see if. . . We

do not make the decision whether the document that the patient is

getting is based on the proper assessment, initial assessment by the

doctor, yes we do look into that. Patient records review, we review

and look at the records, patient records. Yes, randomly we select

the file. We ask for randomly the patient files yes in retrospect.


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CHAIRPERSON The regulations require these facilities that is the

private facilities to keep these records, to keep records relating to

the treatment and admission of patients, is that right?

MARCUS MOLOKOMME Yes, it is chairperson.

CHAIRPERSON And they are required to keep this what? For fiv e

years I think?

MARCUS MOLOKOMME There is a differential in terms of the

kind of records; for paediatrics on child birth it is up to 18 years,

other occupational and TB’s it can go up to 25 to 30 years. So

there is in the national prescription all thos e differentials.


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CHAIRPERSON What is the rationale for them to keep this

record? Is it to make them available for inspection in case you

need them?

MARCUS MOLOKOMME Yes, firstly it is just for clinical

governance in terms of being able to do audits and research and

also evidence based medicine going forward, but also there is a

legal component because if you do not keep any person born today

can show up within the eighteen years that they received and for

occupational is the same. So there are many oth er acts that enter

this space and inform how the records should be kept.

CHAIRPERSON In terms of regulation 31 I think it is 31.1, every

private health establishment shall ensure that region record relating

to history, assessment and treatment of each patient are kept


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appropriately and then it goes on to say each private establishment

shall retain a copy of the records described in this regulation for a

period of five years from the date of service of the patient. And

that in case of a minor it is abou t three years after the minor has

attained maturity, so they are only required to keep them for five

years.

ADV FINGER That is correct, that is the time that we thought you

know is reasonable because you cannot keep them forever

especially for adults.

CHAIRPERSON Yes, and thereafter they can destroy them?

MARCUS MOLOKOMME No, the expectation is that they should

be archiving them according to the National Prescription but for the


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purposes of our audits we expect them to keep them for this

prescribed periods – that is what we are capturing there.

CHAIRPERSON But don’t you think that it would be helpful for

the provincial government if these records are kept and there is a

record of you know how many patients have been treated at these

facilities, the kind of treatment they are getting so that you can

assess the outcomes that you are talking about?

MARCUS MOLOKOMME Yes, I think the struggle here with the

five and three years was for the purposes of these assessments, but

the expectation is as a hospital themselves, the private facilities,

must comply with all other prescription of archiving of the clinical

records. So for the purposes of this process what we are saying is


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that we can ask for any record within those timeframes for us to do

an audit, a clinical audit.

CHAIRPERSON Now is there a central place where all the records

of these facilities are kept so that they can be accessible?

MARCUS MOLOKOMME Not with us, each facili ty have got their

own archiving arrangement. Some have more electro nic based

health records, but for such things as consent to treatment and so

forth we expect the more prescriptions, we expect them to archive

those and keep them as we are saying in the act, in the regulation.

CHAIRPERSON You have told us today that you are going to do

this and do that to improve the system. Now when did this occur to

you? Today?


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MARCUS MOLOKOMME No chairperson, since we got into.. .

What you are looking at in front is almost 60% of the committee so

what we got in late 2014 these are some of the things that we have

found on the table and we have been interrogating systems,

interviewing people and even past panel members to identify these

challenges and address them. As an advisory committee we can

only submit to the head of the department for him to them make

policies where possible, to make other circulars for other facilities

and also engagement with other already licensed private facilities.

So as a committee what we are putting forward here are from the

minutes of our meetings where we are saying this should happen

and that. So it is not something that happened over night, nothing

didn’t happen last night – we did not even sleep so.

CHAIRPERSON Why not?


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MARCUS MOLOKOMME In anticipation for today, we needed to

be fresh and alert.

CHAIRPERSON The beach is not too far from here, I can

understand why you did not sleep. You were here were you not

when Dr Ruff I think it is, where he made a presentation describing

what would be the ideal healthcare system and also describi ng

where we are and how we can get to the ideal system. Now has the

provincial government had the occasion to do that exercise – look

at the healthcare system that you have in your province, look at

what you are required to provide which is set out clearl y in the

Constitution and consider how you might meet your Constitutional

mandate?


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MARCUS MOLOKOMME Yes, thank you Chairperson , yes this is

what we do as a department, we are constantly reviewing how we

run the system. One of the main things that we i ntroduced via our

MEC, it has been four years now, it is the use of the balanced

scorecard to measure our performance and the balanced scorecard

as you know coming from the kind of economic or financial set up,

really asks those questions of managers in th e public sector to

behave as if there is a profit to be made. What we are doing is to

assess ourselves constantly on evidence based practice and

evidence based management. The biggest problem that we

identified is data management and the use of it in dec ision making

and we found that as a province we have always been struggling in

terms of not just having it, just from capturing, its quality, the

infrastructure to make sure, its archiving and then its availability

in terms of decision making. With having a pilot sight at Thabo


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Mofutsanyana we have started quite a number of projects and quite

a number of tests. So to us Thabo Mofutsanyana is both a symbol

and a laboratory so we are able to put it up as an NHI pilot site as a

symbol, but also as our biggest and poorest and vast, but also look

at it as a laboratory in terms of testing all the systems that are

needed. So we are not waiting for it to finish its pilot ship, we

want to implement as on ongoing concern in all other provinces.

Let me give two quick examples – we first started with a referral

pattern and we learned lessons from there. We secondly went with

connectivity in terms of IT connectivity, we implemented health

information management systems, we even know with what Dr Ruff

was delivering yesterday we looked at financing models in terms of

partnerships with private practit ioners and we are now engaging

with the private practitioners to see how we can get them into the

system on a capitation set up, not a fee for service. It was


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interesting that in all of the models that was put in terms of the role

of the State, what I did not see and I am not here to punch any

holes in any presentation, that is not what I am here for, is that all

those other areas were touched, but the issue of pricing a nd the

financing was not highlighted as where the State must come in and

we are of the opinion with the experience that we have had in

Thabo Mofutsanyana that that is where the State needs to be at

because part of the NHI is to protect against catastrophe. So we

agree with many of the things that we have seen, many of those are

things that we are battling with in terms of our role as the private

facility licensing unit, but we have a model of where we have been

and where we are going.

Finally we have produced service transformation plan which then

starts to look at the issues of need in terms of private and public


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beds, ICU’s and so forth and how we can transform what we

already have. So we are not only looking at building new things,

how we can make what we have work.

CHAIRPERSON A couple of questions ago I asked you about the

need to have the information stored. One of your concerns now

that you are now articulating is your inability to collect data, store

it and have it accessible to make the kind of assessments that you

are required to make, but you have got the regulations which could

have made provision for that but they do not do that.

MARCUS MOLOKOMME Having set regulations is one thing, I

think also the business model in the department had to be looked at

because in terms of. . .


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CHAIRPERSON You are complaining about the fact that you do

not have the data; collection of the data which will enable you to

make these kind of assessments. What I am saying to you, if you

had made provision in your regulation for the collection of data and

its storage that would have been helpful – that is what I am saying.

MARCUS MOLOKOMME Yes, I agree.

CHAIRPERSON The problem of attracting and retaining

specialist, it is a major problem, is that right?

MARCUS MOLOKOMME Yes, it is chairperson.

CHAIRPERSON How are you going to manage that?


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MARCUS MOLOKOMME The biggest problem we face is

obviously the geography and not being a metropolitan but in terms

of our training platform we have deliberately exp anded many of the

numbers in terms of training, but whilst we are training we need to

link and align that training to the available posts. So the intention

is to, even though people will be a bit junior, is to recruit from our

own team like what we produce because the Free State like I said

competes with many medical schools in production of specialists,

even though there is just one University, the problem is being we

are even failing to retain those that we have produced. So it is two

balls that we need to juggle and balance – firstly we are losing the

ageing population or people are a bit irritated with the way we want

to manage RWOP’s, but this side we are producing good quality in

high numbers so we need to now transfer those into those posts, but

the issue with where the Free State is based that have always been


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issues in terms of our geography because many of those specialists

will have to leave Bloemfontein and our biggest problem has

always been people want to stay in Bloemfontein and not go to you r

Bethelehems, your Harrismith, your [inaudible] and so forth.

CHAIRPERSON One of the criteria that is set out in the

regulations which you apply when you consider a license is the

need to promote high quality services which are accessible,

affordable, cost effective and safe – how do you address the issue

of affordability?

MARCUS MOLOKOMME The issue of affordability, remember

chairperson, once we set those regulations we also sometimes in

our minds have the PPP arrangement that we hold with Netcare

even though it does not influence the final outcome or the final


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word we put in, the issue of affordability what we are saying is that

there will not be those catastrophes where what we are mentioning

where patients are now dumped into the public sector. We still do

not have a tool of measuring and penalising people for that which is

why we are saying we need to relook at our penalties framework.

Like we heard yesterday your failures should be recognised in the

market and dealt with and that is the framework we are talking

about. So there is no particular way of measuring affordability, but

we cannot expect to allow hospitals to continue to dump patients in

the way they are doing based on funds because that is the

affordability we are talking about.

CHAIRPERSON You mentioned a joint venture you know in order

to encourage the establishment of health facil ities in what is


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considered to be less economically viable areas, have you had any

one of those joint ventures so far?

MARCUS MOLOKOMME At the moment we have a proposal in

Lejweleputswa where an old dilapidated mine hospital with up to

four hundred and fifty beds – there is an offer for a private sector

supplier to renovate the whole building and apply for a license for

about one hundred and fifty of those beds and the rest of them we

should enter them as a joint venture because in that area we have

no facility. So those are the proposals that we have now, but

before we get. . . We have learned from the wounds of the past, that

we are not going to jump into a lock, stock and barrel in such

arrangements without proper regulation and regulatory frameworks.


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CHAIRPERSON What is contemplated is that the provincial

government will enter into a joint venture with a private sector to

provide those facilities .

MARCUS MOLOKOMME Correct chairperson.

CHAIRPERSON Do you consider that to be a better alternative

than the PPP?

MARCUS MOLOKOMME Correct chairperson, we in the current

regulated space we believe we will be able to meet all those

principles that should inform any arrangement, either a joint

venture or some sort of PPP.

CHAIRPERSON Is there any precedent for this in any province?


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MARCUS MOLOKOMME Not necessarily. What we have looked at

our own experience, we have looked at Folateng in Gauteng and

then we are looking at all those models and see if we can find a

hybrid of those because there is some good and bad so we need to

learn from both those ones, but there is no particular model where

we can go and learn that this is how it is done because we also from

yesterday, all those regional innovations should be looked at. So

that is why we are not going to jump into it without learning the

lessons.

CHAIRPERSON Is there anything else that you want to tell us

which you had come to tell us about, bu t which you have not had

the opportunity to tell us about?


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MARCUS MOLOKOMME No, except to just say thank you very

much for the opportunity to allow the Free State Provincial Health

Department to come and present as honestly and openly as they can.

CHAIRPERSON No, we need to thank you too for your generosity

in coming to come and share with us the experiences of the Free

State Provincial Government, but of course one should mention that

this is not the end of the engagement. We anticipate that there ma y

be a need going in to the future to probe some of these issues more

closely than we have done given the limited time that we have had

with each other. Thank you to your members of your team, thank

you so much.

Is the Limpopo Provincial Government he re? Yes, okay would you

come forward please if you do not mind.


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We have just, well good day gentleman. We are running behind

schedule. Would it be convenient at this stage for us just to take a

fifteen minute tea break whilst you are settling in to yo ur seats and

then we will come back and then listen to your presentation.

Would that be okay?

DR KGAPHOLE Good day chairperson and if you could just lay

out the you know approach of the presentation so that when you

come back we run with it . We do not mind for fifteen minutes

break.

CHAIRPERSON I think what you have given us quite an extensive

oral presentation and we have considered it and we would simply

request you to highlight the key points of your presentation, but of

course I have no intention of restricting what you want to say to us,


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but whatever you say just bear in mind that we have had a look at it

and you need just to highlight that, but again feel free to tell us

whatever you want to tell us. Is that clear to you?

DR KGAPHOLE Yes chairperson, it is clear. Like I was

suggesting that as you break for fifteen minutes we will quickly

look at a few highlights here and there and then that is it .

CHAIRPERSON A break and then we will then resume the

hearing. Thank you.

. . . [END OF SESSION ONE].. . .


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SESSION 2 PRESENTATION BY DEPARTMENT OF HEALTH

LIMPOPO.

JUDGE NGCOBO If you could just indicate to us who is making the

main presentation.

DR KGAPHOLE Good afternoon Chairperson and the team, I am

Dr Peter Kgaphole currently acting as Head of Department in

Limpopo. I am here; let me start with my immediate left hand side.

I am with Dr Thabo Pinkoane who is the acting Chief Director of

District Health Services; this is the man who is in charge of the

district hospitals in Limpopo and even what we call regional and

specialised hospitals

In the region of 38 hospitals and then immediately on my right

hand side there is DDG Deputy Director General for Health Care in

general in Limpopo. That means it includes at last I hear the

programs like HVI Aids and TB and others. And then further more

on the right hand side I have got the Advocate PG Ramothpo, he is


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in charge of the development of the memoranda of understanding in

the department and mostly again any of the disputes which may

come through any entity or private entity in the department. Then

the last one is Mr James Ramolai he is the Deputy Director for

infrastructure technically he is leading the team when we are here

doing the inspections in terms of whether you know the technical

part of building, it is well done. Chairperson this is actually what I

can introduce the group in but it is a one force team in terms of we

have taken people from the two teams in Limpopo which are

currently doing the processing of applying for permissio n to plan,

erect and finally operate. In Limpopo licensing is the last part of

the whole process, Chairperson. I thank you.

JUDGE NGCOBO Thank you. Who is going to lead the presentation?

DR KGAPHOLE Sorry Chairperson, myself who introduced the

team I am presenting. I was currently requested to act as the head

of department and I have been chairing the actual adjudication part

in the committee. So I am going to lead and the colleagues are now


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and then going to introduce them as they are playing a b ig part of

the process. So now and then, with your permission, I would like

to invite one of them to deliberate more. Thanks.

JUDGE NGCOBO Thank you very much indeed. I wonder if you

could just spell your surname, just for the record.

DR KGAPHOLE Um, my surname is spelt in this way

KGAPHOLE. Ngami would call it Nkgaphole.

JUDGE NGCOBO You are in KZN so should we call you Nkgaphole?

Laugh.

DR KGAPHOLE Indeed Chairperson, I am in Rome.

JUDGE NGCOBO Thank you. Housekeeping matter . We’ve got this

presentation which we have found on my desk and then there is a

presentation that was sent to us some time ago. Are you going to

make use of the one that has just been presented to us?


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DR KGAPHOLE Chairperson, the one that you have just been

handed in is a power point instruction of the main one that was sent

a while ago. So, indeed, there won’t be any differences but it is

just for the presentations sake that we would want to request

indulgence on using it. Can I carry on or is there something

Chairperson?

JUDGE NGCOBO By all means, please do carry on.

DR KGAPHOLE Um, good afternoon and like I said I have

already introduced the Limpopo team who I want to heartily and

really welcome. You know the invitation told us to also talk about

our experiences in the Limpopo relating to how we are handling the

applications and Chairperson there are a couple of pages on the

document and there are more you know, the story begins with

ourselves and we are telling the team in terms of where we are

coming from. How many people are in there and then in terms of

you know, stats from South Africa, you know how many men and

how many woman are working there, I would humbly request with


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your permission that we take note of that information and then

maybe for the presentation, if you allow Chairperson, but by the

way we can always still go back and bring your interrogation to dig

more. If we could immediately start looking at page 20, um, which

is talking about, you know, currently the beds which are available

and in both public and private. We will be talking about the

processes presenting how we are doing the deal in Limpopo but if

you could immediately look at that Chairperson, we have got 5568

public beds in our province and then these are all solely related to

what we call district hospitals.

There are other people who call them level one hospitals. And

then, then comes what we call regional hospitals which is a level 2

hospitals, these are hospitals that are also having some specialists ,

general specialists. Now the number of beds available in our

province is 2149. And then the specialised here mainly we are

talking about the three hospitals what is called Mental Health Care

Hospitals, these are three and the total number of beds is 1576.

Then tertiary beds which comprise of two hospitals, they are in one


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district in our province and then the total number of beds is 1210

and then, private beds, you realise Chairperson that in every

district we have tried to give you information and the total number

of beds is 925, maybe I can quickly mention that in November the

northern part of our province is 44 and the Capricorn districts are

our hub in Limpopo and that is where Polekwane city is and that is

why the high number of 493 and then Mopani that is where Zanin e

other towns are 197 and then Sikakone there is 14 and then in

Waterberg it is 191. And then Chairperson, if you could

immediately turn over to the next page we have tried to just talk

about how many, the number of hospitals and PAC we have just for

noting. On page 22 just a correction there Chairperson, um, it is

Limpopo Academic Hospital not Fakamato Hospital, Fakamato is in

Gauteng and there is a Fakamato hospital in Limpopo which we are

currently planning to build. We have not actually started with it , it

is a national competancy and then indeed the plan is there. And

then I am going to briefly and not be lead and talk about the

processes Chairperson how we are handling the process in our

province that we have got two teams which the first team we c all it


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the technical evaluation committee and the second team is the

Polekwane adjudication team and when the applicant writes a letter

to the HOD then the research form which we give it to the applicant

to fill in and when that form is f illed then it goes to the technical

committee. Which will sit there in that form crudely, it wants to

know the numbers, the resources of how many human bodies in

general, the staffing, and where do you want to have that facility,

you know, operating and then why, in that area would you want to

have a private facility and then once that is done with that form.

By the way we do actually technically say that if you scored less

than 37 out of 75, your application will not make it through to the

next level. The next level is where we will be saying you can start

actually consulting your Architects to and start actually making

drawings and everything and which you shall. After doing that you

send us that plan and men and woman like Mr Ramolai in that

technical committee look a t your plans and they see if whether

technically it makes any sense and they engage with the applicant.

If there are any issues which we need to raise as a department we

will engage with the applicant to say please, this line this way and


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this line this way until finally you know the application makes

sense. After that the next level, then the Chairperson of the

technical committee brings the decisions which were made during

the technical into adjudication to formally present to their

adjudication committee. Then the Chairperson would be asked

questions by their adjudication committee in terms of clarity

through their processes. Once that is done then adversity is found.

In the absence of the Chairperson in the committee then a decision

will be taken by the adjudication committee whether they agree

with the technical committee or not. Then after that the process

would be taken to the office of the HOD. Now, um, Chairperson,

you realise that I was not going through point by point but luckily

it is just part of the process, you know, not necessarily going

through it page by page, just describing the whole process. Now,

let’s take the decision has been taken, now let’s look at page 25

Chairperson. If the application has been found to be of approval by

the HOD then a letter will be writ ten to the applicant to say you are

permitted. It is permission and I want to emphasis this part

because even the people who finally get their letter they are sti ll


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celebrating it taking it as a licence. The letter will say that you are

permitted to plan, erect and finally operate the facility as you had

planned by yourself. And then you would be sent to the individual

and hold it there and then the next bullet, I would want to apologise

to the team, as you Chairperson know that we didn’t include what if

the application did not succeed for whatever reason which, yes, it is

another process as we will still write a letter to say that your

application was not successful. We normally don’t give reasons.

The reasons are been given by the Authority. In this case it is

actually the Minister who has delegated and has the authority of the

MEC. Then when you appeal then the reasons are being afforded to

you that here are the reasons why your application did not succeed.

The commonest being where you are applying they are talking

about no available beds in the area you have applied to. That is

also the negative part and further to say you are allowed to appeal.

And yes the appeal can be heard and finally politically a decision

can be taken. We have an example in Polekwane where a politician

was taken because of the outcry by the applicants. I can indulge

you on that party if you would like to know more about what really


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finally happened. Then we take the process where not the ap plicant

will now start negotiating with the Municipality in terms of where

they would want to have their si te and everything. Some would

come in slow as the sides referred to by the Municipalities are just

there. Is there any way you could assist the dep artment. The only

assistance that we do Chairperson is we would write a letter to the

Municipality to say these people are working within a time frame

and if you could assist, you know, in terms of their requests and

not to push the Municipality to allow them but to just make sure

that a decision is finally taken by the Municipality in terms of

demarcation, in terms of environmental impact studies and

everything so that they could do that part. But that Chairperson

still remains a big challenge with some of the big applications

which I will talk to as the pages go on. And then we let the person

actually start building and during the building they build under the

regulations of the Municipality where they are building. We come

now and then, they will actually invite us and say we are now at

this level, whatever, and then time allowing you you would go and

look at the situation whether they continue complying with the


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regulation of 158. Um, maybe I could just request Chairperson to

quickly look at page 31, I am sorry I am not going page by page,

most of the things I have already said are captured on all those

pages and then if we could look at page 31, that now these are you

know privately run facilities in our province. The number of beds

with which we have allowed them to operate. That Tabazimbe and

Pollale is in Waterberg and Bella Bella and Amanda belt, all of

these are in Wartburg. Then in Capricorn District also likewise,

like I have already alluded to that fact that Chairperson, don’t be

surprised to see so many beds. It is merely because most of the

beds are within Polokwane itself. Let’s say it is like our

Johannesburg that is where a lot of private beds are concentrated

in. And then with a total number of 493 and then in Mobane

District we have only got two facilities which are run, you know,

privately, the first one clinic Parabola is not a whole hundred

percent as a private entity it is a triple p which I can talk to a bit

about. But many clinics are one hundred percent privately run and

then in Vhembe we have only got two and they are around

Makhabo, Makhabo is a small town in Vhembe, formerly called


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Louis Trichardt and these two facilities are there. And then in

Skakoone there is just one private small entity and in and around

Grobleister and that is i t as far as Skakoone is concerned. I have

already spoken about this currently run private entities. But we do

have applications that we have received Chairperson, some of them

in terms of status, you know, they have lapsed, but very few are

still carrying on in terms of finally developing. In Waterberg,

Mollegwane the licence and not necessarily the permission has

lapsed. Mokhabani private has lapsed. Then Mokomed is still in

Mohabani, this was formerly Pieter’s Rust Town, these have lapse d.

Moleweni this is private. I am sorry the capturer is not showing

that this has also lapsed. And then Capricorn District, um, Polowe

private is in Polokwani which was previously Pietersburg there

were 3,4,5 and 6 applications, all of them have lapsed. And 50

beds which were applied for their application has lapsed also.

Pinlo Rehabilitation Centre the application also is on, we have just

received the plans and everything, this one is still alive

Chairperson. Then in Mopani the applications have lapsed and then

in Sikakoone we did receive applications, you recall in terms of a


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previous available infrastructure which was run it was only running

at around 14 beds around Grobleister. Applications are in and then

we gave them permission to operate and plan and then their

application has lapsed which is Betterford Private and Platinum

Health, both have lapsed. In Vhembe it is around Thando, the

applications were received honourable Chairperson, also lapsed,

both applications. And that is i t Chairperson wit h regards to the

processing purposes where we are, we must allude to the fact that

we have received fresh applications which we are going to have a

look at and we will make a decision on that. We continue assessing

and then continuing to see the applicant s as they qualify to plan,

erect and finally operate. I am going to skip in terms of the health

personnel as in the state centres we are known that we don’t have a

specialist, they are very few and scanty and that is why we receive

applications especially in Polokwane when we ask the applicants

where would you get the specialist from they keep on telling us that

they are going to recruit from Gauteng and to bring those

specialists but we continue in the process to bleed with a few who


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will be there. We have lost quite key personnel when the facili ties

opened recently. In and around Polokwane.

JUDGE NGCOBO Is the ability to attract specialists one of the

considerations in applications for permission to operate the

facility?

DR KGAPHOLE Chairperson, yes they do but they are not on a

full time basis in terms of them travelling from Pretoria which is

over 270 kilometres into Polokwane, not on full time basis. But

mostly Chairperson there are some specialists who are currently

practicing as solo practitioners. Specialists in Polokwane

themselves so some of them are really recruited directly into those

facilities. But I guess I am saying, we also in the department we

also lose key specialists. I will give you an example we lost a

Geologist that was keen then to a recently opened private facility

which is now and then beyond our control merely because of

money. Chairperson I would want to come to maybe towards the

end, that is page 47 that we are realising that our applicants don’t


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understand the reason why they are making applications to run a

private entity wherever in our province and we have taken i t upon

ourselves that they have now understanding. It is not just to say

that we are having private hospital in this, it is a business entity

but also, us the Department of Health in Limpopo, we are looking

for, or looking at finally benefitting not necessarily having

everything in our facilities. Private entities may have, you know,

MRI scans and we do not have that in Limpopo and our patients

may benefit from that and when an application which was permitted

fails, it really worries us quite a lot and some people go to an

extent, I will give you an example Chairperson, they will even go

around with that paper which is not a licence, soliciting money

from whoever. They may come to you and say that we have got a

licence how about a hundred thousand rand and you can become a

partner of the deal. And it continues till it lapses unfortunately.

You were approached by IDC as a provincial government to say we

did not have anything in writing Chairperson but this is what they

told us that they were mandated by Parliament to go out to start

seeing how they can support the rural areas in terms of


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development. They came into our department to say that they hear

that we are receiving applications now and then and what happens

to those people. We told them that some of them are being assisted

by the big three but there is no Life, Netcare and Mediclini and

even in some incidences there can even be some kind of a move

around because this person could walk into a clinic and listen to the

conditions and next thing walk into Netcare and listen to the

conditions and then decide who is the technical developer

financially and otherwise. So that is actually our experience. So

we had thought that guy in the IDC was going to assist applicants

and we feather again as a department to advise all those applicants

who might have been successful in being permitted to plan and

erect to communicate with the IDC in terms of the financial needs

and everything. Up to now, Chairperson everything had just

lapsed, lapsed, lapsed, lapsed and some of these people are people

that I know that have actually advised them, except for the big

three or banks, we advise them to go and approach the IDC f or now

we have not actually found any application having been funded by

IDC. There could have been other processes that we are not party


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to. I applied for financial assistance with the IDC which made me

fail but we had hoped that as you have seen most of our rural areas

in Limpopo don’t have these private facilities. They endeavour,

the try has been there, applications which we have already shown

but unfortunately we finally sti ll , for some reasons there is no

success. The only success has been in and a round Lepalle where

Mediclinic has been operating for some couple of years. So

application was also made to us to increase the number of beds.

Now those beds in Lepalle is booming economically. Mediclinic

requested for more beds and we allowed them. So with your

permission I may have to hold it here as engagement I think should

be very important. With our assistant team here we shall listen and

do our best to assist the system so indeed we can assist with the

country. Thank you.

JUDGE NGCOBO Thank you. Have you had the occasion to decline

permission of a certain facility because you were not satisfied that

that facility would not be able to attract a specialist .


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DR KGAPHOLE Chairperson, we usually always, you know

because the areas where the appl ications are coming out of are

actually being looked at are small towns. Being small towns we

always think that there can be one or two specialists who may go

there like I said most of the specialists are not going to reside in

the area. So they would come on specialised occasions and those

ones who are actually practicing as a group. So they would send

this gynaecologist to Polokwane and he would go and spend the day

and be interchanging so we never lost hope and that is the reason

why even when we are asking how are you going to really going to

get specialists. And this is the motivation that we are going to try

and attract the specialist into the area.

JUDGE NGCOBO But you have never declined an application simply

because you were not satisfied that they would not attract

specialists?

DR KGAPHOLE No Chairperson.


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JUDGE NGCOBO The main problem appears to be the funding. Is

that right.

DR KGAPHOLE I would say yes, Chairperson. I would say

looking historically there are not competition between the business

itself if like in the Pallale Medical Clinic it is already there and

any application coming in and in this case it may obviously not be

Mediclinic as they already exist in there. Any other competitor

may look at it and now does it make any busin ess sense to go and

put another hundred beds in the area unless there is a need. There

is always this fear of not making, you know, the business out of the

area. So, except for let’s say within Polekwane which is our city or

a bigger town or the capital of Limpopo where now generally it is

seen that most of the people can afford private services in the area.

But generally fear of competition in the outlying areas also remains

a challenge.


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JUDGE NGCOBO But outside of the competition what other problems

are faced by potential licences?

DR KGAPHOLE The ruralness Chairperson. In terms of economic

status in an area like if you look at the Skakoone area, not

necessarily talking about Beggersfort, which is also something that

I have been talking about in terms of that facility by the ruralness

which is also obviously also directly linked to the economic status

of the area, you know, it threatens the potential projects in our

province.

JUDGE NGCOBO The licences that have lapsed, what are the reasons

for that. Why has these individuals not succeeded with the

operation of the facility?

DR KGAPHOLE Well, where you know again Chairperson the

experience of the applicants when they were actually applying i t

was also becoming most fashionable so maybe a couple o f them

wanted to own a private hospital in such an area but the real nitty

gritties of making sure that the project finally you know comes up


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remains a challenge and you know that is the way I think the

problem would l ie. The people that are with us are m ore dealing

with paper but outside us, now going to have to now operationalise

this permission that becomes a reality that many of the people some

of which I have given an example of Chairperson, it just becomes,

you know, an excitement that we are going t o build a private

hospital in this area but in terms of project plan it fails because

they don’t have naturally started to think now the next step is an

everything. I will give you another example, a women’s’ group in

Polokwane which we had given permission to really plan and erect.

When in fact they were really just moving around at the meetings

talking about money and how much to contribute and then before

you are a member and then time continues and then unfortunately

the time allowed lapses and the pe rson would run away with the

money. Fortunately some of the people would come to the

department and they said we wrote them this letter which would be

true and we want to know where is Ms so and so because she has

run away with our money. So it is really important Chairperson to

have management planning and i t is still a big issue. And many


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times this is the reason that there is still a monopolisation of the

big three. That I go there helpless and they say O.K. I give you

some money and then you give me two percent, this is just another

example, of the entity and we will develop. And that is currently

what has been happening. And that is under our first bullet of

challenges and we understand that the whole process entails how

much it will cost you to build a 50 beds hospital. So these are just

the excitements and we have decided as a team to start talking to

some of these people as some of these applications that have

lapsed, technically they are qualified and there are even fresh

applications in different names of possibly people that have

reapplied. But we have to make a way to teach our people what it

means as it adds value when a private hospital comes up. We don’t

see it as a competitor from the Governments’ side. That is the

reason why when we are planning for 2010 we counted some of

these private beds which were being planned to be built but

unfortunately two projects could not make it.


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JUDGE NGCOBO And when you consider these applications do you

take into consideration of the abil ity of the applicant to finance the

project or the expertise of the applicant to operate a facility.

DR KGAPHOLE Our tool person we had been using as a province

was not yet looking at the financial abil ity part. I must say that

like yourself I must get to that fact with all these experiences and

one big challenge is project plan with actually by the applicant

which we shall get and make sure indeed that these people but

remember Chairperson in many of these areas were mostly rural

areas. Those people who can actual ly have a good plan to succeed

and everything, maybe amongst ourselves even here who are not

even in those rural areas, just given two leading examples you

know. A group of woman who are not necessarily by the way

professionals, we are going to have to, IDC was actually prepared

to start doing that but unfortunately that part of the communication

went into a litt le lull last year to make sure that they were

capacitated.


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JUDGE NGCOBO An applicant for a licence amongst other things

must have learnt on which to build a hospital. There must be

finance to finance the project and then the third thing is the

permission to operate. Now, you can’t get the finance until he has

the land and he can’t get the finance too until he has the licence. Is

that how it works? Is that the reason why, the reason I emphasise

that you must have land you must have, the expertise must have the

funding?

DR KGAPHOLE It is agreed Chairperson and we have even made

decisions as a department and not necessarily as a team that when

you are applying in our assessment to the Municipality shall make

it in writing that yes there is an identified land and other processes

of finally demarcation and everything we know it may take a li ttle

bit longer but as long as, one the Municipality is ac tually showing

keenness to really assist in such a project. Number two what the

IDC has actually approached us about where we are going to have

to now form a tracker. The applicant technical developer who will

also be finally someone who is financing you and even managing


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that hospital because it is not just building and seeing patients

walking in and out, you need to manage that entity. The

management part, you know, to see that you are part of and

developed into that level. We have agreed that we are actually

going to have to close that kind of gaps which, you know, are

showing in most of those applications. Few applications we had

earlier on in terms of no technical support and financial assistance,

most of them Chairperson would immediately show tha t I’m

partnered with the Mediclinic or that I am partnered with Medicare.

In such a case with history we don’t actually have, you know, a

query. But we have an application now where they need it

immediately cleared that they are partnered with this group or

whatever in that we will actually dig deeper and see who has

actually finance here.

JUDGE NGCOBO Does this not worry you when you have granted

many permissions to operate these facilities yet these licences lapse

because of inability of the individua ls to secure funding?


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DR KGAPHOLE It does your honourable Chairperson. Like

yourself already alluded that we were already engaged with IDC.

We have appropriately even referred the applicants irrespective of

the outcome before by the way Chairperson, in the way of the

outcome of the technical evaluation. We referred the freshest.

Most of these lapsed, all these applications, we referred them to the

IDC which we were hopeful that they would break the monotony of

the big three in those rural areas. What has happened between the

applicants and, now let’s just say this IDC, we are not privy to

now. But we are not going to leave it because IDC approached us

and we are going to want to know what has happened even if they

are not even saying sorry they so fa iled because of this and of

everything so if they failed we can see, you know, how these

projects can finally succeed.

As you said Chairperson, that there is a department where we

always look for some of those projects. In those outlying rural

areas where a specialist would go into Skakoone. In those few

hours we are also even agreeing that they can assist us in


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government in terms of patient care as they are specialists and we

are not having a specialist in that regional hospital at that moment.

So we were hopeful that these projects really would make it but

unfortunately they did not. To an extent that I can give another

example. Around Tondo we had received about three applications

only one application, application where we were only looking for

about one hundred beds, which were available. They were all

gunning for that we could only afford one. We approached them to

form a group of themselves to finally make sure that this project

succeeds. Unfortunately still it never went further.

JUDGE NGCOBO I understand, Dr Bhengu.

DR BHENGU Thanks Judge. Thank you for the presentation. I

just want to ask here on page 17, it was not in the presentation.

But it is your written submission. There is a table of health

personnel, I think it is L. Are we there?


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DR KGAPHOLE Referring to the written submission and not the

presentation. I think we do have a, if you would allow me, I think

that we do have a slide on human resources. I am going to just

quickly going to page through and I hope that it is the same and

then. Yes, page 42 on the presentation if you could, I am not sure

if it is the same slide Chairperson.

DR BHENGU No, my question is really just a quick one around

this. I mean one of the things that we are trying to do here is to

confirm the statistics that we are using for the final report and I

couldn’t help but notice in your footnote here going with the table

here, you seem to rely on the South African Health Review for

statistics about your employees. How is that supposed to work? It

is a publication, that means it says per sal, which is obviously is

the salary system here. But are you using the latest information

from the South African Health Review of 2013 or 2014. I mean the

question is if the department cannot get its own statis tics and relies

on a publication to get statistics about i ts own employees. Should

we be concerned about the reliability of the statistics that you are

getting?


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DR KGAPHOLE May I request Dr Pinkoane to deal with it and I

will also talk to i t Chairperson .

DR PINKOANE Thank you Chairperson. In actually fact this is

from our own persel. Not someone sitting elsewhere so also like

persel will assure us that so many medical specialists and medical

staff. So we drew the medical statistics from persel our ow n persel

and not something that was brought in from outside the province.

DR BHENGU I would not have a problem whether it is the

national persel or yours. I suppose the question is about the

publication of the South African Health Review and relying on it. I

would imagine that to start with that they would have gotten the

stats from you. But I was just asking and I suppose the question is,

do you believe that this system is reliable.

DR PINKOANE Thank you Chairperson. Yes, we believe that this

system is reliable because persel is actually updated on a monthly

basis and with that information it is actually the bodies that we are


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paying every month so we know that they are actually in the

province.

DR BHENGU Thank you. Going on to the issue of licen ces. I

don’t know, when you say that you do the licences last doc. What

do you mean, is there ever a situation where whoever the investor

is can start the construction before the licence? It doesn’t make

sense but I guess I did not get you right?

DR KGAPHOLE Chairperson, when we are saying licence it is

when now, maybe let me say in Limpopo we also have a team

outside of this team that I have alluded to introduce you. This

other team is what we call the licensing team and that is the team

that says now you are done with brick and mortar with all the

machines and everything painted and you have recruited all the

necessary warm bodies in the facility then they come and visit you

and they do inspections. And after having being satisfied then you

get this licence that you display in this facility which every twelve

months is being renewed. If something of serious material is


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found, we don’t allow you to get that licence. We actually request

you to correct that mistake which we are seeing then we finally

licence you. I can give you an example about a Netcare which is

one of the latest licensed in the province. When we went there we

found that things were not the way we were expecting when we are

doing inspections on you. Then they were not licensed to o perate.

They had to actually quickly deal with all of those concerns and

once they are done then we finally give you a document which is a

licence. The first one is permission to plan to operate and to erect.

Once you have finally managed to erect, and the system is ready,

like a car when you start it then we give you that document we call

a licence. Which unfortunately I tried to emphasise that

unfortunately am out there. The first document that the HOD

would sign and then take it as a licence to have a private entity. As

you can see now some of them have lapsed. They don’t even have

a foundation of whatever they wanted to build, nothing, so that is

why it is not a licence it is a permission which is taking you to

finally have a licence.


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JUDGE NGCOBO Has it happened that a structure completely built

and then you find that the Department cannot build which means

that it stands empty, unused, has that happened?

DR KGAPHOLE So far that has not happened but let me introduce

you Mr Ramolai here for him to talk to us about his findings. But

we do not have any project that is still there because of serious

conflicts in terms of infrastructure.

MR JAMES RAMOLAI Thanks. Currently we don’t have such a

finding.

JUDGE NGCOBO But it is possible?

MR JAMES RAMOLAI If it is possible, the issue is when we do an

inspection if there are serious findings then we report these

findings to the appropriator that is engaging in that particular

project so that they could be able to rectify to be able to get that

licence. We don’t just leave issues where they are but it is a

collaborative effort.


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DR KGAPHOLE Maybe as an addition there are two types of

licence inspections that we conduct. There are existing

establishments that are already operating where we do the an nual

inspections and we renew them. Then we also have the newly built

facilities. But so far we have not had a new facil ity that has been

built and then we find that they are not compliant with all the

requirements. But what we have had so far, if you l ook at the

presentation, when it comes to Skakoone, the 14 beds, you will see

that we put it there under asterisk. The issue there is that the

facility has been existing. So with the previous l icence inspection

we realised that they are non compliant with a lot of issues and

they were given two months to address the issues and when we re -

inspected them in two months, we saw that the facilities are st ill

the same and the conditions had not improved and as a result we

were left with no option but to withdra w the licence. In terms of

the R158 it is actually referred to as the Certificate of Registration.

So, we have withdrawn it but we have also made provision for the

facility for them to find themselves having at any point finalised all


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the issues that we have raised then they can write to the Head of

Department to requesting for us to go and re -inspect and relinquish

that decision. There is also an appeal process that they have been

given. So that is the only facil ity so far that we have withdrawn

their licence because of these gross non-compliant issues.

DR BHENGU Thank you. We’ve heard here some of the provinces

that the R158 licences are outdated; they don’t cater for the needs

appropriately. And Western Cape runs on a different sort of

regulations now as this morning we had the Free State. Um, is

Limpopo satisfied with R158 that it is adequate for the purposes for

which it is meant?

DR KGAPHOLE We are not satisfied Chairperson. Not

necessarily regarding the age of the regulation but that things have

moved on in terms of infrastructure and planning’s and the like. I

must actually inform you that we have formally engaged national in

that way because this is a national issue that we need to urgently

start at reason be at the R158.


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DR BHENGU You have turned some licences down. What I think

you have given us is I think, what I want to know is do you, have

you worked out, I mean in terms of each region how many beds

each region can actually absolve? How do you know when

Capricorn is over traded for example?

DR KGAPHOLE Chairperson it is true. We have turned down

some applications as fresh as late last year or so. For some

different reasons which I will quickly mention. One, you find that

the recent permission already given to so and so and this person is

moving around as if they are already allowed to and they are

already negotiating with financiers. As long as people don’t see

the real structure in that area, then there is nothing. Then these

applications will come in and even those regional departments will

say is there a mechanism which we could employ to let people

thinking of applying for a private entity in an area, to let them

know that for now this is saturated. Please consider the following

areas if you are interested at this type of an activity. So we have


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actually spoken to our MEC about it . It is a matter of logistics how

we really sell out that information. Where I am, Polokwane was

saturated at such stage where all these lapses. There is technical,

when we go back and see if any fresh applications, we see that

three applications had been put off. This one is requesting so many

beds, technically within or just above or whatever and then we

accordingly do that. Lastly, Chairperson to give you another

leading example, where the current Mediclinic in Polokwane had

applied for extra beds on their current structure, we could not give

it to them because there were no more available beds. Two three

applications had been done and we were expecting them to come

up. Unfortunately they did not come up and technical Mediclinic

know that now most of those applications have lapsed so they came

and said now we are still requesting for these 20 beds and we had

to give because by that time then that number of beds were

available and Mediclinic were available to add 20 more beds. But

generally, yes, l ike yourself had already alluded to the fact that

where you see all these lapsed applications are where we are saying

looking at both private and public number of beds which are


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available therefore this entity will succeed in operating. We do

that, but unfortunately for the reasons that I have told you the

project fails.

DR BHENGU Last one, really regarding the also from your side,

the issue of liabilities is important but I do see, well, the proj ects

have not been taken to fruition, but it seems like i t was permission

granted from your side. But, I mean, is a 30 bed a viable hospital?

Do you have that in your mind as to before you own a licence, at

least minimum level of viability? Because I see as a 30 bed I see,

the little I know, it may just battle to be viable.

DR KGAPHOLE Chairperson the beds there are not necessary

referred to a fully fledged regional hospital, it might be 30 beds for

a maternity unit, which we would say would be viable a nd all that,

or a rehabilitation centre or specialisation. Like you will not

generally find therapies for children, 7 for woman and everything is

for specialisation.


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JUDGE NGCOBO We were supposed to take a lunch break at 1:15

and the time is now 1:30, my colleague has assured me that we

won’t go beyond 2 o’clock so would it be convenient for you if we

continue until 2 o’clock.

DR KGAPHOLE Yes Chairperson we are ready to continue, mainly

because we are going to fly out of Durban to Limpopo sometime

late in the afternoon.

JUDGE NGCOBO Your flight is at 4 o’clock? We’ve got every

reason than to continue.

DR KGAPHOLE With due apologies Chairperson.

PROFESSOR SHARON FONN Thank you very much Chairperson,

um the public private partnership in Polokwane, um, we had a

presentation from the private part of the partnership and the point

that was made was that there has never been a referral of a public

patient to this um, particular facility. Is that correct? And if so

can you explain to us why?


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DR KGAPHOLE Chairperson, I am not sure because the one that is

in Polokwane is the one with renal dialysis and our patients are

benefiting. It is one of the most success triple p. My suspicion is

that you are talking about Parabola?

PROFESSOR SHARON FONN Yes, you are correct, sorry

Parabola?

DR KGAPHOLE To speak briefly about Parabola, Chairperson, in

that we have gone into that partnership with you know private

entity clinics and unfortunately, you know, in their part they are

expecting us to send every patient in our next door hospital which

is about 10-13 kilometres away could manage. Our looking on the

partnership was on speciality and for some reasons we suspect that

this government they are running away from liability. One, they

did not want to admit orthopaedic patients, those ones with broken

legs and arms. Two, they did not want to admit patients who were

most delivering with some conditions. So as a potential liability


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and when we are looking at them, like I was saying earlier on, as a

private entity that comes into the area, our benefit would be to

actually tap into the specialists who will be actually servicing that

entity but they were expecting us to send any patient, even if they

were just having ordinary diarrhoea and just to give an example.

Then we may as well just close our facilities as a government in

that area. That is actually where the biggest problem started, not

by the way, I know I have been signing off requests for payment,

we do now and then send patients of need to that hospital but we

can’t reach their target. Mainly because they refused the areas

where they would be adding value to that area. You can imagine

all the pregnant woman cannot be operated on by an ordinary

general practitioner in our hospitals who need an obstertrition, b ut

they say no. We did not see any need really. But we are currently

awaiting for them to look at these areas of service that is patients

with surgical or are pregnant and need an obstertrition. Once an

agreement has been done the project will survive. And we are

optimistic and I think that it will make them too, I am sorry to say

the words, wake up because we can’t now send every patient who is


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supposed to be serviced in a township into the hospital. But we are

currently negotiating to see how we can finally do that. Thanks.

PROFESSOR SHARON FONN Thank you it is good to have your

side of the story as well. I just want to check, two questions on

page 42, again on that graph on employment, um, question one, is

do you employ clinical associates and where are they on this table

and then the second question, is your community health workers,

your final column is annual cost per staff member and I think that

there must be an error here as otherwise these are the best paid

community health care workers in, possibly the world. Um, at half

a million a year, so can we correct, am I right that this is an error?

DR KGAPHOLE Yes, you are right, we will actually correct the

payment here. Yes, we do employ clinical associates, although

very minimal. This current year we are also start ing to train some

of them. We do have them in two to three hospitals and I will not

mention their names now. These are actually working in our

district hospitals. They add value wherever they are, that is the

information that we have got.


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PROFESSOR SHARON FONN So, just for clarity are they then

captured under all other personnel or are they missing?

DR KGAPHOLE Yes, they are included Chairperson.

PROFESSOR SHARON FONN The last question was um, the first

thing that you list, well one of the things that you list is that you

bleed um, specialists and practi tioners into the private facilities.

Um, you have also explained to us that the population is very rural

and that the density can be a challenge for viable services and the

question is whether the department needs to spend a lot of time

thinking about hospitals, or is it something else that you might

need that will meet your needs. Um, for example, a very good

referral system to actually move people from more peripheral areas

to more central areas which do have capacity and if the province is

keen on or has the ability to or if there are any obstacles to stop

you from engaging in different kinds of interactions or contracting

with different kinds of providers that are not hospi tals that could in

fact meet the needs of the province and its health.


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DR KGAPHOLE I will just comment a bit and request both doctors

Pinkoane and Ndambi to quickly talk about it . You know

specialists you need in the province but from my side just too

quickly mention that yes, we are currently engaging groups of

individuals, specialists, mostly within the Polokwane city, um,

there is already a group of orthopaedic surgeons that have grouped

themselves and we are engaging with them. The last

communications that we have had with them, because of

indemnities and everything they were looking at negotiating that

part. We are also looking at signing a memorandum of

understanding per every grouping because I can write you an

indemnity letter and the day you go away from Limpopo that letter

is gone. So we are going to have a memorandum of agreement per

group of specialists so that we agree with them when they will be

assisting us in our hospitals. But in terms of recruitment I am

going to request Dr Ndambi to t alk about the recruitment part and

Dr Pinkoane if there is anything to add onto that.


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DR NDAMBI I thank you Chair. Um, yes, well within our

province it has been difficult and we have put plans in place and

some of them have been working and one of the i ssues that we are

trying to do is to actually reduce the turnaround times in terms of

the recruitment in the sense that sometimes we headhunt. And

when we headhunt it does not mean that we do not interview. We

actually look at the C.V.’s and we actually set up an interview as a

matter of urgency but over and above that with these people

because we have had bad experiences before where people have

come from far away states and I think that everybody knows what

they do and they actually employ the wrong peo ple. Now, the thing

is the office of the HOD had actually put up a team who looks at

the people who are about to retire and then they get assessed to see

if maybe they can be given further contracts to see if they can

actually continue to work. Now, as everybody knows doctors have

families as well, so the other issue is the timing of our recruitment

is important as they need to move their children in terms of

schooling and so on. So if you recruit in March it may not be of

good help unlike if you start r ecruiting in July or August where you


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can start negotiating the movement of their children to appropriate

schooling. We have now put into place plans to target medical

schools and the registers qualifying specialists knowing full well

that they may not immediately get a specialist post. And we

negotiate with the specific professors, in particular at UCT, where

for instance, we negotiate that maybe the specialists go with us,

even if it is a minimum of two years in rotation, um, as long as we

pay them. And also to allow some of the registrars who will put on

our payment roll to pay to go to UCT, or Stellenbosch or anywhere

else so that when they come back we can actually utilise them. We

have been engaging with the National Health Department, um, for

this issue that relates to the following; when you look up at the

OSD dispensation where everything is now drawn to assume that

things are normal, where you find that the head of department is

supported by the head of clinical. You need a specialist and so on .

That is for the luxury of Tigersberg and Groote Schuur you will

find that the head of department is alone in the entire department so

the directive is that the head of department in terms of time can

only qualify and maybe for 8 hours. So we have been negotiating


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that maybe we should relax that part a bit where it is informed by

the volume of work being done. So if the head of department has

to get up more often or figuratively speaking ahead of the any

department in Tigersberg, for instance, he should be compensated

for 16 hours instead of 8 hours. That would perhaps keep them to

stay with us. The MEC has actually instructed us to continuously

with everybody who is a specialist in a meeting which is going to

be involved in a way to also try to pay th ose that are there. So that

if there are problems they can approach them as a matter of

urgency. I think that we are doing relatively well because, I think

a few days ago Dr Pinkoane and I had been implementing some of

the directives as instructed by the department and already in two

weeks, at least by this Friday, we will be interviewing the first

three very highly ranked specialists. One is an obstetrician and

gynaecologist and the other one is an anaesthetist and the other one

is an urologist as well. So, um it may bear some fruit. Thank you.

DR PINKOANE So, medicine addition, we have formed a

collaboration with UCT and the department of internal medicine


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where Professor Myosi is actually assisting us in training some of

the specialists for us. Already we are having a specialist that is

training for us as an urologist and this doctor, after he has qualified

we are paying him a salary and everything so for six months he is

at UCT and working and everything and then for six months he

comes to the province to assist. So what we are intending to extend

is the collaboration so that we get more specialists and so that we

get more in the other departments as Dr Ndambi alluded. Now the

other thing that we have been doing is that we also have been

having programs that they were participating in like the UNV

where there are doctors participating (United Nations Volunteers)

where there is an agreement that was signed by the late President

Mandela and the UNV where the UNV come and then we mainly

send them to our district hospitals in our rural areas, we actually

provide quite a good service to those communities. We are also

engaged in another Cuban program where the department has a

memorandum of agreement with the Cuban government to provide

us with the doctors. Mainly we get those that are specialising in

the various disciplines. And we have allocated them mainly to the


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regional hospitals and the district hospitals so as to address the

issue of referrals. I must say it is a little difficult to implement a n

ideal referral policy because of the rural nature and the geological

location of some of these hospitals. Because you may find that in

some of these districts the peripheral pattern will not work because

for instance in Capricorn there is no regional ho spital and the only

hospital that is around there is a tertiary hospital and then there is

next a district hospital about 10 kilometres. So then if we have to

formulate ideal referrals patterns, it is going to create a lot of

problems there. However, we are trying to accommodate as much

as possible where we will even provide different levels of care even

in tertiary hospitals so as not to inconvenience patients. But to

derive at these levels there are the plans that we have already put

into place and the active recruitment is actively going on. Even as

we were sitting here last night, we were busy speaking to some of

the specialists so there will be more that we will be bringing in.

DR LUNGISWA NKONKI Thank you for your presentation, um,

my first quest ion is on the presentation, I think it was on slide 35,


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you had the Skikoone district , um, and their certificate was

suspended for non compliance. Could you talk about in what areas

where they non-compliant.

DR KGAPHOLE Thank you Chairperson. The facili ty was actually

having 14 beds and they were licensed to provide maternity care

and also to look after HIV Aids and TB patients. Now when we

inspected their facility, it was actually one ward, which was

divided by a swinging door which was leading form th e HIV TB

wards leading to the delivery room. It was just next to the said

demarcation which was actually the delivery room. And the issues

that really of serious concern were issues of infection control and

the cleanliness. We found the place to be very dirty and the

policies were not there. Issues of security, they did not even have

cameras or security at the entrances, especially for children and all

that, especially outside the security was not that adequate. Also

patients that were in the TB ward, there were not policies like, I

mean, no ventilation, they did not have any standard operating

procedures, no windows and all that and some of the observations


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that we made. Like one, they were not there, they just delivered a

baby next door and the nurse delivering the baby went to the ward

wearing gloves which was touching everything, opened the door

and went to the baby with the very same gloves. And we found that

those prevention control procedures are very serious as part of our

inspection we put more emphasis on the seriousness of cleanliness

and sterilities. And if things are not correct there we issue

penalties and we did request that they could not mix HIV Aids and

TB patients with freshly born babies. It is a very serious risk. But

they did not correct that. Now, when we also went to other areas

like the laundry we found that they were just using these domestic

irons, you know, to iron the linen. In terms of infection control

these are not effective. We expected them to be using those which

would assist. So those are some of the wide issues that we picked

up which we thought were very gross and will compromise patient

care if we don’t suspend the licence.

DR LUNGISWA NKONKI Thank you,um, my further question on

your written submission you have outlined the l icensing process to


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be run in three phases. On page 10 one of your criteria on phase 1

is whether the public institutions would be a disadvantage

especially in attracting rival staff and manpower. Having explained

your difficulties in a ttracting specialists in your area, how do you

apply these criteria?

DR KGAPHOLE I think the issue of bleeding in terms of staff is

quite a difficult one like HOD has already said. When they apply,

we are promising that we will be attracting staff from all over and

elsewhere and we are not necessarily going to approach you. But it

becomes very difficult again when people become, or people send

in their letters of resignation, we cannot stop them if they want to

resign and move onto what they say are greener pastures. With the

opening of this new facility we lost quite a number of people

because, I think what the private sector did is they put a very good

package for them, to say that we will give you a facility that is

fully equipped and everything and you are not going to pay for a

certain amount of time and all of that and many people thought that

this was the opportunity for them to start with and go into a private


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practice. And we lost quite a lot of specialists that went there.

Even those that we had that were doing sections for us because

there was this new opportunity for them and unfortunately this is

the problem. But we always try by all means to keep them within

the public’s sector as well. But unfortunately we cannot have

much influence on what they finally decide. If they want to leave,

unfortunately there is no mechanism, or no policy we can use to

stop them from leaving.

DR LUNGISWA NKONKI Thank you.

DRS CEES VAN GENT Dr Kgaphole I am following up on a

question that the Judge asked you on the lapsed l icences, um, have

you ever drawn up a report and done research yourselves on the

background, on the, we talked about the IDC and the finance and

about finding medical specialists ect. Is there any report or any

sort of research been done and can we have that?


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DR KGAPHOLE Chairperson our engagement with IDC is of

recent especially relating to most of these applications we have just

followed on and that is the reason that I have already alluded to the

committee that we are planning to visi t IDC, even if they are not

saying the Dr Kgaphole’s application fell off because of whatever

but that we would want to know and see the reasons. We would

like to see some of these projects really succeeding. So for now,

yes, we have not actually formal ly engaged with the IDC and it is

of our interest because we are seeing a different way of

approaching the way it has been carried out especially in rural

areas. We are going to visit the current department which is the

acting head of department. It is my plan to make sure that it is

done.

DRS CEES VAN GENT To be sure, there is no comprehensive

research being done on the reasons for the lapsed licences over the

last five years or so?

DR KGAPHOLE No Chairperson.


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DRS CEES VAN GENT Thank you very much. You were here this

morning and you alluded to fact that also Municipalities could also

have something to do with the fact that the parties can’t proceed

after they have received a licence. You even mentioned the fact

that you would go as far as send a sort of letter of recommendation

to the municipality and explain to them how important it is to co -

operate with this group that wants to invest. And also, this

morning we heard the same from the Free State, where sometimes

the municipality does not co-operate. So that sounds really strange

to me because I know that every suburb is struggling with

unemployment and I think that I am from a country where if there

would be a plan to invest in a hospital in a municipality, the Mayer

of the municipality would send out all the beautiful young woman

with flowers and try and welcome this company. What is the

background, I don’t really grasp, what would be the reason that the

municipality would not be co-operating with this types of

investments.


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DR KGAPHOLE Chairperson this will be more as an opposition

really, in the sense when Mr Kgaphole makes an application to

municipality X, is this person known in his community and

everything. I have many leading examples in Mpokane in the town

area where a group of, starting now to look like a group of

racilistics and whatever, I think I’ve got to say this, a group of

Indians with a few Whites, they have been knocking on the doors of

the municipality for some time now. Till now literally they have

been joined by somebody else and now we see some movement in

terms of a resolution been taken by the Counsel for that particular

municipality. So this is the little experience that I have seen. They

also look at the name and see who is that, even before looking at

what you are saying in terms of the benefits to the community.

They don’t look at the business part as, I don’t want it to go to

rumours but, it will also be like well what will I be getting, which

some of them they tell us.


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DRS CEES VAN GENT So what you are saying if I understand it is

that political interest trump the interest of the people that are being

represented at the municipality level?

DR KGAPHOLE Well the level that I am talking about is the

stability has been there for a bit long. It has been there for the

media. May I access in there today with the Counsellors, who

come in now and again and then a new one comes in and finds some

of those things. Those are realities and are unfortunate in that

area. But generally in the rest of the province where the biggest

challenges be the waiting for the request. But it takes long for

Counsel sittings and prioritising such requests. They are maybe in

the need of water and electricity in the area, so it takes long. But

in that area it was most unfortunate that we experi enced those

challenges.

DRS CEES VAN GENT Thank you. So you are, Limpopo, consists

of five districts, five municipalit ies, isn’t it? So you could invite

the municipalities in a small room together and talk to these people


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on the importance of the expedi ting of these. Have you ever had

this sort of discussion with them?

DR KGAPHOLE Chairperson we went about four or five months

ago, let me safely say late last year, we called all the departments

in the province and all the municipalities to actually sha re the

issues that have bearing on us. Unfortunately those meetings were

poorly attended for reasons unbeknown to the department. But now

we have decided to take it on by visiting the Department of

Education and sit with i t and even we are having a lette r of

memorandum drafted for a letter of understanding by Advocate

Ramothpo. And finally then we will sit with you and discuss where

we can co-operate in terms of government co -operation and then we

will sign that memorandum of understanding as well as wit h the

municipalities Chairperson. So i t is a process that is now on that

we hope that some sort of co-operation will come of it and sure

they are also looking for something from us, from health, which

can also assist. But by the way we want to see some p rojects

coming through IDP. Currently IDP infrastructure is only relating


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to public/government infrastructure where you are building a

community clinic and hospital or you know, health centre. During

our engagement we will be looking at some kinds of del iberations,

you need to start recognising this type of activities from health.

DRS CEES VAN GENT Thank you very much.

JUDGE NGCOBO Some of these licences lapsed because people

have no access to land, is this one of the problems?

DR KGAPHOLE Yes Chairperson I can give you an example in

Polokwane.

JUDGE NGCOBO Please do.

DR KGAPHOLE A project in Polokwane I know that they have

been battling to finally purchase land. Remember like my

colleagues have already alluded that some land will already belong

to the municipali ty and most will be on privately owned land. And


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when you knock you want to build a private hospital with a person

who will want a lot of millions and now, that is what the problem

is. But yes availability remains a bit challenging.

JUDGE NGCOBO That is a separate problem but there is the

problem of the processing of the building plans and the transfer of

the lands. Does this also lead to the lapsing of these licences?

DR KGAPHOLE Well, Chairperson we open our doors in this way

so that applicants communicating with us tell ing us that the

municipality has not taken a decision on demarcation or an EIA and

therefore please extend, we do. And I have got examples where we

have now and then we would give them six extra months to ensure

that that process is done. We do that Chairperson, key is

communication. They need to tell us that they are battling to get

the land or that we have a piece of land but i t is not formally

demarcated by the concerned municipality, please we are sti ll

negotiating and we are requesting for an extension. We do do such

extensions Chairperson.


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JUDGE NGCOBO The EIA is that the Environmental Impact

Assessment?

DR KGAPHOLE That is correct, Chairperson.

JUDGE NGCOBO Now you have set out at least a report for broad

issues that you say are of concerns to the province. One of these

and the first issue that you draw attention to is the urgent need to

review the current regulation 158. This is on page 18 of your

written submission.

DR KGAPHOLE Thanks Chairperson indeed, like I say we have

already mentioned during our presentation as a Limpopo provincial

department we actually want to engage with national and sit with

the R158 so that it is freshened up.

JUDGE NGCOBO What abili ty is there to review the current

problems? Other provinces, like the Cape has its own regulations

and the Free State, you heard this morning have their own


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regulations with dealing with the licensing of facilities. Gauteng

has its’ own statute but it has not come into operation. What is

holding Limpopo from taking this initiative?

DR KGAPHOLE Indeed Chairperson I would want to take this

concern to Limpopo. But the rest is assured that we have been I

think in 2014 we have been called by the NCOP for health and

private licensing which we previously mentioned. Our approach is

Limpopo and that is why we are saying that we are engaging with

national. Not that we can’t do it but that we would want to be part

and everything. There are three provinces that can take the

initiative and we will actually benchmark on everything. But

finally where we are it should be a national document that should

be standardised to avoid Limpopo from doing its own thing and that

is why we are sti ll living unfortunately with the old R158. But we

are taking note and we have realised that we actually need to

urgently engage with national and then there could be a plan where

we could take what is currently happening and move on.


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JUDGE NGCOBO At national level the legislation which was

activated in 2003, you know some of those provisions have stil l

needed to come into operation. In particular the very provisions

that you have been talking about to standardise the issuing of

licences are not yet in operation and there is no indication when

these are going to come into operation.

DR KGAPHOLE Chairperson, yes indeed. We agree with your

observation and I guess we are not saying national, do it . We are

saying let’s do i t and then we want to make sure that this project is

done. It is not only this one Chairperson where we ha ve been

engaging on national levels on the policy issues. But we will

always, and by the way when we say national we mean us, even in

other provinces. So we are happy that other provinces have taken

up the initiative so we can only see what is happening like, there

might be good things that we can take in and there might be some

good things that they might have missed so we bring in everything

and that is why we are talking about standardisation. But in that it

is of critical importance that this regulat ion is national reviewed.


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Limpopo can try and do i t here and there but in our way of looking

at it is the entire country.

JUDGE NGCOBO What I am suggesting to you is that more than 13

years ago there was a legislation that was enacted. One of its

purposes was to standardise issuing of the licences by entrusting

that responsibili ty on the national government. Those provisions

have yet to come into operation. An attempt was made to bring

them into operation in 2014 but last year that attempt was struck

down by the court because there were no regulations 13 years later

to bring these provisions into operation. The other provinces in the

meantime have taken the initiative to settle the situation. Now, my

concern is if Limpopo is going to stand by and wait for how long

are they going to wait?

DR KGAPHOLE Chairperson we take note of the seriousness of the

matter especially in Limpopo. One, we will quickly, by the way I

am talking here as an acting HOD which is going to make sure that

the commitments are immediately implemented. I am sitting here


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with the committee, the Chairpersons and colleagues of the

department representing the province but the one quickly within the

first week or two will communicate with the other provinces and

see how they feel about the issue and take lessons from there.

Number two, lastly that we will continue, like I said when I say

nationally I say it is us, including other provinces we will make

sure that we include nationally we do have this regulation

reviewed. Irrespective of whether our other colleagues have taken

the init iative to appreciate and we are going to immediately

benchmark on that and move on, definitely in that I can commit to

the Limpopo department of health.

JUDGE NGCOBO The forum where you can raise this issue is the

forum of the Minister of Health, mixed with the MEC’s of all the

provinces at which your MEC is represented. You could speak to

your MEC to raise this issue when all the other MEC’s are present

to witness it . The issue can be expedited, that is just another

option.


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DR KGAPHOLE Definitely, Chairperson, the national Health

Counsel with the Deputy Manager and the MEC’s are sitting with

the HOD’s of which I am a part of and I will escalate it after this

engagement so that it can be a proper discuss ion to be added to the

Agenda. I will definitely raise the concern that the Chairperson is

raising as it is correct.

JUDGE NGCOBO the other concern that you raised is finding ways

of facilitating the underserviced rural areas. As I understand it, is

it about 80% of Limpopo which is rural areas? And how many

people are there, the population that is there roughly?

DR KGAPHOLE Chairperson, um, I would be, unless if I actually

classified, unless I say in Capricorn, Capricorn is around and

measurably like very rural but the rest is over 85% to 90% that is

rural. We might have a litt le light in small towns where are where

these applications are imitating from. But history states to move

slowly in both Mopolane and Bergersfoot where there are a lot of

mines coming up. In the next couple of years, there will be


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definitely economically a little bit of an improvement. This

economically, you now, coming up of an area, and the rest you can

drive 5 kilometres out of Bergerfoot and you are in the villages of

serious poverty. So, I would say nothing less than 90% of

ruralness in there.

JUDGE NGCOBO And people who live there are entitled to have

the right of access to health care services and it is your

responsibility to facilitate the achievement of that right in these

areas. Do you have a strategy for that?

DR KGAPHOLE Yes Chairperson in both ways Dr Pinkoane has

just alluded to enter into government, you know, collaborations

with Cuba being number one in this respect. About two or three

months ago we received 22 Cuban specialists. Out of those 22 I

think that actually only 1 specialist was left in Capricorn and the

rest were sent out to these rural areas to go and try and close the

gap but the gap still remains here and there. But the other reason is

the reason that we allowed, you know, these applications to go


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through, we are looking at that. We can’t afford 25 or 5 MRI scans

in those districts. Private entities can have that with their

specialities visiting in terms of that kind of collaboration that when

the specialists visit the clinic in Skakoone, definitely there will be

patients that are in need and agree in terms of fee

.

JUDGE NGCOBO I am not too sure whether you are familiar with

this matter. There is an initiative that was made in Limpopo which

involved a consortium consisting of a group of black doctors,

Keystone Company and Netcare where they were going to set up a

hospital. Are you are aware of that initiative? Is anyone aware of

that initiative?

DR KGAPHOLE Yes Chairperson I am aware of that. That is the

one that I alluded to when we were planning for the 2010 World

Cup, we were even counting the number of beds from that enti ty.

JUDGE NGCOBO In whose name was the licence issued at the time

when this initiative was formed?


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DR KGAPHOLE Chairperson I can only recall the leader in the

team, unfortunately he has passed on, the late Dr Bena. He was an

OMG specialist and leading the entire team of black specialists.

When I was saying that an application was politically decided on

that time when there were no number of beds but politically it made

sense for these group of people, you know, to plan and to finally

operate a private entity, but unfortunately it fell through the cracks.

The members started fighting amongst themselves and

unfortunately we even lost the key team leader the late Dr Bena

who was their project manager.

JUDGE NGCOBO But at that time the building of relations had

commenced there. At least the foundation had been carved.

DR KGAPHOLE Yes, definitely and we are looking forward.

JUDGE NGCOBO Now that hospital was eventually completed, is

that right?


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DR KGAPHOLE No, knowing these things but a totally new

application was looked at which happened to have used the same

site that was belonging to the previous groupings.

JUDGE NGCOBO Are you saying that the application for a licence

in respect of those premises, did it lapse?

DR KGAPHOLE Chairperson are you referring to the current

project?

JUDGE NGCOBO The proposed hospital that was going to be built

by this consortium of black doctors, keystone and Netcare, I think

it was.

DR KGAPHOLE Yes, Chairperson it unfortunately lapsed like I

have been saying they started actually disagreeing amongst

themselves.


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JUDGE NGCOBO So a new licence was issued in connection with

the same premises?

DR KGAPHOLE A new licence was issued and this licence used the

same site.

JUDGE NGCOBO To whom was this new licence issued?

DR KGAPHOLE Um, it is Paul Shaw and Netcare but both names

are there Chairperson.

JUDGE NGCOBO And Netcare was part of the group that was

supposed to build it the first hospital?

DR KGAPHOLE The first group, Netcare was part .

JUDGE NGCOBO Now, is there anything else that you would like to

draw to our attention. Something that you set out to come and talk


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to us about but which you have not had the opportunity to draw to

our attention?

DR KGAPHOLE Um, Chairperson I am sitting here with colleagues

and I have been engaged mostly with the rest of you and I would

humbly request them to say before I answer because I wo uld like

them to be afforded that opportunity through you allowing us to

request the colleagues if there is anything else really that they want

us to carry the message to the committee.

DR PINKOANE In terms of reaching out to the patients that

cannot afford the medical care, the province had embarked on

introducing a Telemed scheme that was set up in those areas that

are far out. Um, the last active size was 14 of which one of them

was a private size clinic sitting in Waterberg in an area where no -

one could reach easily in terms of consulting with specialists.

ADVOCATE RAMOTHPO About the review of resolutions on the

R158. Around the 7t h

or the 8t h

of April the South African Law


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Association met the Dilikwaan hospital where the Limpopo

Department of Health and the Mpumalanga Department of Health

made presentations and raised issues of the need for the review of

the revelations. So taking from what the commissioners indicated

to us. We will l iaise with the law commission and also contact the

other brother departments and in light them with the view of

looking at the regulations.

JUDGE NGCOBO And I think that you need to understand that the

real issue here is that, you know, the present regulation which is

R158 as you point out yourself, does not set ou t the criteria for the

establishment of a facility and the result is that people who have a

private licence will have no way of knowing what criteria you will

be applying and the result will be the granting of permits which end

up lapsing. So that is real ly where the concern is. Yes, thank you.

DR KGAPHOLE Um, from me Chairperson, um if there could be a

way of communicating with the big three, Lifecare, Netcare and

Mediclinic. Looking at such kinds of needs only not for I hate to


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say, not necessarily for profit. We know they would want to make

some money in the process but when are they going to start looking

out in the rural areas. Not only concentrate in the big towns and

cities where we know, obviously open today and quickly start

making some bit of cash. Then the province will start adding, you

know getting some value. The issue relating to the national health

insurance, you know, since this song has been sung, everyone is

thinking that they will be guaranteed some money of some sort, that

better I have a private hospital or clinic. I think if we could just

remove that part of notion and remember that we are partners in the

health care industry and we are not looking at private enti ties as

enemies, we are seeing them as a partner in making sure th at life

becomes better for all of us. Thank you.

JUDGE NGCOBO Yes, thank you gentleman for sharing with us the

problems that you are encountering in Limpopo. We wish you good

luck and we will take into consideration the issues that you have

raised with us and thank you so much for taking the time to come


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here and make your presentation and I think Dr Kgaphole you can

take a moment the minute you take your flight. Thank you.

[END OF SESSION TWO 02:10]


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SESSION 3: PRESENTATION BY THE NATIONAL PATHOLOGY GROUP.

JUDGE NGCOBO: Good afternoon, we are just one panel member who is on his

way and perhaps in the meantime we can just deal with the housekeeping matters.

Now perhaps the leader of the group will at some point you know just at the

beginning introduce the rest of the team and also indicate who is going to be leader of

the team.

DR. TJAART ERASMUS: Chair should I begin or should we wait for your final

panel member?

JUDGE NGCOBO: Whenever you see a red button up here switch off yours and

whenever I see a red button there I will switch off mine. Those are the rules of

engagement here. Very well, do you want to introduce the team members?

ADVOCATE GOTZ: Yes, good afternoon Chairperson and members of the panel.

Thank you very much for inviting the National Pathology Group to give their

presentation to the Health Market Inquiry. My name is Anthony Gotz. That is GOTZ,

I am an Advocate with the Johannesburg Bar. I will simply be introducing the


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participants from the NPG this afternoon and then making one small observation

which we believe is important. Our primary presenter this afternoon is Doctor Tjaart

Erasmus, during the course of our presentation we have asked three pathologists to

come and give a brief presentation in their areas of specialty. Those are Doctor Anil

Bramdev. That is spelt BRAMDEV. Doctor David Rambau, that is RAMBAU. And

Doctor Shameema Khan. Doctor David Rambau will also give a presentation on a

particular issue later on in the presentation and we will also here from Mr. Andrew

Good. We have a presentation which we have provided a hard copy to the Health

Market Inquiry this morning and it runs to approximately 120 pages. We anticipate

that it will take an hour and a half to run through the presentation.

JUDGE NGCOBO: You can assume that you know we are familiar; you have sent us

the documents. You do not have to read everything that is here. If you could just

summarize it for us so that you leave the balance of the time for questions. As I have

indicated it to you when we met we do not expect to go through the process of

somebody reading the entire document to us. I think the main thing is to give us a

sense of what the presentation is about, highlight the important issues in your case

because I mean if you are going to read the entire 119, we will be fast asleep by the

time we get to page 40. So I think the way we should manage it is this, I think you


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should highlight the key points of your presentation and then we will engage in the

discussion. Because as I understand, how many people are going to make a

presentation?

ADVOCATE GOTZ: Chairperson, it is 5 people in total but we will make a

concerted effort to limit the presentations of each of the people. I think they have

heard Chair what you have said and they will keep it as short as they can.

JUDGE NGCOBO: At the end of the process of engagement if people feel that there

is something that did not come out at the course of the engagement they should feel

free to add those and I will give you that opportunity. But I am just concerned that we

shouldn’t limit the amount of time for the engagement. There will be ample time to

read the document in the light of what you have given us. Which is fairly

comprehensive, okay. But with that said you must make sure you must tell us

everything that you have set out to tell us.

ADVOCATE GOTZ: Thank you Chair, before I hand over to Doctor Erasmus; I need

to highlight one point of importance and that is that the party that is presenting to you

today is the National Pathology Group which is made up of competitors of


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pathologists. Because they are competitors, it is a strict rule of the National Pathology

Group that matters relating to pricing and location in markets are not matters which

are discussed at the association level. For that reason, there may be questions, or

maybe issues which are appropriately addressed to the members themselves. So for

example how a particular member will negotiate with a medical scheme particular

issues relating to pricing. Those are issues which the National Pathology Group feels

quite strongly it is not an area which the group itself as an association of competitors

is comfortable or competent to address. But we are happy to take questions on those

issues and then direct those questions, such questions to the individual members for a

version to the Health Market Inquiry.

JUDGE NGCOBO: But do you, there are individual pathologists who will be

making presentation. Isn’t that right.

ADVOCATE GOTZ: Yes, indeed Chair. It may not be those individuals are able to

answer the particular questions that you may have. And so they may be a process

whereby with respect we say it can be...


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JUDGE NGCOBO: Answer them. I mean I can understand the group not being able

to tell us what the kind of, what negotiations go on between you know the individual

members and you know the medical schemes, or whoever they contract with. That I

understand. But to the extent that there are individuals who you have brought to us to

talk to u. I mean are we not entitled to ask those individual members how they

negotiate those tariffs or are you claiming confidentiality. Because if you are

claiming confidentiality I am prepared to sit here and just listen to your argument in

that issue.

ADVOCATE GOTZ: Chair it is not a question of confidentiality. It is a question of

what we understood was the reason for the National Pathology Group being called in

the engagements with the Commission personnel. We understood that this

Commission was interested in particular on the role of pathologists its various

interactions with various stakeholders at the level of principle. But the details in

relation in relation to how a particular laboratory for example Lancet may engage

with a medical scheme is not something that we believe or understood will be an

issue for this session to be answered by the present panelists. So we haven’t prepared

and we believe quite strongly Chair we have made this point in correspondence in

advance of the hearing to the personnel of the Health Market Inquiry that we


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understood the remit of this panel to be informative as to the role of pathologists in

the Health Market system. Not to go into the precise details relating to the way in

which a particular group may negotiate with a particular medical scheme for

example. It is not that we do not deal with issues which as a matter of principle...

JUDGE NGCOBO: You see you are here to make a presentation to tell us how you

interact with other stakeholders. That interaction includes how you interact with

medical schemes. If you are able to answer the question you will answer the question.

Do you understand that? Yah, I understand.

ADVOCATE GOTZ: I hand over to Doctor Tjaart Erasmus.

DR. TJAART ERASMUS: Chair, thank you very much Chair and your panel

members for the opportunity for us to speak here. I will as you have been presented

with the full slide package as well as our previous written document. I will touch on

aspects that I believe are important. The National Pathology Group is the official sub-

group of the South Africa Medical Association for pathology. It is affiliated with

SELMA. We have 295 members and it is essential or it is a prerequisite that our

members; that members of our group are registered pathologists. The prime purpose


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of our group is to promote specific standards in pathology with the objective of

improving the quality of patient care. We will touch on the role of Pathologists.

There is a quote here by Sir. William Aslow, who said as with your pathology as with

your medicine. That quote is nearly 100 years old. And as much as it was true then it

is true now. Pathology is the critical to on which at least 70% of medical diagnosis is

based. 20% of medical care subsequent to the diagnosis is based on pathology. Not

only for the establishment of the diagnosis but also in the process of caring of the

patient in terms of its efficacy. We have a slide here which I believe unfortunately

you do not have sound which is part of a humorous clip but I do apologize if you find

this incorrect. But we will move to the next slide.

You will see the slide unfortunately you will not hear the sound. It is very short about

30-40 seconds, thank you. The pathologist or the lady is now being examined by this

person who says let’s see what month it is. It is that money and he says well it is easy

we will just run a couple of tests. He shakes his hands and there is sound going and

he asks her to hold the egg. She is obviously rather doubtful about the process and he

rings the symbols and he essentially say oh he knows exactly what the problem is

then, He looks at her and she is obviously incredulous about the process and he says

well he surely knows exactly where to go. And he says well we will attend to your


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diagnosis soon. He turns around obviously and the result is clear. And the message is

clear that if the pathologist did not exist, where would the answers come from.

And in essence that is the fundamental aspect of our presentation. And in terms of

were the pathologist is placed in terms of the bridge between the laboratory and the

clinician. You need to remember that pathologists are trained medical practitioners.

The have spent pregraduate time at University, who have subsequently done an

internship and subsequently two years’ community service. Only then can a

pathologist specialize for four or five years in a specific discipline and possibly

subsequently in a sub-discipline. This may take up to 15 years for a pathologist to

qualify.

There are a Number of pathologists sub-disciplines. The primary and we have in our

presentation and we will have three pathologists who will be dealing and their focus

is primarily to give an amplification of these sub-disciplines in pathology. The

categories of pathologists which exist, are registerial specialties within at the Health

Provisions Council. An anatomical pathology, chemical pathology as well as medical

microbiology and virology. In addition to that there is also the branch to forensic

pathology. Largely not really with the presence in private pathology laboratories

although there are certainly laboratories in South Africa who have forensic


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pathologists within their grouping. As a focus of those mostly in medical legal

aspects. Then of course we go on to super specialists in fields of pathology being

neurologist-pathology which speaks for itself and then a field which becoming

increasingly important; molecular diagnosis or molecular pathology and genetics.

This field is developing rapidly and the reason for its rapid development is obviously

increasing pace of technological development and the scope with which this

development offers us. The advantage of extremely rapid diagnosis, extremely

accurate diagnosis and also what one could even call the business of prediction in a

very long term because one is looking at the genetic profile of an individual which

will give you an indication of the pre-election of a disease. And more and more this

will become part of the services which pathologists offers. Using an example there of

the BRCA gene which is indicative of the potential development of the ... and that

has now changed the whole outlook for women in terms of the selection of how to

care for themselves. It is just a note that the area of molecular biology resorts within

the biology practice environment that is largely the degree of skill required is that

largely of medical scientists.

Now going on to the role of the pathologists. What is important, we believe to make,

the important point to make is that pathology is a referral specialty. Many specialists


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see patients off the street. They see patients, gynecologists do, pediatricians do; many

other disciplines see patients without referral from a general practitioner. A

pathologist is, does not; it’s in the rarest circumstances that patients present

individual at the pathology laboratory, I will touch on that a little bit later. Very

shortly.

The primary role of the pathologist is to oversee a professional pathology laboratory

and to take responsibility for the diagnostic laboratory. The technical aspects of a full

laboratory functioning lie within the control and the expertise of the pathologist. As I

have indicated to you before pathologists are trained clinicians and then they become

trained laboratory specialists. They are therefore placed in this unique position of

being able to extend a hand to the clinician on one hand and on the other hand to the

laboratory and understand the value of a specific diagnosis. How much attention

should be attached to that and also what the problems and complexities are around

that.

In addition to that there are also in the South African health care environment, there

are also medical laboratory technologists, technicians and medical scientists. And this

skill is an essential skill in the totality functioning of the laboratory service. There are


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a number of sub-disciplines in pathology as I have indicated before and one of the

advantages of this sub-disciplines is the skill to look at a specific perspective or

component but then to communicate with one another to act as a diagnostic team.

Which would not be possible if these pathologists were in separate compartments.

And one of the beauties of private pathologists fortunately is this level of interaction

within practices between the disciplines.

We will now go on to an example and we will ask Doctor Anil Bramdev who is a

histopathologist to give you a short overview, to be followed by Doctor Rambau and

after that by Doctor Khan. So over now to Doctor Anil Bramdev, thank you so much

sir.

DR BRAMDEV: Chair, ladies and gentlemen. My name is Anil Bramdev. I am a

histopathologist by profession having qualified from the University of Natal in 1987.

For the last 27 years I have been practicing as a private histopathologist. My task

today is to in a nutshell explain to you the responsibilities of a histopathologist and

where he fits in, in the health care delivery system. Essentially a histopathologist also

referred to as an anatomical pathologist has the responsibility of making a diagnosis

of disease by analyzing tissue samples. Now the kind of disease diagnosed includes a


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variety of conditions but the most important one being cancer. And usually the

biopsy specimen would be a... biopsy or an excision of a lump but in addition the

pathologist also looks at other samples for example smears like pap smears as well as

analyses bodily fluids like urine, CSF and sputum. Now the diagnosis on histology

involves a close interaction with the entire health care team. And this will include

consultation with the referring Doctors, looking at other lab tests, looking at x-rays

and once a diagnosis is made the clinician looking after the patient then can decide on

the level of medical care which can be medical or surgical and that will then

determine the prognosis.

By the way of example, I would like to take you through an actual case to show you

what happens in histopathology lab. The case I want to talk to you about is a 45-year-

old African female who presented to a Doctor with a lump in the breast, The Doctor

decided to remove the lump, send it to the laboratory to make sure if it is cancer or

not. And as you will see in the slides ahead we have a mass which is 3cm in diameter

and pathologists’ 1st task is to analyze this mass including slicing the mass to look at

its proper characteristics. And these slides show the actual lesion being cut and

analyzed and described in detail. The next step after the microscopic examination is

the processing of the tissue. Now this is a complex procedure and it involves a


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processor which runs over 6 to 8 hours and the tissue is subjected to a whole lot of

chemical steps before a slide can be made. The next slide will show you the tissue

being sliced into tiny sections; 3-5 microns in diameter and a micron being 1000 of a

millimeter. The tissue is then placed on a glass slide and eventually stained and cover

slipped. And thereafter it come to the pathologist to analyze the tissue under the

microscope. At this point I just want to make the point that a pathologist needs to

know what is normal for each organ of the body from head to toe. And he needs to

know what kind of abnormalities are visible under the microscope. When it comes to

cancer there are many types of cancer which involves every single organ and the

pathologist when he is training, when he is experience as well as constant updating of

information will be able to work out what the pathology is.

In our index patient, the following is a slide of the breast cancer and the background

pic is a normal breast trauma and you can see the cancer cells present as the blue

straining glandular structures invading the tissue. So in this patient we have come to

the diagnosis of a breast cancer. And in addition to make the diagnosis, the important

role of the pathologist is to grade the tumor. We need to decide is it low grade, is it

high grade. This is crucial for planning of management. High grade tumor being very


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aggressive. In addition, the pathologist has to comment on the excision margins

because if the tumor is incompletely excised you need to go back and excise wider.

In addition to this cancer the buzz term today is target treatment for cancer. And it is

the pathologist’s role to look at each cancer and determine what special molecular

and genetic features are available. This is called profiling of the tumor and this is

absolutely crucial for management purposes. And in our patient the next slide will

show we subjected the breast tumor to a whole lot of special strains. The 1st one is

estrogen receptor which is a molecular protein and the brown staining there indicates

positivity. So this tumor is estrogen receptor positive.

The next strain that we do on breast cancer routine is her two gene stains. And on the

right hand slide you see the bright red staining that indicates positive signal for her

two gene. Now this is crucial for breast cancer because identifying her two gene

means an oncologist will use specific targeted drugs to stop the tumor growing. Now

the drug Herceptin is now regarded as the magic drug in breast cancer. It has

dramatically improved outcomes and lives of patients with breast cancer and the only

way to identify which patients are suitable for this drug is for the pathologist to look

for this gene and molecular expressions.


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So coming back to our patient the final report will read as such. The patient has a

breast duct adenocarcinoma that is actually a type of cancer, its 3cm in diameter, it is

low grade, the excision is complete and it expresses ER estrogen receptor,

progesterone receptor and ...2. With this information the oncologist is now armed and

will know exactly how to treat this patient. In summary this slide demonstrates the

flow where the specimen is examined with the naked eye under the microscope.

Special procedure is done before the final report is released.

This principle applies to all cancers and not just breast cancer. And targeted therapy

for cancer is the new way of treating cancer today. Just as an example if you look at

brain cancers, 5 years ago patients with malignant brain cancers there was nothing

understands could do for them. They had a few months to live and that was about it.

But today after we understand the biology and morphology of these tumors we can

identify certain tumors which express certain receptors or certain genes and new

specific drugs to control that and that has really improved the survival rates in

patients who were previously regarded as terminal. Just a quick note the other job of

a histopathologist is to analyze smears. The pap smear being the classic smear that

we analyze. I am sure the panel is aware cancer of the cervix is the commonest

malignancy in South Africa. In fact, it is rampant and it is estimated that one in nine


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women in South Africa will get cancer of the cervix in a lifetime. The pap smear is

crucial to screen for this before the lesion becomes apparent and that is the job that

the histopathologist has on his hands. An example of a normal pap smear on the left

hand side compared to an abnormal smear on the right hand side. You can see the

blue dots represent the nuclei show great variation. And in this way the Doctor knows

that this is an abnormal pap smear. He can act on this before the cancer develops. So

screening is a crucial place to prevent cancer.

And lastly I just want to touch on the value of frozen sections. This is another

technique that the histopathologist performs in theatre while the patient is under

anesthetic. So a sample of the tumor is given to the pathologist who analyzes it in

theatre and gives the surgeon an immediate answer. This then empowers the surgeon

with the full knowledge knowing exactly what he is dealing with. How intense to

take the surgery for example. It also has the distinct advantage of having one

procedure done as opposed to calling the patient back to have a repeat anesthetic.

And the next slide shows a cristek which is an instrument placed in most theatres

were the pathologist performs a frozen section. With that I thank you.


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ADVANCE GOTZ: Chair, thank you. Doctor Rambau will now continue. He is a

chemical pathologist. We ask him to continue, thank you.

DR. RAMBAU: Thank you Chairperson and the panel for the opportunity. My name

is David Rambau and I am a chemical pathologist. I have got a but 20 years’

experience in private practice. I am going to outline my talk by way of examples and

try to stay out of the technical jargon. My objective is to try and get the panel to

understand what we actually do in the laboratory.

The 1st example I have got, it’s a case of a patient who came to South Africa. Who

for many years was being treated for having removed the thyroid. This patient had

cancer and the thyroid was resected, removed it and had to replace the hormones

which the thyroid gland normally provides in the body. And this patient was put on

eltroxin that is thyroid hormone replacement therapy. So when this patient came to

South Africa they did the normal thyroid function test. When the Doctor received the

results the Doctor was very unhappy because it appeared as if the patient was being

over treated. The results show that the TSH was suppressed, the ... was elevated and

that is a sign of over treatment. Now on discussion with the Doctor, I specifically

asked the Doctor why is this patient getting the treatment? That is when the story of


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the cancer came in. Now although this results indicates over treatment, ordinarily any

other patient who has had the thyroid removed; in this specific patient this treatment

was proper because you have to suppress; you must give suppressive therapy to

suppress the TSH. Because the TSH is a stimulant for cancer cells. If this Doctor

didn’t contact the laboratory and went ahead to alter the therapy, to normalize the

TSH, this could have put the patient at risk. Because whatever cancer cells are

lingering in the body will be stimulated by TSH and start growing. Now after that

advice, telling the Doctor that this was suitable an additional test was recommended.

We suggested that this patient needs a thyroglobulin which is also a cancer marker.

This will tell us if this patient has got less cancer cells because if there is increased

burden of cancer cells you will have a more thyroglobulin circulating in the body.

The other responsibility of the chemical pathologist is in reviewing results. So we

have got an information laboratory system which we use; which we program so that

the majority of results which are produced by these automated systems can be

checked against the rules set by the pathologist and released. Those with failed the

rules will be returned for the pathologist to look to view them physically to decide on

whether additional information is necessary from the Doctor or to compare with the

previously results or to interpret with other results which are produced on the same


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request. And this helps the Doctor interpret correctly what the most likely diagnosis

and what is most likely results are for that particular patient.

Now I have put the next slide on interpretation of test results using cholesterol as an

example because cholesterol is a very common test which is requested on early basis.

This is a patient who had very high cholesterol level of 6ml per liter. The Doctor

decided to put this patient on anti-cholesterol therapy which is... And four weeks later

the Doctor wanted to know how effective the treatment was and the cholesterol

results was 7.1ml per liter. The question is the patient is on treatment, why does it

appear as if the cholesterol is increasing. So the Doctor contacted the laboratory to try

and understand what the issue is here. Now in the interpretation especially in

monitoring of results specifically cholesterol, one needs to understand the variability

that occurs with the analysis and also the variability that occurs within an individual

biologically. Cholesterol tends to be that good example of ... which are naturally

found in the body which have that biological variation. Now cholesterol has got that

biological variation of about 6.1% and analytically it is recommended that the

variation when you analyze it should not exceed 3%. It is 3% and less. So the

majority of laboratories aim at 3%. Now when you look at variability of cholesterol

within the body and the variability analytically. It will give you a combined expected


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significant change of 21%. So in other words any variation of a cholesterol measured

repeatedly in an individual at different times you will get numerically different

results. If they do not exceed 21% it means, there is no change. Now in this particular

patient cholesterol which appears to have moved from 6 to 7.1ml per liter is actually

no change. What it means is the Doctor requested the monitoring too early. The

Doctor should have waited at least two to three months before the test is repeated.

Now the other problem related to that is that repeat because the Doctor doesn’t

believe the results repeated testing tends to happen unnecessarily and that

unfortunately the patient has got to pay for. So the interaction with the pathologist

does cut some of those costs. Because in this no further testing was necessary but just

an explanation why the two results are numerically different but actually the same.

The last part I am going to talk about briefly is dynamic functioning testing. In other

words, we do not only technically look at what has been measured using instruments.

We do interact with patients. There are certain investigations which require the

pathologist to interact directly with the patient through consultation by a specialist.

Now this is one case where a patient who has been taking a tablet which was

unidentified for a skin condition happened to have undetected levels of cortisol and

undetectable levels of STH which is a pituitary hormone; a hormone from the brain.

Now the Doctor was wondering if this patient has got some organic disease which is


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causing this suppression. So what was necessary was for the laboratory, the

pathologist to test the function of the adrenal gland and the function of the pituitary.

So we started with a short sinaxtihin, in other words testing the adrenal glands. We

stimulated that and there was no response. So we needed on a longer because it

depends on the patient will respond on a shorter or longer one. You can’t make

conclusions based on the short one if there is no response. So we had to do a long

STH stimulation and there was a phenomenal response. Which meant the organ was

intact, it was responding. Now we were left with the pituitary functioning. We had to

do an insulin stimulation test which showed a phenomenal response as well. So

which means the two systems were intact. Now from this one can deduce one small

tablet the patient has been taking for a long time for this skin condition was actually a

steroid which suppressed the two systems. With that I thank you.

ADVOCATE GOTZ: Chair we will now continue with Doctor Shameema Khan the

microbiologist. Thank you.

DR KHAN: Good afternoon Chair, ladies and gentlemen. I am a medical

microbiologist with about 20 years in medical microbiology. So just to introduce

what is medical microbiology. It is that branch of pathology concerned with the


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diagnosis, treatment and prevention of infectious diseases. This specialty involves

four types of organisms which cause infections and that is bacteria which is referred

to as bacteriology, viruses referred to as virology, parasites referred to as parasitology

and fungi referred to as mycology.

The study of these infections staining and cultures of samples to assess whether

infection is present or not. And if a bacterium is present then we identify this in a

laboratory and we perform further tests whether they are susceptible to antibiotics or

not. Secondly infections can also be diagnosed using molecular methods. These

molecular methods are generally rapid, more accurate methods used specifically to

diagnose certain infections such as viruses, micro bacterium, tuberculosis and these

bacteria may take weeks to grow on cultures. Molecular methods are also used to

monitor certain infections. For example, we perform viral loads such as in HIV to

assess whether the anti-retroviral in HIV positive patient is working or not.

The third method used to diagnose infection is detecting antibodies. And this falls in

the subsection of serology which detects antibodies not only two infective organisms

but also to diagnose non-infective conditions. The infective conditions for example

that serology will use is HIV, hepatitis B and the non-infective viruses such as lupus.

So in addition to infections microbiologists are also involved in the field of allergy


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and immune deficiency conditions. So what do we do? In the laboratory qualified

technologists analyze patient samples on a 24/7 basis and the medical microbiologist

gets involved once the results are available for clinical action. And these results may

either be preliminary results or final results. And all results are verified by a medical

microbiologist. This ensures that the results are correct and allows the medical

microbiologist to interpret the findings and we add interpretive comments and

therapeutic advice on the reports.

These comments may include for example we suggest the antibiotic with the correct

dose with the correct duration that antibiotic should be given for. It is vitally

important that the report for the various health care providers caring for patients are

presented in a clear, concise and clinically relevant manner. This verification process

of laboratory results in general takes up about 50% time of medical microbiologists.

Clinicians phone for consultations with the microbiologist on a wide range of issue.

So the other 50% of our time is to serve as consultants for health care providers. For

example, how to diagnose and the treatment of infective anti... which antibiotics to

use as therapy for certain infections, which antibiotics to use before the laboratory

results are available, what dose to use and which drugs to use for example in anti-

retroviral regiments.


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The clinicians also phone to discuss which tests to perform to confirm their suspected

clinical diagnosis. In some situations, these clinical consultations may involve ward

runs with the clinical team responsible for the patient. So these telephonic

consultations may account for about 20% of our time.

About 20% of our working day is to phone out life threatening results to the clinician.

And this we phone out all cases of meningitis, we phone out all cases of positive

blood cultures better known as septicemia, if there is an Ebola infection in pregnancy,

if a patient has a recent hepatitis virus infection and infections caused by resistant

bacteria which may not respond to the normally used antibiotics. Thus the

clinicalizing of the medical microbiologist with the clinician is done anytime during

the day either proactively or at the clinician’s request. And at each clinical interfacing

opportunity focus is placed on the entire clinical context and not necessarily just the

microbiology and viral result of the patient.

As an example there was an Ebola scare in Durban and one had to take into

consideration the travel history, the signs and symptom of the patient before testing

for the Ebola virus. We had a number of phone calls from various clinicians and we


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had to actually go through the history and the signs and symptoms and actually refuse

testing for Ebola during this time.

And another example I would like to use of our clinical interaction with a clinician on

one of the Mondays a pediatrician called me. And he had an 8-year-old child that had

nausea, vomiting, diarrhea and he had severe abdominal cramps. And when he called

me he told me he had done investigations for example a CT scan, he had done an

ultrasound and he had sent to the laboratory a full blood count and a stool

examination. And he thought that this child had an appendicitis, at the time that he

called I looked at the computer the results of the full blood count and I saw that the

lymphocyte count was low. So the patient had lymphopenia. And I told him that this

is unlikely to be an appendicitis because there was no... I then told and he also told

me he had referred this patient to the surgeon. And then I told him I would look at the

culture results of the stool and phone him back. I had a look at the culture results of

the stool and we have a preliminary result that this bacterium was a salmonella and I

was happy that we had the diagnosis and I phoned the clinician and told him we have

got the diagnosis and it is definitely not appendicitis but the salmonella infection

which gives you this picture. Then we started on a broader spectrum of antibiotics

and the following day I told him based on the susceptibility of the results to start the


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patient on a narrow spectrum of the antibiotics and the patient could be started on IV

antibiotics and went on to oral and was discharged home a day later.

So about 5-10% of our time is involved in management issue which includes Human

Resources, IT, instrument placement, region changes, implementation of new tests

and deleting obsolete tests. Medical microbiologists also offer a consultative focus on

hospital prevention and control. This entails various meetings with the different

infection control personnel of the multiple private hospitals. These meetings occur at

the premises of these various private hospitals.

And most hospitals have antibiotics stewardship meetings which we also actively

involved in. So apart from consulting we give various talks on appropriate

management to Doctors. We train nurses, we train pharmacists on antibiotic

management to work in a multi-disciplinary team, to manage infections in a patient.

As an example in one of the hospitals we attended an infection control and antibiotic

stewardship combined meeting. In this meeting there is generally there is a

pharmacist, there is an infection control nurse, the medical microbiologist as well as

other clinicians. The pharmacists had presented their utilization of their antibiotics in

that particular hospital and I noted there was a very toxic drug that was used which


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was taken off the market and the drug is called colistin and it is not, we need special

permission from the medical control council to use on patients. And the pharmacy

had about 5 patients who were on this drug. I later presented the microbiology of the

institution and noted that there were a lot of bacteria called pseudomonas which was

multi-drug resistant and only susceptible to this drug. The infection control nurse

then told us that in the ICU there were 5 patients with these multi-drug resistant

organisms which constituted an outbreak. So with the multi-disciplinary team we

went into the ICU and with observations, testing and a lot of collaboration we

discovered that the pseudomonas that was spreading to all the patients found in the

drain pipe of a few sinks in the ICU. The maintenance had changed those drains and

subsequently strict infection control and antibiotic stewardship antibiotics we had

eradicated the pseudomonas in that particular hospital.

In conclusion medical microbiology is about managing patients’ infection related

diagnostic, therapeutic and infection control needs. A result is only meaningful based

on the therapeutic interpretation by a medical microbiologist. Thank you.

DR TJAART ERASMUS: Chair, thank you very much. Just that it has broadened the

perspective from one being a pathologist which is a laboratory with a piece of paper


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with numbers on it as opposed to giving some indication of the range of pathologist

services. But pathology laboratories would be nothing without the persons who work

in the laboratories. And I am not referring to the pathologists now but to the other

personnel who are there. These groups are mostly registered with the Health

Professions Council Board of Medical Technology and the they are medical

laboratory scientists, medical technologists, medical technicians, lobotomy

technicians and laboratory assistants. In addition to that the category of nurses and

nurse sisters are enrolled are enrolled with the South African National Council also

forms a significant group of persons employed in the laboratory.

In our next slide, you will see a summary, maybe this is a bit slow. In our next slide

you will see a summary of the groups of persons employed in the laboratory. And

this, the data reflected here is from the National Pathology Group membership

laboratories.

JUDGE NGCOBO: That is in hospitals, the individuals who have testified; where do

they work from? Do they work from home, do the work from hospitals, where do

they work from?


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DR TJAART ERASMUS: Chair, they work from laboratories

JUDGE NGCOBO: Which laboratories?

DR. TJAART ERASMUS: The laboratories are placed in different parts of the

country. We could ask them which laboratories they work in but maybe if I could just

note that we requested the presence of these pathologists based on their fields of

technical skill in their fields of discipline as opposed to their involvement in the

management of the laboratory services. So they, maybe just as a background please

question me if you like. Must I continue, I beg your pardon.

JUDGE NGCOBO: Yes.

DR. TJAART ERASMUS: Chair, I am a bit confused. Should I continue? Thank

you, I am getting confused with the buttons I am so sorry. What we are trying to

present here is the employment statistics of the members of our group. You will note

there that there are 10 000 employees who are employed by these laboratories and

that we have; sorry there are 295 pathologists, 3 000 laboratory technologists, 1 000

technicians and 200 lobotomy technicians. That is a skill which was developed within


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the private pathology laboratory environment and trained, about 50 medical scientists

and approximately 3 000 nursing sisters. So it is a fairly significant group of persons

who are involved in the laboratory services.

Now I would like to touch on what happens in practice in the laboratory. And the

perspective I have tried to give is the perspective of the patients, the clinician who is

not directly associated with the laboratory and the next group of patients who are I

some way referred to the laboratory or the tests were requested for the laboratory to

be done on specific patients.

The Doctors in clinical environment refer the patients’ specimens and these are the

Doctors who are distant from the laboratories and will perform specimen collection

themselves. Are distant from the laboratory and they make a selection of tests based

on their clinical diagnosis and what they believe is the specific field of expertise

which the laboratory office which they wish to refer the test to and in addition

obviously the skills that are involved as well the turnaround times and quality of that

laboratory.


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The clinician indicates how urgently this specimen must be analyzed and that is

indicated on the form. And an important point we wish to make is that no practitioner

may receive any financial gain for referring any patient to a laboratory. The

specimens, the referring Doctor selects tests based on the provisional diagnosis. What

he or she does is that they use a laboratory sheet which contains tick boxes. He ticks

or he or she ticks in the tick boxes and decides which tests are to be done.

Why do we have tick boxes? The tick boxes reduce the error rate on the clinician and

on the other side of the pathology laboratory knowing exactly what is being requested

and what should be done.

JUDGE NGCOBO: How do Doctors decide to which pathologists a patient will be

referred to?

DR. TJAART ERASMUS: I noted a short while back that my understanding is that

the referral laboratory will be based on physical proximity. The laboratory which is

in the area, the laboratory which has the skilled expertise to do the analysis, the

laboratory which has to do with the quality and is accredited with that quality. I

would say those are the most important aspects why a specific laboratory will be

used. And turnaround time.


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JUDGE NGCOBO: Patient consulted in the process? Given options?

DR. TJAART ERASMUS: Chair, now I am obviously speaking on behalf of the

clinician and that is not my role. But we absolutely would insist that there is a

preference that the patient be given a preference. That patient may not always be

made aware and I am not sure whether each clinician informs the patient of the

choice and in certain areas there are competing laboratories in the same geographical

areas.

JUDGE NGCOBO: When a patient goes to a pathologist or to these laboratories,

does anyone there explain to the patient why he or she is there and what is going to

happen in the entire process, how much blood is going to be taken from him or her

and what is going to happen to the blood, how long he may have to wait for the

results?

DR. TJAART ERASMUS: Chair, the section I am referring to now is the section

where the specimens are collected by the Doctor. What you are referring to now is

when the patient arrives at the laboratory? Would you like me to comment about

that? Chair, I am unable to answer that question fully. I do know the laboratories

request, having been a patient at the laboratory myself and I am currently not


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practicing and having been a patient myself, arriving at the laboratory requested to

sign an informed consent. The other aspect probably or not dealt with in terms of

how long it would take unless the patient asks as a routine; there are many pamphlets

in the laboratory environment. I think frequently patients will ask as a; because if

there are a number of tubes, why are there so many tubes. The answer may be simple.

Because different tubes are required for different analytical processes and that

improves the quality and simplifies the whole analytical flow within the laboratory.

JUDGE NGCOBO: A patient will be concerned about how the specimen would be

handled so as to avoid a situation where you know a wrong label is put to a wrong

specimen with different results. So those are the kind of questions I am trying to

understand whether those processes are explained to the patient.

DR. TJAART ERASMUS: Chair, I am not sure they are specifics explained to every

patient. But the general process is that as I indicated earlier what I was busy telling

you was the specimens collected by the Doctors outside who are not associated with

the laboratory. So now let us move on to and I want to make sure that I do not; do

you mind if I come to your question in 15 seconds, finish this section on specimens

that are collected by the Doctors in the periphery?


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JUDGE NGCOBO: No, you can deal with the question at some point whenever it is

convenient to you.

DR. TJAART ERASMUS: Thank you very much Chair, I will do so. Again returning

to when the Doctor collects the specimen and I mention now about tick boxes

because it is important to understand because the accusations made against

laboratories is that all they want is a form with as many tick boxes as possible so the

as many tests ca be requested as possible. I will attend to the request forms again a bit

later. But also to note that tests can be requested in groups. In other words, there

would be something and I am using this by way of example. There could be a liver

function test which can take 6 or 8 different tests or there could be a tests for excuse

me, blood lipids, blood fats which contains 4 or 5 different tests within that. But

those tests can be requested individually should the Doctor prefer to do so. The

Doctor always has a choice of what is to be done. And we will touch on the request

forms a bit later.

But I would like to just comment on something that is specific as well that is also

often suggested, why do laboratories not use blank request forms? Why do they not

just have a form with the patient’s name on top the laboratory and let the Doctor


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write out the tests requested? In fact, experience; firstly, the error rate is significant.

Point number 1. The irony is experience shows that blank request form generates

more tests than tick box request forms do. And this is not only in South Africa, this is

worldwide. So the tick box gives a level of certainty and clarity for all parties

involved.

Now I would now move to the area where specimens are collected from by the

laboratory personnel with a laboratory request form having been sent, given to a

patient to go to a specific laboratory. The patient would arrive at the laboratory, the

demographic data will be collected and the tests completed on the form and the

patient will see a nursing sister or the lobotomist who collects the blood. And at that

point and now I will get to the point where you were referring to the concern about

specimen tubes mixed up. and that is really understandable and that is obviously of a

great concern.

You may have noticed if you have been to a laboratory yourself which I am sure you

have that when you enter the area where the blood is collected; on the request form

there is a collection of barcodes to be attached. That barcode is split between the

same barcode on the form is attached to a different tube. And after that in essence it


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really doesn’t matter how those tubes go away from one another because that unique

identification remains linking that request form with that tube and that patient result.

The great Number of tubes collected are largely a reflection of achieving efficacies

within the laboratory, different tests require different specimen collection protocols.

In some the patient may have a ... on their arms for the test to be collected; in others

there must be a free flow of the blood. There are a number of test requirements and

that influences the test tube aspect which sometimes looks overwhelming. The

Doctor will at that time indicate whether they wish to have the test done urgently or

on a routine basis and an additional note that absolutely makes no difference in terms

of the price that is eventually paid by the patient. Or whether the test is done within

hours or out of hours. All results, all testing is done at the same rate.

I have mentioned the signed consent; I do not have to touch on that again. Eventually

the focus is to get the report back from the clinician which has referred the test. When

the specimen arrives from the laboratory, the specimen needs to be processed. The 1st

aspect is the data capture of the patient demographics and the tests which have been

ordered. If there are ICD10 codes which have been included by the referring

clinician, these are captured. I will touch on that later.


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The request forms are scanned to have a copy of the tests requested by the Doctor so

that there is a, should there be a query or an enquiry by the medical schemes or the

patient. And then subsequently the specimens are transported to theatre main

laboratory. Now where does the analysis occur? The analysis on fact happens in most

large laboratories have central core processing facilities and a Number of smaller

processing facilities which are geographically distant from that. And in between or

mixed this would be emergency laboratory that are also part of the overall process.

The focus of the emergency laboratories obviously is testing for immediate results

and immediate availability when there is a critical clinical need. As the specimen

moves up the laboratory chain from the smaller to the larger laboratory; the degree of

automation of the laboratory process increases and obviously this improves the

efficacy of the instruments in terms of the volumes that are required for the analysis

and also improves the quality of the outcome of the result.

Some tests however; are manual. They need always to be done individually and they

always require a one to one relationship between the person doing the test and also

the test being done. So instrumentation varies from high throughput automated

instruments which are interfaced with the laboratory computer systems to thee

manual testing methodologies. The different types of tests which are, I do believe we


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do not the waste time to touch on. These analytical machines are produced by

instrument manufacturers of International stature, the quality is excellent and the

results produced are absolutely excellent.

It is more cost effective for a laboratory to centralize analysis on specimens that are

not urgent. So the focus will be in general terms to move the laboratories to the, to

move the specimens to a central processing facility. But that is, I would say that rule

that comment is flexible and that is always dealt with in terms of the individual

requirements.

Laboratories are extremely dependent on information technology systems. Without

the integration of an information technology system which can pull all of this

together from the point of the barcoding of the patient, the requesting of the test, the

doing of the test to the ultimate point of the test resulted as we have the mention from

the colleagues how these results are viewed and verified by the pathologists up to the

point now this is available as a totality and which may be which will be made

available to the clinician.


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So the critical role, the role of the pathologist is the integration of all aspects of

laboratory service, analysis and diagnosis. What is also, yes, it was touched on the

issue of normality I am not going to deal with it here. I do not want to duplicate and

waste time.

A key component of the pathologist’s work is to communicate with the clinicians

even in terms of an individual result which has become available or in terms of

consulting to a clinician when there is an enquiry or in instances when an unexpected

combination of tests are pointing to a specific diagnosis which the clinician may not

be aware to or sensitive to. Some of the instruments of pathology like the

histopathologist we have heard interact with each specimen on a single one to one

basis. The advantage of multi-disciplinary practices is the fact that there are

pathologists in the disciplines who are in the same practice who can interact with one

another in terms of discussing patient diagnosis and diagnostic needs of the clinician.

I want to touch on some statistics again, I have referred to those slightly earlier but

here specifically analytical aspects. Approximately 90% of all pathology laboratories

within our group are accredited. Doctor Rambau will speak about that just now and

this is an aspect that we are very proud of which is critical for quality patient care.

We travel about three and a half million kilometers a month collecting specimens.


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We do 300 000 tests a day on 60 000 patients of these about 20% are collected from

the rural areas and 48% of the tests are done in the hospital. 44% my apologies.

I will now touch on aspects pertaining to consolidation because we believe this has

been a concern that has been raised. Most pathologist laboratories started 90-100

years ago. Started with one or two-person practice. Over time these laboratories were

consolidated, amalgamated with one another. The amalgamated groups amalgamated

with other groups. What was the purpose? The purpose was to improve the quality, to

improve the quality of the diagnosis and to improve the cost efficacy of patient care.

The centralization of laboratory services is a logical response to the health care

requirement in South Africa and the disease patterns in South Africa. Only through

this human resources, skilled human resources be effectively utilized. You need to

note that this consolidation of laboratory services is not an only within the private

laboratory arena but also has happened at the same level of the national health

laboratory services and it is also indeed a reflection of what happens worldwide.

In addition to these larger, these increased amounts have led to the development of

laboratories sub-specialists as I have referred to earlier on. And only in a large

practice can you have the luxury in inverted commas of having sub-specialists. If are

a one or two man practice it is impossible to cover the range of services and have the


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depth of knowledge that is available within these specialist groups. The staff are

highly trained and salaries are commensurate. And I am not referring to the

pathologist Doctor but the other staff or highly trained persons and the salaries are

commensurate with these skills.

The medical ideology has increased dramatically over the last century. Diagnostic

needs have grown and there is an increased requirement on professionals and it is

critical that the sub-specialties have developed to be able to deal with these needs.

Pathology tests range from a simple to a highly sophisticated and the only way

pathologists to deal with this whole range is to amalgamate and to form larger

practices. What is being the benefit? The patients are benefitting significantly from

this. Tests have become more rapidly available, more widely available, more cheaply

available and with a greater need for immediacy and a range of tests have increased

significantly. Inevitably we work with all our equipment are imported, ... are

imported, so we are exposed in terms of the cost structure to the ever depreciating

value of the South African currency.

I have noted before that laboratory runs have to be consolidated in order to save costs

and also touched on the question of the infrastructure required to transport these


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laboratory specimens from the ...areas to the central laboratories both by roads and

flights. But the wonderful thing for us has been the development of information

technology because the is the backbone of which the technology practices exists and

functions. Without that it would not be possible to have this level of result

availability in terms of its immediacy and in terms on how widespread it is available

for the clinician. It would have been impossible to manage otherwise.

We are now going to touch on accreditation and I will ask Doctor David Rambau

who presented before to do the section of laboratory accreditation which is extremely

important for us.

DR RAMBAU: Thank you once more Mr. Chairperson and panel. I am going to talk

about laboratory accreditation. This is the cornerstone for the quality of services

rendered by the medical laboratories. What is accreditation? Accreditation is the

formal recognition of the competence of a laboratory to produce reliable results and

this is done by an authoritative body in South Africa. That authoritative body is

SANAS. And anywhere around the world the authoritative body which normally

performs this function has to be a member of ILAC, that is International Laboratory

Accreditation and Cooperation and the standard which is applied in accreditation,

there are two main standards that the laboratories have to comply by with. They have


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to conform to ISO15189 and ISO22870. Now South Africa healthcare was ranked

Number 6 by the International Monitor Group. In the year 2000 when the

accreditation started in South Africa, the private pathology groups were the 1st the be

accredited. They embraced it and to date we have over 90% of private pathology

groups accredited and this has become; it has actually stopped being a competitive

part of the business. It is a must for you to produce good quality results you have to

undergo accreditation.

Why should we get accredited? Why should we accredit the medical laboratories? It

is in the interest of all of us including governments that our laboratories produce

results of an international standard which are comparable across geography, across

borders. And it is also in the interests of the competent laboratories, laboratories

considering themselves to be offering international standard service that their

competence is independently verified. And that is why most of the majority will

choose to get accredited and this has become an industry standard because whenever

you do businesses or companies select laboratories to do businesses with, one of the

prerequisites is that you have to have accreditation because that means you have

proven your competence through an independent body.


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Now why is ISO15189 standards so suitable for the medical laboratories? This

standard focuses on the patient outcome without necessarily compromising the

required accuracy in the measurement and it also looks at the totality of service

which is inclusive of the consultation, the advisory services I referred earlier on, the

turnaround time as well as the cost effectiveness. So these are addressed by the

standard as well.

Now what is the main purpose of these standards? There are three main areas where

these standards can well serve the community. Firstly, these standards are adopted by

laboratories to conduct self-assessments. We call these internal audits. Every

laboratory has got to conduct internal audits. They have got to have self-assessments

whether they are going for a third party accreditation or not. They need to have a look

at themselves whether the systems are intact, the systems are able to deliver good

quality results. And secondly this standard is used by accreditation bodies like

SANAS, they use this standard to conduct voluntary accreditation. Accreditation is

still voluntary in South Africa; you can choose not to but the majority of laboratories

especially in private practice have chosen to subject themselves to that independent

verification of competence.


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JUDGE NGCOBO: When do they do this?

DR. RAMBAU: Okay, when these bodies accredit laboratories they look for quality

management systems if they are in place and there are many components of these. In

my presentation I do have a list of what they look at. Broadly, the look at the

management and the technical aspects.

JUDGE NGCOBO: Do they look at patient satisfaction? Do they look at outcomes,

patient outcomes?

DR. RAMBAU: Yes, they do look at patient satisfaction. Every laboratory is

mandated to keep a record and during accreditation this is what the Accreditation

bodies look at. Any complaints related to patients, every laboratory has got to do that.

Now in terms of outcomes...

JUDGE NGCOBO: They keep a record of what?

DR. RAMBAU: They keep a record of a patient’s comments, complaints, the

compliments. Every laboratory has got that division.


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JUDGE NGCOBO: But you know they can comment on the quality of treatment?

DR. RAMBAU: Yes, they can do that.

JUDGE NGCOBO: But when does that occur? Are you given forms when you get

in?

DR. RAMBAU: The patients through our staff members whenever there is a

question, a complaint raised it is logged into the system by anyone of our staff

members can do that. We also have a call center. The patients can contact the call

center. We do get a lot of comments coming through telephonically at the call center.

JUDGE NGCOBO: But is there anything though that tells the patient when he or she

goes to these laboratories that if you have any complaint about the treatment that you

have received here this is who to contact and this is how you lodge your complaint?

DR. RAMBAU: In the facility there are two areas. Either at the initiation of a request

with the Doctor in the Doctor’s rooms the Doctor has full information about the

laboratories. The contact numbers are available there. In the second option where the

patient walks to the lab to be bled or for the samples to be collected by the laboratory

staff the information is available there in the facility. It could be a depo that is a non-

laboratory facility but it is an outlet for the laboratory to collect specimens.


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JUDGE NGCOBO: But what I am asking you is, is there anything that indicates to a

patient who goes to these laboratories which says to the consumer if you are unhappy

about the treatment that you have been subjected to whilst at this facility here is a

number to let complaint or this is how you go about lodging a complaint?

DR. RAMBAU: That will vary from laboratory to laboratory. I will not be able to

speak broadly on that because individual member laboratories will handle it

differently. Should I continue? Thank you.

The 3rd

purpose for this standard is governments can adopt these standards and use it

to enforce accreditation within their territories to make it a basic requirement that any

laboratory operating within that particular country should undergo accreditation.

Now I have a list of what the standard looks like. I am not going to go through the

list. This is just to display to you that this is the list which accreditation bodies go

through in detail when they conduct accreditation. It varies, it can take a day to 3

days depending on the size of the test menu, the size of the facility, the size of the

accrediting team. Obviously the more people the shorter the time because various

people will look at various aspects within the laboratory. But the two categories they

look at that is the management as well as the technical side.


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Now I would like to briefly talk specifically on the technical aspects because...

JUDGE NGCOBO: The quality of the services that pathologists offer to the public?

DR. RAMBAU: I didn’t get that?

JUDGE NGCOBO: Do they look at the quality of the services that pathologists

offer?

DR. RAMBAU: Yes.

JUDGE NGCOBO: That information from?

DR. RAMBAU: It is the responsibility of the laboratory to keep records of what they

do. One of the central issues in the, the central requirements in any laboratory is

proficiency tasting which I am going to talk to in the next slide. That defines one

aspect of the quality required. Obviously because the standard looks at the totality of

the service this includes what we call the turnaround time. This is the point; from the

point the request is made to the point a result is delivered. Now laboratories are

expected to document the turnaround times of various tests they offer in the


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laboratory. They would bring accreditation; laboratories would have to produce such

evidence depending on what tests they are looking at. And that is considered to be

one critical point in quality measurement.

JUDGE NGCOBO: Yes, continue. I mean I understand measuring efficiency of this.

But I am only interested, I am interested in whether; do they consider the quality of

the treatment that is offered to the consumers and if so how do they get that

information because from what you have told us. You have told us that the practice

of keeping these records of these complaints from laboratory to laboratory.

DR. RAMBAU: Yes, when you look at the list; can we go back one slide. Yah, that

slide I have got there you will notice that they do look at how the complaints have

been resolved. Resolution of complaints. How this is done it differs from one facility

to the other but the standards accommodate that. So when the assessors come into

your facility, they would like to look at the evidence related to that. Thank you.

Now I have extracted this part which deals specifically with the technical aspects of

the measurement in the laboratory, the quality of the result. Unlike other industries

the laboratory tends to be different. In other industries if you produce a product

which is tangible whether it is a loaf of bread; you can touch it, you can weigh it, you


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can smell it, you can do all sorts of things because the quality of measurement stays

with the product. But in laboratory measurements the quality of the results stays with

the system that produced it. So there are certain system requirements which one has

got to document. You can buy instruments from wherever you get them but when

they come to a laboratory there are certain basic requirements. You have got to

validate the system in the environment to make sure that it measures what you want

to measure.

And secondly and very important is the traceability of scale of measurement. What

are you going to use as calibration? Because the calibrator is the ruler, it is the

standard of which the measurement is made. Now without being too technical let me

just give you a practical example. If you have a drum full of water let us say it is 400

liters of water and you want to express this in cup units. So if you have got let us say

three individuals and say tell me how many cups this 400 liters is? One might say it

is 1600, another one might say it is 2600, another one might say it is 1300. Now the

question is who is correct? Who is giving you the correct answer? The answer is they

are all correct because we haven’t defined the size of the cup. And that is what

traceability is all about. If we say the size of the cup is traceable to a standard cup,

then we would expect similar results and not these different results. Now in


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measurements in the laboratory it is important to note whether the yard stick, the unit

of measurement you are using is traceable to some international standard.

I would show you in the next slide the significance of this. Why consistency is

important?

JUDGE NGCOBO: Is there a way the rest of these presentations can be summarized

so that we can get on with the rest of the presentations. Can you summarize the rest

of that or is it too much to demand? Please, so that there will be sufficient time for

others who are still remaining.

DR. RAMBAU: Thank you. So the issue about uncertainty is how you feel the cup

because if you define that the cup is 250ml no one knows exactly if the cup has been

filled to exactly 250ml mark. There will be over fillings and under fillings and that

creates variability. This speaks specifically to the cholesterol example that I gave you

that there is variability in the measurement. So a single number, it tells us about the

quality of a number which is produced from the laboratory. If 5 is, if I say black

sugar is 5ml per liter; what other numbers represent equally that amount of black

sugar? That is set into a measurement.


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Right this is the slide I was talking about. If you have that traceability, this is about

the HB1C in treating diabetics. HB1C will tell you about the risks of developing

complications in a diabetic. Now in 1993, there was no traceability of the scale of

HB1C measurement. So patients who were healthy could have been told that they

were diabetic and vice versa. Now after the B1C study, the BCCT was published, the

method used in that study was used as a reference method and it took over 10 years to

perfect this traceability of unit of measurement. From 2012 we could now see the

fruits of that traceability that all over the world these are participants from all over

the world. From Russia, from Japan, from US, from Europe. On the same specimen

given to them they are producing comparable results. What this means is the HB1C

results are portable, they are transferable, they can cross borders. A traveler from the

US who normally undergoes monitoring using HB1C can come and continue

monitoring in South Africa so that we can compare the subsequent results which are

produced in South Africa against the results which have already been measured in the

United States provided they are done by a laboratory which participates in this

programme.

Now just to finish off, after successful assessment that is the end you know the end of

the assessment of the laboratory for accreditation and Accreditation is certificate is


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issued to the laboratory and that certificate will be valid for four years but there will

be an interaction of every year or two-year period an assessment to show that every

laboratory complies with the standard. And it is important to note that of all the

health, of all the medical disciplines pathology is the one subjected to accreditation.

And if you want to know which laboratories are accredited in South Africa and this is

open to patients, any consumer one can go on the SANAS website you will see the

scope of tests accredited and the name of the laboratories. With that I thank you.

DR GENT: You can also see on the website what the differences in quality between

the laboratories. I mean the certification sets a basic standard isn’t it. It explains 70%

of the quality without 100%. 100% is explained by individual brilliance by excellent

teams, by super specialization without fragmentation etcetera. We live in a

commercial world isn’t it. Can we see it; can consumers see which laboratories are

better than the other.

DR. RAMBAU: Unfortunately, the accreditation is not about who is better than the

other. It is about who conforms to the standard.


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DR GENT: My question was not that. I understand certification. It is a worldwide

phenomenon. My question is you live in a commercial world isn’t it? Pathology

groups and laboratories differ in quality in term of however; they organize, how the

organize super specialization of fragmentation come up with the best results

compared to other competitors. Can consumers benefit from that knowledge? Is that

knowledge available in South Africa by the pathology groups and the laboratories

and can consumers benefit from the fact that you represent the commercial industry?

DR. RAMBAU: That information will be available for individual laboratories

because what you will find on the laboratory is that this laboratory participates in

proficiency testing for the following tests without which you will not get those tests

accredited. But if you need detailed performance characteristics for that particular

laboratory you will get it from the individual member laboratory.

DR GENT: I will have a look, thank you.

JUDGE NGCOBO: Can I just press this question? Dr. Erasmus or somebody

suggested that you decide on the pathologist based on the distance you know from

where you are or the Doctor’s. But take a case of laboratories which are located at the

same hospital, how do I know as a consumer which pathology group to go to? How


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do I make that choice because I need to be able to know who is better than the other?

That information is not available, is it?

DR. TJAART ERASMUS: Thank you, let me think for a minute. I think one of the

issues, aspects that you have touched on are one would call soft issues. Not that they

are not important, that is not what I am trying to say. And the access for the average

patient to this kind of information to even interpret this kind of information is not

available and I do not believe it is possible.

JUDGE NGCOBO: This question as simple as I can. If I am a patient and I am

consulting with my Doctor. We are trying to decide to which pathologist must I go.

Now one of the factors that will weigh heavily with me apart from the distance is the

quality of the service. Accreditation doesn’t tell me anything other than you are

competent to do this. The quality of the services, is that information available which

will enable consumers to decide whether if I go to this particular facility and you

know this because there are facilities that have got at least two groups of pathologists.

So the distance doesn’t matter there. And I need to go there and I need to decide

which one to go to. Now is there any information that tells me what Group A is going

to charge me, the quality of the services that I am going to get from Group A, what


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Group B is going to charge me and the quality of the service that I am going to get

from Group B? Is that information available to the public?

DR. TJAART ERASMUS: Chair, the charges of the laboratory are available for the

individual laboratories to the patient. So those are very clear and easily available.

Maybe one to put this into perspective if one would say if you go and see a surgeon

or if you see your clinical practitioner who decides if he or she wishes to refer you to

whatever other medical discipline. I would think that largely your trust is in that

referring clinical practitioner who is probably the best informed to be able to make

that decision or suggest a decision for you as opposed to being able to on a

quantifiable basis do that decision the patient themselves.

JUDGE NGCOBO: I will not take as is what I am told. I need to make an

independent decision and that is why I need to make this decision. So the question is,

is this information available concerning the quality of the services that pathologists

offer?

DR. RAMBAU: Chair, if I could answer that question. I think the short answer is, no.

There is no independent verification standard to compare one laboratory with the


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another. In the same way there is no independent standard to compare one’s surgeon

with another or with any other health care provider with another. It is not available I

think in the South African context.

JUDGE NGCOBO: Why is it that so?

DR. RAMBAU: I am sorry I cannot answer that. I think. I know if you go to the

States for example you can open a magazine and they will tell you which is the top

ranking plastic surgeon in the country. That kind of instrument is not available in this

country.

JUDGE NGCOBO: Does it have to do with the fact that there is no independent

evaluation of the quality of the services that you render?

DR. TJAART ERASMUS: Chair, we believe that SANAS is the independent

evaluator and accreditor. It may not be available consequently in a digestible format

for an average lay person in all respects to be able to digest or understand. And we

think that we are street aid in any other medical discipline in terms of quality and in


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terms of accreditation. There is nobody who even comes close. The deficiency

undoubtedly is this level you are referring to.

JUDGE NGCOBO: We understand that but surely the information concerning the

quality of the service that one group offers compared to the other surely cannot be so

complex that it is completely inaccessible to everyone except the pathologist. I mean

surely somebody must be able to tell me that for example I went to that pathologist

you know, they mixed my blood sample with somebody else’s as a result I got a

diagnosis that I had cancer when in fact I did not have cancer. It turned out to be it

was a mistake. That is what I am talking about. I mean surely you do not need to be a

radiologist to know that, that is wrong. So that is what I am talking about. How does

one evaluate? How does one decide? I mean it must be simpler and the question is

why has it, why is it not being done?

DR. TJAART ERASMUS: Maybe to allude to what I have said earlier, specimens

are referred to us by clinical colleagues. That clinical colleague is probably the best

place to make that decision or to make that recommendation. But given what you

have said I suppose one as a professional must always have a level of sensitivity

about these issues and about services to the public. Whilst this is a high focus of what

we do and I believe we set ourselves very high standards there is certainly something


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we can take away from here and try and understand what the need really is and see if

it is possible to attend to that need because it is for us an urgent matter. If it were not

so, we wouldn’t have embarked on this process of accreditation and measurement

which is not simply putting a bunch of stars beyond your name. That is not the

purpose.

JUDGE NGCOBO: Accreditation is one thing. Now if the information as you

suggest is not available I mean it is so complex that only pathologists can understand;

how then will my Doctor be able to understand that? Because he is supposed to

advise me and how will he or she advise me on quality if he or she can’t even

understand this?

DR. TJAART ERASMUS: Chair I think we maybe we are forgetting the fact that

there is an independent accrediting body.it has nothing to do with the laboratory. It

gains or losing nothing by accrediting the laboratory. So it is like in the old terms like

the South African bureau of standards. It is a stamp of quality. That is at least there

comparable which does not exist in other medical discipline. Clearly for what you are

saying it is deficient in that level but again I would think that it is important that the

referring clinician is aware the quality of results that he gets back. He or she gets


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back, quality of interaction with the laboratory which is a very dynamic and intuitive

process.

DR GENT: Doctor Erasmus I am from the Netherlands and we did a lot of research

on what is known to Doctors and what is not known to Doctors and Doctors have no

clue. If they have no information they have no clue. They only have individual

experience and that is how fast can we get results or whatever. Whether the results

from one group is better and more consistent from other groups, he or she has no

clue. So without a specific system of generating information on outcomes Doctors

have no clue. Hospitals have no clue even within hospitals Doctors have no clue

about the quality of care being provided by colleagues so that is out the question. The

question is not whether the standard of the certificates provide a basic quality level,

that is okay of course. We understand but if you take this reason further you can say

nationalize pathologists because then we all need to comply to a grade 7 or I do not

know what you call it in South Africa. A double A standard, that is it. Everybody

complies to that and then there is no need for competition within the groups and the

hospitals and pathology groups and pathology. You could nationalize it. But that is

not the world we live in and people live in commercial world and they offer their


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services on a commercial term. So to do that we need, I think in the system we need

the differentiation both on process of course and on quality

DR. TJAART ERASMUS: Okay, Chair can I ask if such a system exists through you

to Doctor van Gent in the Netherlands and how is it dealt in that area because we

would love to learn by example.

DR GENT: Yes, there is quite a bit of information and I have been responsible for

that for 4 years in trying to generate that information. It is a step by step process

which is quite complex but it is a process that is inherent to a commercial world. I

mean if you liberate the prices of oranges, if you can’t see the quality of oranges then

the quality of oranges will also go down and you will just buy the lowest prices isn’t

it. This is a very simple example and healthcare is much more complex. But in

principle you can’t do without and maybe in this case it is not the consumer that

directly decides, it is the intermediate and in some cases it is the medical schemes of

course that contracts and of course it is the hospital that the referring Doctors that are

involved. They haven’t got a clue of quality. In fact, you yourself have a clue of

course because of your basic quality. I enjoy being proud of the system that you work

in, I do acknowledge it but the differences in quality are there and you can bet there


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are there. And quite important differences and there are not known to you, to us, to

referring Doctors, to everybody. And there are systems in the world that are trying,

that are working hard on this new... there is an extended system. In Holland we have

that, in Sweden, in the United States of course but it is an ongoing process. It has

been ongoing for now more than 10 years.

DR. TJAART ERASMUS: Chair, we are happy to note the concerns raised and we

will try to do our best to deal with them in the appropriate manner because we are

serious about the discipline which we practice. May we continue then and ask

Doctor. Andrew Good now who will add aspects about utilization. Thank you.

DR. GOOD: Thank you for the opportunity today. The slides have been prepared

about our company called Prognosis. Prognosis is an actuarial and consulting entity,

assists companies’ life choice which is a data warehousing expert company. We have

been assisting National Pathology Group to contextualize pathology trends since

2010. When a large scheme within the industry took out adverts in national

publications reflecting pathology in particularly a poor light by showing certain

trends that were there and encouraged their colleagues to address pathology trends by

working together to ensure sustainable health care. National Pathology Group


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approached us to say can we firstly, are the trends are correct and if the trends are

correct can they be explained. And we were successful, and we had to show that the

trends were not actually correctly reflected. In fact, that they were other aspects that

should be addressed sooner than actually starting to focus on pathology.

Subsequently we produced an annual report using the base available public data and

publish it so that National Pathology Group members have the ... to say these are

trends in the pathology landscape and these are the factors that are driving these

trends and that need to be borne in mind before you decide exactly how you going to

approach pathology related interventions.

The way we produce our reports is the Council of medical schemes produces a

significant amount of information and we have taken that information and using our

data warehouse expertise and we have loaded that data into data warehouse. The

analysts and statistical experts have developed modules that allows to extract the

trend lines and produce these reports. Our actual colleagues in that regard that is the

report.

Our presentation that was included, well the last annual report that was included you

know is an example of the reporting. Today’s presentation is based on the sort of the


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methodology used. But we have actually chosen to extend it forward to 2002 because

the inquiries already had a presentation that actually shows pathology trend lines and

it is important to contextualize those pathology trend lines based on the various

dynamics within this industry. So if you look at our 1st slide here we have a trend line

that is chosen to reflect pathology with the increasing cost of pathology. It runs from

2002 and it was chosen and I think the point that was trying to be made is there is a

perceived specific concern about the trend of pathology. If we and perhaps the fact

that they have chosen to show pathology in red they really want to highlight the

specific perceived concern.

I think it is important when we look at the slides, this slide looks at the increases in

expenditure the medical schemes are experiencing since 2002. In contextualizing that

the trend let us have a look at that. This slide shows a differential of about 140%

between pathology cost increase schemes and that of medical specialists between

schemes. Then contextualizing the costs; we first use the information that our

warehouse has loaded and it has been scrubbed and cleaned. Next slide. You see in

the next slide that when information comes out of our data warehouse we pretty have

the same trend lines we expect because it is the same as being analyzed. We have

added an additional year because an additional year is where the data has been ... and


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we see pathology has increased by 360%, medical specialists around 200% and a

140% differential. But I have go to stress that this is a cost that schemes are

experiencing.

If we actually look at the next slide, what we have simply done is we have actually

looked at where pathologists reclaiming and if you actually look at what pathologists

are claiming rather than the schemes are paying we see that the trend lines of

pathology are not too different right. Why, what is going on, on the background that

you know is impacting that. But before we do that I think it is important that we look

at inflation; next slide sorry, it is tricky not being able to control your slides. Yah,

once we adjust from inflation we see that 140% differential drops to a 14%

differential when you look specifically the what is being claimed by the discipline

and adjusted for inflation. What is going on in the background or what a lot of people

fail to look at and see is the perceived problem with pathologists is that the portion

that the scheme is paying towards pathology costs versus the portion that the

members are paying the pathology costs has changed. If we look at it in terms of if

you look the data that goes all the way back to 2002 and you only have data that goes

back to 2006, you see that in essence the main portion that the members are paying

from their own pocket has dropped to 67% and that the scheme portion has gone up


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14.5% which actually if you multiply what that portion was you know has a huge

impact on the scheme costs. And the reason behind this I think with regulation means

more schemes are obliged to cover pathology almost in total which actually causes

what blunt people perceive as a specific problem. Let’s go to the next slide.

Before we can actually... is there a problem which is not a problem we have to

actually go and look at other factors. One of the other factors that one has to

understand is that if clearly something is going up then there is utilization of the

service. If you look at the utilization relative to other various other... we are

comparing about. So once again using Council of medical schemes data we produced

utilization trend lines here going back to 2002. You can actually see pathology

utilization trend alright we see a significant increase vis a vie the other specialists of

16%. So if you were correct you can always conclude that pathology increases are

pretty much in line with the increases we are seeing in the broader specialists’ arena.

And are generally are in line. Can I have the next slide please.

So what other factors could be driving the utilization of pathology services. Now if

we look at, there is a lot of information available at the Council of medical schemes

data but the Council of medical schemes kind of also have to put out reports now and


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then and they had to put out a report in December last year were they looked at the

general survey of chronic diseases. And in that data they give us drivers of utilization

and they give us the prevalence of certain conditions and once again this data is only

available from 2006. But they actually report when we look at HIV and medical

reports, we see that HIV and medical schemes has gone up by 135%. If we look at

diabetes type 2 it has gone up 90%. Now hyperthyroidism 34%, hypertension 39%,

hyper... 32%. So certainly given the information that is there we should expect an

increases in utilization pathology just based on the disease burden the is prevalent.

The CDO conditions actually ignore things like cancer that also have a major impact

especially considering the technology advances. If I can have the next slide, please.

Another significant change that the industry or the medical schemes are experiencing

that also impacts the utilization and services is the industry age profile. What we have

done here is to show you in red how the relative number in the age bands in 2002 and

in blue the relative number of people in age bands in 2014. And I think what is quite

striking is if you look at the age bands that lead sort of 0-5 up to sort of 24 we see a

significant drop off in younger members. If we look across we can actually see past

50 we see a rising number of people in the blue bands. If I can have the next slide.

Now I think we did have, when molecular schemes was implemented there was talk

about medical schemes risk equalization fund. I was fortunate to participate in that


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risk equalization fund with the technical advisory panel. There were various models

that were out in place to actually address that there shouldn’t be any risk transfer. We

viewed one of those simpler models to say what is the likeness of this case scenario

and that case scenario impact to that aging from a risk perspective of a medical

scheme and you can actually see that there certainly should account for a 10% growth

in utilization molecular risk profile. Next slide, please.

So in summary scheme costs have increased, pathology costs are not out of line with

the general trends if you correct appropriately. One of the drivers are age in disease

burden. We certainly need interventions to protect the existing members in the

medical schemes because of those changes that we see. Also the PMB impacting

schemes we need some intervention there and I think that also comes out in the trends

that we see. The impact of these various drivers will differ by discipline and we just

asked when people consider pathology any other costs the analysts must correct the

increase and decreases in the member portion, inflation and utilization. And I think

what is really important in the context of pathology is that we need to consider costs

and benefits. And within the South African context we spend 5.1% on pathology of

the total contributions that come in. And I think we mustn’t underestimate the


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importance of this 5.1% in you know creating certainty around diagnosis, directing

treatment and effective monitoring within the system.

And certainly in my opinion there is lower hanging fruit in adjusting our schemes to

make them more affordable to members in pathology. If I could have the next slide.

So we should expect pathology cost increase as they have increased and are

continuing to increase. The change in age profile, the reality of our country’s

environment and the change in disease profile is a reality. Access to specialists we

have a system were people access to specialists directly, that was an impact on. We

also have a change in climate in mitigation in terms of in the last 10 years the number

of employers you see on adverts advising you, asking you whether you want to see

your Doctor has changed significantly. And then we also need to bring in a change in

technology and that impacts certain aspects.

As my colleagues have said, the National Pathology Group members have said

practically, is all pathologist services result from clinician referrals. I think as a

scheme in the industry we need to explore models that move to coordinated care

where we improve referral to appropriate conditions, we improve clinical pathology

referrals, we improve the appropriate use of pathology in terms of pathology in our

context possible examples we could use less pathology but there are certainly other


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examples were we actually not utilizing the full value of pathology in terms of

managing our HIV and Diabetes collaborate our national surveys do not suggest that

at all and I think we need to improve transparency of costs included by all clinicians.

Thank you Chair.

DR TJAART ERASMUS: Chair, for us to continue we have given our concern about

time we thought that we will skip aspects of our presentation and touch on a few of

the points which were raised. Wait I interrupted myself. The formally structured part

of our presentation is really over now. There are a number of aspects that were raised

by other parties previously in submissions to the Commission which we wanted to

touch on. We may not touch on all of those. I am not sure what the position is in

terms of time because I want to touch on the aspects specifically about employment

of Doctors by hospitals and specifically about an aspect called reflex or what we

prefer as reflexive testing. These tests so called added on tests the I would like to

touch on those. Please I need to be guided by you. We are comfortable to continue

but we do not want to waste time of the Commission. Thank you.

JUDGE NGCOBO: I think you better continue with your presentation.


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DR. TJAART ERASMUS: Chair, just give me a minute to relocate myself.

JUDGE NGCOBO: Do you perhaps want to take a 5 minute or a ten-minute break?

DR. TJAART ERASMUS: Chair, certainly given my age my bladder will appreciate

it very much.

JUDGE NGCOBO: I understand. Okay, shall we take a ten-minute break then.


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Session 4 National Pathology Group continued

DR ERASMUS Thank you for the break, that we had. We

believe that most of the aspects of our presentation have really

been dealt with in one way or another, as it has flowed through.

There are aspects which we have available should there be

questions, but there is one aspect that we feel we would like to

touch on specifically and that is the slide 114 and that relates to the

employment by hospitals of practi tioners, of doctors and

specifically in our instance, obviously we are talking about

pathology.

JUDGE NGCOBO And also the add-ons.

DR ERASMUS Yes I will talk about that with the greatest of

pleasure, but we will deal first with the issue of the employment of

doctors and then maybe I just need a minute to get to that slide

again, but we will talk about that with the greatest of pleasure.


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JUDGE NGCOBO Before you proceed, can I just raise one or two

questions with Mr Wood if I may? The information that’s

contained in these graphs that you’ve presented, does it come from

your members?

DR GOOD The Council of Medical Schemes makes a lot of

information available and the background to the Council of Medical

Schemes information is that scheme is required to submit annual

statutory returns and those returns have a specific format and have

a lot of information available.

Those annual statutory returns to a large extent are available on

specific requests through the access to the Acces s of Information

Act. We access those and they need to convert that information

into a structured data format to our analysis, so it’s actually

information from across the industry as submitted by schemes.

JUDGE NGCOBO I mean one of the issues that has emerged in

the course of these hearings is the reliability of the data that’s


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available. So one thinks that there has to be a way of verifying the

accuracy of the data that’s available, now I understand that this

information would be information that’s sub mitted by the schemes

to the Council of Medical Aids, but do you keep data

independently?

DR GOOD Through our work with various schemes, we do

work for a number of different players within the industry. We do

have access to schemes specific data, but obv iously depending on

how big the schemes are that you’re consulting to, that limits your

ability to actually verify specific trends off a significant sample.

JUDGE NGCOBO I’m just thinking here of the way one can

verify some of the information that’s conta ined by the Council of

Medical Schemes in so far as example, it relates to pathologists .

Would you have a way of verifying the accuracy of what is with the

Council of Medical Schemes in so far as it relates to pathologists?


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DR GOOD Perhaps I can give you more of a bit of a comment

and insight. I think the Council of Medical Schemes has been

collecting information for quite a long time. I think the fact that

some of the trends we can only back to 2006, reflects the

improvements that are being made in the collection process.

Certainly the questions are raised around, sometimes we deal with

the data and sometimes we can actually see that there is no ways

that the data can be correct in specific areas, but I think significant

progress is being made through the Council of Medical Schemes

and the manner in which they collect data.

I think we are starting to get a very reliable source of information

for analysis of this nature to be done and I think the real trick is to

make sure that the Council of Medical Schemes continues to make

that data available, so that people can actually verify, because one

of our concerns is that they are going to be more restrictive in

giving access to the data for people to actually verify trends.


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JUDGE NGCOBO Perhaps if they know that i t’s, because what’s

important is to work with data that is accurate and reliable, because

if you are working with data that is unreliable, the results that you

are likely to get and the assumption that you are going to make,

will be unreliable, would be wrong perhaps, so it’s a way of trying

to find out how does one ensure the accuracy of the data and its

reliability.

What information in the course of your practice, do you normally

collect that would assist in the collection of data?

DR GOOD Where we have scheme clients, scheme clients

obviously they have administrative processes and managed care

processes which produce data points. We do assist schemes by

taking the information and structure the information and do have

the ability on those specifi c clients to run the exact same models

and same exact progressions to understand what is driving

utilisation and what do the trends say.


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One can verify, but obviously we don’t have the luxury of a sample

size of 8.8 million.

JUDGE NGCOBO Would, you be so upset if you were required to

keep data as an independent body?

DR GOOD I think the question is for MPG?

DR ERASMUS Chair I am not exactly sure, would you please

repeat that, I am not exactly sure whether I understood what you’re

saying?

JUDGE NGCOBO Would it be so disruptive of your practice if

you were to be required to keep data of what you are doing?

DR ERASMUS Chair I am not sure that it is the MPG’s

responsibility to keep data. It would of course be the obligation,

the obligation would then fa ll on the individual members to provide

that data. I understand that each of the members has provided


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significant amounts of data to this Inquiry, but I just wanted to

emphasize the point that it would be inappropriate for the MPG as

an entity, to keep that data.

JUDGE NGCOBO The issue is not so much who has the

responsibility to collect data. All I’m asking is would it be

disruptive of your practice. These are your members and I have no

doubt that you would be interested in the trends and what is

happening with regards to your discipline. Won’t you be interested

in that?

DR ERASMUS Chair that information surely would be

competitive information and I personally would definitely like to

be entrusted with the various sources of information put together

for me to combine in any manner whatsoever. The practices

certainly keep their data and deal with the data in a very

appropriate manner and that is available from them, but as the

group, I do not believe that is our role.


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That is why we depend on public sources of data being specific to

the report of the Council for Medical Schemes and the use of a

company like Prognosis Life Choice who have found significant

objective outside value to that data and gives us a perspective of

the position of where we stand thank you.

JUDGE NGCOBO Do not misunderstand me, no one is suggesting

that you have that responsibility, whether that’s your responsibility

is not the issue. The issue is would you be prepared to take part in

the exercise of ensuring that the data, which relates to pathologists,

is accurate. If you are not, it’s okay.

DR ERASMUS Chair the answer to that would have to be a

qualified yes, but one always needs to understand greater detail ,

but I suppose that’s the best way I can do given the circumstances

thank you.

JUDGE NGCOBO I’m asking this because the new Act which is

the National Health Act has a provision which deals with the


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collection of data, the format and so on. In due course, I would

imagine which must be collected by the service provider th at is

including the radiologists, so all that I am trying to find out, is

your preparedness to help in the exercise of ensuring that the data

that is being collected, in so far as it relates to pathologists, is

accurate.

DR ERASMUS Chair I think the answer to that, can only be in

the affirmative definitely thank you.

We will then continue with the 2 aspects, the one which we

specifically mentioned, the issue of employment of doctors by

hospitals and then also move on after that, to the in quotation

marks, the add-on testing.

Many groups have suggested that the employment of doctors and

specifically pathologists, would lead to cost savings. Now we do

not believe that that is a solution, or we do not believe that that is

appropriate.


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Firstly, the current e thical rules of the Health Professions Council

preclude that and not only does it go as far as saying that this is

unethical, but in addition, it isolates pathology and radiology

practices and indicate that and this was based on a request from

ourselves and from in other words, pathologists and radiologists,

that we wanted it specifically included that these practices may

have no outside shareholding of any person other than a pathologist

or a radiologist, to preclude any possibility of an unethical conduct

or a kickback system which could flow from that.

The difficulty with employment of doctors by commercial entities

would be that the doctor is placed with a split and a dual loyalty.

On the one hand, the loyalty towards the patient, the ethical

responsibility of the patient and then if the doctor was employed by

another party, the commercial entity with a loyalty to your

employer who may or may not, but certainly the possibility exists

that there could be pressures on you to reduce the number of staff,

to use cheaper reagents, to use inferior quality equipment and also,

possibly, to reduce the number of pathologist ratio to the test.


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You have noted before when we said that there are three hundred

pathologists who are currently managing this large volume of tests

with all the complexities around there and all the difficult ies

involved, so that is a very real risk and we believe that this is an

area that we cannot see why it would lead to any reduction in cost ,

because the costs for all the parties would be t he same and we

believe there is a very real risk of unethical conduct following this,

so that ends as much for the employment of doctors.

I will then touch on the aspect of the add -on testing.

JUDGE NGCOBO Mr Erasmus, I think they raise it in the context

of fragmentation of healthcare.

MR ERASMUS Chair excuse me, I’m lost now.

JUDGE NGCOBO Employment of doctors by hospitals, they have

raised that in the context of the fragmentation of healthcare

services which they say is fragmented, whereas if you empl oy, if


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you allow hospitals to employ doctors, everything would be done

in-house.

MR ERASMUS Chair in fact it is done in-house now. They get the

service right inside their hospitals.

JUDGE NGCOBO If that is so, why do you object to it then?

MR ERASMUS Chair I will not react to that if you will excuse me,

thank you. Slide 117 is what I am referring to. You used the term

add-on testing. Now I suppose that is a descriptive term and in

substance what it is, but we believe that an appropriate term is

reflective testing.

Some parties, who want to do this in a derogatory manner, say

reflex testing. Now for me, a reflex is where you react

involuntarily in a specific direction or manner over which you have

no control and that is absolutely not what reflective testing is in a

laboratory.


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The international term is reflective testing. It is a worldwide

practice. I suppose one could compare it to the fact that should a

gynaecologist or a surgeon do a laparotomy and find a tumour on

examination and find other pathology, the patient is primarily being

operated for tha tumour, but find other pathology, it would be

irresponsible of that surgeon or gynaecologist not to attend to that

condition.

Now we believe when a pattern emerges within a specific

diagnostic set of circumstances, that it is appropriate and would be

irresponsible if the pathologist did not add -on that test, but we

know this is a potential minefield and because of that, because of

the potential of these accusations that are levied against laboraties

and in fact, it is really unfair.

In fact, these reflective tests result in no more than 1% increase in

laboratory testing and one needs to understand that within that, are

the group of tests that doctors themselves specify to the laboratory,

if you find this or that, continue to do the following.


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Laboratories do not want to act on their own. They would prefer

not to do so. In such circumstances, it would be irresponsible not

to do so and in some circumstances, it is ideal to do so because it

saves the patient a re-visit, the cost of a re-visit to the doctor, the

cost of another specimen being taken is saved by having the test

added.

To be in specifics, an area where these tests is added on, is in the

area of allergy. We have in our previous submission a nd in also

our current submission, we refer to our guide to coding where the

National Pathology Group guides our members in terms of which

codes to use, also having included a protocol that was negotiated or

rather agreed to between ALSA, the Allergy Socie ty of South

Africa and these are allergologists who function in different or

come from different disciplines.

Ear nose and throat specialists, paediatricians, physicians, general

practitioners have agreed to a specific protocol in terms of

approaching pat ients with allergic conditions. What this proposal


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has done in totality, it has reduced the average overall cost per

patient and it has improved the specificity of the eventual result

which the patient receives, so it has definitely improved patient

care.

This perspective that there is a spray painting kind of approach in

terms of added-on testing, is not appropriate and I think with that,

there are other aspects also to be noted in other conditions, auto

immune conditions and of course the total or the f ree PSA and a

number of other specific issues, but allergy is probably fairly high

up on the list which doctors are aware of.

As far as I know, I have dealt with everything now. I think the

other issues are really not specific, or they are there, but if you

would like to raise any questions, I think we have covered of what

we have said, but we are open to questions thank you.

JUDGE NGCOBO Thank you Dr Erasmus. My colleagues are

going to raise issues with you. We will start with Dr van Gent.


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DR VAN GENT One minor issue and it is about the

robustness of the data and the Judge alluded to that question. Yes I

am a bit hesitant to do that, but I will. Dr Good you used Siemens

data, Siemens data are normally very good, robust, but it is also of

course what you do with the data and we will come back, we do our

own analysis on even deeper data than the Siemens data and we

will find out what is really happening.

Just a minor question, in your presentation you show us some

graphs and I get quiet nervous if I see something of a 20% drop

from 2013/2014 claims or an increase in one year, 20% in

utilisation. You must have been more nervous than me seeing that

drop or increase. What is behind that?

DR GOOD I agree with you in terms of when one sees

within data sets, fluctuations like that and obviously when one sees

the drop, one does the various tests to check that the data you’ve

received, you’ve run properly to actually try and interpret what is

behind it.


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That is where it is very difficult to, in terms of if we were actually

specifically looked at some of the graphs, I mean the starting point

of 2002, I was also going to show you that, I also wasn’t very

comfortable at the starting point of 2002, because if you looked at

the pathology costs in 2001, they were actually higher than 2002

and then they suddenly dropped, so I think while we must credit

that the Siemens data process is improving, we will also

acknowledge that there are sometimes concerns with the patterns

that come out.

DR VAN GENT We will find ou t , you can’t answer my

question. I am a bit nervous on the robustness of the analysis done.

Dr Erasmus I really want to understand what the employment by

hospitals and the resistance by individual pathologists is all about.

I am not really sure what your relationship is. Are some of the

pathologist’s members, or do you have relations to one of the three

big pathology groups? Are you employed, or are you a partner of

one of the pathology groups?


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DR ERASMUS Chair no I am not associated with any practic e

at all. I have now for in 2001, I left Ampath, I was a haematologist

before that, but subsequent to then, to that point, well up to now, I

have only been involved with the national pathology group and not

any specific practice thank you.

DR BRAMDEV I’m a partner at Lancet Laboratories.

DR RAMBAU I’m a partner at Lancet.

DR VAN GENT So partners of organisations like partners in

lawyers, partners in a law firm or in an audit firm or a consulting

firm, can be under considerable pressure within their orga nisation

in terms of the turnover they have to come up with. I remember a

friend of mine was a partner in a law firm and I was really feeling

pity with the guy about the pressure he was on and in some years,

probably not adhering to the targets that he wa s set, so you are all

part of a commercial organisation.


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You have pressure to produce, so how is that different from being

under pressure, possibly under pressure from a hospital if you are

employed by a hospital, not even being a partner within that

hospital, but just being employed by a hospital. I ask that question

because so I am from the Netherlands, we have a private healthcare

system, so private hospitals, private insurance companies. Half of

our medical specialists are employed by hospitals, half of them are

self-employed.

They are free they can do what they want. I think there is a light

preference from the government for employed doctors, precisely

because of the question that the Judge, because of the

fragmentation point that has been put forw ard to us, the fragmented

nature of healthcare in South Africa.

In the UK, exactly the same, the private healthcare sector in the

UK, doctors can either be employed or not be employed, it is their

choice. Even within your own reasoning, I find inconsiste ncy in

the sense that you explain to us that there is a concentration of


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pathologists in pathology groups and I do understand that there is a

technology driven part of that, but there is also the complexity, the

super-specialisation etcetera, so you have to come up with that and

working in multi -disciplinary teams.

Exactly the same goes for within hospitals, also there the

complexity is enormous I think and it has grown enormous and the

same argument applies for working in these teams, these multi -

disciplinary teams within hospitals, so the same argument that

applies to your group, could apply and it applies I do think to

hospitals.

Why would a pathologist or a medical specialist, give in to pressure

from a hospital? Why would a journalist that is being p art of a

commercial group or a commercial firm like almost all journals and

journalists are employed by journals that are part of the commercial

group, why would they not be, I mean full grown and ethical

themselves, not pointing to the ethical rules of so me organisations

somewhere, but pointing to your own ethical rules. Why would


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they be compromised because of the fact that they are employed by

commercial organisations?

DR ERASMUS It is obviously not an absolute. One of the

interesting things, I was in the pathology partnership for about

twenty years and you speak about pressure on turnover. Now in all

that time, never ever, were there issues of pressures of turnover.

There were concerns about turnover, there were concerns about the

fact that there are fewer patients coming for testing and is there

something happening, but the focus is on quality and the other

paradox about a pathology practice, it consists of equal partners

and it is in a sense, some of the most chaotic components that exist,

because they all have an equal opinion.

But the risk of an outside group who employ you, it is different, it

is just very different. You are beholden to that person for your

pension, for whatever, so I do believe and you say that that

ethicality intrinsic of you, I think all humans have a difficulty with

these aspects and the risk of this going wrong.


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It is an opinion and obviously we cannot talk about absolutes, but I

think there is a very real risk thank you.

DR VAN GENT We are repeating actually the arguments put

here, but I gave you a number of other arguments and I would like

you to just comment on that?

DR BRAMDEV I think as a doctor, the fact that you work for a

corporate entity l ike a hospital group, I think the bottom line is that

corporate entities are driven by profit. As a doctor, you have an

ethical and clinical responsibili ty to your patient. The biggest

concerns for doctors working for corporates, I think would be the

loss of your clinical performance.

In other words, there would be restrictions on the way you practice

and there would be protocols put on the way you can treat, there

will be limitations, because it is all driven by the cost and I think

that is the biggest concern not just amongst pathologists, but among

all clinicians and we just want independence to practice proper


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clinical care without any business or economic reasons to curtail

the way you treat a patient.

DR KHAN As a Microbiologist, I do deal with hospitals, I do

train pharmacists and infection control sisters and I am proud t o

say that in working in Ampath, I am not driven by any cost

whatsoever and I don’t have to produce based on turnover how

many specialists or what I do. I enjoy my work and the one

problem I do have and I know there are some hospitals here, but as

a microbiologist, when I have to deal with a physician looking after

a patient, for example, if I am employed by a corporate by the

hospital, I’ll have argument every day.

They are driven by costs, so the antiobiotics that they use, are

probably generics and in micro terms, we can see if a patient is on

a particular antibiotic, by the blood results, we can see whether

they are responding or not.


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Many times, we ask the clinician, he is on the appropriate

antibiotic, but why is he getting worse looking at the num bers and

9 times out of 10, the patient is on a generic antibiotic and we fight

in some circumstances to use the ethical proper antibiotic and many

times, we have seen that once the ethical antibiotic is used, the

patient responds dramatically, so I defini tely will have a fight with

them.

DR RAMBAU As a pathologist, you have got a responsibility at all

times, to act in the interest of the patient and you have to keep

yourself uptodate and employ evidence based medicine, the current

evidence based medicine.

Now there is a process of continual improvement to look at the

system and within Lancet, I am very much responsible in looking at

the new tests, looking at the new methods when technology

improves, we have to look at it and see how best we can serve the

patient.


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Now if I am under a corporate, or under a non -laboratory

employment, that may not fall within my responsibility. Someone

else will take the responsibility to look at the capital investment

which will suit the company or the corporate. I will not have the

free hand to look at what is quality, what can I experiment with,

because currently within the Lancet group, we have got a free hand

to look at what is available out there. We test them, we reject

some, we accept some based on their performance.

We benchmark ourselves against the international groups in order

to be uptodate at all times.

DR VAN GENT Thank you very much.

JUDGE NGCOBO Can I just press this point a bit, you know the

example that we were given as I recall, is the case of a patient who

suffers from a heart condition, chest condition, maybe something

wrong with the brain, so that it would be desirable to have that

patient who is at a facility to have access to only the specialists


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that he might need as opposed to being treated by one specialist,

only to find out that the other condition requires another specialist,

whereas if they all work together, they can all have equal access to

that particular patient.

DR BRAMDEV I think Mr Chair if I could answer that, I think

what you are descr ibing certainly exists. I don’t think you need

employment by a corporate entity to have that existence, because

they already exist. Most of the facilities have multiple disciplines

in one place, including pathology labs and complex specialised

centres as well. So you don’t need to be employed by an entity to

have that in existence.

JUDGE NGCOBO On a different matter, as I understand it, you

practice in a group and within the group, there are different

disciplines right, microbiologists and the others th at you have

described this afternoon. Now do you come together to discuss

complex cases?


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DR KHAN We do, we need other disciplines, probably we

will walk to them, so I will probably have to correlate for example,

chemistry, if the liver functions are up, I would want more

information from the Chem Path and discuss with him, my clinical

case, whether i t’s infection, whether it could be a hepatitis ,

whether it could be an auto immune condition.

I also speak regularly probably with the haematologists like wi th

the case of appendicitis, there was a lymphophenia and I wanted the

haematologist to have a look at the slide and to advise me further

on the lymphophenia whether we’re missing something else on this

patient and spoke to the haematologist about that cli nical case in

particular.

We also walk to the histopathologists and they have like multi -

header microscopes and often if we have a pathology that we want

to tie in with what they see, we have that report available, or vice

versa, they may call us to have a look at what they are saying, not

that we understand what they are saying in any case, but we


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correlate with the clinical findings and many times, we need

multidisciplinary input and assistance from the various disciplines.

DR NKONKI Thank you very much for your presentation, my first

question is on that you are an industry body and I would like to

know if you do have any concerns or interests in monitoring

perverse incentives that your members might be prone to?

DR ERASMUS Dr Nkonki I think if there is one expert on perverse

incentives in South Africa, I think it’s me. Now that sounds rather

ridiculous, I am not saying that in a facetious manner, but there

was an issue of perverse incentives which arose in the laboratories

in the late 1990’s. I was at that time, the Chair and really carried

the can for what was happening or what was supposedly being

exposed with different practices.

I am very grateful to say that the practice that I was involved in at

that time, Bouwer and Partners, which was not yet at that time, part

of Ampath, there was absolutely no issue about that at all.


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Nevertheless, we were faced with this pathologists with this very

negative image that had been painted of kickbacks that had

occurred in the profession, or that were believed t o have been

occurring.

I never was ever personally seen anything of that nature at all, but

was told that this was happening. At that time, I said to the

members, this is absolutely totally impossible for us to continue

practicing if this is an issue within our profession and it is totally

unacceptable for me to continue functioning in the role that I am in

if this was the way that things were going to happen.

At that time, we requested the assistance of Professor [Sus] Strauss

at the University of South Africa and he created a new constitution

for us, a peer review component of that constitution, but then

specifically our code of ethics. Now that code of ethics, we

submitted eventually to the Health Professions Council and it

appeared on the advice of Professor Strauss and this is who

compiled it , that we were possible exceeding our powers in


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quotation marks if you could call it that, because in essence, this

was changed then to indicate that our code of conduct was

supplementary to the Health Professions Council, but could

obviously never replace this.

This was never the intention for that to do so, it was the creation of

a document which gave clarity in concrete terms to issues that

pathologists had to deal with at a practical level. This code is

available. The code was included in our submission and everyone

of our members is obligated when becoming a member, to agree to

abide by that code of conduct.

So I do not believe it is an issue at all in the profession anymore.

Where it is an issue, that person should simply be reported, thank

you.

DR NKONKI I see that on slide 119, you do talk about the peer

review process, so what I would like to know, is what do you, you

mentioned that you have both the [inaudible] and the peer review


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process, what do you do with the findings from the peer review

process?

DR ERASMUS We have a formal peer review process which is

accessible to anybody who should complain and it’s a rather

complex structured process and in fact, to be honest with you, I

have never ever had a complaint which has to go through a formal

peer reviewed structure as indicated in the document of ours, but

there have been concerns raised either by patients, or by colleagues

about another colleague where one deals with an issue in an

informal manner amongst the groups who are involved, requesting

for instance, feedback from a practitioner, that is a patient who is

unhappy about a specific cost or a specific result and resolving that

more at a level of an Ombudsman as opposed to a formal peer

review process.

So we do not have a monitoring process for results in the broad

sense in terms of monitoring whatever components of the process.

There is the formal accreditation which exists, but there is not a


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formal monitoring process that exists, but the peer review process

is there should anybody wish to complain and of course their

complaints could always be lodged with the Health Professions

Council.

DR NKONKI So you don’t have any sanctions for, if you were to

find a member who is not practising appropria tely?

DR ERASMUS We are not allowed to have any sanction. The only

sanction which we may have is to request a member to leave and

not be a member of our group anymore.

I think that does weigh rather, the irony is that members are aware

that other members look out for them and look at them, so that

awareness of your group, that peer group around you, I think is a

very important mediator and motivator to act in a specific manner,

so we are not legally or in any way, able to act in a disciplinary

manner that belongs to the Health Professions Council of South

Africa.


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DR NKONKI My final question is with the issue raised by other

stakeholders around charging specialist fees when the tests were

not done by a pathologist, but maybe done by a medical

technologist.

DR ERASMUS In fact, our total discipline in fact exists of

teamwork. A laboratory is a team of people working together.

You’ve seen the numbers of specimens involved. You’ve seen the

numbers of medical technicians and medical technologists who are

involved and the number of pathologists, so pathology by its

nature, does not mean that I have to tighten the bolt on the car

that’s going off the assembly line.

My involvement could be the totality of the process whereby the

assembly occurs and that could be simply intellectual information.

It does not have to do with anything I do, so pathology is a totality

of a service, of which the analytical component is but one.

You’ve heard earlier from Dr Khan how much time is spent by the

pathologists interacting not with an individual result, you heard


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about the infection which happened in the neonatal ward in the

infection control meetings that are held in hospitals. The

involvement of pathologists at the National Cancer Registry, all

these aspects are contributions that we make in a very broader

sense, so we believe it is a very superficial perspective to say a

pathologist did not do that one test, but the fact remains that that

test was done within the environment and control and within the

parameters set by the pathologists.

So we believe it is perfectly appropriate to charge a specialist rate

for that thank you.

DR NKONKI In a case where the results ae generated by a

computer and there is no interpretative report accompanying the

test, do you still think that in principle?

DR ERASMUS Sorry my apologies, my attention was lost there for

a minute. May I ask you to repeat that please?


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DR NKONKI So in instances where the results are generated by a

computer and there is no accompanying interpretative report, do

you still that in principle, that should be reimbursed the same?

DR RAMBAU I have addressed this on my slide in the reviewing

of results. There is a section on auto -verification. It is the

responsibility of the pathologist to set up the rules on the IT sys tem

and this is based on the common conditions, i t is based on the

performance of the systems in the laboratory and these get

reviewed regularly.

The other component includes the previous results and also, the

accompanying results, the core testing that h appens at the same

time, so in other words, you set up the roles, the algorithm which

will pull for example the LFT, it will pull the UME and this is

specific in that particular laboratory.

It is not transferable. What you have set up in that laboratory, you

can’t copy and apply it in another laboratory and it is only valid for

a certain period, after which you have to review that, so it is a tool


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a pathologist uses, so it still falls under the pathologist, so the

section on the slide, I have indicated that there are those which fail

this auto-verification and they fall to the screen for the pathologist

to actively do that, because you can’t possibly code everything.

You can’t programme for everything, but those which are

programmed, according to the rules, they will go, but they will pick

up the relevant comment and go out.

It is not that they go without a pathologist, adding any value to

them thank you.

DR NKONKI Thank you.

PROF FONN I am going to pick up on some of the questions from

my colleagues. The one is the issue you say working for a

corporate, but you all work for a corporate, it’s called Lancet, it’s

called Ampath, so I don’t quite get where the line suddenly

changes?


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DR BRAMDEV I think the pathologist who work for a company

like Lancet, own the company, it is all owned by doctors and

pathologists. There is no outside party there is no shareholding

with anybody else but the partners.

PROF FONN I understand that fully, it only means that your

interests in terms of profit are even more perfec tly aligned?

DR BRAMDEV I think the point that I made earlier, I think the

key issue is that the doctor partnership is only interested in clinical

care as a primary objective. In as much as it may sound that there

is like a corporate, some financial incentive, but I think as Dr Khan

has clearly stated, there are many examples in pathology which

shows that if you work for a corporate, you’ve got restrictions in

terms of what kind of tests you can do, what kind of

recommendations you can make without the cl inical interest of the

patient at heart.


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PROF FONN I hope you’re right that all these doctors are

apparently so pure, because even the individual doctor working by

himself or herself, is just as l ikely to decide to do additional

investigations where the interest of the patient might not be

compromised, but it might not be entirely necessary either.

So I think this notion of this doctor, being one myself, as being a

perfect human being who has never a conflict of interest or would

never imagine over-charging or doing an extra test here and there,

doctors income is determined by the activities they do, particularly

in a fee for service environment and under these conditions, the

potential to increase your fees exists.

DR ERASMUS Proff Fonn obviously everyth ing that you are

saying, is true, because none of these are absolutes, otherwise the

answers would be very simple. The one advantage is that in

pathology, it is a referral specialty. We do not go and catch

patients and collect blood. The specimens are s ent to us by doctors

who have absolutely no arrangement with the laboratory in terms of


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financial aspects at all and I believe that that is a huge difference

compared to other clinical disciplines who see patients off the

street.

We do not see patients of f the street and I think that is a feather in

our cap, thank you.

PROF FONN The other question I want to ask in terms of

decisions around purchasing of latest equipment and those kinds of

things, keeping up with standards, being internationally

competitive, in relation to that, do you do formal health technology

assessment?

If you do, do you include cost benefit analysis and then if you do

do cost benefit analysis, what denominator population do you use

and thirdly, are these available in the public domai n? Can I come

and get it? Can a patient come and get it? Can a competitor come

and get i t? Can a doctor who refers to you, come and get i t? Can a

hospital group who uses you, come and get it?


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DR RAMBAU Now in the introductions new technology, we follow

the CLSI guidelines, the majority of the member laboratories use

CLSI as standards and we don’t do the cost benefit analysis as you

would find for example, with the European laboratories or with the

NHS, where they publish those detailed evaluations.

We largely would do the verification which is a downgrade on the

validation. Now the validation is performed when there are

completely new tests which are not on the market, it’s a new test

which has just been developed where you have got to do the

clinical validations and those we rarely do.

If they are available, they will be done in conjunction with the

universities, but because we test, we verify for use, we only verify

it for suitability in our environment to try and verify whether the

manufacturers’ claims hold, whether the total error allowables in

other words, the performance specifications are met. We do not

have regular training environment, where we have to meet certain


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things like you have with the [inaudible], we don’t go to that

extent, we only do just for implementation and that is limited.

We do the stability testing, accuracy testing, just comparing the

two methods, one against the other.

PROF FONN So then I am correct in assuming that basically what

you do, is test and see that the machine says it does and that in fact

it is quite possible, although we might be having state of the art,

we might be having something that is totally inappropriate and

unaffordable for our population, because we’ve never tested it , if it

is in fact something that is cost effective and therefore brings

health benefit, given opportunity costs.

DR RAMBAU The suppliers we use, commonly the same suppliers

which are used, worldwide, now they would have information

which they gained from the validation of these analyser s, although

the costs may not be transferable to our country, so that element,

that aspect, we really don’t look at at all.


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PROF FONN And then still on the cost issues, these reagents that

you use in your industry, how complicated are they? What is so

special about them that there is no industry in South Africa that can

produce them, or is it that there is international copyright on them?

I mean why is it that we have to import everything?

DR RAMBAU Yes the majority of reagents, maybe with a few

exceptions in microbiology where you can have you own media,

nearly all reagents we use on our platforms, are imported and they

are patented, so you can’t use them across platforms.

If you’ve got a Roche platform, you can’t use the Abbot, so there is

exclusivity. There is certain information which we can’t get even

if we request from these suppliers. In fact, reagents are not

compatible with each other, to an extent that if you do try, some

reagents from one platform will damage another platform if you do

try another laboratory, so it is very exclusive.


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DR ERASMUS As I said, I was a haematologist and there was a

time in the early phases of these flow cytometric type of analytical

machines that became available, that Lennon, the group who make

the little whatever bottle drops, started making what they believed

to be largely water containing not too significantly complex

chemicals and we certainly tried them locally here and we burnt our

fingers badly.

We burnt our fingers badly in terms of damage to the machine,

unreliable results, in the end it was not worth the salt at all. That

was my personal one very bad experience.

PROF FONN Well, that seems to be very clever of the suppliers.

The other question that I have and it might be in your code. I have

read it, but I don’t remember. Do you encourage the members to

make their quali ty control processes or protocols available to the

public?

DR ERASMUS Not specifically, no.


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PROF FONN Would you be surprised if they refused to give it to

someone who asked for it?

DR ERASMUS I am not exactly sure, I would love to answer, but I

don’t know exactly how to answer, what the question is. I am a bit

lost.

PROF FONN So if I came and said I want to know exactly what

happens after my specimen from a swab came into your laborat ory,

what is your protocol until such time as it arrives in your

laboratory and I get my result?

DR ERASMUS I am sure nobody would object to that at all.

DR RAMBAU I just want to confirm that yes, that is available, that

is not confidential information, because that is what the doctor

would get if the doctor wants to know what the quality control

procedures, or what have you done to make sure that this result is

reliable and it is valid.

PROF FONN And patients?

DR RAMBAI Yes the same applies to the patient.


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PROF FONN I am sorry I want to ask some questions and this

arrived this morning when we had started which is your document

in spite of asking for it in advance, so I haven’t had time to read it

and it is not the same the document that I have in front of m e,

particularly in relation to the various actuarial investigations,

because the document that I could look at before, went back to

2009 and not 2002, so if you don’t mind, I have no choice but to

refer to the other document.

So I understand from the writ ten document that you gave us, it is

not paginated, so I can’t tell you which page to look at, but it is

where your section is, that is all I can say. You say that when

correcting for increase in utilisation, it is found that pathology

costs per utilisation, have increased by 19% in real terms.

So I understand this to mean that you have taken utilisation into

account, so in addition to utilisation, there is still an increase in

costs?


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DR GOOD In the extended version of that report, we do

specifically deal with util isation, because the Council for Medical

Schemes report utilisation figures, actually need to be understood.

The ideal thing to use would be actually the number of claims. The

utilisation reports is actually the number of visi ts, so when one

sees that increasing amount of 19% per utilisation, one is unable to

take the analysis deep and say is that an increase in the number of

actual items tested per visit, or is the number of items per visit

constant.

PROF FONN The costs have gone up in addi tion to utilisation,

that you’ve taken utilisation into account, isn’t that what the

sentence means? It might not mean what you meant, but that is

what it would mean by taking uti lisation into account, it means you

have nullified the effect of utilisation .

DR GOOD I think the correct position, is that all we are

able to, the only aspect of utilisation that we are able to sort of

correct for, is the number of visits. Obviously within these visits ,


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there could be a significant number of tests. There is s till a

component of uti lisation that cannot be corrected for.

PROF FONN So then you say this could be a result of more tests

being requested per visits, or more expensive tests being requested,

or simply charging more, which is what you have left off?

DR GOOD One could add that, but obviously when

dealing with scheme data, one has a sense of in terms of what the

changes have been across the industry from tariff perspective and

how tariffs have increased and by and large, in our experience,

what we have seen, is that the tariff components have really got

inflationary or pretty close to inflationary linked increases and

there haven’t been significant charges in increasing a specific

tariff.

PROF FONN I was wondering if you work for the national

pathology group, why couldn’t you use the actual data? Why did

you have to rely on CMS data? You work for the groups, they are


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asking you to do it, they, have the data, why didn’t they just give

you their data?

DR GOOD We did indicate to the national pathology

group, that the ideal would be to get all the various memebrs’ data,

so that you can actually check what is happening to the case mix,

what is happening to tariffs etcetera, but I think that given South

Africa’s entry, or fears around what we constitute an ti-competitive

behaviour, most of the groups weren’t comfortable to embark on

such an exercise.

PROF FONN I wonder if their lawyer wants to comment, given

that they could give it to you totally anonymised, you would have

no idea and pooling the data, would have absolutely no affect on

competition.

ADV GOTZ I am involved in no less than 5 cases at the moment,

where industry exchanges through an external party, or an industry

association, have raised concerns amongst the Competition


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Commission. There are of course ways to do it , but the moment

individual members start to channel data to either the MPG or to an

external service provider who at some point, is expected to

aggregate that data and report back, you are in dangerous waters

and in dangerous terrain and I think that has been the concern.

I also point out that in terms of the exercise that is being conducted

here, of course the pathology groups would not have the

information in relation to other medical specialities and so, it may

not be appropriate to use data from the pathologists to compare to

CMS data for the radiologists.

I expect one would want to get one’s data from a similar source, so

in terms of the exercise being contemplated here, I would

respectively say that the CMS data is probably th e most appropriate

to use given these exercises.

PROF FONN Certainly, if you were going to compare with other

specialties, but if you want to look at pathology costs, it is not. I


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wanted to explore something you said earlier where you said well

the things that make people decide where to go, is how close and

how their quality and the turnaround time and I would put it to you

that certainly in the big metros and in the big cities, the answer is

they are equally close, we apparently know nothing about their

quality, so we know they are accredited, so they meet the minimum

standards and I would suspect that they have pretty much exactly

the same turnaround time, so given that those things are constant,

why does Dr X go to Lancet, Dr Y refer his patients or he r patients

to Path Care or to Ampath, or to one of the other groups? Do you

have any idea on that?

DR ERASMUS I would imagine that personal relationships in a

sense of you heard earlier in the presentation, how much the

pathologists intereact with their clinicians in terms of telephone

calls, either phoning them, or receiving telephone calls, so I would

imagine there would be a natural trend for the person who you

know that laboratory you would tend to use.


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There is no obligation obviously, but it would m ake your process of

communication easier, I would imagine, but there are undoubtedly

areas of pathology which are even super specialised where specific

pathology practices have expertise which the others do not have,

although with the amalgamation of the p ractices currently, the

practices are all very large and really are largely commensurate in

terms of the availability of their professional resources and the

quality of work that they are rendering, so I think they would be

very comparable and I think we are in a fortunate position for that

competition to be there and for this choice to exist thank you.

PROF FONN One of the issues we had quite a lot of feedback on

from the schemes I think, I think all of them, was the issue of Z

codes, Z codes. So I noticed, I read through, it wasn’t that

interesting, but I can see it is very helpful, I read through the

national pathology group coding guidelines. Unfortunately it

didn’t have the insomniac effect I was hoping for, but nonetheless

and it says there, that members must ensure that the appropriate


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descripted code is used for each investigation for tests performed in

their laboratories.

Now I thought this was at odds with what we had heard and then I

thought well maybe it is actually the linkage to the ICD10 co de that

is missing. Is that correct? So you code the test right, but you

don’t put the link code in and that is where the Z code comes in, is

that correct?

DR ERASMUS Yes the ICD10 coding, now we are dependent on the

clinician sending us an ICD10 code and by far, the majority do not.

Now one can appeal to them in circulars. This is done constantly,

because that is not what we want to do. We are going through a

whole data collection process in any event. Whatever we get, we

transfer to the medical scheme, because that goes through with the

account to the scheme via the code that is used.

That is the code we get and then the other sets of codes which we

make ourselves. The one set of codes is in the histopathology


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environment, they code, they, diagnose and they code specifically,

because they know it is in their control.

Then we move to the clinical environment where often, or mostly

the results are not specific and unfortunately we have to use the Z

codes, the non-specific codes. To do anything else would be

irresponsible and untrue.

PROF FONN So this is where I come to the long description that

you gave us of what you do and how you add value and I know we

need pathology in decision making and I am really aware of that, I

am not questioning that for one second, but you also implied that

you interpret and if you don’t know at least differential diagnosis,

then what value and I am not talking about histopathology, because

often the diagnosis is made at histopathology, then how can you

interpret something meaningfully, or give any meaningful feedback

to a practi tioner if you don’t know what the differential diagnosis

is?


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DR ERASMUS It would be wonderful if we had that differential

available from the clinician, they say how can one do that, I believe

there are certain patterns that are visible, but these patterns are not

necessarily absolute, so on the basis of that and this is where the

interaction with the clinician frequently happens, is a telephone

call to say what is going on, what is wrong with this patient, can

we assist, there is a specific pattern here.

Unfortunately, one sometimes has to say the possible causes are, to

be looked at an excluded, so at least that assists the clinician. In

the ideal world, it should be better, but unfortunately tha t does not

happen.

PROF FONN There is an alternative explanation which is that in a

whole number of pathology tests , actually the referring physician

or GP or nurse, actually doesn’t need your interpretation. They can

interpret i t themselves, because i t is pretty straightforward and we

all know what normal levels for a hemaglobin are, because even if

we forget, you put them on your reports and so on.


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There are a number of automated, I mean we are very fortunate

with the advance of technology and there are a huge number of

automated tests, so where I’m leading to here, is that what we are

interested in this Inquiry, is the soaring costs of healthcare and the

fact that they are becoming increasingly unaffordable for increasing

numbers of people which is exac tly the opposite of what we are

trying to achieve in the country and that, well let me put it this

way, is it not reasonable to assume that task shifting in relation to a

whole series of tests, is possible, that good diagnosis is possible

without the interpretation of a pathologist and I would say that in

many instances, i t is not.

I am not saying this is true for the entire industry or for the entire

specialty and that we have seen this happening in a few different

ways. The automation and the production of a once your machine

is calibrated, spits out the results, so you stick it in, it goes through

a whole series of tubes. In fact, there are half of us who don’t even

know anymore what to mix with what to make the real answers and

it spits out an answer which can then be emailed in an automated


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way to whoever receives it on the other end and they can interpret

it .

That seems to me, offers a potential cost saving. Further, we know

that there are many point of care tests, where in fact we don’t even

go through the pathology loop. I agree they have to be calibrated

and there certainly is a skill and a cost in that and that it seems to

me also that technology, new technology, clearly people who

develop it, put a patent and a premium on it, but technology has

become cheaper and cheaper. We pay less and less for more

sophisticated computers, less and less for more sophisticated cell

phones and yet, we see absolutely no transfer of this in benefits.

Isn’t that surprising?

DR ERASMUS I disagree that you see no transfer. You see transfer

consistently in the availability of pathology services at levels

which increase below the level of inflation. If you compare the

price increases in pathology per unit, I am talking per unit of

service, to the clinical services, there is no comparison. Pathology


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is at the lower rates, so the fact that pathology costs, this increased

automation and increased efficacy has been past through to the

patient already and is constantly being passed through to the

patient, both in quality and availability and in price increase which

is less than what would have been otherwise.

It is possible to rip out a piece of pathology, to say only that is

going to be done by the pathologist, all the rest is going to be

automated, but that single piece that you then have to pay for that

you dearly need, will be completely unaffordable. You will just

not be able to pay for it at all.

You’ve seen the ratio of pathologists to specimen and that puts us

where we are at the moment, so if you reduce that even further,

thinking that if you take the pathologist out of the permutation, you

are going to reduce your costing, I think that is a dream.

PROF FONN I don’t want to get rid of pathologists that, is not

where I am going with this. I suppose if any of the submissions


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people had presented to us some of these data where costs had gone

down, then we could see that and then that leads us to the next

question which is in relation to, so is all the increase in costs then

ascribed to the new testing that is going on?

So where are these costs if for routine stuff which we are doing a

lot, you know the kind of stuff you speak about for example, where

we know chronic disease, hypertension, diabetes, these are the big

disease burdens we are worrying about. The se are not new tests,

these are old tests, so we have to do and if the tests are going

down, even if the numbers are going up, there shouldn’t be such an

increase from this burden, so then the increase in costs, must be

coming from somewhere else and then the only other thing that we

have been told about, has been about the new tests, so the various

tests around biologicals and specificity around cancers and all these

kinds of things, so is that what is driving the cost? Is it all new

technology and again if we ask these questions because we don’t

know the answers, it is because when we asked the questions, we

didn’t get the data.


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DR ERASMUS I am not sure whether one can answer that question,

except that util isation is increasing, but utilisation also adds

benefits to the patient in terms of reduced hospitalisation, less

morbidity, improved mortality, so the quality aspects that are spin -

offs of these, are definitely there.

PROF FONN I’m not arguing that they are there, but in order to

claim that they are there, then you need to be doing the cost benefit

analysis and these are not very complicated things to do.

DR ERASMUS The irony is if one looks at chronic diseases, you

look at the chronic diseases that you have mentioned and how poor

the control is of patients who are diabetic and I mean that is not a

complex thing to do, but the pathology cost in that is not the big

issue. The cost of the complications is a big issue and it is just

simply not done, so and that is an issue of management of the

medical schemes. That is where that should be more effectively

done and the services that are there should be better used.


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PROF FONN I’m sure you are right, that there are other places,

but you are not a medical scheme and you are not doing that stuff ,

you are pathologists and you do what pathologists do and if you

want to make the argument, then you need to present us with the

evidence and it is not that I am disputing it.

Personally, I have done that work. I am the person who did the

research that said we need to spend millions every year on cervical

cancer screening, because I did the cost benefit analysis to show it,

so I am just suggesting that it is much more helpful if you had

given us the data, if you had shown us that in fact the unit costs for

old tests is going down and here is the costing that is on new

technology. Then we would have this information to hand and on

the utilisation rates.

DR ERASMUS The brief for this group, could not include the

costing. It is not possible, we do not have access to th e data, we

could not share that data, so that data you should enquire from the


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specific individual practices concerned, I think that is more

appropriate, thank you.

PROF FONN I think you are quite right and I am using this

opportunity for those people who are here from those places, to say

to them please do it and if you want to encourage your members to

cooperate, that would be very nice.

DR BRAMDEV Sorry could I add to that, I think Dr Good

showed in one of his slides, that the chronic diseases like

hypertension and diabetes is on the increase. The number of

patients who are being treated, have grown dramatically and

therefore, there is more of those simple tests you talk about, being

done and that is pushing utilisation and also I disagree when you

said there is no new tests.

There are lots of new tests that can be used today which were not

available twenty years ago and new technologies as well within the

same test, so I think it is just not that the price is going up.


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PROF FONN I agree with you and it would be nice to see it . I

wanted to understand one thing about coding and that has to do,

now we’ve heard a lot that coding is very old, it hasn’t been

updated and no one is taking control of that, no one is showing

leadership around that and in one of the submissions, it was clear

that for radiology, the codes don’t differentiate between when a

technician is doing it, a scientist or a technician compared to when

what would be a pathologist in this environment is doing it. Is that

the case in pathology, that the code whether a technician, a

cytologist, or a pathologist is doing it, is the same code used?

DR ERASMUS The coding system and to use a descriptor, the

billing coding system that we make sure that we are referring to,

the copyright for that belongs to the South African Medical

Association and used to be the doctors’ billing guide which is now

called the Medical Doctors’ Coding Manual, of which in pathology,

in clinical pathology, there are about seven hundred and forty tests

approximately and his tology, a small number, so less than eight

hundred.


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I am also a director on the South African Private Practitioners

Grouping which is largely a group of specialists. I am not sure

whether you are aware of the initiative that has been attempted

from there with great opposition in the establishment of a group

called SACHI. Now I just hope I get the acronym right, it is the

South African Coding of Healthcare Interventions, it is in essence

that.

A company was established for this with participants being the

doctors, the medical schemes [interjects]

PROF FONN Can I interrupt you, I do know the history of that

and I do understand the attempts and I understand the frustrations,

which I was hoping to indicate in my introduction to my question

and I apologise if I didn’t make that clear.

The question I am asking, is the current codes, do they differentiate

depending on who the person is who did the test?


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DR ERASMUS I am sorry I got myself into a flat spin, I am sorry,

the same code can be used whether you are a medical technologist ,

or a medical scientist or a pathologist, provided that that area is

within your scope of practice. Certain areas of pathology may not

be done by a medical technologist or a medical scientist, so even

though the codes may be used, it is not appropriate. Does that

answer your question?

PROF FONN Well I want to follow up, so if I’m paying, I pay the

same amount no matter who did the test.

DR ERASMUS Are you referring to within a professional pathology

environment, or are you saying i f a medical technologist does the

test in a medical technologist private pathology or a private

laboratory practice, is that what you are asking?

PROF FONN Let me explain my problem and then you tell me

what the answer is. Here is what I am thinking, the cost of

something depends on the infrastructure and the tubes and the


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bottles and the stuff that comes out of it and the machine it goes

into and the person who does it , so if I am a technologist, I have

studied for lesser time, I can do tests A to C, if I am more skilled, I

can do tests A to L and if I am a pathologist, I can do tests A to Z

and so the costs are related, so if I am paying for test whatever and

it is a test that anyone can do, if a technologist did it , then the total

cost to company for producing that test, is lower than the total cost

to company of a pathologist doing that test and is that reflected in

the price or not?

Is the price the same, no matter who does the test?

DR ERASMUS Pricing is freely done on a competitive basis, so the

persons who supply the service, will charge the price that they

prefer. I am not exactly sure where I am getting this maybe I could

just give you the background. Originally, medical laboratory

technologists were not allowed to practice indepently. In the early

1990’s, they presented a case to the Health Professions Council that


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they wanted to be able to practice independently and that they

wanted to be able to send accounts for their own services.

This was eventually agreed to with a number of proviso’s by the

Health Professions Council and one of the proviso’s at that time,

was that the fee should be less than that of a pathologist and my

recollection which is I am not absolutely sure of, that it should be

two thirds of that of a pathologist.

In practice, medical technologists now practice independently

provided their board has approved them to be able to do so and they

would set the fee that they believe to be appropriate and we set the

fee that we believe to be appropriate for our practice. Maybe I was

missing the one aspect that do you mean that let’s say in a

pathologist practice, which employs medical technologists now, if a

medical technologist does the test, or when a pathologist does the

test, the same test, there would be one price, whether the

pathologist or the medical technologist does the test, it would be

the same price, but by the nature of it , pathologists would do

certain things and medical technologists would largely do other


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things,but that doesn’t mean the fact that the pathologist is no t

doing the individual test mixing the tubes or stirring the bottle, that

there is no pathologist involvement.

You have heard the background which has been given before.

PROF FONN We’ve been told that in relation to charges, when

hospital nurses take, as far as I understand and I might not be right,

my understanding is that if I send blood specimen to a laboratory, I

pay whatever I pay for my test R1 and that that from the laboratory

point of view includes the collection, so if I collect it myself and

send it to you I still pay R1? Is that right?

MR ERASMUS Whether we collect or do not collect, it’s the same

rate, we don’t differentiate the rate, or we do not differentiate the

time either. Whether we do it in the middle of the night, or in the

middle of the day, we do not differentiate.


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PROF FONN It seems silly to me, can’t I pay less if I wait longer,

or do part of it myself? No I can’t?

DR ERASMUS I can’t answer that.

PROF FONN I suppose that brings me onto the next thing is why

can’t that be negot iated do you think? I mean it does sound

reasonable, that is the point about the market. The market is

supposed to work. I’ve got the money, you’ve got something to

sell me, I say to you, I want to wait a bit longer, I’ll take it myself

and I don’t want to pay so much and you say too bad. How come

that can happen?

DR ERASMUS You will take the specimen to the laboratory

yourself, it will lie on the dashboard on your car while you are

shopping for food, stopping at the robot, the specimen will

deteriorate and you will get a result which is unreliable and which

you cannot use for any diagnostic purpose at all , because you do

not know what you are busy doing.


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PROF FONN I think you are going off on a tangent. I take it to

your thing, I take the blood myself , so you haven’t had to pay the

nurse to take my blood, I am not bringing it to your thing, it’s got a

quality control arrival. I mean I don’t want to argue about that

point. What I want to know is why the market doesn’t work, why

am I with the money, unable to negotiate with you as pathologists

and say I will wait 2 days, I don’t care, I don’t want it

immediately, don’t rush, don’t charge me overtime hours, I don’t

mind if you sleep tonight, I don’t want to be charged for somebody

else who wants i t immed iately, so I don’t want your night staff to

do it, I don’t want your overtime, I will take i t in normal hours,

why can’t that happen in this market?

DR ERASMUS There is negotiation with the individual practices

where funders have specific disease profiles that they deal with,

whether it is going to happen with one individual patient walking

in, I don’t know, but I suppose you could try, there is nothing

precluding you.


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PROF FONN I just want to clarify one point, so there are codes

that medical scientists can use and if they are approved, they can

work independently and they can claim from medical schemes for

their work, is that correct?

DR ERASMUS That is absolutely correct, provided they have been

approved by the board of the medical laboratory technologi sts to

practice independently, and/or the board of medical scientists

which paradoxically falls under the Medical and Dental

Professional Board. There are slightly different boards involved,

but yes, the answer to that is yes.

PROF FONN Thank you, because people had complained to us,

that was one of the submissions and so I just wanted to understand

if that was correct.

So I just want to check something again. The Ampath data that we

have, we had a whole breakdown, but in general , they were saying

3 things and I suppose I want to check with you. The aging


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population, the increased risk profile and the third one was the

residual, explained the increase in costs.

So you would agree then that the age profile hasn’t changed

significantly, then that would no t be a driver of costs, am I right?

DR GOOD If an age profile hasn’t changed in the current

environment, there could still be an anti -selection driver, because

the absence of mandatory cover means people can elect to stay out

until they are going to win in the system and then join.

PROF FONN And then I have one quibble, I am sure it is just me

and this is the very last thing I want to ask. Why don’t actuaries

do statistical testings on their slopes? You present us with these

data, so I come from an epidemiological background and I just

don’t understand why you never do statistical tests to tell us if the

change is significant or not. Is this something they don’t teach

you?


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JUDGE NGCOBO The pathologists don’t have to answer this

question unless they want to take it to the laboratory and give us

the answer in due course.

DR GOOD I must confess in terms of the preparation of

our reports, is once again similar to pathology, i t is a team effort

where the data gets loaded and the actual person who puts tog ether

the graph and the presentation, whose background is a Bachelor of

Commerce with Stats Cum Laude, so I will take i t up with her and

ask her.

PROF FONN I think it would be really interesting, because you

know something can look like something and as y ou know the

longer the period, the lower the slope. The increase looks like this,

but if you have a significant period, it is actually not such an

increase and so for me, it seems to be in all the stuff, but since you

are here, I am going for you.

It seems to me to be a real missing element in the way that the

actuarial data is presented.


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DR ERASMUS Our apology about our presentation only reaching

you this morning. We certainly made the deadline of last week for

our written submission which was given to u s, we did it on time.

We requested that we allowed to only, bring, the presentation this

morning, so I am sorry if it inconvenienced you.

JUDGE NGCOBO We understand. You see it is always dangerous

to be in bad company, this is what happens. You get to answer

questions.

DR BHENGU Thank you very much for the presentation, without

belabouring the point on the util isation, we can still go through it

obviously in focussed hearings with the companies themselves, but

I think the utilisation factors that you q uoted in my mind, just as a

passing comment, is that they apply to all practitioners really. The

interest would be why, even allowing for that increase for all other

specialists that there is such a significant differential for

pathologists over and above that, but that is not for discussion. I


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am just saying, but we didn’t get enough chance to analyse the

response and you know you speak too fast sometimes.

I mean just to confirm MPG is really the only association for

pathologists?

DR ERASMUS Yes, we are the only society, as far as I am aware

there is no other society, certainly not of any significance and by

far, the majority of pathologists are members of our group, but the

NHLS were at some stage, members of our group, but decided not

to continue, I don’t have the reason.

DR BHENGU The two hundred and ninety five members, I read

that to mean these are two hundred and ninety five specialists.

How many practices are in that number?

DR ERASMUS The three large pathology practices Ampath, Path

Care and Lancet are members and then a smaller histopathology

only practice, Doctor [Gritspen] and Partners and as far as I am

aware, you also requested data from them earlier, but they are also


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in one of our groups. Periodically there are isolated persons who

apply for membership, but don’t really follow up their application,

so as far as I am aware, there is nobody else other than associated

with these 4 practices.

DR BHENGU So about three hundred specialists in about 5

practices really?

DR ERASMUS I suppose rounding off with three hundred and 4

practices really, 3 large ones of varying size and 1 smaller practice.

DR BHENGU Why is it essential that your members be members

of SAMA as well?

DR ERASMUS The national pathology group has come a long way.

I think it was started in 1948 somewhere approximately and there

are a number of other specialist groups within SAMA. Some have

larger left SAMA and have joined the South African Private

Practitioners Forum for whatever complex reasons there may be,


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but the SAMA statute and I am using the wrong terminologies, so

please excuse for that, so whatever the name would be, the rules of

SAMA, I am not sure if it the constitution, but I will use that word

for the purposes of statement, that’s for a specialist group to be

affiliated with SAMA, we are affiliated with SAMA, for that to

remain, we have to have a minimum number of members being

SAMA members, so that is the answer.

Firstly they have to be pathologists, they have to be SAMA

members and they have to be registered with the Health Professions

Council, so it is because of the SAMA statute that that exists.

There are other professional groups who are completely

independent, but we are not.

DR BHENGU I think the point one just needs to understand if you

are the only party that represents pathologists, we need to

understand further what happens in that black box that is MPG and

we need to be comfortable that there aren’t any anti -competitive

issues that should raise a flag.


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Now the natural question is, if al l members are members of SAMA

that we know handles practice issues, is that by extension a

problem if the membership mirrors each other in that way, so that

is fine, but today you didn’t cover what you do for your members,

but I think from your previous submission and website, it says you

promote the practice and professional interest and establish

professional relationships, so among pathologists with medical aid

schemes, what actually is it that you do in establishing that

relationship among your members in medical schemes? What does

that entail?

DR ERASMUS That is far more of a historical statement than a fact

on the ground. Historically speaking there were times when of

course the pathology, or the pathologists negotiated as groups with

the Council for Medical Schemes and represented the practices at

the Council for Medical Schemes and periodically also with

interaction with individual medical schemes.


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There have discussions over the past few years with medical

schemes about the establishment of a laboratory reque st form for

instance, where we decide, where we agreed to limit the number of

tests on the request form, or create a compacted or create a reduced

request form. We have mentioned that in our submission.

Other than that, the interaction with medical schem es is currently

extremely limited, if not non-existent, so our focus is really to

create a standard an agreed quality standard for pathology in terms

of the various activities which we have sketched out for you and

that is really the primary role.

DR BHENGU If you don’t get involved on tariff issues, what was

your involvement in the case against the Department of Health all

about, because if I am not mistaken, MPG was a player, or an

applicant or whatever the legal term.


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DR ERASMUS We are members of the South African Private

Practitioners Forum and as such, we contributed to the costs

involved in the case, so does that answer the question?

DR BHENGU It was just that contributing to the costs, not so

much that you were involved in practice studies and anyth ing else,

no role at all in the case other than just contributing towards the

legal fees, is that what you are saying?

DR ERASMUS To be really honest with you, I think in fact we did

not even pay our share of the legal fees to be really honest with

you, so I think that is a bill we have outstanding.

DR BHENGU Now you say this is historical, but the other point,

your code of conduct seems to be quite ancient if it was 2002. It

was amended and adopted in 2002. We have heard how the practice

of pathology has changed. Surely it can’t still be relevant? Why is

it not seen to be important? Dr Nkonki raised the question about

what do you have as a means of discipline and effectively you said


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nothing and we’ve got here a code of conduct and it is a 2002

edition.

Is it because you don’t really see your role as instilling discipline

among pathologists?

DR ERASMUS It is impossible for us to discipline pathologists.

We are not legally entitled to do that. That is the role of the Health

Professions Council. At best, we can entice pathologists and we

can set standards that we believe are appropriate, standards that

have been agreed to by the members of our executive committee

and held up as a mirror which every practice can use in which to

view itself.

But essentially, i t is a process whereby the parties involved, police

themselves, but at least there is an attempt to create a set of clear

rules, even though it may have been established in 2002, I can

assure you amongst my membership, there is high value attac hed to

that as a document reflecting ethical standards.


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DR BHENGU Let me just ask a few questions that have come up

in the past. I understand that I cannot ask if you do know if there

is market allocation among your players, but I can ask factually as

to the distribution of the practices of your members relative to

hospitals.

If I were to basically say here for example, if I say let’s just say

Ampath, where are most of Ampath’s practices relative to the

hospital groups? Is there a sort of trend that one c an determine and

mind you, I am not asking if there is an improper relationship, it is

just a statement of fact.

DR ERASMUS I am really unable to answer that question. The

different practices are now so wide-spread throughout South Africa

and in so many different areas, that no practice has a discreet

geographic area or location and to be really honest with you, it

does not interest me at all where the practices are. That is not what

I do, or try and be involved, so from my point of view, that is a

practice issue, I have absolutely nothing to do with that at all.


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DR BHENGU No that is fine, I accept it , but it is obviously

something we can follow up on.

JUDGE NGCOBO All that you are being asked, is whether you

have knowledge of that and we assume that, because your

organisation prides itself as the only organisation that represents

the pathologists, prides itself as being the organisation with

members who are accredited by international organisations. We

would have thought you would have known this info rmation.

DR ERASMUS I did not mean that in a derogatory manner. I rather

meant it in the sense that there has been an anxiety amongst

membership about anti -competitive behaviour and a great concern

that whatever activity we are busy with, we should make sure that

there is no risk of that involved at all, so my statement of saying

that I have no interest in it , is linked to that aspect specifically, so

I do apologise, I was not trying to be offensive at all, thank you.


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JUDGE NGCOBO And when you say I have no interest, what do

you mean? Are you suggesting that the national pathology group

has no interest, or you personally don’t have any interest?

DR ERASMUS No I was referring to my capacity in the national

pathology group and the fact that I would rather not have data

which could be of such a nature that it could be considered as being

of an anti-competitive nature, that is all that I was saying. It is not

that I am not interested in where the pathology services are, not at

all, but it is not an area where we involve ourselves at all. It may

be a deficiency I do not know.

JUDGE NGCOBO I understand, I was curious to hear you suggest

that I am not interested, whether you were saying that as an

individual, or as the organisation, but you have clarified that you

are speaking on behalf of the organisation I understand.

DR BHENGU Some of your members have indicated that have got

shareholding in group practices, is that if your code of conduct


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were to be updated, what would your position be around this? Is it

something that you would encourage or you have no view about?

The groups like Health Works like Inter Care.

DR ERASMUS Dr Bhengu I am unaware of the detail of that at al l.

The only comment that I could make or could say is that one must

be very careful of any risk of possible perverse incentives. I don’t

know the detail and I am not able to comment about that at all.

DR BHENGU Ja the question I’m asking, but I assumed you had

read the submissions of your members to the Health Market Inquiry

before you came to represent them?

DR ERASMUS No, I did not read the submissions.

JDUGE NGCOBO Are you suggesting that the submissions that

have been made to us by some pathologists, you didn’t read those?

DR ERASMUS Chair I have not read the submissions which were

made by the individual practices to the Commission, not at all, no.


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JUDGE NGCOBO You only read, I mean the one that you

responded to, those are the submissions made by some of the

practitioners, the hospital groups, which talked about the reflexes.

DR ERASMUS Chair sorry I was misunderstood, I thought you said

had I read the submissions of the other pathologists groups and by

that I meant the pathology practices who are members of our group,

being the ones who are around the table, which I have not read, b ut

I did read some of the submissions that were made by a company

specifically called [Verirad], I also read summaries that were made

by parties of activities that occurred in submissions to the

Commissions in the broader sense of the word, yes I did.

JUDGE NGCOBO I think that is what Dr Bhengu was asking you.

DR ERASMUS I’m so sorry, I am lost now, I don’t know where we

are, what did you request of me Chair please?


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JUDGE NGCOBO Your response was that you did read some of

the submissions, so what I was suggesting to you, is that that is the

question that Dr Bhengu was asking of you.

DR BHENGU Now when I open a new hospital , what process do

your members go through in bidding to be the laboratory that gets

space in my hospital?

DR ERASMUS Unfortunately I cannot answer that, you will have to

ask that of the individual members, I cannot comment on that at all,

I do not know.

DR BHENGU They are on your panel.

DR BRAMDEV I think in general, when a new hospital opens,

they invite presentations from the various laboratories, so there is a

tender process in place and the laboratory is invited to make a

presentation in terms of what kind of services you offer etcetera, so


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ultimately I think it is left to the owners of the hospital or the

hospital group to make that decision.

DR BHENGU Are they usually open tenders in the sense that

anyone can sort of come, or is it up to just the 4 practices?

DR BRAMDEV In my experience, it is an open tender. You

often get presentations from all the laboratories involved.

DR BHENGU Does MPG among the guidance that it gives it

members, does MPG feel it is an obligation to drive transformation

in this sector? I mean for all intents and purposes, you are

companies do you have an idea if any audits have been done and

what is the general level of BEE status among your members?

DR ERASMUS No I do not know that, I think also maybe to

understand that, that the MPG is an organisation which consist of

me and one personal assistant, that is the sum total of the

organisation, so the resources are limited and dependent on the


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members for the majority if not all of the activities, where the

expertise lies as well.

The individual practices would report on their BEE status. We are

aware of the requirements. We have offered the services of th e

private pathology laboratories in terms of training to the national

health laboratory service to encourage circulation of the registrars

through the pathology practices.

In fact, many of the practices are involved in training of registrars

and that registrar intake would be determined by the standards set

by the NHLS, so we would accept all the registrars and train

registrars as they are available.

So other than that, in a pro-active sense, the answer to that would

be from a specific MPG, individual per spective, the answer to that

would be no.


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DR BHENGU I think Judge I will stop here, because it seems as if

many of the questions are not known.

JUDGE NGCOBO Were you here this morning?

DR ERASMUS We were here this morning, we greeted you this

morning, but we did not sit in on the presentations.

JUDGE NGCOBO Did you hear the presentation by the Free State

Provincial Government?

DR ERASMUS No I did not attend that. We came about 1:00, so we

saw part of that, but that was all.

JUDGE NGCOBO They referred to some issue which affects

radiologists in the Free State, who it was suggested had lent their

practice number to be used by the Department in return for getting

something like 63% of the fees gathered from that practice and the

Department only getting 33% despite the fact that the equipment

being used, were those of the Department, do you know anything

about that? No? Okay.


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The group of the radiologist society which was here, I think we

heard them 2 weeks ago, they urged us to consider the issue of

regulating the prices or the tariffs. Do pathologists have any view

on that, regulating the tariffs?

DR ERASMUS Chair as a group, I have no specific view on that,

except that we believe our members negotiate now and there is very

stiff competition with the members with the schemes that they

negotiate with, so I believe ultimately, that regulation, but that is

from a very philosophical perspective, that regulation is not a good

thing personally.

I believe it would be counterproductive in the longer term, so I do

not believe that regulation is the right way to go. I think the free

market competition is a far better situation which we have now.

JUDGE NGCOBO Within a group, is there a concern about lack

of work at times when there is a drop in the amount of w ork that

you guys get?


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DR RAMBAU I think the answer to that is no, beause in this

country, there is a shortage of pathologists. I think in all fields,

certainly in the field I practice in, histapathology, there is a critical

shortage of pathologists. In fact, there is more work than we can

do for the number of pathologists out, so I don’t think there is a

real concern in that regard.

JUDGE NGCOBO And then the partners, do they get a salary

from the practice, or do they get a dividend, how does it work?

You are very opposed as I understand to being employed by a

hospital group, beause you believe that there is a commercial

interest on the one hand and there is an ethical issue on the one

hand, now how does it work within the group?

DR BRAMDEV I can speak for our practice. As pathologists,

we get a salary and as partners, we get an annual dividend as well

and the salary is usually commensurate with the level of

performance.


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JUDGE NGCOBO When a request for pathological analysis or

tests lands at the laboratory, how does it get allocated? Does it get

allocated based on what is required from the test, or is it just a

random allocation?

DR BRAMDEV Well I can speak for histopathology, which I

am involved in, when specimens come to the laboratory, it is

divided among pathologists which have got expertise in certain

area, so if you get a brain biopsy, it will tend to go to a certain

pathologist as opposed to another specimen, but in general, there is

an equal allocation of work, except for where there is a speci al

interest.

JUDGE NGCOBO Is there someone who is responsible for the

allocation of work, or how does it work? I can understand where

allocation is based on the speciality. What about those where it is

just a general matter?


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DR BRAMDEV I think the head of each department makes that

decision, that allocation, so there is somebody who supervises in

terms of the work distribution.

JUDGE NGCOBO To make sure there is an equal distribution of

work?

DR BRAMDEV Yes, that is true.

JUDGE NGCOBO There are no complaints that so and so is not

pulling up his or her socks?

DR BRAMDEV That’s true.

JUDGE NGCOBO Do you decide what to charge for a particular

test, or does somebody else make that decision outside of your

practice?

DR BRAMDEV Ultimately, it is the pathologist when he signs

the report, he has got to ensure that the charge is correct. For


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histapathology, the charge is determined by the complexity of the

case and the level of service and [inaudible] you do, so it is the

pathologists responsibility, it is not an automated feature in

histapathology.

The MPG has got billing guidelines that cover most of the

procedures.

JUDGE NGCOBO Those guidelines are available to the public,

are they?

DR ERASMUS Chair I am not exactly sure what you asked now,

could you just repeat that please that I understand clearly what you

are requesting?

JUDGE NGCOBO I am talking about what pathologists charge for

tests. Is there a guideline about what to charge? Who determines

those guidelines? Are those guidelines available to the public?


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DR ERASMUS Chair what we have, is what is called the guide to

coding which is the SAMA medical doctors’ coding manual, so it

will have in that, I am just referring to that guide to give you

clarity, it wil have a test with a number 1 2 3 4, adjacent to that

test, it will have what is called an RVU, a reference value unit and

then there is no price attached to that, but all that that does is that

it says test 1 2 3 4 as opposed to test 5 6 7 8, may have 10 RVU’s,

the other one may have 4 RVU’s , so that just gives the relative

value units between the two different tests, so it means that the one

test will cost twice what the other one is, but it doesn’t say what

the actual cost may be, because that conversation, that Rand

multiplier, is determined by negotiations between the practice and

the medical scheme.

So that is how the price is ultimately determined.

JUDGE NGCOBO Is it available to the public?


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DR ERASMUS The medical doctors’ coding manual, one has to

purchase it from SAMA to gain access to it , but it is a public

document.

JUDGE NGCOBO I am referring to the one that is used by the

pathologists?

DR ERASMUS What we have, is a guide to coding which we

submitted to you previously last year and what that guide is used

for, it uses the number codes within the SAMA doctors’ medical

coding manual. It then says that if you are going to do a lipid

investigation, so a lipid investigation would use the following

codes as tests within a component.

But that is simply the codes and the code names, bu t the price that

is attached to that, is not appended to that, because there is no

price, because the price is based on the individual practice

concerned, but that document is publically available for anybody


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who wishes to use it , or to gain access to it , because we promote

that as the basis, but that is not going to help you very much.

You will know what the test number is and you could enquire from

the practice, what that cost would be for that number, I don’t know

whether that answers the question, but I think one of my colleagues

wanted to add something.

JUDGE NGCOBO What I want to know is this, if I go to any of

your practices and say before I submit myself for any test, please

let me know what your charges are, will you be able to give me

that?

DR ERASMUS The answer to that is yes.

JUDGE NGCOBO So there is a price list what you charge for this

particular test, which is kept by a practice, is that right?

DR ERASMUS That practice would have a list for that specific

service, but it is possible that tha t price may vary given which


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medical scheme you are a member of. It is possible that the one

medical scheme may pay less for the service.

JUDGE NGCOBO So each individual practice has its own

pricelist which may differ according to the medical scheme to

which one belongs?

DR ERASMUS Chair I think that detail, we are going into very fine

detail now, but there is a pricelist available and you as an

individual patient, will have access to that if you want it . It is

available, but then the subtle differences within the medical

scheme, I am not able to comment on, you will have to ask the

individual practices about that.

DR BRAMDEV Just to clarify, I think the prices that individual

practices charge, depends on what they have negotiated with each

medical aid, so it varies from practice to practice. The second

point is you mentioned is there a guide to how you bill and I think

the point Tjaart is making, is that we have got codes, but not


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necessarily with the prices attached, which gives you a guide to

which test you can do. For example if you have a stool specimen,

what are the acceptable organisms to test for as a guide and then

you attach a value, so those guides are available to the public.

JUDGE NGCOBO Each practice determines what prices it would

charge for for specific tests?

DR BRAMDEV Yes, that is correct based on the negotiation

with the funders.

JUDGE NGCOBO And it is the partners who decide that after

listening to the medical aid scheme?

DR BRAMDEV That is correct.

JUDGE NGCOBO Are there any concerns that you have

concerning the regulatory framework that regulates either the

health profession in general, or pathologists in particular?


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DR ERASMUS Chair a very broad philosophical comment would be

the and this is not really my field of specific exp ertise, but the acts

pertaining to the medical schemes that many of the parties who are

involved with medical schemes, they say that the Act has not been

fully implemented in terms of, in other words, an aspect where by

the schemes, would cross -balance the risk profiles and there is a

specific word for that and many of the actuaries are of the opinion

that should this Act be fully implemented, it will lead to a

significant increase of individuals who are covered under the

Medical Schemes Act. I think that could be one aspect.

JUDGE NGCOBO The word risk equalisation ring a bell?

DR ERASMUS Thank you Sir, I would certainly also love to be in a

position whereby we are not in this impasse with the medical

schemes in terms of implementing a proper coding syste m. Our

coding system is deficient, we are in the process of creating a new,

you heard that we have about 750 odd codes and these codes are

insufficient for the needs at the moment. They also only contain 4


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digits and are not structured in a manner that i s really logical in

terms of its flow, so it would be wonderful to be able to have a new

coding system and we are in fact working on such a coding system

which only has the code and the descriptor, there is no RVU

attached to that, because we are concerned about the issue of

competition, but what we want to agree on, is that the same code

number be used and that the same descriptor be used, so that at

least as a point of departure and once we have completed this task,

we are in process, it is a task of inordinate magnitude, but it is

progressing well.

Once we have that, we would like to enter into discussions with

funders about the principles of such a process. Some already

indicated interest in this because it can only add value to all of us

if at least we agree as David has said earlier, what is one cup and

what are we measuring with it .

JUDGE NGCOBO Who should be responsible for the revision of

the code, should it be an independent body?


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DR ERASMUS Chair you have heard my reference to SACHI

earlier. The difficulty around that is that ultimately the input into

such a body, must come largely from the professionals who know

and understand the system, so you often enter and this is the same

problem that we had previously when we were submitting codes to

the SAMA private practice committee.

You would submit a code and you would sit amongst peers, but the

peers that you sat amongst, knew nothing about pathology, they

were really not able to act in a manner of peer reviewing you

efficiently, they were dependent on your providing the data in an

honest manner being questioned about the data and accepting or

modifying it, whilst it is easier for them in a clinical environment,

a group of surgeons are more able to understand what the other one

is doing, or the other person is doing, or physicians whatever, you

know they are more comparable.

We and the radiologists tend to be outliers or different in that

respect, but all that notwithstanding, a group like SACHI I believe


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can be at least a central point where these points are agreed to or at

least the differences are agreed to and at the moment, that does not

exist, so that is a huge deficiency I believe in the current market

and it should be addressed soon.

JUDGE NGCOBO Would an independent body which is

representative of the various discipline, not cater for your concern?

DR ERASMUS The question now, would those disciplines be only

the medical disciplines because there are also many other services

in medicine. Would there be representatives from the medical

schemes, how widely does it go. I think it certainly has potential ,

because a body, because at the moment, there is a state of paralysis .

JUDGE NGCOBO Is there anything else that your team would

like to raise with us? Okay, well that being the case, then t hank

you for coming here and for sharing your knowledge with us and

for the presentation which I thought was quite informative in the


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beginning. I know more about how pathologists function than I

was when I first say here today, thank you so much.

DR ERASMUS Chair thank you so much for inviting us over this

morning early and setting our minds at rest, it helped a lot,

although it has been a tiring long afternoon and I would also like to

say thank you to my colleagues who have been here, who have

presented and we appreciate the questions that have come from the

panel. We have tried to answer them as best we can and thank you

very much for the opportunity thank you.

[END OF RECORDED PROCEEDINGS]

market inquiry into the private healthcare sector public hearing 6 … · 2020-03-24 · market...

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