The paucity of patient outcome data in South Africa is a major hindrance to best-practice medicine, helping drive the tide of litigation against healthcare professionals, says Natalie Zimmelman, CEO of the South African Society of Anaesthesiologists.
She said that the lack of specialist clinical outcomes measures is not only preventing best practice medicine, but also driving up costs and exposing doctors to malpractice suits.
Thinly-spread specialists in both the public and private sector, especially within maternal services and neurosurgery are highly vulnerable, with burgeoning claims threatening to render these fields unviable. The number and value of clinical negligence claims brought in South Africa has risen rapidly in recent years.
According to Treasury, estimated payments for medical negligence claims against the State grew at an average rate of 45% between 2012/13 and 2016/17, leaving a State contingent liability of about R56bn in 2016/2017. In the private sector, a major London-based local insurer estimates the number of claims (across all disciplines) to have increased by 35% between 2011 and 2016. Over a 10-year period demands in excess of R5m increased more than nine-fold, with claims sizes having increased by over 14% on average, each year between 2009 and 2015.
If these trends continue, it is conceivable that soon even those willing to pay for private services may struggle to find access to high-quality specialised services like obstetric care, because of scarcity of qualified staff (similar to specialised paediatric neurosurgery, which is no longer available in the private sector).
Over half of members belonging to the South African Society of Obstetricians (SASOG), believe they will stop providing obstetric services in the next five years, while a fifth of SASA members are “vulnerable to move or leave South Africa,” surveys conducted by the two groupings show.
Collecting enough data around patient outcomes will enable clinicians and healthcare cost centre managers to find the most effective, best value-for-money and lowest risk treatments, Zimmelman contends. She adds: “We can capture the one-to-one patient stuff, but it’s currently very difficult to compare outcomes on an aggregate level. Clinicians have a responsibility to identify and capture the clinical data that points to the best outcomes and what happens to patients as they proceed with treatment. We need to start tracking in real time so that, with sufficient data, we can start risk stratification.”
According to Zimmelman, clinical improvement currently comes mainly through periodic research. Instead, what’s needed is the creation of core competencies and an IT system to back them. With the financial and logistical kickstart of a local indemnifier of healthcare professionals, EthiQal (a division of Constantia Insurance), this is now happening.
“They knew what we wanted to do, so in 2017 we got the ball rolling. The aim is to capture a critical mass of outcomes data to enable better evidence-based medicine, so the practitioners can benchmark themselves. Where they’re currently being bench-marked is not efficient. It has to be clinician-driven, trusted and protected,” Zimmelman said.
She concedes that it may take several years, but a carrot and stick approach, involving better remuneration for better-performing doctors, the satisfaction of successful treatments plus a contractual requirement for data collection, will help.
Dr Phil Matley, chair of Surgicom, a private company representing 300 general and vascular surgeons in South Africa, (whose individual members pay medical indemnity subscriptions of around R220,000 per year), says action is urgent. “The obstetricians and gynaecologists (who individually paid up to R850 000 per annum in 2018 with some indemnifiers), are further down this road than we are, but we’re part of a pilot project on risk stratification in partnership with Discovery who are really trying to understand and invest in our general surgery environment,” he says.
A significant investment from Constantia Insurance has enabled the EthiQal-Surgicom Collaborative Risk Management project which focuses on the development and sharing of clinical and legal risk management tools. Clinical guidelines have already been produced for surgical circumstances that commonly lead to litigation, like bile duct injuries during minimally invasive surgery and major injuries occurring at the time of abdominal entry during laparoscopic surgery. A series of patient education leaflets for common surgical procedures, together with an informed consent template, are aimed at strengthening the patient informed consent process and boosting patient knowledge prior to surgery.
Says Matley: “EthiQal has been very pro-active in helping us drive medico-legal risks down and hopefully will enable organisations like ours to secure comprehensive cover at more competitive rates.”
Zimmelman, who defines herself as, “a business generalist and activist,” says the core competencies of an IT system must be a) the identification and codification of data captured, b) the creation of an intra-operable platform (for use across disciplines) and c) competent data security and governance.
“Once we have those three core competencies in place, we can collate and analyse the data. It’s going to require social change and physician willingness but we can see the why and how,” she says.
Dr Bettina Taylor, clinical risk specialist at EthiQal, added: “We all share a common vision of improving access to high-quality affordable healthcare. Legal reforms, collaborative risk management projects, and doctor-driven solutions, including peer review and support programmes, will help get us there.”