As KZN relented after protests by unemployed junior doctors, and advertised 120 posts for medics this week, experts are suggesting that the debate should turn to young doctors setting up private practice instead of depending on the state for employment, writes MedicalBrief.
Among the suggestions is for young doctors to spend part of their community service year working in a private practice to develop critically needed administrative skills and discover what’s needed to set themselves up.
Chris Bateman reports that's according to the immediate past chairperson of the South African Medical Association, Gauteng GP, Dr Angelique Coetzee, who says this would help stem an alarming flow of youngsters away from family practice and benefit critically needed primary healthcare delivery.
Coetzee's comments come as a group of young doctors ended their sit-in outside the KwaZulu-Natal Department of Health’s headquarters in Pietermaritzburg, and an agreement was reached, leading to 120 posts being advertised.
The department said the recruitment process was expected to be wrapped up by the end of April, reports IOL.
The department said that finding the money for the posts was one of the key challenges to hiring the graduates, reports TimesLIVE.
The MEC had said there were funds from the MTEF (medium term expenditure framework), but “those are not for hiring unemployed doctors”, they were meant to foot the bill for the wage agreement agreed upon last year.
Meanwhile, both Coetzee and Dr Unben Pillay, the chief executive officer of the Independent Practitioners Association (IPAF) and the Alliance of South Africa Private Practitioners Association (ASAIPA), say the solution could be a change in focus towards private practice as GPs in South Africa are in danger of becoming a dying breed.
Among reasons they cite are that they are unable to collectively bargain for tariffs and face rising overheads as more patients go straight to fee-unregulated specialists or to the public sector to address their maladies.
This becomes a potential crisis because the looming NHI has primary healthcare as a fundamental pillar aimed at restoring the gatekeeping and overall cost-saving role of the GP on a capitation payment/value-based care basis. NHI chief Dr Nicholas Crisp has said universal healthcare required sufficient GPs to enable it to function effectively and confirmed that they would be the first cohort of doctors to be embraced by universal healthcare.
Pillay says “currently we are unable to negotiate of behalf of GPs as a collective because the system doesn’t allow for it. Ourselves and the Board of Healthcare Funders have been awaiting our application for an exception to the Competitions Commission for two years now and it’s very frustrating.”
The Competition Commission released the Healthcare Market Inquiry (HMI) Final Findings and Recommendations Report on 30 September 2019, having probed the level of competition in private healthcare to diagnose the factors that prevent, distort, or restrict competition. One of its chief recommendations was that GPs be allowed to negotiate collectively and be restored to their role as healthcare gatekeepers.
Pillay says that from a funder and the government point of view, negotiating with a family practitioner collective is far more efficient. Medical aids – unlike the regulators – have creatively pivoted to create ‘preferred providers’ among GPs, thus avoiding what would otherwise have become a mere trickle of patients to them.
However, regulatory amendments have been delayed with National Health Minister, Dr Joe Phaahla yet to pronounce on four-month-old Council for Medical Scheme recommendations for amended regulations allowing low-cost benefit options, streamlining prescribed minimum benefits, (PMBs), and putting in place tariff ceilings for specialists.
Adds Pillay: “There’s general agreement that in the past 10 years since the Competition Commission said it was anti-competitive to negotiate, all that’s happened in the funder space is that payment for GPs has been decimated and decreased. We’ve lost the ability to be the primary healthcare provider and gatekeeper. As a result, we’ve seen the general family practitioner almost becoming extinct. We’re not seeing many new young doctors going into private family practice anymore. Many long-standing GPs can’t keep their practices open. Most find the cost of running their practices almost unaffordable and many are closing down. We’re on a negative growth pattern, purely because of the way the system is structured. There’s a very aged population of GPs and it’s approaching crisis proportions.”
Pillay says the Competition Commission favours a block exemption for the whole industry, but the challenge remains what this means in terms of the applicable legislation.
Pillay says his two organizations want to be able to compete with the corporate providers (GP networks like MediCross and Intercare) so they can have ‘some countervailing power,” regarding medical schemes and administrators. “You want to be able to undertake centralised procurement, negotiated terms and conditions like all the other players,” he adds.
Coetzee said young doctors were ‘simply not skilled enough to get into private practice – so they sit at home or wait in vain for a public sector post. The funders talk about fraud, waste, and abuse, but so much of it is simply ignorance of billing and coding by more junior doctors who often leave it to someone else to do. Our universities are producing hospi-centric doctors and not enabling them enough to get into private practice.”
She said salaries of medical officers, (the most junior doctor rank in the public sector), were ‘quite good – you won’t get that in the private sector working on your own.” Council for Medical Scheme data showed that out of every rand, just five cents went to the doctor. “Dentists and the allied healthcare professions are at about six or seven percent while the pharmacy sector is at 10-12% of the healthcare pie.”
She said the cost of hiring locums when a doctor wanted to take leave stood at about R1 000 per hour while paying VAT, (15% of every patient consult bill once your annual turnover exceeds R1m), every second month was another major burden.
Coetzee said it took her two decades to set up her practice with everything she needed, staff and equipment-wise.
“I’d say at a thumb suck, youngsters need about R850 000 to a million to get a practice running. Also, youngsters will look at the impending NHI and say they’d rather go to some overseas country where universal healthcare is at least up and running reasonably efficiently. They don’t know what they’re going to get here,” she added.
However, National Health human resources chief Dr Percy Mahlati said obligatory community service was strictly for public health service. "It would be inconceivable to reduce this by placing these young doctors away to learn how to set up a private medical practice. A skill of managing one’s private medical practice is not something that the public health service should be responsible for."
Mahlati, however, said there was a dire need for family physicians. "However, that is an academic matter that the National Department of Health has raised with the SA Academy of Family Practice."
"In short, there is no way that the community service year can accommodate those who wish to learn how to set up private practice at the expense of public health. The reason that provincial Departments of Health are not able to employ everyone is purely a budget issue," he said.
TimesLIVE article – ‘Please be patient,’ KZN’s health MEC tells unemployed doctors (Open access)
See more from MedicalBrief archives:
Only 270 out of 800 unemployed doctors placed
About-turn as Phaahla says jobless doctors will be hired – by April
Cum laude medical graduate sitting at home, unemployed