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Moonlighting drains specialist care at state hospitals

At least a quarter of senior government doctors and specialists are abusing a dual-practice system allowed by the state by working both jobs at the same time, causing “artificial shortages” at state hospitals, and eroding the quality of training of would-be-specialists.

Doctors at government hospitals are legally allowed to do extra work in the private sector as long as they do this outside normal work hours. This is called dual-practice or moonlighting.

It makes it hard for junior staff to report doctors who break dual-practice rules because some departmental heads (the people to whom they are supposed to report) are doing the same thing, write Jesse Copelyn and Joan van Dyk for Bhekisisa.

In the dilapidated paediatric ward of a state hospital in a small town, Emily Benson, not her real name, was growing anxious inside the children’s ward. It was 8.45 on a Monday morning, her first rotation in that department.

An infant was having a seizure. Blood tests showed at least two of his organs were failing. Benson knew she had to treat this baby first – but didn’t know how.

She was a second-year intern doctor – she had graduated from medical school, but still needed to complete her last internship year and a year’s community service before she could work without supervision.

There was a general practitioner (GP) on duty. It wasn’t enough. The intern and GP needed the help of a child health specialist. But the hospital’s only full-time paediatrician had left the facility to work at her private practice.

Benson put the infant on a drip, but she and the GP were out of their depth. “I didn’t know what to do to save this child,” she recalls. “I was terrified.”

There’s little room for mistakes when treating babies, and even tiny errors can have devastating effects on a body so small.

But the person who could save the baby, and had been appointed full-time by the hospital, was treating kids with wealthier parents somewhere else.

Money talks

The fact that the hospital’s paediatrician also works in the private sector is not illegal.

Government health workers can apply to work limited hours in the private sector, as long as it’s outside their government working hours and doesn’t compromise state patients’ care.

They need written permission from their supervisor, who sends a recommendation to the provincial health MEC – or someone to whom they’ve delegated the job, often the hospital’s ethics officer – to make the final decision about whether private work would interfere with a doctor’s government job.

The call must be made within 30 days. If not, health workers are allowed to assume the request has been approved. But a 2015 study found that a quarter of doctors interviewed moonlight without applying for permission.

And even when they get approval, not all follow the rules.

The specialist Emily Benson was waiting for is one of them: “She works full-time at this hospital but full-time in private as well.”

So taxpayers pay her a full salary to work in state hospitals, and then private sector patients pay her again. And the baby Benson was looking after was running out of time.

Benson recalls: “I was so out of my depth. Every minute without the right medicine increased (his) chance of dying”.

Skills shortage

South Africa has only 9,731 specialist doctors, which is not enough – 17 for every 100,000 people.

When it comes to paediatricians, the country only has 818.

South Africa’s specialist-patients ratio is much lower than in many other middle-income countries. Brazil has nearly twice the number of specialists for every 100,000 people. In Mexico, the number of specialists per 100,000 people outstrips SA’s count nine to one.

Most specialists work in the private sector, servicing only 27% of the population. There are 69 of them for every 100,000 private patients.

And in the government facilities? Only seven.

And things are worse than they appear on paper. Because while the government might pay seven specialists for every 100,000 people, many don’t show up to work.

When Benson and the GP called their hospital’s paediatrician at her private practice to find out when she was coming, she replied: “I’m quite busy.”

All Emily could do was to run back to the dying boy to resuscitate him after each fit.

About a third of SA’s state specialists make extra money at private facilities. But it’s unclear how many exploit the system.

“It’s probably about a quarter of doctors (who abuse dual practice), but that places a burden on everyone else and compromises the entire system,” says Shabir Madhi, head of the University of the Witwatersrand’s medical school.

Research in Gauteng in 2004 showed that abuse of the dual practice concession was so widespread “most doctors work only for four hours (per day) on average before leaving to consult private patients in their private clinics”.

Bhekisisa spoke to 11 medical professionals, most of whom said it was common.

The NHI plans to make the same quality health services available to everyone. But for the system to work, we need enough professionals, and the workforce to train them.

Specialists in training are called registrars, who do a combination of theoretical and practical training. Theory can be learned from books, but practical training requires supervision.

Dr Nicholas Crisp, deputy director general at the Health Department heading up the NHI implementation, says: “As doctors, we learn not just from what’s written in a book, but also when someone watches you while you’re putting in stitches and drains. If that senior person isn’t there, how much are you really going to learn as a registrar?”

The dearth of mentoring won’t just affect those training to be specialists, Crisp says.

“If the registrars aren’t around because they’re tired from doing the consultant’s work, and there are no senior medical officers around, what will junior doctors learn?”

It’s ‘white-collar crime’

So, if dual practice is potentially bad for both patients and doctors, why do managers allow it? Because in many cases, they’re abusing the system too, according to three of those interviewed.

One medical intern, who was often abandoned by her moonlighting superiors, told Bhekisisa it was hard to complain because her department heads, to whom she’s supposed to report this, were doing the same thing.

That culture trickles down to juniors, a clinical manager said, who then copy it when they become supervisors.

Crisp says there’s no real shame about abuse of the system. “We have senior clinicians at government hospitals who brag that they have not been in the public hospital for weeks.”

For Madhi, the bottom line is clear: “It’s white collar crime.”

Back in Benson’s hospital’s children’s ward, it’s 3pm. There’s still no sign of the paediatrician she called six hours earlier. The little boy’s mum is at his cot.

Benson tries to explain what is happening, but her isiXhosa is broken and there’s no translator around.

The parent is worried. She’s been by her child’s side, plastered to a cheap plastic chair for days. It’s people like her who bear the brunt of doctors’ greed, encouraged by a badly managed system.

Moonlighting was originally supposed to compensate for low salaries offered by the public health sector. The idea was that the government could prevent underpaid doctors from leaving state hospitals by allowing them to earn extra from private work.

But government doctors’ pay has ballooned since 2009.

A new wage policy meant that in a single year, medical officers’ salaries increased by up to 68%, and specialists’ pay rose by up to 50%, with the annual salaries of chief specialists rising to R1.2m.

As a result, medical officers in SA government hospitals were earning more than their peers in the UK and Australia (when considering the actual purchasing power of their wages).

For instance, a medical officer at a South African government hospital with 5-9 years of experience earned R423,846 a year in 2009 after the salary adjustment. Their peers in the UK and Australia were earning R385,314 and R327,127 respectively (when their wages are converted to rands and then adjusted for their actual purchasing power).

The NHI might, however, make it harder to moonlight.

There will be far fewer opportunities for dual practice under the state-funded medical aid because private medical insurers will not be able to cover the services provided by the NHI. This will make it more difficult for specialist doctors to open a private practice separate from the scheme.

But Crisp reasons that rather than relying on the NHI to stop moonlighting, the principle of dual practice should be scrapped altogether.

“The clinical department head in a provincial hospital now earns millions a year with overtime and then still does (dual practice), sometimes during public sector time. Why would you allow that?”

Is there an upside?

At Cape Town’s Groote Schuur Hospital, Allan Taylor is a specialist who runs the unit that operates on people’s brains, spines and nerves.

Taylor runs a tight ship. His team does dual-practice by the book.

“Banning the practice wouldn’t solve the problems with moonlighting,” he says.
“It will erase some of the benefits of the practice.”

State doctors can gain skills from working in the private sector, which they can bring back into government hospitals. “They can take the management lessons they learn in the fast and efficient private sector back to state facilities.”

Moreover, spending time in private practice gives doctors the chance to do procedures they would not have the resources to perform in government hospitals.

John Ashmore, a public health researcher, also warns that changing the rules that allow for moonlighting may not actually stop the practice; it would simply push it underground.

And there could be bad consequences.

Staff who are already angry at the department could feel vilified, Ashmore says.

What happened when the paediatrician returned?

Where Emily Benson works, the only full-time paediatrician at the state facility is finally back at her post.

She orders a seizing baby boy to be rushed to the intensive care unit. She is livid. She says the GP who supervised Benson should have known to admit the infant to the ICU far sooner. “This should have been done this morning,” she scolds.

But Emily and the medical officer had kept the baby alive for seven hours, not without potential consequences.

He’s doing all right – for now – but doctors couldn’t rule out the possibility that he might show signs of brain damage.

Additional reporting by Regan Boden.


Bhekisisa Centre for Health Journalism article – SA’s moonlight sonata: The illegal cash cow draining specialist care at state hospitals (Creative Commons Licence)


See more from MedicalBrief archives:


NHS doctors banned from ‘rip-off’ moonlighting


Moonlighting KZN doctors rake it in


KZN hospital CEO’s lucrative moonlighting




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