RWOPS abuse - Government's had enough - Izindaba - South African ...
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Izindaba
RWOPS abuse – Government’s
had enough
Working privately during their official
State working hours, nearly one in four
specialists forensically reviewed and
employed at the Nelson Mandela Academic
Complex and/or Walter Sisulu University
in Mthatha earned between R6 500 and
R126 000 extra over six months last year.
One professor was paid R781 867 by six
medical aid schemes reviewed, but there was
no evidence of his having used the private
hospital theatre so popular with his ‘two-
timing’ colleagues – and which he listed
in his application to do 15 - 17 hours of
private work per week. The forensic auditors
suggested a further probe into his payments.*
What appears to be avarice and a lack of
moral fibre is not unique to this minority
of Mthatha specialists. Rather, it mirrors
nation-wide abuse of the Remuneration for
Work Outside the Public Service (RWOPS)
system. It was introduced by government in
January 2000 as a recruitment and retention
tool and to encourage on-going research struggle to fill specialist vacancies caused Extensive fall-out
and the development of skills (not always by a clampdown on RWOPS than employ The Gauteng probe found that those
available in the public sector). With a chief ‘dishonest professionals who are never there specialists and registrars left behind to ‘hold
specialist in the public sector today earning a anyway’. ‘On top of complaints of corruption the public fort’ were ‘overloaded, angry and
gross salary (including commuted overtime in government, here you have professionals resentful’, while RWOPS led to general high
of up to 16 hours per week) of between R1.4 stealing from the public and the nation. absenteeism, abuse of sick leave privileges,
and R1.6 million per annum and a specialist We’re going to have to probe and review high stress levels (headaches, insomnia,
with more than 10 years’ experience in line the entire thing, it’s just not on.’ Pointing to fatigue, heart problems and endocrine
to earn R1.163 million annually, one of the weak management coinciding with some disorders), low morale, fewer services offered
foundation stones of RWOPS (recruitment/ specialists outranking hospital CEOs in and long patient queues. It also uncovered
retention) has crumbled. This and the experience and qualification, he cited a CEO ‘aggression, resignations, group conflicts
widespread abuse have led to an almost in the department of anaesthetics at Steve and group coalitions, abuse of medical aid
unanimous call across political lines for its Biko Hospital (Gauteng) who was ‘very soft facilities and an abuse of state assets to treat
scrapping, with provincial health chiefs and on his specialists’ – until the situation got private patients’.
the national minister about to clamp down. out of hand with some taking days off to do The Mthatha probe showed that many
RWOPS. When the CEO took action, six RWOPS application forms filed failed to
resigned. Observes Motsoaledi: ‘We say that’s declare private surgeries the specialists were
better, because then you actually have a real running in town or failed to state what
vacancy, not a false one.’ He confirms that times they would be operating privately. In
professional conduct hearings are among the several cases where times were applied for,
avenues of redress being explored, this being they were inconsistent with the consulting
echoed by his operational counterparts times posted outside their private surgeries.
in KwaZulu-Natal and the Eastern Cape, One misleading application showed the
respectively. consultant to be doing RWOPS from 17h00
A 2004 public service commission probe to 18h00 Mondays to Fridays (legitimately
into RWOPS abuse in Gauteng’s health outside official working hours of 08h00 -
services reported that more than half the 16h30), but theatre records told a different
‘Professional theft’ – Health Minister specialists owned private practices, mirroring story. He was operating privately from as
A ‘disappointed’ National Health Minister, last year’s Mthatha findings. When private early as 08h00. Theatre time records of
Dr Aaron Motsoaledi, believes that patients work hijacks public sector contractual the favoured private hospital also show one
are actually dying because of specialist obligations the effect on patients and on consultant to be working within the hours
greed. He says high mortality rates at certain collegial morale, not to mention the long-term stated on his application form for just 11 out
hospitals correlate alarmingly with high implications of a major dumbing down of of 91 procedures conducted over the six-
RWOPS abuse. He says he would ‘far rather’ registrar supervision/learning, is disturbing. month review period. A professor is recorded
899 December 2012, Vol. 102, No. 12 SAMJ
Izindaba
as performing nine of his 96 RWOPS staff were absent during normal working
procedures out of applied-for hours and a hours were regarded ‘with contempt’ by
cardiothoracic surgeon as performing 13 other departments which fulfilled their
illegitimate procedures (outside of applied- duties properly, he added.
for hours) out of the 51 privately performed, ‘I cannot get over how flouting the absolutely
earning R49 736 over and above his state basic tenet of breach of contract is tolerated,’ he
salary in six months. One gynaecologist fumed. His colleague said many offenders were
earned R123 271 for nine procedures over sub-specialists to whom he regularly referred
the six-month review period, only one of patients, hence his request for anonymity in
which fell within the applied-for times. A spite of breaching the ‘collegial silence about
check with the Board of Healthcare Funders the elephant in the room’. His experience was
(BHF) revealed that of 54 specialists working that a real work ethic was highest in well-
at the Nelson Mandela Academic Complex motivated and well-led rural hospitals. His
and/or Walter Sisulu University, 30 had colleague, after much agonising, also chose to
practice numbers (some no longer in use). remain anonymous, adding: ‘It’s a small town
and many of these people are colleagues with
Patient neglect costing billions in whom I once worked closely and continue to
litigation maintain a professional relationship.’*
Dr David Mbokota, Head of the South African
Medical Association (SAMA)’s Specialist
Private Practice Committee, says tertiary One professor was paid
hospitals are ‘haemorrhaging’ specialist skills R781 867 by six medical aid Eastern Cape Health Department chief, Dr Siva
to RWOPS. Besides the cost to service delivery, schemes reviewed, but there was Pillay.
registrars were not being properly supervised, no evidence of his having used
meaning that when they qualify, they lack the private hospital theatre so the State were in the offing for ‘these greedy
sufficiently honed skills. He’s certain that the money chasers raking in millions extra a
popular with his ‘two-timing’
RWOPS abuse contributes significantly to the year at public expense’. She had warned her
national 2011/2012 Department of Health
colleagues – and which he listed doctors that ‘either you are in or you are
patient litigation bill of R1.4 billion (with in his application to do 15 - 17 out. You cannot have your bread buttered
several cases still pending). Mbokota says that hours of private work per week. on both sides. This nonsense will end soon.’
with 65% of the national health budget going Eastern Cape Health Department chief,
to salaries (granted, partly due to a bloated Dr Siva Pillay, questioned why anyone
administrative cadre), just 35% is left for KZN weighs in with a probe earning more than R1 million per annum
vital operational issues. ‘And then we wonder KwaZulu-Natal’s Health Department chief, would want to earn more and deprive poor
why equipment is never maintained,’ he Dr Sibongile Zungu, said more than 250 people of a service. ‘There’s something we
observes dryly. He also believes that with the doctors are being probed for RWOPS abuse need to change in the mind-set of people.
current levels of public service remuneration, in her province. Of these, 200 had been You can only remain rich and comfortable
RWOPS should be banned. ‘You’re either in identified as having private practice numbers as long as the mass of people are not at the
private or public, not both. If they come to the and making regular claims from medical point where there’s a second revolution.’ He
public service, let them do normal sessions. aids. Many were also abusing their paid said the RWOPS application forms had a
They’re actually working full-time in private leave to earn money privately. Disciplinary major loophole: if there was no official reply
and part-time for the State, instead of the charges and repayment of losses incurred by within 30 days it was tacitly accepted that the
other way around.’ specialist had permission.
Health Ombudsman, Mboneni
‘Basic breach of contract’ – physician Bhekiswayo, said the weakness in the system
Two KwaZulu-Natal tertiary hospital was that no one monitored compliance and
physicians interviewed by Izindaba were able adherence. Putting an immediate stop to
to cite examples of specialists making initial RWOPS would improve the quality of public
patient assessments, formulating treatment sector patient care and have a positive effect
plans and ordering tests before ‘dropping on waiting times both in outpatient clinics
out of sight’. ‘There is no or very limited and wards. Professor JP van Niekerk, Dean
teaching from these people, who have a lot of Medicine at UCT at the time RWOPS
to share,’ one said. The other said the issue was introduced (and outgoing Managing
‘periodically makes my blood boil – the rest Editor of the SAMJ), said that ‘generally’
of the time it merely simmers’. The conflict surgeons were for it and medical specialists
involves ‘powerful individuals and will not against. His faculty dealt with the vexed
be resolved without ugly confrontations’. question of control by introducing a central
He believed pay and working conditions billing mechanism, which stands to this day.
were not ‘of themselves’ enough justification ‘RWOPS is ethically neutral; it all depends
to breach an employment contract – the on how well it’s managed,’ he said.
culprits chose to work in the public service. Dr Sibongile Zungu, KwaZulu-Natal Health Dr Ernest Kenoshi, CEO of Steve Biko
Departments where significant numbers of Department chief. Academic (formerly Pretoria Academic)
900 December 2012, Vol. 102, No. 12 SAMJ
Izindaba
16 consultant anaesthetists short, leading SAMJ correspondents break
to 120 patient procedures cancelled collegial silence
per week. He believes RWOPS abuse Dr Lara Nicole Goldstein, of the Division
is worse at second-tier hospitals where of Emergency Medicine, University of
superintendents fail to keep tabs. ‘I ask my the Witwatersrand and the Department of
guys to give me their week’s programme Emergency Medicine, Helen Joseph Hospital,
and tell me where they’ll be when. I police broke a long-standing collegial silence in the
the time they’re supposed to be at the SAMJ this September in a letter which she
hospital.’ RWOPS had allowed significant ended with the following: ‘Some specialists
broadening of training but abuse should justify this (RWOPS) theft from the state by
not be tolerated, he added. maintaining that the health system would fall
Agreeing, Professor Allan Taylor apart if they were to leave. That may be so – but
(Department of Neurosurgery, University of surely they should be honest enough to declare
Cape Town) said these pressures existed long the hours they’ve actually worked and only get
before the RWOPS policy was introduced, paid for those? Would that not help our failing
Professor Ken Boffard, Head of Surgery at Wits. adding that levels of care were ‘appropriate health system, which could re-distribute the
and often exceptional’, given their allocated funds saved to other more useful resources –
Hospital, said public sector doctor salaries budgets and volumes of patients. Boffard medication, equipment and staff?’1
had doubled in the past three years and conceded that there was no official RWOPS
would continue to increase annually at monitoring system in place at Charlotte
an unusually high rate because of the Maxeke Academic Hospital, explaining that A ‘disappointed’ National Health
implementation of the grading system it was extremely difficult to monitor doctors Minister, Dr Aaron Motsoaledi,
of the Occupation-Specific Dispensation because they were not allowed an office or
believes that patients are actually
(OSD). This meant that by the time the work area in the hospital, forcing them to
last phase of the OSD was implemented, use private rooms for academic work. ‘If
dying because of specialist greed.
public sector specialist net income would they’re in their private office doing academic He says high mortality rates
exceed that of many of their private sector things and I ask them to come across, they at certain hospitals correlate
colleagues. always do.’ alarmingly with high RWOPS
While there was ‘some’ validity in claims abuse.
of lack of surgical training for junior
One gynaecologist earned doctors at some hospitals, it had little to do
R123 271 for nine procedures with RWOPS. Instead the reduced number The response in a subsequent letter by
over the six-month review period, of lists, and therefore cases, meant the Dr Robert Ian Caldwell, a KwaZulu-Natal
only one of which fell within the trainees got less surgical training. As a physician intimately involved in an internal
applied-for times. ‘knock on’ senior registrars had to do more medicine ‘flying doctor’ outreach programme,
surgery to try to increase their exposure, went further: ‘These are criminals. Stick a
further reducing training for juniors. couple of them in jail. That would stop the
Surgery chiefs highlight RWOPS Boffard agreed that the RWOPS policy rot overnight. These are not derring-do cat
benefits ‘needs revisiting’, especially in the light of burglars or romantic Robin Hoods. These are
Professors of surgery across a wide the impending national health insurance, the hoods who rob the poor to satisfy their
geographical spectrum strongly refuted which would render it ‘unaffordable’. greed. Nail them’.2 Boffard pleaded with fed-
allegations that waiting lists were longer Professor Brian Warren, executive Head up provincial and national health leaders not
and surgical throughputs down because of of the Department of Surgical Sciences at to ‘throw the baby out with the bath water’.
RWOPS. Professor Ken Boffard, Head of Stellenbosch University, said monitoring
the Surgery Department at Wits, said the should not be based on how much time was Chris Bateman
drop in surgical throughput at Charlotte spent in the public sector, but on whether chrisb@hmpg.co.za
Maxeke Hospital in Johannesburg over the the staff member met all of his or her full-
past five years was due to a 50% reduction time commitments. S Afr Med J 2012;102(12):899-901.
in available theatre time and a reduction A ‘kissing cousin’ of RWOPS, Limited DOI:10.7196/SAMJ.6481
in the number of beds available. Even Private Practice (LPP), was permanently
though surgeons were available, they were withdrawn on 31 August 1999 after a year- *The author has deliberately not named
limited in what they could do. Because of long phasing out period and agreement at specialists under preliminary investigation
restrictions in facilities, it was no longer the Council for Conciliation, Mediation and and has respected the requested anonymity
possible to solely train fellows and registrars Arbitration (CCMA) between the National of several sources. Due to the deeply endemic
in a provincial environment, he said, citing Health Department and unions representing nature of RWOPS abuse, he believes it would
the extremely rare occurrence of costly doctors and dentists in the Public Sector be discriminatory to single out individuals
vascular stent procedures in provincial Coordinating Bargaining Chamber. LPP without the benefit of long-overdue, wide-
hospitals. Without the private sector there was introduced in 1991 as a ‘temporary ranging and properly constituted enquiries.
would also be virtually no access to MRI measure to alleviate the conditions of service
1. Goldstein L. Thieves of the state. S Afr Med J 2012;102(9):719.
training while the only positive emission of doctors and dentists’ – provided the care [http://dx.doi.org/10.7196/SAMJ.6165]
tomography (PET) scanning was done in of state patients, research or teaching did 2. Caldwell R. Thieves of the state – a response. S Afr Med J
2012;102(10):775. [http://dx.doi.org/10.7196/SAMJ.6301]
Johannesburg General Hospital, which was not suffer.
901 December 2012, Vol. 102, No. 12 SAMJ
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