The General Manager: Professional Boards 21 st February 2013

Transcription

1 Unit 16, Northcliff Office Park 203 Beyers Naude Drive Northcliff, 2115 Tel: (+27)(11) , Fax: (+27)(11) P.O. Box 2127, Cresta, Johannesburg, 2118 The General Manager: Professional Boards 21 st February 2013 Health Professions Council of South Africa P.O. Box 205, Pretoria, 0001; ing to: Bertha Peters-Scheepers, Senior Manager: Public Relations and Service Delivery, HPCSA Tel: / Note: Hard copy by courier delivery for your attention. PROPOSED HEALTH PROFESSIONALS COUNCIL OF SOUTH AFRICA GUIDELINE TARIFFS: REQUEST FOR COMMENTS SUBMISSION BY SURGICOM ON BEHALF OF SPECIALIST SURGEONS Dear Sir / Madam / Colleague Please find enclosed our submission in respect of your request for comments on the proposed HPCSA Guideline Tariffs. Yours Truly Dr Stephen Grobler MMed (Chir) (Gastroenterol) Surgicom Director Directors: J Mook (Chair), S Grobler, P Matley, S Pillay, M Wellsted; Company Secretary: Healthman

2 SUBMISSION BY SURGICOM FOR SPECIALIST SURGEONS REQUEST FOR COMMENTS: PROPOSED HEALTH PROFESSIONALS COUNCIL OF SOUTH AFRICA GUIDELINE TARIFFS Contact details: Stephen Grobler, Casper Venter, Surgicom Unit 16, Northcliff Office Park 203 Beyers Naude Drive Northcliff, 2115 Tel: (+27)(11) , Fax: (+27)(11) P.O. Box 2127, Cresta, Johannesburg, 2118

3 REQUEST FOR COMMENTS: PROPOSED HEALTH PROFESSIONALS COUNCIL OF SOUTH AFRICA GUIDELINE TARIFFS: SUBMISSION BY SURGICOM FOR SPECIALIST SURGEONS Table of Contents 1 Surgicom Representation and Scope of Practice 2 Introduction 3 The Association of Surgeons of South Africa: Comparative Study into the Remuneration and Working Conditions of General Surgeons in South Africa 4 What constitutes an appropriate ethical standard or tariff when assessing the conduct of health professionals? 5 Coding and Tariffs 5.1 Procedural Coding scope of practice and terminology 5.2 Procedural Coding unit values 5.3 Procedural Coding billing rules 6 Procedural Coding, rcfs and Tariffs 7 Practice Cost Studies 8 After the Practice Cost Studies Conclusions Appendix 1. Appendix 2. Appendix 3. Appendix 4. Briefs by Surgical Societies Colleges of Medicine of SA (CMSA) President's Survey of numbers of practicing Specialists The Association of Surgeons of South Africa: Comparative Study into the Remuneration and Working Conditions of General Surgeons in South Africa Articles: Kahn D, et al. South African Journal of Surgery Volume 44(3) August 2006: a. General surgery in crisis the critical shortage. b. General surgery in crisis comparatively low levels of remuneration. c. General surgery in crisis factors that impact on a career in general surgery

4 Unit 16, Northcliff Office Park 203 Beyers Naude Drive Northcliff, 2115 Tel: (+27)(11) , Fax: (+27)(11) P.O. Box 2127, Cresta, Johannesburg, 2118 The General Manager: Professional Boards 21 st February 2013 Health Professions Council of South Africa P.O. Box 205, Pretoria, 0001; ing to: Bertha Peters-Scheepers, Senior Manager: Public Relations and Service Delivery, HPCSA Tel: / Note: Hard copy by courier delivery to 553 Madiba (previously Vermeulen) Street, Arcadia, Pretoria, 0002 for your attention. REQUEST FOR COMMENTS: PROPOSED HEALTH PROFESSIONALS COUNCIL OF SOUTH AFRICA GUIDELINE TARIFFS: SUBMISSION BY SURGICOM FOR SPECIALIST SURGEONS 1 Surgicom Representation and Scope of Practice 1.1 Surgicom hereby places a separate submission before HPCSA on the proposed guideline tariffs. This submission will emphasise some of the issues pertaining to specialist surgeons in private practice in South Africa. This submission must be read in conjunction with the prior and later submissions by the Profession, particularly the detailed submissions by the South African Private Practitioners Forum ( SAPPF ), Healthman, Webber Wentzel Attorneys, Genesis Analytics and others. Directors: J Mook (Chair), S Grobler, P Matley, S Pillay, M Wellsted; Company Secretary: Healthman 1/25

5 1.2 Surgicom was established as the business arm of the Association of Surgeons of South Africa (ASSA) in 1996 to manage strategic private practice matters for General Surgeons. Surgicom is a public company owned and managed by General Surgeons. 1.3 Surgicom herein also acts on behalf of The Federation of South African Surgeons (FoSAS). FoSAS was recently established to represent multiple surgical societies, other surgical organisations and interest groups in South Africa. FoSAS comprises the Association of Surgeons of South Africa (ASSA), the College of Surgeons of South Africa (CSSA), the South Africa Association of Paediatric Surgeons (SAAPS), the South African Colorectal Society (SACRS), the Hepato Pancreatico Biliary Association of South Africa (HPBASA), the Surgical Research Society of Southern Africa (SRSSA), the South African Society of Endoscopic Surgeons (SASES), the South African Society of Surgeons in Training (SASSiT), the South African Transplantation Society (SATS), the Trauma Society of South Africa (TSSA) and the Vascular Society of Southern Africa (VASSA). FoSAS has enjoined the Society of Neurosurgeons of South Africa (SNSA) and the South African Society of Anaesthesiologists (SASA) in its consultative framework. Letters of support for this submission are enclosed as Appendix We represent approximately 350 general surgeons in full time or limited private practice. There are some 800 registered general surgeons in South Africa, of whom about 635 are active surgeons. 1 2 Introduction 2.1 On 7 th December 2012 the Medical and Dental Board (MDB) gave notice of its intention to embark on a new process to determine and publish a tariff of fees as contemplated in section 53(3)(d) of the Health Professions Act, 56 of 1974 ( the Act ). This notice followed an unsuccessful attempt by HPCSA a few months earlier to implement a new ethical tariff guideline for medical and dental practitioners. The averred purpose of the new guideline was to direct practitioners in billing and 1. College of Medicine of South Africa (CMSA) President s survey in 2011 indicated a total of 635 Specialist General Surgeons in South Africa, of whom 332 are in private practice (Practice Number prefix -042). See Appendix 2. for further details. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

6 rendering of accounts to patients, and to enable the HPCSA to adjudicate on complaints of overcharging It is averred by most of our associates and advisors that directing of practitioners in billing and rendering of accounts to patients falls outside of the statutory mandate of the HPCSA and that the only authorised purpose of a guideline tariff as mandated by section 53 was to enable the HPCSA to adjudicate on complaints of overcharging. 2.3 We have noted the revised terms of reference and methodology proposed by HPCSA for the proposed tariff guideline for medical practitioners and dentists. 2.4 Any person or entity wishing to effectively and successfully develop and implement a normative guideline to serve as a professional standard must ensure that the guideline adheres to the principles of legality, rationality, consistency, openness and impartiality. Such an entity must have the legal authority to do so, i.e. an explicit and clear legislative framework for doing so. This is even more important where the guideline aims to establish a norm that will be used in the assessment of what constitutes unacceptable professional conduct on the part of a practitioner, such as instances of overcharging. 2.5 It is our contention that the HPCSA foray into tariff last year was ill-advised, reactionary and a waste of resources. Whilst HPCSA may be able to justify their actions on political grounds, we respectfully submit that HPCSA neither has the legal mandate nor the resources to perform this assumed task without the assistance of the professional service providers (doctors, dentists and allied professions), hospitals, pharma and the supply industry. A project of this magnitude has already, in the ill-fated RPL process, run into difficulties due to the complexities in such a process and the perceived objective of price setting (as opposed to price benchmarking). 2. Mandate of HPCSA as per the Health Professions Act 56 of 1974 Section 53: fees charged by registered persons - Section 53(3)(d) empowers the professional boards to determine and publish Guideline Tariffs. The purpose of such Tariff is to assess complaints by members of the public on overcharging by registered professionals. An advisory opinion was obtained from the Competition Commission which confirmed the HPCSA s mandate and proposed process for formulating a new tariff. The initial process of determining a tariff was renewed afresh due to many complaints by professional associations regarding participation and the base tariff to be used (Presentation by Dr BN Mjamba-Matshoba, HPCSA Registrar/CEO). Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

7 2.6 We recognise that the modernisation of coding and setting of tariffs has been stalled by a multitude of complex interdependencies. The perception exists that there has been a general market failure. 2.7 We believe that emphasis must be directed to the real issues, viz. urgent intervention to establish a multi-party coding and tariff forum that has the legal framework (including the blessing of the Competition Authorities) to forge transparent consultative processes on coding and tariffs. This entails either utilising the existing provisions in the National health Act or establishing a new legislative framework. The processes must support the common goals of promoting access to and quality of care for all in South Africa and the requirements of an NHI. 2.8 An HPCSA guideline tariff is an option that is ostensibly an immediate solution (in the opinions of Council for Medical schemes-cms and HPCSA). Other processes that are in the offing are a health sector Competition Commission market enquiry and a statutory pricing authority We advise HPCSA against an internal project to develop a reference tariff. If HPCSA were to continue this project unilaterally, we predict concerted legal challenge. Our recommendation is that we embark on a broad, collaborative process to develop a coding and tariff structure that would be robust, yet adaptable, but foremost, a proud, endorsed and legal product. We would welcome, approve and heartily support the HPCSA, as one of the role players, to develop, maintain and govern a modern, appropriate coding structure and cost-based tariffs on these premises HPCSA must continue its governance mandate in general practice affairs, such as informed consent (including financial disclosure and agreements), elimination of kick-backs, dishonest billing (e.g. split billing, unbundling, cosmetic surgery under the guise of clinical necessity) and other perverse or irregular business practices, as is permitted by its legislative framework Most of the coding and tariff complaints should have been prevented by adequate communication to ensure and counsel upon medical necessity and appropriateness, befitting ethical financial conduct, an honest advisory process, including 3. Monwabisi Gantsho, CMS Registrar and CEO before Health Portfolio Committee 31st October Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

8 confirmation of benefits with Schemes, particularly in cases of expensive or unusual treatment plans. This is why we are called to be and deemed as professionals and specialists and doctors! 2.12 Surgicom, ASSA and FoSAS welcome referrals of cases for peer review and audit and would propose that the HPCSA utilise this mechanism to address section 53 complaints. 3 The Association of Surgeons of South Africa: Comparative Study into the Remuneration and Working Conditions of General Surgeons in South Africa The Association of Surgeons in South Africa (ASSA) commissioned an independent study, carried out by P-E Corporate Services, into the remuneration and working conditions of General Surgeons in South Africa. The study was prompted by Growing concerns within ASSA about the diminishing number of applicants that were presenting themselves for General Surgery training in South Africa; and The consequent increase in the number of General Surgery posts that were vacant in the State sector. Terms of reference for the study focussed particularly on remuneration and working conditions of General Surgeons and covered those employed in both the State and Private Sectors. 3.2 ASSA s concerns were well founded. A progressive and serious decline was noted in both the earnings and working conditions of General Surgeons and particularly those employed within the State sector. A significant and meaningful disparity existed between earnings of General Surgeons and other professionals working within the State sector, and the earning potential of General Surgeons who choose to emigrate from South Africa. State sector shortages (vacancies) had reached alarming proportions and the profession was in crisis. Extreme shortages of qualified personnel had led to a situation in which many General Surgeons and 4. See Appendix 3 for the complete report and related articles published in peer reviewed journals. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

9 Registrars were working dangerously long hours and often in inadequately equipped and poorly managed hospital environments. An analysis and comparison of remuneration earned by General Surgeons in State sector employ indicated that earnings lagged those of other professionals in State and Public Sector employ by significant margins. Differentials of 30 to 40 percent existed between earnings of recently qualified General Surgeons and professionals such as legal practitioners, engineers, municipal managers and airline pilots, at comparable levels of seniority and responsibility. General Surgeons in State employ were also relatively poorly remunerated in relation to their international counterparts. Low, uncompetitive levels of remuneration coupled with long working hours and sub-standard facilities inevitably impacted the lifestyle of General Surgeons who choose to remain in State sector employ. 3.3 To the extent that these conditions had been allowed to deteriorate and continued to do so, they provided a growing incentive for General Surgeons to seek alternative work opportunities internationally. 3.4 The data appeared to strongly support the contention that General Surgeons in private practice were poorly remunerated relative to their peers in other specialities. An analysis of movements in fee rates for defined General Surgery procedures indicated that fee rate increases had slipped during the period of high inflation between the mid 1980 s and early 1990 s. A common currency comparison of South African fee rates (for the same defined procedures) with those in Australia and the U.K. revealed that Australian rates were, on average, 2 to 3 times those in South Africa, and U.K. rates between 4 and 9 times South African rates. To the extent that such rates could be taken as indicative of earnings differentials, they would suggest that General Surgeons in private practice in these countries enjoyed considerably better earnings and living conditions than those in South Africa. 3.5 Perceptions among recently qualified specialists interviewed about their choice of General Surgery as a career were that the profession continued to enjoy high status in South African society but largely as a result of its intellectual standing. There was widely held belief that poor and declining earnings levels had adversely Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

10 impacted the profession s status in recent years. The concern was expressed that factors such as declining earnings potential, changes in work environment and standards, community service requirements, etc., would place even further pressure on already critical shortages in South Africa. 4 What constitutes an appropriate ethical standard or tariff when assessing the conduct of health professionals? 4.1 The determination of fair and reasonable professional ethical standards or norms is challenging due to different (sometimes conflicting) values found in our society with its troubled history and immense social challenges, great socioeconomic disparity, diverse customs, beliefs, religions and cultures. 4.2 It is critically important that any proposed guideline tariffs intended to serve as a norm for the determination of an amount that a practitioner should have charged for a service (viz. ethical tariff ) be clearly distinguished from a reimbursement tariff. A reimbursement tariff is defined as a particular tariff or price that forms the basis for or guides reimbursement by a third party payer or guarantor (e.g. medical scheme, insurance company, WCA, RAF, civil claims) for a particular service or product rendered by a practitioner. 4.3 In South Africa a reimbursement tariff is closely linked with the reference price list(s) envisaged under section 90(v) of the National Health Act, 61 of Following the consent orders issued by the Competition Commission in 2004 / 2005 against the Board of Healthcare Funders (BHF), the South African Medical Association (SAMA) and the Hospital Association of South Africa, healthcare providers and funders were no longer allowed to negotiate and agree on a reimbursement tariff as this was seen as collusion and price fixing in contravention of the Competition Act, 89 of In the absence of a negotiated tariff, CMS and subsequently the Department of Health (under section 90(v) of the National Health Act) embarked on a process to determine and implement a reference pricing system in the private health care sector. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

11 4.5 The introduction of a National Health Reference Price List ( NHRPL ) determined by CMS in 2006 and the Reference Price List ( RPL ) determined by the Department of Health in 2007 onwards, led to a decision by the HPCSA in 2008 to scrap its published ethical tariff which had served as the standard used to evaluate complaints of alleged overcharging by practitioners. Instead it was proposed that ethical conduct in respect of the charging of fees by practitioners should be assessed in accordance with the principles of informed consent having regard to the RPL (in the case of uninsured patients) or the relevant medical scheme rate (in the case of insured patients). The medical scheme rate as determined by the individual medical schemes was at the time also based on the RPL. 4.6 In 2010 the RPL (and all its previous versions), as determined and implemented by the Department of Health ( DoH ), was declared null and void by the North Gauteng High Court. The Court found that the process followed by the DoH as well as the content of the various guidelines published by the DoH in determining the RPL, was unlawful and not in accordance with established law. In particular, the Court found that any person or entity acting in accordance with a provision in law must always adhere to the purpose of the specific law. It must be stressed that the court did not find section 90(v) or the principle of benchmarked price lists unlawful or unconstitutional, but rather the manner in which the process had been implemented. 4.7 In the absence of a RPL and with no ethical tariff in place, MDB of HPCSA has no clear criteria, standard or norm against which to consider complaints of overcharging by practitioners. 4.8 The only way to consider allegations of unprofessional conduct is therefore to rely on the principle of informed consent (as prescribed by the National Health Act and as required by the ethical rules of conduct). It should also be noted that, apart from the National Health Act, the Consumer Protection Act and the Competition Act also provide patients with remedies against unfair, unreasonable and/or exploitative pricing. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

12 4.9 The benchmark of what is ethical (i.e. distinguishes acceptable from unacceptable conduct) is an objective assessment of the fairness and reasonableness of the fees charged, having regard to all relevant factors, such as the complexity of the services rendered and the seniority and skill of the practitioner involved The former ethical tariff published by the HPCSA was calculated by using the fees recommended by SAMA plus 20%. It is within this 20% that weights according to relevant factors such as complexity of the service, skill and level of training, seniority and experience, geographic location and practice costs and difficulty of service could be apportioned. It is respectfully submitted that such a guideline is more appropriate as it observes what is fair and sensible. 5 Coding and Tariffs 5.1 The differences between coding and tariffs must be appreciated, although complex interdependence exists. 5.2 Procedural Coding scope of practice and terminology It is important to note and understand that the scope of practice, naming, description and coding of procedures is the right and responsibility of the profession and its subgroupings. These codes have been formally maintained in a responsible, peer-reviewed and transparent process by specialist societies, SAMA and SAPPF Any contemplation of scope of practice, naming, description and coding of the procedures must be a valid, current, authorised derivative of the prevailing codes, currently the 2013 version of the SAMA Doctors Billing Manual (DBM). 5.3 Procedural Coding unit values Unit values are assigned by the profession to procedural codes to reflect the relative values linked to time, effort, complexity, risk, costs and utilisation. These are called relative value units (RVUs). In the SAMA DBM all codes and unit values have been harmonised for inter-disciplinary relativity, inter alia by referencing according to the RVUs from the Complete CPT for South Africa (CCSA) based on the American Medical Association (AMA) Current Procedural Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

13 Terminology (CPT ). All codes and unit values are under annual scrutiny by coding and tariff committees and peer review processes; adjustments may be required to reflect changes in practice, procedural components, costs, interdisciplinary relativities and utilisation General surgeons have been using CPT-based billing with validated ICD-10 codes since 1998 in contractual arrangements with selected Schemes. Hospitals and Medical Schemes commonly utilise CPT as descriptors in billing and contractual interactions and in management software. General Surgeons have amassed a large database and experience with CPT. We have satisfied ourselves that CPT represents a valuable tool to express the wide range of surgical procedures and the relative values and costs of procedures. The RBRVS system includes many subcomponents that should form an integral basis of our coding and billing. 5.4 Procedural Coding billing rules Services provided by a surgeon to any patient, by their very nature, are variable. The codes that represent a readily identifiable surgical procedure thereby include a variety of services. In defining the specific services "included" in a given surgical code, the following services are usually included in addition to the operation per se: local or topical anaesthesia, one related consultation encounter on the date immediately prior to or on the date of procedure, immediate peri-operative care, including making operative notes, talking to family and other surgeons, writing orders, evaluating the patient in the post-anaesthesia recovery area and typical, uncomplicated postoperative follow-up care for a defined global period of care (usually one to three months, less for smaller procedure and none for purely diagnostic procedures) Rule C in SAMA DBM: comparable services : a service may be rendered that is not listed in the coding structure. The fee that may be charged for the rendering of a service not listed shall be based on the fee of a comparable service. For these procedure(s) / service(s), the use of the item must be supported by a motivation, including adequate definition or description of the Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

14 nature of the procedure / service and final diagnosis supported by appropriate ICD-10 codes Deviant billing practices, such as unbundling of codes are unethical. This nefarious practice of unbundling ( also referred to as code farming or basket coding ) attempts to invoke a variable number of separate codes that are added to a distinct stand-alone procedural code (thereby attempting to increase the unit value of the main procedure by adding codes for the steps of the procedure). Unbundling has been exploited by various disciplines and practitioners in an attempt to increase the value of procedures Schemes have compounded the problem by acceding to pressure from the professional societies and authorising payments in the face of obvious coding malpractice. Their reliance on the erstwhile BHF and CMS RPL lists without the declaratory information in the SAMA DBM is another reason for falling prey to inventive billing on the one hand or denial of payments in other instances Deviant billing practices, such as the unbundling conundrum, are an abusive distortion of the definitions and intended unit values and application of codes The unbundling conundrum has seriously distorted interdisciplinary relativities and harmed interdisciplinary professional relations These billing peculiarities are leading criticisms of the current SAMA DBM, and related coding and tariffs committees. This is unfair denigration of processes dear to us. We have been careful to maintain our fiduciary and professional responsibilities towards coding and tariffs despite constrictive Laws and Regulations, exorbitant costs (time, manpower and intellectual contributions) and unfair condemnations. 5. This deviant practice pressurises the guarantor into paying more than was intended by the coding and tariff guide. Insured benefits, including in the setting of PMBs, are extorted from the entrusted Scheme benefits to increase pay-out by the Scheme and /or to diminish co-payments by the clients, as well as to circumvent unusually high fees from being exposed as unethical. 6. A scenario of specialist anaesthetist complaining that GP assistant at procedure earns way more than anaesthetist is testament of a skewed billing application. In this scenario, the general surgeon would earn the LEAST of all of the doctors in theatre!!! Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

15 The denunciations must be directed to: The specialists and their Societies as some of them are individually and collectively guilty of abusive billing practices The Schemes, CMS, BHF and DOH for persisting with remuneration that is well below practice costs in most cases, yet publicly making repeated libellous and discourteous allegations against Specialists and the Profession The market failure that has forced some professionals to resort to upcoding by unbundling, inappropriate utilisation of procedures and technology and even fraud. 6 Procedural Coding, rcfs and Tariffs 6.1 Procedural unit values are translated into monetary values by using a rand conversion factor (rcf) NHRPL does not fulfil the basic requirements of a coding and billing system in that it has become outdated with respect to interdisciplinary relativities and lacks many codes and relative value units for procedures that are currently in use. 6.3 The history of the development of the 2006 NHRPL needs to be understood, and this understanding will demonstrate that it is entirely unsuitable for the task of giving a solid and valid basis for a guideline tariff. 6.4 The early SAMA Guide to Fees was based on benchmarking studies that had considered time and activity costs. scientific practice cost benchmark. Thus, even from early days, there was a 6.5 A differential discounted contracted-in fee was later negotiated in exchange for direct payment of the service provider by contracted Medical Scheme. 6.6 The origin of the 2006 NHRPL lies in the Billing Manual developed in the mid 1900 s by the Medical Association (originally MASA, later SAMA) with codes, descriptors, rules and unit values for each Health Intervention. An rcf was then negotiated by SAMA, the funding industry and the Minister of Health. This rcf allowed a monetary Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

16 value to be allocated to each health intervention by multiplying the unit value allocated to each code by the rcf. 6.7 The SAMA published two major rcf s: Scale of Benefits (SOB) was the monetary value that the funding industry agreed to pay per unit (see above) for the services offered to their clients SAMA (Private Tariff) was calculated from the initial studies by the Medical Association in the 1960 s This Private Tariff was used for many years by the HPCSA as a determinant in deciding whether medical practitioners had overcharged, or not. 6.8 The SAMA Guide to Fees and later Doctors Billing Manual (DBM) is updated annually by the SAMA Private Practice Committees (PPC - Specialist PPC and GP PPC) under SAMA Private Practice Unit (PPU). Radiology left the SAMA PPC arena many years ago and produced an independent Integrated Radiology and Imaging coding and tariff guide. Some Specialist groups work outside of SAMA SPPC via SAPPF. Considerable overlap and collaboration exists between SAMA SPPC And SAPPF. The processes are public, transparent, peer-reviewed and associated with expert technical, legal and professional governance. New codes, obsolete codes, changes to codes or descriptors and interpretations, including interdisciplinary relativities, equipment costs and many other issues are debated and agreed by consensus and accompanied by comprehensive documentation. 6.9 Proposed amendments were serially negotiated with the funding industry at an annual forum; many other market and practical issues were traded. Emanating from this exhaustive and time-consuming process was the declaration by the authorities (DOH, later BHF, and later CMS) of the magical rcf s for various sections of the tariff. 7 The rcf was supposed to be the product of calculations of inflation, e.g. Consumer Price Index (CPI) and other financial factors. Benefit designs and actual benefits offered by the Medical Schemes were calculated, overseen by CMS. 7. Differing rcf for Consultative Services, Psychiatrists, Anaesthesiologists, Radiology, Radiation Oncology, Ultrasound, Computed Tomography, Clinical Pathology, Anatomical Pathology Cytology, Anatomical Pathology Histology, Human Genetics, etc. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

17 6.10 We all held our breaths each year, awaiting the 1 st January declarations of the benefits for the New Year, publication of various schedules and the invariable moaning and legal battles that ensued Important aberrations in the negotiation and pricing process were documented over the years since the 1960 s, mainly due to the fact that the funding industry granted increases in the Scale of Benefit tariff that were, on average, well below CPI, whereas the SAMA Private Tariff was tagged to CPI. This relationship between CPI, SOB and SAMA tariffs is demonstrated in figure CPI Cumulative% SAMA Cumulative % SOB Consultation Cumulative % Proc SOB Cumulative % 50 0 Figure 1. Comparison of Private and Scale of Benefit Tariffs against CPI as cumulative percentage increase (CPI data from Stats SA and tariff from SAMA historical data). The Private Tariff increased in parallel with the CPI, remaining below CPI until The SOB increased at a rate well below CPI. In 1980 the Scale of Benefit tariff (SOB) was 73% of the Private Tariff and in 1994 it was 43% of the Private Tariff (Read CPI). In 1994, a unilateral decision by the funding industry established two levels of the SOB tariff, differentiating between the RCF for consultations and procedures/operations, the tariff for consultation being higher than for procedures. This has been maintained since the as can be seen in the graph. The consultation SOB tariff in 2003 was 42.5% of the Private tariff (read CPI), down from 73% in The Procedural SOB tariff was 32.17% of the Private tariff (read CPI), down from 73% in Different rcf for consultations and procedures: BHF and later CMS erred and seriously disadvantaged specialist surgeons by deflating the rcf for procedures, Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

18 creating an rcf for consultations significantly higher than procedures. Almost all surgical procedure code includs perioperative and postoperative consultative services within the defined global period of care. The effect has been to underrate procedures as a whole and underrate their inherent consultative services and the surgeon that supplies these services No other tariff structure differentiates consultation and procedural fees 8. The 2006 NHRPL entrenches pretence where specialist surgeons are paid less for their skilled operating time than for consulting time. Furthermore, the surgeon is paid less for his / her consulting services compared to other non-operating specialists This discrepancy widens each year as the same CPIX related inflator is used for both fees. In 2010 the Discovery procedural tariff was 48% less than the consultative tariff Consultative Services have been a bone of contention for many years We have advocated a tiered consultation framework to allow factors such No. of Diagnoses or Management Options place (office vs. hospital vs. emergency department) and / or type of service (initial, follow up, consultation) and the content of the service to be defined viz. nature of the presenting problem(s), history & examination level and the time typically spent providing the service, face-to-face, but also on the floor, or in consultation e.g. family, professional conferences, tracing information and writing of notes, referrals, scripts, forms. As an example we have offered the CPT approach to consultative services. See Table 1. Amount &/or Complexity of Data Reviewed Risk of Complications, Morbidity/Mortality Type of Decision Making Minimal minimal or none Minimal Straightforward Limited Limited Low low complexity Multiple Moderate Moderate moderate complexity Extensive Extensive High high complexity Table 1. Complexity of Medical Decision Making Medical Schemes have refused to invocate tiered consultations, despite an 8. Even WCA / COIDA uses parity for consultative services and clinical procedures, and have applied tiered consultations. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

19 earlier agreement to introduce tiered consultations based on time and complexity. It is noteworthy that the tiered consultations have been iterated in the SAMA DBM since the combined industry decision endorsed tiered consultations Even the ailing WCA (COIDA) has incorporated tiered consultations It is of seminal importance to note that Psychiatry have succeeded in having their cost studies benchmarking their purely consultative services as per the DOH and CMS RPL process accepted into the RPL realm, endorsed in Law, and now successfully applied for many years, to their significant financial advantage. Other groups that had their studies accepted have not enjoyed the same success e.g. Anaesthesiologists Why this crazy discrimination by DOH? These anomalies were pointed out in the scathing judgement that was handed down with costs! DOH paid heavily for their impropriety. Their downfall was mainly due to lack of capacity, refusal to allow a broad consultative process and political interference (our results ostensibly did not fit the political agenda). HPCSA be warned! Psychiatry serves as a straightforward model as their services are all consultative Psychiatry is a pivotal benchmark that all disciplines may use as a reference point in determining discipline specific relative values Instead of introducing tiered consultations, the tariffs now refer to an arbitrary goulash of Consultative Services, where different fees are allowed for Physicians, Psychiatrists, Paediatrics and Paediatric Cardiologists, Anaesthesiologists, Cardiology, Ophthalmology, Orthopaedics, Otorhinolaryngology, GPs, etc. The lowly general surgeon has to make do with one of the lowest fees for consultations No deference is paid for subspecialty qualifications General surgeons are deeply aggrieved at the low esteem they have been 9. Even WCA / COIDA uses parity for consultative services and clinical procedures, and have applied tiered consultations. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

20 dealt for consultative services Most Schemes make small allowances for consultative services out-of-hospital and these so-called day-to-day benefits are invariably and quickly depleted Most specialists charge a private rate for consultative services and expect same to be paid on the day of the service. These out-of-pocket expenses add considerable hardships to the client The 2006 NHRPL is the result of years of manipulation. Various economic, technical and obscure reasons, introduced mainly by the funding industry, have tarnished and tainted its value. It in no way represents the original and updated versions of the SAMA balanced manual. The frequent iteration and copies of the tariff guides infringe on the copyright and intellectual property that should be paid to SAMA The 2006 NHRPL is a deceptive construct that unfairly prejudices remuneration of specialists, particularly specialist surgeons As a result of the below-cpi tariff increases over many years, the discriminatory low rcf for procedures and the lower rating of general surgeon consultations, the net effect is a significant deterioration of the real income of surgeons Administrative practice costs for all medical professional, including surgeons, have soared since the introduction of so-called managed health care and clients that seek to be more informed of their health and diseases. Rampant increases have been experienced in the time, effort and costs of administrative services (motivations, chronic medicines, registration of PMBs, coding issues, billing rejections, short payments, etc.), data, billing and collection services. Increasing attention to and compliance with the rigours of informed consent, financial agreements, the National Credit Act, Consumer Protection Act, Promotion of Access to Information Act, the envisaged Protection of Personal Information Bill, data integrity and increasing levels of medico-legal litigation and indemnity insurance costs have increased the complexity of running of medical practice, as well as greatly enhanced administrative- and compliance costs far in excess of the CPIXrelated increases. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

21 6.16 Standard and specialised equipment costs, and staff numbers and costs have increased way above CPIX. The extraordinary levels of increases in administered prices, such as electricity and fuel are well-known and highlighted in publications of, amongst others, the SA Reserve Bank It is commonly agreed that specialist surgeon fees are too low for the work and responsibility they carry On average, general surgeons charge 108% for non-pmbs and 112% for PMBS to clients with scheme benefit options at the fees guaranteed at basic historic CMS- RPL levels Most schemes have entertained payment arrangements, paying between 4% and 300% above base rates, depending on scheme options and costs. In many instances the majority of surgeons have signed one or more of these payment arrangements. Surgicom plays an important role in brokering bilaterally acceptable terms for these agreements. We insist on exhaustive attempts to reduce the time and costs of administrations for all parties The majority of our patients are thus protected against excessive charges. We pride ourselves in the services we offer. We often serve as coordinators and managers of the larger, complex issues administration, informed clinical and financial consent and facilitation of financials for the team and point of service, hospital costs and selection of cost-effective, appropriate pathways, continuity of care, and many related and extraneous issues When we talk fees and tariffs, we place too much emphasis on the cost of a procedure or intervention. An important financial principle in any business is that: 6.22 We must research and control global and down-stream costs and adverse outcomes. Training, teaching, streamlining, exception management, risk-sharing and many more, are the vernacular of the managed health care we should be applying, rather than obstructive haranguing about tariffs. 10. From CMS studies published during the time of the PMB Review process, 2010; corroborated by data shared by a large medical scheme administrator. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

22 6.23 Our social contract keeps us intimately involved, often without proper recompense. 7 Practice Cost Studies 7.12 Surgeons were compliant with and repeatedly studied and reported their practice costs as per the CMS and DOH directives during the NHRPL and RPL-phases of the tariff-history These studies were costly and time-consuming The studies were performed by independent auditors and management groups General Surgery reached similar results from two independent initial studies by different auditors; our findings were corroborated when the studies were repeated two years in a row! Sub-subspecialty Vascular surgeons (VASSA) performed a highly detailed time-activity cost study. Many smaller surgical disciplines pooled their data to derive a measure of specialist surgeons as a group It is important to note that at least 60% of specialist overhead costs are fixed and similar for all specialists and specialists: staff, offices, basic and specialised equipment, billing, collection and taxes, indemnity insurance, societies and studies Despite conservative estimates of time-volumes, target income, practice costs, and punitive statistical corrections for small sample sizes, the results of the time and activity-based practice for general surgeons, vascular surgeons, other surgical disciplines and all surgical disciplines together produced a similar result, viz. the prevailing medical scheme base remuneration was estimated to be 2 to 3 times lower than what the studies predicted In the meantime, significantly influenced by the ASSA Comparative Study into the Remuneration and Working Conditions of General Surgeons in South Africa (para 6 above), State salaries were partly lifted out. This has the result of significantly increasing the level 13/14 target salary that was used in the CMS / DOH practice costs studies. This further vindicates the need for an upwards adjustment of specialist and surgeon fees by a factor of at least 2 to 3 times current base remuneration levels. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

23 7.19 DOH never published or revealed the results of their audits of the practice cost studies. The legal challenge showed DOH up as incoherent and having failed the profession. 8 After the Practice Cost Studies 8.12 DoH and CMS issued a Discussion Document on the Determination of Health Prices in the Private Sector during October This appeared to be a further attempt by the DoH and CMS to introduce Price Control in the Private sector following the setting aside of the RPL by the Gauteng North High-Court. The deadline for commentary on this proposed voluntary process was 15 th January SAPPF and SAMA provided detailed responses to this document during December 2010 and further supplementary comments on 15 th January To date neither the DoH nor the CMS have responded on any of the submissions received, nor are they willing to discuss them. They have also not published any of the submissions received On 30 th December 2011 the Competition Commission announced that it intended to launch a full enquiry into Private Sector Healthcare pricing during We do not believe that this will be a threat to the Healthcare Professions market as costs and tariffs have been a transparent process, as was echoed by Acting Judge Piet Ebersohn in the 2010 judgement against the DoH RPL process. We do not however believe that the same can be said of Medical Scheme Administrators who unilaterally impose fixed tariff increases across all schemes administered by them and across all disciplines, irrespective of the specific scheme s risk profile and affordability levels. Medical Scheme Trustees do not appear to apply their minds and are blindly led by the Administrators in this regard. The recent spate of cases against trustees, schemes and Principal Officers, as published on the CMS website in December and January bears testimony to this In the meantime a joint delegation, initiated by SAPPF, met with the Minister of Health in December 2012 to discuss, amongst other, the whole issue of pricing. The meeting was positive and is to be followed up in The delegation included Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

24 South African Dental Association (SADA), IPA Foundation of South Africa (IPAF), BHF, Discovery Health and Medscheme Legally there is no longer a RPL, nor a National Benchmark of tariffs (although the legal framework for it is still in existence and could be implemented without the requirement of an exemption from the Competition Act). In the absence of any guidance to schemes as to what tariffs to apply in 2013, Schemes must independently set their tariffs. The reality is that this process is not happening and that Administrators are setting tariffs on behalf of the Schemes they are administering. If one then compares various Scheme rates it is obvious that Schemes also do not really differ from each other and that they are jointly setting a National Benchmark Tariff. This is ample fuel for the Competition Commission We aver that most Schemes and Administrators do not have capacity or insight into coding structures; they merely default to follow the illegally published RPL. Tariff increases are essentially still based on NHRPL 2006 and therefore do not contain all changes to codes, descriptors, rules and modifiers approved by SAMA, SAPPF and other Associations for 2006 to It is also inconsistent in many respects. Disputes between Practitioners and Schemes will increase and ultimately Scheme members will be worse off The coding and tariff process has been seriously derailed. No mechanism exists to ensure a fair, transparent and efficient method of assigning tariffs. Collective negotiation is prohibited by competition law. Individuals, fearful of the Competition Commissioner, are left impotent and weak in their direct approaches to powerful Medical Schemes and their administrators Specialists are trampled upon and invariably have their every move questioned (often by clerks, computers, Scheme rules, nurses, administrators and lesser qualified or even retired-from-practice doctors). Increasing interference with specialist-directed care is being experienced, including denial of payment of ancillary services e.g. anaesthetic, radiology, pathology, physiotherapy, dietetics and enterostomal and wound care. The Scheme and their medical advisors are at dire risk and may be liable for adverse consequences (e.g. interference with doctor patient relationship, unprofessional behaviour, supersession, not examined patient, questioning treatment and/or tests when not similarly qualified). Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

25 8.19 Schemes, hospital groups, professionals and suppliers, negotiate in a disjointed manner, lacking in transparency. It is common practice for suppliers, hospitals and Schemes to collude on pricing, discounts, selective formularies, and many other dubious issues. Specialists are seldom allowed access to these parleys and are infrequently consulted from a clinical or governance point of view. The Competition Tribunal will hopefully sort them out! 8.20 The net effect has been compromise of quality, accountability and affordability of specialist services Current practice costs and management tools in individual practices and for groups consistently corroborate our initial work. We continue to collect data on practice and equipment costs. Many groups, disciplines and individual practices formally keep audited records of their own costs. Some of our latest applications can track practice costs on a daily basis (in real-time ) and can provide independent audited management data. We have assisted and are indebted to Healthman and SAMA that have continued to refine the practice cost assessment tools so that we can invoke them as proof of our plight of low fees, tariff and remuneration The predicted increases in tariffs should be managed on the supply and demand sides of the chain. Less administrative hassle by Schemes and their Administrators could reduce our and their costs exponentially Professional indemnity costs must be fought by improving education, training, risk management and more realistic medico legal processing and costs Alternate reimbursement models, including risks-sharing, further complicate Private and State billing practices. Alternate reimbursement tariffs (fixed fees, global fees, per diems, pay for performance, capitation, etc.) are issues that need research and wider implementation in an effort to share risk and manage costs Improved preventive services, health and wellness strategies, and management of the burden of diseases are all hamstrung by the wasted efforts in coding and billing of skewed fee-for-service therapeutic services. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

26 8.26 Conclusions We welcome a cost and activities based reimbursement system that fulfils the requirements of all parties. It must be an inclusive and transparent process. Tiered consultations are long overdue. Parity of rcf between consultations and procedures is non-negotiable. We implore HPCSA and MDB to lobby to develop, maintain and govern a modern, appropriate coding structure and cost-based tariffs in a multi-party, transparent structure. Specialist Surgeons are willing to work shoulder-to-shoulder on these projects, believing that administrative justice and workable, enduring coding and remuneration structures can be established in support of improved access and quality of health care in South Africa. However, we do not believe that section 53 of the Health professions Act is the right legal home for this, neither do we believe that the HPCSA is the correct body to set guidelines relating to the commercial and professional realities faced by our profession. The HPCSA should stick to its mandate of enforcing professional and ethical behaviour, and dealing with complaints relating to those, and in which our societies will gladly assist. All of these issues are at play as NHI is rolled out. Specialist services are complex issues that have not really been aired for NHI. Nevertheless, we will assist with coordination and management from a clinical and process side. Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

27 Unit 16, Northcliff Office Park 203 Beyers Naude Drive Northcliff, 2115 Tel: (+27)(11) , Fax: (+27)(11) P.O. Box 2127, Cresta, Johannesburg, 2118 We respectfully submit these matters and request confirmation of receipt as well as cognisance of our availability to assist in clarification, research, discussion, negotiation and implementation Our rights are reserved. Yours Truly SURGICOM for ASSA and FoSAS These documents were collated by: Dr Stephen Grobler ; MP MMed (Chir) (Gastroenterol) Surgicom Director fax: Directors: J Mook (Chair), S Grobler, P Matley, S Pillay, M Wellsted; Company Secretary: Healthman 24/25

28 REQUEST FOR COMMENTS: PROPOSED HEALTH PROFESSIONALS COUNCIL OF SOUTH AFRICA GUIDELINE TARIFFS: SUBMISSION BY SURGICOM FOR SPECIALIST SURGEONS Table of Contents: Appendices Appendix 1. Appendix 2. Appendix 3. Appendix 4. Briefs by Surgical Societies Colleges of Medicine of SA (CMSA) President's Survey of numbers of practicing Specialists The Association of Surgeons of South Africa: Comparative Study into the Remuneration and Working Conditions of General Surgeons in South Africa Articles: Kahn D, et al. South African Journal of Surgery Volume 44(3) August 2006: a. General surgery in crisis the critical shortage b. General surgery in crisis comparatively low levels of remuneration c. General surgery in crisis factors that impact on a career in general surgery Surgicom for Specialist Surgeons to HPCSA on Proposed Tariff Guideline /25

29 Federation of South African Surgeons Secretariat: Wits Donald Gordon Medical Centre, 18 Eton Road, Parktown. Johannesburg. 2193; Postnet Suite 199. Private Bag X 2600, Houghton South Africa Telephone: Facsimile: +27 (0) [email protected] Appendix A. 16 February 2013 The Registrar Health Professions Council of South Africa Per Dear Madam Re: PROPOSED HEALTH PROFESSIONALS COUNCIL OF SOUTH AFRICA GUIDELINE TARIFFS: REQUEST FOR COMMENTS - SUBMISSION BY FoSAS ON BEHALF OF GENERAL SURGEONS The Federation of Surgeons of South Africa (FoSAS) is the unifying forum for all General Surgical associations and societies. Its EXCO consists of the presidents and other senior office bearers of these societies. FoSAS aims to speak on behalf of all these organisations on matters common to us all. The HPCSA guideline tariff is just such a matter. The organisations represented by FoSAS are represented at the bottom of the letterhead, and include vascular, laparoscopic, colorectal, trauma and paediatric surgeons. FoSAS also represents the College of Surgeons of South Africa (our academic and examining body), as well as the national General Surgical trainee association and their research association. This is by far the largest grouping of surgeons in the country. It is our contention that the HPCSA's foray into tariff setting is ill-advised. FoSAS respectfully submits that HPCSA has neither the relevant intellectual resources nor the experience to perform this task, without the assistance of the relevant professional service providers (doctors, dentists, and allied professions), hospitals, pharma and the supply industry. We believe HPCSA should urgently intervene to

30 Federation of South African Surgeons establish a multiparty coding and tariff forum that adheres to the principles of legality, rationality, consistency, openness and impartiality. In this way, you, our regulatory body, will serve the interests of both patients and surgeons by promoting improved access to healthcare and improved quality of care in South Africa. FoSAS supports the attached submission from Surgicom, made on behalf of the the general surgical community, on the proposed HPCSA guideline tariffs. Yours sincerely Robert Baigrie, Chairman Appendix A.

31 Appendix A. The Association of Surgeons of South Africa affiliated to The South African Medical Association. Incorporated Association not for gain. Reg No February 2013 To: The Registrar Health Professions Council of South Africa Per Dear Madam, Re: PROPOSED HEALTH PROFESSIONALS COUNCIL OF SOUTH AFRICA GUIDELINE TARIFFS: REQUEST FOR COMMENTS SUBMISSION BY SURGICOM ON BEHALF OF GENERAL SURGEONS The Association of Surgeons of South Africa agrees with, endorses and fully supports the submission made on behalf of the general surgical community by Surgicom on the proposed Health Professions Council of South Africa guideline tariffs. It is our contention that any entity wishing to effectively and successfully develop and implement a normative guideline to serve as a professional standard must ensure that the guideline adheres to the principles of legality, rationality, consistency, openness and impartiality. We believe that this is only possible if a multiparty coding and tariff forum is established that has the legal framework to embark on transparent consultative processes with the goal of promoting access to and quality of care in South Africa. Yours sincerely, Martin Veller, Chairman ASSA Suite (c/o SAMA Office) Postal Address: Wits Donald Gordon Medical Centre Postnet Suite Eton Road Private Bag x2600 Parktown Houghton 2041 Administration Contact: Alison McLean: Tuesday Thursday (011) Susan Parkes: Mondays and Fridays (011) [email protected]

32 SASES The South African Society of Endoscopic Surgeons From the Office of the President Appendix A. General Enquiries: Susan Parkes Tel: Fax: Postnet Suite 199, P/Bag X2600 Houghton 2041 Website: To: The Registrar Health Professions Council of South Africa 17 February 2013 By Dear Madam Re: Proposed HPCSA Guideline Tariffs: Submission by Surgicom on behalf of General Surgeons The South African Society of Endoscopic Surgeons (SASES) is the largest surgical special interest society in South Africa, with more than 250 active and paid-up members. We agree fully with the submission made on behalf of general surgeons by Surgicom regarding the proposed Health Professions Council of South Africa guideline tariffs, and support it completely. We firmly believe that any attempt to develop a tariff that will be used as a professional standard, should adhere to the principles of legality, rationality, consistency, openness and impartiality as clearly elucidated in the above-mentioned document. Furthermore, as far as a tariff for remuneration is concerned: we believe this can only be set through a transparent consultative process involving all interested parties in a coding and tariff forum, with the necessary legal framework in place. Only by this process can we ensure accessible and quality surgical care in South Africa. Sincerely Danie Folscher President SASES EXECUTIVE COMMITTEE 2012/2013 PRESIDENT: Dr D Fölscher PAST PRESIDENT: Prof R Baigrie VICE PRESIDENT: Dr M Naidoo SECRETARY: Dr D Brombacher TREASURER: Dr R de Beer MEMBERS: Dr M Brand, Dr C Jann-Krüger, Prof A Numanoglu, Prof E Panieri CO-OPTED MEMBERS: Dr S Grobler, Prof Z Koto, Dr JA Potgieter

33 Appendix A. SASSiT PHONE WEB To Healthman / Surgicom January 21, 2013 We hereby pledge our full support to you, with regard to your dealings with the HPCSA on pricing matters. We feel that the their proposed system is both flawed and outdated and we believe that it will be a future deterrent for prospective surgical registrars, in a already short staffed healthcare system. Sincerely yours, Abri Bezuidenhout SASSiT chairperson

34 Dr Sameer Nadvi President Appendix A. Professor Allan Taylor Secretary Professor Rasik Gopal Past President Dr Jacques du Plessis President Elect Professor Patrick Lekgwara Treasurer Dr John Ouma Membership Secretary February 2013 Dear Colleagues RE: HPCSA ethical tariff guidelines The Society of Neurosurgeons of South Africa supports the Surgicom submission to HPCSA on behalf of FoSAS. It should be emphasised that all surgical specialists stand to be affected by the HPCSA implimenting a benchmark tariff. And while we support a plan to impliment a comprehensive, fair and transparent coding structure with attached remuneration value it would be premature to impose an ethical tariff. Yours sincerely Sameer Nadvi President SNSA Allan Taylor Secretary SNSA

35 College of Medicine of South Africa (CMSA) President's Survery 2011 Appendix B. Results 2 CMSA President's Survey Current numbers of Specialists Speciality Current Speciality Current Anaesthetics 1199 Anaesthetics Oral Path 14 Cardio Thoracic Surgery 120 Cardio Thoracic Surgery Periodontics 54 Dermatology 186 Dermatology Prosthodontics 72 Emergency Medicine 34 Emergency Medicine Orthodontists 128 Family Physicians 790 Family Physicians Maxillo Facial 111 Forensic Pathology 45 Forensic Pathology Total 379 Neurology 123 Neurology Neurosurgeons 135 Neurosurgeons Nuclear Physicians 45 Nuclear Physicians GRAND TOTAL 9618 Obstetrics and Gynae 888 Obstetrics and Gynae Opthalmology 273 Opthalmology Orthopaedics 605 Orthopaedics ENT 292 ENT Paediatricians 680 Paediatricians Pathologists 537 Pathologists Physicians 641 Physicians Plastic Surgeons 157 Plastic Surgeons Psychiatrists 641 Psychiatrists Public Health Medicine 103 Public Health Medicine Occupational Medicine 22 Occupational Medicine Radiation Oncologists 153 Radiation Oncologists Radiologists 713 Radiologists Surgeons 635 Surgeons Urologists 222 Urologists Oral Path 14 Oral Path Periodontics 54 Periodontics Prosthodontics 72 Prosthodontics Orthodontists 128 Orthodontists Maxillo Facial 111 Maxillo Facial TOTAL 9239 TOTAL $

36 College of Medicine of South Africa (CMSA) President's Survery 2011 Appendix B. EC FS GA KZ LI MP NC NW WC TOTALS Anaesthetists Anaesthetics Public #N/A Private #N/A Cardio Thoracic Surgeons Cardio Thoracic Surgery Public #N/A Private #N/A Dermatologists Dermatology Public #N/A Private #N/A Emergency Medicine Emergency Medicine Public #N/A Private #N/A Family Physicians Family Physicians Public #N/A Private #N/A Forensic Pathologists Forensic Pathology Public #N/A Private #N/A Maxillo Facial & Oral Surgeons Maxillo-Facial Public #N/A Private #N/A Neurologists Neurology Public #N/A Private #N/A Neurosurgeons Neurosurgeons Public #N/A Private #N/A Nuclear Physicians Forensic Pathology Public #N/A Private #N/A Obstetricians and Gynaecologists Obstetrics and Gynae Public #N/A Private #N/A Opthalmologists Opthalmology Public #N/A Private #N/A Oral Pathologists Oral Path Public #N/A Private #N/A Orthodontists Orthodontists Public #N/A Private #N/A Orthopaedics Orthopaedics Public #N/A Private #N/A ENT ENT Public #N/A Private #N/A Paediatricians Paediatricians Public #N/A Private #N/A Pathologists 1 0 #N/A Public #N/A Private #N/A Periodontics Periodontics Public #N/A Private #N/A Physicians Physicians Public #N/A Private #N/A Plastic Surgeons Plastic Surgeons Public #N/A Private #N/A Prosthodontists Prosthodontics Public #N/A Private #N/A Psychiatrists Physicians Public #N/A Private #N/A Public Health Medicine Public Health Medicine Public #N/A Private #N/A Occupational Medicine Occupational Medicine Public #N/A Private #N/A Radiation Oncologists Radiation Oncologists Public #N/A Private #N/A Radiologists Radiologists Public #N/A Private #N/A Surgeons Surgeons Public #N/A Private #N/A Urologists Urologists Public #N/A Private #N/A GRAND TOTAL TRUE 9081 #N/A

37 Appendix 3. THE ASSOCIATION OF SURGEONS OF SOUTH AFRICA Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector December 2007 P-E Corporate Services Management Consultants

38 Appendix 3. STRICTLY PRIVATE & CONFIDENTIAL THE ASSOCIATION OF SURGEONS OF SOUTH AFRICA Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector 1. INTRODUCTION AND BACKGROUND P-E Corporate services ( P-ECS ) was commissioned during 2004 by The Association of Surgeons of South Africa ( ASSA ) to carry out a comparative study into the remuneration and working conditions of General Surgeons in South Africa. The study was prompted by growing concerns within the Association at that time about : the diminishing number of applicants presenting themselves for general surgery training; and the increasing number of general surgery posts that were vacant in the State sector, Our final report, which was submitted to ASSA in September 2005 confirmed that the concerns expressed by ASSA were both valid and relevant in that : shortages of qualified General Surgeons in the State sector had reached critical levels; major contributory factors included low levels of remuneration, extremely long working hours, excessive levels of stress and an inadequately resourced working environment; General Surgeons employed within the State sector were also poorly remunerated in related to other professionals at comparable levels of responsibility employed elsewhere within this sector. P-E Corporate Services SA (Pty) Limited

39 Appendix 3. The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page 2 ASSA has now requested P-ECS to update the aspect of our research dealing with comparative differentials between remuneration of General Surgeons in the Public Sector with that of other professionals employed in the same sector. Our brief in this regard was confirmed during a meeting between Professor Martin Veller, representing ASSA, and Martin Westcott and Adele Slotar of P-ECS on 02 October, RESEARCH OBJECTIVE AND TERMS OF REFERENCE One of the primary objectives of the study undertaken on behalf of ASSA in 2004/05 was to evaluate the relative equity of remuneration earned by General Surgeons working in the State or Public Sector in South Africa. Relative equity in this context refers to the extent to which remuneration earned by General Surgeons could be considered as equitable in relation to factors such as responsibility, working hours and conditions, and professional risk. A reasonable basis for making this assessment is to compare remuneration earned by General Surgeons with that of other professionals at comparable levels of responsibility and also employed within the Public Sector. While comparisons of this type are never precise, robust job evaluation methodologies are available which provide an acceptably accurate basis for comparison. The use of such methodologies is common practice within commerce and industry and within the Public Sector. This approach was adopted in our 2004/05 study and by following a similar and consistent approach and methodology it is possible to compare differentials in remuneration measured at that time with current market data. With this in mind our terms of reference for this study were confirmed in our letter dated 10 October, 2007, as follows : P-E Corporate Services SA (Pty) Limited

40 Appendix 3. The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page 3 The scope of work covered in terms of this request is reported in section (pages 35 to 42 inclusive) of our report dated 15 September, This section of the report deals with remuneration of general surgeons employed within the State sector and compares this with earnings of other professionals employed within the public sector. As a basis for comparison, the selected positions were graded, remuneration data researched and comparative ratios developed reflecting differentials between earnings of general surgeons and the other professionals. Differentials are then analysed and reported by grade. The activities we would need to carry out to update this research would be as follows: prepare an initial list of the professional positions to be used as a basis for comparison, and agree this with ASSA. We do not anticipate that this list would vary materially from that used in the 2004/05 study. As much similarity as possible is also desirable in view of the need for consistency. However, comparative studies are always influenced by factors such as availability of current and accurate data. There may also be an opportunity to cover certain additional professional positions; confirm job grades (in line with our previous work) and/or re-grade new positions or positions where job responsibility has changed; research current remuneration data for all positions; analyse and present results together with comparative ratios and appropriate comment. The deliverable would thus be a report with updated data and comment in much the same layout and format as that in section of our previous report. 3. METHODOLOGY The methodology adopted for this (updated) study may be summarised as follows : (i) a list of professional categories to be used as a basis for comparison was selected. The list of categories used for the 2004/05 study was necessarily based on the availability of accurate, current market data. To ensure consistency, the same job categories were selected for the update study. However, the list for this study was increased to include accountants employed within the public sector. P-E Corporate Services SA (Pty) Limited

41 Appendix 3. The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page 4 The full list of professional categories used for pay comparison purposes was thus : judges/magistrates in state sector employ; engineers employed within the public sector (state, local authority or parastatal); accountants employed within the public sector (state, local authority or parastatal); municipal managers employed within local authorities (the position of executive mayor was added to this category as well); airline pilots employed in state owned airlines (SAA, SA Express, SA Airlink); (ii) (iii) (iv) (v) representative benchmark job titles/descriptions were selected within each professional category as a basis for the market comparisons with the seven medical job titles used as the research basis in the 2004/05 study. The selection of job titles was made so as to obtain positions of comparable responsibility across the different professions; positions were graded (or previously applied grades checked) using the Paterson system of job evaluation. (Positions, grades and a brief description of the Paterson system is included in the next section of this report); current market remuneration data was researched for each benchmark job description within each professional category. Research involved a combination of desk and phone research using both our extensive national remuneration data base as well as remuneration data available in the public domain. Our remuneration database contains current market data on some different benchmark job titles / descriptions sourced from our national, regional and industry sector surveys encompassing all sectors of the South African economy. Over 850 organisations employing over 1,5 million staff participate in these surveys; market data collected in this fashion was analysed and collated and forms the basis of the market comparisons presented in subsequent sections of this report. P-E Corporate Services SA (Pty) Limited

42 Appendix 3. The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page 5 4. BENCHMARK POSITIONS 4.1 The Paterson System of Job Evaluation The use of a versatile job evaluation system provides a rational and generally accepted basis for comparing jobs across different functional areas. This is achieved by analysing the content and responsibility of different jobs and grading or ranking this, using the selected job evaluation system Job evaluation may best be defined as the process of determining, without regard for personalities or personal competencies, the worth of one job, relative to others. Job evaluation systems thus measure the intrinsic worth of jobs. Various such systems are used in South Africa, and all employ a conceptually similar approach. For the purpose of this particular analysis we have used the Paterson system of job evaluation. This is the most widely used system in South Africa and categorises jobs in terms of decision bands. Each band represents an increasingly complex decision level and thus a more senior management level. For the purpose of evaluating and grading (or ranking) jobs, the bands are divided into grades and sub-grades. Six bands are recognised in the Paterson system, from the lowest to highest organisational decision levels. Only the three highest bands were required for comparative purposes in this exercise and these bands, grades and sub-grades and typical management and decision responsibility levels, are shown in the table overleaf. P-E Corporate Services SA (Pty) Limited

43 Appendix 3. The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page 6 Paterson Band Management Level Broadband Grades Sub Grades Decision Type F Top management / executives in large companies F upper F lower F2 F1 Policy making or strategic decisions usually made at top management / board level E Senior executives reporting to the CEO. Holding or subsidiary / single unit company E upper E lower E3 / E4 E1 /E2 Programming decision usually made by senior managers or heads of major functions / business units D Middle managers and professionally qualified, experienced specialists, e.g. in finance, IT, etc. D upper D lower D4 / D5 D1 / D2 / D3 Interpretive or probabilistic decisions usually made by middle management and professional staff based on overall corporate strategy Note : The classic approach adopted in applying the Paterson system is to grade jobs into sub-grades (F2, F1, E4, E3, etc.). In recent years, however, many organisations have adopted a broadband approach, grading positions according to the lesser number of broadband grades (F upper, F lower, E upper, E lower, etc.). This allows greater flexibility and simplifies the application. For the purpose of the comparative analysis which follows, however, we have used both broadband sub-grades to provide as accurate a basis, as possible. 4.2 Benchmark Positions The professions and job titles / descriptions used for benchmarking comparison purposes are set out in the table overleaf. Positions are as identified for the 2004/05 study with the addition of accounting positions. A review of the grades used in 2004/05 confirmed that no changes were required to previously assigned grades. P-E Corporate Services SA (Pty) Limited

44 Appendix 3. The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page 7 Profession Job Title / Benchmark Job Paterson Grade / Broadband Medical Practitioner in State sector employ Judge / Magistrate in State sector employ Engineer employed in the Public sector (State, Local Authority or Parastatal) Accountant employed in the Public Sector (State, Local Authority or Parastatal) Municipal Manager : Local Authority Intern Registrar (Leg 1) Community Services Doctor Medical Officer Junior Specialist (Working under Supervision) Senior Medical Officer Specialist Principal Medical Officer Chief Medical Officer Senior Specialist Magistrate Senior Magistrate Regional / Chief Magistrate Regional Court President / Special Grade Chief Magistrate Judge e.g. High Court, Labour Court Qualified professional engineer (5 10 years experience) Qualified professional engineer (over 10 years experience) Engineering manager in intermediate-sized organisation Qualified accountant (B.Comm. or CIS; up to 5 years experience) Qualified accountant (CA; 5 10 years experience) Qualified accountant (CA; over 10 years experience) Chief Accountant (B.Comm/CMA or CA; 10 years + experience) Financial Manager (B.Comm/CMA in intermediate sized organisation) Financial Manager (qualified CA in intermediate sized organisation) Small local authority Medium sized local authority Intermediate sized local authority e.g. Kimberley, East London Large local authority (Metro) e.g. Johannesburg, Cape Town D2 D3 D3 D3 D5 D5 E 2 E2 E3 E3 D3 D4 D5 E2 E3 D3 D5 E2 / E3 D1 D2 D3 D4 E1 E2 D3 D4 E1 E3 D lower D lower D lower D lower D upper D upper E lower E Lower E upper E Upper D lower D upper D upper E lower E upper D lower D upper E lower / E upper D lower D lower D lower D upper E lower E lower D lower D upper E lower E upper Executive Mayor Medium sized local authority D4 D Upper P-E Corporate Services SA (Pty) Limited

45 Appendix 3. The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page 8 Profession Job Title / Benchmark Job Paterson Grade / Broadband Airline Pilot in State owned airline, i.e. SAA, SA Express, SA Airlink First Officer : Narrow Bodied Aircraft Senior First Officer : Wide Bodied Aircraft Captain : Narrow Bodied Aircraft D1 D3 E1 D lower D lower E lower Captain : Wide Bodied Aircraft E2 / E3 E lower / E upper 5. MARKET DATA Comparative, current market remuneration data is presented in this section. As noted previously, pay data was researched using both our database and desk / internet research of published data such as gazetted reports of government departmental pay scales, benefits and conditions of service. In the case of medical personnel, updated salary data was sourced by the Department of Surgery at the University of Witwatersrand. The market data should be read in conjunction with the following notes : comparisons have been made on the basis of total employment cost, i.e. basic salary plus cash allowances (e.g. car allowances, annual non-performance related bonus, etc.) plus value of company / state contributions paid on behalf of the employee (e.g. retirement funding, insurances, medical aid, etc.); where employees in selected benchmark positions are eligible for short-term incentive pay (i.e. a payment, typically annual, for achieving pre-agreed performance criteria) the amount for achieving budget or expected performance has been included. (This amounts, most typically to percent of basic salary); data is shown either as average remuneration or the calculated mid-point of the pay range at the grade concerned. Where appropriate, pay ranges are also reflected. Since more than one benchmark job may be incorporated into a pay range, data in the table may not correlate exactly with published pay scales (where these are applicable); the most current available pay data has been used. In the case of State employees, in most cases these are the most recently published pay scales, effective April 2007; in the case of professions such as engineers and accountants we have used data current at July 2007; P-E Corporate Services SA (Pty) Limited

46 Appendix 3. The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page 9 in the case of medical practitioners, rates are based on Department of Health salary scales and include commuted overtime (16 hours per week) and the 15 percent scarce skills allowance. The rural allowance which is only applicable in certain circumstances has not been included. Pay scale mid-points have been reported, consistent with the comparative data. Comparative pay data is set out in Table 1 below. For reference we have also included, as Table 2, the comparison included in our September 2004 report. The final column in the table shows the relationship (comparative ratio) between the remuneration of medical practitioners and the average of remuneration paid to the basket of selected benchmark, comparator positions. Table 1 : Comparative Remuneration : Professionals Employed in the Public Sector : 2007 Data Paterson Grade D1 Medical Practitioners in State Sector D Annual Total Cost of Remuneration (Rands) Average Salary / Grade Mid Point (Range Reflected in Brackets Where Applicable) Judges / Magistrates in State sector D D D E1 E E Engineers in Public Sector ( ) ( ) ( ) Accountants in Public Sector ( ) ( ) ( ) ( ) ( ) ( ) Municipal Managers: Local Authorities ( ) ( ) ( ) ( ) ( ) Airline Pilots: State Owned Airlines ( ) ( ) ( ) Comparative Ratio Medical Practitioners vs Average of Benchmark Positions 0,65 0,69 0,52 0,50 P-E Corporate Services SA (Pty) Limited

47 The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page 10 Table 2 : Appendix 3. Comparative Remuneration : Professionals Employed in the Public Sector : 2004 Data Paterson Grade Medical Practitioners in State Sector Annual Total Cost of Remuneration (Rands) Average Salary / Grade Mid Point (Range Reflected in Brackets Where Applicable) Judges / Magistrates in State sector Engineers in Public Sector Municipal Managers: Local Authorities Airline Pilots: State Owned Airlines D D D D D ( ) ( ) ( ) ( ) E E2 E ( ) ( ) ( ( ) ( ) ( ) Comparative Ratio Medical Practitioners vs Average of Benchmark Positions 0,67 0,72 0,56 0,55 6. COMMENT Remuneration offered to medical practitioners within the State Sector has increased by 20 to 25 percent at lower levels and by approximately 18 percent at the more senior levels, over the past three years. By comparison : remuneration of both engineers and airline pilots has increased within a 30 to 40 percent range; and remuneration of judges and magistrates, and officials within local authorities, has increased within a 20 to 25 percent range. Remuneration across all job categories and all sectors of the South African economy as measured by our national survey (950 organisations, 1,5 million employees) has increased by : P-E Corporate Services SA (Pty) Limited

48 Appendix 3. The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page percent at executive level; and 23 percent across all levels, over the corresponding period. Increases awarded to medical practitioners over the past three years lag increases awarded to other professionals surveyed by a slight margin. The result is that the calculated comparative ratios in Table 1 have weakened in relation to those in Table 2 (representing the 2004 data). Differentials between the earnings of medical practitioners and those of other professionals employed within the State sector thus remain very substantial. Registrars and medical officers earn only 65 percent 70 percent of the total remuneration paid to their peers; at senior management levels (senior specialists, principal medical officers, etc.,) remuneration is only 50 percent 52 percent of that paid to the selected comparator group. Pay curves illustrating this shortfall are shown in Figure 1 below (2007 data) and Figure 2 (2004 data) overleaf. Figure 1 : Comparative Pay Data : Paterson Grade D1 D2 D3 D4 D5 E1 E2 E3 Airline Pilots Judges Magistrates Medical Practitioners Engineers Municipal Managers Accountants P-E Corporate Services SA (Pty) Limited

49 The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page 12 Figure 2 : Comparative Pay Data : 2004 Appendix Paterson Grade D1 D2 D3 D4 D5 E1 E2 E3 Airline Pilots Judges Magistrates Medical Practitioners Engineers Municipal Managers P-E Corporate Services SA (Pty) Limited

50 Appendix 3. The Association of Surgeons of South Africa Comparative Benchmarking : Remuneration of Surgeons Employed in the State Sector Page CONCLUSION We trust this report will be helpful and look forward to discussing it with you. Submitted on behalf of P-E Corporate Services by D WILSON Senior Consultant ADELE SLOTAR Principal Consultant M J R WESTCOTT Managing Director /ub P-E Corporate Services SA (Pty) Limited

51 SAJS General Surgery Appendix 4. General surgery in crisis the critical shortage D. Kahn, CH.m., f.c.s. (S.A.) S. Pillay, f.c.s. (S.A.) M. G. Veller, f.c.s. (s.a.), m.med. E. Panieri, f.c.s. (s.a.) M. J. R. Westcott, B.SC. (CHEM. ENG.), M.B.L Association of Surgeons of South Africa and Departments of Surgery, Universities of Cape Town and the Witwatersrand General surgery is facing a serious crisis. In the past general surgery was an extremely popular career choice for newly qualified medical graduates. There was a healthy competitive demand for registrar posts at all local medical schools and these posts were always oversubscribed. However, there has been a dramatic decline in the number of applicants for registrar posts at all of the academic centres. 1-3 Some of the 88 Summary Introduction. General surgery is facing a serious crisis. There has been a significant decline in the number of applicants for registrar posts and an inability to attract and retain general surgical specialists in the state sector. The Association of Surgeons of South Africa (ASSA) undertook this study to determine the extent and cause of the problem. Methods. The study involved a combination of desk research and structured interviews. In addition, the Health Professions Council of South Africa (HPCSA) database was reviewed and compared with the South African Medical Association (SAMA) and ASSA databases. The medical schools provided information about student numbers and demographics, and the National Department of Health pro vided information about the status of medical practitioner and specialist posts in the state sector. Results. Overall, 26.1% of the specialist posts were vacant. The situation was particularly critical in Mpumalanga and the Eastern Cape, where 84% and 58% of the specialist posts were vacant. Using a predictive model, a conservative estimate of the need for general surgeons was found to be at least 50 per year. Currently the eight medical schools graduate about 25 general surgeons per year. The changing demographics of medical students may be partly responsible for the decline in registrar applicants. Conclusion. The findings from this study have revealed that the shortage of general surgeons in the state sector has reached critical levels. VOL 44, NO. 3, august 2006 SAJS departments have had as many as 25% of the posts unfilled. A further concern has been the inability to attract and retain general surgical specialists in the state sector. Although it would appear that we have been training adequate numbers of general surgeons over the years, very few of them continue to practise in the state sector. Consequently many of the specialist posts in the non-academic centres, especially in the periphery, remain unfilled. The Association of Surgeons in South Africa (ASSA) has been concerned about both the diminishing number of applicants presenting for general surgery training and the increasing number of general surgery posts that are vacant in the state sector in South Africa. As a result, ASSA took a decision in May 2004 to initiate a study to determine the extent and the cause of the problem. The primary objective in commissioning this study was to collect and analyse comparative data that would enable ASSA to evaluate the factors which impact on a career in general surgery, in particular, the working conditions and the relative equity of the remuneration of general surgeons in South Africa. The relative equity not only referred to a comparison with other fields of medical specialisation, but also extended to other professions in general. ASSA would also like to use the study findings as a basis for developing strategies to correct the current inequities between surgeons and other medical specialists as well as other professionals, and to enhance the attractiveness of general surgery as a profession. There were four aspects to the study, including an assessment of the shortage of general surgeons, an assessment of the factors that impact on the choice of general surgery as a career option, a report on the level of remuneration of specialists in the state sector, and a report on the level of remuneration of specialists in the private sector. In this paper we report on the critical shortage of medical practitioners and specialists in the state sector. Methods P-E Corporate Services (P-ECS) were contracted to undertake this study on behalf of ASSA. The terms of reference were to report on the work environment, conditions general surgery-critical shortag /25/06 3:49:16 PM

52 Appendix 4. SAJS ARTICLES of service and remuneration for general surgeons, both in the state and the private sector. The approach to this assignment was based on a combination of desk research and structured interviews. The desk research included an in-depth study of relevant data in professional medical publications, other studies and the Internet. P-ECS also utilised their own extensive database of remuneration levels and employment policies across most sectors of the South African economy. The structured interviews were undertaken with general surgeons in the state sector and in private practice, heads of departments, registrars, and other medical specialists. The surgeons interviewed were from Gauteng, the Free State, the Western Cape and KwaZulu-Natal. A structured questionnaire was developed to research the perceptions of recently qualified specialists and registrars about their choice of general surgery as a career option, and about the current state of the profession in general. The Health Professions Council of South Africa (HPCSA) database was reviewed to determine the number of medical practitioners, both general practitioners and medical specialists, in practice. These data were compared with the South African Medical Association (SAMA) and the Association of Surgeons of South Africa (ASSA) databases. The medical schools also provided data with regard to the number of applications, the number of students registered, and the number of students graduating. The National Department of Health provided data with regard to the total number of medical practitioner and specialist posts available in the various provinces, and whether the posts were filled or vacant. Results Populations of medical practitioners The most recent statistics available from the HPCSA indicated that general practitioners were registered with the Council and this, plus some community service doctors, yielded a national total supply statistic of approximately general practitioners (Table I). At the same time there were specialists registered with the HPCSA, of whom 954 (10.5%) were categorised as surgeons. ASSA is the official representative body for all general surgeons in South Africa and includes subspecialists such as vascular, trauma and gastrointestinal surgeons. The current ASSA membership totalled approximately 550. The general surgeons who were not ASSA members were assumed to be no longer practising in South Africa, retired, or not members of the Association out of choice, since membership was voluntary. SAMA claimed that approximately 70% of all specialists belonged to the Association. In fact the SAMA database included specialists. The number of surgeons included in this SAMA database was 540, approximately 8% of the population of specialists. Public and private sector breakdown The breakdown of the medical professionals into those employed in the public and private sectors, according to the HPCSA and the SAMA statistics, are shown in Table I. There was excellent correlation between the statistics obtained from the HPCSA and the SAMA databases. Both databases indicate that approximately one-third of the specialists were employed in the public sector compared with two-thirds employed in the private sector. The SAMA statistics also revealed that 27% of the population of specialists on the database had graduated/ qualified during the past 10 years ( ). Similarly, 23% of the population of surgeons on their database had graduated/qualified during the past 10 years. A review of the ASSA membership database showed that of the 161 members for whom identity numbers were available, 22% were over 60 years of age, 40% over 55 years and 63% over 50 years. The ASSA database also indicated that 43% of the general surgeons worked exclusively in the private sector. Of the 30% of general surgeons who worked for the state, 67% (or 20% of the total sample) participated in remunerated work outside of the public sector (RWOPS). The remaining 27% of general surgeons in the ASSA database worked in both the state and private sectors. Vacant posts in the state sector The Department of Health statistics as of August 2004 indicating the shortages of medical practitioners and medical specialists in each of the provinces are shown in Table II. The number of posts, number of posts filled and number of vacant posts are shown for each category of staff. The national data for medical practitioners and specialists indicated that of the general practitioner posts available in the state sector, 26.6% were vacant and of the specialist posts available, 26.1% were vacant. The situation was particularly critical in Mpumalanga, the Northern Cape and the Eastern Cape, where shortages exceeded 40%. More specifically, 84% of the specialist posts in Mpumalanga, 58% in the Eastern TABLE I. HPCSA and SAMA statistics of General Practitioners and Specialists in the State and Private sectors HPCSA statistics SAMA database Public sector Private sector Total Public sector Private sector Total General (42%) (58%) (100%) practitioners Specialists (37%) (63%) (100%) (32%) (68%) (100%) Surgeons n/a n/a (36%) 335 (64%) 540 (100%) (included under specialists) SAJS VOL 44, NO. 3, august general surgery-critical shortag /25/06 3:49:19 PM

53 SAJS ARTICLES Appendix 4. Cape and over 40% in Limpopo and North-West province were vacant. In contrast, in the Western Cape only 4.7% of the specialist posts in the state sector were unfilled. Predictive model of the need It is difficult to determine the actual demand for general surgeons in both the state and private sectors. A predictive model could be used to estimate the number of general surgeons that need to graduate annually to meet the demand for surgical services in South Africa. Thus, for example, the following assumptions and calculations could be made. It can be assumed that South Africa s population of 40 million people will require general surgery admissions per year and that a general surgeon may typically handle 5-10 admissions and/or consultations of varying complexity per day. General surgeons, after allowing for leave, conferences and development time, etc. may be expected to have working days available. A general surgeon would therefore have the capacity to handle some admissions/ consultations per year. A 5-10% attrition rate should be applied to allow for normal retirements, deaths and those who leave the profession for other reasons. The theoretical need, calculated on the basis of the above assumptions, would therefore be approximately 500 general surgeons to meet current demands. However, considering the nature of the assumptions, this need could range from 350 to 700, i.e. between 1 surgeon per population and 1 surgeon per population. Based on the above attrition rate, the calculations suggest that the number of surgeons that need to be graduated annually to meet the demand would be in the range. It should, however, be borne in mind that the above theoretical calculation assumes that the full population of general surgeons is engaged in providing full-time service. This is obviously a simplification, particularly in the state sector, where surgeons have additional academic and administrative responsibilities. Furthermore these figures do not take into account the high net rates of emigration of medical graduates from South Africa. TABLE II. The Department of Health statistics indicating the number of filled and unfilled Medical practitioner and Specialist posts in each Province Province Occupational classification Total filled Total vacant Total posts % vacant Eastern Cape Medical practitioners Medical specialists Free State Medical practitioners Medical specialists Gauteng Medical practitioners Medical specialists KwaZulu-Natal Medical practitioners Medical specialists Limpopo Medical practitioners Medical specialists Mpumalanga Medical practitioners Medical specialists North West Medical practitioners Medical specialists Northern Cape Medical practitioners Medical specialists Western Cape Medical practitioners Medical specialists National Depts Medical practitioners Medical specialists Total Medical practitioners South Africa Medical specialists VOL 44, NO. 3, august 2006 SAJS general surgery-critical shortag /25/06 3:49:19 PM

54 Appendix 4. SAJS ARTICLES Currently the eight medical schools graduate approximately 25 general surgeons per year. This therefore represents only half of the most conservative estimate of numbers required to maintain the country s current service levels. Trends in university/medical school applications Collectively, South African university medical schools have received an average of applications for admission to medicine, per annum, for the past 4 years (Table III). About 9% of these applications were successful and admitted to the first year. It should be noted, however, that this understated the actual percentages of successful applications as many students applied to more than one medical school. It was evident that there was a steady supply of school leavers eager to enter the medical profession each year. Of the numbers of medical students graduating annually, medical school statistics indicate that approximately 40 doctors (3.5% of graduates) were applying to specialise in general surgery each year. This admission rate to surgery was approximately 30% lower than the numbers required to maintain the service levels. The impact of transformation of the South African economy and socio-political structures It is common cause that the South African economy and socio-political structures are in transformation. The background and reasons for this are well established. Of relevance, however, is the Employment Equity Act, which has as its stated objective: to eliminate unfair discrimination in employment practices and, at the same time create a diverse workforce which reflects the national and regional demographics of South Africa s economically active population. In the medical field the changes have impacted on diverse issues ranging from the racial and gender composition of university student admissions to how and where medical services are delivered. University admissions The racial and gender mix of students registered for firstyear studies at the South African medical schools over the last 4 years are shown in Table IV. Sixty per cent of all student registrations were now females, with only 40% being males. The proportion of female students has increased from 10% in the 1960s to 17% in the 1970s, 22% in the 1980s, 46% in the 1990s, and the current 60%. The proportion of black students increased from 35% in 2001 to 43% in Registration of white students has declined from 39% to 33% over the same period. The total proportion of students with historical pdi status, i.e. black and female, has increased from 61% to 67%. While the rationale on which these directives were based was fully understandable, there have also been certain unavoidable consequences. Many of the country s most talented and ambitious school leavers, who might otherwise have considered a career in medicine, have elected to pursue other professions. Furthermore, the gender mix trend in student intake has had an adverse impact on the availability of general surgery candidates in particular. The proportion of female doctors who elect to specialise in surgery has traditionally been lower than for male doctors. In addition, the perception among interviewees was that those females who did want to specialise tended to select specialties where practice hours were usually limited to normal working hours. Reluctance on the part of females to enter into general surgery was attributed both to family reasons and to concerns about security associated with after-hours work. At the University of KwaZulu-Natal Medical School only 16% of the current registrars were female, compared with a female student intake of over 50%. The University of the Free State only had 2 female registrars. A previous study from the University of the Witwatersrand noted that 9.9% of male graduates sampled have specialised in surgery and surgical specialties, compared with only 0.9% of female graduates. Table III. University applications and admissions to Medicine in South Africa Year No. of applicants No. of admissions % admitted Average TABLE IV. Racial and gender mix of students registered for first year at the South African medical schools Gender mix Racial mix Total Male Female Black White Indian Coloured Year registrations No. % No. % No. % No. % No. % No. % SAJS VOL 44, NO. 3, august general surgery-critical shortag /25/06 3:49:20 PM

55 SAJS ARTICLES Appendix 4. Practice qualification requirements Transformation within the medical profession has included changes in the way in which doctors qualify to practise, and are authorised to practise. Medical students are required to complete a year of community service, which is seen as being of potential benefit. However the lack of consultation about the location of postings, restraints on personal freedom of choice, and poor and inadequate facilities, expertise, supervision and administration at many hospitals, have all provided strong disincentives. The pending legislation that will require doctors in the future to obtain a Certificate of Need dictating where they may practise was seen as impacting on personal freedom of choice and a further disincentive to specialise. Immigration and emigration According to official statistics (Statistics SA), emigration from South Africa has ranged between and people per annum, and has averaged per annum over the past 10 years. Immigration, on the other hand, has ranged between and over the same period, averaging per annum. The country has therefore suffered a net loss of some people per annum over this period. Medical practitioners have comprised % of total emigrants over the past 5 years. It is not known what proportion of this sample comprised specialists. However, data from Statistics SA for 1997/98 indicated that specialists accounted for 20-30% of medical practitioner emigrants at that time. As a rough approximation medical practitioners may be estimated to account for some 1% of an average of people per annum, i.e. 40 practitioners per annum. Specialists could account for 8-10 of these professionals. However, it is well acknowledged that many professionals leaving South Africa permanently do not necessarily follow official emigration procedures. Thus the real brain drain statistic would have been approximately three times the official statistic. A crude deduction would suggest that South Africa was currently losing at least medical practitioners, including specialists, annually as a result of emigration. South Africa apparently loses almost half of its qualified doctors to the UK, Canada and Australia. According to Departmental estimates from 2001, over South African medical health professionals (all categories) were working overseas in English-speaking First-World countries. The majority are in the UK (38%), the USA (30%), Australia (15%) and Canada (10%). The impact of the exodus of medical professionals from developing countries has been enormous. Approximately 6% of all British and 10% of all Canadian hospital-based doctors are South African. Only 60 of 500 doctors trained in Zambia since independence still work in that country, and Mozambique has only 500 doctors to service a population of 18 million. Malawi has only one general surgeon and one orthopaedic surgeon in the government health service. Discussion The Association of Surgeons, because of concern about both the decreasing number of applicants for general surgical registrar posts and the increasing number of unfilled specialist posts in the state sector, commissioned P-ECS to undertake this study into the status of general surgery. This part of the study documents the shortage of general surgeons and some contributing factors. The findings from this study have revealed that the shortage of qualified general surgeons (and other medical practitioners) in the state sector has reached critical levels, to the extent that this is receiving regular media attention. Where over 50% of specialist posts remain continuously vacant in certain provinces, it is difficult to understand what additional evidence is required for the situation to be acknowledged as a crisis. The situation is particularly critical in Mpumalanga, the Northern Cape and the Eastern Cape. The extent to which the number of general surgeons practising in the private sector is in line with the demand for medical treatment is difficult to gauge with accuracy. Various sources, such as the SAMA and the medical aid associations, have suggested that in their opinion South Africa had an adequate supply and possibly an oversupply of medical professionals within the private sector. However, it should be remembered that the high-volume demand for medical treatment in South Africa is met through state sector institutions. HPCSA statistics indicated that some general practitioners were registering to practise each year. These numbers may be reconciled with annual demand for general practitioners by applying a 5-10% attrition rate to the current population of ± general practitioners, i.e. an annual requirement of between and general practitioners. The fact that there is believed to be an oversupply within the private sector is counter-balanced by severe shortages in the state sector. In overall terms it is therefore very possible that the requirement for medical practitioners exceeds the current supply. The above sources also suggested that South Africa had an adequate supply of specialists in most medical specialties within the private sector. The population of specialists as noted above exceeds 50% of the number of general practitioners, indicating that there is one specialist for every two general practitioners. The population of surgeons may be estimated from the same statistics as 5% of the population of general practitioners, or one surgeon for every 20 GPs. It has been estimated that South Africa needs to produce in excess of 50 general surgeons per year, based on the usual attrition rate. Currently the eight medical schools graduate less than 25 general surgeons per year on average. In other words, the numbers of general surgeons qualifying annually is substantially lower, and possibly no more than 50% of current estimates. Furthermore, a significant proportion of these recently qualified specialists emigrate, either temporarily or permanently, to practise abroad. Further evidence of the critical shortage of surgeons is the fact that 63% of the general surgeons belonging to ASSA were over the age of 50 years. Not only are the numbers of general surgeons being trained inadequate, but many young surgeons elect to emigrate. Various factors have been identified as being responsible for the decline in the number of applicants for general surgical training posts. Changes in the demographics of medical students, with an increase in the numbers of female and black students, appear to be partly responsible. Female and black students tend not to consider a career in surgery as an option, probably because of the lack of suitable role models. 92 VOL 44, NO. 3, august 2006 SAJS general surgery-critical shortag /25/06 3:49:20 PM

56 SAJS ARTICLES Many black students also have financial responsibilities that preclude them from specialising after completing the internship and community service years. Other factors contributing to the large number of unfilled specialist posts in the state sector, such as poor remuneration and poor working conditions, will be discussed in the subsequent reports. In summary, therefore, the critical shortage of specialists in the state sector, which has reached crisis proportions, has been aggravated by the fact that the number of surgical graduates per year has been grossly inadequate. Transformation at medical schools may be partly responsible Appendix 4. for the decline in the number of applicants for surgical registrar posts. Mr Brian Ruff, of Discovery Health, provided the predictive model to estimate the need for general surgeons. REFERENCES 1. Marschall JG, Karimuddin AA. Decline in popularity of general surgery as a career choice in North America. World J Surg 2003; 27: Podnos YD, Campbell B, Wilson SE, et al. Patterns of graduating medical student career selections from 1997 to 1998 and their effect on surgery as a career choice. Arch Surg 1999; 134: Cofer JB, Biderman MD, Lewis PL, et al. Is the quality of surgical residency applicants deteriorating? Am J Surg 2001; 181: clinical medicine ad 11/11/05 11:57 AM Page 1 PRICE: R SAMA MEMBERS: R HMPG TO ORDER CONTACT: South South African Medical Association Health & Medical Publishing Group 1-2 4th Lonsdale Floor, Sanclare Building, Building, Gardener 21 Dreyer Way, Street, Pinelands, Claremont, Tel: Tel: (021) (021) / Fax: Fax: (021) (021) / [email protected] 94 VOL 44, NO. 3, august 2006 SAJS general surgery-critical shortag /25/06 3:49:24 PM

57 SAJS General Surgery Appendix 4. General surgery in crisis comparatively low levels of remuneration D. Kahn, CH.M., F.C.S. (S.A.) S. Pillay, F.C.S. (S.A.) M. G. Veller, F.C.S. (S.A.), M.MED. E. Panieri, F.C.S. (S.A.) M. j. r. Westcott, B.SC. (CHEM. ENG.), M.B.L. Association of Surgeons of South Africa and Departments of Surgery, Universities of Cape Town and the Witwatersrand Summary Introduction. Several factors, including comparatively low remuneration, may be responsible for the decline in applicants to general surgery. In this study, the levels of remuneration of general surgeons in the state sector were compared with other professionals in the state sector and general surgeons overseas. Methods. The study involved a combination of desk research and structured interviews. The Paterson system of job evaluation was used to compare general surgeons with other professionals. The levels of remuneration of general surgeons in the state sector were compared with those of other professionals. Results. There was a significant difference in the levels of remuneration between state-employed medical practitioners and other professional positions such as legal professionals, municipal managers and airline pilots. At senior levels (senior specialist) the remuneration was only ±55% of that paid to the selected comparator group. There was also a significant differential between the remuneration of state-employed general surgeons and their overseas counterparts. Conclusion. Levels of remuneration of state-employed medical practitioners continue to lag behind other professionals. There is a serious concern about the diminishing interest in general surgery as a specialty. 1,2 The last 5-10 years has seen a significant reduction in the number of applicants for surgical trainee positions at all local academic institutions. Furthermore, there are an increasing number of vacant posts in surgery in the state sector. As a result, the Association of Surgeons of South Africa (ASSA) undertook a study to determine the extent of the problem. ASSA has a membership of about 500 and is the official body representing general surgeons in both the state and the private sectors in South Africa. The decline in applicants to general surgery has been noticed throughout the world. 1-3 Several reasons may be responsible for this serious threat to the future of surgery, and include factors such as graduates placing a greater emphasis on a favourable lifestyle, the lure of private practice, the lure of overseas, and the comparatively low remuneration. 4-7 In this study we compared the levels of remuneration of general surgeons employed in the state sector with both other professionals employed in the state sector, and general surgeons employed in selected English-speaking First-World countries, with the objective of assessing the degree of remuneration parity general surgeons currently enjoy. Methods P-E Corporate Services (P-ECS) were contracted by ASSA to undertake this comparative study into the remuneration and working conditions of general surgeons in South Africa. The study involved a combination of desk research, structured interviews, and a brief visit to an international destination that typically attracts South African doctors. The desk research involved in-depth reviews of relevant data in professional medical publications, other studies, the internet, and P-ECS s own extensive database of remuneration levels and employment policies across most sectors of the South African economy. Structured interviews were undertaken with general surgeons, including heads of departments, recently qualified specialists, and registrars, other medical specialists, and professionals in other fields, such as law, accounting, engineering, etc. The interviews were spread through Gauteng, the Free State, KwaZulu-Natal, and the Western Cape. A structured questionnaire was developed to research the surgeons perceptions of their choice of general surgery as a career option, and of the current state of the profession in general. The international field research was limited to two interviews in the UK plus fairly comprehensive desk research. The levels of remuneration of general surgeons within the state sector were compared with other professionals in the state sector and general surgeons employed in selected English-speaking First-World countries with the objective of 96 VOL 44, NO. 3, AUGUST 2006 SAJS general surgery-comparatively lo /25/06 4:10:05 PM

58 SAJSARTICLES assessing the degree of remuneration parity general surgeons currently enjoy. R e m u n e r ation c o m p a r i s o n s b e t we e n m e d i c a l professionals and other professionals were necessarily best approximations. Job descriptions and content obviously varied from profession to profession and factors such as the nature of work carried out, working conditions, decision-making structures, consequences of error etc. also varied correspondingly. In the case of the international comparisons, job alignment was somewhat easier. However, factors such as differences in tax and social security structures, living standards and cost of living had to be taken into account. Nevertheless, methodologies to provide reasonably meaningful comparisons were employed. Comparison of general surgeons with other professionals employed in the state sector Comparisons of jobs across different functional areas were made by analysing job content, and grading or ranking this using a job evaluation system. Job evaluation may be defined as the process of determining, without regard for personalities or personal competencies, the worth of one job relative to others. Job evaluation systems therefore measure the intrinsic worth of jobs. Various such systems are used in South Africa, and all employ a conceptually similar approach. For the purpose of this study the Paterson system of job evaluation was used. This is the most widely used system in South Africa and categorised jobs in terms of decision bands. Each band represents an increasingly complex decision level and thus a more senior management level. For the purpose of evaluating and grading (or ranking) jobs, the bands are divided into grades and sub-grades. Six bands are recognised in the Paterson system, from the lowest to highest organisational decision levels. Only the three highest bands were required for comparative purposes in this exercise and these bands, grades and subgrades, and typical management and decision responsibility levels are shown in Table I. Pay scales applicable to general surgeons working in the state sector were analysed and compared with selected professions employed within the same sector. The selection of comparator professions was necessarily constrained by availability of comparative data. For example, single-state pay scales were not readily available for professions such as accounting and engineering where such skills may be located Appendix 4. in various job functions across various departments. In such cases overall public sector data were used. Comparisons were made by grading jobs at different professional levels and computing total cost of employment figures. The professions and benchmark jobs which were used for comparative purposes are shown in Table II. General surgeons compared with their counterparts in English-speaking countries The level of remuneration and net disposable income earned by medical practitioners in state employ in South Africa was compared with that in selected English-speaking countries. In order to provide meaningful comparisons of earnings in different international locations, it was necessary to take factors such as taxation, social security costs, costs of living and essential living expenditure into consideration, in addition to gross remuneration earned. P-ECS had developed a robust methodology for this purpose, which involved computing the net disposable income (NDI) associated with levels of remuneration earned for comparable jobs in different international locations. Application of the methodology in this particular situation involved the following steps: 1. The gross remuneration data (total cost of employment) for medical practitioners at different levels in different international locations was researched. The three countries selected for comparison with South Africa were the UK, Australia and New Zealand. 2. The deduction of taxation and social security (retirement funding, medical health insurance costs, etc.), based on normal market practice in the country concerned, from the gross remuneration yielded a net income figure. 3. The essential living costs applicable at the remuneration level and in the country concerned were determined. Essential living costs were defined as costs required to purchase non-luxury needs such as food, housing, transport, etc. in the country concerned. 4. Deduction of the essential living costs from the net income yielded the NDI. The NDI represented that portion of the gross remuneration available for discretionary spending or saving. 5. By dividing the NDI by the essential living costs we were able to develop a convenient index of the purchasing power of the net disposable income. TABLE I. COMPARISONS OF JOBS ACROSS DIFFERENT FUNCTIONAL AREAS Paterson band Management level Broadband grades Sub-grades Decision type F Top management/executives F upper F2 Policy making or strategic in large companies F lower F1 decisions usually made at top management/board level E Senior executives reporting to E upper E3/E4 Programming decision usually the CEO. Holding or subsidiary/single E lower E1/E2 made by senior managers or head unit company of major functions/business units D Middle managers and professionally D upper D4/D5 Interpretive or probabilistic decisions qualified, experienced specialists, D lower D1/D2/D3 usually made by middle management e.g. in finance, IT, etc. and professional staff based on overall corporate strategy 98 VOL 44, NO. 3, AUGUST 2006 SAJS general surgery-comparatively lo /25/06 4:10:07 PM

59 Appendix 4. SAJS ARTICLES TABLE II. PROFESSIONS AND BENCHMARK JOBS USED FOR COMPARATIVE PURPOSES Profession Job title/benchmark job Paterson grade/broadband Medical practitioner in Intern D2 D lower state sector employ Registrar (Leg 1) D3 D lower Community service doctor D3 D lower Medical officer D3 D lower Junior specialist (working under D5 D upper supervision) Senior medical officer D5 D upper Specialist E2 E lower Principal medical officer E2 E lower Chief medical officer E3 E upper Senior specialist E3 E upper Judge/magistrate in Magistrate D3 D lower state sector employ Senior magistrate D4 D upper Regional/chief magistrate D5 D upper Regional court president/special grade E2 E lower Chief magistrate Judge, e.g. High Court, Labour Court E3 E upper Engineer employed in Qualified professional engineer D3 D lower the public sector (5-10 years experience) (state, local authority Qualified professional engineer D5 D upper or parastatal) (over 10 years experience) Engineering manager in intermediate-sized E2/E3 E lower/e upper organisation Municipal manager: Small local authority D3 D lower Medium local authority D4 D upper Local authority Intermediate-sized local authority, e.g. Kimberley, East London E1 E lower Large local authority (Metro), e.g. Johannesburg, Cape Town E3 E upper Airline pilot in First Officer: Narrow-bodied aircraft D1 D lower state-owned airline, Senior First Officer: Wide-bodied aircraft D3 D lower i.e. SAA, SA Express, Captain: Narrow-bodied aircraft E1 E lower SA Airlink Captain: Wide-bodied aircraft E2/E3 E lower/e upper Salary increases The salary increases awarded to state-employed medical practitioners over the past 5 years was analysed. The increases in basic salary and in total cost of employment were analysed separately. The increases were compared with the average increases awarded to all staff categories across all sectors of the South African economy, and with inflation. All sector increases were extracted from P-ECS s annual National Surveys of General Staff Remuneration in South Africa. The surveys report on a database of over 900 organisations across all sectors, employing between 1.5 and 2 million staff. They are regarded as highly authoritative and are used as benchmarks by numerous South African companies. Inflation data was based on Statistics S.S. data, and the CPIX indicator had been employed for this purpose. Results General surgeons compared with other medical professionals in state employ Consultant general surgeons and registrars in state employ were paid on a comparable basis with other medical professionals in state employ. The remuneration package included base pay for a 40-hour working week, 16 hours of overtime, a scarce skills allowance, and a rural allowance where applicable. A standard bonus (thirteenth cheque) was paid in the birthday month. State benefits also included the pension fund, medical aid contributions, a housing allowance and education subsidy. No provision was made for the provision or cost reimbursement of essential productivity tools such as cell phones or laptops, which have to be provided at the cost of the employee. General surgeons compared with other professionals employed within the state sector Comparative remuneration data for various professionals employed in the state sector are shown in Table III. Comparisons were made on the basis of total employment cost, i.e. basic salary plus cash allowance (e.g. car allowances, annual non-performance-related bonus, etc.) plus value of company (state) contributions paid on behalf of employee (e.g. retirement funding, insurances, medical aid, etc.). Where employees in selected benchmark positions were eligible for SAJS VOL 44, NO. 3, AUGUST general surgery-comparatively lo /25/06 4:10:07 PM

60 SAJSARTICLES Appendix 4. TABLE III. COMPARATIVE REMUNERATION FOR DIFFERENT PROFESSIONS Annual total cost of remuneration (rands) average salary/grade mid-point (range reflected in brackets where applicable) Airline pilots: Paterson Medical Judges/magistrates Engineers in Municipal managers: state-owned Comparative grade practitioners in state sector public sector Local authorities airlines ratio D ( ) D D ( ( ( ) ) ) D D ( ( ) ) E ( ) E ( ) ( E ) ( ) short-term incentive pay (i.e. a payment, typically annual, for achieving pre-agreed performance criteria), the amount for achieving budget or expected performance has been included. The data are shown as either the average remuneration or the calculated mid-point of the pay range at the grade concerned. When available, the pay ranges are also reflected. The most current available pay data have been used. It is evident that significant differentials exist between the remuneration of state-employed medical practitioners and other professional positions. The registrar remuneration trailed that of state-employed legal professionals by 23%, municipal managers by 33%, and airline pilots in stateowned airlines by 50%. The remuneration of senior medical specialists in the state sector trailed that of their legal counterparts by 45%, and was less than half the remuneration for municipal managers and airline pilots. The comparative ratios in Table III indicate the relationship between the remuneration of medical practitioners and the average remuneration paid to the basket of selected benchmark, comparator positions. This highlighted the fact that registrars and medical officers receive only ± 70% of the remuneration paid to their peers. At more senior levels (senior specialists and principal medical officers) the remuneration was only ±55% of that paid to the selected comparator group. It should also be noted that about 25% of the remuneration of medical specialists comprised non-pensionable allowances, which further disadvantaged them in relation to other state employees. The differences in remuneration for the different professionals in state employ are illustrated graphically in Fig. 1. General surgeons compared with their counterparts employed in selected Englishspeaking First-World countries The gross remuneration by job level for each of the four countries is shown in Table IV. The remuneration data were reflected in a common currency (South African rands) converted at the following exchange rates: GB 1: R11.6, AU$1: R4.8, NZ$1: R4.5. At each job level gross remuneration for South African medical practitioners was less than for their international counterparts. At specialist and senior specialist level the gross remuneration was only marginally less than in Australia, but approximately 30% less than in New Zealand and less than half of that in the UK. However, it should be borne in mind that medical practitioners in Australia work in private practice as well and this income is not reflected in their gross remuneration. The net disposable income (NDI) calculations for specialists and senior specialists are shown in Tables V and VI. According to the calculations the NDI for South African specialists and senior specialists was greater than for their Australian counterparts, equivalent to those in New Zealand, but less than half of that in the UK. The NDI for senior specialists in South Africa was R compared with R for those in the UK, and R and R for those in Australia and New Zealand respectively. The purchasing power ratios relative to South Africa (as base 100) averaged for specialists and senior specialists is shown in Fig. 2. Compared with the base of 100 for South African specialists and senior specialists, those in the UK, Australia and New Zealand had purchasing power ratios of 102 VOL 44, NO. 3, AUGUST 2006 SAJS general surgery-comparatively lo /25/06 4:10:07 PM

61 SAJSARTICLES Appendix Airline pilots Engineers Judges,Magistrates magistrates Municipal managers Medical practitioners Practitioners D1 D2 D3 D4 D5 E1 E2 E3 0 South Africa UK Australia New Zealand Fig. 1. Comparative remuneration for different professions. 130, 56 and 76 respectively. In other words the standard of living of general surgeons employed in comparable positions in the UK was some 30% higher than in South Africa, whereas South Africans enjoyed higher living standards than their colleagues in Australia and New Zealand. In order to make meaningful deductions from these statistics, however, it is important to reconcile this analysis with comparable statistics for business executives working in the commercial sector. Summary purchasing power ratios for South African executives compared with their counterparts in selected developed countries are shown in Fig. 3. Fig. 2. Purchasing power ratios relative to South Africa (as base 100). The most striking feature of the most recent commercial sector comparisons was that South African executives enjoyed purchasing power parity with American executives and exceeded those of counterparts in the UK and Australia. Salary increases The salary increases awarded to state-employed medical practitioners over the past 5 years are shown in Table IV. The data in Table VII indicate that the basic salary increases awarded to state-employed medical practitioners TABLE IV. GROSS REMUNERATION BY JOB LEVEL FOR EACH COUNTRY Total employment cost (rands per annum) Benchmark job title South Africa UK Australia New Zealand Intern Medical officer Registrar (1st leg) Senior medical officer Registrar (2nd leg) Principal medical officer Specialist Chief medical officer Senior specialist TABLE V. PRINCIPAL MEDICAL OFFICER/SPECIALIST South Africa UK Australia New Zealand Total employment cost Tax and social security Net income after tax/social security Essential living costs Net disposable income NDI/ELC (purchasing power of NDI) ratio Purchasing power ratio relative to SA as base VOL 44, NO. 3, AUGUST 2006 SAJS general surgery-comparatively lo /25/06 4:10:08 PM

62 SAJSARTICLES Appendix 4. TABLE VI. CHIEF MEDICAL OFFICER/SENIOR SPECIALIST South Africa UK Australia New Zealand Total employment cost Tax and social security Net income after tax/social security Essential living costs Net disposable income NDI/ELC (purchasing power of NDI) ratio Purchasing power ratio relative to SA as base South Africa USA UK Australia Fig. 3. Purchasing power ratios for executives in South Africa relative to counterparts in selected developed countries. have trailed both all sector averages and rates of inflation by ±36% and ±24% respectively. The position improved if increases in the total package were considered, with medical practitioners trailing all sector increases by 13%. Remunerated work outside of the public sector (RWOPS) The low level of remuneration paid to state-employed surgeons over many years has led to the entrenchment of the practice of RWOPS. It has become accepted practice that general surgeons need to supplement their public sectorbased pay packages by carrying out private practice work. It is estimated that over 90% of medical professionals in the state sector now engage in this practice at least to some degree. Additional earnings potential can be attractive. Discussion In this part of the study, the levels of remuneration of general surgeons within the state sector were compared with other non-medical professionals in the state sector, and general surgeons employed in selected English-speaking First-World countries. The data showed that recently qualified general surgeons in state sector employ were remunerated at rates some 25-30% below the public sector positions used in the comparisons, including state-employed legal professionals, municipal managers, and airline pilots in state-owned airlines. These differentials increased up to 100% at higher levels of seniority. In addition, the level of gross remuneration for South African medical practitioners was also less than their international counterparts. In the broadest sense, remuneration may be interpreted as the cost of labour. In developing remuneration policies, therefore, it is conventional within the private sector that higher levels of pay are required to attract and retain higher level skills and skills that are in short supply. The national remuneration survey statistics confirm that some 54% of South African organisations (across all sectors) currently pay premiums, over and above their established or normal pay scales, to attract and retain scarce skills. TABLE VII. SALARY INCREASES AWARDED TO STATE-EMPLOYED MEDICAL PRACTITIONERS AND OTHER STAFF EMPLOYED ACROSS ALL SECTORS OF THE ECONOMY COMPARED WITH THE INFLATION RATE State-employed General staff employed medical practitioners across all sectors of Period Basic salary (%) Total package (%) the economy (%) Inflation (CPIX) (%) n/a n/a n/a n/a n/a Cumulative increase n/a = no data available 106 VOL 44, NO. 3, AUGUST 2006 SAJS general surgery-comparatively lo /25/06 4:10:08 PM

63 In recent years the public sector has in many areas begun to adopt pay policies that are more closely aligned with current best practice in remuneration. For example, municipal managers are now remunerated with reference to overall market rates and packages include incentive pay structured around performance criteria such as service delivery. In contrast, levels of pay of stateemployed medical practitioners lag behind private sector rates by very substantial margins. In addition remuneration paid to medical practitioners is also low in relation to that paid to state and public sector employees in other professional and managerial categories, and in relation to job-related skill levels. Many factors play a role in the choice of a career in medicine. Financial compensation is usually regarded as an important consideration in choosing a career option as a young medical graduate. 7 The decline in physician income, and in particular, the declining reimbursement for surgical services, is universal and we would argue that this may one of the major reasons for the significant decline in the number of applicants for surgical registrar posts, both locally and overseas. The performance of RWOPS has been critical in retaining general surgeons in the state sector. However, RWOPS practice has obvious implications that cause ongoing debate. The ethics and morality of carrying out what is in effect a second job while under an existing contract of employment are questionable. This is justified on the basis that the state system would collapse as a result of mass resignations if surgeons were not allowed to supplement their income in this way. In addition, this practice is not unique to South Africa and there are many similar examples throughout the world. One of the problems with RWOPS is the lack of control on the amount of work carried out. The onus is placed on the individual to act responsibly. Conflicts inevitably do arise, particularly when cost of living pressures force surgeons to prioritise a certain number of RWOPS hours to the detriment of the state jobs. Other s argue that it would be unreasonable to condemn the practice of RWOPS as unethical and immoral given that it has become entrenched and accepted practice, and that it has become essential at this time to avoid further losses of already scarce medical skills from the state sector. South African executives in most sectors of the economy were currently enjoying a period of unprecedented relative prosperity in relation to their international counterparts. This was largely due to the recent good performance of the South African economy and in the case of the business/commercial sector, significant increases in executive pay flowing partly from globalisation of pay scales. Other factors included the low inflation and a stable rand, relatively low living costs in South Africa, and a weak US dollar. The position of general surgeons in the state employ is in stark contrast to that of executives in other sectors. While South African business executives enjoyed living standards over 60% higher than their UK counterparts, general surgeons lagged behind comparable UK living standards by 30%. Differentials of this type obviously provide a strong inducement to doctors to emigrate. Comparative data for Australia indicated that relative living standards of both commercial sector executives and general surgeons were lower than in South Africa. This may, however, be attributed largely to flatter commercial sector wage structures. Also remember that greater use is made of regional incentive allowances, for example, in Australia. The basic salary increases awarded to doctors employed in the state sector trailed both all sector averages and the rates of inflation. The increases in the total package were an improvement. However, the total package comparison is somewhat misleading in that it includes the benefit of adjustments in allowances such as overtime, which are only made occasionally, and the adjustments do not form part of the pensionable portion of the remuneration. In summary, therefore, remuneration of general surgeons in state employ lagged behind their non-medical professionals in state employ, colleagues in the private sector, and general surgeons overseas. REFERENCES 1. Marschall JG, Karimuddin AA. Decline in popularity of general surgery as a career choice in North America. World J Surg 2003; 27: Podnos YD, Campbell B, Wilson SE, et al. Patterns of graduating medical student career selections from 1997 to 1998 and their effect on surgery as a career choice. Arch Surg 1999; 134: Cofer JB, Biderman MD, Lewis PL, et al. Is the quality of surgical residency applicants deteriorating? Am J Surg 2001; 181: Schwartz RW, Simpson WG, Strodel WE, et al. Career change: in quest of a controllable lifestyle. J Surg Res 1989; 47: Woodworth PA, Chang FC, Helmer SD. Debt and other influences on career choices among surgical and primary care residents in a community-based hospital system. Am J Surg 2000; 180: Erzurum VZ, Obermeyer RJ, Fecher A, et al. What influences medical students choice of surgical careers. Surgery 2000; 128: Fakhry SM, Watts DD. What s a trauma surgeon worth? A survey of the Eastern Association for the Surgery of Trauma. J Trauma 2000; 49: Appendix 4. SAJS ARTICLES SAJS VOL 44, NO. 3, AUGUST general surgery-comparatively lo /25/06 4:10:09 PM

64 SAJS General Surgery Appendix 4. General surgery in crisis factors that impact on a career in general surgery D. Kahn, CH.M., F.C.S. (S.A.) S. Pillay, F.C.S. (S.A.) M. G. Veller, F.C.S. (S.A.), M.MED E. Panieri, F.C.S. (S.A), M.MED. M. J. R. Westcott, B.SC. (CHEM. ENG.), M.B.L. Association of Surgeons of South Africa and Departments of Surgery, Universities of Cape Town and the Witwatersrand Summary Introduction. The Association of Surgeons of South Africa (ASSA), because of a concern about the decline in the number of applicants for registrar posts, undertook this study into the various factors that may influence the choice of surgery as career option. Methods. The study involved a combination of desk research and structured interviews with heads of departments, specialists, and registrars in general surgery. Results. The reasons for choosing general surgery as a career included the immediately visible results of a surgeon s efforts and the practical and intellectual challenge of the specialty. General surgery continued to enjoy a high status in society. The greater focus on primary health care has affected facilities at tertiary and secondary institutions. General surgeons worked excessively long hours, which was associated with increased levels of stress and placed severe strains on family life. All respondents felt that their levels of remuneration were poor in relation to other disciplines and professions. Conclusion. In this study we identified various factors that impacted either positively or negatively on the choice of general surgery as a career option. Interest in general surgery as a career option has diminished worldwide in recent years. 1-3 Similar trends have been noted in South Africa. The Association of Surgeons of South Africa (ASSA) has been particularly concerned about the decreasing number of applicants for registrar posts at the various medical schools, as well as the increasing number of vacant specialist posts in the state sector. Several factors could account for this trend. These include poor working conditions in the state sector as well as poor remuneration levels both in the state and private sectors. In May 2004 ASSA took a decision to initiate a study to determine the extent of the problem. ASSA engaged P-E Corporate Services (P-ECS) to undertake a comparative study into the working conditions, including factors that impact on the choice of general surgery as a career option, and remuneration of general surgeons in South Africa. The primary objective of the study was to collect and analyse comparative data that would enable ASSA to evaluate the relative equity of the working conditions and remuneration of general surgeons in South Africa. Relative equity in this context referred particularly to comparison with other fields of medical specialisation, but also included a comparison extended to other professions in general. The study also included an assessment of the reasons why general surgeons chose medicine as a career option, why they decided to specialise in general surgery thereafter, their perceptions about the status of general surgery, and the various factors that impact on surgery as a career. The findings from these studies would be used to develop strategies to correct the current inequities in working conditions and remuneration, and to enhance the attractiveness of general surgery as a profession to potential candidates. In this study we present the factors that could either positively or adversely influence the choice of a career in general surgery. Methods ASSA requested P-ECS to report on the work environment, conditions of service and remuneration for general surgeons in the state sector. In particular, attention was to be focused on the nature of the work done, the hours worked and the responsibility of specialists and registrars in training in the academic and non-academic centres. In addition the impact on and the quality of family life was to be assessed and compared with colleagues in other disciplines such as cardiology, orthopaedics, dermatology, ophthalmology and anaesthetics. The remuneration of general surgeons was also compared with those of other professions such as judges, advocates, accountants, engineers and actuaries. Furthermore, the remuneration of general gurgeons was compared with those in the UK, Australia, Canada and New Zealand, taking into account inflation, cost of living index and other relevant factors. 108 VOL 44, NO. 3, august 2006 SAJS general surgery-factors that imp /25/06 4:09:27 PM

65 Appendix 4. SAJS ARTICLES The study involved a combination of: 1. Desk research, which included a review of relevant data in professional medical publications, other studies, the Internet, and P-ECS s own extensive database of remuneration levels and employment policies across most sectors of the South African economy. 2. Structured interviews and focus group sessions with general surgeons, including heads of departments, specialists, registrars, and other medical specialists, as well as professionals in other fields such as law, accounting, engineering, etc. 3. Brief visits to international destinations that typically attract South African doctors, such as the UK, Australia, Canada, and New Zealand. A total of 77 interviews with heads of depar tments, specialists and registrars were carried out in Gauteng, the Western Cape, the Free State, and KwaZulu-Natal. A structured questionnaire was developed to research the perceptions of recently qualified specialists and registrars about their choice of general surgery as a career option, and about the current state of the profession in general. Perceptions of recently qualified specialists regarding general surgery as a career option The opinions and perceptions of recently qualified specialists from both the state and private sectors regarding the choice of general surgery as a career option were researched. This was done using a structured questionnaire and supplemented by a follow-up phone call. Although the interview sample was relatively small (10 specialists, 6 of whom completed the detailed questionnaire), we believed that the responses provided a representative set of opinions. The responses received were in line with expectations and consistent with other interview findings. The surgeons were asked about the reasons for choosing medicine as a profession, and in particular why they chose general surgery as a specialty. They were also asked about their perceptions of the status of doctors and specialists in South Africa and abroad, and whether the status has changed over the past 10 years. Further questions related to the reasons why many doctors choose to emigrate, respondents perceptions of the selection process for university and the standards of training, and working conditions, remuneration and lifestyle issues. Results The decision to study medicine Most respondents stated that their decision to choose a career in medicine was a clear-cut one, based on an overwhelming desire to become a doctor and a genuine love for the profession. Half of the respondents had actively considered alternative careers, with engineering, chemistry, and even architecture and music rating consideration. Few doctors had considered careers in business. Reasons stated for choosing medicine included: (i) the intellectual challenge, status and standing of the medical profession; (ii) a desire to work with people; (iii) the wide range of options available to one after completing a medical degree; and (iv) the potential security and fulfillment of working for oneself. Many doctors interviewed felt that they would have been highly dissatisfied working in an office, i.e. in a business environment. The decision to specialise in general surgery The reasons stated for choosing general surgery as a career included: (i) the results of a surgeon s efforts were almost immediately visible and thus rewarding and satisfying to a surgeon; (ii) it was an extremely challenging specialty requiring comprehensive medical knowledge, immediate decision making, and considerable practical ability; it thus allowed a medical professional to strive for perfection ; and (iii) it provided an opportunity to work with your hands a specific skill requirement but also a source of satisfaction to most surgeons. In some cases surgeons had experienced some initial uncertainties about their choice of this specialty. All, however, were now pleased that they had made the decision to specialise in surgery. The reasons given ranged from finding other specialties too narrow to the time taken to see the results of your efforts. SAJS VOL 44, NO. 3, august general surgery-factors that imp /25/06 4:09:30 PM

66 SAJS ARTICLES Appendix 4. Perceptions about the status of general surgery Half of the respondents believed that medical professionals continued to enjoy high levels of status in society. The collective view was that this status was earned primarily as a result of the intellectual standing of doctors rather than as a result of high incomes earned. There was uncertainty about the relative status of general practitioners versus that of specialists. Some doctors believed that the public, particularly the more affluent, had less respect for general practitioners, and preferred to be treated by specialists. Others believed that there was little differentiation. One respondent expressed a view that general surgeons were not regarded as true specialists in contrast to, for example, orthopaedic surgeons. Half of the respondents believed that the status of doctors and specialists had declined significantly over the past 5-10 years. This decline was attributed to: (i) an erosion of public confidence and trust in the profession catalysed in particular by both the more litigious environment in which we live today, and the fact that the public were not disposed towards accepting any form of medical failure; (ii) the fact that the remuneration earned by medical professionals had declined considerably in recent years, in relative terms, in comparison with that earned by business executives and those employed in other non-medical professions; (iii) the poor image of the public health sector that had developed during the past 10 years ( the government-run health system is in shambles ); and (iv) the fact that doctors themselves had not been proactive in promoting the status of the profession or in challenging government regulations that had been imposed on the profession, where relevant. Working environment There was constant reference to the impact of the structural changes that have been made to the administration and delivery of medical services in South Africa. Government has placed stronger focus on primary health care and family medicine with the primary objective of making affordable health care available to all South Africans. Implementation of this strategy has, however, had a variety of consequences, many of which have led to a deterioration in the quality of available medical facilities, services and standards. To give effect to the policy of focusing on primary health care, significant government and provincial funding has been re-channelled from tertiary to secondary health care institutions. Facilities at most secondary institutions, however, remained very basic. In addition, such institutions suffered severe shortages of adequately trained and experienced practitioners. The lack of skills, experience, resources and capacity resulted in the institutions having little to offer to attract experienced medical practitioners. Young doctors allocated to these institutions were required to function with insufficient resources and without quality supervision at a key stage in their careers. The problems noted above obviously impacted adversely on the training and skills development of young doctors. Registrars in general surgery were particularly vulnerable in this regard, given the fact that their work was particularly dependent on the use of hospital facilities and resources. Factors noted by registrars as adversely impacting on their training and effectiveness included: (i) dirty, depressing and poorly resourced rest rooms, kitchens, sleeping quarters, and offices, often lacking the most basic facilities; (ii) long working hours and sleep deprivation; (iii) unsympathetic and uninterested management; and (iv) lack of productivity tools such as cellphones and laptops, making it difficult to use on call time effectively. It should be noted that actual standards did vary from hospital to hospital. In addition, perceptions about the extent and seriousness of these problems also varied. For example, Groote Schuur Hospital was described by interviewees as still a model training hospital, and Universitas and Pretoria Academic hospitals as having excellent training standards. The high work volumes and pressure under which registrars typically worked were also thought to have some real benefit described as wide-ranging, crash course experience gained at an early stage in one s career. The Trauma Unit at Johannesburg General Hospital was one such example. Working hours Most of the professors in general surgery who were interviewed worked well in excess of the 40 normal working hours required in terms of their employment contracts. Apart from their university commitments, they were on call regularly, for which they were paid 16 hours of overtime. They also typically carried out hours of private work, considered virtually essential to supplement the low levels of remuneration earned by state-employed medical professionals. Registrars interviewed claimed to work between 80 and 100 hours per week. They were paid for only 56 hours based on the 40-hour normal working week and 16 hours of overtime. The situation was exacerbated by the fact that on call arrangements often required long periods of continuous work. Examples were provided of registrars working continuously for 36 hours. The tiredness and stress associated with the long working hours placed severe strains on family life at a time when many registrars would be establishing young families. It was also thought to be dangerous and risky when linked with trauma and the associated life and death situations. There were also concerns about the possible risk of litigation. Working hours were also considered to be excessive in relation to international practices. In the USA general surgeons currently work some 60 hours per week. In the UK estimates of average working hours ranged between 56 and 58 hours. However, the European Union regulations have introduced the European Work Time Directive, which prevents doctors from working more than 48 hours per week. There was little doubt that long and irregular hours worked and the relationship between workload and reward had a material impact on the ability of the state to attract and retain general surgeons. Emigration Respondents were asked about work colleagues and associates and other medical professionals with whom they were acquainted, who had emigrated or who were considering emigrating. Respondents were asked to state what they thought the main reasons were for this decision. Respondents were prompted with commonly cited reasons for emigrating, and the following responses were received: 1. Pay. There was a perception that the pay was better overseas, particularly in the state sector. However, doctors 110 VOL 44, NO. 3, august 2006 SAJS general surgery-factors that imp /25/06 4:09:31 PM

67 Appendix 4. SAJS ARTICLES were unsure about the impact of factors such as the exchange rates and the living costs. 2. Working hours. The opportunity to work a more normal working week, i.e. less overtime as legislated in Europe, was seen as a big attraction at certain levels. However, it was recognised that this factor was situational. 3. Working conditions. Working conditions were generally perceived as being better, with more access to state of the art medicine, but not always so. 4. Career advancement opportunities. The opportunity to travel and gain international experience in the medical profession was seen as a plus, but opinions were divided on whether this benefited career advancement or not. Some respondents thought that South African conditions, i.e. the shortage of medical professionals, particularly in the state sector, the trauma load, etc. could provide unique opportunities for experience and career advancement. 5. Lifestyle issues. This factor was obviously influenced by personal perceptions and preferences. High crime levels and security fears were definite factors encouraging emigration. Educational standards were also of concern to certain people and groups. In contrast, the South African climate, standards of living and the lifestyle enjoyed by professionals were recognised as unique advantages of being South African. These were the reasons why many young doctors considered returning to South Africa. 6. Risk of HIV infection. The risk of HIV was another factor that could influence the decision to emigrate. Training standards Interviewees were asked to comment on issues such as selection of medical students for university admission, educational standards, and the requirement to do community service. Half of the respondents believed that the current selection procedures were inappropriate, but offered little comment on how these should be changed or improved. Some thought that only academic criteria should be used, while others felt that the choice of trainees based on marks obtained accounted for most of the problems within the profession today. Over 80% of the interviewees noted that the training methods and structures had changed, but necessarily so given South Africa s history. A concern was expressed that South Africa had lost many good teachers and mentors to private practice and through emigration. Young doctors were therefore forced to cope with problems for which they had not had sufficient training or experience. This was contributing to the erosion of public confidence and trust in the medical profession. Over 80% of the interviewees felt that the 2 years of compulsor y community service was not necessarily a deterrent to would-be doctors. It was noted that similar requirements existed in other parts of the world and had not adversely impacted on student application levels. However, there was a real concern about how the 2-year community service period was spent. Interviewees felt that the community service period should be designated differently and incorporated into the structured postgraduate training of newly qualified doctors. Some thought that community service for medical students was discriminatory since similar requirements did not exist in other professions. Stress and its impact on lifestyle It was difficult to develop a consistent set of views from respondents about the level of inherent stress in a general surgeon s job and its impact on lifestyle issues. On the one hand there were obvious stresses associated with general surgery in that human lives were dependent on the skill of a surgeon. However, different individuals had different coping mechanisms, which allowed them to handle stress more easily, or less easily. It was clear that, as in the case of an airline pilot, a certain level of stress was an unavoidable component of every general surgeon s daily work life. Work stress also resulted from the need to make complex decisions and from long working hours. However, working hours varied widely. Those interviewed experienced between 1 and 2, and between 5 and 10 call-outs per week. Registrars often worked abnormally long hours. One respondent had noted that he had regularly worked 36-hour shifts as a surgical registrar. Another had noted that he had worked successive 12-hour night shifts for a week, every 9-10 weeks. This situation was contrasted with the position in Europe and the USA, where working hours had been regulated to reduce the risk of fatigue. SAJS VOL 44, NO. 3, august general surgery-factors that imp /25/06 4:09:31 PM

68 SAJS ARTICLES Appendix 4. All interviewees indicated that general surgeons had less control over working hours than was the case with other specialties. The risk of legal action against general surgeons was not seen as a deterrent to prospective entrants to the profession. Remuneration All respondents had a common perception that their levels of remuneration were poor in relation to other professions. The comparison was drawn with top business executives, who earned multiples of what surgeons earned, while surgeons were required to take what were perceived as equally complex and risky decisions. The fact that remuneration in the medical profession had not kept pace with increased pay levels in other professions was attributed as one of the factors causing the perceived decline in status of the medical profession in recent years. The above concerns extended to perceptions about future earning potential as well, particularly in the state sector. All interviewees expressed reservations about their ability to provide for normal family commitments and comforts, i.e. housing in a good suburb, decent schooling and education for their children, in line with personal aspirations. Those in the state sector noted that the difficulty of surviving on a government salary would probably precipitate a future move into private practice. Discussion The Association of Surgeons of South Africa has identified and was concerned about the decline in the number of applicants for registrar posts and the critical shortage of general surgeons in the state sector. ASSA commissioned P-ECS to undertake a comparative study into the remuneration and working conditions of general surgeons in South Africa, as well as an evaluation of the various factors that may impact on general surgery as a career option. The study involved desk research, structured interviews and focus group sessions with general surgeons. Interviewees were asked about their reasons for choosing a career in medicine. The intellectual challenge and the standing and status of the medical profession, as well as a desire to work with people, were some reasons why doctors did medicine. Respondents chose a career in surgery because the results of the surgeon s efforts were immediately visible, and it provided an opportunity to work with one s hands. Surgery was also regarded as an extremely challenging specialty, requiring both theoretical knowledge and practical ability. All of the surgeons were pleased that they had made the decision to specialise in surgery. The perception was that medical professionals continued to have high status in the community, and that this was related to their intellectual standing rather than a high income. However, many of the respondents believed that the status of doctors and specialists had declined in recent years, due to erosion of public confidence in the profession, the decline in the remuneration earned by medical professionals in comparison with business executives, and the poor image of the public health sector. It is well known and accepted that choice of a career in medicine requires a corresponding commitment to a lengthy period of study and practical training. 4,5 The commitment is particularly onerous when a doctor goes on to qualify as a specialist. General surgeons are required to spend some years undergoing various forms of training before they are able to begin to earn at levels comparable with other professionals and commercial sector executives. The career choice of medicine and general surgery is usually based on clear-cut desire to enter the profession. Medical students are therefore prepared to accept the lengthy training and qualification requirement in the knowledge that they will eventually qualify to do what they really want to do. However, it would be naïve to assume that lifestyle factors, such as work opportunities, conditions, compensation etc., do not also play a very significant part in influencing career choice decisions. 6-8 In this regard opportunities for wealth accumulation play an obvious role. Young surgeons qualify to practise at a time when their professional peers are well advanced in their careers and are earning at highly competitive levels. Medical students are extremely ambitious and therefore likely to expect to earn competitively after qualification. Unfortunately this is far from the case with state-employed specialists. The combination of low, uncompetitive levels of remuneration, coupled with long working hours and substandard facilities, provides an overwhelming disincentive for doctors and specialists, and general surgeons in particular, to remain in state employ. It is difficult to visualise any impact being made on current, critical shortages of skills in the state sector until at least some of these issues are addressed. It is well known that a significant number of medical graduates choose to emigrate from South Africa. Reasons included the perceived better remuneration, more normal working hours, better working conditions, and better career advancement opportunities overseas. Lifestyle issues such as crime and educational standards were also factors. The impact of the HIV epidemic was also cited as a reason why doctors choose to emigrate. REFERENCES 1. Marschall JG, Karimuddin AA. Decline in popularity of general surgery as a career choice in North America. 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