National Health Amendment Bill Comments

1. National Health Amendment Bill Comments Public Hearings Health Portfolio Committee 13 March 2012 DR KIM FAURE PURE HEALTH CONSULTING, Redefining Healthcare

2. Comments on NHA Bill • The comments represent my own views along with those of a number of individuals who have contributed their insights towards this submission. • Pure Health Consulting: • Independent healthcare consultant • Integrally involved in: • The implementation of the latest version of the National Core Standards for Health Establishments, • The strategic documents and plans for the future Office of Health Standards Compliance (OHSC); • Passionate about ensuring that this new body achieves its mandate in a way that adds integrity to the health systems 2

3. Specific Comments

4. The Mandate of the Office “Protect and promote the health and safety of users of health services” • Culture of patient centeredness guides the work of the staff of the Office • Positions the Office as a patient advocate

5. Fulfilling the Mandate of the Office of Health Standards Compliance “Protect and promote the health and safety of users of health services” Four strategic objectives • Fostering an improvement in the quality of health services; • Disseminating information and promoting awareness amongst users of health services; • Acting swiftly against poor and hazardous health services and; • Function with integrity and sound governance

6. 1. Fostering an improvement in the quality of health services; • Establishing norms and standards • Inspecting compliance of health establishments against standards; • Enforcing compliance to the standards through a variety of incentives and sanctions

7. 1. Fostering an improvement in the quality of health services; • Establishing norms and standards • Inspecting compliance of health establishments against standards; • Enforcing compliance to the standards through a variety of incentives and sanctions Advising on Norms and Standards Risk based inspections Progressive approach to enforcement

8. 1.a.i. Advising on Norms and Standards NDOH Independent regulator (OHSC) Provincial DOH, districts, establishments

9. 1.a.i. Advising on Norms and Standards • Bill not clear on advising role of the Office Recommendation: • Standards setting and development role should be within the NDOH • The Office should be consulted on standards and norms with legal repercussions on their work • The Office should participate in the review of standards and norms • Functions of quality improvement should remain with health establishments (reports on compliance should provide guidance)

10. 1. Fostering an improvement in the quality of health services; • Establishment of norms and standards • Inspecting compliance of health establishments against standards; • Enforcing compliance to the standards through a variety of incentives and sanctions and; Advising on Norms and Standards Risk based inspections Progressive approach to enforcement

11. 1.a.ii. Inspection compliance to standards and norms • Ideal world – the Office can assess every facility in South Africa every 3 yrs • Risk based directed inspections: • Each facility is risk classified (Early Warning Indicators and NCS self assessments) • ALL high risk establishments assessed 1- 2 yrly • Medium and low risk randomly sampled • ALL submit yearly self assessments and weekly EWI • Recommendation Regulations need to address: • Rules for inspections • Risk profiling based frequency of inspections • Set guidelines for self assessments • Declare that self assessment tools will be made public

12. 1. Fostering an improvement in the quality of health services; • Setting of norms and standards • Inspecting compliance of health establishments against standards; • Enforcing compliance to the standards through a variety of incentives and sanctions and; Advising on Norms and Standards Risk based inspections Progressive approach to enforcement (HAS, CQC)

13. 1.c.i. Progressive approach to enforcement Recommendation: • Negotiating a grace period • Reporting any misconduct by practitioners (HPCSA or SANC) • Setting progressive fines for continued gross non-compliance • Suspending management and the Chief Executive or Head of Department as relevant • Recommending the closure of non-compliant wards

14. Fulfilling the Mandate of the Office of Health Standards Compliance “Protect and promote the health and safety of users of health services” Four strategic objectives • Fostering an improvement in the quality of health services; • Disseminating information and promoting awareness amongst users of health services; • Acting swiftly against poor and hazardous health services and; • Function with integrity and sound governance

15. 2. Disseminating information and promoting awareness amongst users Education function Reporting function

16. 2. Disseminating information and promoting awareness amongst users Education function Reporting function • Educate users as to their rights and expectations for quality of care • User involvement through seeking their opinions on norms, standards and quality of care • Views of healthcare professionals as patient’s advocate • Recommendation: • User surveys on quality driven by the Office

17. 2. Disseminating information and promoting awareness amongst users Education function Reporting function • Dissemination of information to users engenders accountability within the healthcare system • Sect 79D(5)(a) – implies the MOH has an opportunity to first sanction reports before publication • Silent on public reporting • Implications on transparency, autonomy and integrity of the Office Recommendation: • No sanction by the MOH • Reports published direct to public while informing the MOH(CQCeg) • Educate users as to their rights and expectations for quality of care • User involvement through seeking their opinions on norms, standards and quality of care • Views of healthcare professionals as patient’s advocate • Recommendation: • User surveys on quality driven by the Office

18. Fulfilling the Mandate of the Office of Health Standards Compliance “Protect and promote the health and safety of users of health services” Four strategic objectives • Fostering an improvement in the quality of health services; • Disseminating information and promoting awareness amongst users of health services; • Acting swiftly against poor and hazardous health services and; • Function with integrity and sound governance

19. 3. Acting swiftly against poor and hazardous health services

20. 3. Reactive Surveillance - Ombudsman • “consideration, investigation and disposal of complaints relating to non compliance with prescribed norms and standards in a procedurally fair, economical and expeditious manner” • Adjudicative (settle matters judicially) versus commission (no powers, provides recommendations) • Investigations unit – structural concern limiting objectivity of findings (findings are against the OHSC) • Complaints Investigations unit – no powers of adjudication, make recommendations, investigate • Risk of increased litigation (free investigations) • High workloads as ALL complaints will be investigated (resources, capacity, overshadow the inspection functions) • Concurrent jurisdiction with Consumer Commission

21. 3. Reactive Surveillance - Ombudsman Recommendation: • Powers of adjudication and dispute resolution • Progressive complaints management process – only escalated complaints, high risk complaints • Remedies available to ombudsman to ensure redress • Preference given to health sector ombuds for quality related complaints

22. Fulfilling the Mandate of the Office of Health Standards Compliance “Protect and promote the health and safety of users of health services” Four strategic objectives • Fostering an improvement in the quality of health services; • Disseminating information and promoting awareness amongst users of health services; • Acting swiftly against poor and hazardous health services and; • Function with integrity and sound governance

23. 4. Governance structures of the Office • Regulators are by definition agencies that safeguard the health and safety of citizens • Agencies are only effective if they are empowered with appropriate enforcement tools and governance structures • Public entity • greatest autonomy in its functions and decisions – promotes public confidence • Requires a board or council which sets the strategic agenda, approves reports and decides on enforcement measures • Chief executive officer manages day to day operations • Level of separation that may shield the Minister from extensive litigation resulting from claims of poor quality care

24. Governance of the OHSC – public entity

25. 4. Governance structures of the Office • Concurrent jurisdictions – overlapping provisions between this Bill and other legislation (Consumer protection act, Health professionals act, Pharmacy act) • Co-ordinated approach – where other government agencies have the power to take action, the Office works with them to co-ordinate their actions to avoid duplication • Reduce regulatory burden of health establishments • Memorandums of understanding between regulators and Information Sharing Protocols (HPCSA, SANC, SAPC, MCC, public protector, Human Rights Council, Auditor General)

26. Fulfilling the Mandate of the Office “Protect and promote the health and safety of users of health services”

27. Thank you! Pure Health Consulting Dr Kim Faure 082 565 1388 kim.faure@mweb.co.za www.ourhealthsouthafrica.blogspot.com 27