New HPCSA CEO/Registrar, Dr Raymond Billa

 The past few years have seen the HPCSA
staggering under a plethora of claims relating to maladministration,
dysfunction, corruption, a lack of communication, registration hiccups and not
adhering to its mandate of protecting the public and guiding the profession.
Much has been done to resolve these issues. However, with the impending
implementation of NHI, mounting calls on the Council to relax its ethical
rules, a staggering rise in medical negligence claims and threats of legal
action by foreign-trained doctors, the pressure on the HPCSA continues. Central
to ensuring that the HPCSA meets its obligations and tackles the challenges it
faces, is the new Registrar and CEO, Dr Raymond Billa. A medical doctor by
profession with an MSc in Bioethics and Health Law, and other management
qualifications.  Dr Billa has extensive
management experience in the public sector. Among others, he was Chief
Executive Officer at Sterkfontein Hospital, Director: Clinical Services at
Chris Hani Baragwanath and since 2013 CEO of the Helen Joseph Hospital in
Johannesburg.

Only a month into his new job, he
spoke to MedBrief Africa co-editor, Marietjie van den Berg on how the Council
plans to address some of the challenges it is facing.

MVB: Providing guidance for the
education of medical students and accrediting institutions for the placement of
medical interns is one of the key roles of the HPCSA. The Department of Health
is now considering shortening internships from two to one year as it is running
out of space to place the increasing number of interns.  Your view?

RB: We need to look at the
reasons why the 2-year internship was originally introduced in 2005. The aim
was to produce well-rounded, adequately trained doctors who have had exposure
to most medical disciplines at the end of their internships. Shortening the
period because of space constraints will prevent them from achieving that goal.
My personal opinion is that we will be shooting ourselves in the foot if we do
that. We should rather look at expanding the training platform and consider the
option of opening up other avenues where there are enough senior medical
practitioners to ensure that they get the training and supervision they
require.

MVB: Are you suggesting that
the private sector should be roped in to assist?

RB: Although I don’t want to
venture there, I think we need to start thinking about one healthcare system
for the country without any differentiation between private and public. However,
if the private sector is considered in a bid to extend the training platform, checks
and balances should be put in place to ensure that it is properly managed. We
also have a number of regional and district hospitals with adequate resources that
can potentially be used as we need to expand training away from just tertiary
hospitals and metropolitan areas. Another possibility that could be considered is
to get private GPs and specialists practising in rural areas involved in
assisting with the supervision of young doctors at public institutions in their
areas.

MVB:  Foreign-trained doctors are now threatening
to take the HPCSA and the DoH to court because they claim they are prevented
from doing their internships and community service in South Africa because the
HPCSA didn’t allow them to write their board exams last year.

RB:  Most of the 150 foreign-trained medical
graduates that are complaining have studied in countries such as China and
Russia. Many of them went to study abroad because they didn’t find places to
study medicine at South African universities. It is therefore important that we
ensure that they have the academic knowledge and clinical competency to work
here, which is not always the case because the curricula of those foreign
institutions are not always comparable to ours. That is why they have to write
the board exams and be tested for clinical competence. Currently, this is only
done at the Sefako Makghato University. However, because most of them have failed
the board exams and are given a second chance to write, it has created a
bottleneck as we don’t have the resources to accommodate both the new entrants
and those who have to rewrite their exams. The question is why they didn’t go
to the UK or Canada or some of the African states whose medical councils already
have a structured relationship with South Africa and whose curricula are
recognised here. My advice would be that students who want to study abroad
should first be accredited by the HPCSA to study at universities that don’t
have a relationship with South African institutions. I would go as far as
saying that the Department of Home Affairs shouldn’t give them visas to study
abroad unless they have been accredited by the HPCSA.

MVB: Following the damning
Ministerial Task Team report in 2015, doctors threatened to establish their own
statutory body outside of the HPCSA. What is being done to assure doctors of
the value of the HPCSA as their statutory body?

RB: I won’t deny that there is
a perception amongst some doctors that the HPCSA is not looking after their
interests, and that is a challenge that the Council needs to deal with.
However, I think this perception is mainly driven by poor communication and
ignorance about the HPCSA’s functions and that is a position that needs to be
explained. Practitioners should understand that without the HPCSA the
profession could be doomed because without the Council, there won’t be a
custodian of standards. That will allow them to do what they like and set up
practices without meeting the registration requirements. We need to ensure that
doctors get proper training and can practice with confidence. That is why there
are accreditation- and registration processes in place because without that the
public won’t have confidence in the country’s practitioners. We also need to
ensure that training institutions deliver on their training mandate and that
training deficiencies are addressed. We are aware that there are problems with
the curricula of the Colleges of Medicine. One of my key objectives is to
assist the HPCSA to look in depth into the complaints that have been leveled
against the Colleges of Medicine. As much as we have concerns about training at
foreign institutions, we also need to look at the standards of training within
our own borders.

MVB: The provisional report of
the Health Market Inquiry (HMI) has indicated its support for many of the
HPCSA’s functions and the importance of maintaining health practitioners’
independence and protecting the public through regulations. However, it also
found that the Council’s ethical rules relating to issues such as
multidisciplinary group practices are too stringent and should be relaxed to
allow for innovative models of care and the coordination of care in a bid to
bring down the cost of healthcare and increase efficiencies. What is the
HPCSA’s response to that?

RB: Subsequent to the release
of the HMI provisional report, the HPCSA held a workshop to look at the rules
and to determine why they were implemented in the first place. One of the
attorneys who were involved in the drafting of the rules is now compiling a
report on what informed those regulations. I hope to receive the report within
the next two weeks and then we will have another workshop to review the rules
and suggest how we can overcome the cited challenges with these rules. We are not
saying we will scrap or change these rules, but we will review them along with other
rules and regulations in the Act that have been identified as problematic. This
will inform us on how we should proceed and if new regulations should be
written.

MVB: The cost and incidence of
medical negligence in the country are ballooning. What is the HPCSA doing to
address this critical issue?

RW: Yes, it is getting out of hand,
but we need to understand that while there are legitimate complaints, the costs
are driven by lawyers who are taking on more cases and this leads to high
contingency fees in the public sector as more cases of litigation and
complaints are received. The HPCSA is currently working with the SA Law Review
Commission and the DoH on measures that can be taken to contain the costs in a
way that will protect both the public and practitioners. Currently, claims are
dealt with in terms of criminal law and I think this should change to create
legislation that specifically deal with claims of medical malpractice.

However, as the HPCSA, we have a role
to play in speeding up investigations. Currently, it takes between 18 months to
two years to conclude cases, but we are now working with the Council’s Complaints
Handling Unit to bring down that time to six months.  In the beginning of February, we also
appointed people with a health background, mostly medical practitioners, to
deal with cases as we receive them rather than them being dealt with by lawyers
who, in the past had to refer them to medical experts. They will specifically
decide on the cases that qualify for mediation and ensure that they are
mediated quickly, which we hope, will reduce the backlog of cases at the HPCSA
dramatically.  Only the more complicated
cases will then be referred for plenary investigation.

MVB: In the past many doctors
have complained about the inefficiencies in the registration process. How is
that being dealt with.

RB: Our new automated
online-registration system has streamlined the process for registrations and
renewals. We will also be introducing an online App by the end of March which
will allow practitioners to register quickly wherever they are as well as access
to other HPCSA services.

MVB: What would you state as
your main goals for the Council?

RB: I have been given an
organisation and a team and my aim is to ensure that we all work together and
are committed to overhauling the structures that have caused problems in the
past. I will also be focusing on communication to indicate the purpose of the
HPCSA and ensuring that it delivers on its mandate in order to win back the
confidence of the public and healthcare practitioners. We need to ensure that
there is value for money for practitioners. Towards that end, every member of
staff will need to understand why they work for the HPCSA and deliver on the
mandate of the Council. We need to know what is the “Smell of the Place” and
how to be an effective and efficient organisation.