Centres of Excellence

During the past few years, many CENTRES OF EXCELLENCE and similar institutions have been established, particularly in the private sector. Of concern has been the implementation of and the perception of exclusivity that some of these centres have portrayed. SASOG strongly supports maintenance of ethical practice and as a guideline I have included SASOG’s perspective and extended policy statement pertaining to the establishment of AREAS OF EXCELLENCE.

Advertising expertise or the establishment of areas of excellence in obstetrics and gynaecology in South Africa is occurring on a daily basis. At present, the Health Professional Council of South Africa (HPCSA) essentially gives every health care professional the fundamental privilege and right to advertise either his or her field of interest or field of practice. Even though this is the case, there is still, unfortunately, a paucity of guidelines or rules, which clearly define both appropriate ethical behaviour in advertising “expertise”, and the minimum requirements to ensure that the proposed service meets the standards of an area of excellence.

SASOG accepts that the establishment of areas of excellence will continue to take place. Not only are they necessary, but if structured in an appropriate manner, they have significant benefits to the practice of obstetrics and gynaecology in South Africa. SASOG does not wish to be prescriptive, but strongly supports and urges that any advertising or establishing of such areas, is ethical, transparent and has as a priority, the improvement of clinical services for our patients.

In summary, the following are what SASOG would deem as being the concepts that must be met to ensure ethical conduct and appropriate provision of services:

In terms of the current legislation, there are a number of acceptable business models and undesirable models for registered practitioners.

The accepted models are:

  • Solo practice
  • Partnership
  • Association
  • Incorporated practices
  • Any of the above who outsourced their administration or established a close corporation to manage the administration

All health care professionals should at all times act in the interest of their patients with their clinical needs being of paramount importance.

Practices may consist of health care professionals derived from either the private sector or from academic centres or both. All members must be registered with the HPCSA.

Multidisciplinary group practices are permissible, provided radiologists and pathologists don’t form part of the practices.

Health care professionals should refrain from self promotion. Any advertising that suggests that the practitioner has a particular ability, as compared with other practitioners, which is likely to attract patients or promote professional advantage or financial benefit or encourage patients to refer themselves directly to the health care professional, is deemed unprofessional behaviour.

Canvassing for patients and advertising with the primary aim of offering best prices for services provided may be misconstrued as unprofessional behaviour.

A health care professional may make information about his or her practice known by publishing notices in any media, printed or electronic, including the internet and television provided they comply with the guidelines.

Logos on professional stationery may be used, but graphics or pictures may not depict an anatomical structure. These logos can’t be used on outside signs or name plates.

The use of an expression such as hospital, clinic or institute or any other specific term which could create the impression that the practice forms part of, or is in association with the hospital, clinic or similar institution, may not be used.

There should be no perverse incentive. An undesirable practice is one that enriches a practitioner either financially, or in kind, at the cost of the payer for professional services which are not evidence-based on scientific principle or do not have cost effective considerations.

A building occupied by health care professionals who are registered with the HPCSA may have a name indicating the profession of the occupants, only if there are at least two such independent professional practices in the building. Should only one professional practice be conducted in the building and the name of the building refers to that profession i.e. medical centre, psychologist centre, optometrist centre, the impression may be created that the single practice is more important than the other individual practices. In the case of registered health care professionals of different professions, such as a medical practitioner, psychologist and optometrist practicing in the same building, the name “Health Centre” may be used.

Direct or indirect corporate ownership of professional practices by a person other than a registered practitioner is not allowed.

Corporate involvement is allowed, provided ethical rules are complied with and the practitioner takes responsibility for the corporate partner/partners involvement i.e. the practitioner/s should not hide behind “the corporate veil”, but should assume accountability.

The Public Service, Universities/Training institutions and all registered practitioners within the HPCSA may employ fellow registered practitioners. The motive for the proposed employment should be carefully considered. If the motive is to generate income to the employer, or remunerate the employee on a fee-sharing basis, it will not be approved. At no time must there be exploitation and patient needs must always be met.

Expertise offered must be credible, form the greater part of the practitioner’s practice, and be available to all patients who may need it, provided they qualify for it. The practice offering the expertise should undergo some formal auditing, be it through analysis of disease or procedure outcome, complication rates, development of new management strategies or refinement of existing protocols. Research output or publications which may emanate from these units is very important.

Teaching and research must take place and must be a priority, in line with the primary function of providing an optimal clinical service.

Health care professionals must at least have local or international recognition, or must have published or undertaken credible research in their field of practice/service of excellence, in which they are advertising their expertise.

If a health care professional chooses to make known that he or she practices in a specific field, the health care professional assumes legal and ethical responsibility for having acquired a level of proficiency within that field of expertise. This must be demonstrable and acceptable to his or her peers. Note that “field of practice” is not the same as “field of interest”. “Field of practice” is only permissible if a practitioner limits almost exclusively or for the most part limits his or her practice to that field.

Information included in notifications and advertisements must be limited, but communications to colleagues may include information of the individual practitioner’s “field of practice”.

Composition of practices:

  • SOLO PRACTICES: Members are either wholly private or university affiliated practitioners or combinations thereof.
  • GROUP PRACTICES: These will be made up of members either from only within obstetrics and gynaecology or members from across the specialties and will have practitioners who are either totally private, university affiliated or a combination of both.

Both these entities may either be private practice initiated/university supported, university initiated/private practice supported, public service initiated/university supported.

The establishment of areas of excellence which provide expertise will produce significant short-term and long-term benefits, not only to the community in general, but also to the medical fraternity:

Patients will be offered better treatment options which are formulated on evidence based medicine and consequently given better care overall.

Will foster and establish units responsible for sub-specialty training - a much needed priority. In a climate of significant budgetary curtailment in the public service hospitals, it may ultimately have to be these centres of excellence which will be responsible for providing sub-specialty teaching to both undergraduate and post graduate students.

These units will enable access to facilities, equipment and staff that is not readily available in the public service.

Will establish, encourage and produce research that is meaningful and contemporary. If the level of research is appropriately maintained, it should foster contract research which will in turn produce revenue that can be re-invested into the practice. Alternatively, this revenue could allow the public service or university departments access to funds which could be used to purchase much needed equipment or finance posts within the university department.

Will provide full-time specialists in the public service an opportunity to practice their sub-specialty and hence allow them to earn sufficient remuneration which will hopefully retain them within the service of the public hospitals.

Will allow university staff access to expensive and sophisticated equipment.

The fundamental priority and primary motivator, when advertising one’s expertise, proficiency or desire to establish an area of excellence, must be the delivery of quality health care to our patients. SASOG believes that this perspective will in the majority of cases be the ethos. At the same time however it urges all its members to maintain high standards of professionalism and ethics whenever they desire to advertise or establish a clinical practice providing an “area of excellence”