Remunerative Work outside Gauteng Health Sector: Public Services Commission briefing

Meeting report

PUBLIC SERVICE AND ADMINISTRATION PORTFOLIO COMMITTEE
14 October 2004
REMUNERATIVE WORK OUTSIDE GAUTENG HEALTH SECTOR: PUBLIC SERVICES COMMISSION BRIEFING

Acting Chairperson: Mr N Gcwabaza (ANC)

Documents handed out
Public Service Commission Report on Remunerative Work Outside the Public Service
Public Service Commission PowerPoint presentation on Report

SUMMARY
The Public Service Commission briefed the Committee on its investigation into remunerative work outside the public service, undertaken in the Gauteng provincial health sector. Widespread moonlighting and abuse of leave (particularly sick leave) was noted. The reasons given for this common practice included inadequate salaries. A high percentage of persons profiled were ignorant of the Code of Conduct. The Commission recommended that there be a revision of working hours and that monitoring and accountability systems be implemented. The Committee noted that management problems were evident from the Report, particularly ineffective HR management.

MINUTES
Public Service Commission briefing
Mr J Ernstzen (Deputy Chairperson) said that the investigation had been very sensitive and delicate but that it had been necessary to confront the issues. The investigation had originated from a request from nurses employed by the Gauteng Department of Health. After the investigation, the Commission had compiled their report and tabled it in the Gauteng legislature. Two briefing sessions had been held, one in the Oversight Office and the other to the Health Committee in Gauteng. On reflection, an invitation for the Chairperson of the Portfolio Committee on Health to attend this meeting should have been issued through the chairperson of the Public Service and Administration Committee.

Dr N Maharaj (Commissioner) said that the Public Service Commission (PSC) was mandated in terms of Section 195 of the Constitution to promote a high standard of professional ethics in the public service. In terms of Section 196(4)(b) of the Constitution, it is further empowered to investigate, monitor and evaluate the organisation, administration and personnel practices of the public service. Principal stakeholders in the Commission are Parliament, Legislatures, the Executive, and National and Provincial Departments. The investigation undertaken in the Gauteng provincial health sector was initiated due to a complaint from Gauteng nurses concerning non-compliance with the Code of Conduct (COC) with respect to remunerative work outside the public service (RWOPS) by health professionals performing RWOPS without prior approval, fraudulent abuse of sick leave to undertake RWOPS and theft of state assets for private use. The investigation was conducted at Johannesburg and Pretoria Academic Hospitals. It was important to note that, although the investigation had been conducted in Gauteng, the problem was not limited to Gauteng, or to the health professions.

Interviews were held with health professionals, including nurses, doctors, allied health professionals, HR staff, Chief Executive Officers, hospital health advisory committees, the Health Professions Council of South Africa (HPCSA), the South African Nursing Council and senior managers in the Gauteng Health Department. The interviews were supplemented by questionnaires. The HPCSA had a mandate to promote national health, to determine standards of professional education and training and to set and maintain fair standards of professional practice. During the interview, the HPCSA remarked that RWOPS was being abused by nurses, doctors and allied health professionals. Ethically, they regarded such activities as a cause for serious concern and felt that such activities were unprofessional.

The objectives of the investigation were to assess the level of compliance with the COC, with specific reference to RWOPS, to identify the key ethical issues and problems related to moonlighting and to determine some of the general working conditions in hospitals and their possible negative effect on personnel. The sample base used was 200 officials. 51 of these officials indicated that they were fairly acquainted with the COC while 7 stated that they were unaware of it. 58 officials indicated they were aware of the departmental policy that regulated RWOPS, while other respondents did not answer the question. Only 12% of respondents indicated that employees complied with the provisions of the COC and 88% of the respondents indicated that employees and senior management did not adhere to the COC. The reasons given for moonlighting by doctors and nurses included perverse incentives, such as non-recognition of performance by senior management, working conditions at state hospitals and delays in processing RWOPS application forms by management. Common justifications were that everyone else was doing it and that public officials were poorly paid and deserved an extra reward. A significant problem was that some specialists were invited by private hospitals to offer their skills and knowledge.

The Commission found that there was abuse of official working hours and that scapegoats were often sought to cover up. Sick leave was abused and approved leave with full pay was misused for work in other state hospitals. Moonlighting activities occurred during the day and night and it was found that a person who worked a 24-hour day became exhausted and stressed, putting patients at risk. 50% of specialist doctors owned private clinics and often abused official time and sick leave to moonlight at these clinics. Health officials further believed that their salaries were not competitive, e.g. in 2002/2003, a Medical Officer received R115 575 and Nursing Assistants R31 695 per annum. These figures should be seen as old and dating to prior to salary and package negotiations. The Commission found that, in 2002, the majority of nurses and doctors moonlighting at Gauteng hospitals came mainly from the Eastern Cape, KwaZulu-Natal, Limpopo, Mpumalanga and the Free State.

The Commission recommended an investigation of the current salary structure of health professionals. It further recommended a revision of other conditions of service and suggested that some doctors be required to work only five-hour shifts per day instead of eight hours, thus working elsewhere in their own time. Such doctors would be remunerated pro rata for working shorter shifts and this should apply to a percentage of posts depending on the workload or type of service required. The Department of Health should review the conditions of employment of full-time health professionals moonlighting through private agencies within the public service. Some monitoring mechanism was needed such as a clocking system to control absenteeism, unauthorised leave and to ensure that officials were remunerated for actual hours worked. The Commission further saw a need to improve the RWOPS policy according to international best practice and create measures that would address the conflict of interest, address changing circumstances arising from approved RWOPS and the utilisation of paid and unpaid leave as well as unpaid voluntary work. PERSAL was not being used optimally and quarterly printouts of sick leave records captured should be made available to line managers to ascertain the trends for each employee. It was further suggested that, in order to improve the delays in processing RWOPS application forms, a dedicated human resource component be assigned the task and weekly reports be submitted to the Chief Executive Officer. An accountability system needed to be put in place, and annual audits of RWOPS applications should be conducted by means of, among others, comparing the records kept by HR components with the corresponding records kept by doctors or nursing staff.

The Commission requested the Committee to seriously consider their recommendations and said it would monitor implementation of the recommendations on a six monthly basis.

Dr R Mgijima (Commissioner) said that moonlighting was a very big problem and was very widespread in all institutions, particularly in hospitals around the country. After the Commission had presented its findings to the Gauteng legislature, the Limpopo legislature had requested a presentation. Because the problem was so big, all stakeholders needed to make a concerted effort to ensure that good ethics prevailed. Within the health sector, most workers were doctors and nurses. It was frequently said that there were not enough doctors but experience showed that there were sufficient numbers, but that they were incorrectly deployed. Doctors were employed full time, but only gave the State part of their time, hence the suggestion for part time work. This would save the State a lot of resources.

There was a very peculiar situation regarding nurses. Retired matrons and nurses had formed BEE agencies and these recruited off duty nurses. When hospitals were short of staff, CEOs contacted these agencies. This posed a problem. There had been a suggestion that these agencies be closed down, and Dr Mgijima's personal opinion was that they should be internalised, so that the State had a unit to identify available nurses. In Gauteng, however, a plea had been made for the State to enter into discussions with these agencies to have information sharing on resources.

Discussion
Mr M Baloyi (ANC) asked whether the Commission had made an effort to assess the validity of some of the reasons given. Only if this had been done would it be possible to make recommendations. He said that salaries seemed a reason and not a finding and this indicated that the Commission might have made an effort to assess the validity of this issue and asked for clarity. It would assist the Committee if the Commission could expand on the justification for its recommendations, particularly in the revision of the salary structure as this appeared to be rewarding those who were moonlighting. He said that, although the investigation had been triggered by nurses coming forward, it appeared that the Commission was not referring to specific individuals. He asked whether some individuals had been identified and if so was there any recommendation that particular action be taken against these people? It was important to see whether this was not an indication of failure to manage more than anything else. It should be easy to identify people working 24-hour shifts and leaving early, for example. A change in approach was needed. He fully agreed with the Commission that the Committee could not afford to drag its feet on the issue.

Dr Mgijima said that questionnaires had been administered, focus groups conducted and information collected. The findings reflected the problems as stated by nurses and doctors. The custodians of ethics had also been brought in, such as the councils. The HPCSA looked after the ethics of doctors and had its own set of rules. In its opinion, the situation was out of hand. The situation was overwhelming. The Gauteng Health Department had tabulated additional policy rules stating that non-one might work out of hours without the consent of the head of department. The practice was overwhelmingly hard to implement, hence the suggestion of a clocking system. In terms of salaries, the Commission had been unable to come to a conclusion and had therefore recommended further investigation. His opinion was that salaries were rarely the sole issue.

Dr Maharaj said that when the Commission had started to investigate, it had found issues that had not been in its original terms of reference. The issue was much more complex than allowed for in the very narrow terms of reference in the complaint.

Ms P Mashangoane (ANC) asked whether there was any intention to extend the programme to other provinces.

Dr Mgijima said that he personally did not see the point of this as it would be a repetition of the exercise yielding similar findings. He felt the recommendations should be carried over to all stakeholders nationally.

Ms Mashangoane asked whether the reduction in working hours would work. She felt there were not enough doctors particularly in rural areas like Limpopo. Had the Commission also considered conditions of work and resources in rural areas as there might be a need to define a means to attract doctors and nurses to those areas?

Dr Mgijima said the suggestion was not that all doctors would work five-hour shifts, but that some would. Doctors should only be employed for the time they were required. He was convinced that there were enough doctors and said with this system, doctors could be taken to rural areas. The same applied to nurses. A rural allowance had been implemented and packages were much more favourable for work in rural rather than urban areas.

Dr Maharaj said that the report highlighted the question of utilisation of human resources in rural and urban areas. Public Service regulations stated that all departments should have strategic plans and HR plans. If properly drafted, the HR plan would be able to allocate doctors and nurses.

Ms Mashangoane said that, if agencies were to be dismantled, could statistics on them be gathered before this happened?

Dr Mgijima replied that the agencies were part of the BEE strategy so they could not be eliminated. It was important that the State share information on deployment of nurses with them. The agencies sometimes tendered in hospitals and were appointed. The problem was that the hospitals did not engage with them to combat moonlighting.

Ms W Newhoudt-Drunchen (ANC) referred to the staff moonlighting in Gauteng from other provinces and asked whether they worked in the public or private sectors in those provinces. Did doctors from private hospitals who were invited to work in public hospitals follow the same COC?

Dr Mgijima replied that this was a two-way flow. Because Gauteng had the biggest number of private hospitals, when doctors took leave, or took work time off in Limpopo, for example, they drove to Gauteng and worked there. It was also happening from public hospitals in Gauteng to private clinics in Gauteng. Doctors claimed that the private hospitals had requested their skills.

Ms Newhoudt-Drunchen asked what systems were now in place to check on sick leave, especially in HR and in terms of the cost involved.

Dr Mgijima replied that the Commission had reported previously on tightening systems to monitor sick leave.

Ms Newhoudt-Drunchen said that if 71% of respondents in Gauteng had not known of the COC, this was likely to be the case in the other provinces and asked what the Commission was doing to publicise it.

Dr Mgijima said he had been surprised at the high lack of knowledge. The Commission and stakeholders should intensify their advocacy. The Commission was conducting workshops and had written an explanatory notebook on the COC, and this had been distributed.

Dr Maharaj said that the Commission had printed one million copies of the COC and that these had ostensibly been distributed. The issue came to implementation of policy. Policies were very often adequate but the implementation was problematic. This should be investigated.

Mr Gcwabaza suggested looking at the management structures in the health sector. The problem of moonlighting could be a problem of uneducated management structures and the issue that not all management posts had been filled. Managers might not know what they were supposed to do.

Dr Mgijima agreed that the problems could be related to a lack of management, hence the recommendation of the clocking system and the need for a clear understanding of the COC. Because the problem was so widespread, it could not be stopped by tightening management only. Some management was very tight, but unable to keep up. Disciplinary actions carried out were far fewer than desirable, with the majority being taken against nurses.

Mr B Mthembu (ANC) said that both ignorance and non-compliance were shown in the report. 88% non-compliance was linked to 51 out of 200 not knowing the COC. He said a bigger problem was the question of management especially HR practices. Previous reports had found that, in one province, HR was regarded as a minor area and had no dedicated manager. Most questions raised in the Report were simply basic administration. The location of HR management should be identified. The problem would not be there if there was dedicated management. HR management should be located near the top of the organisation. He asked whether this area had been investigated and suggested it might be part of the solution.

Mr Baloyi agreed that most were management issues. He respected the Commission's approach of seeing management as an issue but not the most important issue, but disagreed. In addition, as new staff were recruited, they should be familiarised with the COC.

Dr Maharaj agreed and said that, in medical terms, the symptoms had been investigated but a final diagnosis had not been done. There might be more than one problem and it may be a symptom of something far bigger and more complex. The Commission might need to do something collectively with all stakeholders about this.

Mr Baloyi said that perception management was important. In situations where people made allegations, investigations could contribute to perceptions. The 88% might be seen as a real situation, not just a group that was interviewed and this would create a very negative perception. The Committee should not embark on an academic exercise but needed to address the allegations. Specifics would assist in rising above generalisation.

Dr Maharaj said that the Commission did not want to create a perception that the state of health services in Gauteng was bad, or just that in two hospitals, or just in the health sector. He agreed on the need to be very guarded in interpreting the Report.

Mr Baloyi agreed that the Commission's narrow terms of reference had resulted in the Report as tabled. If an allegation warranted investigation, the terms of reference and methodology should be broad enough to cover all areas. Misconduct cases did not tally with allegations and this was significant. A "Yes / No" questionnaire had been issued but if this was reported as a thorough investigation it might unwillingly assist in negative perceptions. Further engagement between the Commission and the Committee might be needed. The issue was not complete. Dr Maharaj concurred.

Mr Ernstzen said that there had been various debates when the Commission had analysed the Report. With regard to the veracity of statements, the Commission had tried to use tools to obtain the most accurate reflection possible. The investigation built on other investigations that crosscut it, e.g. abuse of sick leave. Those reports speculated on moonlighting. Perception management was very important, and as factual a situation as possible needed to be maintained. The Commission may have erred by not inviting the Portfolio Committee on Health or the Minister of Health to their briefing. In investigating, the Commission had been complying with a request, but he questioned whether moonlighting was confined to the health sector. The Commission's function was to be a watchdog and to operate in tandem with policy overseers. He stressed the need to engage with other role players and that the issue should not be sensationalised.

Mr E Saloojee (ANC) said that highly qualified medical practitioners were involved. There was a perception that income in the public and private sectors did not compare. He felt that the Commission should be sensitive to that in the context of the discussion, but he did not see this.

Mr Gcwabaza said the briefing had shown the need to deal with the implementation of at least some of the recommendations, and to look deeper into some issues, particularly management and HR structuring. The need to revisit issues had emerged but the Commission had been limited by its terms of reference. Genuine cases of moonlighting needed to be addressed, and other stakeholders should be involved in a significant way. The issue could not be closed in one day.

The meeting was adjourned.