Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694434662178.pdf (Trinidad and Tobago)
Committee to Review the Levels of Health Care Delivery by the Regional Health Authorities and to Rationalise the System of Public Sector Doctors in Private Practice Report 1B Rationalizati YI of the System of Public Sector Do tors in Private Practice c) • FEB 0 ) 2017 nPkL-Y TO T;.

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K.I;E* &WIER - '• j Contents 1.0 PRIVATE PRACTICE 1.1 POSITION 1 SIGNATURE PAGE FOR POSITIO1 1 ON PRIVATE PRACTICE 1.2 POSITION 2 SIGNATURE PAGE FOR POSITION 2 ON PRIVATE PRACTICE 1 2 5 6 13 1.0 PRIVATE PRACTICE The second mandate of this Committee relates to the continued grant of private practice to doctors employed in the State sector.

The Committee debated vigorously and at length on this matter.
In the face of differing views, two (2) positions are presented herein.

1.1 POSITION 1 For decades Senior Medical' Officers employed in the public service have been granted the privilege of conducting private medical practice to supplement their incomes.

There was the admission that the employer, the State, could not afford to pay an adequate salary.

It could hardly have been envisaged that the public sector employment would play a secondary role for some doctors in this arrangement.
Over the years however, there have been many expressed concerns in the public arena and from the employer as well that mar y doctors have not been true to their obligation.
There has been the contention that:- 9 Many doctors sped most of their working time in private practice and are hardly 111 available at their p aces of employment 9 Some are actively engaged either directly or indirectly in soliciting patients to their private practices Some have becorre medical entrepreneurs with businesses seemingly in competition with the State sec or and the doctors themselves being more actively engaged in the management of th ir businesses.
Some non-medimil operatives within the institutions are engaged in channelling patients to doctors offices.

The net result has been several reports of inadequate senior officer presence and activity within their places of work.

e The above concern is not oily directed to State (RBA, MOH) doctors.

At the inception of teaching in the Eastern Cari bean, University staff came to be granted private practice on a limited basis.
Here over ime some university staff have disclaimed certain clinical responsibilities and seem to ave an abundance of time for private practice to the disadvantage and disquiet of State employ medical staff.

It should be indicated at the outset that there is nothing inherently wrong with private practice in itself.

Indeed there can be merit in doctors working across regions and sectors.
It is also to be observed that there are many perhaps the majority of, doctors who are faithful to the discharge of their obligations.

Additil ally, there are many doctors who appear to be desirous of an adequate salary and are not n cessarily keen on private practice.
i In wrestling with the discom ort created by some errant doctors exhortations have been made by the employer over the years and certain compromise arrangements like reduced hours of work have been utilized in the exp ctation that compliance would resolve the difficulty, unfortunately not.

2 The fact is that concerns remain about the delivery: The question is: - Should public doctors be allowed to continue in private practice?
The Committee has had to wrestle painfully with the several factors impacting this issue.

There is a very powerful view that the public/private practice breeds a conflict of interest, promotes inefficiency and is anathema to the delivery of good health care and that private practice should be abolished entirely with or without adjustment of salary.

That view also holds to the position that a salary is available for the job offered and the prospective employee has an option.
Indeed there is a strong view within the Committee that private practice for State employed doctors should be abolished.

A matter which also impacts has been the provision of specialists' positions.

There appears to be insufficient analytical rigour in the development, expansion or retention of specialists' positions.

The paint here is that underutilized specialists march off to their private offices.
It is clear that administrators must be called upon to rationalize and justify the numbers of specialists in their establishments.

That being said, whether private practice is permitted or not the doctors must now be held to account for the performance of their duties and are to be put on notice in that respect.

Accordingly several indicators of performance are advanced in this document and represent the standards by which the Senior Medical Officer should ordinarily be held.
(See Part A, particularly Senior Medical Officers, section 3.2.10.)

Further, the Heads of Departments, the Medical Directors and the CEOs ought to hold themselves responsible for the effective monitoring and supervision of these functions.

It is indeed regrettable that one has to prescribe performance for senior medical staff who are leaders and supervisors in their own right.

What then of compensation?

The discussion ought to recommence/continue on what represents an adequate salary.
In the meantime the grant of private practice is recommended to continue subject to the senior officers meeting their respective obligations and patients deriving the appropriate level of service and satisfaction.

Monitoring of performance should also be conducted by an independent and separate review/audit committee.
Public sensitization on these issues is necessary 3 With doctors having the benefit of yet another opportunity to revisit the existing deficiencies, it is hoped that the defaulting doctors would put their houses in order.

Should there be no immediate and sustained ii.

pact in the areas of performance identified, then the employer would have little choice but to co ont the abolition of private practice.
In the meantime, let the debate and the performance and delivery output at the respective areas of continue on an adequate sal employment.

ry 4 SIGNATURE PAGE FOR POSITION 1 ON PRIVATE PRACTICE Mr Winston Welch ' Dr Adesh Sirjusingh 5 1.2 POSITION 2 .1).

One of the main policy issue which impacts on the quality branding of the public health system is the prevailing practice of d ctors in the public health system engaging in private practice.
For decades, senior medical offi ers employed in the public health system have been granted the privilege of conducting priv te medical practice to supplement their incomes.

There was the admission that the employer, e State, could not afford to pay an adequate salary.

Of course this dual practicel phenomenon, with public doctors allowed to engage in private practice is not unique to Trinidad and Tobago.
In the Journal, Human Resources for Health (2004) we read: dual practice (DP) is probably present in all countries regardless of income, even in settings — such as China — where thee are major regulatory restrictions.

In Latin America physicians usually hold jobs in both pub ic/social security and private systems.'
t' The Nature of the Problem The same Journal goes on to ay that: Dual practice (DP) may lea to predatory behaviour (behaviour in which self-gain is pursued to the detriment of the legiti ate interests of colleagues, services and/or patients by health workers.)
i Similarly, in a 2014 RAND Report on the Iraq health system we read: the profit incentive could de ease efficiency in the health care system if physicians shift patients to the more lucrative private sector, or if they simply do not work hard during the time they are paid to provide care in the jublic sector.
The latter behaviour is common in many health care systems with DP2 and There is no evidence that dual practice by public sector health professionals complements public practice or promotes greater equity of health care distribution... ... DP decreases equity in the type and quality of health care received by individuals at different income levels.

Individuals who receive care in the private sector pay for it out of pocket or 1 Ferrinho, Paulo et al., Dual 2 Anthony, C. Ross et al.
Dual RAND REPORT, 2014 n the Health Sector: Review of the Evidence, Human Resources for Health, 2004 Options for Dealing with Combined Public and Private Practice Among Physicians , 6 through their own private insurance; these payment options are typically not available to low- income individuals.

3 In other words, both from an efficiency and an equity angle, dual practice is bad news for the health system.
In another study, which pointed out the main positive feature of dual practice as giving public sector doctors the opportunity to earn a decent income, the point is made that: However, in some contexts its negative impacts by far exceed the positive.
These include: the rise of predatory behaviour, whereby self-gain drives the health workers to generate demand for their own services in the private sector by over-prescribing treatment; conflict of interest, whereby health workers lower the quality of services they provide in the public sector in order to drive clientele to the private sector.4 There is no question that there have been quite a few of our medical/nursing professionals who have extended themselves beyond the call of duty and who are to be commended and applauded.
However, this does not negate the fact that some of the public criticism and the very unfortunate events at the nation's hospitals have had their foundations in the truancy of some of the officers.

The implications for the quality of care afforded to patients in the public health system are serious.

3 Ibid.
3 Ibid.

4 Kiwanuka SN et al., "Dual practice regulatory mechanisms in the health sector A systematic review of approaches and implementation" EPPI-Centre Report, 2011 7 Options for dealing with thel Problem The literature on dual practice suggests five options for dealing with the phenomenon: I.

Let the market evol e without constraints on dual practice.

2.

Impose constraints lased on physician time, income, or some other variable.

3.

Impose legal constr ints on physician work in the private sector.
4.

Provide financial in entives to physicians.

5.

Guarantee quality i4 the public sector.5 3 For Trinidad and Tobago thp first two policy options do not make sense.

The first option amounts to doing nothing abs: ut the problem and hoping for the best.

The second option, on the other hand will in principle a dress the issue of the time spent at public institutions but will not address the issue of divided oyalties which speaks directly to the quality of care afforded to patients.

I .
I .

11 ecommendation The position taken in this alt ative report is that the present system which allows public sector doctors to engage in private p actice be abolished.

In other words we begin by adopting the third option on the list.

The ideal ould be a situation where all doctors working in the public sector work exclusively for the pub ic sector.

This will not only make it possible to guarantee a good quality of service but may even do so at a lower cost to the country.
i ,itn The truth is that it is the spe ialists who have to be the clinical leaders dedicated to achieving excellence in the public heal system in respect of output standards and efficiency.

In order to do this, leadership must be rovided in the setting of standards.

It is these doctors who will spearhead the branding of the public health sector as a quality institution.

They must therefore be completely dedicated and co itted to the vehicle created to deliver this quality, namely, the RHAs.
In these circumstance there can be no room for divided loyalties.

This exclusive public sector arrangement was made in respect of the position of Chief Medical Officer many years ago, and should now be applied to all senior physicians in the public health system.

ft e The health system is now pr nted with the opportunity to change the culture of practice in the public health system by esta lishing new job descriptions in the RHAs and the MOH, for top ctions go beyond having clinical expertise.
This would hold for level medical staff whose Medical Chiefs of Staff, Heatils of all departments and Consultants.

All senior staff should now be exposed to some level of management training and medical ethics as well as the basics of research.

The ultimate objective will be to fill all senior positions with full time public doctors.
However, where there is a need which cannot be filled by the public sector doctors, institutions should seek part time services from other specialists in the country, including those from the UWI.

It will be S RAND Report, 2014, pg.

8 8 necessary to make use of contracts which clearly spell out the terms of engagement and to put in place robust monitoring arrangements.

Any arrangement that jeopardizes the objective of adequate care is inconsistent with the mission of the public health care services.
To accept the present situation is to accept that we are not prepared to advance the cause of good health care, but simply pay lip service to it.

This is the absolute position.

The bottom-line is that there can be no guarantee of excellence in the public health system if the specialists are kept in a position of divided loyalties.
This is not to deny that in the history of dual practice in Trinidad and Tobago there have been excellent doctors who kept the flag of quality service flying high in the public system.

However, these were clearly the exceptions over the years and the time has come to take the steps needed to make quality and public health care synonymous.

The recommended change will also serve to bring about the dismantling of a culture of moonlighting which has now permeated to all level of health professionals.
It is known that key support practitioners are engaged in private practice along with the doctors.

We speak here of nursing staff, radiographers, ultra-sonographers, lab technologists, biomedical engineers/technologists and physicists.

There is an obvious link here to the perennial delays in receiving lab and radiology reports, treatment delays, greater length of patient stays, overcrowding of the hospitals and increased costs.
Equipment failure and down time in the public health sector are now becoming the norm resulting in a long waiting list of patients for MRI and CT scans.

The public hospitals then outsource to get them done at private institutions where public sector technicians are duly present.

We need to bring to an end behaviour which takes as its cue: "if the priest can play."

This is a culture that will forever keep the quality of health service in the public health system at a second rate level.
It is a culture which must be abolished.

Public sector specialists must be required to work exclusively for the public sector.

Of course, it would be unconscionable to suggest making specialists exclusive to the public sector without recognizing the need for a significant adjustment in compensation and in working conditions for the designated full time public sector specialists.
The current remuneration packages are not commensurate with the qualifications and expertise of professional doctors required to provide leadership in the specialties.

Improved packages are required if doctors at this level are expected to forego opportunities in the private sector.

The RHAs will need to note that these packages will, of course, go beyond remuneration.
They will now accept responsibility for providing the appropriate working environment, including, on call accommodation, clerical support, and office space of which there is very little in many institutions.

9 In this sense, we also fully support the suggestion made by Ferrinho et al.

(2004): It makes no sense to ex ect health workers to perform well in circumstances where the equipment and resources are patently deficient.
But improving working conditions involves more than providing an 4dequate salary and the right equipment.

It also means developing career prospects and proifiding perspectives for training.
Perhaps most important, it requires a social environment that reinforces professional behaviour free from the favouritism and arbitrariness prevalent in the public sector of many countries.6 In other words we will also adopt options 4 and 5 from the list suggested in the RAND Report (2014) above: we need to pay our specialists much better and offer them vastly improved working conditions.
It is recommended that discu.tsions along these lines be started as soon as possible both with the specialists and their industria relations representatives.

ci The argument that we can co tinue with the present system if we are prepared to implement the necessary controls is a porou one.

The fact is that the private health institutions are owned and operated by the very senior ractitioners who are employed in the public sector.
The heads of departments and most SMO' all practise in these private institutions and are colleagues.

The question that arises is, "wh is going to guard the guards?"

Any arrangement therefore to accommodate shared practi by public physicians will diminish our resolve to provide the public with good health care.

The proposed arrangement is portrayed in Figure 1 below.

6 Ferrinho et al.

pg.
17 10 PHYSICIANS AND POPULATION HEALTH CARE ON TRINIDAD AND TOBAGO The Proposed Configuration POPULATION HEALTH CARE I PUBLIC HOSPITALS AND CLINICS I PRIVATE HOSPITALS, CLINICS AND OFFICES I EXCLUSIVELY PUBLIC PHYSICIANS I , p ..._ PART-TIME „ CONTRACTED PHYSICIANS I EXCLUSIVELY PRIVATE PHYSICIANS I I 1 NATIONAL POOL OF PHYSICIANS Figure 1 What the diagram portrays is a system that is fundamentally driven by a quality motive.
The goal of the system is to be a world class public health system, thereby making itself attractive to practitioners from any part of the globe.

Moreover, although, it is acknowledged that the specialists in this system will have to be compensated handsomely, this issue is not really about compensation.

It is about a culture of excellence which the system seeks to inculcate.
To make the case that because of the current economic restrictions we should not seek to bring this new system on board is to misunderstand how central the branding of the system is to those in charge of it, and how important changing the culture of patient care is to the population of this country.

With the significant investments being made in the Trinidad and Tobago health system, having a world class quality brand should be our main objective.

The benefits to the population will be tremendous.


11 1 Our main argument for not h lding on to the present system is that the fundamental point which this report wants to make is that the health system is not designed for doctors or other health professionals.

It is designed that patients get the best care that is available.
In this regard the public health system cannot ontinue to expose patients to a choice between unpredictable care within the public system and ood quality care in the private system, where this care is provided by one and the same special St.

This arrangement is both inefficient and inequitable.
Since the country has now committe itself to Universal Health Coverage, the system which grants physicians employed in the public sector the leeway to engage in private practice must be immediately brought to an en .

12 SIGKATILME PAGE FOR POSITION 2 ON PRIVATE PRACTICE Mr Karl Theodore Mr tank De Games Mil Valerie Alle,yne Rawlins Dr Albert Persatsd DT Wayne Frederick 13