1. Society of Private Nurse Practitioners of South Africa February 2016 Health Market Inquiry

2. Society of Private Nurse Practitioners of South Africa INTRODUCTION 2 Profile of Private Nurse Practitioner sector Oral submission and response to Statement of Issues

3. Society of Private Nurse Practitioners of South Africa Private Nurse Practitioners (PNP)  A Professional Nurse and Midwife,  Registered by the South African Nursing Council  Provides nursing care on a fee for service basis, Reimbursed directly or indirectly by the patient. *Does not include practitioners who are salaried, eg. agencies (duty nurses), doctors consulting rooms, pharmacy or occupational health clinics nurses on salaries. *But these practitioners also contribute toward reduction of cost of care & face most challenges being presented 3

4. Society of Private Nurse Practitioners of South Africa SERVICES PROVIDED BY PNPs 4

5. Society of Private Nurse Practitioners of South Africa SERVICES PROVIDED BY PNPs Consultation, not shift based General – frail care, home visits Wound care – Basic & Advanced Psychiatry Lymphoedema mgt. Stomatherapy Dermatology Palliative care / end of life Childbirth education Midwifery – ANC, PNC, Births Lactation consultants Immunization and Well Baby clinics School nursing Occupational health / wellness Renal dialysis 5

6. Society of Private Nurse Practitioners of South Africa Practice Models Independent practitioners – sole proprietor, partnership, companies (Pty & cc) Health centre & pharmacy-based clinics Franchise-type model – Unjani & Owethu / Sha’p Left primary health clinics Reimbursement Fee-for-service Direct or 3 rd party funding 6

7. Society of Private Nurse Practitioners of South Africa PRACTICE SETTINGS 7 *Feb 2016: Rural towns / region practitioners now 30%

8. Society of Private Nurse Practitioners of South Africa AGE DISTRIBUTION OF PNPs: 2016 8

9. Society of Private Nurse Practitioners of South Africa STATISTICAL SNAPSSHOT 9

10. Society of Private Nurse Practitioners of South Africa FEE STRUCTURE Tariffs previously set by BHF, currently subject to High Court ruling as for other professions Linked to public sector nursing salaries Does not take practice expenses into account 2016: 2006 tariffs + annual inflation 10

11. Society of Private Nurse Practitioners of South Africa 11 Revised statement of Issues Feb 2016 Sha’p Left clinic under construction in Cape Town FOCUS OF SUBMISSION

12. Society of Private Nurse Practitioners of South Africa BARRIERS TO ACCESS OF CARE REGULATORY FRAMEWORK – Authorisation of advanced practice PNPs – Advertising / listing restrictions FUNDER CONSTRAINTS – Procedural codes – Specialist nursing services – Reimbursement PRIVATE SECTOR POLICIES – Access to services for patients – Indemnity insurance – Recognition of PNPs legal authority 12

13. Society of Private Nurse Practitioners of South Africa 13 39.2. Consumers are unable to make informed choices in the selection of health products (i.e. insurance, services and products) due to lack of transparency in the healthcare sector. 39.5. The coherence of the existing configuration of regulatory interventions on the supply-side (services and products) requires careful review to assess the extent to which contradictory objectives are currently pursued with harmful effects for efficient competition. Revised Statement of Issues 11 February 2016

14. Society of Private Nurse Practitioners of South Africa REGULATORY FRAMEWORK Authorisation of Advanced Practice PNPs Nursing Act, 33 of 2005 10 years after promulgation, regulations still not adopted 14 S38(A) / S56(6) authorisation to perform functions beyond the basic scope of practice to provide primary health care not available to private practitioners, which provides for diagnosis, treatment & prescribing by PNs Scope of Practice S22(c ) Medicines and Related Substances Act, 101 of 1965 - Private practitioners excluded, leaving patients in rural areas without access although appropriate nurse practitioners available. Dispensing licenses Act requires Minister to make regulations (refer Acts or Omissions) Regulations regarding PNPs

15. Society of Private Nurse Practitioners of South Africa REGULATORY FRAMEWORK Advertising & Practice Restrictions 15 Regulations regarding Acts or Omissions for which the SANC may take Disciplinary steps Prohibits nurses from making their services known to patients or other healthcare providers Prohibition on Advertising Restricts partnerships to other nurses only, therefore cannot be part of a multidisciplinary group, therefore cannot be included in proposed NHI proposals, unless as employees. Mirrors HPCSA ethical rule. Group practice restrictions

16. Society of Private Nurse Practitioners of South Africa FUNDER CONSTRAINTS Procedural codes Authority Codes required HIV testing & STIs Rx Diabetic education - insulin therapy Lactation consulting – promotes breastfeeding Contraception, insertion of implants & intrauterine devices Lympheodema management by nurse practitioners 16 No mechanism to generate new / additional codes for nursing procedures or those not “authorised” by BHF prior to 2006 BHF, CMS – not within their remit SANC not part of funder / reimbursement system Mechanism Claims are being rejected, patients become responsible for payment Not recognised as part of Prescribed Minimum Benefits

17. Society of Private Nurse Practitioners of South Africa FUNDER RESTRICTIONS Reimbursement for Specialised nursing services Insufficient or unspecified benefits for nursing services, leaving patients at the discretion of case managers’ interpretations Medical schemes ward accommodation includes nursing, but will also reimburse Stomaltherapy and fund Midwife-assisted births Not funded - psychiatry, advanced wound care, diabetic nurse education, lactation consultants Commonly schemes may authorise, but later reverse authorisation, leaving patients responsible for fee Medical schemes ward accommodation includes nursing, but will also reimburse Stomaltherapy and fund Midwife-assisted births Not funded - psychiatry, advanced wound care, diabetic nurse education, lactation consultants Commonly schemes may authorise, but later reverse authorisation, leaving patients responsible for fee 17 In hospital Out of hospital

18. Society of Private Nurse Practitioners of South Africa CASE STUDY 18

19. Society of Private Nurse Practitioners of South Africa Why have PNP when the hospital is being paid to provide nursing? “The dramatic increase in hospital-based claims, …. is argued to be, in significant part, driven by nurse salary increases” 113.3 Revised Statement of Issues 11 February 2016 Private hospitals have reduced / eliminated nurses with advanced level skills Patients still require these services to improve outcomes, reduce hospitalisation, continue recovery in the home setting 19

20. Society of Private Nurse Practitioners of South Africa PRIVATE SECTOR POLICIES Access to services for patients 20

21. Society of Private Nurse Practitioners of South Africa HOSPITAL RESPONSE 21 Medical practitioners request advanced nursing services Funders and hospital management restrict funding although the service is not provided by the hospital Patients may also not access their own nurse practitioner while in hospital due to this policy, as well the reluctance of ward staff to follow nursing care plans recommended by the advanced nurse practitioner

22. Society of Private Nurse Practitioners of South Africa Key cost driver influencing choice of Caesarian sections Women pressurised to accept C/S as the norm High cost of professional indemnity for obstetricians Limited indemnity for Midwives Restricted access to obstetric units and small number of obstetricians to backup midwives, who have limited privileges (public & private sector) 22 PRIVATE SECTOR POLICIES Indemnity Insurance

23. Society of Private Nurse Practitioners of South Africa RECOGNITION OF PNPs LEGAL AUTHORITY Refusal by pharmacists to dispense prescriptions from nurses with legal authority to prescribe as per S22( C) permit / S38(A) Refusal by employers to accept sick certificates issued by nurses, even where authorised to diagnose and treat selected conditions in primary health settings. Patients incur additional costs to see FP, further absenteeism, additional out of pocket costs 23

24. Society of Private Nurse Practitioners of South Africa CURRENT RESEARCH “The Clinical Nurse Specialist also plays an essential role in care coordination and transitions of care that result in reduced hospital length of stay, fewer hospital readmissions and hospital-acquired conditions “ NACNS 2013 24

25. Society of Private Nurse Practitioners of South Africa CONCLUSION Nursing services can contribute significantly to the reduction of hospitalisation costs and access to affordable health care Requires review and acceleration of regulatory framework, particularly authorisation, licensing & advertising Inclusion of critical nursing practices within PMB framework 25

26. Society of Private Nurse Practitioners of South Africa