Medical Aids

With you from start to finish – with a ‘bus’ along the way

Main sponsor of The Comrades Marathon, Bonitas Medical Fund, has reiterated its support for the 25,000 runners, their families and beneficiary charities at this year’s gruelling ‘up’ race with a number of initiatives to ensure they are there from ‘start to finish’.

‘The true spirit of The Comrades is the guts, determination and teamwork it takes to finish this 89km ultra-marathon,’ says Lee Callakoppen, Principal Officer of Bonitas. ‘We believe every runner is a hero and want to honour their success. For the past decade we have been an integral part of the incredible Comrades story and continue to salute runners for the time, patience, effort and commitment they have invested to be part of this race. It is such a proudly South African event and we are thrilled to once again be on the start and finish line at this year’s race.’

The Bonitas support

The sponsorship is multifaceted and designed to help runners every step of the way – pre, during and post the race. It began with the hosting of a number of countrywide educational, motivational and inspirational seminars to assist runners make it across the finish line. The seminars were aimed specifically at the novice runner and women to get them prepared, both physically and mentally for the race. There were also roadshows held to provide tips and important information to run a safe and healthy race.

Talking of Heroes

A mini website has been created by Bonitas that provides important information on the route, nutrition, hydration, rest and much more. It also features Comrades heroes – past and present. Real people telling their Comrades story. Runners are encouraged to share their experiences online.

Bonitas has also brought on board a digital partner who will live stream the event – details and links are on the website.

Pre-race boosts

During the Comrades expo, in addition to having various BMI testing and physiotherapy at the Bonitas stand, there will also be an ‘expert advice booth’ manned by Coach Parry and other experienced runners. They will be available to answer any questions and give invaluable route tips, especially when it comes to pacing.

You can also relax and enjoy some light-hearted fun and win fabulous prices with the ‘win and spin’ activation at the exhibition.

At the start

On Sunday, June 9 in Durban the team from Bonitas will be on the start line to cheer on the runners. In addition a total of eight ‘Bonitas Buses’ led by experienced pace setters have been co-ordinated to assist runners run their best race. These buses are grouped in time categories, geared for different running styles and pace and finishing the race at different times. The ‘bus drivers’ will be appropriately dressed with signage to keep the ‘passengers’ together as they run the race – all in keeping with the 2019 slogan of ‘Together We Triumph’.

Crossing the finish line

Make sure you sign up for the Bonitas ‘find me’ app which will send a text or WA message to your family alerting them once you have crossed the finish line and providing information on a central meeting place.

Standing out from the crowd

Bonitas believes its involvement in The Comrades goes way beyond the sponsorship. ‘It’s about making a difference and giving the runners and their supporters what they want – from pre-race tips and advice through to on the day support’, says Callakoppen. ‘For us it is about living out our slogan promise and being with the runners ‘from start to finish’. We are a proudly South African company that promotes health and wellness and provides accessible quality healthcare, which makes this race an ideal fit for the brand.’

“This race is billed as the ultimate human endurance and it is no surprise when you consider some of the stats,” says Callakoppen including:

  • The fact that for every km run 66 joints, 55 bones and more than 100 ligaments, muscles and tendons go into action every time a shoe hits the ground
  • Most runners will lose around 3-5kg during the race
  • Around 43% will suffer from cramps

Yet this does not deter them in their quest to cross that finish line.

‘We salute the dedication and determination of these runners and are proud to be part of this amazing journey – from start to finish.’

For more information or to share your Comrades hero story go to:

New principal officer for Bonitas Medical Fund

South Africa’s second-largest open medical scheme, Bonitas Medical Fund, has announced the appointment of a new Principal Officer. Taking up the reigns from 1 May 2019 is Mr Lee R Callakoppen.

Callakoppen, who has a Masters in Human Resources Management, began his career in the retail sector before moving into Human Capital, holding positions in various industries ranging from retail to telecommunications and media. Over the past 10 years he has been involved with Medscheme and the AfroCentric Group in various functions including Human Capital, Facilities Management and Transformation. Callakoppen also spent time managing the Medscheme International Operation and was appointed as Head of Bonitas Business Unit in June 2017.

“Under the successful leadership of Gerhard van Emmenis since mid-2017, Bonitas has grown in terms of stature and membership and also went through one of the biggest medical amalgamations seen in South Africa,” says Callakoppen. “The Scheme has strengthened its financial position considerably. I look forward to building on the solid foundation that has been laid. The key focus areas will be to ensure the Scheme maintains strong corporate governance, strong performance and controls and to build on the mandate of making quality healthcare accessible for all South Africans, within an ethical culture.

“Together with the board and management team we will look at finding opportunities to further grow Bonitas. This means not only retaining our existing membership base but attracting younger and healthier members to ensure the sustainability of the Scheme,” says Callakoppen.

“I would like to emphasise that the intention is to build excellence in all we do to enhance member value, especially in light of the challenging economic environment our members face as well as improving the administrative processes.”

Callakoppen is in full support of a universal healthcare system, which aligns to Bonitas mission to make quality healthcare more affordable and more accessible. “I have a good team working alongside me and we hope to keep the Fund sustainable and offer our members access to benefits and services of the highest standard.”

Callakoppen succeeds Gerhard van Emmenis who was appointed Principal Officer in July 2017. Van Emmenis was part of the Scheme’s Executive Team since 2006 when he joined at Chief Operations Officer. Under his leadership the Scheme announced, in July 2018, the best financial results in its 36-year history, reporting a solid surplus of R730.2 million and recouping a R16.9 million deficit. Bonitas has also led the way in terms of fighting fraud, waste and abuse within the healthcare industry. Van Emmenis’s contract ended on April 30.

Callakoppen wishes to thank Gerhard for his commitment towards Bonitas and its members over the years. “Although Gerhard steps down as PO, we will work closely together through the transition period.”

Barcoding the healthcare world

In our daily lives we hardly give the barcode a second thought. We only really come across it when we’re shopping and even then, it’s merely a bunch of lines and spaces that helps us process the transaction and buy an item.

But the barcode is so much more than that. It powers everything from shopping to dining out, to healthcare and even logistics. It is estimated that it is used on more than a trillion possible products worldwide and this number will only increase as more products and services are being created.

While this might sound like an over exaggeration, it is not. The barcode, from its humble beginnings, has become one of the most essential tools of modern life. The famous song lyric tells us that, “money makes the world go round,” but in our current, always-on and connected world, it is in fact the barcode.

The best in health bar none

The barcode was invented in 1952 by Norman Joseph Woodland and Bernard Silver and was inspired by Morse code. Its first use was on American railroads in the 1960s and involved placing colored stripes in various combinations on steel plates fixed to the sides of railroad stock. It wasn’t until an additional decade of adaptation that the barcode was trialed in a Kroger US grocery store, opening the door for the barcode’s inclusion in everyday life.

In hospitals and the pharmaceutical sector, the barcode is enhancing processes.

Even today, many healthcare systems still rely on handwritten documents which can lead to mistakes stemming from illegible handwriting and fading ink. This is where the barcode brings multiple benefits.

Instead of using paper and pen to manually document treatment, barcodes and scanners can be implemented along with a patient identity management solution to accurately and quickly match patients to their records, medication and treatments. This ensures mistakes are kept to a minimum, while patients receive the right care.

Such benefits can also be seen across an entire healthcare facility. To ensure care teams can communicate and work together to assist multiple patients, institutions are adopting healthcare mobility solutions. These solutions enable hospital staff to reliably communicate with each other and quickly and securely provide critical medical information. Patient data can also be collected and shared in real-time, providing access to patient vitals, diagnoses, imaging and much, much more. This all equates to workflow efficiency improvements and a reduction in false alarms, notifications and most importantly, fatalities.

Finally, the barcode is being used to monitor the health of the institution itself. From physical assets like an MRI machine to the staff, it can help enhance real-time data sharing and analytics, making the facility even more efficient and effective.

According to the World Health Organisation, about 700,000 deaths worldwide every year are caused by the sale of counterfeit medicines. No country is immune from this scourge, with traffickers primarily targeting anti-cancer drugs which can carry an annual treatment cost of more than $50,000.

Thanks to a unique identification code, specific to each unit being sold, the origin and composition of a product could easily be ascertained. Using a basic 2D barcode flash, distributors would be able to follow their listed products in real time anywhere in the world. In the example of a bacterial contamination, distributors could react quickly to prevent it from reaching consumers.

Track and trace

The barcode is also playing a crucial role across industry in tracking and tracing items by knowing the location of any item in the world. This is something many industries need now.

In the healthcare sector, more than 400,000 pharmacies in Europe will be impacted by the new European Directive entitled the Falsified Medicines Directive to outlaw fake and illegal medication floating through the supply chain.

It is estimated that one percent of medicines sold to the EU public through the legal supply chain are fake. Under the directive, safety features will need to be placed on individual packs so that they can be identified, and authenticity is guaranteed. These will also allow pharmacists to check if the outer packaging has been tampered with.

The intent of this measure is to prevent the introduction of illegal medicine into the legal supply chain. This means pharmaceutical industry players must consolidate their medicine traceability practices to fight a rise in counterfeiting.

Thanks to a unique identification code, specific to each unit, the origin and composition of a product could easily be ascertained. Using a basic 2D barcode flash, distributors would be able to follow their listed products in real time anywhere in the world.

As for the future, the barcode is here to stay. Its journey is not even a decade old and we have seen such innovative and life-saving developments that its value will only increase, being critical to the success of global industries and re-writing the future in lines, small squares, radio frequencies and much more.

Cipla Medpro acquires a stake in connected health company Brandmed

In recognition of the importance of the critical shift to a more patient-centric, integrated and predictive healthcare environment, Cipla Medpro South Africa (Pty) Limited (“Cipla Medpro”), wholly-owned subsidiary of Cipla Limited (BSE: 500087; NSE: CIPLA EQ; hereafter referred to as “Cipla”) and South Africa’s third largest pharmaceutical company in the private sector, will acquire a 30% stake upon closure in the connected healthcare company, Brandmed (Pty) Limited. In February, Cipla had announced a similar partnership in India with Wellthy Therapeutics to offer a clinically-validated digital disease management platform to patients in cardio-metabolic health.

Brandmed, founded in 2014, has developed a unique fully integrated end to end solution to address outcomes and value-based care for patients with chronic lifestyle and Non-Communicable Diseases (NCDs) such as hypertension, diabetes, high cholesterol, asthma and chronic obstructive pulmonary disease. KardioGroup, a subsidiary of Brandmed was awarded the prestigious Frost & Sullivan South African Product Line Strategy Leadership, Internet of Medical Things South Africa, award in 20191.

The Brandmed ecosystem, developed in South Africa, seamlessly integrates a combination of connected solutions across the health continuum for patients, healthcare professionals, practices and institutions, and aims to deliver personalised patient care.

Paul Miller, CEO of Cipla Medpro, said: “This transaction will help to transition healthcare from being reactive to a proactive and real-time monitoring model that focuses on promoting wellness instead of managing illness. This aligns with Cipla’s vision and focus on ‘human care’ and a future where good health is expected, not for the few, but for the many.”

“By pairing our strengths with Brandmed’s innovative, patient centric approach to healthcare, Cipla Medpro will enhance its diverse portfolio in the NCD area to provide holistic care to patients from awareness through to disease management, thereby enabling patient adherence and compliance.”

The brainchild behind Brandmed, cardiologist Dr Riaz Motara, said: “Drugs alone are not enough to manage a disease and the disease burden will become unmanageable unless innovative solutions are implemented.”

“We’re integrating medical expertise with ground-breaking technology to deliver better patient care and offer an integrated disease management solution. We’re also shifting the focus from managing diseases in separate silos to a comprehensive risk reduction and treatment approach. Greater success in patient health outcomes, value-based care and efficiencies could be achieved in South Africa if more healthcare stakeholders are willing to work together,” said Motara.

The Indigo Wellness Index report reveals that South Africa has tremendous scope for improvement on various health indicators. Measures captured included healthy life expectancy, blood pressure, blood glucose (diabetes risk), obesity, depression, happiness, alcohol use, tobacco use, inactivity (too little exercise), and government spending on healthcare2.

According to the World Health Organisation, NCDs – mainly cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes – are the leading cause of death worldwide. More than 38 million people die annually from NCDs (63% of global deaths), including 16 million people who die before the age of 70. Nearly 50% of global disability is attributed to NCDs. Reducing the avoidable burden caused by NCDs and their risk factors means taking actions now to change the narrative around NCDs3.


About Cipla:
Established in 1935, Cipla is a global pharmaceutical company focused on agile and sustainable growth, complex generics, and deepening portfolio in our home markets of India, South Africa, North America, and key regulated and emerging markets. Our strengths in the respiratory, anti-retroviral, urology, cardiology and CNS segments are well known. Our 44 manufacturing sites around the world produce 50+ dosage forms and 1,500+ products using cutting-edge technology platforms to cater to our 80+ markets. Cipla is ranked 3rd largest in pharma in India (IQVIA MAT Dec’18), 3rd largest in the pharma private market in South Africa (IQVIA YTD Dec’18), and is among the most dispensed generic players in the US. For over eight decades, making a difference to patients has inspired every aspect of Cipla’s work. Our paradigm-changing offer of a triple anti-retroviral therapy in HIV/AIDS at less than a dollar a day in Africa in 2001 is widely acknowledged as having contributed to bringing inclusiveness, accessibility and affordability to the centre of the movement. A responsible corporate citizen, Cipla’s humanitarian approach to healthcare in pursuit of its purpose of ‘Caring for Life’ and deep-rooted community links wherever it is present make it a partner of choice to global health bodies, peers and all stakeholders. For more, please visit, or click on Twitter, Facebook, LinkedIn.

About Cipla in South Africa:
Cipla Medpro South Africa (Pty) Limited is a wholly owned subsidiary of Cipla Limited, India and third largest pharmaceutical company in the private sector in South Africa. Through Cipla’s purpose of ‘Caring for Life’, Cipla Medpro produces world-class medicines at affordable prices for the public and private sectors, advancing healthcare for all South Africans. For more information, visit

About Brandmed:
Brandmed (Pty) Limited is a South African digital health healthcare company founded in 2014 with a vision to create a global people-centric, integrated, value-based, outcome inspired health ecosystem. This vision is underpinned by visionary leaders who care, simple, validated and sustainable solution driven technologies.

Brandmed is a world first in delivering a unique fully integrated end to end solution to address outcomes and value-based care for patients with chronic lifestyle and Non-Communicable- Diseases (NCDs) such as hypertension, diabetes, high cholesterol, asthma and chronic obstructive pulmonary disease.

The KardioGroup ecosystem, developed in South Africa, seamlessly integrates a combination of connected solutions across the health continuum for patients, healthcare professionals, practices and institutions, and aims to deliver personalised patient care. This is achieved through key entities of the KardioGroup ecosystem such as, KardioFit, KardioPro, KardioLife and KardioLytix.

KardioFit an automated patient disease management, engagement and monitoring suite to empower patients to actively manage their own health in an era of the quantified self and assists medical professionals to make better informed decisions based on real world experience, resulting in improved clinical outcomes and efficiencies.
KardioPro is an integrated provider/practice point of care suite allowing for real-time validated and accurate wireless collection of clinical biometrics. The solution backed by accepted Global and South African Guidelines, automatically guides data interpretation, predictive risk profile analysis and diagnosis to inform standardised, personalised patient treatment and management.
KardioLife is a unique anti-inflammatory lifestyle programme.
KardioLytix provides real-time actuarial analyses of all data parameters in the Brandmed ecosystem. With the data generated on unified standards and formats, KardioLytix caters for objective measurement of value-based care outcomes.

For more information go to:

Start up offers alternative to financing palliative care

Current medical aid models for end-of-life care will pay for costly in-hospital care but won’t pay for home-based care. But an all women fintech startup is offering an affordable and compassionate healthcare alternatives to SA’s medical schemes.

Alignd is the brainchild of Dr Linda Holding, a palliative-trained doctor with 20 years of clinical risk management experience; Victoria Barr, a healthcare economist and senior director at FTI Consulting; and Shivani Ranchod, a healthcare actuary and academic. Its main intention is to provide alternative, more patient-centred and value-led healthcare models.

Metastaticised cancer in South Africa absorbs a disproportionately high percentage of funding from medical aids. The most recent estimates indicate that 8% of scheme expenditure is in the last year of life – a staggering R11.6bn in 2017 alone. The current focus of end-of-life care for these patients is on curative care and mostly in a hospital setting making it hugely expensive and geared to manage the patient’s medical costs in the final stages of their life.

“In current medical scheme approaches, healthcare costs in the last year of life are more than three times higher than in the second last year. This ramping up of cost represents the huge efforts to stave off death, efforts that are often invasive and non-beneficial,” says Ranchod.

“Using a combination of innovation, data analytics and a desire to bring the patient’s life to the fore, we believe we have a model that benefits all stakeholders and incentivises them to collaborate for the greater comfort of the patient and their wellbeing,” she says.

Collaboration encouraged

“Atul Gawande’s book, Being Mortal, talks about hospital-centric and aggressive treatment options at the end of life as a symptom of modern medical philosophy,” Ranchod says.

“There is little financial incentive or pressure for doctors to consider alternatives. A key moment in Gawande’s book is a discussion of a study where patients with complex and high-risk diagnoses had a consultation with a palliative specialist. The results were astounding – patients made dramatically different choices, costs came down and both the patient and their families reported higher levels of satisfaction,” she says.

The Alignd model brings to the healthcare system a carefully-constructed set of basic operating principles: a multi-disciplinary team naturally means that collaboration between role players lies at the heart of the business. It is also one that will be less costly to medical schemes.

Cofi Bill brings down regulatory siloes for medical scheme customers

Healthcare sector stakeholders have long advocated for a single regulator, believing that the current dual framework creates a regulatory arbitrage not conducive to offering the consumer maximum protection.

Just as the public and private healthcare sectors need to work together for South Africa to achieve universal healthcare, the same applies to government departments and regulators. “A silo approach to these complex issues will only serve to detract the process and delay progress. The dual regulation of participants in the medical scheme industry is not ideal, and in some areas creates conflict,” says Butsi Tladi, managing director of Alexander Forbes Health.

The Conduct of Financial Institutions Bill (Cofi) Bill, aimed at regulating how the financial services industry treats its customers, was published by the minister of finance in December for public comments until Monday April 1. The Bill advocates removing core regulatory functions from the Council for Medical Schemes (CMS) and placing them with the Financial Services Conduct Authority (FSCA).

A form of insurance

Tladi says medical schemes are a form of insurance, “… even the CMS acknowledges this in their submission on the Cofi Bill. Greater alignment is in the interest of the industry. Because of the varied nature of insurance products, including health insurance products, The FSCA has had to develop a depth of skill to regulate this dynamic industry.

“Had we appreciated this fact, and allowed the best suited government entity to spearhead our National Health Insurance efforts, we would have made far more progress,” she says.

Market conduct

It is also clear to Tladi that the FSCA’s ability to regulate market conduct of financial institutions is more advanced. In fact, CMS already refers compliance relating to conduct to FSCA for consideration.

“Through related legislations such as the Financial Advisory and Intermediary Services (Fais) Act, FSCA has proven that it is far more capable of managing possible conflicts of interest in the provision of independent advice to consumers.

“The Cofi Bill approach is refreshing in that it sets out the specific intention of the law, rather than setting rules for compliance. Compliance with the spirit of the law, rather than narrow technical compliance will be important. If we appreciate the efforts of the Competition Commission’s Inquiry into Private Healthcare, then we must welcome efforts that support and facilitate better competition and innovation. Furthermore, Cofi aims to promote financial inclusion and transformation, particularly that of emerging black-owned financial institutions.”

Did the Health Professions Council trade cash for qualifications?

The Special Investigating Unit (SIU) is awaiting the president’s go-ahead to investigate allegations that Health Professions Council of South Africa (HPSCA) employees may have taken bribes in exchange for medical registrations and board exam passes.

HPSCA ombud Munyadziwa Kwinda recently revealed the allegations while speaking at a symposium held by the Wits Students’ Bioethics Society. The head of SIU communications Nazreen Pandor confirmed that the unit has applied to the Office of the Presidency to begin investigating the beleaguered health regulator. Legislation requires the SIU to obtain this kind of approval via the department of justice for each inquiry it launches.

If allegations prove true, it may mean that people who were not qualified to provide medical care were fraudulently given HPCSA registration numbers that could have allowed them to masquerade as healthcare professionals and bill medical aids.

The HPCSA says it has already supplied the SIU with requested information and documentation pertaining to the allegations, according to HPCSA head of communications, Priscilla Sekhonyana. She declined to comment on how many officials were under investigation or whether any had faced disciplinary action.

Although allegations of bribery at the council are a revelation, it is not the first time the HPCSA has been under investigation.

Nothing new

In 2015, Health Minister Aaron Motsoaledi appointed a ministerial task team to look into maladministration, irregularities, mismanagement and poor governance at the council. The team concluded the council was in “in a state of multi-system organisational dysfunction” and that staff reported that some funds were unaccounted for in part because of a dysfunctional accounting system.

A year later, the body fulfilled one of the task team’s recommendations, parting ways with its CEO and a contract with a consultancy firm to help the HPCSA implement a turnaround strategy is expected to end later this year.

The proposed SIU investigation may be the latest signal from the state watchdog that it is getting serious about corruption in the healthcare sector.

In 2018, SIU head advocate Andy Mothibi announced that the body would create a special anti-corruption forum for the health sector, which he says would include civil society. An attorney with the public interest law organisation Section27, Nkululeko Conco, confirmed that the National Health Anti-Corruption Forum has been launched and now includes Section27 as well as the National Prosecuting Authority and the non-profit Corruption Watch. Pando says the forum has already received multiple complaints.

But Conco says it’s not enough that the newly created forum responds to complaints and cautions that we can’t always be reactive. He says once we’ve dealt with corruption, we need to ensure it doesn’t happen again, otherwise, it makes investigations into it meaningless.

Introducing the e-patient

Almost half the South African population has access to the internet, including 8-million Twitter users and 16-million Facebook users. This digital revolution has unlocked enormous opportunities for the creation of online communities for large-scale engagement around often complex topics like the management of health conditions.

Enter the e-patient. A term describing individuals who are proactive in their health and healthcare decisions.

E-patients are people that use digital resources such as the web, smartphones or other wearables to educate themselves about their condition and navigate the health system to track and manage their health. “In the age of consumerism, many e-patients, in managing their health, exhibit behaviours similar to that of people who research reviews before making online purchases, although the concept of an e-patient goes beyond that,” says Vanessa Carter, a Stanford University Medicine X e-patient scholar

A study conducted by the Office for National Statistics in the UK in 2018 found that 59% of women and 50% of men looked for health-related information online. In the US, 56% of people used websites and 46% used mobile phones to manage their health in 2018, according to Accenture Consulting’s 2018 Consumer Survey on Digital Health.

While there are no comprehensive statistics available for South Africa, Carter says the evolution of online resources and engagement has come a long way to empower patients. “Digital resources in the 21st century are going beyond the web and will include wearables and mobile applications that capture health data.”

Improving outcomes

Government involvement is key to driving the use of digital technology to improve the health of its citizens. E-health tech like electronic medical records, telemedicine and mobile electronic systems have been successfully used to improve health outcomes and empower populations. South Africa, however, has previously struggled to migrate traditional district health information systems to an electronic storage system that can be accessed by any health facility or practitioner. This has caused it to be ranked poorly in the global e-health maturity index.

Government initiatives to digitise healthcare have been evident in applications like MomConnect, a cell-phone based app that provides online resources to pregnant women. Since its creation, it has gained over 1.7-million users in over 95% of public health facilities to become one of the largest initiatives of its kind globally. NurseConnect is an extension of MomConnect for nurses to receive weekly information on aspects such as maternal health, family planning and new-born health.

Carter says that while these innovations are positive, governments could do more to bridge digital gaps and provide quality resources. “This includes wi-fi services in hospitals and clinics as well as websites for hospitals and clinics, both of which are fundamental resources that could empower patients and save time and money in researching online.”

She adds that a simple function on a hospital website notifying a patient about a medicine stockout for example, might save them an expensive trip to the hospital, long queues as well as reduce some of the heavy burden on overcrowded facilities.

Carter has no doubt that digital technology will be key in ensuring the sustainability of future healthcare provision, and that the e-patient will have a pivotal role to play.

“It is going to be a challenge to develop meaningful e-health systems if patients are not equal participants. Although e-patients are still evolving, especially in emerging countries like ours, they must not be undervalued as, in the future, they will be fundamental to collecting quality data in partnership with their medical professionals. Doctors can’t do this digital health transformation alone,” she adds.

Informed consent: The costly legal implications if it’s not done right

The value of keeping proper written records of explanations, discussions and advice leading to the informed consent to avoid protracted legal proceedings for both doctors and patients was highlighted in the the Supreme Court of Appeal judgement in the case of Beukes v Smith.

What is informed consent?

The introduction to the ethical guidelines published by the Health Professions Council of South Africa succinctly describes informed consent in this statement: “Successful relationships between healthcare practitioners and patients depend upon mutual trust. To establish that trust practitioners must respect patients’ autonomy – their right to decide whether or not to undergo any medical intervention, even where a refusal may result in harm to themselves or in their own death. Patients must be given sufficient information in a way that they can understand, to enable them to exercise their right to make informed decisions about their care. This is what is meant by an informed consent.”

Medical treatment cannot be provided in the absence of consent. Our courts have held that, to give proper informed consent, a patient must be informed of all material risks associated with the treatment. What is material? If a reasonable person in the position of the patient, warned of the risk, would attach significance to the risk, it is material. To give proper informed consent, the patient must know, appreciate and, understand the nature and extent of the harm or risk.

The claim in the proverbial nutshell

Dr Smith performed a laparoscopic hernia repair on Mrs Beukes. She sued him for damages alleging that he had negligently failed to provide her with sufficient information so as to enable her to give informed consent for the surgery. Smith’s alleged failure was to inform her that the hernia repair could have been done by way of a laparotomy procedure. His failure caused her to give uninformed consent to the laparoscopy during which her colon was perforated and as a consequence of which she suffered complications and damages.

Beukes lost in the Gauteng Division of the High Court in Pretoria. The appeal was against that judgement.

Consultation, motivation, operation, complication

Against the backdrop of the surgery lay Beukes’ medical risk. She was a high risk patient which meant that because of her health, lifestyle and medical history the risk of her suffering complications related to surgery was high.

Beukes was referred to Smith who consulted with her on 21 February 2012. He admitted her to the hospital as surgery was inevitable if she did not respond to conservative treatment. The issue would then be which surgery to perform.

After having consulted the referring doctor’s report and radiological reports, Smith’s recommendation was that the laparoscopy would be the best option for Beukes in the circumstances.

Smith wrote a detailed motivation for approval for the laparoscopy to Beukes’ medical aid in which the reason for his recommendation for the laparoscopy was stated and the general and specific advantages of the surgery were listed.

The laparoscopy was performed by Smith on 23 February 2012. Beukes was discharged from hospital on 28 February 2012.

Three days post-discharge, Beukes was re-admitted to hospital with various complications associated with a perforation of her colon which included sepsis. She underwent three further surgical procedures and remained in hospital until 19 April 2012.

Trial and tribulation

According to Smith, Beukes gave him informed consent orally on 22 February 2012, after he had consulted with her and explained the nature of each of the two options available, being the contemplated laparoscopic surgery and the laparotomy, and the material benefits and risks associated with both. He had informed her that, in his opinion, the laparoscopy was the better option in the circumstances. He also testified that she had signed a written consent shortly before the operation on 23 February 2012 which formed part of the record and was a confirmation of the oral consent given the previous day following his explanation of both procedures.

Beukes, on the other hand, denied that Smith had explained both procedures to her. She insisted that, in her first consultation with Smith on 21 February 2012, he told her that he would first consult with the radiologists on her scans and thereafter perform a “quick ……. 15 to 20 minute operation” to repair her hernia with a mesh and in “two or three days” she would be home. On her version, Smith made the decision to do the laparoscopic hernia repair during the first consultation on 21 February 2012 before having consulted the radiologists. She also denied having signed the written consent. She testified that had she been informed that the hernia could also have been repaired through a laparotomy, she would have discussed her options with her family and would have opted for the less risky of the two procedures, but she trusted Smith and believed him when he told her that the laparoscopy was a simple procedure that would take 15 to 20 minutes and that she would be discharged from hospital in three days.

The specialist surgeons who gave expert testimony on behalf of Beukes and Smith agreed that Beukes was a high risk patient, that under the circumstances, the laparoscopy was the better option, the procedure had been performed by Smith without negligence, and that Smith’s post-operative management of Beukes was acceptable.

The only issue was whether informed consent had been obtained.

At the heart of Beukes’ contentions was the fact that there was no written record of the details of the informed consent discussion.

It was not disputed that no record had been made of the content of Smith’s explanation to Beukes.

Beukes’ version was that, in the absence of evidence on the detail of her consultation with Smith, the court had to conclude that Smith had not given Beukes the necessary information as he alleged and further, even if he had given her some information, it was not sufficient to enable her to make an informed decision

Smith’s evidence was entirely reliant on his memory of what had transpired over the relevant period. However, as found by the trial court, several aspects supported his version such as his demeanour and diligence which were more consistent with his version that all had been sufficiently explained. Added to this were the medical records which also supported his version as opposed to that tendered by Beukes. Her version was inconsistent with Smith’s undisputed caring and diligent nature. The medical records suggested that there had been a more substantive discussion between her and Dr Smith than she was willing to admit. The written representations made by Smith to Beukes’ medical aid after his consultation with her the morning before the laparoscopy were consistent with his version and revealed that the material risks and benefits of the medical procedures occupied his mind. Nothing in the medical records contradicted Smith’s evidence.

Judgement day

Fortunately for Smith, the Appeal Court found no basis upon which to overturn the factual finding by the trial court that Smith’s version was probable and that of Beukes was not.

The cost of not recording what is said

Unfortunately for Smith, as it would appear from what was stated in the judgement, he was subjected to lengthy cross-examination from which he might have been spared had there been a written record or other record of his explanation, discussion and advice leading to the informed consent. That is aside from the cost of the litigation to Smith and by cost, I don’t just mean legal costs. Litigation is stressful and takes one out of one’s day-to-day professional practice. It comes with a high personal and economic price tag.

Keeping record not only protects the patient which is primary. It also protects the practitioner and may well avoid the risk of becoming embroiled in costly and lengthy ‘he said – she said’ debates.

SA medical schemes in good health

The insights were drawn from the Alexander Forbes Health Medical Schemes Sustainability Index which tracks key performance metrics of medical schemes and aims to provide a comparative assessment of future sustainability between schemes. The index is calculated from a base year of 2006 and considers a scheme’s membership size, membership growth, average beneficiary age, operating results, accumulated funds per beneficiary, and trends in the scheme’s solvency levels.

“In the open schemes industry, the sustainability index for the top 10 schemes has improved since 2006, meaning that the medical schemes industry has become stronger,” says Zaid Saeed, senior actuarial specialist at Alexander Forbes Health.

Among restricted schemes, Polmed has been the top performer in the index over the 10-year period considered, although it was not the top performer for 2017. The scheme achieved an operating deficit for 2017 and saw a decline in its level of reserves. Transmed has consistently been one of the worst performers on the index because of its sustained loss of membership, worsening demographic profile, low solvency ratio and persistent operating deficits.

Other key findings include:

  • The number of medical schemes reduced to 80 in 2017 driven by amalgamations and liquidations in the industry.
  • The growth in principal members slowed to 0.5% from 2016 to 2017, compared to growth of 1% from 2015 to 2016.
  • The average age of beneficiaries increased to 33.2 years at the end of 2017 (2016: 32.5 years), with the pensioner ratio rising to 8.4% (2016: 7.9%).
  • Family size has consistently declined over the last 17 years. At 31 December 2017 the average family size was 2.21 compared to 2.59 at the end of 2000.

Saeed says affordability of medical aid cover was the reason behind decreasing family sizes. “For those in formal employment private medical cover is usually a condition of service, but in a struggling economy members are removing one or more of their children from cover before cancelling their own membership. Younger members of a household are generally healthier and therefore less in need of medical cover.”

The increasing average age and pensioner ratio of members indicates a worsening risk profile of the industry. “This is one reason why members’ contributions increase in excess of CPI inflation annually, as it requires a medical scheme to adjust its pricing to absorb a higher rate of benefit utilisation by its members.”

Three-year cycle

Operating results in the industry seem to follow a three-year cyclical pattern. “Due to volatility in claims experience, schemes tend to over- and under-compensate when correcting their pricing, which can cause peaks and troughs in operating results from year to year,” Saeed says.

The industry had been consistently generating operating deficits since 2014 but this trend reversed in 2017. “Overall, the demographic profile and financial strength of the industry remain stable.”