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Society o
f Private N
urse P
ractition
ers of So
uth
Africa
Society o
f Private N
urse P
ractition
ers of So
uth
Africa
Society o
f Private N
urse P
ractition
ers of So
uth
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
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Society o
f Private N
urse P
ractition
ers of So
uth
Africa
SERVICES PROVIDED BY PNPs
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Society o
f Private N
urse P
ractition
ers of So
uth
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
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Society o
f Private N
urse P
ractition
ers of So
uth
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 3rd party funding
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Society o
f Private N
urse P
ractition
ers of So
uth
Africa
PRACTICE SETTINGS
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1
57,6
27,5
7,8
4
2,3
Other
Residential areas
Business district / malls
Industrial areas
Rural towns /regions
Informal settlements
SPNP PROFILE OF PRACTITIONERS 2014 N=371
*Feb 2016: Rural towns / region practitioners now 30%
Society o
f Private N
urse P
ractition
ers of So
uth
Africa
AGE DISTRIBUTION OF PNPs: 2016
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48%
45%
7%
> 55 years 40 - 55 years < 40 years
Society o
f Private N
urse P
ractition
ers of So
uth
Africa
STATISTICAL SNAPSSHOT
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No
. P
Ns
Cli
nic
Ho
spit
al
Ho
me
Pts
pe
r m
on
th
Mixed practice KZN
Infant vaccines given 3 804 77 604
Well baby clinic visits 3 357 357
Wound care visits 3 137
Unjani clinics National 19 15857 835
Sha’p Left clinics W Cape 1 450 450
Wound care visits Gauteng 2 25 18 169 212
Society o
f Private N
urse P
ractition
ers of So
uth
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
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Society o
f Private N
urse P
ractition
ers of So
uth
Africa
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Revised statement of Issues Feb 2016
Sha’p Left clinic under construction in Cape Town
FOCUS OF SUBMISSION
Society o
f Private N
urse P
ractition
ers of So
uth
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
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Society o
f Private N
urse P
ractition
ers of So
uth
Africa
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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
Society o
f Private N
urse P
ractition
ers of So
uth
Africa
REGULATORY FRAMEWORK Authorisation of Advanced Practice PNPs
Nursing Act, 33 of 2005 10 years after promulgation, regulations still not adopted
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• 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
Society o
f Private N
urse P
ractition
ers of So
uth
Africa
REGULATORY FRAMEWORK Advertising & Practice Restrictions
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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
Society o
f Private N
urse P
ractition
ers of So
uth
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
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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
Society o
f Private N
urse P
ractition
ers of So
uth
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
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In hospital Out of hospital
Society o
f Private N
urse P
ractition
ers of So
uth
Africa
CASE STUDY
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Society o
f Private N
urse P
ractition
ers of So
uth
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
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Society o
f Private N
urse P
ractition
ers of So
uth
Africa
PRIVATE SECTOR POLICIES Access to services for patients
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Society o
f Private N
urse P
ractition
ers of So
uth
Africa
HOSPITAL RESPONSE
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• 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
Society o
f Private N
urse P
ractition
ers of So
uth
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)
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PRIVATE SECTOR POLICIES Indemnity Insurance
Society o
f Private N
urse P
ractition
ers of So
uth
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
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Society o
f Private N
urse P
ractition
ers of So
uth
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
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Society o
f Private N
urse P
ractition
ers of So
uth
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
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Society o
f Private N
urse P
ractition
ers of So
uth
Africa