Western Cape Health Department's clean audit: A user's experience

This is a response to Daily Maverick section editor Mark Heywood's article about the Western Cape Health Department's (WCHD) first clean audit. In it he interviews head of department Dr Beth Engelbrecht.

The pedant in me corrects Heywood where he mentions "superintendent-general" Beth Engelbrecht.  The correct title is "head of department". (Hospital "CEO" replaces "superintendent".)

Many people, especially politicians, bureaucrats and media, make too much of clean audits. There's ignorance and misinformation about financial year-end audits. The objective of an audit is to express an opinion on the financial statements. It's not to express an opinion on management's decision-making prerogatives, service delivery or any other aspect, as Engelbrecht and Heywood believe.

I assume the WCHD previously received "[financially] unqualified audits with findings on "reporting on material [significant] performance objectives or non-compliance with legislation".  

I was once a contract auditor for the auditor-general. Findings can be expected in most audits. It's the materiality – deviation from accounting parameters – that's important. A clean audit, i.e. financially unqualified and free from deviation regarding performance objectives and legislation, is fairly easy to obtain provided management-instituted accounting policy, which the auditor is not responsible for, is obeyed, but this appears hard for government departments to do. 

That they're excitedly praised for doing something they ought to do in the normal course of their business indicates the low standards of good governance in the country. But more than once former premier Helen Zille infamously and ignorantly said the (international) system of auditing should be changed because it was inconvenient to her government, which not even the ANC government – state capture central – suggested and that introduced legislation to empower the AG's recommendations. 

But my main purpose in writing is Heywood's statement: "Equity, equality, quality – these are issues this writer has insufficient information to pass judgement on, so her word must stand. But Maverick Citizen invites readers to write to us with your observations about the quality and equity of health services in the Western Cape." 

In this blog I've written extensively of our experience at WCHD facilities and with Engelbrecht personally, MEC Nomafrench Mbombo (a cipher; no reaction – MECs take instruction from HoDs) and former premier Zille. I wrote to Daily Maverick a few times but my letters weren't published. 

We don't have a flattering account of the department and Engelbrecht personally including again this year when she batted away my complaint of poor service when I presented at Groote Schuur Hospital with an urgent medical matter, implying they weren't to blame. They – she, department and facilities – always do this, never accepting responsibility. 

Also, the tale about doctors disciplined for repairing chairs and another who sexually assaulted a nurse – he roofied her – and was allowed to work as a locum in the department are stories a financial year-end audit don’t reflect of the true state of affairs.

Don't take my word for it. The TAC's State of WC Health 2018 report stated the service is "failing the people it serves". And the South African Health Review 2018, based on users' perception, gave them 48.3%, the fourth lowest grade in the country. The national average was 55.1%.  Also, see stories like here and here, two of many that Engelbrecht and her colleagues downplay, dismiss or ignore. 

With this in the public domain including from his old organisation, I don’t understand how Heywood can claim he has “insufficient evidence [sic]” to question Engelbrecht’s assessment unless it’s to present a positive spin for them. This is poor journalism and confirms my impression of Daily Maverick, which considers itself the country's preeminent independent, and local media. (Three times I emailed managing editor Janet Heard about errors of fact and pure speculation in its business-related articles – here, here and here – and suggested better editing. And it's not the first time I've had problems with their, at times, leniency toward certain people, Helen Zille, a former columnist of theirs, among them.)

The WCHD may deserve kudos for financial management only, the DA’s strength, but they do so at the expense of a patient-centred approach where they're failing. This year I had reason to compare service at another public facility – UWC's Tygerberg Oral Health Centre, which is excellent – with theirs, and it’s chalk and cheese. 

In fact, I told Engelbrecht she should ask UWC to give WCHD staff seminars on the patient-centred approach, which c2009 then GSH CEO Dr Terence Carter (he later joined the national health department) told me he was trying to implement. Apparently he failed. 

She didn't respond to that. 

Engelbrecht showed a "civil" side to the media, which impressed Heywood. Of course she did. But from my experience, like her colleagues, she's duplicitous, unquestioningly and pre-emptively defends staff right or wrong as the WC government does; deliberately fails or refuses to act on patient complaints of medical malpractice and (but her department prosecutes staff for repairing chairs!), and inadequately oversees the proper functioning of WCHD facilities to prevent patient-related problems arising. 

On the last point, spend time at any facility and what will strike you is the lack of supervision with staff apparently having too much time on their hands, wandering who knows where, at the expense of an efficient and effective patient flow, and often displaying a careless, unfocused indifference to patients. This would never happen at a private facility.

This is independently backed by media reports like those I mention above and my GP who last year quit from volunteering at a WCHD hospital saying “they waste people’s [everyone] time”.  Instead, she volunteered three months for an international medical NGO.

While I’ve heard compliments, the service is too patchy to be anything like Engelbrecht’s (and Zille’s) self-serving assessment and the public’s perception of the DA-run province’s purportedly good service.  As I wrote her, “The department and its political masters appear incapable getting their house in order, preferring self-congratulatory bromides, spin and photo-ops [like Heywood’s uncritical article] rather than doing the work ... [And] concentrat[ing] on bureaucratic minutiae, but compassion is absent and even professional interest as doctor[s]".

I also said, “The test of [WCHD] system integrity is not that it passes 99% of the time, but the 1% failure. Politicians and bureaucrats concentrate and boast about the 99% and overlook the other because it's flattering to them". 

This irrelevant obsession with clean audits, which is not the Holy Grail as politicians and public aver, ignores the over sixty percent other aspects of good governance that includes service delivery, compliance with promotion of administrative justice, transparency and accountability and ethics where government at all levels, including Western Cape, is consistently failing.

While one compliments Engelbrecht and WCHD for sound financial management, where it matters they’re failing the people they serve.  

*

I complained to the Health Professions Council (HPCSA) about Engelbrecht and her colleagues about my late mother's care and death at GSH in 2017.  (The case is independently proceeding at Cape Town Inquest Magistrate’s Court, status unknown.) The complaint was dismissed this year, but I found out a month later one of the HPCSA's preliminary committee members, Prof. Elmin Steyn, head of the department of surgery at Stellenbosch University and Tygerberg Hospital, that adjudicated the complaint had a prior and ongoing private-professional relationship with one of the respondents, Prof. Andrew Nicol, a subordinate of Engelbrecht's and a head of department at GSH. 

The finding itself was irrational and violated the HPCSA's regulations on committees of inquiry and case precedent HPCSA itself set for the type of complaint. Bias, conflict of interest and procedural irregularities were evident.  (Incidentally, in a current case, Dr Jacques de Vos complained the HPCSA violated inquiry regulations by refusing to hand over the complaint to him.  And the HPCSA lost court cases, the latest this year in his ongoing battle, against Dr Wouter Basson for irregularities regarding their inquiry against him.) 

I attempted to lay a criminal charge against the HPCSA in August under the Prevention and Combating of Corrupt Activities Act of 2004.  First SAPS, then NPA declined to accept the charges. (The head of detectives at the local station aggressively questioned me for wanting to do so.  At first the NPA said they’d attend to the matter laid in my affidavit, but later changed their minds.) I shall try again this month.[1]

Ironically HPCSA, SAPS and NPA among others are members of the Health Sector Anti-Corruption Forum President Cyril Ramaphosa launched on October 1 (see here). The SIU is investigating HPCSA staff for bribery. The foxes are guarding the hen house.

Heywood invited WCHD users' observations. This article is a slightly edited version of the one I sent Daily Maverick. 

Footnote: [1] On October 1 I laid the charge at Woodstock Police Station. It took some persuasion for them to open the case, first with the charge officer and then the detective I was referred to. I don't have a case number yet which is unusual. I received a message the following day to call detectives at the station, but there was no answer (30/10/2019).

Postscript

I visited Dr. Abdurahman Community Health Clinic in Athlone on November 1. I had never been there before, not counting the time I went and the queue was at the door. I left after waiting an hour without been seen, and I tried. For most of the time there were no staff behind the counters, main reception (supposed to be three queues) and pharmacy (four counters) where I needed to be.

I eventually attracted the attention of three employees. The first, at main reception (most of the time no one was behind this counter), referred me to pharmacy.  At the latter I was sent to another counter behind which an employee passed. He acknowledged me but never returned, passing by, doing important stuff. Another spoke on the phone, ignoring us. One patient asked why they all took lunch at the same time but that wasn't the reason, though.  Another asked what's going on. To him I said they're ignoring us.

I doubt Engelbrecht and WCHD management visit their own facilities and know what's really going on there. If they do, they have stars in their eyes about their alleged "equity, equality, quality" service. Naturally, they attend private clinics for their needs.

Dr Giovanni Perez, in his youth an anti-apartheid ANC-aligned activist before he became a government suit, is the WCHD's chief director for Metro District Health Services for the DA-run administration. Apparently, much escapes his notice (see here, here and here regarding the Eerste River Hospital debacle).

I'll never forget when as superintended of GF Gooste Hospital in Manenberg he responded in the Athlone News to the complaint of nurse turning a patient away (this happens a lot at WCHD facilities which they always deny) with suspected viral meningitis by the banal - for it's shirking of responsibility - reply that it's "dangerous to make accusations against hospital nursing staff" and irrelevantly quoting his hospital's patient through-put statistics while admitting he was still to investigate the matter. The patient's diagnosis was later confirmed at a private hospital where her daughter took her.

His response was classic WCHD: not to accept responsibility for anything and distract with irrelevant issues, which they utilised in the Eerste River Hospital problem, a long-standing problem Perez, the district manager, was apparently unaware was happening.  One wonders what they do for their million rand salaries. (Disclosure: he and I were in the same classes for 10 grades. I last saw him briefly four years later when we were both at university, he in medical school, I engineering.)

Heywood is fatuous to take their good news statements at face value. (Postscript added 4/11/2019.)