Figure 38: Stock and Flow Diagram of Medical Specialists Workforce Planning (Adapted from Morecroft, 2015)
The medical workforce planning stock and flow diagram in Figure 38 represents variables of various categories of doctors, namely, medical students, junior doctors and specialist doctors employed in the KZN DOH. This stock flow diagram illustrates the process of medical students who are recruited into medical schools where the five years are spent in training to become junior doctors. Then, if the junior doctor chooses, another four years are spent to undergo further specialist training (Matsoso, 2011).
Once qualified, specialists can be appointed in either the public or private health sector or may choose to emigrate to practice their skills overseas.
To ensure that equilibrium in the supply and demand of specialists is maintained, the rate of medical student recruitment needs to equal to the rate at which doctors of all categories are leaving hospitals (Morecroft, 2015). Stocks and flows are the foundation of any system as it conforms to the laws of conservation and accumulation. When the inflow rate, for example, of medical students is higher than the outflow rate of the qualifying junior doctor, the stock progressively increases. If the outflow rate is higher, for example, regarding attrition of specialists, than the inflow, the stock steadily decreases.
The delayed response of the input and output flow and changes in flow cause disequilibrium in the health ecosystem (Meadows, 1997).
Medical Studenrs
Junior Medical Doctors
Specialist Doctors
Rate of Specialist Doctors Retirement Rate of
Medical Student Recruitment
Rate of Medical Student Training Duration
of Medical Student Training
Rate of Junior Doctor Training Junior Doctor
Attrition Rate of
Non Hospital Appointment Annual Loss Non
Hospital Appointments Annual Attrition
Duration of Specialist Training
Annual Attrition
Specialist Attrition
Workforce Deficit
The policy directive received from KZN Office of the Premier, Provincial Treasury and HRM in KZN DOH on cost containment in April 2016 impacted on the recruitment and employment processes of specialist doctors resulting in reduced number of medical specialists in the tertiary hospitals (KZN HRM Cir. 62.2016). Another cost containment strategy in 2015/16 which affected the number of medical specialists qualifying was the withdrawal of the KZN DOH equitable share funding source from the registrar training programme. The impact of this strategy was a reduction in the supply of qualified medical specialists (HPTDG, AR, 2015/16).
To understand the impact of these HR and finance policy directives, the shortage of specialists and the effect on the clinical and hospital performance in the KZN tertiary hospitals was studied using the system dynamic approach.
Figure 39: Loop Diagram Policies, Tertiary Hospital Performance and Investment in Capacity (Focus Group)
The dynamic hypothesis in my study, which was based on the Morecroft Growth and Underinvestment Model as described in Chapter Three, Figure 9, noted that clinical service performance and patient satisfaction depend on the stability between patient demand and specialist capacity. Morecroft (2015) defined the Underinvestment Model as consisting of a limiting process that is influenced, for example, by the performance of services in the tertiary hospitals. This model also illustrates how reinforcing growth feedback interacts between patient demands and growing specialist performance. Systemic balance between demand and capacity needs to occur for service performance to be effective and patient express satisfaction with service delivery. From FGD it was observed, as shown in Figure 39, that when the KZN DOH organisation’s capacity to provide services decreased in relation to the patient demand, then performance at the tertiary hospitals deteriorated.
R
B Investment
Floating Goal
Over a period of time, hospital performance perceived by patients dropped with increased patient complaints and litigation for clinical errors soaring (KZN DOH AR, 2015/ 2016). The expenditure on medical litigation, according to KZN DOH Annual Financial Statements, was R251 278 million in 2016/17 (KZN DOH Annual Financial Statement 2016/17).
Tertiary hospital performance is perceived as high quality, responsive availability, consistent reliability or value for money of services rendered. Patient perceptions of tertiary hospital performance are determined by the balance between the health needs demand and the hospital’s capacity to provide the service. When there are delays in service provision, as in the case of shortage of specialists, the hospitals’ capacity to deliver the service decreases in relation to the demand which result in performance declines. This decline in hospital performance is perceived by patients as poor- quality services and the feedback effect results in the decreased demand. When hospital performance is sub-standard, this indicates the need to invest. In Figure 39, the balancing loop for capital
investment links performance, perceived need to invest, investment in capacity and capacity. This balancing loop supports growth by determining adequate specialist capacity to retain acceptable tertiary hospital performance. When the performance standard is stable, then capacity is adjusted to goal-seeking feedback. In the dynamic complexity of tertiary hospital performance as indicated in this figure, the reinforcing loop, also called floating goal, allows the goal to adapt. The reinforcing loop stabilizes capital investment, aligning performance to the performance standard, perceived need to invest and investment in capacity. Increased specialist capacity and tertiary hospital performance occur when performance recovers after a delay and the performance standard improves (Morecroft, 2015).
When policies are modified, the systemic effect is that the proportion of specialists required at any point in time in the service chain would take hospitals at least three to five years to re-establish an appropriate balance of specialists. This systemic re-balancing is one significant consequence of the KZN HPTDG decreased budget allocation directive, as reducing funding will require hospitals to employ a larger proportion of junior doctors in order to achieve the same medical specialist allocation to meet patient demands as in the past (Morecroft, 2015). Another consequence of this change in budget allocation directive was the flow rates of doctors as described in Figure 38.
The flow rate of doctors is inter-related with the structure of medical staff posts, especially for registrars and specialists, which has not been finalized in KZN DOH. Also, the NDOH policy
directive affects dynamic complexity of the health ecosystem; for example, the junior medical doctors as either interns or community service officers, post allocations, are coordinated by the NDOH without considering provincial needs. This process of allocation for junior medical doctors influences the experience sequence all the way to specialist doctors. The systemic effect is a high attrition rate
among provinces, as the balancing effect of supply and demand of specialists are not measured or evaluated.
From this permutation of exogenous and endogenous demand disparity, it can be deduced that healthcare delivery in SA and specifically in KZN, is in crisis. As health delivery systems evolve, these ecosystems convert into interconnected systems. These complex health services demand variations cause more interdependencies among these ecosystems resulting in current problems escalating. Thus, the ability to adapting rapidly and responding to the consistently-changing patient demands and flow through the healthcare system is fundamental to the complete success of healthcare delivery (Rust, 2013).