After a successful event held on 21 November 2022 where we hosted as keynote speaker Mr. Alex Rothwell (NHSCFAs Chief Executive, anti-fraud unit of NHS), we brought to light the need for systematic and detailed audits in the National Health System, in order to avoid incidents of corruption and misuse of resources, with the ultimate goal of having real transparency in the health system.
The Manifesto below is the result of an event titled "Transparency and Combating of Corruption in “GESY” (=National Health System) organized on the 29 June 2023 by the CYPRUS INTEGRITY FORUM in collaboration with the Cyprus Medical Association (PIS), the Commissioners of Transparency and GESY Audit, the Office of the Auditor General and under the auspices of the Ministry of Health.
All the stakeholders associated with the Health System were invited to the event, while there was also a public call for the submission of views and opinions. The following organizations were represented at the event, in which professionals from the wider spectrum of health and society also attended:
- CYPRUS INTEGRITY FORUM
- Cyprus Medical Association (PIS)
- Commissioner of Supervision of GESY
- Transparency Commissioner
- Office of the Auditor General
- Ministry of Health
In the round table discussion, some alarming concerns emerged in the current running of the Cyprus National Health system (GESY) that need to be immediately and effectively addressed, otherwise the system is at risk of collapsing in terms of both financial and quality aspects.
In summary, the 5 sections that were discussed and that need to be addressed immediately are:
1. Transparency in the execution of the actions of the GESY – Risk of Corruption
2. Control of all GESY medical operations (at any level)
3. Anti-Corruption Mechanism and Audit.
4. Expenses of the Cypriot citizen allocated to health.
5. Medical Auditing (=systematic performance audit of professionals and infrastructures that provide medical services).
After a detailed and extensive discussion at the round table level by the participants, as well as views and questions raised by the attendees, we came to the following observations and conclusions:
A. The lack of transparency is created by many factors, the main ones being:
1. The inability of the Commissioner to exercise the level of audit assigned to his department and to publicize data on insufficient health professionals,
2. The incomplete and weak exercise of audit by the Health Insurance Organisation (HIO),
3. The incomplete exercise of audit of the HIO by the Ministry of Health,
4. The incomplete legislation that governs all the above involved and their supervision and the amendment of any distortions that cancel each other's provisions of the law (see reports of the GESY Supervisory Commissioner).
5. The ambiguity associated with the interpretation of the philosophy of the system, which allows the interpretation at will by each participant in the system.
B. The lack of quantitative and qualitative AUDIT of GESY services:
1. The administrative audit of a health insurance organization (HIO) by the audit service of the Republic of Cyprus showed disappointing results in terms of the audit rate (note almost all, below 5% audit).
2. There is no quality audit of diagnostic devices or medical equipment in diagnostic and medical centers.
3. There is unclarity relating to profitability levels and degree of quality medicine.
4. There is no effective audit and no consequences attributed in cases of negligence.
C. Encroachment on Corruption
1. There is a lot of laxity in the implementation of the already deficient legislation and often infringement of audit procedures.
2. The Commissioner for the Supervision of GESY reported that the House of Parliament Audit committee has been informed about this alarming situation, however they do not allow the publicizing of any case on their behalf.
3. There is geographic disparity - several areas are unfairly treated or neglected but no reassessment has been done.
D. Expenses of the Cypriot citizen for health.
Everyone agrees that there is unclarity regarding how the funds allocated on health are calculated.
1. GESY Contribution – Everyone contributes. How much?
2. State (taxpayer) payment for maintenance and existence of State Hospitals. How many?
3. Medical Funds – EAK, SYTA, ETYK and other 200. How much? Why do they still exist?
4. Medical insurance – ? 33% of the civilians have a personal insurance. Why? How many?
5. Ministry of Health +/- 80 million for emergencies not covered by GESY?
6. Patient Links – Huge sums, privately owned buildings (5-15m), physiotherapists, Offices…
Are we receiving the benefits we should in terms of quality medicine? Where is all this money going? Could all this money be used in a national General Health System?
E. Medical Auditing. Medical and Clinical Scrutiny.
1. Medical audit is a systematic evaluation of performance in an organization/institution that provides health and/or care services.
2. Medical audit means the retrospective examination, review and evaluation of the clinical application of medical knowledge used in the diagnosis and treatment of patients as revealed in the patient's clinical record and carried out for purposes of education, accountability and quality control”.
3. The round table discussion showed that there is no thorough check, nor that any check is done by medically qualified people. Based on the suggestions of the expert who was hosted at the event on 21 November 2022, the director of the Audit Department of the National Health System of the U.K. Mr. Alex Rothwell said: "Even in a strict and experienced audit framework that we have managed to create, there is corruption, loss of resources and exploitation, especially when there is no adequate audit system. The demands from the health system are of such magnitude that any delay in establishing a system of adequate and in-depth scrutiny or any laxity in the exercise of control, can bring about traumatic consequences to the economy of a country".
RECOMMENDATIONS:
1. To carry out a relevant and detailed study, so that there is thorough and detailed training/updating of all those involved, as practiced in other countries. Overlooking this important step (=evaluation report as well as training) led to the launching of GESY without adequate preparation, resulting in omissions, mistakes and generally adverse consequences.
2. The legislative framework is fragmented and vague, resulting in each participant interpreting it as they see fit. The legislation should be re-evaluated, to answer questions such as: A) Is there a GESY philosophy and what this is, B) Who defines this philosophy and how does he interpret it (with the validity of the interpretation for everyone). C) Is there a defined policy of the government regarding GESY? It is imperative that it is re- evaluated and re-defined!
3. More and adequately qualified personnel (from the Health sector), sufficient financial control as well as quality control (not only in the financial part, but also in terms of services offered). Transparency in procedures (employment - assignment, provision of services, evaluation of equipment, and everything else that involves the provision of health services).
4. Need for immediate action, but also preventive control so that the OAY (and by extension the public) knows what we pay and what we get before the provision of the service and not after. The services it pays for should be evaluated for quality, as well as the ethics with which the service is provided, whether it concerns a doctor or a medical center or a laboratory or another participant in the system. In addition, the HIO should exercise quality control in terms of people, especially in terms of the ethics with which work is carried out.
5. The HIO must impose controls in regular time frames, to ensure the provision of quality health services, at all levels. Also, OAY must re-assess the contracts it signs with service providers, for the whole range of services provided (including attitude towards patients). There should be NO compromise whatsoever, whether in entry criteria or thereafter, just for the sake of a generous registry of professionals, but each one participating should be regularly evaluated and re-certified. Ensuring quality is and should always be a TOP priority. The Ministry of Health must exercise control over HIO that they keep these commitments. The GESY Supervisory Commissioner should be able to publish verified information of fraud or malpractice that he has is his possession.
6. The cost per taxpayer must be accurately calculated. , In addition, publicise all reports before and after the GESY, as well as the relevant study prepared by the audit firm DELOITTE CYPRUS, which can be used for comparing with the results of the research of the audit service of the Republic of Cyprus. In addition, there is unclarity in figures made public anywhere, which intensifies our concerns about the scope of the "debt" and the consequences due to it. Therefore, the need to impose pressure to implement a strict audit system is imperative, as this has a direct impact on the Cyprus economy, if we are to avoid unpleasant consequences.
REGARDING MEDICAL AUDITING:
· URGENTLY initiate the process to establish a thorough and strict audit system. In this context, it is important to strictly adhere to the existing parameters.
· Consequently, initiate the process for the amendment of the legislation, to develop and improve the control parameters, so that we have the control system that will allow the viability of the GESY.
· The stakeholders involved should participate in the creation of the control system, with their own suggestions.
· Insurance companies can help create the framework and train the operators who will carry out the claims’ audit.
· The Commissioner for the Supervision of GESY should actively participate in the design of the audit framework.
· Establish regular communication of the progress of the Project to the Audit committee of the House of Parliament at regular intervals.
All the participants below subscribe to the conclusions of the Round Table Discussion as defined above and will monitor the progress for their implementation.
- CYPRUS INTEGRITY FORUM
- ALL CYPRUS MEDICAL ASSOCIATION
- SUPERVISORY COMMISSIONER GE.S.Y.
- TRANSPARENCY COMMISSIONER
- OFFICE OF THE AUDITOR GENERAL
- MINSTRY OF HEALTH