Family physicians poised for bigger role in public healthcare after years on the sidelines

About twenty years ago, family physicians seemed set to take up roles as critical cogs across SA’s public healthcare system, but in the years since doctors trained in this speciality have largely been underutilised.

That is now finally set to change, according to the department of health which has signalled that they want to see more family physicians appointed as clinical managers tasked with leading multidisciplinary district hospital teams.

This follows years of lobbying by the SA Academy of Family Physicians (SAAFP) advocating for the greater utilisation of family physicians in the country’s public healthcare system.

The SAAFP has long argued the cost and clinical effectiveness of these “super generalists”, who undergo an extra four years of training, with an emphasis on clinical governance and knowledge of social factors influencing people’s health.

And it seems their patience has been rewarded with a five-year district health blueprint from the government.

This was confirmed to Spotlight by Dr Luvuyo Bayeni, the department's chief director of human resources for health.

Advocates for the speciality argue that family physicians have been neglected, with posts thin on the ground and their potential contribution underestimated. The discipline was registered with the Professions Council of SA in 2007.

Prof Bob Mash, distinguished professor at Stellenbosch University where he heads the Division of Family Medicine and Primary Care, describes the speciality as “one of the most underutilised solutions to many of the problems facing district health service delivery”.

Mash is the immediate past president of the SAAFP.

Bayeni, a former clinician/administrator in the Eastern Cape, was appointed to lead the health department’s human resource operations in July last year.

Since then, he attended the last two annual SAAFP conferences and has been meeting regularly with the academy's leadership.

With austerity measures being the catch-all rebuttal by provincial heads of department whenever the wisdom of freezing posts is questioned, Bayeni is trying to persuade his provincial counterparts to adopt a policy of appointing family physicians to clinical manager posts as a highly cost-efficient move, citing successes in the Western Cape. The idea is that family physicians can quickly diagnose and treat patients while mentoring junior colleagues. They also help design or tweak hospital and referral clinic systems for efficiency and identify preventive health interventions at a community level.

Bayeni said his family medicine-orientated blueprint had been approved by the dresidency’s department of policy planning, monitoring and evaluation for inclusion in all future health indicators.

He plans to initially get family physicians as clinical managers into all medium to large district hospitals (150 beds and above), before ensuring they are placed in every health district, including at lower-level hospitals and community health centres, at all times leading a multidisciplinary team.

“Instead of waiting for HR [human resources] plans and organograms, this is going into the mid-term framework for monitoring. It’s a strategic opportunity, where we ask ourselves, ‘how do we define a multidisciplinary team for a district hospital?’ and then work through and with them. We’ll define and map where our priority district hospitals are, starting with the medium to large district hospitals,” he said.

Bayeni said he met with his provincial counterparts and military health service chiefs last week, (October 14–18), where he said he was going to, “make sure they all know about this. Organigrams are all fine and well and necessary, but I want this top of mind when they consider them”.

“Personally, by April next year, [the new financial year], I want to see more family physicians being appointed, either in the district or in the position of clinical managers wherever there are vacancies. I’ll ask the provinces to help me with monitoring and evaluation,” he said.

He said his ambition is to change the mindset of provincial healthcare leaders “wherever necessary” about family physicians being regarded as “just another speciality” when creating and enumerating posts.

Mash said SA’s previous health policies saw family physicians as a sub-specialty of internal medicine or as specialists who should work at tertiary hospitals and within primary care teams.

Now, chiefly due to the lack of posts, only a third of family medicine graduates were retained in the public sector, with 10% emigrating and 11% giving up medicine altogether.

Most were employed in the Western Cape, where the health system had committed to appointing family medicine practitioners at district hospitals and primary care facilities, Mash added.

The SAAFP recommends a mid-term goal of one family physician at every district hospital, community health centre or sub-district.

To achieve this, said Mash, another 400 family physicians are needed, but at current training rates this could take up to two decades, (not accounting for the current shortage of posts).

He agreed with public health medicine specialist Tracey Naledi, that only when there’s a wider and stronger investment in primary healthcare across provinces will better deployment of family medicine practitioners begin to make a real difference to district-level health and wellness.

Naledi is an associate professor in public health medicine and deputy dean of social accountability and health systems at UCT’s faculty of health sciences.

Naledi said that while there are many highly skilled veteran “utility” medical officers in the district health system, the greater utility of family medicine is in clinical governance, health systems strengthening initiatives and capacity development.

Besides teaching, monitoring, and evaluating healthcare delivery, she said family physicians also more appropriately and timeously refer patients to secondary and tertiary care.

“The family physicians should not just be seeing 60 patients at their door daily. They are specialist support – the medical officers should be calling them for advice. If family physicians were optimised, we’d see far less referral to tertiary level services,” she said.

The problem is structural, she believes.

“There are not enough human resources for health in general, so at district level people get pulled into doing what’s needed on the shop floor. There’s not enough time to do the strategic work.

“You can’t just talk about family medicine without talking about full staff requirements. When a family physician goes on outreach, it should not just be about dealing with difficult cases but building the capacity of the outlying areas. They need to ask themselves what they’re leaving behind. Otherwise, you’re cleaning the floor but not closing the tap,” she said.

Mash agreed that family medicine practitioners are “not the magic bullet – but introducing them into district health services can go quite a way towards strengthening the system”.

“We’ve trained them to work independently, to be the senior clinician with the full spectrum of needed skills, on top of which they provide the confidence for the doctors who are there to practice the skills they have. It’s very reassuring having a senior person to help if things go wrong, so it’s a combination of increased confidence and bringing in additional skills,” he said.

“A primary health nurse and community health worker can provide coverage and connection to the community, but a [family medicine] FM practitioner brings in a level of expertise so the team has both coverage and quality.”

*This article was first published by Spotlight