Not all government clinics have doctors on their teams but the skills and knowledge of a medical doctor in such settings were absolutely critical to managing patients in more complex cases, a recent study in KwaZulu-Natal has found, MedicalBrief reports.
Their data, researchers said, support the benefit of a doctor working at every single primary healthcare clinic (PHC) clinic: in fact, the doctor is a “must-have” member of the clinic team, “offering a regular, reliable and predictable medical service” – and not just a “nice to have”.
The main pillars of strength at these PHC clinics are the full-time, dedicated, and hard-working operational managers and PHC professional nurse clinicians (PNs). Yet doctors form only a part of these teams, although they offer a decentralised medical service for patients with more complex clinical conditions.
There are currently two sources of doctors for the clinics – outreach doctors and National Health Insurance (NHI) doctors. However, there are no directly funded medical posts at the PHC clinics in KZN.
NHI introduced the concept of GPs working in PHC clinics in 2013 in three pilot districts in KZN, including uMgungundlovu, with the posts renewed on a yearly contract basis.
This research was to assess whether these GPs are of benefit in clinics.
When the clinic operational managers in uMgungundlovu were interviewed using a provincial NHI monitoring form, without exception they all said the NHI doctors add benefit.
Management of patients onsite at the clinic has become more important as busy hospitals can no longer manage all of the patients with hypertension, diabetes and other chronic illnesses like HIV. These patients are either cross-referred from hospital to a PHC clinic or initiated on treatment at the PHC clinic.
Primary care services at clinics and CHCs are struggling with high patient numbers, the complexity of undifferentiated problems, multiple comorbidities and serious illnesses. In an earlier study on diabetes in KZN, largely based on data from the District Health Information System (DHIS), data specific to uMgungundlovu from 2010 to 2014 showed that >90% of 10 417 diabetic patients had started their treatment started at PHC clinic level.
The authors concluded that “these clinics should receive increased staffing in the form of doctor support and nursing, which is the way forward envisaged by NHI”.
The consensus was that district management needs to be supportive, especially regarding transport of the doctor to the clinic; the visiting doctor needs to be oriented to clinic work, and needs extra skills, such as working with mental healthcare users, knowledge of the Essential Medicine List (EML), rational prescribing and knowledge of IMCI; a specific doctor should be allocated to a specific clinic long term; the doctor should display good relationships, mutual respect and teamwork.
For this most recent study, published in the South African Medical Journal, the team wanted to know what tasks doctors perform in PHC clinics: how much they improve the package of care.
Their findings showed that the GPs are trained to manage patients with undifferentiated presentations and complex medical conditions beyond the scope of the PN, like chronic kidney disease or virological failure.
They can also initiate scheduled medicines; manage obstetric problems beyond basic antenatal care; manage child health problems not covered by integrated management of childhood illness (IMCI); perform more complex management of emergencies such as poison ingestion; perform minor surgical procedures; and interpret X-rays.
The doctors concluded that most of the consultations (93.6%) should indeed have been conducted by a doctor. Only 477 (6.4%) doctor consultations were regarded as inappropriately referred to the doctor, and the patient should rather have been managed by the PN.
Emergencies constituted only 2.5% of doctor consultations, even though one of the important functions of a PHC doctor is to better manage emergencies in the PHC clinic. The study team’s perception that workload from emergencies was greater than the number measured could be due to the longer time spent with each emergency patient, such as for resuscitation or suturing.
Maternal and child health (MCH is perhaps the most important function of a PHC clinic. However, only 10.2% of doctor consultations were for antenatal women and children aged <10 years. The low consultation rates could due be to three factors: the clinic midwives do not refer antenatal patients to the doctor; the doctors discourage referrals because they feel unsure of their knowledge of primary care obstetrics; and some NHI doctors reported having reservations about antenatal work due to lack of medicolegal indemnity.
PHC clinic doctors in uMgungundlovu have, for several years, been requested to get more involved in MCH – e.g. every pregnant woman should be reviewed routinely at least once by a clinic doctor between 28 and 34 weeks’ gestation. Several continuing professional development (CPD) sessions for doctors had been spent on antenatal care as well as ART in pregnancy.
The even lower rate of paediatric consults could be due to two factors: first, most of the PNs have been trained in IMCI, which covers primary care paediatric conditions, so do not need to refer many children to the doctor. Second, all PHC doctors have attended CPD sessions on basic IMCI, but not all have attended a full 10-day IMCI course, and may have felt unsure of their IMCI skills.
Non-communicable diseases (NCDs): It was expected most consultations would be for NCDs, and this was correct, with 58.9% of consultations for NCDs. Epilepsy and mental health problems are both common conditions in uMgungundlovu, and important for the doctor to be involved in and knowledgeable about.
Renal and urological conditions were surprisingly common especially chronic kidney disease. Thyroid conditions accounted for <1% of consultations, but are important for the PHC doctor to be involved in.
Miscellaneous doctor consultations: Interpreting laboratory results was a common reason (15.9%) for a patient being referred to a doctor. Interpreting these forms a large part of a doctor’s undergraduate training, but less so for a PN. The teaching of lab result interpretation forms a more significant part of NIMART and postgraduate PHC nurse training. So it is very helpful having a doctor in the PHC clinic to interpret these results.
More research could be done on: referrals from PHC to hospital; models of how best to place and fund doctors in PHC clinics; and clinical competencies required for a doctor to work in a PHC clinic.
However, the research showed that at PHC clinics, the more complex patient consultations did indeed require the skills and knowledge of and MD in managing these patients. These data support the benefit of a doctor at every PHC clinic.
A doctor at a PHC clinic: A ‘must-have’ or ‘nice-to-have’?
TP Kerry, P Cudahy, H L Holst, A Ramsunder, N McGrath.
Published in the SA Medical Journal on 20 December 2023
Many patients have their healthcare needs met at primary healthcare (PHC) clinics in KwaZulu-Natal (KZN), without having to travel to a hospital. Doctors form part of the teams at many PHC clinics throughout KZN, offering a decentralised medical service in a PHC clinic.
To assess the benefit of having a medical doctor managing patients with more complex clinical conditions at PHC clinic level in uMgungundlovu District, KZN. Two key questions were researched: (i) were the patients whom the clinic doctors managed of sufficient clinical complexity that they warranted a doctor managing them, rather than a PHC nurse clinician? and (ii) what was the spectrum of medical conditions that the clinic doctors managed?
Doctors collected data at all medical consultations in PHC clinics in uMgungundlovu during February 2020. A single-page standardised data tool was used to collect data at every consultation.
Thirty-five doctors were working in 45 PHC clinics in February 2020. Twenty-six of the clinic doctors were National Health Insurance (NHI)-employed. The 35 doctors conducted 7 424 patient consultations in February. Staff in the PHC clinics conducted 143 421 consultations that month, mostly by PHC nurse clinicians. The doctors concluded that 6 947 (93.6%) of the 7 424 doctor consultations were of sufficient complexity as to warrant management by a doctor. The spectrum of medical conditions was as follows: (i) consultations for maternal and child health; n=761 (10.2%); (ii) consultations involving non-communicable diseases (NCDs), n=4 372 (58.9%) – the six most common NCDs were, in order: hypertension, diabetes, arthritis, epilepsy, mental illness and renal disease; (iii) consultations involving communicable diseases constituted 1 745 (23.5%) of cases; and (iv) consultations involving laboratory result interpretation 1 180 (15.9%).
This research showed that at a PHC clinic the more complex patient consultations did indeed require the skills and knowledge of a medical doctor managing these patients. These data support the benefit of a doctor working at every PHC clinic: the doctor is a ‘must-have’ member of the PHC clinic team, offering a regular, reliable and predictable medical service.
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