Pandemic is an opportunity to reform primary healthcare in SA
System’s private component should manage two or three times the volume of patients given its professional capacity
Successful healthcare systems have strong primary healthcare sectors, with general practitioners (GPs) being the patient’s first point of contact with the systems. Most services patients need can be provided cost-effectively in these practices, but the same service costs 10 times more when provided in a hospital.
Highly functional primary healthcare systems are structured in multidisciplinary teams that usually include four or five GPs, with nurses, allied professionals such as social workers and occupational therapists, and specialists who visit. They are funded as a team and are organised to work together to be accountable for their shared patients, constantly evaluating outcomes and adjusting their approach.
These effective primary healthcare teams have a comprehensive view of all patients and their families. This includes information beyond all of their clinical problems, but also their disabilities, their behavioural and social challenges and the environment in which they live. Effective GP practices are the patient’s advocate and guide through the healthcare delivery system.
Covid-19 has posed many challenges to SA’s healthcare system, beyond the focus of treating critically ill patients in intensive-care units. The primary healthcare role should include promoting responsible social conduct and ensuring continuity of care for people on chronic treatment because they are living with HIV or chronic diseases. Primary healthcare providers should support noncritical Covid patients at home to keep them out of hospital, with advice, monitoring devices, medication and even access to home oxygen. They have an important role to play in Covid patients’ recovery after discharge – rehabilitation and the management of long-term complications.
Yet for most people reading this our description will feel like a fantasy as SA’s , primary healthcare system has not enabled most GP practices to provide such support. This is a terrible pity, because countries with good primary healthcare that has been made central to the Covid response have been the best performers for their populations. Unfortunately, SA has very weak primary healthcare systems.
In the public sector, primary healthcare is the poor relative of the hospital system, with overwhelmed and traumatised staff and poorly served patients. Although not the focus of this piece since neither of us is an expert, it is clear that this is largely the consequence of how the system is structured and funded. Primary healthcare services are managed separately from hospital care rather than as an extension of the same, integrated system. There is little collaboration between them, and communication between these “levels of care” is poor, so the primary healthcare team works in unsupported isolation.
Many complex patients are blocked from access to services at the level they need to properly manage their illness, while tertiary hospital services are full of lower “case mix” patients rather than those for which they are staffed and funded. This results in low productivity and poor value. Addressing this should be a major focus of the proposed national health insurance (NHI) system.
Private primary care is based on some 9,000 GPs. However, their role is marginal in the sector because of scant and badly structured scheme primary healthcare benefits and funding, which results in a low productive service model. The typical GP practice comprises one or two doctors with low capacity, funded to work in isolation and not in a team. Even the big “corporate” GP clinics are generally lone “hamster wheel” practices that share only the premises. Even in this setting there is seldom teamwork to leverage skills.
Because there are too many doctors per scheme member (one per less than 1,000 people), they find themselves in competition with hospital-based specialists for available scheme funds. The result is patients without an identified GP practice as their “medical home” instead have a few non-communicating specialists and use the hospital emergency room as the default, from which they are inevitably admitted to a ward.
Since the advent of democracy in SA there has been no policy or regulatory support for the core primary healthcare GP role. GPs are typically unaware when their patients have had significant hospital services or procedures, since the competition referred to above has mostly terminated the courtesy specialist letter. Currently, GP practices cannot take accountability for their patients. This is the recipe for a wasteful and ineffective private primary healthcare system. SA’s private primary healthcare system should be managing two or three times the volume of patients (18-million to 25-million people) given its professional capacity.
The GP role in the Covid vaccination campaign is crucial because their knowledge of their patients can facilitate prioritisation and scheduling of patients and provide support for any adverse events. A recent survey showed people are expecting to get their vaccine from their GP practice or the local pharmacy. Yet, disappointingly, there is no plan to put our GPs at the centre of the Covid vaccine rollout. Such a plan, with funding, organisational and resource support, could begin a shift from small practices with limited capacity to bigger organised team practices that are cost-effective and have capacity. This shift would boost our entire healthcare system, which we urgently need as the country strives to create a high functioning universal healthcare system with the NHI.
The pandemic is an opportunity to reform primary healthcare in SA, especially the private sector — the focus of this piece. The current minimum requirements and funding model, inclusive in theory, in practice makes it impossible for GP practices to participate. Branded stadiums, marquees and hospitals are the expedient, costly solution. It’s much easier to work with corporates, but it will not move us forward.
Where is the creative and far-seeing leadership the moment deserves? What happened to: “Never allow a good crisis to go to waste”?
• Dr Coetzee chairs the SA Medical Association. Dr Ruff is CEO of healthcare management company PPO Serve.
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