The role of the district family physician

Abstract

District clinical specialist teams were formed in 2012. One member of the team is the family physician. The role of the district family physician is discussed and the case made for focusing on the organisational health of the medical teams practising family medicine within the district as an effective way to improve the quality of medical care delivered in the district.

Keywords:

• district hospital
• family professional role
• interdisciplinary health team
• physicians
• primary healthcare

Introduction

The author has been working as a family physician based at Umkhanyakude Health District Office since 2008. Previously he worked at Mosvold Hospital in the same district, initially as a medical officer in 1994, and later as medical manager from 2003. In July 2012 he was appointed as acting district clinical specialist: family medicine, as part of the district clinical specialist team (DCST) for Umkhanyakude. At present the DCST in Umkhanyakude District is composed of four members: a family physician, a specialist midwife, a primary healthcare specialist nurse, and specialist paediatric nurse.

Umkhanyakude District is a rural district in northern KwaZulu-Natal. All hospital medical posts are presently generalist posts. Apart from the author, there is only one other registered family medicine specialist within the district, and one family medicine registrar, both employed at one hospital.

This article discusses the role of the district family physician (DFP). ‘He’ is taken to mean he or she.

The district clinical specialist team

In the policy paper, ‘National Health Insurance in South Africa’, the South African Department of Health proposes a district-based clinical specialist team to support delivery of priority health programmes in the district.¹ The Ministerial Task Team (MTT) report on district clinical specialist teams in South Africa recommends the following composition of each DCST: an obstetrician and gynaecologist, a paediatrician, a family physician, an anaesthetist, an advanced midwife, a primary healthcare nurse, and a paediatric nurse.² Purpose of District Clinical Specialist Teams

According to the MTT: ‘The aim of the District Clinical Specialist Teams is to strengthen the South African district health system in order to improve the quality of healthcare for mothers, new-borns and children, reduce mortality and improve health outcomes in these groups.’²

Role of DCST members

The MTT states: ‘DCST members are to function first as a team, and second as individuals within their respective disciplines.’ Also: ‘Although individuals in the team have a primary responsibility regarding their discipline they will also act collectively.’²

Their primary role is defined by the MTT as: ‘supportive supervision and clinical governance … However, participation in clinical care is essential.’²

The work of DCSTs is to include: ‘quality of clinical services; clinical training; monitoring, evaluation and improving clinical services; supporting district level organisational activities; supporting health systems and logistics; collaboration, communication and reporting; and teaching and research activities.’²

Purpose of district family physician

According to the MTT: ‘The family physician is a new cadre of specialist trained specifically to work in the district health system as a generalist in primary care and the district hospital.’ Also: ‘The family physician and primary healthcare nurse in the DCST should target the non-hospital district level services in community health centres (CHC), primary healthcare (PHC) clinics and PHC ward based outreach teams.’ ‘For the family physician and primary healthcare nurse a secondary audience will be their colleagues in the district hospitals.’² The DFP is also expected to play a leading role to ensure implementation of recommendations to reduce maternal deaths in district hospitals.³

Induction training

As recommended in the MTT,² the DCSTs in KwaZulu-Natal underwent an induction course involving monthly workshops for 12 months. The training programme was organised by Anna Voce of the School of Public Health, University of KwaZulu-Natal. The topics included: baseline assessments, monitoring key indicators, maternal health, new-born care, child health, perinatal mortality meetings, audit tools, systemic diagnosis and intervention, organisational culture, the power of purpose, values in an organisation, and organisational health.

Organisational health

The topic ‘organisational health’ appeared particularly relevant to the author. It is a philosophy advocated by Patrick Lencioni, who believes that organisational health is an organisation’s most important asset, but one that usually receives little attention from management.⁴ To make an organisation healthy the following are required: a cohesive leadership team, clarity of purpose, which should be over-communicated and reinforced. A healthy organisation is characterised by: minimal politics, minimal confusion, high morale, high productivity and low turnover of good staff.⁵

Challenges to the functioning of DCSTs

The following appear to be challenges to the functioning of DCSTs as envisaged in the National Health Insurance (NHI) policy paper¹ and the MTT document.²

Socio-economic factors, such as poverty and unemployment, are a challenge to the whole Department of Health as they contribute greatly to ill health, but are not predominantly under the influence of the Department.

Specialists, with the exception of family physicians, may lose their secondary and tertiary level skills if working mainly in primary healthcare – a concern expressed by Nathan and Rautenbach.⁶

A large team of healthcare workers, including nurses, midwives, dieticians, physiotherapists, pharmacists and doctors, with special responsibilities has been based at most district offices since prior to the creation of DCSTs. The DCST, which also functions under the supervision of the district manager, has to fit in with the other professionals, who often have overlapping responsibilities.

DCSTs are small teams to cover the large area of a district. For example Umkhanyakude is approximately 100 km × 200 km in size, contains five district hospitals and 54 clinics, with a distance of around 250 km between hospitals at opposite ends of the district. DCSTs have to decide on a manageable constituency within a district to be able visit regularly and frequently enough to make an impact.

DCSTs may act only in an advisory capacity, not being the line managers of the health workers they are dealing with.

As acknowledged in the MTT document, ‘clinical care is essential in order that DCST members maintain their clinical competence, remain cognisant of the context in which services are delivered and retain their individual credibility and authority in the field.’² Maintaining clinical competence and credibility while only performing clinical work part-time, especially in rapidly changing fields such as antiretroviral medication, is a challenge.

Hierarchy of needs

Neil McKerrow, Department of Health, and Mark Patrick, paediatricians in KwaZulu-Natal, have, in presentations to health service staff since 2007, described a hierarchy of needs for clinical governance (Figure 1) as follows:

Figure 1: Hierarchy of needs for clinical governance (McKerrow NH: Draft KwaZulu-Natal Department of Health Policy on Clinical Governance. Unpublished)

Placing socio-economic factors at the base of the pyramid is acknowledging that not only the health of a population, but even the quality of healthcare delivered, is intimately connected with the socio-economic status of that population. For example when a large part of a population is unable to afford transport to their local clinic, the quality of care provided deteriorates. It may be seen in this model that staffing and systems come before monitoring and evaluation. The author would suggest that staffing could be considered an even more fundamental requirement than infrastructure, as a healthcare worker under a tree can do something, whereas absolutely nothing happens in an empty operating theatre. There are similarities between this pyramid model of clinical governance and that described by Scally and Donaldson, which also includes infrastructure and quality methods.⁷ Scally and Donaldson identify the vital importance of organisational culture and leadership in the promotion of improved clinical governance; however, they describe a model integrating approaches, rather than a hierarchy.⁷

The United Kingdom (UK) Department of Health defined clinical governance as: ‘a framework through which NHS [National Health Service] organisations are accountable for continuously improving the quality of their services and safe-guarding high standards of care by creating an environment in which excellence in clinical care will flourish.’⁸ This definition should include promoting the organisational health of the service. The document mentions many approaches to improving quality of service, including setting standards, monitoring, evidence-based guidelines, patient surveys, confidential enquiries, professional development, audits, and critical incident reporting.⁸ Excellent leadership and involvement of staff is identified as important; however, the inconsistencies in service quality of the NHS at that time are attributed to fragmentation brought about by the internal market, a lack of national standards of care, lack of assessment of effectiveness of different treatments and a lack of openness and accountability.⁸

In a similar way to McKerrow and Patrick, based on experience, and supporting the idea of the importance of organisational health promoted by Lencioni,⁴ the author proposes the following hierarchy of needs for a medical team in a district hospital:

From this model (Figure 2) it may be seen that the leadership and morale of the team are the most important team qualities, and therefore where a district family physician should concentrate his attention. The author is certain, from his experience of working with district hospitals, that the leader of the medical team is absolutely crucial to its functioning and that without competent leadership, it is probably impossible to have an effective medical team, however much external support is given. The top priority for the district family physician (DFP) with regard to the medical teams in his district hospitals is to find good medical managers or clinical managers, and to keep them.

Figure 2: Hierarchy of needs for a medical team at a district hospital

How to support the organisational health of teams

If it is accepted that the organisational health of a team is the most important factor to its functioning, the question arises as to the most effective way a DFP can maintain and enhance this. The author’s experience suggests that a collaborative medical style is more effective than a formal inspector style. As already mentioned, the DCST members are not line managers of hospital or clinic staff, and therefore must exert influence through persuasion rather than force. The author believes that the DFP and DCST members must not make the jobs of healthcare workers harder, but, if possible, easier. The DFP’s most important patients are his teams practising family medicine. If he can keep those in good health the impact on healthcare will be far greater than anything he can achieve as an individual doctor. The DFP’s key liaison contacts in a rural area will be his medical managers with whom he must have good relations to be able to exert any influence. He should also have cordial relations with the hospital managers, and announce his presence to them when visiting. He should know personally most of the medical staff in the district. When communicating information the DFP must take care not to bypass or undermine his medical managers. Non-controversial information may be circulated to all medical staff; however, information where there may be local interpretation, or in the form of instructions, is best sent only to his medical managers.

Activities that seem to be beneficial to the district hospital medical team include visiting all hospitals on a monthly basis, listening to concerns, participating in clinical work during the visit, and discussing issues with the medical manager. With regular monthly visits it is possible to obtain an accurate impression of team functioning. When all is well; for example the doctors are all present at 7.30 am, have an orderly hand-over, followed by a clinical teaching session, followed by prompt starting of clinical work, the next visit can occur in a month. However, if the team are showing signs of stress and dysfunction, such as incomplete attendance or arguing over the call roster, then more visits are required, with the intention of anticipating and preventing a major breakdown in the service.

Participating in clinical work, including outpatients, theatre sessions and even ward rounds, during visits has multiple benefits. It enables the DFP to experience how the hospital or clinic is actually functioning, and to better understand some of the difficulties faced by staff there. It creates enormous goodwill among staff, greatly enhancing the influence of the DFP on the medical team. It helps to keep the DFP up to date and maintain his skills, and, not least, provides a service. It is the author’s opinion that a DFP visiting a hospital or clinic without participating in the clinical work is similar to looking at a car but not taking it for a drive. The author would go so far as to say that any visit called a support visit to an institution by the DFP should include clinical work. The MTT recommends that the DFP perform clinical work only 10–20% of his time.² In the opinion of the author, this proportion should be higher, as there is no better way to support clinical staff than to work alongside them, nor any other way to keep his skills.

When a hospital faces a critical doctor shortage the DFP must go and assist. What appears to be a modest input can play a vital role in maintaining the morale and functioning of the remaining core of doctors until reinforcements arrive. The DFP can be the ‘finger in the dyke’ that prevents it bursting. This gives the DFP a role as an emergency floating locum. It perhaps should be mentioned that the author does not work overtime as a routine, but does so when there is an acute staff shortage. Although he does not claim for this irregular overtime, during his first five years, he did some night calls during approximately one third of the months. If the DFP is keeping a close eye on his medical teams, he is unlikely to be taken completely by surprise, and can be proactive to avert crises. If he is needed for manpower, then this can be planned, hopefully for a limited period of staff shortage, which can happen to any rural hospital which has many doctors working for relatively short periods. The knowledge that he will be expected to step into the breach certainly provides an incentive for the DFP to keep a close watch on his medical teams! The fact that he is prepared to do so contributes towards staffing stability in the district.

Activities which, although frequently recommended, have not been found to be particularly effective by the author include giving instructions as to how teams should function, and arriving with a long checklist. To begin a visit with a checklist is similar to beginning a consultation with a systematic inquiry before the patient has had an opportunity to tell his problem. The checklist agenda rarely coincides with the agenda of the staff. For example, while the visiting inspector is enquiring about the frequency of infection control meetings, the staff may be more concerned that their hospital has been without water for the past ten days. As already mentioned, the DFP depends on the goodwill of his medical team to exert influence. If he starts to annoy them with his checklists, he may be amazed at how quickly staff become too busy to talk to.

Building relationships to create a ‘district club’ of institutions is valuable, and encourages hospitals to assist each other in times of staff shortage. Neighbourly assistance has been crucial on several occasions for maintaining the basic service at hospitals during the author’s nearly six years in post. The DFP should keep an up-to-date list of the email addresses of all medical staff which can be used to circulate useful information. Feedback on such circulars has been surprisingly positive. As previously mentioned, the DFP must be careful not to issue instructions over the heads of the medical managers.

Other activities

Other activities of the DFP include participating in the district management team, liaising with referral institutions to build relationships and ease referral pathways (inreach!), organising district review forums such as the district perinatal mortality meeting and child health forum, encouraging and participating in systems of continuing education, monitoring of key indicators, and liaising with non-governmental organisations and private practitioners. Education receives prominence in the role of the DFP according to the MTT;² however, in the author’s opinion it is more important for the DFP to check that hospitals have their own educational systems in place, such as regular journal clubs, grand rounds, and mortality reviews, than to try and do a lot of teaching himself. The DFP probably has as much to learn from his clinicians as the other way around.

Support for clinics

Support for clinics is considered a core function of the DFP in the MTT report.² Colleague family physicians in other, more urban districts have concentrated their attention on primary healthcare clinics in preference to district hospitals. However, the question arises as to whether it is more effective for the DFP to support the medical teams at the district hospitals who in turn support their clinics, or try to cover more than 50 clinics with his primary healthcare nurse partner. It is the opinion of the author that while clinic visits should certainly be part of the job, the former option is more achievable and likely to have the greater impact on primary healthcare. The author presently visits one particular clinic every two weeks, to see referred general patients, and those with problems with antiretroviral drug regimes, which alone takes up 10% of his working time, and is probably the minimum he can spend to maintain clinical competency in that environment. Effective clinic work needs rhythm and familiarity. Harmonising the format of medical visits to clinics across the district is likely to be more effective than trying to regularly visit them all in person.

Variation in role according to environment

The role of the DFP will vary with his environment. The priorities in an urban district, of smaller area, with regional and tertiary hospitals, will be different from those in a large rural district with no specialist centres. His role will also vary with the specialist colleagues available in the district. If the DFP is the only doctor at district level, he will inevitably tend to have a primary responsibility for his own discipline.

Effectiveness of approach

While any improvements in service are the result of the efforts of many, it may be mentioned that a number of indicators in Umkhanyakude District have improved since 2008. For example, the number of doctors in the district has increased from 52 to 88 (January 2013), the perinatal mortality rate has fallen from 27/1 000 to 21/1 000, the maternal mortality ratio has dropped from 140/100 000 live births to 99/100 000. The author believes these improvements are mainly due to improved hospital maternal and paediatric care, as a result of better functioning medical teams. In 2008 only two thirds of clinics were receiving at least monthly visits from doctors based in district hospitals, whereas in 2013, all clinics in the district are being visited at least monthly, with most receiving weekly visits, during which doctors see referred patients, and often give teaching to clinic nurses. From this it may be claimed that the approach of the DFP as a physician to his medical teams, at least, in that most important medical principle ‘does no harm’.

Conclusion

The first priority of the DFP must be the organisational health of the district hospital medical teams, who are practising family medicine at the hospitals and clinics in the district, whether or not qualified in the speciality. Without a healthy team, no amount of mentoring or instruction is going to improve the service delivered. The most effective way to assist the team is through collaborative support, especially of the medical leadership.

Conflicts of interest

I declare that I have no financial or personal relationship which may have inappropriately influenced me in writing this paper.