CPD Article

The contribution of family physicians and primary care doctors to community-orientated primary care

Robert Mash, Bernhard Gaede, Johannes (Jannie) F. Hugo

Received: 10 Feb. 2021; Accepted: 15 Feb. 2021; Published: 10 Mar. 2021

Copyright: © 2021. The Author(s). Licensee: AOSIS.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

South Africa envisages a community-orientated approach to primary health care (PHC). Family physicians and primary care doctors have important roles to play in leading, implementing, supporting and maintaining community-orientated primary care (COPC). In this article, we define COPC, its key principles and approaches to implementing it in health services. Following this we describe the key competencies expected of family physicians and primary care doctors in leading and supporting its implementation; providing clinical support to the PHC teams and linking these teams to other parts of the health system, other sectors and the community. The required knowledge and skills underlying these competencies are also discussed and some specific tools included.

Keywords: primary healthcare; primary care; community orientated primary care; population health management; family physicians; general practitioners; primary care doctors.

Introduction

The primary health care (PHC) system in South Africa is organised around a commitment to community-orientated primary care (COPC).¹ This means that family physicians and primary care doctors have important roles to play in leading, implementing, supporting and maintaining COPC. For many doctors this will require some re-orientation and development of new competencies.

The move towards COPC was driven by a desire to address the health needs of the whole population and not just those that access primary care facilities, with an emphasis on health promotion and disease prevention for both individuals and communities.¹ South Africa invented the concept of COPC in the 1940s and exported it around the world.² In many ways COPC embraces the core principles of a PHC approach as described in the Astana Declaration.³ Such an approach can be very cost-effective with the resources available in South Africa.⁴ The PHC performance initiative also describes population health management and primary care as key aspects of effective service delivery.⁵

This commitment to a COPC approach is seen practically through the widespread implementation of ward-based outreach teams (WBOT).¹ This means that each geographically defined ward or similarly delineated community has a team of community health workers (CHWs), led by a nurse and supported by a primary care doctor. As we move forward to the implementation of national health insurance, each contracting unit for PHC will need to accredit both community-based and facility-based services in a COPC framework.⁶ At this point all practitioners, whether in the public or private sector, will need to understand COPC.

What is community-orientated primary care?

Community orientated primary care has been defined as a continuous process by which PHC is provided to a defined community on the basis of its assessed health needs, by the planned integration of primary care practice and public health.⁷

The need for this type of integration has also been highlighted by the response to the coronavirus pandemic – where PHC teams were instrumental in home delivery of medication,⁸ community screening and testing⁹ as well as in the future vaccinations. It differs from other approaches to healthcare delivery in that it explicitly makes the link between clinical services to individuals with broader interventions at the community level. Community interventions may be in household, working, learning or social spaces.

Nine key principles of COPC have been identified in the African region (Table 1).¹⁰

The process of analysing local health needs and assets, prioritising those needs, planning interventions and evaluating them can be seen as a COPC cycle (Figure 1). Community and stakeholder participation in this process is also essential. In the African context COPC most often involves CHWs as illustrated by our WBOTs.

FIGURE 1: The community-orientated primary care cycle.

The practical implementation of COPC has been articulated in a variety of settings locally and internationally.¹⁰ It has been used in both high- and low-income countries, in rural and urban communities and at times with interventions that have a particular focus such as homeless people, or follow-up post cardiac surgery.^10,11 In South Africa large projects are being implemented amongst others in Gauteng and Cape Town. In Cape Town, for example, a 10-point framework for implementation of COPC has been adopted as shown in Figure 2 and Table 2.¹² A number of training manuals on how to implement COPC have come out of the Tshwane experience^13,14,15 as well as a special collection of research studies.¹⁶

FIGURE 2: Elements of the framework to implement community-orientated primary care in Metro Health Services, Cape Town.

Roles of the family physician and primary care doctor

Many of the roles and competencies around COPC stretch beyond the clinical role. However, this does not negate the need for high-quality clinical services to be provided and supported. In fact, the provision of a clinical service offers powerful opportunities to transform and build stronger links with health promotion and disease prevention strategies at the household and community levels.¹⁷

Lead and support the implementation of community-orientated primary care

The current policy direction is supportive of developing COPC approaches at primary care facilities. Family physicians are often located in districts, district hospitals, sub-districts and community health centres where they can help lead the implementation of COPC with local decision makers and implementers. Primary care doctors are also in a position to help with this for the community they serve from their facility or practice. Regardless of where they are based, their responsibility stretches beyond the walls of the institution.

Practically speaking this may involve the following activities:

• Explaining the principles of COPC to other healthcare workers and managers
• Collaborating with the local management team to plan and implement COPC
• Assisting with the interpretation of data on the community’s health assets and health needs.¹⁸
• Assisting with the prioritisation of health issues in the community.¹⁸
• Assisting with the planning of responses or interventions to address these health issues in the community.
• Participating in the implementation of these responses or interventions in the community.
• Assisting with the evaluation of these responses or interventions.
• Advocating for vulnerable and neglected individuals, or communities within the population served by the healthcare team.

Underlying these competencies is a need to understand and embody COPC principles, to build relationships with key role players, to analyse and interpret data, to facilitate prioritisation processes such as the nominal group technique (see Box 1), to facilitate rational planning processes and design of interventions as well as plan their evaluation. Design of projects may require the ability to clarify the logic behind the project that is expected to lead to change (see Figure 3). Such a logic model can be used to plan evaluation of the intervention. Implementation science may be of particular use with a mixed-methods approach to evaluating a range of implementation outcomes (see Box 2).¹⁹ Mixed methods implies the collection of both quantitative data (e.g. routinely collected, a simple survey) as well as qualitative data (e.g. interviews) to evaluate implementation. In addition there will be measures of the expected effects or effectiveness (outputs and outcomes) that need to be collected, although these may take longer to change.

FIGURE 3: A logic model approach.

Provide support to the primary healthcare teams in your community

As a clinician you will be used to providing support to more junior doctors, nurse practitioners and others in your facility. With a COPC approach such support extends to the community-based nurses and CHWs. Community health workers may refer patients to you for help in the facility or in the community. At times this may necessitate a home visit to support the PHC team if, for example, the patient is complicated and housebound.²⁰

Family physicians usually take responsibility for leading clinical governance along with the rest of the team.²¹ Clinical governance focuses on the quality of care and patient safety. In a COPC approach, this responsibility extends to the whole PHC team and not just care in the facility. It therefore includes the clinical governance processes for the care in the home, the quality of the referral system and the inclusion of services such as rehabilitation or palliative care. Clinical governance activities may include:

• Training of other healthcare workers
  • For example, training CHWs in use of personal protective equipment or screening for the coronavirus disease 2019 (COVID-19), responding to problems or challenges that arise from practice
• Clinical audit and feedback
  • For example, quality of active surveillance for tuberculosis (TB) in the community²²
• Facilitating reflection on health information
  • For example, the analysis of household assessment data collected by CHWs²³
• Implementation of new guidelines
  • For example, how CHWs can calculate cardiovascular risk with non-laboratory data²⁴
• Review and appraise new evidence for the team
  • For example, value of home delivery of medication by CHWs²⁵
• Participating in research to address questions that arise from practice
  • For example, what is the role of CHWs in non-communicable diseases

These activities also imply a wide range of underlying knowledge, skills and attitudes. Creating a learning environment is important to continuously improve and to train or teach effectively.²⁶ The ability to analyse and interpret data, appraise evidence and sometimes create new evidence is also key.

Link the primary healthcare teams to the rest of the health system, other sectors and community

The family physician and primary care doctor should pay particular attention to the coordination of care within and between PHC teams. For example, help in building a strong relationship between facility-based and community-based members of the PHC team, to coordinate care for the patients. The introduction of home delivery of medication by CHWs during COVID-19, for example, necessitated much closer cooperation between clinicians, pharmacists, nurses and CHWs.⁸

Family physicians and doctors may also be a strong link between the PHC team and the local district hospital, or higher levels of care. Multidisciplinary ward-rounds can include members of the PHC team and improve coordination of care for patients as well as improve the understanding of the hospital teams in the context of the community. It is important that each hospital, health centre and clinic has a specific plan to link COPC practice to care in the institution. This is in the form of care-coordination ward rounds, multidisciplinary patient and family discussions, well-structured referral letters, discharge summaries and patient retained records. In some hospitals a team of CHWs and a WBOT team leader works full time in the hospital to facilitate the coordination of care. This should be facilitated and supported by the family physicians and other doctors.

Family physicians and doctors should also use their leadership positions to build relationships with other sectors, particularly social services. Health and social services often go hand-in-hand and require mutual linkages and collaboration. Other sectors may be important depending on the prioritised needs of the community. For example, concern for illegal circumcision schools or crime and violence may need links to the police and neighbourhood watch, whilst concern for teenage pregnancy may need links to the educational sector. As mentioned above, this often involves a range of advocacy skills.²⁷

Family physicians and doctors should also use their leadership positions and authority to build relationships with formal and informal community structures. Participating in local community health forums may enable community engagement and participation in the COPC cycle.

Whilst such coordination and relationship building is not the sole responsibility of the family physician or other doctors, they are in a powerful position to offer leadership alongside managers and senior health professionals.

Conclusion

South Africa has moved towards a COPC approach to providing health services, which has tremendous potential for improving the health of communities. Family physicians and primary care doctors need to understand and embody the principles of this COPC approach so that they can help lead the health services in this direction. They will also need to provide clinical support and clinical governance to the whole PHC team engaged in COPC. They can also be instrumental in coordinating care within and between levels of the health system, supporting community and stakeholder engagement. These various roles and activities require an expanded knowledge base and skills-set, beyond the traditional clinical roles.

Acknowledgement

The authors have declared that no competing interests exist.

R.M. wrote the initial draft, which was revised and edited by B.G. and J.H. All authors approved the final version.

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.

References