The South African health system is struggling with many challenges including financial constraints, a high burden of disease, a relative scarcity and maldistribution of healthcare professionals, crumbling infrastructure, inadequate health information systems, limited electronic medical records and problems with the supply of medication and other items in some areas.

There are also complaints about the quality of primary care and skills gaps at our rural and district hospitals.

Within this challenging landscape, the family physician stands out as one of the missed opportunities to strengthen our ailing health system.

South Africa created a new speciality of family medicine in 2007 and the specialist in family medicine is called a family physician. Family physicians are trained over four years, as with all other specialists, to work in district hospitals and primary healthcare. They are medical generalists and focus on the whole person, rather than just a particular part of the body or biological system, as is the case with hospital-based specialists.

They expect to see people of all ages and to appropriately manage any health problem at the district level of care. They are trained in all the surgical, anaesthetic and obstetric skills appropriate to a district hospital.

In primary healthcare, they often emphasise the need to promote health and prevent disease as much as to treat illness and disease. They may also support palliative care and rehabilitation in the community.

South Africa relies on undertrained and poorly equipped health workers to deliver care on the frontline. Nurse practitioners, who consult 80% of people in our clinics and health centres, only receive one year of additional training to function as clinicians, and sometimes not even this.

Community health workers are lay people who receive basic training to work in local communities. Even our medical officers and general practitioners are not required to have any additional training beyond what they received as undergraduates and interns.

The family physician can bring much-needed expertise to this team to raise the quality of care, increase patient safety and bring a comprehensive service closer to the community.

The South African Academy of Family Physicians is calling on the government to make better use of family physicians. Our 10-year goal is to have one family physician at every district hospital, every community health centre and every sub-district (that does not have a community health centre).

To achieve this, we need to double the number of training opportunities for doctors to specialise in family medicine. This will help ensure that 70% of them successfully complete the training and that they are retained in the public sector. On average, each province needs to create four to five family physician posts per year for 10 years.

District clinical specialist teams

Despite the availability of family physicians, many provinces have not invested in them. An exception is the Western Cape where most district hospitals and community health centres now have family physicians, often more than one.

National strategy and policy on human resources for health has misunderstood the roles of family physicians and calculates the numbers needed on the basis of inappropriate assumptions.

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In 2012, the Department of Health introduced district clinical specialist teams to improve maternal and child healthcare in every district. These teams included a family physician and created the opportunity to employ a family physician in each of South Africa’s 52 districts.

Although this provided much-needed posts, the initiative misunderstood their contribution. Family physicians should be employed at facilities in the district and not just as part of a higher-level team. They are also trained to be generalists and their focus is not limited to one health programme, such as maternal and child health.

Added value

In our recently published national position paper on the contribution of family physicians to public sector district health services, we elaborated on the threefold contribution that they make.

• First, they are clinicians who bring additional expertise to the team in primary care and district hospitals. They can help the team manage more complex patients. For example, people with multiple diseases (such as HIV, TB and diabetes) or complications of their disease.

This can also prevent the need to refer patients to the next level of care, saving money and time for both the patient and the health system.

In addition, they act as a consultant to the team. This means that nurse practitioners and junior doctors can ask them for help or to see a patient, without having to refer the person elsewhere. In the district hospital, family physicians help the team offer a full package of services and bridge the gaps that are common in surgical, anaesthetic and obstetric care.

• Second, family physicians are trained to build the capability of the rest of the team. They may do this through direct supervision or demonstration, support for clinical decision-making, as well as teaching and training. Having a family physician present may also give people the confidence to practise their skills, knowing there is someone to help if this is needed.

Many students are placed in district health services and family physicians are ideally equipped to organise and provide training. This includes training of medical students, clinical associates, interns as well as registrars. All South African interns are obligated to spend six months in family medicine and primary healthcare and the family physician can be key to ensuring the success of this.

• Third, family physicians are trained to lead clinical governance. This means putting in place systems to improve the quality of care and patient safety as well as the implementation of such systems. Family physicians may help design and implement new guidelines, audit the quality of care and provide feedback, or facilitate learning from clinical management where a poor outcome could have been avoided (so-called morbidity-and-mortality meetings).
• They may help the team reflect on its use of laboratory investigations or medication, or help analyse and interpret routinely collected data on service delivery.
• The focus is often on improving the system of care as much as the quality of care for specific diseases. For example, improving the coordination of care between primary care and hospital or ensuring that the model of care is more comprehensive.

Community-oriented primary care

One aspect of clinical governance that is particularly important is shifting the focus of primary healthcare services from only the people who attend a clinic to include the whole population served by that facility.

By focusing on the whole community, health services can give more effective attention to health promotion, disease prevention and early diagnosis. This is called community-oriented primary care and was introduced as part of health system reform some years ago.

Although many communities have community health worker teams to implement community-oriented primary care, there are many problems. Family physicians are trained to support the implementation of community-oriented primary care, clinically support the community-based teams and build the connections that are needed to engage with communities and broader stakeholders.

Family physicians improve the cost effectiveness of the health system and should be a rational investment. Cost effectiveness is improved by reducing the need to refer to more expensive hospital care and to transport patients.

Many provinces are facing enormous costs from litigation and are struggling to prevent or defend such claims. A doctor recently informed me that in one province most claims in district hospitals were from maternal care, and that the only defendable claims were from hospitals with family physicians. Claims can run into tens of millions of rand.

Family physicians may also reduce the number of visits needed to reach a diagnosis, reduce duplication and waste of resources.

Given the many benefits of including family physicians in the primary healthcare and district hospital teams, it is surprising that most provinces have so far missed the opportunity to strengthen their services in this way.

Decision-making on the use of resources largely rests with the provincial governments and their departments of health and we call on them to make better use of family physicians. DM/MC

Prof Bob Mash is a family physician and the executive head of family and emergency medicine at Stellenbosch University. He is the president of the South African Academy of Family Physicians, the professional body for family physicians.