Abstract
BackgroundEffective primary health care requires a workforce of competent medical generalists. In South Africa nurses are the main primary care providers, supported by doctors. Medical generalists should practice person-centred care for patients of all ages, with a wide variety of undifferentiated conditions and should support continuity and co-ordination of care. The aim of this study was to assess the ability of primary care providers to function as medical generalists in the Tygerberg sub-district of the Cape Town Metropole.MethodsA randomly selected adult consultation was audio-recorded from each primary care provider in the sub-district. A validated local assessment tool based on the Calgary-Cambridge guide was used to score 16 skills from each consultation. Consultations were also coded for reasons for encounter, diagnoses and complexity. The coders inter- and intra-rater reliability was evaluated. Analysis described the consultation skills and compared doctors with nurses.Results45 practitioners participated (response rate 85%) with 20 nurses and 25 doctors. Nurses were older and more experienced than the doctors. Doctors saw more complicated patients. Good inter- and intra-rater reliability was shown for the coder with an intra-class correlation coefficient of 0.84 (95% CI 0.045–0.996) and 0.99 (95% CI 0.984–0.998) respectively. The overall median consultation score was 25.0% (IQR 18.8–34.4). The median consultation score for nurses was 21.6% (95% CL 16.7–28.1) and for doctors was 26.7% (95% CL 23.3–34.4) (p = 0.17). There was no difference in score with the complexity of the consultation. Ten of the 16 skills were not performed in more than half of the consultations. Six of the 16 skills were partly or fully performed in more than half of the consultations and these included the more biomedical skills.ConclusionPractitioners did not demonstrate a person-centred approach to the consultation and lacked many of the skills required of a medical generalist. Doctors and nurses were not significantly different. Improving medical generalism may require attention to how access to care is organised as well as to training programmes.
Highlights
Effective primary health care requires a workforce of competent medical generalists
Effective primary health care is an essential part of any successful health system and strengthening primary health care is a priority in South Africa especially with the huge burden of disease [1, 2]
According to the World Health Organization (WHO) one of the key reforms required of primary health care is to become more people-centred and to move away from a focus on selected diseases and vertical programmes [4]
Summary
Effective primary health care requires a workforce of competent medical generalists. In South Africa nurses are the main primary care providers, supported by doctors. In South Africa clinical nurse practitioners (CNPs) became the main primary care providers (PCPs) because of the shortage of doctors [7] and in order to reduce healthcare costs [8]. Primary care facilities include community health centres and clinics. Community health centres are larger facilities in metropolitan areas or towns and have a broader range of services offered by a multidisciplinary team that includes CNPs and doctors. In South Africa the main medical generalist is a nurse supported by doctors
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