Family physicians and district health system

Albert Lee 李大拔

HK Pract 2019;41:57-59

Majority of health problems have their originals in community.¹ If those health problems cannot be well managed in community setting (primary health care), they can then become more complicated and serious ending up in secondary care causing long waiting time at Accident and Emergency (A&E) services and Specialist Out-patient appointment time, and also overcrowding the in-patient wards. If primary health care lacks the resources and support to provide comprehensive, holistic and co-ordinated care, it can only provide episodic care. Our citizens will then have immediate desire to have more clinical services from hospital setting for treatment and they might not perceive the importance of primary health care system.

The key philosophy for investment in primary healthcare development is to enable the hospital services sustaining the high quality of care. Primary health care should not be just extension of hospital care to community, and it should focus to fulfil the unmet needs of community-based care. The model should focus on how to equip the patients and the carers with support to manage their illnesses in their home environment so their clinical conditions would be more stable to avoid unnecessary hospital and/or A&E admission. One should also aim to focus on their day to day living rather than another conventional medical care model.

Patients with chronic illnesses usually have multiple health problems, multi-morbidity under the care of different specialties in hospital setting. Patients as well as hospital specialists always have a question in mind how primary health care would manage those chronic illness patients notwithstanding the inputs from multi-specialities. It is important to understand that the complexity of multi-morbidity management requires more than an ‘assess-and advise’ model of care.² Primary healthcare professionals help patients navigating the complexity through comprehensive and holistic care with good co-ordination of care essential to patients’ needs, which is at the heart of primary health care. Patient-centred care is to enable patients’ accessibility to professional inputs from different disciplines at different stages of clinical pathway according to their needs and clinical circumstances. Supporting patients to adopt behaviours across a wide range of lifestyle factors for management of their underlying conditions is very much needed but there is little guidance how to achieve these recommendations.³ Therefore, it is NOT the question which specialists the patients need, and it should be whether the patients can have a specialist team to assess their needs continuously and co-ordinate the best possible care for them.³ Family physicians (FPs) supported by effective primary health care system can be the specialist team in community setting to assume the role in balancing contributions from several narrower specialties, advise on different management plans and helping patients to make decisions meeting their health needs. However, majority of FPs in Hong Kong are operating as solo practitioners. It lacks an infra-structure of quality primary health care to enable FPs to provide comprehensive, whole person and continuing care for their patients.

The concept of District Health Centre should closely integrate with local FPs as one stop professional services hub for better health covering primary, secondary and tertiary prevention.⁴ For primary prevention, it should conduct health promotion activities to enhance community action and capacity and capacity to positive health and avoid exposing to health risks according to local need. Family physicians would contribute to decide the needs as they are usually the patients’ first encounter in health care system. The District Health Centre can provide well-trained health promotion practitioners to empower and monitor health behaviours of local residents and also health promotion actions of the community. For secondary prevention, it should help FPs to identify those with chronic illnesses at risk of hospital admission apart from usual screening services. For tertiary prevention, chronic disease management plans can prevent further deterioration of chronic health conditions and restore usual functional capacity as far as possible. The District Health Centre would also work hand in hand with FPs in “quandary prevention” to prevent side effects of medical intervention by close monitoring of patients with long term health conditions requiring long term treatment.

The District Health Centre with virtual integration with services of FPs can serve as one stop professional services hub for better health coverage of primary, secondary, tertiary and quandary prevention. This will truly evolve a seamless health care model to maintain care in community. Enhanced community care initiated by hospital setting cannot serve the purpose so patients end up returning to hospitals. In fact, we need a District Health System and NOT just a District Health Centre in order to fulfill the key objectives:

1. Cover the different tiers of prevention (primary, secondary, tertiary and quandary)
2. Personalise patient management in addressing the complexity of their health conditions/issues
3. Meeting patients’ needs with desired outcomes and
4. Preventing and delaying disease or disease progression through individual and population-based approaches.

Service Scopes can range from:

1. Individual and group counselling and/or health interventions
2. Self-management and empowerment training, activities to maintain health and well-beings.
3. Joint case management approach with FPs as required

There are challenges in making District Health Centre a success such as:

• Needs to shift the concept from enhancement of healthcare to community to truly develop a distinct district health service mode with engagement of key stakeholders in community
• It should be bottom up approach from community healthcare providers such as FPs as well as users (local residents) rather than top-down approach from hospital and/or government
• Adequate training for primary health care practitioners to understand the philosophy of primary health care as well as concept of trans-disciplinary care
• Needs to have sufficient inputs from the operator of District Health Centre and local medical and health practitioners for planning the infra-structure of Core Centres and Satellite Centres as well as services development meeting the needs of the community
• Subsidy and co-payment system should match with the socio-economic status of potential users

The organisation operating the district-based primary care needs to have the following attributes:

• Understanding of the local needs
• Experience in engaging the local community especially local FPs and other healthcare professionals
• Experience in establishing a cross-disciplinary team for community-based care
• Professional support from experts in primary health care
• Good working relationship and partnership with hospitals and FPs in localities
• Experience and also facilities for outreaching and also establishing services at peripheral centres in the district
• Expertise in building “Medical-Welfare-Community” model and able to support physical and psychosocial needs of residents with chronic conditions
• Professional support from experts in evaluation and audit of care for continuous quality improvement

It can be quite puzzling for FPs to see themselves working with a District Health Centre. It would create a wrong impression that there is just another community health centre. In fact, the current operation of District Health Centre comprising of one core centre and few satellite centres serving the local population is not simply clusters of health centres. It aims to become a service hub promoting the holistic health of the population. However, the current framework hinders the dynamics of transformation of healthcare with greater emphasis on primary health care. The mission should be broader and visionary to evolve a District Health System to fulfill the gaps of primary health care services being accessible, available, affordable and assurance of quality helping FPs to deliver holistic, comprehensive and whole person care. The concept of District Health System not only has the dynamics of active engagement and involvement of FPs to improve the existing services in primary health care, and also the broader vision to promote the health of the local population.