Who gives the best health care?
In 1994 I came back to South Africa from Canada to deliver a paper at a conference in Cape Town suggesting just that. At the time I was working in Labrador, a remote region of mainland Canada that is part of the province of Newfoundland. I worked for the Grenfell Regional Health Services (GRHS) in a salaried position. GRHS was the brainchild of Wilfred Grenfell, a British doctor who came to Labrador in the early days of settlement and dealt with the medical needs of the fishermen in their isolated coastal communities by setting up a health service that was staffed mainly by nurses. The tradition of nurses as the backbone of health provision in this region has remained. The clinic that I worked out of in Forteau was staffed by highly trained nurse practitioners who ran clinics in parallel to my own and provided care for acute and chronic conditions--referring to me where they felt it necessary. They also took first call out of hours. We had a well-equipped laboratory and X-ray facilities, run by a lab/X-ray technician. I referred either to specialists in the GRHS hospital in St Anthony in northern Newfoundland, or to specialists in the larger centres of Cornerbrook or St John's if patients requested. There was also a dental surgery and a dentist visited once a month, with full dental referral to St Anthony where necessary. My own patient population was around 2 500--drawn from the small fishing communities on the southern shore of Labrador.
Further afield, the small, completely isolated communities each had a clinic run entirely by nurse practitioners. These nurse practitioners were covered by a doctor who was based in St Anthony and who visited the clinics regularly to see referred patients. The most northerly community, Nain, sometimes had a dedicated doctor, but more commonly also had access only to nurse practitioners because retaining doctors in such isolation was very difficult.
Without these nurse practitioners this population would have had very little access to health care. But because of the way that the system was structured, two or three doctors were able to look after the population of the whole coastal region of Labrador. The nurse practitioners were highly trained and were able to prescribe acute medication such as antibiotics without referral and to continue chronic medication prescriptions, working to guidelines.
To my mind, the population of these coastal communities were extremely well served, although in the manner of all people, they felt that they should have more! Forteau was on the Quebec border and the Canadian system allows people to cross provincial boundaries for health care. The little town of Blanc Sablon on the Quebec side had a fully equipped hospital, staffed by doctors, with nurses in the more traditional role, and many patients chose to see a doctor in Quebec in preference to a nurse in Labrador. I was never convinced that the treatment they received in Quebec was any better than that provided by GRHS in Labrador. They used to hop from provider to provider, so I had good feedback! I think they also liked the more flamboyant French approach --particularly in emergencies!
The point of this is that a country like South Africa needs to look at a similar system for a number of reasons. Doctor retention in rural and poorer peri-urban areas is poor, even without our own particular problems. This is a global problem. The nursing staff in GRHS were remarkably stable and were drawn mainly from the local population. The doctors were almost entirely from South Africa and Sri Lanka and were far from a stable population. Most were using Newfoundland as a staging post to move to the more populated provinces of Canada.
When I have suggested this route to fellow doctors many are sceptical of the ability of nurses to carry out routine medical care, but the research says otherwise. Nurses will often follow guidelines more closely and are generally better at dealing with minor illnesses than doctors are. They are often better at listening to patients as well! Patients in rural areas will also find that they can identify more closely with nursing staff, usually from their own communities, than they can with doctors who are invariably from outside.
There are many potential pitfalls that we need to be aware of on the road to the NHI system, which I feel is inevitable and indeed needed, in some form or another. Hopefully we can relinquish ideology and use the road as an opportunity to improve health delivery across the population.
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|Publication:||CME: Your SA Journal of CPD|
|Date:||Aug 1, 2009|
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