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Tue 21 Oct 2008 04:00 AM

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The primary problem

The UAE is looking to unclog its overloaded emergency departments with long-term solutions.

The United Arab Emirates is in the grip of a primary care revolution. Jo Hartley reveals the schemes set to unclog overloaded emergency departments and deliver long-term health solutions to a growing population.

Overloaded emergency departments are a familiar problem in the United Arab Emirates (UAE). Many people see A&E as the natural port of call for any ailment or complaint, whether it's a true emergency or not.

But this cultural norm is on the way out, with city-to-city initiatives aimed at persuading, cajoling - and in some cases forcing - people with aches, pains and chronic diseases to visit a family doctor instead; and to keep going back to them for continued care.

Family care medicine meets 95% of a patient's needs, from pediatric care to geriatric care.

It's a significant step in the thinking behind the UAE's health service delivery, and one that mirrors the approach more developed healthcare systems have followed for years.

In the UK, general practitioners (GPs) have been seen as the gatekeepers to free, state-run hospital care for more than 60 years. In the US, a shift to a primary care-led health system was made under the Clinton administration in a bid to cut escalating healthcare costs.

Across the Middle East, soundings on the importance of developing community-based services have grown louder. Last June the Gulf Cooperation Council concluded that 20% of all doctors in its six member countries should be trained as specialists in family medicine over the next 10 years to meet demand.

For the UAE, which, at 6.1% last year, boasts one of the world's fastest growing populations, time is of the essence. The question is; is the country's primary care system up to the job? Are the necessary facilities, staff and equipment in place to meet demand, and how will the public take to the changes?

From cradle to grave

Primary care is itself a wide reaching concept. Described as the ‘medical home' of patients; it is a place that should provide continuous and integrated care for a broad spectrum of ailments and diseases - and ideally over a person's entire lifetime.

Traditionalists believe the beating heart of this system is the family physician and his or her staff, whose purpose it is to establish a solid and lasting relationship with their patients.

It is a model that makes medical sense, says Dr Ali Khalili, acting chair of family medicine at Sheikh Khalifa Medical City (SKMC) in Abu Dhabi, as it promotes well-planned care by a doctor familiar with the patient's medical history.

"Family care medicine meets 95% of a patient's needs from paediatric care to geriatric care," he says. "People want to have the same physician; it is like seeing an old friend rather than a new one."

Dr Omar Al Jabri, president of the family medicine arm of the Emirates Medical Association agrees: "Family medicine has its own characteristics - namely continuity of care - where each doctor has their own group of patients, coordinates care and provides a holistic type of care for them."

It is more convenient for patients and makes economical sense too, says Simon Hodges, senior advisor to the Dubai Health Authority transition team. "Family healthcare is a more efficient setting from a patient point of view as well as government."

Economics show it is far cheaper for a patient to visit a GP and be referred on to an expensive specialist if necessary, than for a patient to refer themselves. It costs about US$35 for a family doctor to treat a case of conjunctivitis, for example, while a specialist will charge up to $600.

"If you look at most healthcare systems, most insurance companies would like people to use a gatekeeper because medically and economically it makes much more sense," Hodges argues.

The preventative arm of primary care medicine has big benefits too, as it lessens the need for higher-cost surgical or medical interventions later on, he adds. "Even if someone comes in for a cold, as a GP part of your remit is to include [preventive] screening and health promotion."

Primary moves

In Abu Dhabi, the move to a fully-fledged primary care led service is well underway. The shift in thinking began three years ago, but took off in September last year after the Abu Dhabi Health Services Company (SEHA) took charge of government health services as part of a move to mandatory health insurance.

The move allowed the public the choice of private or public healthcare, and the resulting competition has forced the larger government sector to look long and hard at the services it offers.

In response, SEHA established a subsidiary body called Ambulatory Healthcare Services (AHS), which was charged with developing Abu Dhabi's underused primary care sector. At the time, the general public had little confidence in being treated outside hospitals and so religiously visited specialist doctors instead, recalls Dr Khalili.

"For a long time patients had difficulty trusting the physicians because they were hopping from clinics to clinic, with very little patient advocacy. The problem was they were just getting a lot of episodic care," he explains.

In a bid to boost public trust in government-run clinics, the AHS began a five-year redevelopment programme of all 35 of its primary care clinics. The scheme plans to turn them into high-tech ambulatory care centres that offer traditional family medicine, topped up with screening programmes such as mammograms, day surgery, urgent care and a long list of specialist-led clinics, reveals AHS director Dr John Evangelista.

"The clinics are a one-stop-shop where you have primary healthcare doctors such as GPs and family medicine physicians, specialists, an imaging department and operating theatres,' he says. "The whole idea is to offer specialist services within the clinic, because all the things that were traditionally done in hospitals can, with advancements in medicine, now be done in outpatient [centres]."

Four of AHS' existing clinics have already been revamped and 11 more will be refurbished in the coming year. However, Dr Al Jabri fears that such centres are missing the point of good family medicine. Primary health centres are tuning into mini-hospitals. he warns. "It is confusing for the patients because they do not see a proper model of family medicine."

Continuity of care, in practice, is difficult too, admits Dr Khalili, who runs the four primary care centres aligned with SKMC. Patients are not guaranteed an appointment with their chosen doctor. "We aim right now for 40 to 50% of the time," he admits.

The issue often boils down to old-fashioned appointment systems. Dr Khalili is hopeful a new electronic appointment system, currently under construction, will boost the proportion of matched consultations to 80 or 90% of the time.

Open access

In Dubai the road to a fully integrated primary care system is less travelled, but it is now being paved. As one of the most rapidly expanding emirates, home to an estimated population of over four million by 2017, primary care is an area, the government has recently acknowledged, in need of urgent attention.

Driving the changes, says Hodges, is the need to increase access to care for the growing number of expatriate labourers in the city. Many currently go without medical treatment due to the expense. Edging this group into mainstream healthcare will be propelled by a new mandatory health insurance scheme requiring all employers to pay an annual fee for each of their employees.

This money will then be redistributed by the government in annual lump sums to designated outpatient care centres (OPCs), Hodges explains, which will provide basic healthcare to all for a minimal visit fee of AED25. "It's for those that have very little. We're trying to bring the standards for those people up to those the government require."

DHA is in the process of assessing Dubai's 500 primary care facilities to decide those with the potential to become OCPs. However, there is a still a large question mark over how many private practices will agree to become designated centres.

Dr Ottmar Schmitt, director of marketing and public relations at Welcare World Health Systems, says the company is reluctant to expand its primary care facilities until the government reveals how much OCPs will be paid per registered patient. "The problem is we are a private entity and we need to look at the costings first. We are not in the position to offer consultations for AED50."

Dr Carole Chidiac, medical director of French Medical Clinic, is keen to expand but has refrained from making firm plans until she knows what fee clinics will be paid. "I have a plan to expand but the expense in Dubai and not knowing what we will be paid in the new system is holding me back," she admits.

Medical manpower

Another barrier facing the expansion of primary care across the UAE is the ongoing difficulty in recruiting well-qualified primary care staff. At present, there are 1,300 doctors working in primary care, of which just 300 have internationally recognised Arab board or MRCGP qualifications in family medicine, Dr Al Jabri reveals.

He predicts the number of doctors needs to double, with at least 1,000 having a recognised postgraduate certificate, to match the demand for primary care. "We need to have 1,000 trained family doctors as a basis, to have a good model of general practice, and after that we can build up," he believes.

But rising living costs and expensive rents are leaving clinic owners struggling to find doctors within their budgets, warns Dr Chidiac. "I am looking for a GP in India at the moment and am offering $5,000 per month, plus incentives, which would allow them to double their salary, but I have been told that is too little."

AHS' Dr Evangelista is also suffering from hiring difficulties. He is in need of 30 family doctors, 25 medical technicians, 25 imaging technicians and 200 nurses, some of which he expects to recruit from neighbouring Arab countries, India and the Philippines.

"The recruitment process is very slow and quite difficult worldwide," he says. "We have to make it competitive and, from what I know, we are compared to other Middle East countries."

Another option is national training schemes to tempt more doctors to become family physicians. However, a 20-year-old initiative to do this has ground to a halt. The UAE still only the capacity to train 36 medical graduates in family medicine per year, laments Dr Al Jabri. "Abu Dhabi had 20 applicants to the programme, but is taking just four to six because of a shortage of trainers," he explains.

As a result, the bulk of primary care doctors working in the UAE are traditional GPs who left medical school and went straight into practice, without any postgraduate education. It's a situation that has led to a lack of public confidence in family doctors and that has encouraged patients to seek out hospital care instead, acknowledges Dr Khalili.

Patient persuasion

However, opinion is changing. "Patients would just go straight to the hospital when I came eight years ago," he remembers. "But that has changed. Over the last number of years a large number of family doctors take care of the majority of the patient's problems. And if we encounter something beyond our speciality then we send them to a specialist clinic," he adds.

Patients are also voting with their feet for the new ambulatory care centres in Abu Dhabi. One clinic in Bain al Gasneen saw a trebling of patients in the month after it opened its doors, notes Evangelista. "People have more confidence [as] it looks smart, more modern and more spacious."

DHA advisor Simon Hodges believes the same will happen in Dubai once the system has bedded down and people learn to expect high quality care from OCPs. "We believe it will lead to an improvement in quality for the healthcare system overall," he says, "Clinics will get a relationship with their patients and...they will, as part of their improved services, be looking to plan an improved life for that patient."

Evangelista concedes that competition between the public and private sectors is also forcing quality improvements in primary care. AHS, for example, is establishing dermatology clinics that not only deal with pathological disease but with cosmetic procedures; something traditionally more in tune with the private sector.

Still, in the rush for more business, warns Dr Al Jabri, providers must not lose sight of the true value to patients of being cared for by well-trained clinicians within the family medicine model. He fears that the benefits of true primary care may never be realised in the UAE.

"Investing in primary care is the way to go as it is the most efficient and effective way to do healthcare," he tells MT. "But most of what's gong on now is not family medicine, because [patients have] fragmented care."

THE FACTS: Primary care in the UAE exposed

• There are 1,300 doctors working in primary care at present.

• There are 300 primary care doctors with postgraduate qualifications in family medicine.

• There are 36 postgraduate training places allocated to family medicine.

• Local authorities are recruiting problems due to high costs of living.

• There are uncertainties in Dubai's private sector over the financial worth of the OCP plan.

• The population is growing at 5.6% a year.

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