In the first round, a total of 20 members of the FHT consisting of doctors, AMOs, nurses and pharmacists between the ages of 30 and 47 years old, and eight individuals from the intervention design team (i.e. programme managers: individuals and institutions that participated in designing the EnPHC initiative) aged between 39 and 57 years old were interviewed. In round two, the participants comprised of 35 patients aged 25 to 76 years old (Table 1), and a total of 49 doctors, AMOs, nurses, pharmacists, dietician, as well as 10 others (clerks, attendants, lab assistants), from the FHT teams, all aged 25 to 57 years old. Details of the clinics are in Table 2.
Table 1. Characteristics of patient
Age
|
Sex
|
Ethnicity
|
Education background
|
Occupation
|
Diabetes, hypertension since
|
64
|
M
|
Malay
|
Secondary High School
|
Retiree
|
2011
|
58
|
M
|
Malay
|
Secondary High School
|
Retiree
|
1996
|
53
|
F
|
Malay
|
Secondary High School
|
Housewife
|
2008
|
50
|
F
|
Malay
|
Secondary High School
|
Housewife
|
2014
|
51
|
M
|
Malay
|
Primary School
|
Self-employed
|
2006
|
46
|
F
|
Malay
|
Secondary High School
|
Private Sector
|
2005
|
48
|
F
|
Malay
|
Secondary High School
|
Private Sector
|
2014
|
70
|
M
|
Malay
|
Secondary High School
|
Retiree
|
1994
|
25
|
M
|
Malay
|
Secondary High School
|
Unemployed
|
2015
|
45
|
F
|
Malay
|
Secondary High School
|
Unemployed
|
2017
|
67
|
F
|
Malay
|
Primary School
|
Self-employed
|
2011
|
55
|
M
|
Malay
|
Primary School
|
Self-employed
|
2017
|
63
|
F
|
Malay
|
Primary School
|
Unemployed
|
2013
|
70
|
M
|
Malay
|
Primary School
|
Retiree
|
2006
|
76
|
F
|
Malay
|
Primary School
|
Unemployed
|
1986
|
47
|
F
|
Malay
|
Secondary High School
|
Unemployed
|
2006
|
67
|
M
|
Malay
|
Primary School
|
Retiree
|
2010
|
60
|
M
|
Malay
|
Higher Level Education
|
Retiree
|
2015
|
60
|
F
|
Malay
|
Higher Level Education
|
Retiree
|
1997
|
63
|
F
|
Malay
|
Primary School
|
Unemployed
|
2000
|
41
|
M
|
Chinese
|
Primary School
|
Self-employed
|
2013
|
64
|
F
|
Malay
|
Primary School
|
Housewife
|
2008
|
74
|
F
|
Malay
|
Primary School
|
Unemployed
|
2015
|
46
|
F
|
Malay
|
Secondary High School
|
Public Sector
|
2010
|
59
|
M
|
Malay
|
Secondary High School
|
Retiree
|
2011
|
65
|
F
|
Malay
|
Secondary High School
|
Retiree
|
2002
|
70
|
F
|
Malay
|
Secondary High School
|
Housewife
|
2010
|
64
|
F
|
Malay
|
Secondary High School
|
Retiree
|
2018
|
49
|
M
|
Malay
|
Secondary High School
|
Self-employed
|
2016
|
70
|
F
|
Malay
|
Primary School
|
Unemployed
|
2011
|
60
|
F
|
Indian
|
Primary School
|
Unemployed
|
2010
|
55
|
M
|
Malay
|
Secondary High School
|
Retiree
|
2015
|
49
|
M
|
Malay
|
Higher Level Education
|
Private Sector
|
2016
|
67
|
M
|
Iban
|
Primary School
|
Retiree
|
2009
|
58
|
F
|
Malay
|
Higher Level Education
|
Self-employed
|
2003
|
Participants shared their experiences and perceptions on the FHT implementation, its benefits, shortcomings, and challenges. In general, three themes were identified namely, the implementation of FHT concept, continuity of health care, and quality of health care.
Feedback given by participants were consolidated from both rounds, which encapsulates the similarities in their perception on the FHT implementation. And the findings do not differ between the two rounds.
Generally, there were positive sentiments across the board with respect to the implementation of the FHT concept at the clinics. Challenges in terms of teething issues were inevitable, however, HCP and patients acknowledged its benefits and initiated efforts to adapt to their local contexts.
Table 2. Features of EnPHC intervention clinics
Health Clinic
|
Family Health Team
|
Medical Officer
|
Assistant Medical Officer
|
Nurse
|
Community Nurse
|
Other health personnel
|
Visiting
|
Permanent
|
1
|
2
|
3
|
2
|
7
|
9
|
Family Medicine Specialist, nutritionist, physiotherapist, occupational therapist, Dietitian
|
|
2
|
4
|
12
|
non-zone
|
13
|
5
|
nutritionist, physiotherapist, occupational therapist, Dietitian
|
|
3
|
2
|
7
|
4
|
9
|
7
|
Family Medicine Specialist, nutritionist, Dietitian
|
Physiotherapist, occupational therapist
|
4
|
2
|
4
|
2
|
3
|
1
|
Family Medicine Specialist, nutritionist, physiotherapist, occupational therapist, Dietitian
|
|
5
|
3
|
8
|
3
|
11
|
10
|
Nutritionist, Dietitian
|
Family Medicine Specialist
|
6
|
2
|
8
|
2
|
4
|
non-zone
|
Family Medicine Specialist, nutritionist, physiotherapist, occupational therapist, Dietitian
|
|
7
|
2
|
4
|
3
|
3
|
0
|
Family Medicine Specialist, nutritionist, physiotherapist, occupational therapist, Dietitian
|
|
8
|
2
|
5
|
2
|
non-zone
|
non-zone
|
Nutritionist, physiotherapist, occupational therapist, Dietitian
|
Family Medicine Specialist
|
9
|
3
|
6
|
3
|
5
|
3
|
Family Medicine Specialist, nutritionist, PT
|
|
10
|
2
|
5
|
3
|
7
|
8
|
Physiotherapist, occupational therapist, Dietitian
|
Nutritionist
|
11
|
2
|
3
|
3
|
1
|
2
|
Family Medicine Specialist, nutritionist, physiotherapist, occupational therapist, Dietitian
|
|
12
|
2
|
2
|
3
|
2
|
2
|
Family Medicine Specialist, nutritionist, physiotherapist, occupational therapist, Dietitian
|
|
13
|
2
|
3
|
4
|
13
|
7
|
Family Medicine Specialist, nutritionist, physiotherapist, occupational therapist, Dietitian
|
|
14
|
2
|
4
|
3
|
6
|
11
|
Family Medicine Specialist, nutritionist, physiotherapist, occupational therapist, Dietitian
|
|
15
|
2
|
4
|
2
|
4
|
0
|
Family Medicine Specialist, nutritionist, physiotherapist, Dietitian
|
Occupational therapist
|
16
|
2
|
4
|
4
|
10
|
14
|
Family Medicine Specialist, Dietitian
|
|
17
|
2
|
6
|
7
|
6
|
1
|
Dietitian
|
Nutritionist, physiotherapist, occupational therapist
|
18
|
2
|
12
|
4
|
6
|
9
|
Dietitian
|
Family Medicine Specialist, nutritionist, physiotherapist
|
19
|
2
|
3
|
3
|
3
|
0
|
Family Medicine Specialist, physiotherapist, Dietitian
|
|
20
|
2
|
2
|
3
|
9
|
4
|
Nutritionist, physiotherapist, Dietitian
|
|
FHT implementation
Given that some clinics had already implemented the FDC concept prior to the EnPHC initiative, the FHT concept that was introduced as part of the EnPHC intervention was nothing new to these clinics, as it required no abrupt process adjustments. Where FHT was a new concept, patients had noticed subtle differences in service changes even though they were unable to identify precisely the new FHT service. Although they were unable to describe specifically the changes in services from the FHT initiative implementation, they noticed subtle differences and minor changes from what was present prior to the intervention. This was especially so at clinics where FHT was a new concept. At clinics with pre-existing FDC, FHT was not unfamiliar.
Execution of the FHT concept was preceded by the process of population zoning of the clinic operation area. At the clinics, it was found that the FHT concept facilitates management of patient flow and fair distribution of workload to the teams. Some teams applied a colour coding system for zones to ease identification of patients’ records and files. From the HCP perspective, the FHT concept enables mapping of patient attendance in the clinic operation areas, which assists in better planning of resources. One HCP shared on the process of zoning:
“We looked at the percentage of attendance based on the zones. We studied this [patient attendance by zone] for 2 months and then we divide into teams. In May, we had TOT [training of trainers] by KKM [Ministry of Health]; from there [the TOT session] we planned in more detail for the Enhanced primary health care” (HCP, Round 1)
Another crucial step in FHT execution is the setting up of multidisciplinary teams. One of the key members of the team is the Care Coordinator (CC) who is tasked to ensure coordination in the continuum of care delivered to patients (14). Individuals appointed to carry out the CC role were those with supervisory responsibilities at the clinics. Typically, there are at least two CC in a clinic, corresponding to the number of zones. Other team members typically include doctors, pharmacists, nurses, and assistant medical officers.
It was noted that the execution of FHT concept varied from one clinic to another. The variation can be explained by differences in manpower strength and working space and layout such as consultation rooms at the clinics. These were found to be important elements in ensuring effective implementation of the FHT concept and providing health care efficiently.
It was unanimous that the main overarching issue in the FHT implementation was manpower shortage. Some clinics were provided with additional manpower for the purpose of FHT implementation, whilst others were not as lucky. Some clinics underwent staff reshuffling in order to fulfil the team configuration. Clinic staff voiced their concerns on how clinic functions were affected by the shortage, and some clinics had to settle for fewer zones than what they should have.
Patients shared the same sentiments on manpower shortage and voiced their concerns on the well-being of the clinic staff.
“[We have] Two teams because that is the minimum [number of teams] that should be formed for FDC. We can’t form three [teams] due to lack of staff. Our clinic space is another issue, that’s why we end up with only two teams” (HCP, Round 1)
“I requested for them to add manpower, because I feel sorry for them [clinic staff]. The workload per se, me myself feeling stress when looking at their work burden” (Patient, Round 2).
The other chief complaint amongst HCP and patients was space constraints. Space issues did not allow as many FHTs in the clinics as was desired for patient consultation and related activities. Therefore, this required reconfiguration of the zoning system in some clinics, principally to reduce the number of zones. Despite population size and geographical layout which warranted more zones, one clinic found it necessary to reduce the number of zones to accommodate all teams in the clinic.
Teamwork was not only apparent within teams, but also between teams at the clinics, as evidenced in our findings. A few clinics employed a system where patients from different zones were seen on different days of the week. This allowed the clinics to implement a back-up system where one zone team attended to the patients while the other team helped with administrative and preparatory work for the consultation day, as well as helped ease patient load on busy days.
Continuity of care
In general, HCP and patients concurred that the concept of FHT ensures continuity of healthcare delivered to patients. Patients expressed contentment in seeing the same doctor as the familiarity assures better monitoring of their health status. Familiarity with the FHT members also improved interaction between HCP and patients. With the establishment of rapport between them, patients seemed more willing to share information where health care is concerned, and adherence to clinic appointments were more guaranteed. The HCPs were of the same views that patients were gratified with the trust and rapport built with them. They perceived that patients were more open to disclose information which they were previously not willing to share when they were seeing different HCPs at every appointment before the implementation of FHT. In return, HCPs used the opportunity to familiarise themselves with the patients and their families, and improve management of care provided to them. Personalised care can be optimised for the patients and their families, which was one of the main aims of the EnPHC intervention.
“I’m more comfortable with the nurses because we’re familiar with them, so I feel happier talking, like friends. They are friendly, so I’m not shy to tell them things.” (Patient, Round 2)
“Sometimes, patients don’t like it if the doctors keep changing. There are things that they will not tell. When they only see one [same] doctor, they are more open [to share]. When the doctors keep changing, the patients don’t want to repeat themselves. So, when we’re already familiar with the patients, we know them already, because not all of the patient’s history is written in there [patients’ medical records]” (HCP, Round 2)
We learned that some patients were not contented with their respective zones because the team members they were assigned to were not their preferred teams. This was a concern to the HCPs as it could discourage patients from adhering to clinic appointments and jeopardise continuity of care.
“Patients have said to me “I don't like the zone, doctor”. I explained that they need to adhere to the zoning based on their home addresses. The reason for not favouring the zone is because of the doctor who is a bit strict. So they want to be in the zone with the doctor they like” (HCP, Round 2)
Another challenge faced by the clinics was high turnover of doctors, which has an impact on continuity of care.
“Our staff here change frequently. Since we started with FDC in 2015, at first the Sister retired, then we had a Matron but left [after a short while]. Then we had no Matron for a long time. After some time we had a Sister who then moved away. It was only last year that we really had a Sister. It’s difficult [with these changes] because it makes it difficult to pass over [the task].” (HCP, Round 1)
Quality of care
The FHT implementation has in many ways enhanced clinic workflow through its organised system of zoning. Patients were seen by the HCPs in an orderly manner according to zones. This initiative, which seemed rudimentary to some, had managed to improve quality of care by aiding smoother patient movement within clinic. In addition, with FHT implementation and its multidisciplinary team approach, clinics without Family Medicine Specialists (FMS) are receiving regular scheduled FMS visits. Another benefit of the initiative is the enhanced competency of HCPs. This stems from the involvement of all team members in providing care for patients in their zones, demanding for the need to be competent in managing NCD patients.
“Now since Enhanced (EnPHC), every paramedic, everyone (team members) is involved. Before this, only one person in charge of NCD, so only that person knows inside out and everything [about NCD]. So now everyone has to know [having competency in NCD] because everyone is in charge of their zone” (HCP, Round 2).
Quality of care is also improved through the personalised care approach, which includes appointment reminder calls from clinic staff. This was an initiative by most clinics in their efforts to improve adherence to clinic appointments. Many patients applauded the effort and were appreciative of this.
“Now, nurse will call. ‘Tomorrow at 10 [am] you have appointment with doctor’, she will remind us. It’s helpful, because like yesterday I thought I was supposed to take blood. But the nurse insisted that it was to see the doctor. When I got home from work I checked my [appointment] card and yes, I have to see doctor today” (Patient, Round 2)
One of the chief complaints at the clinics is space constraint, which has resulted in sharing of rooms in most clinics. As a consequence, patient privacy is compromised and clinical examination proved to be challenging, compromising quality of care provided to patients, as shared by one HCP:
“Another issue is rooms… that’s where fundus [fundoscopy] is done, and ECG too. The space is very small for MO [medical officer]. All in one place. And there’s no privacy for the patients. When they do fundoscopy they need to turn off the lights… doctor needs to examine patients, we need to do ECG…. All three at the same time”. (HCP, Round 2)
Despite the many challenges faced at the clinics, HCPs were confident on the sustainability of the FHT concept and considered it as an important component of the EnPHC intervention. This is made easier by the zoning system that is already in place in most, if not all clinics. The zoning system was an initiative which originated from the maternal and child health (MCH) services.
The FHT concept is highly regarded by the HCPs as it ensures continuous, comprehensive, person-centred care for patients. As shared by the intervention design team, FHT is designed with the aim to provide personalised care by a team of healthcare providers rather than just one individual. Leveraging on the strong features of the FHT concept, it would ultimately improve quality of care. This would stem from the greater HCP-patient relationship, resulting in improved sense of belonging of the patients to his/her own healthcare matters.
“When we are doing FDC concept now, we are seeing the same patient. So, usually what I’ll do is that, not only will the patient be seeing HCP in my zone, but I’ll see the patient myself. So, I’ll write the in next appointment to come back and see me. So, continuation of care, automatically we will know, because we’ll be seeing the same patient for the past I think like nearly 1 year” (HCP, Round 2)
“[Before EnPHC] one nurse has to take care of 300 patients, so how are they [patients] going to be personalised? So it should be that team [FHT]. In EnPHC, team will work together for personalised care” (Intervention design team, Round 1)