The United Kingdom is taking immediate steps to bring newly graduated and foreign-trained doctors into the health system as cases of the new coronavirus spiral. Could South Africa do the same before the health system becomes overwhelmed?
COMMENT
Across the world, healthcare workers are putting themselves on the frontline. But in South Africa, the Health Professions Council of South Africa (HPCSA) may not have yet given them all the tools they’ll need to win the fight against COVID-19.
On social media, doctors post pictures of exhausted colleagues and recount heartbreaking tales: In the United States, a dying mother is forced to say goodbye to her children via walkie talkies from inside an isolation ward. In Canada, workers recount intubating a 24-year-old father knowing that the final words he utters before succumbing to sedation may be his last.
Chris Hopson heads up the body that represents hospital administrators under the United Kingdom’s publicly funded healthcare system, the National Health Service (NHS). In March, he told CNN that London was facing a “continuous tsunami” of coronavirus patients.
Doctors in the country’s capital had one piece of advice for colleagues who have yet to be inundated with coronavirus cases:
“Do the preparation, because without it you won’t be able to cope.”
The tsunami hasn’t hit yet, but waves are likely coming
We know that healthcare workers are more exposed to the new coronavirus because of the nature of their jobs, but we don’t yet know whether they are at a higher risk of developing severe COVID-19 disease. We do, however, know from experiences across the world that some of our healthcare workers will become sick or even die during the outbreak.
Shortages of workers mean that infectious healthcare workers might need to remain at work when they should be at home recuperating or self-isolating. Research published in the New England Medical Journal Catalyst suggests that because of this, Italian healthcare workers likely played a significant role in spreading the COVID-19 in hospitals.
South Africa needs to anticipate worsening health worker shortages and plan before a crisis develops. Other low and middle-income countries should do the same.
And we may be able to learn valuable lessons from the UK, which has taken simple steps to bring more healthcare workers into the system quickly.
How the United Kingdom found more than 11 000 ‘new’ doctors in just days
The UK’s health professions body, the General Medical Council (GMC), has used emergency provisions of the UK’s Medical Act to automatically grant temporary registration to more than 11 000 doctors who had given up their registration or license to practise in the last three years.
The GMC actively emailed doctors about this as part of an opt-out programme, meaning that doctors were part of the project unless they declined to participate.
The council explained that this was a quicker and simpler way to manage a large number of temporary registrations rather than, for instance, waiting for doctors to respond to adverts. Of course, doctors had to be qualified, experienced, live in the UK and in good professional standing to be eligible for the programme.
Additionally, newly graduated medical students and young doctors who have not yet completed internships, usually needed to practice independently in the UK, can also receive provisional registration to serve on the frontlines of the COVID-19 response.
Five ways South Africa can put more healthcare workers in the field. Now.
In contrast, South Africa’s regulator, the HPCSA, has halted registrations of foreign-qualified professionals during the 21-day national lockdown, due to their qualifications having to be reviewed by the registrar. As of 2010, South Africa was home to at least 8 000 foreign-trained physicians, according to a 2019 study published in the British Medical Journal Global Health.
Registration of locally-trained healthcare workers continues as usual during South Africa’s lockdown.
The HPCSA should be looking at more ways to increase the health workforce now, which may include:
- Temporarily registering foreign-qualified healthcare workers already in the country to act as “acute care assistants” to work alongside registered doctors in emergency units;
- Offering non-practising workers rapid re-registration;
- Granting junior doctors who have not been placed for internship or community service a provisional practice license to join frontline work;
- Relaxing restrictions on scopes of practice between specialities and professions to recognise that in times like these, certain specialists may have to function outside of their scopes of practice to assist in emergencies. Task sharing, meanwhile, may mean that professions such as nurses, may also need to function outside of their scopes of practice. This would require liaison with the South African Nursing Council and other regulatory bodies;
- Facilitating the ability to practice for healthcare workers who, because of underlying conditions or age, may be at an increased risk of developing severe COVID-19 disease. This would mean promoting the use of telemedicine, which entails remote medical assessment and includes telephone and video consultation.
It’s time to telemedicine for real
The HPCSA’s stance on telemedicine has long been contentious, and even in 2010, researchers critiqued both the council’s definition of and approach to telemedicine, writing in the South African Journal of Bioethics and Law.
As the lockdown started, the HPCSA initially elected to reiterate their stance on telemedicine, limiting the use of telemedicine only to patients with whom healthcare workers had existing relationships.
After pressure from medical groups, the HPCSA loosened its criteria for telemedicine for the duration of the coronavirus outbreak. It has now removed a pre-existing relationship between provider and patient as a prerequisite for commencing telemedicine.
The guideline does not, however, allow for the practitoner to weigh the interests of the patient against the interests of the community – and this is a crucial point.
The HPCSA will need to go further to provide for the use of telemedicine which enables remote assessment and management of mild COVID-19 disease, in order to reduce the risk that infected patients come into contact with other patients at our clinics and hospitals.
Virtual consultations may also be a safeguard for vulnerable patients, so that they can be assessed via the phone or video chats as opposed to at health facilities where they can potentially be infected. These facilities may also allow healthcare workers who have been quarantined or who are in isolation to keep practising while at home. The same could be said for healthcare workers who themselves have underlying conditions that put them at risk for serious COVID-19 disease.
Remote consultations may also help decrease the need for personal protective equipment, such as masks, goggles and gowns, which is currently in short supply globally.
Finally, the explicitly temporary nature of these guidelines, with the possibility that the council may revert back to a highly restrictive stance on telemedicine in future, is worrying, as this may deter investment in infrastructure and training for remote consultations.
Telemedicine may not be perfect, but during the pandemic, we cannot ignore it. The UK, Australia and China are already among the countries that have embraced this on a massive scale during the COVID19 outbreak.
In South Africa, the HPCSA also needs to support reliable services on which health workers can communicate with one another and discuss cases to get advice. Currently, much of this happens on general platforms like WhatsApp, but also increasingly through tailor-made apps such as Vula.
The HPCSA’s new guidance in the time of the outbreak is a step in the right direction, but it may need to go further to protect the public and enable health professionals. Let’s hope that the council embraces its unique position to lead many enabling regulations in a time of crisis.
Koot Kotze is a medical doctor and researcher from South Africa, currently based at the Department of Primary Care Health Sciences at the University of Oxford.
