The coronavirus pandemic is challenging health systems and societies. The measures for restricting interpersonal contact that are being taken are aimed at flattening the COVID-19 infection curve, to prevent the health system from being overwhelmed by a sudden increase in the number of those infected and to continue to provide the best possible care for all patients.
The countries that have experienced the pandemic in a severe way up to now have been countries with health systems with a very scarce or non-existent primary care network and therefore the weight of the attention has fallen on hospital care, as is the case of China, South Korea or Italy (See References). This has led these countries to deploy a model of hospital care for all patients with COVID-19, a significant part of whom could have been at home with care directed from primary care teams. Thus, many of the field hospitals organized for less severe patients provided no more care than temperature control, maintenance, isolation and anti-thermal measures.
Patients with deteriorating conditions were referred to more well-equipped hospitals. Cases with mild symptoms remained in these field facilities until the condition was resolved and the isolation ended. It has been a major effort by these countries which, in the absence of primary care with resolution capacity, have had no choice but to care for these patients and reduce the impact of the pandemic.
In Europe, some countries such as Spain, Denmark, Sweden, Norway or UK, among others, have an strong network of primary care teams that provide universal care free of charge to all citizens. That is, primary care family physicians, nurses and pediatricians with a list of patients in their care who provide health care from childhood to old age, supported by social workers, clinic assistants, physical therapists, midwives and administrative support and cleaning services oriented to primary care and who have strong links with the community.
These teams know the population they serve, their risks and their health and social-health problems. This advantageous situation allows for a different and more efficient model of screening and care for COVID-19 patients, while guaranteeing comprehensive care for the rest of the population's health problems and an emotional balance that makes it possible to reduce the side effects of confinement.
Primary care, the first contact with the system, coordinating the care provided at different levels, comprehensive and longitudinal throughout life, is not only very efficient: it also has a proven capacity to make the whole health system provide more satisfactory, quality, safe and close care. The evidence for this is strong.
Therefore, we want to reflect on the role of primary care in this pandemic and certainly in other pandemics or natural disasters that may occur. A primary care with resources, well qualified and organized, can flatten the curve of new infections, reduce the negative impact on the overall health of the community and perhaps even, in the future, facilitate less restrictive confinements that gradually allow us to return to a normal social, work and economic life and enjoy together a healthy life.
How do we implement this model of response to COVID-19 with the network of primary care teams? By guaranteeing the resolution capacity with sufficient means for these teams, so that they can give the best possible care at home, controlling COVID-19 but also the rest of the patients' problems, which still exist such us diabetes mellitus, high blood pressure, other emergency needs.... In this way we would avoid, in part, the saturation of hospitals with mild-moderate cases and we would manage to increase their capacity to attend to serious patients. Monographic consultations on respiratory pathologies are organized at health centers, attended by professionals with personal protective equipment (PPE), masks for patients and access to medical records that allow risk assessment and make the best decision about continuing telephone follow-up at home or referring the patient to the hospital, if necessary.
In order to address the current extraordinary situation, we outline below some possibilities for improving the problem-solving capacity of primary care, in order to unfold its full potential to bring about improvements in both its own results and those of the system as a whole. This is an open issue that will have to be adapted to practical experience and to developments in each local context. Nevertheless, sharing experiences of primary care teams from allover the world will help us to face it better and go on learning on improving as the pandemic is travelling along.
Certainly, there is a stretch from the ideal response of the health system and the population to the real one, and to begin with, in our environment, we do not know who is infected by SARS-CoV-2 in primary care. Test are quite few for all and are prioritaze for severe patients. Therefore, it is important to improve the classification of patients in primary care with telephone triage (supported by the official central services for citizen care) and face-to-face triage by nurses at the door of the centres to resolve doubts by providing written information and making respiratory monographs consultations, with professionals appropiately protective, who can solve mild to moderate patients.The improvement of diagnostic capacity has been reinforced by coordination with diagnostic support services such as radiology and laboratory, with special diagnostic circuits to reduce contacts and adapt treatments.
In this critical situation, we cannot waste the time of professionals in bureaucracy, time that they must inevitably take away from that which they dedicate to patient care: we must resolve by means of extraordinary emergency regulations the elimination or minimization of all non-clinical activity of those in the front line of care as the management of sick leaves and other certifications. It is essential to develop the use of new technologies to facilitate basic management: telematic renewal of prescriptions to pick them up at the pharmacy without going to the health centre, sending sick leave or reports to mutual insurance companies that control risk factors by e-mail... Communication technologies can also be useful in giving information to the population in the health area regarding their care, isolation, medication, exercise and emotional care such as grief management since they can't say goodbye to loved ones etc.... Non-healthcare personnel have an important role in working as a team with clinicians, managing documents, agendas, and in disseminating standardized and protocolized contents to make it easier all the primary care team walk together with the same goal.
Finally, assuming home care with PID that allows patients who cannot go to the health center to be evaluated. In this way, appropriate care is given to people who require urgent home care, both patients with other health problems and those with prolonged and moderate respiratory symptoms compatible with COVID-19 that require re-evaluation, either to consider referral to hospital, or to confirm good evolution and remain at home, or to perform radiography if there is an organized circuit, or to make efficient use of medicalized and non-medicalized ambulances. In short, to make an efficient management of resources, assessing with knowledge the realities of the patients.
In order to be able to do all this, health professionals need resources, both to attend to the population and to protect themselves from falling ill or into quarantine. With the experience of what happened at the beginning of the outbreak in China, the WHO insists that the main asset to be preserved in order to face this crisis is the professionals. As this editor of The Lancet says, health professionals, unlike respirators, cannot be manufactured urgently, nor can they operate 100% for long periods of time. PIDs are only the first step among other measures such as adequate rest and family and psychological support. Currently, in Spain, at the beginning of the crisis and before the worst comes along, none of these support measures, not even the most basic for survival, protective material, are fully ensured in many primary care teams.
Professionals need realistic protocols to best guide their actions in the real world. There is no point in having a protocol for the good use of a material that is not available or so scarce that it cannot be used in all the cases that previously used it. We need plans, protocols, guidelines and strategies for situations such as the current one in which, as the US CDC crisis strategy for mask optimization says, the usual quality standards cannot be guaranteed.
We need to build on the lessons that have been learned at high cost in the places where the epidemic has hit hardest and earliest. In the NEJM article "Facing the ICID-19 in Italy: ethics, logistics and therapy on the front line of the epidemic" the authors point out, among other problems to be solved, the allocation of insufficient resources among patients. When so many critical cases are admitted at the same time that the ICUs (Intensive Care Units), they do not have the capacity to attend to all of them at the same time, there is no choice but to do triage to decide who is connected to a respirator and who is not. This is a heart-breaking experience from which no one comes out unscathed, not the patients, their families or the professionals. The example of overcoming the capacity to provide intensive care is clear, but the same dilemmas arise day after day, patient after patient to all professionals, family doctors included: who, of all those who need it, will I visit at home, attend to first, call to follow up?
In order to minimise the psychological damage to those involved, as well as to guarantee ethics and efficiency in the taking of these difficult decisions, the health authorities must give clear instructions for action and transparently disseminate what they are and their motivation.
There are many aspects that can be organized in each primary care team to improve the appropriate response to this pandemic in the specific population they serve, and care strategies must be organized in coordination with other resources (social, diagnostic services, community pharmacies, etc.) to deploy all the capabilities provided by a health system based on universal primary care in a country.
Multi-professional teams are usually consolidated in times of crisis. In order for a team to move in the same direction, good internal communication behaviours must be promoted, informative and reporting meetings must be held, and what has been done must be evaluated and rescheduled, if necessary, in order to continue moving forward. The recommendations change, the pandemic is advancing, and it is important to be united, to have a clear leadership in the team and to go all in the same direction. Do not forget to evaluate at the end to continue learning.
We must learn from the experience of other countries to face this pandemic, but not copy to the letter what has been done in countries like China or Italy that do not have primary care like Spain. We must strengthen primary care so that it can fulfil its potential to bring efficiency and security to the whole system, to treat those 80% of patients in whom the COVID-19 has a mild course. As always, to decongest emergencies and hospitals we must not only invest in emergencies and hospitals: we must invest in material and human resources in primary care, the investment that has been proven to be the most efficient in improving the quality and safety of the health system as a whole.
Highly authoritative voices have stressed the central role of strong primary care as the basis for preparedness and response to emergencies such as this pandemic, including former WONCA President Amanda Howe, who signed this article in BJGP among other authors, who recalled that "the Ebola crisis taught us a valuable lesson about what happens when an outbreak takes workers away from their core functions to focus on crisis response; the number of people who died from reduced access to regular care probably exceeded the number of deaths from the virus. Strong health systems, based on comprehensive primary care, are able to integrate both functions... to manage new suspected cases along with routine family medicine. Adequate access to primary health care is essential in health emergencies and its infrastructure is crucial for containment; good access to high-quality primary care is the foundation of any strong health system.
Dr. Tedros Adhanom Ghebreyesus, Director General of WHO, has spoken in the same vein, citing his article in the Commonwealth Health Report: "COVID-19 is a clear reminder of how public health emergencies can cause significant loss of life and disruption to societies and economies. The best defence is to invest in preparedness and primary health care".
We must learn from this pandemic that primary care must be strengthened. We are sure that after this outbreak, pandemic control and disaster response portfolio of services will be included. We are sure that the experiences of the primary care teams along the world will allow us to define guidelines for action that will make it possible to respond to a pandemic without neglecting the other health problems of the population.
Reinforcing primary care teams, trained in the knowledge and monitoring of the population's health, to which they provide the bulk of health services, with competence, organisation and resources, will be the most efficient model for acting in the face of pandemics and disasters, but also for providing more humanised, closer and more available care on a daily basis over time.
Pandemic is a public health issue, that means, it is a community issue so family and community medicine has a real role to deal with and so governments should think seriously to invest in a stronger primary care network to properly answer to community challenges.
Pilar Astier Peña, Coordinator of the SEMFYC Patient Safety Working Group
Originally published in Spanish in: La importancia de poseer un activo como la Atención Primaria para hacer frente a la pandemia por coronavirus: cómo desarrollar todo su potencial
Pilar Astier Peña, Specialist in Family and Community Medicine and Preventive Medicine and Public Health, is chair of the SEMFYC (Spanish Society for Family and Community Medicine) Patient Safety Working Group and chair of the WONCA Working Party on Quality and Patient Safety in Family Medicine. WONCA is one of world organization of family doctors in close collaboration with the World Health Organization (WHO). She is, as well, a member of the Board of the Spanish Society for Healthcare Quality.
She has experience in health services planning and organization. She has been manager of a 800 beds university hospital for more than 7 years and now works as a family doctor in the Public Health Center of “La Jota” (Facebook Joteros Salud Zaragoza, Twitter @CSLaJotaOficial, Instagrama csljotazga) of the Aragonese Health Service.
Her active participation in international events on family medicine, quality and safety and her relationship with professionals from all over the world, together with her work experience, have given her a detailed and overall view of the current situation in health care regarding different models to face the pandemic of SARS-CoV-2.
The Health Systems in Transition (HiT) series - http://www.euro.who.int/en/about-us/partners/observatory/publications/health-system-reviews-hits/full-list-of-country-hits