key: cord-0688568-ayiil30k
authors: Kumpunen, Stephanie; Webb, Erin; Permanand, Govin; Zheleznyaknov, Evgeny; Edwards, Nigel; van Ginneken, Ewout; Jakab, Melitta
title: Transformations in the landscape of primary health care during Covid-19: themes from the European region
date: 2021-08-14
journal: Health Policy
DOI: 10.1016/j.healthpol.2021.08.002
sha: eb32f7f64510f2e7755b68f4f6f562d290330366
doc_id: 688568
cord_uid: ayiil30k

The Covid-19 pandemic has dramatically impacted primary health care (PHC) across Europe. Since March 2020, the Covid-19 Health System Response Monitor (HSRM) has documented country-level responses using a structured template distributed to country experts. We extracted all PHC-relevant data from the HSRM and iteratively developed an analysis framework examining the models of PHC delivery employed by PHC providers in response to the pandemic, as well as the government enablers supporting these models. Despite the heterogenous PHC structures and capacities across European countries, we identified three prevalent models of PHC delivery employed: (1) multi-disciplinary primary care teams coordinating with public health to deliver the emergency response and essential services; (2) PHC providers defining and identifying vulnerable populations for medical and social outreach; and (3) PHC providers employing digital solutions for remote triage, consultation, monitoring and prescriptions to avoid unnecessary contact. These were supported by government enablers such as increasing workforce numbers, managing demand through public-facing risk communications, and prioritising pandemic response efforts linked to vulnerable populations and digital solutions. We discuss the importance of PHC systems maintaining and building on these models of PHC delivery to strengthen preparedness for future outbreaks and better respond to the contemporary health challenges.

Since the start of the Covid-19 pandemic, many primary health care (PHC) providers across Europe have faced the challenge of maintaining essential health services while contributing to the Covid-19 emergency response. PHC includes primary care providers (e.g. family doctors or general practitioners) who act as the first level of professional care where people present their health problems and the majority of curative and preventative health needs are satisfied (1, 2) . Yet PHC also includes public health and other community providers (e.g.

pharmacists, opticians and in some cases social care providers), which, if aligned with the World Health Organization's vision of a strong PHC system, would work as integrated health services with primary care to maximize the level and distribution of health and well-being across a population (3) .

The mix of disciplines that make up the primary care workforce may differ from country to country, but general practitioners (GP) or family medicine practitioners are often considered to be the core of primary care (4) . Other than GPs/family practitioners, the most common primary care providers in Europe are general internists, general paediatricians, pharmacists, primary care nurses, physiotherapists, podiatrists, home care workers and mental health care professionals (4) . The skills and competencies employed by the workforce also vary significantly across countries, as does the training, system level funding and facilities, thus demonstrating the heterogeneity of PHC across different countries in Europe.

The models of care employed by PHC, the focus of this paper, are conceptualizations of how services are delivered. Models often co-exist, and will necessarily adapt with changing aims, priorities and required functions within a health system. Models are facilitated by structural elements such as governance, financing, workforce, information systems, etc. and thus will differ based on their context, whether it be in a fragile, conflict-affected setting or a stable upper-middle income country or between urban and rural communities (3) .

There has been limited examination of the PHC models of care employed during the pandemic to date. Researchers have instead examined local or regional PHC levels of preparedness or response to the pandemic (5-7) or studied patient activity in PHC, noting decreases in the provision of chronic care (8) and screening (9) , and declines in the number of physical consultations in both practice (10, 11) and pharmacies (12) . Publications of surveys of PHC providers have attempted to highlight their levels and causes of anxiety (13, 14) .

Additionally, a few multi-country papers, policy briefs and guidance have described key service changes, innovations across Europe, and the impacts on patients with chronic conditions (15) (16) (17) (18) . We contribute to this literature base by bringing together examples of PHC delivery from international contexts.

In this article we aim to describe and discuss three prevalent models of PHC delivery that we saw either emerge or become strengthened in the WHO European region during the pandemic: 1) multidisciplinary primary care teams coordinating with public health; 2) PHC providers defining and identifying vulnerable populations; and 3) PHC providers using digital solutions for remote care. We also describe the strategic enablers employed by central and local governments that supported health systems to respond to the pandemic.

The examples presented in this article have been compiled from the methodology used and content reported in the Health System Response Monitor (HSRM), an online platform established in March 2020 in response to the COVID-19 outbreak to collect and organize upto-date information on how countries in the WHO European region and Canada are responding to the crisis (see: www.covid19healthsystem.org). It is a joint initiative by the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe and the European Commission.

The HSRM content is structured broadly around the standard health system functions (19) , capturing information on policy responses related to governance, resource generation, financing, and service delivery. In addition, the HSRM includes policy responses that aim specifically to prevent transmission of the virus and other non-health system measures. The information is collected and regularly updated by way of an evolving set of questions that serve as prompts for countries' health policy experts contributing to the platform. By following a structured questionnaire and having a team of Observatory staff editing the responses, information is collected in a way that enables broad comparisons across countries.

Data recorded in the HSRM between March 2020 and March 2021 serve as the primary source for this article. The analysis process started with the extraction of all PHC-related data followed by the inductive and iterative development of an analysis framework, which we agreed through reviews of the data and discussions among all co-authors. The final framework included three models of PHC delivery and four system enablers, each which had at least half of the countries populated with information on the theme. We additionally drew in relevant literature and personal knowledge of country case study examples.

This article does not aim to answer why some countries have responded better to the pandemic than others. Instead, we draw out interesting patterns that highlight how this period of time has transformed the PHC landscape. The absence of a country in a particular theme in the results section does not necessarily mean it did not employ the models or system enablers examined, but rather, that limited information was available at the time of data collection.

Attributing any causal link between PHC policy response and pandemic outcome presents a multitude of methodological challengeswhile some would suggest that strong PHC systems have been a 'robust first line of defence' (20) , others note that good PHC systems in advance of the pandemic have not in fact guaranteed a good response (21)so this analysis instead intends to describe and assess policy responses and draw out critical lessons. This analysis can serve as a basis from which to continue investigating how models of PHC delivery respond to global crises across country contexts.

To respond to the Covid-19 pandemic, PHC providers across Europe have delivered both essential (non-Covid) services and Covid-19-related services using varied approaches. Here we highlight three key models of PHC delivery drawing on reports by country experts and we pandemic may have been involved in managing the testing, remote triage, treatment of mild and moderate Covid-19 cases, surveillance, data collection, reporting and monitoring, prevention messaging and vaccine deliveryall while also maintaining delivery of essential (non-Covid) health services. The locations in which the PHC-based emergency response was delivered varied across contexts, with testing and monitoring taking place in PHC-led centres, on the phone, and in private homes. Table 1 describes examples of coordinated efforts between PHC and public health. Country approaches have differed substantially in terms of defining and identifying who was 'vulnerable' or 'at risk' and also on what PHC actions supported these groups.

In some countries, such as Finland and the UK, PHC providers and local government labelled anyone using long-term care services as vulnerable and proactively offered PHC services. In Estonia, any older person living at home was offered home-based PHC support and treatment. In Croatia, family doctors were required to call their palliative patients and advise on action if they experienced potential Covid-19 symptoms or those symptoms worsened, and they offered home-based medical examinations or the taking of blood samples for those who were immunocompromised. Family physicians in Turkey gave telephone counselling to older patients with chronic diseases, and these same patient cohorts were offered home medicine delivery in Albania. In some countries, mobile services -or services provided in-person outside of a healthcare facility setting -were organized for vulnerable patients. For example, three-member PHC teams visited individuals in care homes and in private homes to deliver essential services in Lithuania, and in Luxembourg the general physicians had this role. In

Kazakhstan, nurse-led teams triaged vulnerable patients for a PHC facility-based visit, provided by a multi-disciplinary mobile team including general practitioner, nurse, social worker and psychologist or for a remote consultation.

To ensure comprehensiveness of reach to all vulnerable people, some services required a much broader definition of vulnerability (beyond their chronic health conditions or current level of need as proxied by use of care services). For example, many countries encouraged all vulnerable people to remain at home, and in some cases obliged them to do so except in the case of emergencies (e.g. Uzbekistan). Other broad-brush measures included free flu vaccines for all those designated as vulnerable (e.g. Ireland), medicine delivery to anyone with a prescription during lockdowns in Israel, minimum durations of prescriptions were introduced (e.g. one month in Croatia, three months in Moldova), and the abolishment of any approvals required for repeat prescriptions in some countries, including for example, Turkey and the UK. In these cases, the definition of vulnerable was intentionally widened to include older people, anyone with illnesses or chronic disease requiring medicines.

In summary, the HSRM data suggested that vulnerable patients were identified and prioritised using narrow definitions for medical outreach based on age, condition or use of care services. It remains unclear how approaches for those with access to linked data (e.g.

Finland, parts of the UK) differed to those who use more rudimentary approaches to identification, as this level of detail was not available. However, broader definitions for vulnerability were used for public health initiatives, such as prescription allowances and delivery, compared to pre-pandemic medical outreach approaches.

The pandemic has led to the development, or increased use of, a number of digital innovations to deliver non-Covid and Covid-related PHC services across Europe, such as remote consultations and electronic prescriptions (see Table 2 ). In some countries, the additional capacity for digital solutions was bolstered by retired GPs and other clinicians who had the ability to consult with or refer to a GP if required (e.g. UK). Or in others, by doctors who had temporarily shifted away from their usual work (e.g. Monaco). Capacity to deliver remote services was cited as a barrier in some countries, such as Malta, the Netherlands and Uzbekistan, and some HSRM respondents suggested this may have led to increased presentation in emergency services and increased reliance on informal carers. 

In some countries, national governments supported PHC providers to deliver remote care by procuring digital technology. Examples in the HSRM included new funding for rapid upgrades in health information system hardware and software in Germany and increased funding for diagnostic equipment in Italy (e.g. telecare, tele-health services, telemonitoring and tele-dermatology devices). The UK government purchased 40,000 laptops for PHC providers.

The HSRM also highlighted that in some countries, support payments or codes to fee schedules for remote care were developed to enable PHC providers to deliver digital services including: medical advice in Belgium, Denmark, and Switzerland; remote triage in Ireland;

and any digital arrangements necessary (telephone, email) in the Czech Republic and France.

The digital technology and support payments were intended to enable the management of symptoms in PHC, although the effectiveness of this remains to be evaluated. We also saw an example in the UK of data protection practices being temporarily relaxed to enable PHC providers to easily share read/write access to detailed medical summaries (including risks relevant to with local pharmacists and urgent care providers.

The results demonstrate that PHC providers across the European region took various innovative approaches that made significant contributions to the pandemic response. The three main models of PHC delivery we identified were multi-disciplinary primary care teams and public health coordinating to contribute to the emergency response, PHC providers prioritising vulnerable patients for outreach, and PHC providers using digital solutions to widen patient engagement options. The data examined was available at the national level and variations were visible within modelsthis likely reflected the differences in PHC systems across Europe. Within these models of care delivery, PHC providers undertook a range of responsibilities that required coordinated efforts with other partners in the health and care system, and for some PHC providers, new ways of identifying vulnerable patients and providing outreach, and again for some, new ways of digitally engaging with patients.

We discuss implications for future epidemics as well as the future of essential services below and suggest three areas for PHC providers to build on from their learning during the pandemic that align with principles of strong PHC described in the World Health

Organization's Operational Framework for PHC and the Alma-Ata Declaration: the varied forms of multidisciplinary collaboration seen during the pandemic should remain to manage short-and long-term challenges; vulnerable patients could be better supported through improved risk stratification approaches at PHC level and countries should share successful 'how to' approaches; and the momentum seen in the use of digital innovations should continue.

Coordination between primary care and other parts of health system at the frontline of an epidemic is essential (23) . Yet in some European countries, primary care collaboration outside of an emergency is not a common feature in their health systems. The HSRM data revealed joint initiatives in country settings we know have little communication and collaboration between parts of the health system and case reports from the literature corroborated this finding. For example, case reports from Italian PHC providers described new collaborations between PHC and secondary care as some of the few positive outcomes of Covid-19 (24, 25) .

Team-based working will be important in safely resuming normal care post-pandemic. This will not only include collaboration between primary care and public health, but also with other providers in the health and care system such as community-based and outpatient care to help manage complex cases of chronic disease and diagnostic services and acute care teams to detect and begin managing all new incidence of disease. The novel collaborations that have emerged during the pandemic must be harnessed and built upon rather than seen as an exceptional one-off response because recovering from limited access to PHC and secondary care services will be challenging. PHC providers have already raised concerns about the potential health consequences of postponed treatment, changes to normal and preventative services (e.g. cancer screening, vaccinations), loss of PHC contact with vulnerable groups (e.g. migrants, victims of domestic violence), prolonged social distancing, and an undermined social and economic life during the pandemic (15, 16, 26, 27) . One study from the UK found a 50% reduction in incidence of Type 2 diabetes and mental health conditions within a deprived population (28) , and another in Germany found significant decreases in new cancer diagnoses across a range of specialities and age groups in 2020 relative to 2019 (29) , suggesting under diagnosis of many conditions during the pandemic. It is possible that the long-term effects of the pandemic may prove to be as challenging as the need to respond initially, and approaches to multidisciplinary working outside of the four walls of providers' buildings may help prevent a discipline or part of the system being singlehandedly overburdened with complex patients.

Many countries described in their HSRM entries which parts of the population were labelled as socially and medically vulnerable, but only a few suggested how these groups had been

identified. An assessment of European primary care from 2015 suggested that with some exceptions the necessary outreach and anticipatory approaches to provide strong primary care

were not widespread (4) . To build on the progress made during the pandemic regarding tackling risk and inequalities, in line with the Operational Framework for PHC, a discussion about how to do identification and outreach may be helpful.

Approaches to identifying at-risk groups can vary depending on the potential outcomes and risk factors. Models can be simplistic, such as those that use GP clinical judgement and/or threshold models based on factors such as age and disease status. Models can also be more 

The HSRM described digital tools being developed by many governments (and others) and then being rapidly implemented by PHC providers across Europe during the pandemic.

Almost overnight, remote consultations became the norm and significant work went in at the systems-and local-levels to make this happen. Interestingly, many country experts suggested that their national influenza pandemic preparedness plans had been revised to develop approaches to manage Covid-19no doubt future plans should examine the strengths and weaknesses in remote care provided through digital innovations and update their national emergency preparedness and response plans accordingly.

Using the UK as a case study of a review, as we understand the switch to digital working was supported by a range of enablers that included: as mentioned, the centralized purchase of 

This research has potential limitations. The data in the HSRM database was written by country experts using a template and edited by staff at the European Observatory on Health Systems and Policies. The country authors used different approaches to report on their health systems, including case reports drawing on personal experience, and had gaps in data entry.

HSRM contributors will have also made interpretations about PHC from within their various country contexts, which we tried to remain mindful of during analysis but cannot be certain we completely accounted for because we did not confirm our interpretations with the country experts. However, our authorship team included experienced PHC researchers and technical officers responsible for PHC in the WHO European region. Furthermore, the HSRM template did not contain a specific section related to PHC, because it was designed around the main health system functions (e.g. financing, workforce, provision), so the content used in this article spanned multiple sections. Some gaps we identified with regard to PHC were addressed with additional checks with other local researchers and the literature, but some topical and country gaps remained including two major gaps described below.

The first major topical gap was that countries implemented schemes at a national level, many of which did not explicitly state a role for PHC providers. This included nationally implemented schemes for PPE procurement, financing, workforce, and support for vulnerable groups. As a result, the HSRM did not adequately capture local level initiatives implemented by PHC providers. However, this gap also may point to an under-emphasis at the national level in creating policies for PHC providers during the Covid-19 pandemic.

The second gap relates to the limited discussion of the connections between PHC and long- There remain many unknowns about the pandemic, including the effectiveness of some of the centralized efforts to manage demand, such as digital apps and messaging to avoid health services. We would encourage more research in these areas to benefit future infectious disease preparedness plans.

During the pandemic we have witnessed significant transformation in PHC services across

Europe. PHC providers in many countries rapidly adapted their activities to focus on advising, triaging and managing treatment of Covid-19 casesall while reaching out to vulnerable patients and maintaining access to essential services for the wider population using new in-person protocols or new digital solutions. There is an urgent need to capture learnings from the pandemic that are specific to public health and PHC services, and to turn these into strategic action plans to strengthen preparedness for future outbreaks and better respond to the contemporary health challenges.

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We would like to acknowledge Astrid Ganzhorn Eriksen, Jorge Espinoso Ossorio, and Nathan Shuftan for extracting the PHC-relevant data from the HSRM, which the authors analysed for this paper.

We would like to acknowledge [names redacted for anonymity] for extracting the PHCrelevant data from the HSRM, which the authors analysed for this paper.