- By Jamie Shea
COVID-19 is causing major human suffering and impacting people’s quality of life around the globe, placing a particularly heavy toll on vulnerable populations. However, although the disease hits the elderly and those with chronic conditions disproportionately, attention has overwhelmingly focussed on hospitals. Failure to see the elderly and primary health care sector as central to addressing the pandemic has arguably slowed the effectiveness of the response in the early phases.
That people with chronic conditions and older populations face an elevated risk of dying from COVID-19 is evident from the data. As many as 90% of COVID-19 deaths have been amongst people aged over 60, with those over 80 accounting for around half of all COVID-19 deaths. COVID-19 deaths per million people aged over 60 years are 3.7 times higher than amongst the population as a whole among 22 European countries. The United Kingdom and Belgium reported the highest COVID-19 mortality rates, followed by Ireland, Sweden, Italy, Spain, France and the Netherlands.
Elderly people living with chronic conditions face a double threat. Not only are they more vulnerable to complications and death from COVID-19, but they also face significant disruptions to the continuity of care. These include large reductions in the use of outpatient services. The number of face-to-face consultations in primary care has for example dropped by 50% in Belgium, 25% in France, 30% in England, and 11% in Norway during peak time of the first wave of the pandemic.
The pandemic has also triggered disruptions to cancer care. Urgent referrals from primary care for people with suspected cancers, chemotherapy appointments for cancer patients, and the number of cancer diagnoses and screening fell significant in France, Italy and the United Kingdom, to mention a few.
Strong primary health care is essential to minimise any complication and direct deaths from the COVID-19 crisis
Individuals living with mental health conditions have also faced unmet needs. Routine appointments with psychiatrists and referrals to mental health services have declined, while discharges from mental health care have increased in various European countries.
Delayed diagnoses and treatment will contribute to worse health outcomes for many people, now and in the future, adding to the health burden from COVID-19. Quite clearly, primary, community, and social care are key for successfully managing the response.
For a start, strong primary health care is essential to minimise any complication and direct deaths from the COVID-19 crisis. This includes monitoring the dynamic of the epidemic, effective contact tracing and isolation measures, follow-up and monitoring of people with COVID-19 to help them safely and effectively manage care at home, and facilitating quick and effective referral to hospital for the most serious or deteriorating cases.
Strong primary health care, based on team practices and with strong links to community services, is also key to maintaining access to routine care during the pandemic for patients, and to alleviating pressure on hospitals. In Iceland, Slovenia or the United Kingdom, multi-disciplinary primary care practices working in collaboration with community care facilities have successfully managed chronic diseases to maintain essential services, helped to identify high-risk patients and provide patient education on COVID-19. In Canada, France, Spain or the United States, the expansion of home-based programmes has facilitated access to care for all patients during the crisis.
Faced with a once-in-a-century pandemic, a new normal for health systems is in order
Innovations in the roles and responsibilities of primary health care professionals offer lasting benefit, beyond the COVID-19 crisis. Enhanced roles for pharmacists and community health workers offer practical ways to maintain continuity of care when elderly and chronic patients are less able to access doctors. In Austria, France, Ireland, Portugal and Spain, pharmacists had greater scope on extending prescriptions and prescribing chronic medications, ensuring patients continued access to necessary medicines during the crisis. There is hope that COVID-19 will accelerate such innovative roles of health professionals, removing pre-existing structural and institutional barriers and permitting a more efficient use of human capital in the health sector.
A much wider adoption of telehealth has helped preserve continuity of care for non-COVID-19 patients. The acceleration in the digital transformation of the health sector is striking and welcome. With rising cases and lockdowns limiting face-to-face care, countries have moved at speed and scale to allow a range of services to be delivered remotely through digital means. Austria, Belgium, Estonia and the Czech Republic have allowed provider payments for some telehealth consultations and clarified regulations. Countries where telemedicine was already allowed before the pandemic, like France, Luxembourg and Poland, have relaxed restrictions and created new platforms to facilitate providers’ and patients’ use of remote consultations. In Poland, new digital services made it possible to conduct around 80% of consultations remotely during the first wave of the pandemic.
Faced with a once-in-a-century pandemic, a new normal for health systems is in order. This crisis has demonstrated the importance of placing primary health care at centre of health systems both to manage an unexpected surge of demand and to maintain continuity of care for all. COVID-19 has accelerated overdue transformations and stimulated many innovative practices and responses in primary health care. These efforts need further expansion – both to ensure that health systems are more resilient against future public health emergencies, and to meet the challenge of ageing societies and the growing burden of chronic conditions.
Building sustainable primary health care systems that better meet the needs of populations will require leadership and managerial support to enable legislation and regulation; well-designed incentives and sharing of useful practice at both national and international levels to accelerate change; and continued willingness to learn and innovate. The OECD Patient-Reported Indicator Surveys initiative (PaRIS), which will collect a new set of internationally comparable measures on outcomes and experiences with primary health care among people with chronic conditions, will contribute to the necessary health care systems transformation.
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