Position statement PRICOV endorsed by EQuIP

  

Position paper  

Moving Forward After the COVID-19 Pandemic: 

Lessons Learned in Primary Care 

The Covid-19 pandemic presented a significant challenge to primary care (PC), its organization, the  people working in it, and its interfaces with the wider healthcare system. The fight against COVID-19 has  emphasized the critical role of PC within the healthcare system: to serve as the first - and, for most  patients, the only - point of contact with healthcare professionals. 

During the pandemic general practitioner (GP) practices had extensive responsibilities. These include providing care for COVID-19 patients among which severely ill patients not hospitalized due to a lack of  hospital beds, treating patients with post-COVID sequelae, ongoing care for non-COVID patients,  contributing to public health services e.g. in vaccination programs, and acting as a point of trust for  worried citizens. 

During the COVID-19 pandemic, a consortium of 48 research institutions, in collaboration with EQuiP  rolled out the PRICOV-19 study. This study analyzed how GP practices in 38 countries adapted their  practices to provide safe, effective, person-centered, and equitable care during the pandemic. Over 5,500 GP practices filled out an online questionnaire. The study's scale and international design allow it to  identify areas for improvement and contribute to the development of strategies to better prepare for  future crises. Understanding patient safety is critical for healthcare professionals in future pandemics  and times of crisis. This position statement highlights the lessons that can be learned from the PRICOV 19 study.  

Eight recommendations to foster PC preparedness for future crises can be formulated: 

1. Value the significant steps taken in patient safety in PC during the pandemic and anchor them  in a sustainable way in today’s daily practice. 

GPs faced significant challenges in ensuring safe care during COVID-19. The results of PRICOV-19  show that GP practices were highly adaptive in their organization to deliver safe care for their  COVID-19 and non-COVID patients. New measures were implemented rapidly including new  patient flow management, triage protocols, infection prevention measures, and remote  consultations (1). Safety measures already in place before the pandemic, such as adequate time  for reviewing guidelines, remained largely in place. Nevertheless, the majority of practices  reported at least one incident compromising patient safety. 60,4% of practices reported delayed  care for patients with urgent conditions while 39.8% reported incidents in patients with non covid fever because of following COVID-19 protocols (2). 

2. Acknowledge the pivotal role of GP practices in addressing health inequalities during crises,  and provide resources to do even better. 

The COVID-19 pandemic disproportionately affected vulnerable populations’ access to health 

care. GP practices made significant efforts to prevent the underutilization of their services by  proactively reaching out to vulnerable patient groups such as patients with a chronic condition,  psychological vulnerability, and patients in a known situation of domestic violence or a child rearing situation. Having the tools to identify vulnerable patients and possessing the necessary  skills for population management are indispensable prerequisites for achieving success. PRICOV 19 also showed that outreaching was strongly associated with the availability of an  administrative assistant, practice manager, or paramedical support staff, thereby stressing the  importance of interprofessional practice teams (3, 4). 

3. Encourage GP practices to adopt interprofessional models of care to enhance their resilience  and adaptability 

PRICOV-19 showed the greater adaptability of interprofessional GP teams in response to  changing circumstances compared to mono-professional teams. Interprofessional teams were  more able to modify their established working routines, such as patient triage and implementing enhanced infection prevention measures. In order to do so, interprofessional GP practices have  shifted tasks from GPs to other practice staff. Non-GP staff members were more involved in  giving information and recommendations to patients contacting the practice by phone, and they  were more involved in triage. GPs took on additional responsibilities as well and were e.g. more  involved in reaching out to patients. Shifting tasks also solved problems due to staff absence.  Whilst GP practices in which task changes were implemented were happy with these changes,  they also felt the need for further training (5). 

4. Support training practices as they are levers for quality in PC practices 

The PRICOV-19 study found that training practices had a positive association with various  outcomes related to safety and quality of care during the pandemic, including a higher number  of patient flow safety measures and more time allocated for reviewing guidelines, as well as a  lower risk of adverse mental health events among staff. These findings underscore that training  young GPs is not only important in developing the future workforce but also in enhancing staff  well-being and improving the quality and safety of care in practices involved in training (6).  

5. Create healthcare working environments that embrace workforce well-being Emerging literature highlights the pandemic’s huge toll on frontline healthcare workers. Prior to  this crisis, the well-being of this group was already a concern. The PRICOV-19 study showed that  during the pandemic, GPs with less experience, GPs working in smaller practices, and those  serving more vulnerable populations were at higher risk of distress. Collaboration with other  practices and having adequate governmental support were identified as significant protective  factors against distress. Improvement of organizational factors at both the practice level and system level is needed to enhance well-being and to support the PC workforce. It is essential to  consider the unique context of each country, as significant differences in the well-being of PC  practice staff were reported between countries (7). 

6. Invest in infrastructure to support the delivery of adequate and safe care More than half (58%) of the practices in the PRICOV-19 study reported infrastructural limits to  deliver adequate and safe care during the pandemic. Large practices, practices with another  payment system than fee-for-service, and practices with a higher number of staff including GP  trainees had a higher likelihood of experiencing limitations to the practice and expressed more  need for infrastructural changes. Practices that experienced adequate governmental support  during the COVID-19 pandemic, were less likely to report infrastructural challenges (1, 8).  

7. Intensify funding for research on patient safety and quality of primary care to inform future  health policies with evidence-based insights

Despite its essential role in providing first-line healthcare services during the COVID-19  pandemic, PC has not received adequate research funding. Yet, understanding the organization  of PC and learning from the COVID-19 pandemic is crucial for practices and healthcare systems  to provide safe and effective care during future crises. Driven by the need for knowledge,  PRICOV-19 was therefore established on a voluntary basis by participating research institutes,  who devoted their own resources to the study. The strong involvement of 47 research institutes  in this study, despite the lack of funding, highlights their eagerness to gain valuable insights into the topic. The inclusive nature of the collaboration also allowed for the participation of countries  with limited research resources. The PRICOV-19 study filled a significant knowledge gap by  offering valuable insights into the adaptations made by practices in organizing healthcare during  the pandemic. It also highlights the role of policy and professional organizations in supporting  such efforts, identifying areas for improvement, and implementing preventive strategies. The  rich database generated by PRICOV-19 allowed over 100 researchers, including a considerable  number of GPs and young researchers, to participate in the study and to obtain insights relevant  to their local settings. Strengthening research capacity among European countries based on this  experience could establish a strong foundation for conducting high-quality multi-country studies  that yield generalizable findings across European regions in the future (9). 

8. Stimulate the international exchange of knowledge and experience among healthcare  professionals and policymakers 

PRICOV-19 showed the impact of the pandemic on the day-to-day work of GP practices. Behind  the overall picture of changes are large differences between countries. This provides  opportunities to learn from each other and to develop and evaluate new models of primary care  delivery. Ways to stimulate the exchange of ideas and experiences is by creating opportunities  for international collaboration and sharing of knowledge among healthcare professionals and  researchers in different countries. This can include organizing conferences, workshops, and  webinars to discuss the findings and implications of studies like PRICOV-19, as well as promoting  the use of online platforms and networks for ongoing communication and collaboration.  Additionally, funding can be directed towards identifying best practices in primary care delivery  across different countries and healthcare systems (9). 

Conclusion 

To enhance PC's readiness for future crises, policymakers, associations for GPs or other PC practitioners,  and the wider healthcare system must act. They have a shared responsibility to increase support for PC in delivering safe, equitable and adequate healthcare during pandemics and other future crises. 

Governments and policymakers must invest in infrastructure to support adequate and safe care,  acknowledge the pivotal role of GP practices in addressing health inequalities, encourage  interprofessional models of care, invest in training practices, and prioritize workforce well-being. Hereto PC should be acknowledged and supported as an essential part of health systems in pandemic  planning, with PC experts involved in health emergency response operational plans, pandemic  preparedness planning and health emergency response operational plans. Funding for research on  patient safety and quality of primary care must be intensified to inform future health policies with  evidence-based insights. 

Associations for GPs or other PC practitioners have the potential to promote the creation of training  programs and resources that concentrate on crisis management and preparedness. These programs  can cover a variety of skills, including clinical abilities, effective communication, and leadership skills, 

which can enhance preparedness for adopting a public health approach in practice. These skills can  assist in identifying target patient groups, conducting outreach, and managing interprofessional teams when responsibilities are changing. These associations should collaborate with other  organizations to share best practices and resources. They need to stimulate research to identify gaps  in knowledge e.g. on the effects of new technologies in PC, and develop evidence-based approaches  to crisis preparedness. They should advocate strongly for primary care and take leadership in advising  policymakers and stakeholders to ensure that PC is adequately supported and resourced during  crises. 

To enhance the preparedness of PC for future crises, GP practices and other PC facilities should contribute. By improving communication and coordination among healthcare providers and care  facilities interprofessional collaboration can be strengthened. They should also invest in resources to  ensure equitable access to care for vulnerable populations. GP practices should engage in teaching  and training future GPs. Furthermore, the well-being of healthcare staff should be prioritized as it  plays a crucial role in maintaining the quality of care provided. 

References 

1. Collins C, Van Poel E, Šantrić Milićević M, Tripkovic K, Adler L, Bjerve Eide T, et al. Practice and  System Factors Impact on Infection Prevention and Control in General Practice during COVID-19  across 33 Countries: Results of the PRICOV Cross-Sectional Survey. International Journal of  Environmental Research and Public Health. 2022;19(13):7830. 

2. Van Poel E, Vanden Bussche P, Collins C, Lagaert S, Ares-Blanco S, Astier-Pena MP, et al. Patient safety  in general practice during COVID-19: a descriptive analysis in 38 countries (PRICOV-19). Manuscript  under review. 2023. 

3. Van Poel E, Collins C, Groenewegen P, Spreeuwenberg P, Bojaj G, Gabrani J, et al. The Organization  of Outreach Work for Vulnerable Patients in General Practice during COVID-19: Results from the  Cross-Sectional PRICOV-19 Study in 38 Countries. International Journal of Environmental Research  and Public Health. 2023;20(4):3165. 

4. Fomenko E, Keygnaert I, Van Poel E, Collins C, Gómez Bravo R, Korhonen P, et al. Screening for and  Disclosure of Domestic Violence during the COVID-19 Pandemic: Results of the PRICOV-19 Cross Sectional Study in 33 Countries. International journal of environmental research and public health. 2023;20(4). 

5. Groenewegen P, Van Poel E, Spreeuwenberg P, Batenburg R, Mallen C, Murauskiene L, et al. Has the  COVID-19 Pandemic Led to Changes in the Tasks of the Primary Care Workforce? An International  Survey among General Practices in 38 Countries (PRICOV-19). International Journal of  Environmental Research and Public Health. 2022;19(22):15329. 

6. Silva B, Ožvačić Adžić Z, Vanden Bussche P, Van Poel E, Seifert B, Heaster C, et al. Safety Culture and  the Positive Association of Being a Primary Care Training Practice during COVID-19: The Results of  the Multi-Country European PRICOV-19 Study. International journal of environmental research and  public health. 2022;19(17). 

7. Collins C, Clays E, Van Poel E, Cholewa J, Tripkovic K, Nessler K, et al. Distress and Wellbeing among  General Practitioners in 33 Countries during COVID-19: Results from the Cross-Sectional PRICOV-19  Study to Inform Health System Interventions. International journal of environmental research and  public health. 2022;19(9). 

8. Windak A, Nessler K, Van Poel E, Collins C, Wójtowicz E, Murauskiene L, et al. Responding to COVID 19: the suitability of primary care infrastructure in 33 countries. International journal of  environmental research and public health. 2022;19(24):17015.

9. Tatsioni A, Groenewegen P, Van Poel E, Vafeidou K, Assenova R, Hoffmann K, et al. Recruitment, data  collection, participation rate, and representa-tiveness of the international cross-sectional PRICOV-19  study across 38 countries. Manuscript under review. 2023.

PRICOV-19 was initiated in the summer of 2020. Under the coordination of 'Quality and  Safety Ghent,' an interdisciplinary center of expertise for quality and safety in primary care  and transdisciplinary care within the Department of Public Health and Primary Care at  Ghent University (Belgium), an international consortium of 48 research institutes was  formed. For a list of partnering institutions see https://pricov19study.ugent.be/partnering institutions.html. The PRICOV-19 study collected data in the following countries: Austria,  Belgium, Bosnia and Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark,  Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Kosovo*,  Latvia, Lithuania, Luxembourg, Malta, Moldavia, The Netherlands, North Macedonia,  Norway, Poland, Portugal, Romania, Serbia, Slovenia, Spain, Sweden, Switzerland, Turkey,  Ukraine, and The United Kingdom.  PRICOV-19 received limited funding from EGPR and from the King Baudouin Foundation  (Belgium). PRICOV-19 was set up in collaboration with the 'European Association for Quality  and Patient Safety in Primary Care' (EQuiP).  This position paper has been written by the PRICOV-19 consortium and is based on the  published and upcoming scientific PRICOV-19 scientific publications. The PRICOV-19  consortium has validated this position statement. The EQuiP council endorsed it following a  discussion by the conference attendees at the 62nd EQuiP conference in Dublin on May 12th 2023.  All credit for this position statement belongs to the 48 partnering institutions of the  PRICOV-19 consortium and the individual PRICOV-19 consortium researchers. The  consortium wishes to express its deep gratitude to EQuiP for their support of PRICOV-19, as  well as their efforts to validate and disseminate the lessons learned.  For more information, please contact the PRICOV-19 research consortium: - Prof. dr. Sara Willems, Principal Investigator, Ghent University,   Sara.Willems@ugent.be  - Esther Van Poel, study coordinator, Ghent University, Esther.VanPoel@ugent.be - Dr. Piet Vanden Bussche, EQuiP liaison PRICOV-19, Pierre.VandenBussche@ugent.be or visit our website: https://pricov19study.ugent.be/  * All references to Kosovo, whether the territory, institutions or population, in the PRICOV-19 study shall be  understood in full compliance with United Nations Security Council Resolution 1244 and without prejudice to  the status of Kosovo.

 

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Year

2023