À la recherche du temps perdu

Alexandre Lourenço 

Portuguese studies from different entities have showed excess mortality from causes unrelated to COVID-19 since early April 2020. Entities like the National School of Public Health, the Faculty of Medicine of Porto, or the Faculty of Medicine of Lisbon have warned about this trend. Later, the Portuguese National Statistics Institute has confirmed it.

The response to COVID-19 has limited the regular provision of healthcare and the postponement of elective healthcare services has led to significant losses in the health and well-being of populations. In April, we called for creating conditions for resuming the regular health services in an organised and coordinated way, through a dual-track NHS. By this time, tens of thousands of surgeries and hundreds of thousands of consultations have been cancelled.

On 7 May, the Portuguese Minister of Health determined through an order that “primary care and hospital services must ensure the identification and rescheduling of all programmed assistance activity not carried out due to the pandemic COVID-19”. On 6 June, through a Resolution of the Council of Ministers, a couple of measures were approved to resume the activity, through incentives to professionals: 7.7 million euros to “recover all the lost first hospital consultations” and 26 million euros for “recovery of 25% of the surgical activity”. After several insistences, in full summer vacation, precisely on 14 July, an ordinance was published that allowed hospitals to apply the incentives to healthcare professionals’ teams.

Comparing accumulated activity until July 2020 with 2019, we found a large reduction:

• Primary care: 

• 38% less face-to-face medical visits
• 34% less home medical visits 
• 21% less nursing visits 

• Hospital care:

• 14% less hospital medical visits (includes phone calls) 
• 24% less surgeries 

• Emergency care: 

• 18% less urgent cases
• 21% less very urgent cases
• 27% less critical cases

Unlike face-to-face encounters, virtual care rocketed. In the same period in primary care, non-face-to-face medical contacts soared 71% and non-face-to-face nursing contacts climbed 54%. In hospitals, telemedicine consultations increased by 40%.

On the other hand, in emergency services, we observed abnormal growth at the level of standard or non-urgent episodes. It has been suggested that this growth is due to the lack of access to primary health care. Lack of access that implies a reduction in referrals for first hospital consultations and, consequently, surgical proposals and other therapeutic plans. However, we have not seen initiatives for the resume of primary care activity.

Aware of the problem, on 8 September, the Portuguese Association of Hospital Managers and the Medical Doctors Association, with Roche’s support, launched the Movement “Health in Day — Don’t Mask Your Health” to appeal to patients not to postpone their visit to health services. We also developed a national survey to understand why patients were not accessing health services and another study about health services activity.

In this sequence, we made public the Ministry of Health’s activity data hitherto undisclosed, carried out a population survey to understand behaviour and motivations, and launched the challenge to a group of experts to present measures. On 29 September, we publicly presented the results and a set of comprehensive actions.

Between 2 March, the date on which the first cases with COVID-19 disease were diagnosed, and 18 October, 72 519 deaths were registered in Portugal, 7936 more deaths than the average, in the same period, the past five years. Of these, 27.5% (2,198) died from COVID-19.

The window of opportunity has passed. Now we are facing a new growth of the COVID-19 pandemic, and we are once again “under fire”. Leadership, coordination, and solidarity are required. All Ministries of Health across Europe should consider non-COVID-19 services as essential, investigate the causes of excess mortality and take advantage to review low-value clinical practices, creating the conditions to leave no one behind.