The pandemic and the agony of primary care

Andreu Segura
 

I thank Xavier Blancafort for the photograph, as well as 

his suggestions, I also thank Laia Riera and Vicente Giner.

COVID-19 has been a real stress test for Spanish health system as a whole, especially for primary care services (PC) ‒particularly in the most advanced phases of the pandemic‒ and public health facilities (SP) in general, although these are rarely the object of evaluation, although we have all paid for their limitations and deficiencies. For some time now, both levels of the national health system have been languishing as illustrated - although, in my opinion, this is not the worst - the continued decline in the proportion of the public health budget that corresponds to them, especially in the SP, which does not reach 2% of the total. Of course, the proportion of spending is not a sufficiently precise indicator of the efficiency neither of the efforts nor the value that its activity contributes to improving and maintaining the population health. That is why I consider the absence of health strategies more serious and, even worse, healthy public policies, since the appeals to health in all policies have been above all rhetorical. Healthy public policies should naturally include health policy, so that it could effectively contribute to the collective promotion and protection of community health, as one more element along with educational, labour, urban, economic policy, etc.

For which, it would probably be advisable for the PC to adequately develop the community dimension that is formally recognized in the qualifications of specialist professionals, both in medicine and in nursing. A dimension that in practice is very minority despite the efforts of the Primary Care Community Activities Program (PACAP), the "Actuendo Unidos por la Salud" (AUPA) network and some notorious but timid contribution from public health like those of Asturias and Barcelona, without forgetting the Community and Health project (COMSalut) or even the strategy of the Ministry of Health.

Regarding the PC, the absence of incentives related to the value of the interventions, including the low investment in facilities and equipment and, of course, the job and wage insecurity explains much of the discomfort and disenchantment of professionals and workers, burdened by an improperly bureaucratic model of care that makes them feel unappreciated by the system and by the population that at the end of the day has more praise for the specialised care. Perhaps these are simply anecdotes, but the echo that social networks make, in the form of jokes, about the inaccessibility of the PC in the times of pandemic is striking.

Although it’s not our exclusive problem. The British Medical Journal has published a short article entitled: "COVID-19: a fork in the road for general practice. We must choose a personal not an impersonal future"(1) which, assuming that crises are also opportunities, insists on the importance of continuity as essential dimensions of PC. 

BMJ colleagues recall that continuity in care is not only associated with greater patient satisfaction, but also implies better adherence to prescriptions and advice, as well as less hospital attendance, including emergencies, particularly for elder people (2), and also a reduction in mortality (3). But if PC is lacking at the base of the health care system, because it does not exist or is not sufficiently integrated, inadequate medication increases, with the consequent waste of resources, and there is a marked increase in iatrogenesis, as Barbara Starfield warned years ago (4).

If we look at the pandemic as a crossroads, perhaps we could take advantage of the decrease in face-to-face demand to intensify personalized care, including continuity, to the population group most in need, provided that we achieve a selective reduction in demand through positive discrimination. Which, without being easy, may cost less in these circumstances in which the population that most fears contagion is not the least economically or socially disadvantaged. Non-face-to-face care (by clearly defining how it should be carried out and establishing adequate regulations) could help reduce unnecessary demand in the future. And in this way put into practice what Jordi Varela proposed in his 5x1: regulate the intensity of care according to the value, in terms of health, efficiency and equity of the results. (5)

1. Pereira D, Freeman G, Johns C, Roland M. Covid-19: a fork in the road for general practice. We must choose a personal not an impersonal future. BMJ 2020; 370m3709. Published 28 September 2020. 

2. Van Walraven C, Oake N, Jennings A, Foster AJ. The association between continuity of care and outcomes: a systematic and critical review. J Eval Clin Pract 2010; 16: 947-56. 

3. Baker R, Freeman GK, Haggertry JL, Bankart MJ, Nockels K. Primary medical care continuity and patient mortality: a systematic review. Br Gen Prat 2020; 70:e600-11. doi:10.1186/1471-2296-13-6 pmid: 22316293.

4. Starfield B, Shi L, Macinko M. Contribution of Primary Care to Health Systems and Health. Milbank Q. 2005 Sep; 83(3): 457–502. doi: 10.1111/j.1468-0009.2005. 00409.x.

5. Varela J. Cinco intensidades de provisión para una sanidad más valiosa. GCV: Barcelona, 2019.