What have we learned in Primary Care during the pandemic?

Salvador Casado

Illustration @72kilos

1. Prioritise. 
2. Team and patient safety. 
3. Self-organisation. 
4. Coordination with the community, society and NHS. 
5. Resilience. Fatigue management.

The Covid19 pandemic has been one of the hardest tests both for the health system as an institution and for its professionals. From a rural health centre, it seemed important to me to open a reflection within the team on what we had learnt in Primary Care over these months. I share the ideas that emerged from this process, which was carried out in a non-systematic way in small group or corridor conversations. The experience of a team is not exclusive to it, nor does it end with it; it is undoubtedly shared with many other professionals and is likely to be enriched by that of other groups with other socio-demographic circumstances, or from other areas of hospital or mental health organisation. The intention of this paper is none other than to extend this reflection and allow the reader to add to it in the form of a commentary on the text or on social networks (twitter: @doctorCasado).

 

The lessons learned have been systematised into five axes: prioritisation, security, self-organisation, coordination and resilience.

 

Perhaps the first thing we learned after the initial shock was to recognise that we were entering a health emergency. Despite receiving information about cases from other countries and from Italy, it was not until we started receiving patients from local nursing homes that we realised the magnitude of what we were facing. Our rural health centre serves three homes with approximately 150 institutionalised elderly people, and in the first few weeks a third of them died. This forced us to prioritise and devote all our energy to the pandemic by modifying our work structure, processes and the way we provided care. 

 

In the following months, we tried to progressively open up the range of care to the most delicate chronic processes, the elderly and care for non-delayable causes. This could be done at a different pace depending on the pressure of care that each phase of the waves produced.

 

The second major lesson learned was to address the issue of professional and patient safety. The first few weeks were the hardest because we had no means of protection. We had to ask for help from the community and protect ourselves with everything from rubbish bags to plastic screens that patients printed for us with 3D printers. We shared the few surgical masks we had with nursing homes and put them in touch with local shops for gloves, plastic mackintoshes and other materials. 

 

The waiting rooms were emptied more quickly than in other centres in Madrid, which meant that there were no staff infections and transmission between patients was greatly minimised. The design of Covid circuits with a separate examination room, triage at the door and organisation of protective equipment was several weeks ahead of the instructions received from the care management. 

 

The third line of learning had to do with the self-organisation of the health centre resulting from the lack of leadership and proper management throughout the pandemic. The ministerial recommendations clashed with the political guidelines of the Community of Madrid, while the healthcare management limited itself to transmitting a long series of protocols without doing any work to facilitate their reading or to improve their implementation. In the absence of reinforcements or direct support, we opted to organise ourselves as best we could as circumstances changed. The arrival of protective equipment and diagnostic tests allowed us to start working on a new line of work that required a lot of energy in the form of assistance to patients and possible contacts, contact studies, follow-up of patients, sick leave reports and so on. Despite spending many months with empty waiting rooms, the care load was extremely high. The distribution of functions and teamwork was essential to carry out a mission that exceeded the worst peaks of demand in the past.

 

It was only at the end of the third wave that we received the reinforcement of one person in the morning and one in the afternoon to perform triage at the door, and two months later, the support of a nurse for telephone contact studies in asymptomatic patients. Of the fifteen doctors on staff, we spent many months with ten, and in the summer period there were fewer, to take on the work of four local clinics next to the primary care centre, in two shifts.

Flexibility was a fundamental value that allowed us to maintain telephone contact with older people and those with chronic processes during the periods of lower incidence between the different waves, as well as the permanent revision of the organisation of the team in line with new developments in our community and the epidemiological and other circumstances that we were experiencing. 

 

Along these lines, we had to learn to go through the consultation without the patient in front of us, something that most of us did not imagine possible. Telephone assistance has allowed us to diagnose, follow up and study contacts in most cases of infection, as well as to handle many acute and chronic pathologies that did not require physical examination. It was necessary to develop new communication skills as well as to learn how to make a blind anamnesis, with directed questions. 

 

Finally, within self-organisation, we have become aware of all that we clinicians have not or should not take on. The enormous bureaucracy, especially of the transitional incapacity processes, the reports, the excessive protocolisation of the programme contract and the portfolio of services....

 

The fourth dimension of learning had to do with coordination with the community, society in general and the health organisation. Initially, it helped us a lot to go out from the centre to the old people's homes to maintain an intensive physical and telephone presence. We also went out to the town hall, pharmacies and social services to keep each other informed and ready to help each other. As there was a great deal of social confusion, we participated from the beginning in the task of informing society, collaborating with the media when they asked us to do so. In this way, we have responded to more than seven requests from the written press, fifteen from Madrid and national television, in addition to the work on social networks, professional blogs and other channels in a personal capacity of the different professionals at the centre. 

 

Coordination with the care management has been respectful, with the centre's management team holding virtual and telephone meetings every week, often lengthy and with few proposals or solutions. We have tried to maintain a balance between the recommendations of the care management and the day-to-day reality, trying to prioritise actions towards what is most necessary at all times while maintaining the highest possible level of safety for patients and professionals. It has been difficult to witness the impossibility of implementing the reform plan for primary care in Madrid sponsored by the previous manager (or the development of the latest white book of the Ministry of Health) and the lack of commitment by the Community of Madrid to provide the funding promised on several occasions, or to strengthen the workforce (something that has not been done, except for the minimal actions to improve the study of contacts in the fourth wave).

 

The last line of learning has to do with resilience, the common care of the team and the self-care of each professional. Our primary care centre is small in size (two nurses and two doctors per shift and another doctor-nurse couple with a late shift, a cleaner, a paediatrician and two administrative staff per shift and an auxiliary nursing care technician) but with a good working atmosphere and good interprofessional relations. The feeling that we were all looking after each other has been present throughout the pandemic and the maintenance of small group communication times with security measures has helped to verbalise the stresses and emotions. 

 

It has not been easy to cope with the increase in incidence in the progressive waves, nor to witness the lack of care at the social level in protection measures or the lack of dialogue between the different administrations. The feeling of living in a "groundhog day" that repeats itself endlessly has been really uncomfortable, with frequent feelings of exhaustion, anger or despair. The good atmosphere among colleagues, the ease of finding someone to listen and everyone's willingness to help have softened the wounds and rough edges that everyone has inevitably experienced.

Dealing with helplessness and helplessness is never easy. The feeling of lack of support from our superiors and the healthcare institution in the face of peaks in demand, situations of sustained overload, insufficient protection against occupational hazards in the first few months, the fact of permanently assuming an increased care load due to the absence of colleagues who have not been replaced has generated fatigue and deep despair. Nor has it been easy to accept the erratic or self-interested behaviour of politicians, patients or segments of society when they were guided more by personal interest than by respectful attitudes towards others.

 

The institutional narrative has not been up to the task, given that the proposal of plans, white papers and so on remains a dead letter if it is not accompanied by lines of reinforcement, adjustments or real funding. On the other hand, the narratives of shipwreck, fire, death or catastrophe that trade unions and fed-up professionals have shared have not been of much help either. What is missing is a new narrative line that brings hope and rescues the values of Primary Care and its mission.

 

These learnings do not end here, nor does the pandemic. We have many months of work ahead of us, and new adventures and adverse circumstances may follow. The important thing is to open up a process of dialogue, reflection and quality communication between the teams among themselves and with the community and institutional leaders. A process that does not necessarily have to focus on "fixing the health system" but rather on enabling each team to manage itself a little better and to deepen its relationship with the community it serves. 

 

We are fortunate to have a public health system that serves the population. We must learn to value and care for this wealth, if possible before we have to turn to it as patients or see it destroyed because we have not known how to maintain it.

@doctorCasado
Link to blog "La consulta del Doctor Casado"

Bibliography

• Martí T, Peris A y Cerezo J. Spain, Transforming primary health care during the pandemic. World Health Organization, regional office for Europe, 2021
• Muñoz E. La entrevista telefónica. AMF 2020;16(11):659-667 available in https://amf-semfyc.com/web/article_ver.php?id=2852
• https://www.tandfonline.com/doi/full/10.1080/13814788.2020.1796962
• https://www.nhsconfed.org/publications/best-practice-and-innovation-during-covid-19
• https://theindependentpanel.org/wp-content/uploads/2021/05/COVID-19-SpanishFinal.pdf
• https://blogs.bmj.com/bmj/2021/04/01/preparing-for-the-next-pandemic-requires-public-health-focused-industrial-policy/