General practitioners’ experiences delivering essential care services during the 2020 and 2021 COVID-19-related lockdowns

During the height of the COVID-19 pandemic from March 2020 to December 2021, fear of overburdened hospitals and high mortality rates observed internationally contributed to aggressive pandemic mitigation strategies in Australia. During this period, the population was mostly unvaccinated.¹ Lockdown orders to work and learn from home, closure of public spaces (including dining and retail), curfews, and restrictions on exercise and group activity (including organised sport and social gatherings) were intended to reduce viral transmission.²

Healthcare delivery was particularly challenging during the lockdowns. Healthcare workers and patients risked COVID-19 transmission in healthcare settings, and managing serious COVID-19 illness became a public health priority.¹ In general practice internationally, strategies such as the rapid adoption of telehealth services (through telephone and video consultations) and prioritising treatment of COVID-19-related illness were used to minimise healthcare-related COVID-19 transmission, streamline workflow, enhance surge capacity, and conserve personal and protective equipment (PPE).

In March 2020, within weeks of the World Health Organization (WHO) declaring COVID-19 a pandemic and months before the introduction of vaccinations, the UK Royal College of General Practitioners (RCGP) released formal guidelines for general practitioners (GPs) and practices for safe service delivery during the COVID-19 pandemic.³ The guidelines acknowledged that some general practice services were ‘unlikely to cause harm if delayed for a short number of months’ and the risk of patients dying from non-COVID-19 illnesses if all healthcare resources targeted only COVID-19-related service delivery.³

The guidelines also presented recommendations for delivering essential care services using a traffic light system (Table 1).

There was no similar published protocol-based guidance available in Australia, and GPs and practices had to make autonomous decisions on how to feasibly provide care. Although primary health networks (PHNs) and state-based Royal Australian College of General Practitioners’ (RACGP) chapters provided educational webinars and Q&As with key health officers and similar to ensure GPs were aware of restrictions and legislative changes relating to COVID-19, emerging evidence and business support, no standardised guidelines were produced to guide actual service delivery. The aim of this study was to describe GPs’ experiences and approaches to delivering essential care services during the COVID-19 pandemic and explore whether GP service delivery in Australia was in line with RCGP guidance.

Methods

Participants

Participants were GPs who were practising in metropolitan Melbourne and Sydney during COVID-19 lockdowns and had practised for at least six consecutive months prior to the pandemic to compare baseline practices. A recruitment target of 381 GPs was identified to reduce research demands on overworked GPs but still meet necessary sample size calculations. Electronic invitations were circulated through newsletters and social media of professional networks (including the Monash University Practice Based Research Network, the SPHERE Centre of Research Excellence, the Australian Medical Association Victoria and NSW, PHNs and the RACGP) and the GPs Down Under Facebook group (for a copy of the electronic invitation, please contact the corresponding author). Interested participants were sent a personalised link to the survey following a short electronic eligibility assessment. On completion of the survey, GPs were offered gift cards to the value of $30.

Procedures

The de-identified electronic survey was conducted in May 2021 using the Qualtrics platform. It included 45 close-ended, multiple-choice questions and took 10–15 minutes to complete (for a copy of the survey, please contact the corresponding author). After a brief section on demographics, Part 1 of the survey collected data relating to change in delivery of general practice care during the COVID-19 pandemic. In Part 2, participants reported their experience delivering various care items as one of three responses modelled on the UK RCGP traffic light system of green (continued regardless of outbreak scale), amber (continued if capacity allowed) and red (postponed, with aim to revisit). Pilot testing for usability and technical functionality was undertaken by 16 academics from various backgrounds at the Monash University Department of General Practice, and feedback was incorporated into revisions before fielding the survey.

Statistical analysis

Survey responses were summarised as descriptive statistics. Participant demographics and practice characteristics are presented as discrete frequency counts and percentages. We assessed homogeneity in proportions based on P-values associated with Pearson χ² statistic. Statistical significance was determined at an alpha of 0.05.

Ethics approval

The project was approved by the Monash University Research Ethics Committee (project ID 27635).

Results

Between May and December 2021, 291 electronic surveys were received, of which 17 were only partially completed.

Participant demographics were generally comparable to the wider Australian metropolitan GP population (Table 2). Most were from Melbourne (190/291; 65.3%), 53% were women (154/291; 52.9%), and half were aged 46 years or over (144/291; 49.5%). Most participants were Fellows of the RACGP (249/291; 85.6%).

Experiences and approaches to delivery of clinical services

Lockdowns changed the mode of GPs’ delivery of medical care, with almost universal uptake of telehealth. Overall, 95.2% of participants reported increased use of telehealth for diagnosis, investigation and management of clinical conditions, and 96.6% increased use for follow-up. Many aspects of general practice were triaged for time sensitivity and postponed by GPs (Table 3). Some 61.2% of participants postponed or delayed a procedure or referral, and 52.9% of participants postponed a GP-initiated scheduled consult. In contrast, only 36.8% of participants postponed a patient-initiated scheduled consult. Additionally, 47.1% of participants reported a decrease in clinical care to emergency walk-in patients.

Preventative care

A varied approach was taken to the delivery of preventative care during lockdowns. Some preventative health activities were largely continued as normal, including childhood and adult immunisations, which only 5% of participants postponed despite requiring face-to-face care. However, other activities were often delayed, including health assessments and medication reviews, which were postponed by 37.6% of participants despite the potential for telehealth delivery of some of these activities. Variation in delivery seemed to relate to the potential health effects of services; activities that had definite or immediate health outcomes (eg immunisations) were continued more commonly that services that had possible health implications (eg screening or health assessments).

Women’s health

Of the seven women’s health-related items asked about, four were continued regardless by most participants: high-risk cervical cancer screening, 68.7%; contraceptive counselling, 68.3%; postnatal checks, 63.3%; and abortion services, 62.3%. Items that necessitated face-to-face care and were not perceived as clinically urgent were more commonly postponed than services that could be delivered by telehealth or were not time sensitive (eg routine low-risk cervical screening was postponed by 28.1% of participants, intrauterine device insertion or removal was postponed by 18.1%, and contraceptive implant insertion or removal was postponed by 14.2% of participants).

High clinical acuity conditions

Care for five of the six conditions requiring urgent care or that were of high clinical acuity were continued by most GPs. For instance, 93.6% of participants continued as normal for care of symptoms consistent with cancer, and 91.1% of participants continued investigations for immediately necessary conditions such as serious anaemia. Most urgent or high acuity care could be delivered by telehealth and was postponed by less than 3% of participants. In contrast, acute home visits to housebound/residential or nursing home patients, which required face-to-face delivery, were postponed by 18.1% of participants.

Low clinical acuity conditions

Care for low clinical acuity conditions varied markedly and was similarly driven by time sensitivity or options for safe telehealth delivery of care. Items commonly postponed included spirometry and routine echocardiograms (postponed by 66.2% of participants), data collection requests (50%) and minor surgery (43.1%). Only 20% of participants postponed aviation or driver’s licence medical examinations and less than 2% postponed (time-sensitive) essential injections such as Prolia for the management of osteoporosis.

Table 4 provides further details regarding GP delivery of specific services during the COVID-19 pandemic. Few differences were found between Melbourne- and Sydney-based participants or by years of practice.

Guideline concordance

Of the 30 essential care services outlined in the RCGP guidance, GPs reported consistent practices for 17 items. Except for acute home visits (which the UK recommended to continue as normal but Australian GPs continued if capacity allowed), the remaining 12 services were all continued as normal or if capacity allowed by Australian GPs, whereas UK recommendations advised more restrictive practices. Table 5 compares RCGP recommendations and consensus Australian GP practices using the colour-coded traffic light system.

Discussion

GPs delivering essential care services during COVID-19 lockdowns described a large shift towards telehealth delivery across the board from diagnosis to follow-up, even for high acuity or urgent care conditions. Almost one-fifth of GPs postponed home visits for housebound/residential and nursing home patients. Time-sensitive conditions and preventive care that might be perceived as having a definite or immediate effect were also continued by a larger number of practitioners.

Despite the lack of clear national guidance (or even local guidance by PHNs, state health departments or state-based RACGP chapters, all of whom were suitably placed to provide standardised guidelines), Australian GPs still appear to have workably triaged the provision of essential care services throughout the lockdowns. This might have been guided by community priorities, social media forum discussions, modelling of peer practices, and independent clinical judgements of COVID-19 risks to providers and patients.^1,4,5 Australian practices were concordant with close to 60% of the UK RCGP guidance and otherwise tended to continue providing care as normal, while the RCGP recommended more restrictive practice. Emerging studies of UK GP compliance with RCGP guidance suggest a similar embrace of telehealth services with potentially more encouragement of video-based consultations.⁶ A qualitative study from 2021 showed general compliance with RCGP recommendations, with some UK GP autonomous decision-making around safe face-to-face care delivery where there was ‘knowledge of the patient, experience and practice resilience’.⁷ Similarly, our results showed that GPs in Australia followed the broad guidance that was issued. The interview study associated with our project might provide more insight into the specific factors that guided Australian GP decision-making processes around service delivery during the lockdowns.

The differences in international findings are likely to reflect the influence of several contextual factors. First, at the onset of the pandemic and throughout lockdowns, Australia introduced rapid and widespread access to bulk-billed telehealth services.⁸ As a result, Australian GPs and practices could continue to provide even low clinical acuity care through telehealth while eliminating the risk of COVID-19 transmission. Second, the UK experienced a significantly worse COVID-19 outbreak than Australia, with more pressure on GPs and GP practices to provide COVID-19-related care.⁹ At the height of the 2020–21 pandemic, Victoria was reporting fewer than 900 new daily COVID-19 cases,² compared to over 50,000 in the UK.⁹ Third, the lockdown objectives in Victoria included eliminating COVID-19 transmission and reaching a ‘COVID zero’ goal.¹ Therefore, more aggressive restrictions were implemented, including healthcare and aged care workers needing to limit their physical presence to a single workplace or healthcare setting to conserve PPE and avoid cross-contamination.¹⁰ This might have influenced Australian GPs postponing visits to homebound or nursing home patients, despite such visits being recommended by the RCGP guidance to continue as normal. Finally, during the lockdowns, GPs faced considerable shortages of and difficulty accessing PPE. Government stockpiles were preferentially channelled to hospitals and practices, practices needed to source and purchase PPE privately, and there was a lack of access to routine fit testing of masks.¹¹ Further research in terms of a national study of Australian GPs might further clarify disparities in practice, given the widely differing lengths of lockdown across the country and the severity of regional COVID-19 outbreaks.

Services that were time sensitive or had immediate health effects were generally continued as normal, even if delivered face to face. Our findings that only 5% of GPs postponed routine childhood immunisations was supported by Australian Immunisation Registry data demonstrating that the Victorian childhood vaccination program was largely unaffected by COVID-19.¹² Local health promotion efforts in later lockdowns might have encouraged parents to follow vaccination schedules despite parental and provider fears of COVID-19 transmission.¹² These Australian findings differ starkly to global averages of 7–8% reductions in childhood diphtheria–tetanus–pertussis and measles-containing vaccinations during the COVID-19 pandemic.¹³ Although participants reduced reported delivery of clinical care to emergency walk-in patients, duty of care requirements did not change during the COVID-19 pandemic. Therefore, it is unlikely that half the number of GPs stopped providing urgent medical assistance. Rather, half of our participants might have seen reduced emergency walk-in patients because of the lockdown.

A key limitation of this study is that it did not achieve the targeted number of participants despite using reliable techniques to improve recruitment (ie a physician recruiter, university affiliation, financial incentivisation and brevity in design).^14,15 COVID-19-related work commitments and personal and professional burnout are likely to have contributed to GP reluctance to engage in this research.^1,5 Demographic data relating to practice funding models (ie bulk-billing or private billing) would have assisted with meaningful interpretation of differing practices, given the financial pressures on GP practices as small businesses during the COVID-19 pandemic. Data relating to proximity or concurrent practice at a government-funded COVID-19 respiratory clinic (that typically had well-stocked PPE) would have provided additional insights into scope of practice delivered and telehealth practices. Finally, some GPs might have had difficulty interpreting survey items due to the wording being derived directly from the RCGP guidelines and, therefore, being more appropriate for the UK setting. Again, the interview study that followed this survey will help explore and interpret these findings.¹⁶

Future research could compare the provision of essential care services across differing healthcare settings (eg general practice, hospital outpatient clinics, councils, schools, and community maternal and child health centres) and timepoints (including before and after the rollout of the national COVID-19 vaccination program and during outbreaks of differing COVID-19 strains). Studies evaluating whether UK GPs followed the recommendations of the RCGP document or had discordant practices themselves are only just emerging and would help in understanding the contextual effects on GP decision making and guiding appropriate revision of the guidelines.

Conclusion

This study reports on the experiences of Australian GPs in 2020 and 2021 during the COVID-19 pandemic. Unfortunately, we are likely to face future pandemics. Understanding the experiences of GPs during the COVID-19 pandemic and providing guidance to practitioners in primary care about how to approach service delivery during a pandemic will help future preparedness. Australian guideline developers should act soon to develop national guidance that considers local contextual factors and provider experiences through the COVID-19 pandemic.