Five principles have underpinned Australia’s primary care response to COVID-19: 1) protection of vulnerable people, 2) provision of treatment and support services to affected people, 3) continuity of regular healthcare services for the whole population, 4) protection and support of primary care workers and services and 5) provision of mental health services to the community and the primary care workforce.
1,2 These were rapidly developed to inform policy at the beginning of the pandemic in collaboration with representatives from the primary healthcare sector, general practice and more than 30 peak national organisations.
1
In scoping the emerging literature on COVID-19 during 2020 and considering its policy relevance, we identified six emerging challenges that highlight the importance of the five principles. These challenges were: 1) improving collaboration between primary care and public health, 2) including primary care–tailored guidance in pandemic preparedness plans, 3) ensuring provision of regular primary healthcare, 4) using alternative consultation modalities to provide healthcare, 5) improving approaches to sourcing, stockpiling and distributing personal protective equipment (PPE) and 6) supporting the mental health of the primary care workforce and patients.
We examine the relevance of the five principles to reported experiences of COVID-19 through the lens of these six key challenges. We show the interconnectedness of the five principles and their applicability to each of the challenges in Table 1.
| Table 1. Matrix of the five principles in relation to early international experiences of COVID-19 |
| |
Principle |
| |
|
1. Protection of vulnerable people |
2. Provision of treatment and support services to affected people |
3. Continuity of regular healthcare services for the whole population |
4. Protection and support of primary care workers and services |
5. Provision of mental health services to the community and the primary care workforce |
|
Key challenge
|
1. Improving collaboration between primary care and public health |
Local, regional and national identification of vulnerable populations |
Understanding of issues that influence implementation of primary care response |
Identification of primary care workforce needs |
Clarification of health and social care networks and services |
| 2. Including primary care–tailored guidance in pandemic preparedness plans |
Primary care–tailored guidelines for identified vulnerable populations |
Coherent participation of primary care clinicians in pandemic response |
Primary care role clarification |
Role clarification and guidance reducing stress |
| 3. Ensuring provision of regular primary healthcare |
Access to care, including face-to-face, as required |
Clarification of separate pathways of care for affected people |
Understanding differences between low-, middle- and high-income countries |
Protection of primary care workers and services |
Ensuring access to ongoing mental healthcare |
| 4. Using alternative consultation modalities to provide healthcare |
Protection of vulnerable patients and clinicians; identification of disparities in access to telehealth |
Provision of treatment and advice to patients with COVID-19 |
Provision of regular healthcare services |
Minimisation of transmission risk |
Access to new and ongoing mental healthcare |
| 5. Improving approaches to sourcing, stockpiling and distributing personal protective equipment |
Minimisation of transmission risk |
Distribution of personal protective equipment to primary care workers and services |
| 6. Supporting the mental health of the primary care workforce and patients |
Identification of vulnerable clinicians and patients |
Clarified pathways of care reduce unwarranted stress for clinicians and patients |
Access to mental health support both virtually and face-to-face as required |
1. Improving collaboration between primary care and public health
While primary care and public health are complementary primary healthcare initiatives, epidemics are largely considered to be public health emergencies, with little emphasis on the critical role of primary care in providing first-contact care. Challenges to collaboration between primary care and public health relate to differing functions and responsibilities, and limited mutual understanding.3,4 Collaboration is an essential foundation for effective information sharing; primary care clinicians and organisations have insights to share regarding the communities they serve and their vulnerabilities, and specific primary care workforce and services requirements.5
While there is some current evidence of effective health sector collaboration,6,7 in many countries primary care specialists are notably absent from COVID-19 taskforces; politicians, public health specialists and epidemiologists predominate while others, including mental and social health experts, are omitted.8 The Australian Health Protection Principal Committee, the peak medical advisory committee to the Australian Government, included primary healthcare experts in daily meetings throughout the early months of the pandemic.9 A primary care voice at decision-making tables enables activation of the five principles from the beginning – identifying vulnerable populations, health workforce needs and appropriate response planning. Without this, it is impossible to gain sufficient understanding of the issues that will influence primary care response strategies for health sector preparedness.
2. Including primary care–tailored guidance in pandemic preparedness plans
Guidelines tailored to each component of the sector, including primary care, are essential to inform coherent participation of frontline clinicians in the response.10–13 Specific tailoring may also be needed when epidemiological context varies at different times and to different degrees across geographic boundaries.14 Appropriately tailored guidance supports enaction of the principles relating to treatment and support of affected people, and continuity of regular healthcare provision. It also shapes workforce participation to protect patients and healthcare workers from disease transmission.
While some countries have developed primary care consensus standards for COVID-19,15,16 internationally, primary care clinicians have reported enormous clinical and emotional burden in responding, with many feeling ill-informed regarding how to fulfil their roles.17,18 While they have been creative in response – developing local health professional hubs, sharing workforce, establishing dedicated clinics,17 introducing or expanding digital consultation methods and triaging COVID-19 from non-COVID-19 care18 – their call for clear and consistent guidance is resounding.17–20
3. Ensuring provision of regular primary healthcare
COVID-19 has exacerbated many existing health disparities.21 The principle of ensuring continuity of regular healthcare services for the whole population protects those who are most vulnerable, including people with new and existing mental health problems. Internationally, disruptions to all essential services have been reported, especially in lowand middle-income countries, where reproductive, maternal, newborn, child and adolescent health services have been substantially affected, increasing mortality risk among these vulnerable populations.22 Some high-income countries have prioritised primary care provision of mental health and social care,23 reporting reductions in adult vaccinations, routine health checks and chronic care.23,24
4. Using alternative consultation modalities to provide healthcare
Widespread uptake of telehealth consultations has played a substantial role in facilitating management of COVID-19 and non-COVID-19 care.25,26 While simultaneously protecting vulnerable patients and clinicians,7,27 unprecedented transition to telehealth internationally has enabled treatment and advice to people with COVID-19, preserved the provision of regular healthcare services and maintained workforce capacity through minimising transmission risks,7 reflective of all five principles.
However, telehealth may not work for some patients with complex needs and is not always an appropriate substitute for in-person care.28,29 Disparities in internet access, digital readiness and infrastructure suitability may accentuate inequity,23,30 especially for the elderly,31 people with disability32,33 and those living in rural and remote areas.34 Identifying and responding to these vulnerabilities needs to be prioritised to fully realise the first principle.
5. Improving approaches to sourcing, stockpiling and distributing personal protective equipment
Adequate and appropriate PPE is a critical antecedent for the protection and support of primary care workers and services, safe treatment of individuals with suspected or diagnosed COVID-19 and, in turn, the continued provision of regular healthcare services. During COVID-19, clinicians have reported being ill-equipped to protect themselves and their patients.18,24 Protection and support of primary care workers, including access to appropriate and sufficient PPE, is ultimately linked to workforce mental health and wellbeing.35,36 The impact on the health workforce has been significant, including elevated anxiety levels; the Australian Government has prioritised implementation of the fourth principle, the protection and support of primary care workers and services, to address this.7
6. Supporting the mental health of the primary care workforce and patients
High levels of stress among primary care workers and increased suicidality among patients have been reported;23 many are afraid of contracting COVID-19 and of passing it on to others, including family members.23,37 Some primary care staff have lost their jobs or been forced to reduce hours due to illness or lack of practice income as a result of COVID-19.23,24 The principle of providing mental health services for the community and primary care clinicians is fundamental to developing community resilience38 and preserving workforce capacity to provide treatment and support for both people with COVID-19 and regular healthcare services. Some require the development of new skillsets to achieve this. Managing work-related exposure risk is a critical work health and safety issue, and a fundamental pillar of mental health and wellbeing for the primary care workforce.
Connecting COVID-19 experiences with underpinning principles
The five principles underpinning Australia’s primary care response to COVID-19 respond directly to the early COVID-19 experiences described. In fact, some directly mirror key challenges, such as the continuity of regular primary care, the protection of primary care workers and services, and support for the mental health of the primary care workforce and the community. The use of a matrix demonstrates overlap between the principles, which we feel provides a protective effect, ensuring that the whole population is considered and cared for through provision of treatment and support for patients with COVID-19, continuity of regular healthcare and provision of mental health support. We believe the five principles capture the key policy requirements to inform a well-rounded primary care response.
First published online 5 February 2021.