16 primary care practices were selected: 5 solo working, 4 monodisciplinary and 7 multidisciplinary. Within these practices, 21 people were interviewed: 3 dieticians (all female, 0 to 6 years of experience), 2 nurses (all female, 9 and 13 years of experience) and 16 GPs (9 female and 6 male, 1 to 42 years of experience). An overview of the participants is provided in appendix 3. There were no important differences observed in the answers between male and female participants. Three major themes emerged: a) changes in health care organization; b) risk stratification; and c) self-management support.
Changes in the health care delivery system and team approach
The providers all observed a general drop in consultations for chronic care. They mentioned the emergency plan and subsequent prohibition to see patient for non-urgent problems as the direct cause, but also referred to fear among patients.
“Because they are afraid to come” (IV 17, GP, monodisciplinary group practice)
In all primary care practices, the initial response was a re-organization with a focus on securing access to and safety of acute care with much attention to COVID-19 suspects. This entailed telephonic consultation and collaboration with triage posts for patients with COVID-19 suspected symptoms and the re-organization of the practice in line with the hygienic guidelines to enable access for patients with acute non-COVID-19 related health problems. This absorbed most time and energy, leaving little room to consider anything else, especially as defining what is urgent was not self-evident to the GP’s.
‘In the beginning it was also very busy, so we just tried to do the most urgent. […]But what is urgent and what is not urgent? Chronic care becomes urgent also on a certain moment’ (IV 7, GP, multidisciplinary practice)
The majority of primary care practices did not plan the (re-)organization of chronic care.
Nurses and dieticians were frequently put on temporary unemployment by the practice owner due to a loss of revenues following the drop in consultations and their services considered ‘not essential’. However, practices with an established culture of dialogue (such as a tendency to hold meetings regularly) took a more systemic approach with team meetings about organization and patients.
‘Throughout the corona pandemic, so for seven weeks now, we have been meeting every afternoon for an hour about our patients, about the care, about the triage center, about having enough material, about cases, about yes, suicidal patients, about everything and more. Every day for an hour, so I think we are very alert for that and are fiercely engaged in doing the best possible care in this difficult period.’ (IV10, GP, multidisciplinary practice)
Collaboration and concertation with medical specialists was more difficult for non-acute matters, also because not all referral centers communicated clearly about their changes in schedule and way of working. Access for acute care was no problem.
Risk stratification and actively contacting patients
Few GPs had made a selection of high-risk patients to proactively contact to check whether they had medical or other problems. Most respondents recognized the value of such approach, but they mentioned barriers such as a lack of time and staff, ethical objections, and a limited knowledge on how to use the Electronic Medical Record (EMR) system.
‘I have a problem with people calling patients myself. There are colleagues who do that, but I have a bit of a problem with that. I have a regular audience, they will come.’ (IV8, GP, solo practice)
An important reported facilitator for pro-actively contacting patients was the availability of a list of the high-risk chronic patients extracted from the EMR, which was present in some larger group practices, and developed ad hoc in some others. GPs in solo practices indicated that they know their patients personally and that they would be able to identify high-risk patients by heart. When asked for examples of such patients, they mentioned different characteristics, such as those receiving home visits, of very old age, those not well-controlled, with recent change of medication, or patients reporting difficulties. GPs would approach such high-risk patients for a face-to-face consultation at their home or at the practice. Approaching patients actively was new to all GP’s.
‘Firstly, we have coded everyone in our practice with chronic pathology: hypertension, diabetes, COPD, asthma. It has been very easy for us to draw lists. We also exported lists of patients with depression and oncological disorders. We started by calling the diabetes lists: if you get sick or if you feel anything contact us.’ (IV13, GP, multidisciplinary practice)
In contrast to GPs, the dieticians interviewed stated the intention to contact all their clients for renewed appointments as soon as possible. This would also compensate for their unemployment during COVID-19.
The new option of teleconsultation provided primary care practices with a potential tool to monitor and support patients with chronic diseases from a distance. However, most respondents said to mainly use these teleconsultations to prescribe medications and to get a quick overall impression of the patient.
‘[...] actually, just verify how it's going. Are there any special complaints? Are they more tired? Can they still do their normal daily routine? Aren't they anxious with this corona virus?’ (IV3, GP, multidisciplinary practice)
They had various reasons to resist to real, complete phone or video consultations. A frequently given answer related to unfamiliarity with this way of doing consultations and the perceived inability to assess patients well. Other arguments were the preference of patients, the lack of perceived need and the lack of time because of long-lasting COVID-19-related consultations.
‘I cannot follow diabetes from a distance. I need to take lab tests, measure blood pressure.’ (IV8, GP, solo practice)
‘I did ask if they wanted it by phone or skype. But there are actually very few who have responded to that.’ (IV9, dietician, multidisciplinary practice)
In addition, self-management support was usually provided by the nurse or dietician, but due to the lower revenues, these staff members were put on temporary unemployment.
‘A nurse has not been able to work all the time, because everything a nurse does is not urgent or not essential or not life-threatening, or how should I put it.’ (IV10, GP, multidisciplinary practice)
Perceptions on the changes and effects on chronic patients
Respondents indicated that for the large majority of previously well-managed chronic patients the consequences of the COVID-19 outbreak and the associated re-organization of primary care would be limited. They argued that missing only one consultation is not problematic.
‘Most of those who follow the quarterly check-ups and are stable, are not going to suddenly get worse.’ (IV21, GP, monodisciplinary group practice)
However, there were worries about the effects on some patients, specifically those with socio-economic problems, whom they expected to experience more distress from COVID-19 and the lockdown. GPs mentioned that for these people, more unhealthy food and especially less physical exercise would probably be important causes of diabetes getting out of control.
‘Because you know a lot of patients have had a lot less exercise than normal. They've only been able to find their salvation in the fridge. So in terms of pounds and exercise, that's been dramatic for a lot of patients in the last few weeks.’ (IV12, GP, monodisciplinary group practice)
Most primary care practices were quite satisfied with the way their practice was organised and were proud of all the work they had done. Therefore, they did not plan on taking other measures next time, besides increasing their stock of protection material.
‘I think that we as general practitioners and certainly we as a practice do that super well, and I think that from the side of the government some other things might have happened there.’ (IV10, GP, multidisciplinary practice)