Organising community primary care in the age of COVID-19: challenges in disadvantaged areas

To tackle the more than 139 000 cases of COVID-19 in France as of May 11, 2020,¹ a tremendous reorganisation of the entire health-care system was done. While public hospitals were on the frontline of the crisis, the growth of the epidemic warranted the inclusion of all health-care system staff in the response—in particular community health-care workers. The challenges of efficiently organising the response of multiple partners were heightened in deprived areas such as the northern suburbs of Paris: pre-existing health-care shortages² combined with the demands of a population often living in unstable and unsanitary housing³ required a different approach. Moreover, specific challenges have arisen from the COVID-19 epidemic. First, the general shortage of personal protective equipment meant it was delivered to community health-care workers in insufficient quantities, sometimes through inadequate channels. Although not unique to France,⁴ this particular issue has crystallised discontent and fuelled a feeling of abandonment from public authorities. Second, the large push towards large-scale implementation of digital solutions such as teleconsultations was found to be inappropriate in deprived areas, where access to the internet is relatively scarce, patients have little digital literacy, and language barriers abound.⁵

In this context, coordinated efforts between hospital and community primary care have been crucial to maintain adequate health services. In the management of the COVID-19 outbreak, these efforts encompass upstream screening of suspected cases and coordination of patients' follow-up after hospital discharge, as well as management of elderly and frail patients with COVID-19 when hospitalisation is not indicated. Moreover, as hospital beds for other conditions have been drastically reduced, primary care providers are now required to deal with emergency situations for chronic diseases.

Experiences of rapid reorganisation of primary care providers' networks in disadvantaged districts with susceptible populations could inform the current governance of the pandemic and could be replicated effectively across France. For example, in Pantin, a municipality in Seine Saint Denis, a network built on previous multidisciplinary collaborations laid the groundwork for a massive and quick reorganisation based on trust and complementary expertise between partners. Specific COVID-19 community screening facilities were deployed in the first weeks of general lockdown, local governments were tasked with securing personal protective equipment (including from donations or home-made equipment) and to obtain temporary housing solutions for patients whose home confinement conditions were inappropriate, and humanitarian associations helped to open dedicated facilities for isolation of homeless patients.

To smoothly tackle downstream care of recently discharged patients, discharge criteria were co-created between the network and the local university hospital. This process helped to increase patient security and to share responsibilities between hospital and community professionals. Home visits were divided between patients with and without COVID-19 to mitigate the risk of disseminating the disease via health-care workers. Teams allocated to patients with COVID-19 included primarily care professionals with few or no risk factors for severe disease or having already recovered from the virus. Finally, triage and prioritisation criteria for patients without COVID-19 were developed to ensure usual care of chronically ill patients to avoid further delays in follow-up visits.

Although ad-hoc solutions were proposed by dedicated professionals, support and resources are far from adequate, with a highly heterogeneous response depending on the local context and existing collaborations.

Overall, these examples illustrate the resilience and innovation capacities of hospital and community health-care professionals' networks at a time of considerable strain. This experience advocates for a renewed partnership between hospital and community health-care after the COVID-19 crisis.