The impact of COVID-19 on primary care in Europe

COVID-19 continues to dominate the policy agenda across Europe. By 15 May 2021, there had been nearly 54 million cases of COVID-19, resulting in a million deaths in the European Region [1]. Countries in central and eastern Europe have been particularly badly hit, with some of the world's highest per capita death rates [2] Primary care has already played a crucial role in the health system response to COVID-19 and will continue to do so as we recover, but only if it is supported, as we now describe.

Primary care workers have struggled. Those in many countries, including Poland, Finland, Sweden, Greece, Ireland, and Germany have described some of the difficulties they faced when the pandemic began. As frontline health workers they confronted the fear and reality of becoming infected, the struggle to support their families, and the lack of resources such as personal protective equipment [3,4]. They had to rapidly rethink the way they delivered care as they embarked on remote consultations, while recognising that many of their most vulnerable patients were digitally excluded: likely contributing to widening socioeconomic inequalities [3]. Yet they came together with colleagues, providing mutual support as they adjusted to new ways of working, and a rapidly changing evidence-base [3] A study utilising the rich data available in England reported large reductions in primary care consultations for cardiorespiratory conditions including myocardial infarction and asthma, and especially so for diabetic emergencies, depression, and self-harm [5]. In Germany, there was a substantial fall in new cancer diagnoses in general practice [6].

Despite these challenges, primary care played a major role and continues to do so, in the pandemic response. Reports from Germany, Greece, Belgium, and England describe the creation of designated areas in primary care to segregate patients suspected or confirmed to have COVID-19, termed ‘corona centres’ or ‘hot hubs’ [7]. Reports from Armenia, Albania, Bulgaria, Belgium, Croatia, the Czech Republic, and Ukraine, among others, described the role multi-professional primary care teams played as the first point of contact for assessing patients with COVID-19 symptoms. They were able to order COVID-19 tests and interpret results, and some were also involved in contact tracing [7]. Remote primary care consultations were quickly implemented in many European countries, such as in Hungary, Greece, Estonia, and England, although this often created problems where patients paid out of pocket for consultations, and with reimbursement by insurers [7]. A report from one English region early in the pandemic found that 90% of general practitioner consultations were conducted remotely but complexities around clinical decision making were identified [8]. The digital expansion of primary care was forced due to COVID-19; rather than coordinated and planned.

Primary care is at the forefront of the COVID-19 vaccination campaign in many countries. Primary care staff, as trusted professionals who know their patients, are well placed to tackle vaccine hesitancy, especially in disadvantaged, and minority populations. However, the scale of the challenge of achieving equitable and high levels of vaccination, leaving no-one unprotected, is great [9].

As we move beyond the pandemic–now a real possibility because of the successful development of vaccines–public health will continue to be needed. The pandemic will leave a long legacy, with families coping with the loss of parents, wage earners, and other loved ones. There will be a continuing burden of disease caused by long-COVID. Those who have lost jobs or missed out on education will be at increased risk of mental health problems: there will be much to do, and there will have to be a sustained investment in primary care in Europe. Thankfully, there is now a better understanding in finance ministries and institutions, that strong primary care is essential if we are to develop resilient health systems and reduce health inequalities [10].

The WHO has an important role in supporting this process and developing sustainable primary care systems that adopt a population perspective. Priorities include reducing regressive out of pocket costs incurred in accessing primary care in some countries, greater awareness of models of good practice in patient-centred care, and co-producing solutions with patients. There are many potential benefits from pan-European collaboration: enabling knowledge sharing across borders is vital. There is also the need for sustained investment in robust, reliable, and secure information technology infrastructure that allows clinicians and patients the opportunity to undertake remote consultations safely aligning to data protection principles.

COVID-19 has shone a light on primary care: if we are serious about securing the health of Europeans in the future, we must now prioritise primary care, before the next pandemic.

Contributions

FM conceptualised and drafted the article. CDM and MM critically edited, revised, and contributed to refining the article, led by FM. All authors agreed on the final version to be submitted.

Declaration of interests

FM is funded by a National Institute for Health Research (NIHR) Doctoral Fellowship (NIHR300957). CDM is funded by the NIHR Applied Research Collaboration West Midlands and the NIHR School for Primary Care Research. Keele School of Medicine has received funding from Bristol Myers Squibb to support recruitment to a non-pharmacological atrial fibrillation trial.

The views expressed in this article are those of the authors, and not necessarily those of the NHS, NIHR, or the Department of Health and Social Care.