Primary Health Care Comes Second in Pandemic Planning
No one knows when the next influenza pandemic will happen. But the odds of it happening in the near future are shortening. H5N1 influenza, an avian influenza of considerable pathogenicity, was first isolated from a farm goose in China in 1996. By mid-November 2006, 258 cases had been reported among humans around the world, and of these, 153 had died. H5N1 has a high case fatality rate among humans, but there have been as yet no confirmed cases of the virus spreading between humans. To do this, the virus would have to undergo genetic reassortment to make it highly transmissible between humans, as well as pathogenic to them - although the case fatality rate will be less than case fatality rates reported for avian influenza. We may be waiting for the disaster that never comes. But wisdom lies in preparing, and so governments around the world have begun to plan for and develop test plans for pandemic response by health services.
The missing plan for primary health care.
What’s missing from most national plans is a detailed plan for pandemic preparedness and response in primary health care. This may seem surprising, as most of the health care in many countries is conducted through general practice or community health services, not hospitals. In Australia, for example, there are nearly 98 million visits to general practitioners per year (equivalent to 4 visits for every Australian per year), and only 6 million visits for ambulatory care to hospitals. In our research into possible primary care responses to a pandemic, we identified three aspects of primary health care which make it central to pandemic response planning.
Most people will prefer to attend their usual primary care provider in a pandemic.
We know from past influenza epidemics, and from the SARS experience, that people trust and go to their local health care providers in an infectious disease emergency. They tend to steer clear of hospitals and other large health services, which can be seen as potential sites of infection, staffed by strangers. Recognising this, the Government of Singapore recently announced plans to move from providing 18 large government-run polyclinics to 1000 general practice-run clinics. A prepared health sector would also have a contingency plan for the early peak in infection rates likely to occur among workers in primary health care treating patients with respiratory infection.
The primary care sector is where the most marginalised, the poor, and those with chronic illnesses are managed.
An effective primary health care system is able to keep the most vulnerable out of hospital. This will become paramount in a pandemic, when hospital beds will be needed for those with complications of influenza. Essential primary health care, for the aged, for people with chronic illnesses, is not discretionary. It will need to continue in concert with the public health effort and the primary care response to influenza.
Primary health care helps to ensure social distancing measures are effective and safe.
The Australian national pandemic response plan, like many national plans, now focuses on social distancing and voluntary quarantine of infected people and their contacts, rather than on treatment with antivirals. This reflects uncertainties about antiviral supply and the effectiveness of antivirals in treatment if not given early in the illness. Social distancing aims to blunt the impact of the pandemic and buy time to develop and distribute a vaccine.
Recent research from the USA has found that those with chronic diseases are least likely to have someone at home to care for them should they need to be isolated. The aged are likely to find that some social gatherings, such as church, that allow intercurrent monitoring of their health, will cease. The public health sector is unlikely to have the capacity to monitor large numbers of quarantined or isolated persons. A more efficient approach may be to use the local health care providers within a region to ensure the health and safety of their isolated or quarantined patients.
How might primary health care reorganise itself for a pandemic?
The key activities primary care services will undertake in a pandemic are:
· provide essential primary health care, including some acute care currently provided in emergency departments
· provide influenza-specific health care
· contribute to the public health containment response for pandemic influenza
How primary care services do this will differ from country to country. Even within countries, the environment of primary health care varies, and so plans will need to be flexible enough to address the needs of a region where services are provided by doctors who also work in community hospitals, and another where services are provided through cooperatives of medical and allied health workers independent of hospitals. Countries with strong interlinkages between primary care services (for example, those with nationalised health services, or systems of linking primary care services such as New Zealand, and to a lesser extent Australia, and some corporate general practices) may find it easier to develop robust, regionalised plans. However, these plans will fail if they are not integrated into hospital and public health plans, with recognition that changes in one sector inevitably lead to changes in the ways that services are delivered in other sectors.
We anticipate that a mix-of-services model is likely to be the most appropriate for the primary care sector. Some health services could provide essential, non-influenza related primary health care, others provide influenza-related care, and others undertake specific services to support public health, such as home contact in person or by telephone. Many of these activities cannot be undertaken at present, because of structural impediments to rapid, short-term reform in primary health care (Box). Careful analysis of the fault lines in primary health care systems, and innovative policies, will be needed to support the most effective use of primary health care in a pandemic.
Box: Impediments to primary care sector responses to a pandemic, and possible solutions
Potential impediments to primary care response to a pandemic
Part-time workers with carer responsibilities
In many countries, part-time workers and women are over-represented in the primary care sector. This workforce is likely to have ongoing carer responsibilities in a pandemic.
Provision of antivirals to be given to families of workers
Restructuring work so that health workers can work from home (eg on telephone)
Undersupply of general practitioners
There is a global shortage of general practitioners.
Other health workers to take on primary care duties (allied health workers, private specialists)
Financing models for general practice
Some financing models for general practice do not allow, or underfund, services such as telephone or internet consultations, and home visits, and require these tasks to be performed by doctors
Review funding models for a pandemic to allow broader mix of services and providers
In the altered environment of a pandemic, it may be impossible to follow “best practice”. Practitioners may find themselves liable for this after the pandemic.
Legal amendments for a pandemic to specify the level of liability for practitioners may need to be enacted.
Lack of collaboration between primary care services
Many primary care services have a history of business competition, and may have little experience of collaborative work
Develop and deepen links between health care services, and define areas of potential collaboration ahead of time.
Lack of collaboration between public health and primary care services.
In many countries, these two health sectors operate almost independently.
Define and develop formal routes for collaboration between peak bodies, and between local public health and primary care services.
Presented at 49th Annual Science Convention, Brisbane, Australia (5-8 October 2006)