Main findings
OOH primary care services play a key role in dealing with acute illness in primary health care, but only in very few countries OOH primary care services had a pandemic plan or had done pandemic exercises before the COVID-19 outbreak in March 2020. Most respondents answered that protective equipment became available within weeks, but in some regions it took some months, and they experienced that secondary care was prioritized. Although many similarities existed among countries in the organization of testing, follow-up, and clinical examination, important differences were found. Some national governments build up new teams/offices, while others used the regular primary care system, but added extended telephone service, testing systems, and systems for follow-up of infected and close contacts.
Strengths and limitations
Although questionnaires have limitations with risk of selection and information bias, we considered this the most feasible method to get a broad picture of many European countries. No validated questionnaire was available. However, the authors who represented a range of countries discussed the questions to ascertain that these were perceived equally, to secure face validity. Still, we cannot rule out that respondents from so many different countries and with different language backgrounds interpreted expressions differently. We used as few answering categories as possible, and we added a free text option to limit this potential bias and secure content validity. The free text answers generally confirmed the answers that were ticked off.
Although the response rate was relatively low, we had answers from 2/3 of the EU countries. As some of the largest European countries, like France, Germany, Great Britain, and the Netherlands, did not participate, the results cannot be generalized to all of Europe. Key contact persons were probably missing for countries with a heterogeneous organization of OOH primary care, more likely larger countries. For countries with heterogeneous organizations, the invited key informants may have felt unable to respond, which might partly explain the low response rate [1].
This study dealt with the first five months of the pandemic, describing pandemic preparedness. Changes took place quickly, and better organization in the face of increasing infections may have occurred later, including increased access to testing and better access to protective equipment.
Comparison with literature
Our study showed that few countries had pandemic plans involving OOH services to such a degree that key informants were aware of them, even though earlier pandemics have made it clear that national and local pandemic plans are necessary to prevent, control, and respond to viruses with pandemic potential [13]. Primary care is central in all phases, and strengthening, integrating, and defining their role is essential in the preparedness [14, 15].
Very few regions reported that they had stockpiles of protective equipment. Nevertheless, only two countries responded that it was problematic to obtain enough equipment to protect health personnel in primary care during the first months after the outbreak. This result is in strong contrast to what is reported from low and middle income countries [16] and also in high income countries such as the US [17], where severe shortages in personal protective equipment during the COVID-19 crisis have been reported. The prior level of organization of primary care may be a factor here, which in general is high in European countries compared to low-income countries.
Extra personnel were used extensively, including students, retired, and former health care workers. All available health personnel were engaged to staff new organizations as “pandemic clinics” and test stations, and to replace health personnel in quarantine. Other studies have shown a large extent of charity present in the health personnel population that made it possible to get enough staff [18,19,20]. At the same time, a decline in the number of other infectious diseases and other emergencies contributed [21].
At the outbreak, alternative strategies for patient contacts became necessary. Our respondents reported that telemedicine in the form of video- and e-consultations was implemented, which is in accordance with other studies [10, 22,23,24,25]. In some countries, such contact types were in place prior to the pandemic, whereas other countries were not digitally ready to install this during the outbreak. Telemedicine has been used in primary care and emergency departments for monitoring patients, and in tertiary care and mental health care [26, 27]. Our results indicate that the OOH primary care services in many regions within a range of countries used video- and e-consultations, even though professionals have less prior knowledge about the patient compared to a daytime GP, and a physical examination probably is more often necessary compared with daytime primary care, where a substantial part of the patient population has chronic diseases.
Implications for practice and future research
As our study focused on the first five months of the pandemic, the results may be useful to compare with the organization of the OOH services in later waves of infection, to get insight into the experiences gained through different stages in the pandemic. Also, it would be interesting to repeat the data collection and ask key informants a second time a few years after beginning of the pandemic about preparedness and established strategies. Furthermore, there is a clear potential for improvement of making and training on preparedness plans that local and central health authorities should take seriously. To what extent OOH primary care was part of the initial response to the outbreak varied due to variations in the organization of OOH primary care. This provides potential for evaluation of the most effective methods and organizations during the pandemic and may inform plans for future pandemics.
The rapid and necessary change in contact forms during this pandemic has shown that telemedicine can be a useful supplement to regular consultations in the future, but it remains to be clarified under what conditions this contact form can replace face-to-face consultations.
Our study did not evaluate the quality of pandemic management. However, other research showed that countries with a fragmented health service seem to have suffered largely [7, 28]. Countries that previously had a well-organized primary health service were able to use this to expand capacity, handle triage, testing and follow-up, and screen patients without the need for hospitalization [10, 29]. Yet, there is a great learning potential for future pandemics.