English and Italian national health services: Time for more patient-centered primary care?

Assessing primary healthcare disaster preparedness: a study in Northern Italy

AIM

The aim of this paper is to outline the steps taken to develop an operational checklist to assess primary healthcare (PHC) all-hazards disaster preparedness. It then describes a study testing the applicability of the checklist.

BACKGROUND

A PHC approach is an essential foundation for health emergency and disaster risk management (H-EDRM) because it can prevent and mitigate risks prior to disasters and support an effective response and recovery, thereby contributing to communities' and countries' resilience across the continuum of the disaster cycle. This approach is in line with the H-EDRM framework, published by the World Health Organization (WHO) in 2019, which emphasizes a whole-of-health system approach in disaster management and highlights the importance of integrating PHC into countries' H-EDRM. Nevertheless, literature focusing on how to practically integrate PHC into disaster management, both at the facility and at the policy level, is in its infancy. As of yet, there is no standardized, validated way to assess the specific characteristics that render PHC prepared for disasters nor a method to evaluate its role in H-EDRM.

METHODS

The checklist was developed through an iterative process that leveraged academic literature and expert consultations at different stages of the elaboration process. It was then used to assess primary care facilities in a province in Italy.

FINDINGS

The checklist offers a practical instrument for assessing and enhancing PHC disaster preparedness and for improving planning, coordination, and funding allocation. The study identified three critical areas for improvement in the province's PHC disaster preparedness. First, primary care teams should be more interdisciplinary. Second, primary care services should be more thoroughly integrated into the broader health system. Third, there is a notable lack of awareness of H-EDRM principles among PHC professionals. In the future, the checklist can be elaborated into a weighted tool to be more broadly applicable.

Improving primary care in Europe beyond COVID-19: from telemedicine to organizational reforms

The COVID-19 pandemic has put under pressure all the health national systems in Europe and telemedicine (TM) has been an almost unavoidable answer for primary care (PC) services to constrain the contagion. PC includes all the healthcare services that are the first level of contact for individuals. General practitioners (GPs) are the pivotal providers of PC throughout Europe. Although GP costs are mainly covered by public services or social insurances in Europe, they are still self-employed physicians everywhere, differently from their colleagues in hospitals who are traditionally employees. TM is a very general term open to various interpretations and definitions. TM can now be practiced by means of modern audio-visual devices and is an alternative to the traditional face-to-face consultation in general practice. Although the adoption of TM seems to be compelling in our era, its practical dissemination in PC has been quite slow so far, and many different concerns have been raised on it. On the whole, TM widespread adoption in PC seems to be more a matter of labor organization and health care funding than of technology and ethics. Larger-scale organizations comprising a wide range of health professionals have become a pressing priority for a modern PC, because working together is crucial to provide high-quality care to patients, and co-location should boost teamwork and facilitate the management of information technology. A national network of large organizations in PC could be rationally managed through local budgets and should increase efficiency by adopting tools such as TM.

General Practitioners' Experiences During the First Phase of the COVID-19 Pandemic in Italy: A Critical Incident Technique Study

Since February 2020, when coronavirus disease began to spread in Italy, general practitioners (GPs) were called to manage a growing number of health situations. The challenges experienced by Italian GPs remained unrevealed. This study aimed at exploring Italian GPs' care experiences and practices associated with critical incidents during the first wave of the pandemic. A qualitative study design involving the critical incident technique through an online survey was applied. Sociodemographic data and open-ended responses were collected. While participants' characteristics were analyzed through descriptive statistics, qualitative data were thematically analyzed employing the framework method. 149 GPs responded to the survey and 99 participants completed the survey (dropout rate = 33%). Eight themes emerged indicating factors related to the organization of the healthcare system and factors related to the clinical management of patients, that were perceived as impacting on the GPs' care provision. The analysis revealed difficulties in communicating with other local services. This, together with the lack of coordination among services, was reported as a major challenge. Primary care was perceived as having been undervalued and criticalities in the organization of GP courses, led in a bureaucratic fashion, posed at risk some trainees to be infected. The digital technologies adopted for remote patient consultations were seen as useful tools for daily practice helping the GPs to stay emotionally connected with their patients. Besides, the improvement in the GP–patient relationship in terms of solidarity between patients and doctors and compliance to rules, had a positive impact. Moreover, many respondents addressed the importance of professional collaboration and teamwork, in terms of both support in practical issues (to find PPE, diagnostics and guidelines) and emotional support. At the same time, the lack of resources (e.g., PPE, swabs) and of specific guidelines and protocols impacted on the care provision. Our findings suggest that GPs in Italy are at risk of being left behind within the epidemic management. Communication and coordination among services are essential and should be substantially improved, and primary care research should be initiated to collect the context-specific evidence necessary to enhance the system's preparedness to public health emergencies and the quality of primary care services.

Increased Risk of COVID-19-Related Deaths among General Practitioners in Italy

To date, data on COVID-19-related death cases among physicians from different medical specialties are incomplete and scattered. In Italy, available data highlight that general practitioners (GPs) are, apparently, the most heavily affected group. Indeed, they currently represent 44.1% of the total COVID-19 related death cases occurred among physicians, whereas they constitute about 15% of the total number of doctors. This high proportion is most likely the consequence of a work-related contagion happening especially during the first weeks of the epidemic, and persisting also in the following weeks, after the national lockdown. There are various reasons for these higher contagion rates: GPs perform a lot of medical examinations daily, usually in close contact with patients. Especially at the beginning of the epidemic, GPs might have had scant information on the specific safety procedures for the prevention of SARS-CoV-2 transmission (e.g., there was limited knowledge on the possibility of contagions deriving from asymptomatic patients) and, moreover, the availability of personal protective equipment was insufficient. Furthermore, the risk of infection is highly increased by the virus' characteristics, like its survival for several hours/days on different surfaces and its persistence in the air after an aerosolization process, with possibilities to be transmitted over distances longer than two meters. Following these observations, and considering the high cost in term of GPs' lives, the COVID-19 pandemic will probably revolutionize the approach to patients in general practice. Clear and effective guidelines are absolutely and urgently needed for the refinement of adequate measures to prevent SARS-CoV-2 infections among GPs.