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      Editorial: Challenge and resilience: primary care in a COVID-19 world

      editorial
      Primary Health Care Research & Development
      Cambridge University Press

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          Abstract

          Primary care is relationship-based care. Connection, communication and collective decision-making with our patients are key components. COVID-19 has disrupted the primary care landscape in many ways, and both clinicians and patients have experienced high levels of stress. The initial lockdowns in many countries meant that suddenly clinicians were unable to maintain the healing relationships with their patients. Primary care clinicians have reported increasing levels of mental exhaustion and burnout as the pandemic has progressed, in part due to their inability to provide the care their patients need. When practices had to close their physical doors, income plummeted for many, and some primary care clinicians lost their jobs. The loss of practice income was compounded by additional costs such as financing personal protective equipment, requirement to adopt new information technologies, and reconfiguring their premises to triage possible COVID-19 cases and provide parallel segregated services for ‘red’ and ‘green’ streams. Hospitals stopped accepting referrals for non-COVID-19 patients, and urgent investigations and treatments were deferred. Practices raced to connect with their patients remotely through telehealth, using phone, video, email, patient portals and other technologies. Innovative apps allowed patients to pass photos to and fro. However, some patients lacked access to mobile phones and the internet, and this digital divide exacerbated health care inequities (Watts, 2020). Once countries’ borders were secured, primary health care (PHC) approaches could mitigate virus spread through public education to reduce person-to-person contact (using physical distancing measures, facial coverings and lockdown procedures), triage of cases, and COVID-19 testing, contact-tracing and surveillance. PHC comprises both population-level public health and individual-based primary care, as well as community-based social services (Muldoon et al., 2006). An international study found that in most countries, public health and primary care were insufficiently integrated for an effective epidemic response (Goodyear-Smith et al., 2021). For example, a coordinated approach to COVID-19 swabbing and contact-tracing of positive cases was often lacking. The pandemic has impacted negatively on patients in a myriad of ways. This includes delays in accessing investigations or medical care, separation from loved ones, loss of jobs, interruption with education, and ongoing stress and mental health issues. Patients or their family members may have contracted COVID-19; friends or family may have died from the infection. People with long-term conditions such as diabetes and chronic cardiovascular, respiratory and renal disease have worse outcomes and increased mortality from COVID-19. Those infected may need intensive hospital services as well as community-based primary care support. At some times and places both of these have been unavailable, as services have become overwhelmed. A further consequence of lockdown and move to remote access consultations has been disruption of non-COVID-19 primary care for these patients. Further, as COVID-19 vaccination programmes progress, there have been disproportionately high rates of vaccine hesitancy in the more vulnerable ethnic minority and socio-economically deprived communities (Razai et al., 2021). An additional burden on primary care is managing long COVID-19. About 90% of patients who test positive for SARS-CoV-2 virus recover within 3 weeks, but a small percentage remain unwell for weeks or months (Greenhalgh et al., 2020). Greenhalgh et al. define symptoms extending beyond 3 weeks as post-acute and beyond 12 weeks as chronic COVID-19. Symptoms can be wide-ranging, often multi-system, but fatigue and breathlessness often predominate. Most of these patients will be managed in primary care. Many will slowly recover with rest, psychosocial support, treatment of symptoms and graduated increase in physical activity. Breathless patients may be monitored using home pulse oximetry, but persistent or progressive symptoms at 3 months warrant specialist referral. While the pandemic has created huge challenges for primary care, in many countries, positive impacts from the pandemic response also have been recognised. Our discipline is used to dealing with complexity and uncertainty, and in many areas primary care has demonstrated great resilience when finding solutions to the stressors COVID-19 has presented. The pandemic response has enhanced team work, with task-shifting and clinicians working at the top of their scope. Collegial and supportive relationships between primary care providers have strengthened. In some countries, additional workforce has been mobilised, calling upon medical or nursing students, retired health professionals, volunteers or those in the non-government or private sectors (European Observatory on Health Systems and Policies et al., 2020). The use of telehealth to connect with patients has brought many benefits including improved access for some patients. Digital tools help to support and manage patients remotely. The ability to prescribe, request investigations and refer electronically is resulting in improved coordination between primary and secondary care, and with community-based providers. Patients with long-term conditions can be supported through home-monitoring for biometrics such as weight, blood pressure and blood glucose, increasing both their access to care and their ability to self-manage. To address growing health inequities such as food insecurity and poor housing, primary care is strengthening existing relationships and forging new partnerships with a broad range of services such as community pharmacies, mental health support, food banks and other social support agencies. In many settings, population-based approaches to care have been strengthened with enhanced cooperation between public health and primary care. This applies both to COVID-19 identification and monitoring, and also now to the mass delivery of vaccinations. Primary care can provide outreach to vulnerable patients in their community, and their relationship with patients is a key to addressing vaccine hesitancy. In many countries, cases are dropping steeply as the vaccine is rolled out. However, the world has changed. COVID-19 will remain endemic, and we need to stay vigilant. We have learnt that strong PHC, with well-integrated public health and primary care, will enable us to address the ongoing effects of this virus and have surveillance systems, preparedness plans and infrastructure in place to deal with another deadly pandemic in the future. Hopefully, the painful lessons have been learnt, and primary care meets the challenge and emerges as a key player in fighting infection and keeping our populations healthy.

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          Most cited references6

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          Management of post-acute covid-19 in primary care

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            Covid-19 vaccine hesitancy among ethnic minority groups

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              COVID-19 and the digital divide in the UK

              Any health-care development that doesn't rapidly become available to all individuals has the unintended but inevitable consequence of fuelling health inequality. The response to COVID-19 is no exception. Although we have neither effective drugs or vaccines to deploy, we do have other resources that bear on our capacity to respond to the disease: resources that include digital health-care technologies. Regrettably their benefits are still far from being equitably distributed. The advent of COVID-19 has thrown a spotlight on this digital divide, most obviously in everyday domestic life —though not exclusively so. Many patients who do not have COVID-19 in the UK, fearful of acquiring the infection, have been reluctant to enter hospital buildings. Attendances have shown a marked fall. Many outpatient consultations can of course be done online—but only if you have access to a computer. So might deepening the concern over the consequences of digital exclusion eventually act as a spur to efforts at overcoming it? Technological exclusion is not a new phenomenon. Writing in the journal Demography in 2008 about the experience of innovation globally, Glied and Lleras-Muney hypothesised that “improvements in health technologies tend to cause disparities in health across education groups because education enhances the ability to exploit technological advances. The most educated make the best use of this new information and adopt newer technologies first.” Education is one of many factors contributing to digital exclusion. But whatever the cause, knowledge and behaviour gaps created in this way have often shown a depressing tendency to remain unbridged for years, and sometimes for decades. The full extent of digital inequity is no mystery. A 2019 report by the Office for National Statistics (ONS) revealed that, although declining, the number of “internet non-users” is still large in the UK. In 2018, there were 5·3 million internet non-users in the UK: 10% of the adult population. Yet many organisations, not least among them governments, still proceed as if access to the internet is already universal. “They do,” Professor Simeon Yates, who is the joint-chair of the UK Government Department of Digital, Culture, Media and Sport working group on digital inclusion and skills, told The Lancet Digital Health. “It's a constant battle we have when we're trying to point to research evidence…Don't ever start from the assumption that everybody's online.” Helen Milner is Chief Executive of the Good Things Foundation, a UK charity set up to make the benefits of digital technology more accessible. Health inequality has worsened in the past 10 years, she told The Lancet Digital Health, and digital exclusion plays into that trend. “There's a massive overlap between digital exclusion and social exclusion, and then social exclusion and poverty, and poverty and health inequalities.” The lockdown strategies in the UK prompted by the COVID-19 pandemic are actually increasing digital inequality, according to Kira Allmann, Research Fellow in Media Law and Policy at Oxford University's Centre for Socio-Legal Studies. She spoke to The Lancet Digital Health about the closure of public libraries and online learning centres. “These are important for people without access to digital technology or with low digital skills.” Their role in what she calls “the front line” of the struggle to overcome the digital divide is currently being lost. The barriers by which people are excluded are equally apparent. Milner puts them into three broad categories: lack of access, mostly on account of an inability to pay for devices and their running costs; lack of motivation among people who do not believe that connectivity is relevant to their lives or worth the effort; and lack of digital skills and education. So how best to bridge the digital divide in the UK? Simply giving people the right equipment or access to it is not enough, says Allmann. “The solutions have to involve human intervention, commitment, and care.” What is needed, she adds, are “intensive, long-term support networks to help people acquire the digital know-how they lack… People helping people.” The effects of digital exclusion on health are mostly the result of difficulties in obtaining information and acting on it. More than half of the people surveyed in the 2019 ONS report listed “looking for health-related information” as one of the key uses of the internet. As a means of communication between public authorities and the general public, the internet is increasingly the channel by which services are publicised and accessed. Booking medical appointments, having distant medical consultations, and acquiring prescriptions electronically are just three health services that are already common, and can be vital at a time when lockdown plays a central role in the response to COVID-19. A lack of access to digital technologies during lockdowns has implications beyond daily practicalities. “It has consequences for wellbeing and mental health,” says Milner. “Being able to connect with other people is critical.” The precise effects of digital exclusion vary by country, but Allmann emphasises that its impact is universal. “It's a complete misconception that digital exclusion only exists in certain contexts and certain places,” she insists. “It's an issue that all countries need to address. There's more similarity between the digital inequalities that exist in Egypt and the digital inequalities in the UK than you might expect.” The problems and consequences of digital inequality might indeed be similar—but differences in the extent of knowledge and usage are pronounced. The biggest and least surprising global difference is between lower-middle-income and high-income countries; the majority of the 46% of the world's population who remain unconnected to the internet live in low-income countries. Less well documented are the digital inequities within and between those countries. A 2020 survey of internet usage statistics for Asia revealed that 70% of the population in Vietnam use the internet, whereas the figure for Myanmar is just 33%. Likewise, 61% of the population in Nigeria have internet access, but only 10% of Burundians and 8% of Eritreans. Differences within countries are also marked. A similar survey of internet access and usage published in 2017 found that 43% of Bangladeshis living in urban areas were at least aware of the internet, whereas the figure for rural dwellers was 30%. These problems notwithstanding, might the spotlight that has now been shone on all digital things serve to boost the drive for greater equality? The response of the health technology sector itself has, not surprisingly, been bullish. In a blog post, Graham Kendall, the director of the Digital Healthcare Council, which aims to champion the role of digital technology in the UK, argues that “the spotlight on digital health may, if we get it right, lead to profound long-term changes for our health services.” He could be right; but reaping the full benefit still depends on being able to achieve greater digital inclusion. Yates agrees that COVID-19 has highlighted digital inequality, but he is not holding his breath in anticipation of fundamental change. “Lots of things have highlighted digital inequality over the past 20 years,” he reflects, but adds that when it comes to tackling it, “We do now seem to have hit the hard-to-reach [sector].” That said, he remains optimistic and thinks that COVID-19 will at least push exclusion up the political agenda. Yet Milner, having said that she too senses “an overall greater awareness that digital inclusion is important,” is less certain that this awareness will be followed by more funds and more action. Her hope is that if the digital divide's many consequences are now seen to impinge on more areas of life than had previously been realised, the pressure for action will be correspondingly greater. Sir Tim Berners-Lee, the engineer who invented the World Wide Web, has long argued that access to it should be viewed, like water or electricity, as a human right. For the moment, though, less ambitious goals seem more realistic. It is clear that of the several countries which responded most successfully to COVID-19 were those which had experienced SARS, as they were conscious that something similar might happen again, and had forearmed themselves accordingly. Singapore and Taiwan, for example, launched mobile contact tracing apps in time to help stall the growth of their epidemics. The possibility that the current COVID-19 outbreak is an event likely to be repeated is chilling, but one that should prompt even greater efforts to abolish the digital divide.
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                Author and article information

                Journal
                Prim Health Care Res Dev
                Prim Health Care Res Dev
                PHC
                Primary Health Care Research & Development
                Cambridge University Press (Cambridge, UK )
                1463-4236
                1477-1128
                2021
                25 November 2021
                : 22
                : e76
                Affiliations
                Department of General Practice & Primary Health Care, University of Auckland , PB 92019 Auckland, 1142, New Zealand. E-mail: f.goodyear-smith@ 123456auckland.ac.nz
                Article
                S146342362100075X
                10.1017/S146342362100075X
                8628556
                34819198
                bbeafa9d-0cbc-4b25-80b7-c6476a70ea33
                © The Author(s) 2021

                This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 28 October 2021
                : 28 October 2021
                Page count
                References: 6, Pages: 2
                Categories
                Editorial

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