How primary care will cope with more Covid cases at home – Expert Reaction

New Covid-19 cases will recover at home in the near future, with GPs, nurses and other primary care staff taking on a bigger role in managing the pandemic.

Last week, Health Minister Andrew Little announced that if case numbers continue to rise, the vast majority of new cases will go into home isolation rather than MIQ.

The SMC asked experts about the role of the primary care sector at this stage in the outbreak.

Dr Maryann Heather, GP and Senior Lecturer in Pacific Health, University of Auckland, comments:

“It is inevitable that with Minister Little’s recent announcement that a move to home isolation and Covid-19 cases to be cared for in the community, once again the primary care sector will be called upon to take on this huge responsibility of care in the community.

“We need clear guidelines, good systems and mechanisms in place to allow this to take place. The planning, preparation, resources and involvement of multiple agencies at all levels is critical to the success of transition to community care. The Covid-19 journey from diagnosis to self-isolation and wrap-around services for support and well-being for the patient, but also the well-being of primary care staff should be a consideration.

“Covid-19 is here to stay, and we must continue with public health measures and strongly encourage high vaccination rates in the eligible population so that we can continue to protect and reduce the impact of Covid-19 in our most vulnerable and at-risk communities like Māori and Pacific Communities.”

No conflicts of interest declared.

Dr Apisalome Talemaitoga, GP in Manukau, South Auckland, and Chair of the Pasifika GP network and the Pacific Chapter of the Royal NZ College of GPs, comments:

“The plan on preparing Primary Care to handle growing Covid-19 cases, which was announced last week, has zero Pacific and Māori input. Having a Karori GP stand up with the Minister to announce this means the Government still hasn’t learned. Why is there no Māori and Pacific primary care leadership at the planning of this ‘community care for Covid’? The pandemic is in Auckland (if people have not noticed) and involving GPs in South Auckland would have been a sensible idea.

“One of the reasons for the low vaccination rates for Pacific and Māori now is that the Ministry and Government refused to listen to Te Pūnaha Matatini modelling earlier in the year that was recommended by the Immunisation Implementation Advisory Group about allowing Māori and Pacific earlier access to the vaccine – over 65 years for others and at least 15 years earlier for Māori and Pacific. This was rejected and was so disappointing to the Māori and Pacific Health workforce and shows there is still that mistaken belief that one size fits all. The Government seems disingenuous in using ‘modelling’ that suits their narrative. Professor Shaun Hendy was brought in to the 1pm news conference two weeks ago to talk about his ‘7000 hospitalisations model per week’ when it suited the narrative. We have to be honest and upfront about using modelling – I say it is a reality check, not reality.

“Putting fear into people’s minds is also feeding the high levels of stress and anxiety already that’s rife, especially in Auckland with job losses, poverty and isolation being felt more acutely in the uncertainty of the future, and a plan without any extra funding! The primary care workforce, which is suffering stress and fatigue with all the increased social and mental health issues we are dealing with, will now be asked to do this extra monitoring work for mild Covid-19 cases in the community without any funding boost! An excellent plan just to annoy the already frazzled workforce.

“Māori and Pacific will bear the brunt of this, and it is the Māori and Pacific providers that will be asked to step up by aiga/vuvale/whānau because they have language and cultural concordance and can provide/access to the ‘wraparound services’ required, and they currently do not have the highest vaccination rates, partly due to the above.

“How is the contact tracing service by Auckland Regional Public Health Service going to cope? They can barely cope now! They will again lean on Māori and Pacific providers and the same fatigued workforce to help them with this as they will be quickly overwhelmed.

“And what about business as usual? What is going to happen with our regular immunisations for children, booster shots for measles, cervical and mammogram screening, diabetes checks, and so on? Or are we just setting ourselves up for the next epidemic? I hear the current supply of MMR vaccines expire early 2022!”

No conflicts of interest declared

Dr Kyle Eggleton, Associate Dean – Rural Health, Department of General Practice and Primary Health Care, University of Auckland, comments:

How much pressure are services under now?

“Rural practices and Māori health providers are under a lot of pressure at the moment. This predominately relates to undertaking business as usual with the addition of undertaking the COVID vaccination role out. For Waikato and Northland practices and providers there is additional strain with having to navigate Alert Level 3 and the restrictions on seeing patients face-to-face. The consequences of this are that chronic care management tends to be neglected along with other preventative activities – for example trying to undertake the Measles/Mumps/Rubella catch-up vaccination programme. Additionally, there is the concern that detection of serious diseases, such as cancers, are impacted by workforce pressures, patients delaying presenting to the doctor for symptoms that they might normally attend to and increasing difficulty in referring to secondary services or requesting investigations. These pressures will increase when we start seeing increasing number of COVID in the community.”

What concerns do you have for services and patients as cases rise to 100 or more a day?

“As we start seeing increasing cases of COVID there will be increasing pressure on services. Government has indicated that primary care will take up a large burden of monitoring patients with COVID in the community and this monitoring function will result in some other services not being performed. My chief concerns are around cancer detection, preventative care and chronic care management. The burden of monitoring patients in the community will likely fall more heavily on the primary care nursing workforce who undertake a lot of the preventative care and chronic disease monitoring in practices.

“Telehealth has been suggested as the mechanism in which monitoring patients will occur. Although some practices use video consultations, in our Quick COVID surveys in 2020 we found video consultations were not happening much, that the vast majority of telehealth was occurring by phone and that a significant number of practices reported that patients struggled with telehealth. For rural patients the difficulties that patients have relate to poor cellphone coverage and poor broadband coverage. In addition, patients who struggle financially may lack credits on their phone, be more likely to change phone numbers on a regular basis or share a phone with family/friends, meaning that it can be more difficult to get hold of some patients for monitoring purposes.

“The increasing difficulty in trying to contact rural patients, and patients who are struggling financially will result in increased inequities. Rural areas generally have a higher percentage of Māori and Māori are more likely to experience financial disadvantage, and so there will be additional inequities for Māori patients, with COVID, being monitored. Effective monitoring patients with COVID will also require access to oxygen pulse oximetry to measure oxygen levels. General practices do not currently have access to pulse oximeters that they can give out to patients.”

How might the growing pressure affect access to care for the NZ public?

“The growing pressure will cause increasing difficulty in accessing care. As outlined above the most likely areas will be cancer detection, chronic disease management and preventative care. There is likely to be a shift from general practice to emergency departments in urban settings as patients find it increasingly more difficult to access primary care. This will place more pressure on hospitals and result in poorer quality overall care. In rural settings there will be less shifting of patients, as there is poorer access to secondary care emergency departments in rural areas. Consequently, rural general practice and rural hospitals, will likely experience increasing pressure and demand on their workforces.”

No conflict of interest.

Associate Professor Lynn McBain, Head of Department of Primary Health and General Practice, University of Otago, Wellington, comments:

“Primary care and general practice will have to be involved in the care of Covid-19 patients at home, and ideally patients would be monitored by their own primary care team (practice where they are enrolled). Keeping the care local and personal is likely to obtain the best engagement by both patients and health professionals. We at our practice (for example) see this as a professional obligation to our enrolled patients.

“Robust systems for monitoring will need to be made available – there are some models from overseas that can be adapted to the New Zealand situation, and I understand that there is active work occurring on this.

“Concerns are the unknown numbers that may require monitoring, particularly if there are clusters /larger numbers in one area at the same time. Depending on how immunisations continue to track (less coverage among Māori/Pacific/disengaged populations), the care burden could disproportionately fall on the care providers for these groups. There are likely to be more challenges for those in rural areas. Funding will be required to support this.

“There will need to be an adaptable capacity to assist – possibly other health professionals from other areas where the infection rates are lower, possibly people employed solely for this purpose. The health workforce is limited and if more people are needed for Covid management in the community there will be less capacity for other health care.

“High immunisation rates are still part of the strategy everyone should still be striving to the highest possible coverage.”

Conflict of interest statement: Dr McBain owns a general practice in Wellington.