Policy-makers are currently facing the challenge of striking the right balance between two competing goals: ensuring adequate capacities to treat those affected by COVID-19 and providing services that are necessary to maintain the health of the population.
Repurposing physical infrastructure (such as entire hospitals, hospital wards or beds and technical equipment) and workforce resources to respond to the COVID-19 pandemic has required considerable restructuring of care in most countries. Related measures are often part of pre-existing epidemic plans at national or regional level that were activated for COVID; thus, they may not constitute new policies in themselves.
The World Health Organization (WHO) provides detailed recommendations on how to reorganize health care delivery to ensure that essential services are maintained and mitigate exposure of non-COVID patients and others to SARS-CoV-2 (recommendation 7 for strengthening the health system response to COVID-19 and corresponding technical guidance). This overview looks at the ways countries in the European Region modified service delivery to meet the needs of non-COVID patients along some of these recommendations. Information on countries was identified using the COVID-19 Health Systems Response Monitor (HSRM) (up to 4 May 2020). We summarize general trends and highlight some individual country examples.
Table 1. Postponing non-urgent care and moving to telemedicine
Most countries have postponed elective surgery and other types of non-urgent care
Among reporting countries, almost all have decided to postpone elective surgeries (see Table 1). In most cases, in-person visits for other non-essential services at different levels of care were also postponed, or replaced with telemedical applications (see below and also the post, How are countries using digital health tools in responding to COVID-19?; more posts on the use and potential of digital health tools to follow). The timeline of measures follows the development of the pandemic in Europe, with most countries enacting relevant policies in early to mid-March. As of mid-April, several countries are loosening these restrictions, with a step-wise return to the activation of non-essential services, under the application of new and extended safety protocols.
How countries define what constitutes “essential” or “urgent” care varies, but a common notion is that of services (preventive, diagnostic, therapeutic, rehabilitative or palliative) that cannot be delayed without major disadvantage to the patient´s health. However, the approach and degree of detail in reported approaches to specify related services varies. For instance, while the Irish COVID-19 Action Plan defines the services to be maintained, Italian national and regional policies specified which services could be postponed or moved to other settings. In many countries, cancer care is specifically mentioned as essential to maintain, followed in frequency by dialysis and obstetric care. The final decision about the necessity of services often lies with physicians (see for instance the approach in Germany and a report from the United States).
How (de)centralized or binding such measures are varies across countries. For instance, Belgium required all hospitals to cancel non-urgent services and advised primary care practitioners to limit their activities for essential services. In Finland, some districts limited hospital services, under consideration of the central imperative to maintain all necessary services for those who need them. While Denmark only postponed non-critical elective surgeries, Bulgaria went so far as to limit all planned services; the measure was subsequently modified to allow maternal and child consultations as well as compulsory vaccinations on specifically designated days of the week.
Several countries have introduced or expanded the use of telemedicine
As can be seen in Table 1, several countries have either introduced or expanded the health system’s use of telemedicine in the broad sense of the word (services accessed remotely, without in-person contact between patient and provider). This takes the form of phone-based consultations (e.g. Croatia, Luxembourg, North Macedonia, Romania and Spain), sometimes for specific population or patient groups. For instance, Belgium instituted a general practitioner hotline for homeless people, whereas in the United Kingdom a telephone triage system was introduced to facilitate new cancer referrals and avoid unnecessary hospital attendance. The use of video-conferencing and other online platforms is also frequently reported (e.g. to support prescribing or the provision of mental health services, see below). For instance, in both Belgium and Germany, the benefit basket was modified to allow for more extensive reimbursement of teleconsultations. In Germany, more than ten times as many teleconsultations were performed in March 2020 compared to previous months (19,500 in March vs 1,700 in January and February). This swift increase in the reliance on digital applications has not always been without technical challenges, as was observed in Croatia.
Many countries have increased efforts to provide care at home
With the restrictions in movement and on-site services, many countries have introduced or expanded initiatives to provide care at home, particularly for vulnerable groups. Some countries have mobilized health system resources, while others rely mainly on civil society and volunteers to ensure that patients who are isolated at home can receive necessary care. For example, Croatia enabled primary care visits at home, provided the household had not been exposed to SARS-CoV-2; chronic and palliative patients have access to mobile palliative care teams and physical therapists; and immuno-compromised patients can have blood samples taken at home. Cyprus intensified efforts in public community nursing for general and mental health.
Issuing and filling prescriptions has been adjusted to ensure continued access to medications for chronic patients
To reduce the number of visits to providers, many countries have implemented measures to adjust the process of issuing and filling prescriptions, including making regular prescriptions available by phone (e.g. Greece), introducing or reinforcing e-prescriptions (e.g. Hungary, Ireland, Latvia), extending the validity period of prescriptions (e.g. Albania, Croatia, Ireland, Romania, Russian Federation, Spain), and easing restrictions on prescribing professions (e.g. North Macedonia) or the individuals entitled to fill prescriptions (e.g. Hungary, Russian Federation). As mentioned in the previous section, a number of countries have mobilized organizations like the Red Cross or volunteers in the communities to deliver the necessary medications to patients at home. Continued access to necessary medicines has been challenged by the pandemic in general, as globalized production means that containment measures have exacerbated medicines shortages (see here). Reports on how this affects medicines used to treat COVID-19-patients prompted European Union action to facilitate the continuation of the supply chain.
Mental health: countries move to address pandemic-related challenges
To mitigate the psychological impact of the COVID-19 pandemic, several countries have created pathways for the general population, health professionals and COVID-19-patients to seek support. This has mostly taken the form of designated hotlines (e.g. Belgium, Croatia, Estonia, France, Greece, Malta, Portugal and Spain) along with public campaigns to inform populations about their existence, or tailored material on the websites of public health institutions and NGOs (e.g. Finland, Ireland). Social distancing restrictions, the reorganization of health service delivery, and the temporary closure of NGOs have put a strain on mental health services in several settings. Telemedical provision of already needed mental health services is also supported in several countries (e.g. Cyprus, Finland, France, Germany).
Increasing evidence on delayed or forgone care is worrisome and highlights the pandemic’s indirect health effects
The extent to which these measures have been successful in striking the balance between ensuring capacities for COVID-related care and not endangering health otherwise remains to be seen. Concerns have been voiced from several stakeholders on the implications of delayed care, for instance regarding diagnosing and optimally treating cancer patients (see articles from The Lancet and BMJ; additional anecdotal evidence from media in the United Kingdom, the United States and Germany) and potential future outbreaks of infectious diseases among children (see more on routine vaccinations during the pandemic the Guardian and the World Economic Forum). What is more, many countries have observed a significant drop in emergency cases, such as for myocardial infarctions (heart attacks) or strokes, as well as necessary outpatient contacts (for some examples see Belgium, Finland, Germany, Portugal, Ukraine and the United Kingdom) compared to previous years. This is indicative of patients foregoing necessary care, because they assume services would not be available to them due to the restrictions described above, they are unsure about how or when to access them, or they are worried about exposure to SARS-CoV-2 when visiting providers. In several countries, physicians and their associations have launched public campaigns to inform the public about the continued availability of services and the importance of seeking care when necessary (e.g. Belgium, Germany).
In summary, the vast majority of European countries have implemented measures to restrict the provision of non-emergency services in the inpatient and outpatient sectors in order to ensure capacities for COVID-19-patients and reduce exposure. Beginning in mid-April, many countries have started to re-open non-emergency operations gradually, following increased safety precautions. Good data on utilization and outcomes (mortality and morbidity) are required to evaluate the impact of these measures on population health as a whole and optimize planning for future public health emergencies. The observed increased use of telemedicine and home care as well as more flexible conditions for access to medicines for patients with chronic conditions are in line with WHO recommendations and should be evaluated to determine their continued use in the next stages of the pandemic response. Clear public guidance on when and how to access services not related to the pandemic with minimum risk is required to minimize forgone care and limit the indirect health effects of the pandemic.