The organization and provision of ambulatory care, that is, care provided in an outpatient setting without admission to a hospital (including primary care and outpatient specialised care), has been heavily affected by the COVID-19 pandemic.
Ambulatory care has faced many challenges including increased demand of patients seeking care for respiratory illnesses that may be COVID-19, delays in providing non-COVID-19 care, reduced health personnel because of COVID-19 illnesses in staff, and an increase in patients seeking non-COVID-19 care for chronic conditions and prevention.
This policy snapshot reviews how six countries (England, France, Germany, Italy, Spain, the Netherlands) have resumed routine ambulatory care activities. It extends the work of a previous policy snapshot focused on how routine services in hospitals have been restarted in the midst of the pandemic. Using a similar survey, we asked national experts from six countries within the COVID-19 Health System Response Monitor (HSRM initiative) how ambulatory care providers are restarting care. An overview of the common approaches as of October 2020 to restart routine ambulatory care activities among the selected countries is illustrated in Figure 1, with the most common approaches depicted in Figure 2.
Figure 1: Expected changes in provision of ambulatory services
All six countries initially saw lower activity volume with higher use of teleconsultation
All of the countries surveyed reported lower volumes of care in primary and community care settings, with an increase in care provided in non-face-to-face formats. While virtual care offers the lowest risk of coronavirus transmission, it raises questions about whether the quality of virtual care is equivalent to in-person care, and how the care-seeking behaviour of patients may change. In Germany and France, for example, the Statutory Health Insurance agencies consider teleconsultations as viable alternatives for all indications and will be reimbursed accordingly until the end of 2020 and 2021, respectively.
In England, the Netherlands and Spain, an initial consultation by phone or video determines whether a patient needs to see a physician in person. In the Netherlands, a survey among General Practitioners (GPs) revealed that 72% of respondents were using video consultations at the end of April 2020, compared with 0% in 2019. Moreover, GPs have indicated that they would like to continue to use video consultations after the crisis. In England, the number of phone calls per day to GP practices has increased dramatically, from 856,631 to 2,022,798 per week between 2 March and 18 May 2020, with up to 60 phone calls per day per GP in many areas. Prior to the pandemic, around 80% of GP appointments took place face-to-face. As of June 2020, this had fallen to just under half, with around the same amount taking place over the telephone.
Some countries have decided to use teleconsultation as the primary way to provide certain services. For example, Spain offers administrative sick leave certificates and e-prescriptions for chronically ill patients without in-person appointments to avoid visits to primary care facilities. Germany’s Federal Joint Committee passed a resolution allowing doctors to grant sick leave certificates via videoconference, as long as the doctor had a pre-existing relationship with the patient. Most teleconsultations in France continued existing doctor-patient relationships, as around 80% of teleconsultations were between patients and doctors who already had a face-to-face consultation in the previous year (Richardson et al, 2020).
Prioritization or rationing of treatments is lower in ambulatory care than in hospitals
All six countries reported that hospitals were prioritizing or rationing treatments in a previous policy snapshot; however, not all countries indicated a similar phenomenon in ambulatory care. The reliance on the teleconsultation solutions, as described above, may largely account for this discrepancy. Spain allows for face-to-face consultations only after a first consultation by phone or video. Italy reported a prioritization or rationing of treatments during the lockdown period from the end of February to the beginning of May, but this is no longer the case. In France, certain patient groups, including pregnant women, patients with disabilities, and patients with chronic illnesses, were encouraged to resume ambulatory care following the end of the lockdown with entirely free (no co-payment) follow-up consultations in primary care.
Testing of health professionals in ambulatory care and removing high-risk staff from direct patient contact are used in some countries
While countries have increased testing of health professionals, the uptake varies, and tests may not be available for asymptomatic cases. In England, staff working in primary and social care must get tested and self-isolate if symptomatic. Routine testing for patient-facing staff was set to begin in November, though the announcement has been met with some scepticism given concerns about overall testing capacity and reliability in England. In Italy regular testing in primary care is not available, while ambulatory providers in hospitals had access to more frequent testing. Germany recommends testing staff regularly, taking into consideration the local infection rates. France aimed at systematically testing all health care professionals after the end of its lockdown on 11 May. If a patient visiting a GP practice in the Netherlands has severe COVID-19 related symptoms, testing can be conducted in the GP practice.
Aside from increased testing, high-risk staff in several countries have been removed from direct patient contact (England, Spain) or are eligible for sick leave (France). In England, many of these staff have been furloughed (granted a leave of absence). In Spain, regional health authorities have to guarantee that there is a sufficient number of health workers to provide for early detection, epidemiologic surveillance, infection control and patient care.
Separating infected and non-infected patients is a key priority for health care providers
Similar to the situation in hospitals, countries are emphasizing the need to separate patients depending on whether they have COVID-19. In France, Germany, and the Netherlands, most GPs have dedicated consultation hours for (suspected) COVID-19 patients. In Germany, these are referred to as, “infection consultation hours.” These hours have started to replace the previous approach of using ambulances or COVID-19 ambulatory centres as the first point of care, throughout the summer. However, with rising numbers of cases, these ambulatory centres will be re-opened during the winter especially in metropolitan areas and areas with high incidence of cases within Germany.
In the Netherlands, some GP practices have separate spaces, but not all practices have enough physical space in their building to do so. During the lockdown in England, many practices set up hot and cold clinics, with some Primary Care Networks separating services by practice in order to provide care to patients in different buildings. Spain recommends distinguishing patient pathways for COVID-19, suspected COVID-19, and recovered COVID-19 patients, with COVID-19-specific consultations.
The reorganization of waiting rooms is the most commonly cited change to physical infrastructure, aside from investments in personal protective equipment (PPE)
Limiting the number of patients in the waiting room and ensuring appropriate physical distancing were identified as key changes in ambulatory care settings in response to COVID-19. Spain has even shut down waiting rooms in some specific cases. In addition to reorganizing waiting rooms, guidelines from the Ministry in charge of health in France also requires ambulatory care providers to put away all unnecessary objects (e.g. books, magazines and toys) and provide disposable tissues and trash cans in the waiting rooms. Generally, countries also limit the number of persons accompanying the patient to the appointment, and the use of facemasks within health care facilities is compulsory.
In the countries surveyed, the use of PPE in ambulatory care settings by providers ties closely to its overall availability. England, France, German, Italy and Spain require the use of PPE for all physical contacts with patients. Ambulatory care providers in Spain are required to appoint a responsible person for PPE availability. In the Netherlands, in principle, PPE is not used for non-COVID-19 patients. GPs in England are officially private practitioners and were initially provided with a small stock of PPE, but were expected to purchase the rest themselves, although a central supply and an emergency PPE portal has now been established. The regulatory responsibility for stocking PPE in ambulatory settings was explored in a previous policy snapshot.
Changes in patient pathways, including specialist consultation and patient self-management, are not widely adopted strategies
Only half of countries surveyed reported increased advice from specialists in primary care settings (England, the Netherlands, Spain) and increased patient self-management (Italy, the Netherlands, Spain).
Medical specialists in the Netherlands and England have become more accessible to GPs, in order to coordinate referrals or determine whether the patient can be treated in primary care. In Germany, a regulation has formalized this process such that hospitals may arrange services for patients up to 14 days after patient discharge, when previously the limit was 7 days. These services include medical certificates, home care, medical aids, ambulatory palliative care, psychotherapy, physical therapy, occupational therapy and speech therapy.
Country experiences around patient self-management are mixed. The increased reliance on remote consultations has supported home care monitoring and management; however, this is more of a consequence of the emergency situation rather than a strategy to act on patient engagement. The Netherlands operates a patient-facing website (thuisarts.nl) with medical advice, and although it existed before COVID-19, the website is being more strongly promoted to encourage patients to only seek medical advice when absolutely necessary. Before the pandemic, chronically ill patients in Germany were prescribed quarterly check-ups in disease management programs, but this requirement has been suspended to avoid COVID-19 cases in patients with chronic illnesses.
Figure 2: Common approaches to resuming routing ambulatory care activities with country examples
Group and home-based patient treatments have been affected by the pandemic
More than half of the countries surveyed reported a decrease in group patient treatments, which are often used for mental health services. In Germany, patients can use individual psychotherapy sessions rather than group psychotherapy until 30 June 2021 to lower face-to-face contact. Spain cancelled in-person group treatment sessions and patients may now receive individual remote treatment sessions. England and France report some online group sessions taking place in mental health care, but the latest guidance for lockdowns in England suggests that these can now resume face-to-face.
For home care, most countries are using remote consultations whenever possible, although Spain has reported an increase in home care visits to avoid an accumulation of patients in health care centres. In France, teleconsultations and telemonitoring at home is encouraged but, when this is not possible, home care professionals (GPs and nurses) are required to conduct their home visits each day starting with patients who do not have COVID-19, and end with COVID-19 positive patients and, when possible, dedicate one professional to COVID-19 patients. While in principle, the Netherlands provides home care as usual during the pandemic, health professionals do not have sufficient PPE available to treat this group of patients. In some cases, this has caused patients to restrict the care they receive, which may increase the workload of informal carers/family members.
Conclusions and Policy Implications
As the number of COVID-19 hospital admissions fell after the first wave, policy attention turned to how health systems could restart more routine activities, including in ambulatory care. None of the countries surveyed for this policy snapshot reported on having a national strategy for how to resume non-COVID-19 care in ambulatory settings. On the one hand, this speaks to the breadth of the services provided, the difficulty in developing concrete guidance, as well as the flexible adaption of service provision based on the epidemiological situation. On the other hand, this relates to health systems’ initial emphasis on provision of care in acute, hospital settings. However, this emphasis on hospital care did not necessarily lead to better outcomes; in Italy and Spain, the regions which prioritized primary care as a tool to filter out and reduce the increasing hospital admission rates often had greater success in controlling the epidemic (e.g. Veneto Region in Italy).
Health systems seem to be universally pivoting to more remote ways of providing care, and countries which already offered some teleconsultation services started with an advantage. Looking ahead to when the pandemic is under control, it is likely that certain services will continue to be offered remotely, which has implications for patient access and inequalities. Additionally, research suggests that online and video consultations could increase staff workload by as much as 25% (unless clinicians shorten consultation times), which affects staff workload and risks further burnout after the months of working under strained conditions due to COVID-19. While teleconsultation services are likely here to stay, it remains unclear how the pandemic will affect patient pathways over the long-term. As long as patients may be at risk of having COVID-19, health care providers will need to protect themselves as well as coordinate with one another in order to reduce the rate of transmission, whilst considering the potential wider harms of any resulting limits to patients accessing ambulatory health care. Whether and how this integration of care will continue is still to be determined.
While the subsequent waves of COVID-19 may result in health systems struggling to deliver pre-COVID levels of activity, there is increasing pressure on strengthening primary care to face subsequent waves. Furthermore, if primary care/community care providers are a key channel for administering a future vaccine for COVID-19, the balance between COVID and non-COVID care in these settings requires further consideration and planning. At the same time that inpatient capacity remains the main focus as new lockdown measures are put in place, a reflection on which services can be shifted to ambulatory/home settings and how we can reduce pressure on hospitals is in process. Furthermore, outpatient health care providers may have more agility to adapt care for vulnerable populations based on local infection rates, as they have closer links to the communities they serve and the knowledge of which patients may have increased risk of serious infections. In part due to the local nature of these interactions, the changes may not be communicated to or known by the wider public. These practices may prove vital for improving health systems’ resilience.
Erin Webb, Cristina Hernández-Quevedo, Nigel Edwards, Sarah Reed, Coralie Gandré, Zeynep Or, Fidelia Cascini, Juliane Winkelmann, Madelon Kroneman, Judith de Jong, Enrique Bernal-Delgado, Ester Angulo-Pueyo, Francisco Estupiñán-Romero, Selina Rajan, Sujay Chandran.