BMJ Confidential: For Review Only Strengthening the Third Pillar: Primary Care and the UK COVID-19 Response Journal: BMJ Manuscript ID BMJ-2020-058797 Article Type: Analysis BMJ Journal: BMJ Date Submitted by the 23-May-2020 Author: Complete List of Authors: Park, Sophie; UCL Medical School, Research Dept. of Primary Care and Population Health Elliott, Josephine; UCL Medical School Berlin, Anita; Queen Mary University of London, Institute of Health Science Education Haines, Andrew; London School of Hygiene & Tropical Medicine, Dept of Social and Environmental Health Research Keywords: COVID-19, primary care, general practice https://mc.manuscriptcentral.com/bmj Page 1 of 17 BMJ 1 2 3 1 Manuscripts are submitted online here: https://mc.manuscriptcentral.com/bmj 4 2 5 6 3 7 4 Analysis 8 5 9 10 6 Strengthening the Third Pillar: Primary Care and the UK COVID-19 11 7 Response 12 Confidential: For Review Only 13 8 14 9 Sophie Park1 15 10 Josephine Elliott 2 16 11 Anita Berlin 3 17 4 18 12 Andy Haines 19 13 20 14 1 Research Dept. of Primary Care and Population Health, UCL 21 15 2 UCL Medical School 22 16 3 Institute of Heath Science Education, Queen Mary University of London 23 4 24 17 Dept. of Public Health, Environments and Society and Dept. of Population Health, London 25 18 School of Hygiene and Tropical Medicine 26 19 27 20 Correspondence to: 28 21 Dr. Sophie Park 29 30 22 Research Department of Primary Care and Population Health 31 23 Royal Free Campus 32 24 Rowland Hill St. 33 25 Hampstead 34 26 London NW3 2PY 35 36 27 37 28 Email: [email protected] 38 29 Phone: 0207 794 0500 39 30 40 41 31 Word count: (Target: 1800-2000 words) 42 32 References: (up to 20 references, in Vancouver superscript style) 43 33 44 34 45 46 KEY MESSAGES 47 48 The emphasis in the UK COVID-19 response has been on public health and 49 hospital care, with the potential contribution of primary care largely 50 overlooked. Primary care strengths include provision of comprehensive 51 healthcare for individuals, continuity and gatekeeping. Planning which 52 includes and supports primary care can contribute to the COVID-19 53 response, increase resilience and minimise the impact of COVID-19 on other 54 healthcare needs. 55 56 57 Active engagement of primary care will be essential in management of the 58 second and subsequent waves of COVID-19, in order to improve care of 59 vulnerable patients in the community; reduce demands on hospital services; 60 support rehabilitation of recovering patients; improve palliative care; and https://mc.manuscriptcentral.com/bmj BMJ Page 2 of 17 1 2 3 4 sustain non-COVID 19 care. 5 6 Hospital admissions from COVID-19 require long and intensive treatment 7 with mortality often exceeding 30%. Potentially effective treatments 8 delivered early in the course of the disease in primary care settings should 9 be a priority for research funding. 10 11 ● Additional research and evaluation in primary care would inform the 12 Confidential:response to subsequent COVID-19 For waves, Review and strengthen Only the capacity of 13 primary healthcare to deal with the backlog of non-COVID-19 morbidity and 14 the medium-to-long term physical and mental health sequalae of COVID. 15 16 17 18 35 19 36 20 21 37 Contributors and sources 22 38 23 39 Sophie Park is a practising GP and clinical academic. She is Director of Medical Education 24 40 (Primary Care and Community) at UCL Medical School and Training Co-Lead for the NIHR 25 26 41 School of Primary Care Research (SPCR) Evidence Synthesis Working Group. Josephine 27 42 Elliott is a medical student and has an interest in public health and primary care, which 28 43 developed during her Masters in Medical Anthropology and internship at the WHO. Anita 29 44 Berlin is a GP and Professor of Primary Care Education at the Institute of Health Science 30 45 Education, Queen Mary University of London. Andy Haines is a Professor of Environmental 31 32 46 Change and Public Health at the London School of Hygiene and Tropical Medicine. He was 33 47 formerly a GP and Professor of Primary Health Care. All authors contributed to the 34 48 intellectual content contributed to drafting the text and approved the final draft. 35 49 36 50 37 51 Acknowledgements 38 52 Optionally include this section if you have any acknowledgements to make.N/A 39 40 53 41 54 42 55 Patient involvement 43 56 As The BMJ is seeking to advance partnership with patients, we also ask authors to seek 44 57 their input into articles wherever relevant, and document their involvement as patient 45 58 contributors or coauthors. In your statement, please specify how patients were involved and 46 59 how the article changed as a result of their contribution. If you did not seek input from 47 60 patients, please include a statement saying that no patients were involved. Ideally input from 48 61 patients will be sought at the article planning stage. 49 62 50 63 No patients were involved 51 64 52 65 53 66 Conflicts of Interest 54 67 We have read and understood BMJ policy on declaration of interests and have the following 55 68 interests to declare: 56 69 Note: where a competing interest exists that might disqualify an author from contributing, it is 57 70 wise to discuss it with a BMJ editor before writing the article. 58 71 We have no conflicts of interest 59 60 72 https://mc.manuscriptcentral.com/bmj Page 3 of 17 BMJ 1 2 3 73 4 74 Licence 5 75 The Corresponding Author has the right to grant on behalf of all authors and does grant on 6 76 behalf of all authors, an exclusive licence (or non exclusive for government employees) on a 7 77 worldwide basis to the BMJ Publishing Group Ltd ("BMJ"), and its Licensees to permit this 8 78 article (if accepted) to be published in The BMJ's editions and any other BMJ products and 9 10 79 to exploit all subsidiary rights, as set out in The BMJ's licence. 11 80 12 81 Confidential: For Review Only 13 82 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 https://mc.manuscriptcentral.com/bmj BMJ Page 4 of 17 1 2 3 83 Strengthening the Third Pillar: Primary Care and the UK COVID-19 4 5 84 Response 6 85 7 86 Standfirst 70 8 9 87 Most of the focus in addressing COVID-19 has been on public health and hospital-based 10 88 care. However, initial infection and many deaths occur in community settings with increasing 11 89 numbers of patients recovering from COVID-19 at home. COVID-19 clinical and research 12 90 strategiesConfidential: should capitalise on the strengths For of UK Review primary care including Only comprehensive 13 14 91 healthcare, continuity and gatekeeping, to build NHS resilience by capitalising on existing 15 92 primary care infrastructure and identifying effective, early interventions and follow-up 16 93 strategies. 17 94 18 95 19 96 The current COVID-19 response 20 21 97 This article examines current and future challenges and opportunities for primary care, and 22 23 98 highlights the urgent need for strategic planning and investment in primary care services, 24 99 evidence production and implementation. Globally, societies are attempting rapid 25 26 100 adjustments to direct and indirect consequences of life with COVID-19 1. Healthcare is at the 27 101 centre of these organisational changes, providing opportunities to draw on existing 28 29 102 strengths, and adapt systems to new challenges. Initial World Health Organisation (WHO) 30 31 103 recommendations were based on system adaptations in China, focusing predominantly on 32 104 secondary care (e.g. building new hospitals, initiating early ICU treatment) and public health 33 2 3 34 105 (e.g. early detection and institutional isolation) , . Despite the WHO’s commitment to 35 106 Universal Health Coverage and the universal access to primary care in the UK, primary care 36 37 107 has received less policy focus to date both globally and in the UK. 38 108 39 40 109 Internationally, primary care has experienced unprecedented shifts in work, with potential 41 4 42 110 short and longer-term changes of service organisation and patient outcomes . Systems 43 111 have varied in their capacity for rapid change; PPE availability; and use of volunteer support. 44 45 112 Taiwan, for example, report creating a tiered approach to primary care including walk-in 46 113 access, ‘prepared’ clinics for COVID-suspected cases, and screening 5. In Singapore, 47 48 114 existing primary care networks supported early detection and isolation 6. In anticipation of 49 50 115 subsequent peaks of COVID-19 and post-COVID morbidity, recognition that hospital case 51 116 fatality rates are over 30% (rising to 50% for those in ICU 7), and that hospitals are foci for 52 53 117 transmission, strategies are needed to refine management of patients at home and optimise 54 118 the use of NHS resources. ONS data show that many excess deaths are occurring outside 55 56 119 hospitals either from COVID-19, or from conditions for which care has been disrupted, 57 120 adding to the case for primary care response 8.