Australia’s National COVID-19 Primary Care Response

In late December 2019, a pneumonia caused by a novel coronavirus (SARS-CoV-2) was reported to the World Health Organization (WHO) following identification in Wuhan, China. The virus spread rapidly in Wuhan and then around the globe. The outbreak was declared a Public Health Emergency of International Concern on 30 January, 2020 and a pandemic on 11 March, 2020. The respiratory disease complex was officially renamed COVID-19 on 11 February, 2020. On 27 February, 2020, in response to the evolving global emergency, the Prime Minister of Australia announced activation of the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19) (1).

Australia has a strong system of primary care provided by doctors, nurses and other health care workers, including allied health professionals, midwives, community pharmacists, dentists, and Aboriginal health workers. Comprehensive primary care services are available to all members of the community through general practice, provided by general practitioners, Aboriginal community controlled health services, primary care nurses and, allied health and other health care professionals working at the forefront of the health system. The nation’s most vulnerable people also access services through aged care, home care and disability care services. Australia’s primary care response to COVID-19 acknowledges the need to protect vulnerable populations (2), to continue the provision of regular primary care services to the whole community for acute and chronic conditions, and mental health concerns (3), and the need to support and protect healthcare workers in community settings (4, 5) as well as in the nation’s hospitals (6).

In early March 2020, a targeted action plan was initiated by the Australian Government Department of Health to develop and refine the National COVID-19 Primary Care Response (PCR). This action plan acknowledged the essential, first-contact role of general practice in the nation’s pandemic response (7), and was informed by the lessons from previous epidemics and pandemics where primary care had limited involvement in both planning and response (8, 9), and by focused consultation with primary care stakeholder organisations. Consultation included a COVID-19 Primary Care Preparedness Forum, led by Australia’s Chief Medical Officer and held on 6 March, 2020 with representatives from general practice and other medical specialties, nursing, allied health, pathology, pharmacy, practice management, rural workforce, Aboriginal and Torres Strait Islander health, and the disability sector, as well as representatives from Primary Health Networks (PHNs), and Federal, State, and Territory governments. At the same time, as part of the national approach, the Australian Government also established the National Aboriginal and Torres Strait Islander Advisory Group on COVID-19, co-chaired by the Department of Health and the National Aboriginal Community Controlled Health Organisation (NACCHO). Issues considered in the framing of the PCR included measures required to protect both the public and the primary care workforce from infection, the management of people presenting to general practice with fever and/or respiratory symptoms, the continued health care management of vulnerable people at increased risk of COVID-19, concerns about the impending seasonal influenza outbreak over the winter months, arrangements for pathology testing in the community, and consideration of the impacts on business continuity for community-based health services.

The Australian COVID-19 PCR has four primary objectives: (1) protection – protecting vulnerable people from the effects of COVID-19; (2) function – preserving the functional capacity of the healthcare system to manage both cases of COVID-19 and the ongoing provision of health care services for all conditions; (3) support and treatment – facilitating the most effective management in primary care of people with symptoms that may be due to COVID-19; and (4) capacity – managing and maintaining stocks of personal protective equipment (PPE), ensuring that health care workers in primary care have access to the same appropriate level of protection as health care workers in hospitals, and supporting the mental health and wellbeing of the health care workforce (10). These goals have been supported by a funding package of $2.4 billion announced by the Australian Government on 11 March, 2020. This unprecedented level of commitment also supports the hospital and aged care sectors, provides funds to increase supplies of PPE across the nation, and invests in targeted health and medical research, and includes $1.1 billion specifically allocated to support the COVID-19 response in primary care (11).

Key components of the PCR include: funding of a whole of population model of telehealth (using telephone or video consultations) to support the continuing provision of medical care to all members of the population, with face to face consultations available when necessary; establishment of call centres to triage people with fever or respiratory symptoms and direct them to the most appropriate health services, and to provide advice and support to the public on physical measures required to limit the spread of infection; establishment of a nationwide network of respiratory clinics based in the community and operated by general practices to complement the fever clinics established in association with public hospitals; development and delivery of online infection prevention and control (IPC) training for all care workers; measures to safeguard the health of the members of remote Aboriginal and Torres Strait Islander communities across the continent to minimise the risk of infection through restricted access and community preparedness; and ensuring consistent messaging to members of the nation’s primary care workforce. 

Telehealth

The use of telehealth modalities is being encouraged for all appropriate consultations between patients and their health care providers. To enable this unprecedented shift in service delivery, new funding has been provided through Australia’s Medicare Benefits Schedule. Telehealth initiatives have been rolled out rapidly and in a staged approach: beginning with support for use of telehealth in consultations by general practitioners and other medical specialists with members of the nation’s most vulnerable populations; followed by items specific to obstetrics and midwifery, nurse practitioner care, and mental health care provision; then measures to enable vulnerable health care providers to continue providing care through telehealth for their patients; and then moving to a “whole of population” approach to telehealth, allowing consultations for all patients by all general practitioners and other health care providers funded under the Medicare Benefits Schedule (Box 1 – available in the PDF version). On 30 March, 2020, bulk-billing incentives for people with concession cards and children aged under 16 years being seen in general practice were doubled to ensure there were no barriers for the population needing to access health care services and advice and to support the financial viability of the nation’s general practices (12). At the time of writing (20 April, 2020), over 4.3 million telehealth services have been delivered to the people of Australia.

National call centre

People with fever or respiratory symptoms, or with concerns about possible exposure to COVID-19, are encouraged to call Healthdirect, the Australian Government funded national call centre which provides free health information and advice. Healthdirect activity peaked at around 37 000 calls from members of the public per week in mid-March 2020. The Healthdirect website also provides an online COVID-19 symptom checker which can be downloaded as an app for mobile phones and other devices (www.healthdirect.gov.au). Since 25 March, 2020, up to 370 000 people per day have used the symptom checker.

General practice-led respiratory clinics

Evidence from prior epidemics has demonstrated that neglect of “usual care” can be an unintended consequence of prioritising the emergency response, resulting in increased morbidity and mortality related to other causes (3, 13). The establishment of a network of general practice-led respiratory clinics has redirected people with fever and/or respiratory presentations away from general practices and emergency departments, and has complemented the availability of fever clinics established in association with public hospitals across the country. In addition to protecting other patients and health care staff from potential infection, the respiratory clinics allow other general practices across the country to continue providing routine essential primary care services to their patients. Working in partnership with Primary Health Networks and Local Hospital Districts, general practices, and Aboriginal Community Controlled Health Services prepared to show leadership and adapt, relocate or extend their practice operations have been contracted to provide respiratory clinic services, with 100 clinics progressively opening across the country.

Online infection prevention and control training

The Australian Government has funded the creation of a series of online education modules to provide consistent, evidence-based information to health care workers and others working in community settings with vulnerable people. This series includes eight modules targeting residential aged care workers and a fundamental 30-minute online course, targeting all care workers, including those working in hospitals, primary care, aged care and disability care. Launched on 10 March, 2020 (14), this series provides education on aspects of infection prevention and control for COVID-19 and has been completed by over 500 000 health care workers at the time of writing; including over 90 000 aged care workers, over 45 000 disability care workers, and over 37 000 primary care professionals and staff.

Protection of remote Aboriginal and Torres Strait Islander communities

The PCR recognises that Aboriginal and Torres Strait Islander people, as well as other people living in remote communities, are at increased risk of COVID-19, due to pre-existing health issues, difficulties with service access and high population mobility. Building on the strength of Aboriginal and Torres Strait Islander leadership and on measures initiated by many communities themselves, on 26 March, 2020, the Australian Government enacted biosecurity restrictions on entry and travel to remote communities. Grants have been provided to support remote communities in self-determining appropriate planning and preparedness activities, adapting national plans and protocols for local use to enable early retrieval and evacuation of suspected cases, and establishing the mechanisms to support responses to any outbreak, including the deployment of appropriate health care workers.

Communication with members of the primary care workforce

Regular webinars with primary care doctors, nurses, mental health and allied health professionals have been initiated, along with regular teleconferences with the representatives of national primary care professional organisations, with the aim of providing consistent and ongoing two way communication with the nation’s primary care workforce (15). Since 19 March, 2020, there have been over 50 000 live views of online webinars and over 60 000 accesses of online newsletters along with high levels of use of the content by medical media outlets and reproduction of content by national professional organisations in their own newsletters and emails to their membership.

At the same time, public messaging has been synchronised with the Chief Medical Officer’s appearances on mainstream media channels. The PCR is supported by a series of Government Fact Sheets and other COVID-19 specific resources developed to assist the primary care workforce in knowing how to protect their patients and themselves from COVID-19. These have been made publicly available at www.health.gov.au

Lessons from previous epidemics and pandemics have emphasised the critical importance of engaging early and effectively with primary care (4), and the need for a single source of trusted information from health authorities for both clinicians and members of the public (5). Australia’s primary care response has sought to achieve this, through early collaborative planning and ongoing two-way communication with the nation’s primary care workers. The Australian Government’s investment in primary care during the COVID-19 pandemic is an investment in essential elements of the nation’s health system, enabling optimal frontline care while mitigating spread and protecting the ongoing health of the nation’s most vulnerable citizens.

References

Australian Government Department of Health. Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19) 2020 [Available from: https://www.health.gov.au/resources/publications/australian-health-sector-emergency-response-plan-for-novel-coronavirus-covid-19.

2.         Rust G, Melbourne M, Truman BI, Daniels E, Fry-Johnson Y, Curtin T. Role of the Primary Care Safety Net in Pandemic Influenza. Am J Public Health. 2009;99(Suppl 2):S316-23.

3.         Runkle JD, Brock-Martin A, Karmaus W, Svendsen ER. Secondary Surge Capacity: A Framework for Understanding Long-Term Access to Primary Care for Medically Vulnerable Populations in Disaster Recovery. Am J Public Health. 2012;102(12):e24-32.

4.         Masotti P, Green ME, Birtwhistle R, Gemmill I, Moore K, O’Connor K, et al. pH1N1 - a comparative analysis of public health responses in Ontario to the influenza outbreak, public health and primary care: lessons learned and policy suggestions. BMC Public Health. 2013;13(1):687.

5.         Kunin M, Engelhard D, Thomas S, Ashworth M, Piterman L. Challenges of the Pandemic Response in Primary Care during Pre-Vaccination Period: A Qualitative Study. Isr J Health Policy Res. 2015;4:32.

6.         Hanefeld J, Mayhew S, Legido-Quigley H, Martineau F, Karanikolos M, Blanchet K, et al. Towards an understanding of resilience: responding to health systems shocks. Health Policy Plan. 2018;33(3):355-67.

7.         Collins N, Litt J, Moore M, Winzenberg T, KA. S. General practice: professional preparation for a pandemic. Medical Journal of Australia. 2006;185(10).

8.         Patel MS, Phillips CB, Pearce C, Kljakovic M, Dugdale P, Glasgow N. General practice and pandemic influenza: a framework for planning and comparison of plans in five countries. PloS one. 2008;3(5):e2269-e.

9.         Horvath J, McKinnon M, L. R. The Australian response: pandemic influenza preparedness. Medical Journal of Australia. 2006;185(10).

10.        Kidd M. Australia's primary care COVID19 response. Australian Journal for General Practitioners. 2020;0:0-.

11.        Prime Minister of Australia. Media Release: $2.4 billion heath plan to fight COVID-19. 11 March 2020 2020 [Available from: https://www.pm.gov.au/media/24-billion-health-plan-fight-covid-19\.

12.        Prime Minister of Australia. Press Conference Transcript, 29 March 2020 2020 [Available from: https://www.pm.gov.au/media/press-conference-australian-parliament-house-act-12.

13.        Scott V, Crawford-Browne S, Sanders D. Critiquing the response to the Ebola epidemic through a Primary Health Care Approach. BMC Public Health. 2016;16(1):410.

14.        Australian Commission for Safety and Quality in Health Care. Infection Prevention and Control eLearning Modules 2020 [Available from: https://www.safetyandquality.gov.au/our-work/infection-prevention-and-control/infection-prevention-and-control-elearning-modules.

15.        Australian Government Department of Health. Webinars on the Coronavirus (COVID-19) response for primary care practitioners. Updated 1 Apr 2020 2020 [Available from: https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-advice-for-the-health-and-aged-care-sector/webinars-on-the-coronavirus-covid-19-response-for-primary-care-practitioners.