UEMO Vice President Dr Mary McCarthy explores the burden of COVID-19, resource inequity and vaccine hesitancy on General Practitioners and family doctors.
The Union Européenne des Médecins Omnipraticiens (UEMO) is the European Union of General Practitioners/Family Doctors. It was established more than 50 years ago in Paris, and aims to promote the highest standard of training, practice and patient care within the field of general practice and family medicine throughout Europe and to defend the role of general practitioners (GPs) and family physicians in the healthcare system.
Membership of UEMO is extended to any country which is geographically within Europe; and therefore the membership of the UK has been unaffected by the Brexit negotiations. It holds General Assemblies twice a year to determine the common views of member nations, represented by their delegations, and to present them, through the appropriate channels, to the proper European authorities. It works with other European medical organisations to strengthen professional status and to search for common criteria for professional medical practice in Europe.
General practice is a complex discipline which not only involves a broad knowledge base, encompassing all medical specialities, but which also operates in a holistic manner. It places the patient at the centre, not the disease that the patient happens to have, and considers socioeconomic, psychological and familial aspects of the disease as well as the physical signs and symptoms. As William Osler (1849-1919) said: “The good doctor treats the disease, the great doctor treats the patient”. UEMO is therefore involved in other European organisations and contributes to their debates and discussions. It has been more deeply embedded in the European Medicines Agency since a Joint Statement was signed in 2019 and is also a stakeholder in Health Technology Assessment (HTA).
Its recent policy papers cover topics including Brexit, COVID-19, eHealth policy, childhood obesity, and antimicrobial resistance (It is a member of the EU-JAMRAI project on AMR). It takes part in and is a contributor to EU vaccine policies, the TELL ME project (promoting transparent communication in epidemics), the SMART Project (to measure the use of ICT and eHealth applications) and ENS4Care Project (advocating evidence-based guidelines for nurses and social care workers). It is involved in broad policy discussions in many European health groups and is constantly being asked for advice or participation in special interest groups.
COVID-19, stress and burnout in healthcare
During the COVID-19 pandemic UEMO has been engaged in supporting GPs and family doctors during a time of professional stress. It has monitored burnout among its members and, having noted the increasing harassment of healthcare workers, produced a statement, with other European medical organisations, condemning this. At its Autumn 2020 General Assembly, UEMO also produced a policy paper stating that COVID-19 should be classified as an occupational disease for healthcare workers. The rate of infection for those working in healthcare is three times that of the general population; and it is suggested that more deaths have been caused among general practitioners from this virus than among any other speciality.
The number of general practitioners, in most European states, is diminishing while the number of hospital doctors is increasing. This is not sustainable or economically viable. A cost-effective healthcare system is firmly based on robust and sustainable general practice. Well-functioning and professionally managed general practice provides continuity of care and this continuity reduces hospital admissions, reduces attendance at emergency departments and improves the management of long-term, chronic diseases such as diabetes and cardiovascular disease. When general practice is poorly supplied with adequate, professionally trained doctors, stress increases, workload increases and there is the risk of morale injury as doctors feel they cannot provide the best medical care for their patients. This is enhanced during the present pandemic when the workload in general practice has increased and where general practitioners, family doctors, are seeing 85% of all first COVID-19 contacts.
Family doctors are often poorly supplied with personal protective equipment (PPE), which is itself inadequate. They are resorting to buying their own PPE through commercial sources or relying on charitable donations of these items. General practice undoubtedly needs support and this is true of almost every European nation. Health budgets, as a proportion of GDP, need to aspire to the European average and within these health budgets, general practice, family medicine, should have a bigger slice of the available cake.
Hospitals and hospital staff take a disproportionate amount of healthcare budgets, leaving general practice and mental health departments to fight for what they need. Sharing of resources should be more equitable so that family physicians are funded properly, and their role is appreciated and valued. For far too long they have been the poor relation of health services; and we know, from many academic papers and from the evidence of those nations without robust family medicine, that the cost increases, and efficacy diminishes, when general practice is neglected. Concentrating resources on family medicine, funding it appropriately and increasing graduate interest in general practice would improve the economics and health outcomes in every European state.
UEMO wants general practitioners and family doctors in every European nation to be recognised as specialists in General Practice. This measure would, we feel, raise their status among medical specialities and encourage more graduates to train as general practitioners. We have a constant problem with both recruitment and retention of family doctors and this measure would go some way to address this.
Vaccination and vaccine hesitancy
The roll out of COVID-19 vaccines is happening throughout Europe – though acceptance of this has been varied, not only between different nations but within individual countries. Vaccine hesitancy is a Europe-wide phenomenon which individual nations are trying to combat. The European Medicines Agency has a Vaccine Portal where accurate and updated information is available and some countries, the UK for instance, are putting out videos specifically targeting certain groups. It is known that whereas around 70% of white British people will accept the vaccine, if offered it, only around 40% of Asian or other minority ethic British will accept it; and only around 20% of Black British people. Efforts are being made to allay the fears of these groups, with some vaccination centres being placed in mosques or other places of worship.
Apart from the problem of those who do not want the vaccine, there are also logistical difficulties. The BioNTech/Pfizer vaccine is stored at -70 degrees and needs to be diluted before use. Once moved to normal fridge temperatures (two to eight degrees) the vaccine is viable for five days, but will only last for six hours once it has been diluted. This means that it is easier to manage in central vaccine hubs rather than local GP practices. The AstraZenaca vaccine and the Moderna vaccine can be stored at normal fridge temperatures, so are more applicable for family doctors to distribute. General practitioners have the advantage of being a local, trusted source of information, as well as being easily accessible. In many countries, they are used to supervising, managing and administering annual flu vaccines, so they have procedures in place to cope with COVID-19 vaccinations. These will inevitably be impacted by the rules on PPE and social distancing and these procedures may be slower than the ‘flu clinics’ of previous years, but delivery through general practitioners and family doctors remains the most effective way of ensuring rapid and effective uptake of the vaccine. Moreover, since the elderly and those in care homes will be priority groups for vaccine distribution, it is better to use local expertise rather than ask these vulnerable groups to travel to a vaccine hub that may be a considerable distance away. Using general practice and family medicine as a way of distributing COVID-19 vaccines makes sense, both for logistical and economic reasons.
The need for policy support
General practice relies on close contact with, and intimate knowledge of, a local population. The family physician is embedded in their local community and involved in their problems. It has been demonstrated, in many countries, that family doctors are the most trusted individuals and that their expertise is greatly valued by their patients. It is not the public which needs to make an effort to support them, but rather the governments and healthcare bodies. The public has, mostly, been abiding by the rules on social distancing and self-isolation. In some families, economic necessity has made it imperative to continue working when it may have been safer to stay at home. Not everyone is able to take part in remote working or in remote learning; and problems with internet facilities, lack of devices such as laptops or iPads and crowded conditions, all militate against working from home – or if you prefer, living at work.
Better governmental support and financial compensation for individuals and families under stress may help and, of course, a vaccination programme that is swiftly and competently rolled out will help reassure populations that they are being protected. This pandemic will come to an end, but the virus may be with us for some time. Taking care and staying safe will remain the watchwords worldwide. We have learned new skills and new ways of managing our patients: we are more comfortable with online consulting, with triaging patients by telephone and with only seeing those patients face to face that we cannot advise over the phone. Electronic prescribing has proved a boon, as has remote monitoring of those patients with chronic disease. General practice/family medicine has, as always, proved to be agile, inventive and innovative during this catastrophe. It must be supported and valued as the priceless asset that it is.
Dr Mary McCarthy FRCGP
European Union of General Practitioners