Regional coordination and bottom-up response of general practitioners in Belgium and the Netherlands - Impressions from the field
Hopkins and colleagues give a rapid review of the response of several health care systems across the world to the COVID-19 pandemic (1). The responses illustrate the differences between health systems, including the weak spots in some countries (2). We, as General Practitioners (GPs) from the frontline, present our observations about the coordination at primary care level – or lack of it in the early health system response and the bottom-up reaction from the frontline health workers in two neighboring countries, Belgium and the Netherlands.
The Netherlands has a central public health authority (RIVM) with decentralized municipal public health services (GGD). RIVM developed the national protocol for screening and case finding and public health measures, the GGD were appointed to implement the screening and case finding, for patients that did not need acute medical care. Although there is regional variation in the extent to which this happened, the GGD service was meant to support the General Practitioners (GPs) in the containment of COVID-19 spread through testing and direct expert advice. Belgium also has a central public health authority (Sciensano) that similarly developed national protocols, but it does not have decentralized preventive health services to support at operational level. Implementation of the protocol at the initial stage left to the health care workers, who had to include case detection, reporting and patient care in their routine services. In the absence of regional leadership, many GPs continued their primary task, taking care for their patients. While people with symptoms started to come, this posed operational challenges and pressure.
In both countries, out of hours services and the surrounding GP groups were at the center of local coordination to developing a first response to the increase of ill patients and diagnosis of COVID-suspect cases in the initial first two weeks on the epidemiologic curve. Many bottom-up approaches were organized with separate respiratory triage posts to diverse potential viral and COVID-19 cases from other patients. The rapid preparedness by many local GP groups for this public health emergency prevented chaos in the first two weeks of the pandemic.
In the subsequent stage of the pandemic, both governments are scaling up. National emergency plans for health care response are taking shape for organization of first line screening diagnosis, care and referral and coordination with hospitals and other services. The locus of coordination and the guidance towards health care providers is different in each country. We observe a majority of centralized approaches in the Netherlands with many regional 24/7 triage centers as an adjunct to hospitals, and regional coordination by the Regional Medical Service Organization (GHOR), a public committee responsible for coordination in crisis situation. In Belgium first line triage posts are getting better organized and scientifically and logistically supported. The medical professional organizations in Flanders, Wallonia and Brussels have taken up an active role to support organization of their members. GP groups (huisartsenkringen) remain leading in the organization of the local response. Increasingly, GP practices and health centers reorganize and take measures such as telephone triage, telemedicine and staggered consultations by appointment, to still guarantee the essential and urgent primary care and avoid collateral damage by the epidemic, such as diagnostic delay of other conditions. In the absence of a clearly delineated regional coordination committee, this leads to a more scattered pattern of triage posts, and variation in response, for instance in how triage posts are staffed.
Driver for the differences relate to the set-up of the health care system and the institutional context. The complex and decentralized organization of the Belgium health system with 9 ministers of health slows down central coordination of response, despite a strong unified response in the other policy measures such as the lock-down. The financing system of health care providers also influences the flexibility of health care workers to reorganize patient flow and take up new emergency duties. The gatekeeping role of the first line and the largely capitation-based funding of primary care in the Netherlands enabled regional organization, in collaboration with existing decentralized public health services.
The presence of strong professional GPs in both countries, and in many others, is the backbone of health system response, also in public health emergencies. Central governments and professional organizations need support this backbone by having process and structures in place for efficient coordination and implementation, from central to regional and local level.
This response was written by members of the Department of Primary Care of the University of Antwerp (UA): Josefien van Olmen (UA) and Roy Remmen (UA) are GPs practising in the border area of Belgium and Netherlands; Paul Van Royen, Hilde Philips and Veronique Verhoeven are GPs in Belgium; Sibyl Anthierens (UA) is a sociologist.
1. Hopkins Tanne J, Hayasaki E, Zastrow M, Pulla P, Smith P, Garcia Rada A, et al. Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide As coronavirus continues to spread, doctors and healthcare systems are facing a multitude of challenges at all stages of the pandemic. 2020 [cited 2020 Mar 24]; Available from: www.coronavirus.
2. Tamara Popic. European health systems and COVID-19: Some early lessons [Internet]. LSE politics and policy blog. 2020 [cited 2020 Mar 24]. Available from: https://www.printfriendly.com/p/g/8Vf4G7
Competing interests: No competing interests