Indicators

COVID-19 impacted the utilisation of primary care in a number of different ways, including reduced attendances at some services and new ways of working in others, some of which are explored below.

Figure 1: Number of COVID-19 telephone triages by GPs (running totals shown) with national COVID-19 cases (2020-2021)

What the data show:

General practitioners played a key role in Ireland’s COVID-19 response. The majority (two-thirds) of all COVID-19 PCR tests up to February 2021 were either referred by GPs, followed up on by GPs, or both. General practitioners provided large numbers of telephone-based consultations with patients presenting with COVID-19 symptoms. In fact before each of the first three COVID-19 waves, three peaks in general practice activity can be seen demonstrating how general practice activity can be the predictor of surges in infection and need for care.

How the data relate to Sláintecare:
COVID-19 has inspired significant changes in routes of access to primary care and healthcare workers have risen to the challenge of providing care in new ways. The rapid implementation of responses such as telemedicine provided universal access to remote general practitioner care for those with COVID-19 symptoms as all COVID-related healthcare in Ireland has remained free at the point of use in line with the goals of Sláintecare and the public health benefit of minimising monetary barriers to healthcare access has been emphasised.

Figure 2: COVID-19 testing nationally by location (hospital or community/GPs) with percentage of tests from community/GPs (from Ordnance Survey Ireland open-source data).

What the data show:
Figure 2 shows the total number of PCR COVID-19 tests undertaken in Ireland both in hospital and community settings. As of March 2021, 3.76 million COVID-19 tests were performed by Ireland’s public healthcare system, 2.48 million (66%) of which were referred from the community. General practitioners played a key role in the ordering and/or follow up on these tests, with the proportion. The proportion of tests in which GPs played a role was between 60% and 70% for most months of the pandemic.

How the data relate to Sláintecare:
The findings indicate that general practitioners played an instrumental role in Ireland’s COVID-19 response given that a majority (two-thirds) of all COVID-19 PCR tests were either referred by GPs, followed up on by GPs or both. This is in line with the drive in Sláintecare provide healthcare at the lowest appropriate level of complexity and providing healthcare when appropriate in the community and not in hospitals.

Figure 3: Monthly use of GP out of hours services 2018-2020

What the data show:
Figure 3 shows that during the first wave of the COVID-19 pandemic in Ireland, there was a significant drop in the number of people attending out of hours general practice services compared with the two years prior. Nationally, 57,945 patients were seen in April 2020 compared with 92,369 in April 2019 – a reduction of 37.3%, or 34,424. This decline was maintained until July 2020. In August and September 2020, out of hours general practice care activities returned to pre-pandemic levels.

How the data relate to Sláintecare:
The observed pattern in out of hours general practice usage is in line with other Irish and international literature that has highlighted changes in care-seeking activity during the pandemic, such as in emergency departments. This tells us that patterns of healthcare utilisation are impacted by different events and that that health systems must be intentional about how, where and why they seek to drive user traffic to ensure that patients are seen at the appropriate level of complexity to receive the optimal care.

Figure 4: Cumulative patient numbers seen across eight allied healthcare specialties

Figure 5: Total waiting list figures across all eight community-based specialties (2018–2020)

What the data show:
Figures 4 and 5 shows that during the first wave of the COVID-19 pandemic in Ireland there was a decrease in allied healthcare activity (due to restrictions and protections being introduced) and at the same time there was a resulting growth in the waiting lists for the same services. According to the data presented in figure 4, there was a 35% reduction in publicly provided care across all eight allied health specialties in the community when the first nine months of 2020 are compared to the same period in 2018 and 2019.

Three distinct phases can be seen in Figure 5. First, there was a gradual, sustained increase in waiting list numbers across the specialties in 2018 and 2019. Second, an abrupt decline in the waiting list numbers for all specialties combined was reported in the first quarter of 2020, falling from 162,629 in December 2019 to 100,708 in March 2020, a reduction of 61,921 or 38.1%. Thirdly, a marked increase was seen in waiting list numbers from March to September 2020 for all specialties, offsetting the decline seen earlier that year.

How the data relate to Sláintecare:
A core feature of Sláintecare is a plan for the transition of healthcare when appropriate from the acute hospital to the community. We see in the reduced activity in allied health services resulting in increased waiting list figures that COVID-19 had a substantially negative impact on the levels of community-based healthcare delivered by the public healthcare system in Ireland in 2020. To promote the goals of Sláintecare, the capacity for community-based healthcare should be bolstered and enhanced and preparations should be made to allow services to be safely delivered in future crises. This includes planning how to best maintain access to essential care in the community during future waves or pandemics.

COVID-19 significantly impacted the acute health sector. Below are some examples of how this bore out in the early pandemic in Ireland with regards to in-patient activity.

The timeline for Figures 5-x below is divided into the following periods:

• Period 1: (1 January 2020-1 March 2020) Prior to the first wave of COVID-19
• Period 2: (2 March 2020-29 March 2020) Some restriction but prior to advice to stay at home coming into effect
• Period 3: (30 March 2020-17 May 2020) Stay at home advice and population level health restrictions
• Period 4: (18 May-5 July 2020) phased easing of restrictions

Figure 6: Weekly rate of ED presentation per 100,000 population week 1–26 2019 vs. 2020

Figure 7 Weekly rate of admission from ED per 100,000 population week 1–26 2019 vs. 2020

What the data show:
Figure 6 shows a substantial decline in emergency department presentations during the first COVID-19 wave in Ireland. Additionally, utilisation remained lower than in 2019 even as national restrictions began to lift toward the middle of the year. The study used data from the national Patient Experience Time (PET) dataset, an administrative dataset tracking individual-level ED utilisation across 30 HSE-operated or funded hospitals.

In line with Figure 6, Figure 7 shows a substantial decline in hospital admissions taking place from emergency department presentations during the first COVID-19 wave in Ireland. This pattern remains into periods 3 and 4 covering April, May and June 2020 when national restrictions began to lift on a phased basis.

The data show that COVID-19 has significantly reduced emergency healthcare utilisation. The explanations for the reductions observed are likely complex and may have been due to reduced incidence of some medical conditions such as injuries and non-COVID-19 infections and due to a reduction in unnecessary emergency attendances. However, there was also a likely reduction in presentations for time-sensitive conditions such as stroke and heart attack which should not be delayed. This suggests that necessary care was avoided or delayed potentially due to a fear of exposure to COVID-19 in hospital.

How the data relate to Sláintecare:
These findings hold several lessons for Sláintecare implementation. First, they show that healthcare utilisation in Ireland to some extent takes place at an inappropriately high level of complexity when people attend the emergency department without experiencing a true medical emergency. This finding points to problems elsewhere in the health system when people cannot access healthcare or diagnostics at a lower level of complexity when appropriate. Second, they show that capacity for true emergencies must be in place to manage presentations even in the midst of a pandemic.

Figure 8: Emergency mental health admissions in the aftermath of the first wave of COVID-19

Figure 9: Emergency alcohol-related admissions in the aftermath of the first wave of COVID-19

Figure 10: Emergency admissions with self-harm in the aftermath of the first wave of COVID-19

What the data show:
In the period after the first wave of COVID-19 in Ireland, increases were observed in admissions for emergency mental health problems, emergency alcohol-related issues, and emergency self-harm.

How the data relate to Sláintecare:
In line with Healthy Ireland, Sláintecare seeks to promote population health and wellbeing and reinforce the Public Health Alcohol Act 2018 which aims to reduce the harms caused by the misuse of alcohol as one of its four primary objectives . The data in Figures 8, 9 and 10 indicate that the pandemic, and associated restrictions, have negatively impacted the mental health and wellbeing of the Irish population. Sláintecare implementation may need to focus on the increased needs for mental health and alcohol treatment that have resulted from the pandemic.