Primary care health workers are at the limit of their strength. “Exhausted”, “discouraged” and “exhausted”, they repeat over and over again. In the first wave, they were the retaining wall against the epidemic; in the second, covid lookouts at street level and sentries from the residences. And in the third stage of the virus, they have also assumed the vaccination campaign and care for patients displaced by the pandemic. In the last year, the healthcare pressure that had been dragging on since before the health crisis has intensified and health centers have been installed in a state of permanent saturation. “More and more tasks and with the same resources,” summarizes José Polo, spokesman for the Spanish Society of General Physicians (Semergen). And that takes its toll: to professionals, who notice a worsening of their mental health, and to patients, who get lost along the way or arrive late and in worse condition for the consultation.
In the waiting room of the Creu Alta primary care center in Sabadell, Josefa Cerezo, 76, and her daughter Marga kill time looking at nowhere. “It was hard for me to come. It is difficult to communicate with the health center because the telephones are saturated. I had a sciatica to die for and ended up going to the emergency room. Today I come to control the tension ”, explains Josefa. There are hardly any patients in the corridors. To avoid contagions and optimize resources, telephone consultations have displaced face-to-face ones. There is not so much bustle in the waiting rooms, but from doors to office, the pace is frantic. “Access has changed, but we continue to attend acute demand that is not serious, such as a urine infection, in chronic patients and follow-up at the end of life through home care,” explains Ángeles Zamora, a nurse at the center. On the ground floor there is also the covid area. “In the first wave there were more serious cases. Now there are more family infections, but milder. People are still afraid of the virus and they come scared and anxious, ”says nurse Laura Estirado, wearing an individual protective overall and double mask.
Primary care is the gateway to the health system, but the pandemic has created a bottleneck that is difficult to overcome. The workloads have multiplied: in addition to taking charge of the detection and control of cases with covid-19 and their contacts, family doctors and nurses visit their regular patients, recover those left behind by the pandemic, do home consultations and palliative care, coordinate care in residences in their reference area and assume vaccination, flu and covid campaigns. Everything, they warn, with almost the same resources as before the pandemic. “As we are it is almost impossible to assume everything. Nursing makes 130 million consultations a year and the vaccination of the covid-19 to the general population would imply 50 million more consultations. In other words, it would mean increasing activity by 50%. You need resources ”, says Salvador Tranche, president of the Spanish Society of Family and Community Medicine.RELATED
The toilets are not enough and the pandemic only exacerbates the deficiencies of a sector decimated by cuts for 10 years. “Before the pandemic, we estimated that 15,500 more nurses were needed in primary care. Now, the shortage only in nursing is brutal. It is essential to increase human resources, “says María José García, spokesperson for the Satse nursing union. According to a report by the Collegiate Medical Organization (WTO), the allocation for public health fell by 8,636 million euros (12.24% less) between 2009 and 2014. But in primary care the scissors were harder, from 16.17% (1,742 million less). “We have overflowing agendas and people are already on leave due to mental problems. Precariousness is increasing. If this continues like this, primary care will not hold, ”laments María Justicia, head of primary care at the Madrid union of Amyts doctors.
The rise of the third wave has put health centers in check again. They have more experience, diagnostic resources (they can do tests, which in the first wave they could not) and protective equipment, but they lack hands. “We are absolutely overwhelmed and overcome,” sums up Rosa Magallón, president of the Spanish Primary Care Network of the Spanish Society of Public Health (Sespas).
And that is noticeable, above all, in the access to the system of non-covid patients. Some arrive in worse health and the chronically ill, more decompensated. Others, lost in fear or the bureaucratic network, have not even arrived. “The diagnostic delays we have are brutal. There are hospital tests that are being delayed and we find very advanced tumors or important alterations in the quality of life due to some pathology, ”Tranche warns. Interventions have fallen by 36% in the first half of 2020 compared to the same period of 2019 and the delays have skyrocketed – the average wait for a knee replacement is 183 days, for example. “We see many complaints from patients about delays in tests and operations. A cataract is not an urgent pathology, but the patient does not see, ”says Polo.
Tranche points out that the difficulty of access, linked to the precarious health, which causes a lot of staff mobility, hinders the continuity of care, a key part of primary care. Magallón agrees: “You have to double shifts, you see patients you don’t know because of the discontinuum [la discontinuidad] care and delays occur. Because we haven’t had time to see patients well. Other delays also occur because patients do not want to come to health centers.
The exhaustion of the patients has turned the applause at eight o’clock into reproaches. “The population is angry. They scold us because they don’t feel cared for ”, assumes Tranche. “They are sullen, angry and bounced,” Tercia Polo. However, Zamora believes that this attitude “is not discontent, but fear: they are scared, they fear losing accessibility.”
Working under an atmosphere of continuous care pressure is also not safe for professionals. “We got to the consultation earlier and we left when possible. Nobody asks us for it and nobody pays us back, but we do it. And that is burning you. There is a lot of overhead. The professionals are hopeless and come to work suffering, ”says Cándido Pequeno, head of the service at the Cee health center in A Coruña.
Two studies by researchers from the Hospital del Mar in Barcelona reveal that almost half of health professionals are at high risk of mental disorder due to the pandemic. “There is an increasingly high percentage of health workers who are taking anxiolytics and antidepressants and people on sick leave due to post-traumatic stress,” says María Justicia. And he warns: “We are not a rubber band. We toilets are human and if they continue to stretch, one day we will break down ”.
The Waves to Come: Mental Health and Forgotten Patients
Primary care professionals predict difficult months. Even if the epidemic curve falls, other waves will come, above all, due to the impact of all those ailments postponed – by the system or by the fear of the patients themselves – due to the pandemic. “The wave of poor mental health, decompensated chronic disease and subacute disease is going to emerge. Although the healthcare activity has been maintained, we have lost preventive activities, such as cancer screening ”, assumes Salvador Tranche, president of the Spanish Society of Family and Community Medicine.
In addition, health workers are waiting for a new patient profile, until now unknown: people with persistent covid, who present very nonspecific symptoms, from tiredness and fatigue to musculoskeletal pain, and whose only common link is having passed the covid. “It remains to be seen what it will mean to us, but we are beginning to see it and there are casualties that are already lasting. They are cases of difficult management because there is not much to do with them, there is no treatment, ”says Carlos Eirea, vice president of the Galician Association of Family and Community Medicine. For now, care for these cases is shared with hospitals. “They are new patients for everyone, but we are concerned because they can become chronic patients and there is no treatment,” agrees María Justicia, from the Amyts medical union.
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