Eighty interviews were conducted between 2 April and 2 July 2020 and lasted between 17 and 86 min (mean 35 min). The timing of interviews in relation to lockdown restrictions in each country is summarised in Supplementary Table S1. Basic characteristics of participants are summarised in Table 1.
Given the depth of data gathered across countries, in this article only data on the first theme and its five subthemes are reported. The remaining themes will be reported in subsequent manuscripts. Key findings in relation to each of these subthemes is presented in Supplementary Table S3. Key information in relation to each country is presented in Supplementary Table S2 and additional quotes in Supplementary Table S4.
Theme 1: Transformation of primary care delivery and PCPs’ experiences of these changes
Subtheme 1: managing patients with respiratory tract infection (RTI) symptoms
At first, PCPs in all countries tried to manage the majority of patients with RTI symptoms over the telephone, using history taking, follow-up, and safety netting. Care for patients needing face-to-face appointments was organised differently across countries. England, Belgium, the Netherlands, Germany, Sweden, and Greece set up processes to manage (suspected) COVID-19 patients in their own practice, which involved seeing them in a separate part of the surgery or at specific times to minimise risk.
With time, England, Belgium, and the Netherlands set up COVID hubs in certain cities (places where PCPs could send patients for examination and/or testing). PCPs welcomed them, but they also posed challenges and resulted in having to follow different protocols. PCPs in Belgium initiated and established COVID hubs themselves without any guidelines; and COVID hubs in England were often set up by different primary care organisations (clinical commissioning groups [CCG] and primary care networks [PCNs]):
‘To make it more manageable they should be setting up these hubs … a lot quicker, they should be a lot more standardised but every CCG is doing it slightly differently and every PCN is doing things differently.’
(GP, Participant [P]5, England)
In contrast, PCPs in Ireland stopped seeing patients face to face and all consultations were moved online, and patients were referred for testing by PCPs in drive-through testing centres.
Germany, Greece, and Sweden continued seeing patients with RTI in their practices throughout the pandemic and PCPs in Sweden described how they initially set up tents outside of the surgery, but with time, established more permanent areas for patient care. In contrast, patients in Poland who had symptoms of COVID-19 and were suspected of having contact with someone with COVID-19, were advised to contact hospitals or wards for infectious diseases. PCPs found it difficult at times to interpret guidance on this:
‘Sometimes, when the symptoms are numerous and typical of a COVID-19 infection, we don’t even invite a patient in but we send him to the hospital straight away. In unclear cases, a doctor decides whether to examine a patient or not.’
(GP, P7, Poland)
Subtheme 2: providing non-COVID-19 care
Initially, in all countries, the majority of conditions were managed by telephone. PCPs tried to assess what was urgent and required face-to-face care without much guidance; this appeared to result in variation across practices (see Supplementary Table S3).
With time, PCPs across all countries started to express their concern about ‘collateral damage’ resulting from routine care being postponed or limited, especially for chronic conditions. This made PCPs uncomfortable, and some realised that they would be dealing with the ‘backlog’ for a long time:
‘I haven’t had a diabetes clinic for 3 months now, and that was of course frustrating; … I haven‘t caught up with my waiting list and seemingly won‘t have for all of this year.’
(Nurse, P10, Sweden)
Countries differed in how they tried to maintain routine care. PCPs in most countries described their attempts of providing health checks and annual reviews remotely or in group format to help with a backlog; in contrast, PCPs in Belgium and Sweden suspended annual reviews and annual checks, respectively, for >70 year- olds. Some countries also focused on vulnerable patients by proactively calling them or increasing home visits. These decisions were initiated by each practice individually based on what they found most useful and feasible.
PCPs across all countries felt overwhelmed with constantly changing information from multiple official sources. However, they still reported lacking official training on PPE use, telephone triage, or practical information about how to organise or restart their care. PCPs in England, the Netherlands, and Poland highlighted that resuming care needed to be done in line with secondary care, allowing referrals for hospital investigations and with consideration for safety protocols.
Subtheme 3: resources to deliver primary care services during the pandemic: who pays?
PCPs in Belgium, the Netherlands, and Ireland, where GPs are paid for consultations, described the financial implications of the pandemic. Belgian and Dutch PCPs highlighted initial lack of clarity about whether telephone consultations would be reimbursed or paid for at the rate for face-to-face consultations; Belgian PCPs also set up and financed COVID hubs themselves initially. In Ireland, decreased workload, the hesitance of patients to pay for a telephone consultation, and the worry of PCPs that the patient may move to a different practice, caused financial concern:
‘Nobody talks about the competition but it‘s always there … Patients might just leave one and go to the other practice and all that it has financial implications.’
(GP, P2, Ireland)
Participants reported that lack of PPE or having to source and buy it without government support, sometimes at very high cost, was one of the main problems, coupled with a lack of clear guidance on when to use PPE or being told to ‘save it’:
‘Until the end of March we didn’t have any suits … When the PPE suits arrived, they were very few, so if we used them, they would barely last a week.’
(GP, P1, Greece)
The extent of provision of resources such as computers, webcams, and software allowing PCPs to provide remote care differed within and across countries, with some practices getting support from CCGs in England or the Narodowy Fundusz Zdrowia (National Health Fund) in Poland making it easier for PCPs to set up remote care. Practices had to cover the costs related to changing the layout of surgery buildings themselves.
Subtheme 4: remote care and dealing with uncertainty
All countries organised triage in order to prioritise and respond to patients’ queries. This was in contrast (apart from in the Netherlands) to an ‘open door policy’ that operated pre-pandemic (see Supplementary Table S2). PCPs across all countries described some limitations of remote care for both patients with and without RTI symptoms.
For patients with RTI symptoms, PCPs highlighted the difficulty in assessing whether and when patients will deteriorate. Limited knowledge and changing guidance on typical and atypical symptoms in the early stages of the pandemic was difficult to deal with:
‘There’s no evidence base behind it — everyone’s just guessing … so you feel very unprofessional, you feel … the whole imposter syndrome comes right the way up. You just think, “Gosh, am I doing this right?”.’
(GP, P3, England)
The majority of PCPs across all countries had limited experience with managing patients remotely before the pandemic. Not seeing their own patients and lack of visual clues meant that PCPs often worried about missing something important:
‘Sometimes it’s hard to tell from a phone call if someone actually needs more attention or to be diverted to the hospital. Every choice we make is a risk.’
(GP, P3, Greece)
In contrast, some PCPs in England and Sweden had experience with telephone and video consultations before the pandemic and found it easier to adjust to them. PCPs in Germany, England, Sweden, and Poland commented on wanting to continue with remote consultations for some patient queries in future but highlighted the difficulty of remote consultations for certain groups:
‘I think it works with the younger group of patients … whereas I don’t think it works as well for the older generation. You can’t take away the benefits of sitting with a patient to assess them visually.’
(Nurse, P6, England)
Subtheme 5: adjusting to roles and workloads and the importance of team work
PCPs described taking on additional tasks both formally, such as helping in setting up COVID hubs or acting as a triage person in the practice, and informally, by acting as a ‘counsellor’ to staff. These new roles at times also had an impact on PCPs’ workload; which had a negative impact on their mental health:
‘Such an exhaustion, different from what we usually know, even though we have stressful and exhausting consulting hours, but that is another kind of exhaustion.’
(GP, P8, Germany)
In contrast, some PCPs experienced a decrease in clinical workload and wanted to contribute more (see Supplementary Table S3). PCPs in Poland felt that they had been given a limited remit in relation to management of patients with RTI symptoms:
‘Our role hasn’t been precisely defined so we continue caring for our patients … We are a bit left out.’
(GP, P3, Poland)
In the context of these challenges, PCPs across all countries seemed to turn to their colleagues for moral support and by, for example, setting up daily team updates or using social media to share information and discuss patient cases (see Supplementary Table S3). Working together as a team was crucial, especially within their own practice but also with secondary care and other service providers. PCPs in Belgium and the Netherlands highlighted this in the context of GP surgeries working in groups, and some PCPs in Ireland and Belgium described how for the first time they had felt a sense of community among PCPs:
‘In the practice, we work with four people so we could help each other. Like look there’s a new update on this subject, or have you seen that? Or I do it that way. So yes, you could inspire each other a little bit.’
(GP, P2, Belgium)
Working well together and towards the same goal brought huge satisfaction and a sense of solidarity (see Supplementary Table S3):
‘We see ourselves as all in this together, in the end, we are lucky to be able to have this job because patients allow us to have this job. […] As you know and I said it before, our competitive relationship with each other can make it difficult to collaborate. Nobody talks about the competition but it’s always there. In that people set-up practices beside each other and patients might just leave one and go to the other and all that it kind of has financial implications.’
(P2, GP, Ireland)