Challenges for primary care in the “New Normal” era

Maria KW Leung

HK Pract 2021;43:66-67

The term “new normal” is often used to describe the transformations that have taken place after a crisis. COVID-19 has been, by far, the longest pandemic we have ever come across in this century. For Hong Kong, we have already gone through four waves of COVID-19 since the first case on 23rd January 2020. In our fast growing society, both our public and private healthcare providers have undergone many changes to address with the pandemic. Have we reached “new normal” yet? In fact, what exactly does “new normal” mean to us? And how does that affect primary care and what will be our challenges?

Several major changes in patient behaviours are believed to be contributing to the “new normal” of Hong Kong. Since the beginning of the pandemic, there have been many recommended infection control measures from the Government, including mass mask wearing in public, frequent hand-rubbing, enhanced cough etiquette and keeping social distance. Such practices are believed to have contributed to the significant drop in clinic and hospital attendances due to upper respiratory tract infections during winter surge in 2019-20.^1-3 Compared to 2015-19, the 2019-20 winter influenza season was 63.2% shorter.³ Although one may argue mass mask wearing is compulsory according to the Cap. 599l Prevention and Control of Disease Regulation and this may not be a “new normal” practice once the regulation is lifted, it is anticipated that certain proportion of the population may still wear masks in the post-COVID-19 era, especially during winter. Research has found that the formation of a habit takes place, on average, around 66 days after the first daily performance.^4-6 To some people, these infection control measures would have already been integrated in their daily routines. As a result, such changes in patients’ behaviours would have an impact on the epidemiology of our common encounters in primary care with simple upper respiratory tract infections being replaced by other more common or complex chronic illnesses. Although the duration of such impact is yet to be confirmed, we, as family physicians at clinic level, should be equipped to face the challenge due to the change in epidemiology, including knowledge updates or even clinic setting enhancement to cope with more complex chronic illnesses.

Care delivery system has also changed because of the pandemic. Without doubt, many colleagues would agree the rise of telemedicine is the most significant change when patients could not attend clinics physically. In fact, a Cochrane database review on telemedicine that was published in 2015, including 93 trials and about 22000 patients, already showed some support for use of telemedicine in chronic diseases such as diabetes and hypertension.⁷ Another study in 2017 also showed how the use of telemedicine can shorten the waiting time for consultations between family physicians and dermatologists.⁸ With the recent emergence of advanced technology, such practice has become more easily available for both the public and health care providers. In the update article on a webinar focusing on the practical and medicolegal aspects of telemedicine by Cheng et al, it was found that 75% of participants have taken part in any form of telemedicine in their practices, while 95% of respondents believed that more training on telemedicine is required. ⁹ While telemedicine is still growing and evolving, it is very clear that this new technology has already become part of the new normal care delivery. The next challenge we face in using this new technology would be about how to provide training and guidance for doctors on the use of telemedicine

During the pandemic, many people avoid going to clinics and hospitals because of concerns about infectious risks. They default their follow up appointments and related investigations, which may potentially affect their chronic disease control. Apart from telemedicine, community resources to support patients with chronic illnesses have therefore become very important during the COVID-19 pandemic. A new community support, District Health Centres (DHC), has been in use for chronic illness patients since 2019. From the Chief Executive’s 2017 Policy Address¹⁰, the aim of DHC is to encourage the public to take precautionary measures against diseases, to enhance their capability in self-care and home care, as well as to reduce the demand for hospitalisation. The first DHC has been in place in Kwai Tsing District since 24 September 2019, providing services to that locality. Without much information on the utilisation before the emergence of COVID-19, it is difficult to tell how much the current use of DHC has been affected by the pandemic. Leung et al has carried out a survey on family doctors’ perception on the DHC and one important message from their survey is the future need for engagement of more private family doctors.¹¹ So, the third challenge to face in the new normal would be how to enhance the engagement of community primary care stakeholders in the use of DHC, so that its potential on patient care could be fully maximised in the new normal era.

As COVID-19 pandemic is not yet over, the impact of new normal on primary care will still continue to evolve. Let us family physicians continue to strive for a better population health irrespective of how this “new normal” will affect our society.