3. Providing health services effectively
The section on PROVIDING HEALTH SERVICES EFFECTIVELY describes approaches for service delivery planning and patient pathways for suspected COVID-19 cases. It also considers efforts by countries to maintain other essential services during periods of excessive demand for health services.
3.1 Planning services
All public and private laboratories are allowed to provide tests for Covid-19 since March 7. Research and veterinarians labs will be also allowed to provide tests to increase the capacity after the end of the lock-down (May 11).
In total, 19 million tele-consultations were provided in 2020 (all types of providers included), but peaks were mainly observed during the lock-down periods.
VACCINE SERVICES AND DELIVERY
On October 24, the president announced that a vaccination campaign is expected to start as soon as possible and that vaccination will initially target the most at risk individuals. It relies on two main principles: the vaccination is not compulsory and is free of charge for all. On October 30, and after a public online consultation, the national health authority made the following recommendations for vaccination in five stages: 1/ vaccination of residents and staff of nursing homes; 2/ vaccination of people aged over 75; of people aged between 65-74 with comorbidities; of health professionals aged over 50; 3/ vaccination of people aged over 50 and younger people with comorbidities; 4/ deprived populations and populations particularly exposed to the virus (homeless persons, people living in psychiatric institutions…); 5/ people aged over 18 with no comorbidities. Based on these recommendations, the government announced a vaccination campaign in three main steps after pre-booking 200 million doses. From January 2021, the vaccination campaign was supposed to target residents of nursing homes and staff of nursing homes when they are at risk of a severe form of the Covid-19 (an estimated 1 million individuals). From February to spring 2021, the vaccination campaign was expected to target people with a risk factor (age, chronic disorder…) and some health professionals (an estimated 14 million individuals with a progressive implementation following the arrival of vaccine doses). From Spring 2021, the vaccination campaign will be opened to the whole French population but there will still be some priority persons based on age, work sector or socio-economic vulnerabilities. The implementation of this calendar of vaccination was considered to be challenging considering the French population's mistrusts towards the Covid-19 vaccines in Europe. A council for vaccination strategy was created within the Ministry of Health grouping scientific experts, health professionals, representatives of local authorities, patients’ association and citizens.
The vaccination campaign was launched on December 27, 2020 in nursing homes (with the Pfizer/BioNTech vaccine). However, very low numbers of vaccinations in the first days of the campaign in comparison to other European countries have triggered many criticisms. As a consequence, the vaccination strategy has been adjusted. The first phase targeted older and disabled individuals living in care homes, health professionals, firemen and caregivers at home aged over 50 or with chronic conditions (initially planned in a second phase). People aged over 75 living in the community (who were also in the second phase initially) were included in the vaccination campaign since January 18, 2021. They had to pre-book an appointment by phone or online starting on January 14, 2021. More than 500 dedicated vaccination centres were rolled out on the national territory by the end of January. The time-lapse between the two shots of the vaccine was extended from three weeks to six weeks to allow for a higher number of initial shots. In February 2021, access to the first jab for the priority populations appeared to be difficult with more demand than available stocks of vaccines while the contrary was observed specifically for health professionals who have been reluctant to get vaccinated. This provoked a debate and recommendations by the National Academy of Medicine that the vaccination should be made compulsory for health professionals. However, the subject is highly flammable, and the recommendation was not followed by the government.
A pre-vaccination medical visit with a physician (fully covered by the SHI) and an oral consent to the vaccination are compulsory for all for the vaccination. The information is registered in a specific information system (“SI Vaccin Covid”) starting on January 4, 2021. This register will help to follow-up the uptake of the vaccination and the potential side effects of the vaccine, as well as the issuance of certificates of vaccination. Physicians are remunerated €5.40 for each patient registered. The registry is only accessible to physicians conducting the vaccination, the referring GP of the patient and specific staff of the SHI. To face criticisms, the president also announced that 35 French citizens randomly selected will form a collective in charge of following and expressing their opinion on the vaccination campaign.
Following the authorization of the AstraZeneca vaccine (by the European Medicines Agency), which can be stored in a regular fridge contrary to previous vaccines, pharmacists and midwifes were allowed to participate in the vaccination campaign. They provide the vaccine within their usual practice in addition to physicians and nurses. The national health authority (HAS), however, first recommended the use of this vaccine only for people aged under 65. Hence, individuals aged 50 to 64 with comorbidities were initially targeted in the community with this vaccine (starting on February 25 2021). However, following concerns about the side effects of the AstraZeneca vaccine, it was suspended temporarily before finally being recommended by the HAS for people aged over 55 only. For all vaccines, the HAS also recommended a single jab for people who have already been infected by Covid-19.
Following the rapid increase in the number of cases in France in mid-March 2021, there is a strong pressure for accelerating the vaccination campaign. Large vaccination centres (“vaccinodromes”) supported by the army’s health services were set up by the beginning of April. They will be dedicated in priority to people aged over 70 in the community. In the coming months, the definition of additional priority populations based on their professions (such as teachers or policemen) are under consideration. In March 2021, firemen, dentists and veterinarians have been allowed to vaccinate against Covid-19.
On March 31, 2021, the president announced that the vaccination would be opened for everyone over 60 years old on April 16 and those over 50 on May 15. He further announced that vaccination would be opened for those under 50 years-old after mid-June. Finally, it was announced that the vaccination would be opened for all people aged over 55 by April 12.
There was not an immediate reconfiguration of services, but a care pathway for COVID-19 patients has gradually been defined (see below). There is no designated hospital to deal with COVID-19 patients, and initially patients admitting via emergency departments in several hospitals created tension regarding the risk of contamination. Many hospitals set up tents outside for screening COVID-19 cases. As of week 11, recommendations were to call mobile emergency services (15) rather than to go directly to the hospital. Tele-consultations, which were already available (reimbursed) in France and charged the same price as a normal consultation, are highly recommended in the current situation. Their number has exponentially increased over the weeks and in the first half of April, tele-consultations represented a quarter of all consultations, with 70% of all GPs providing online consultation services (figure which remained similar in May 2020 following the end of the first lock-down).
In addition to the national planning of services, some additional services have also been planned on a voluntary and local basis, such as ambulatory care centres dedicated to Covid-19 patients in the particularly affected Eastern region. These consultation centres, run by private doctors and nurses, opened with the support of the municipalities. In Strasbourg, where several networks of practitioners have also been set up with tools for sharing information between professionals, specific protocols for caregivers working in patients' homes or in nursing homes were implemented.