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
On April 26, the Centre for the Coordination of Health Alerts and Emergencies, collecting the contributions of the scientific community and experts, yielded a document with recommendations for the health system during the transition period. The recommendations aim to step-back to a contention strategy and assure the rapid response of the health system in the eventual case of an increase in the incidence of cases, while assuring equitable and safe access to non-COVID patients. The document includes as recommendations:
-Preventive measures such as physical distancing, respiratory etiquette, hand hygiene or the use of masks by the general population have to be reinforced, following the recommendations issued by the Ministry of Health and regional health authorities.
-Public Health authorities should design and implement new protocols to achieve early detection and monitoring of new cases. For that purpose, early identification and isolation of new cases, early identification and quarantine of contacts, particularly in nursing homes or prisons, should be reinforced. In addition, any data source that can inform on the appearance of new cases and contacts should be included as part of the surveillance system.
-Health care settings, such as hospitals or primary care centres, will have to assure non COVID patients assistance while keeping capacity to deal with potential future COVID-19 outbreaks; as follows: for hospitals, to prevent nosocomial infections at any hospitalization area and to assure sufficient personal protective equipment. These measures could be complemented by differentiating internal flows between COVID and non-COVID patients or, depending on the epidemiological situation, performing screening PCR tests to any admitted patient. In addition, hospitals have to be able to double ICU beds, triple hospitalization beds and store sufficient ventilation equipment and medication to cope with the epidemic upsurge.
-For primary care centres, to dedicate specific spaces to treat COVID patients, design specific circuits to separate respiratory and infectious patients, reinforce home care and telemedicine, along with public health authorities to set up early detection and surveillance protocols, and adopting the use of apps to detect and monitor patients and trace their contacts.
-Finally, healthcare settings should be able to offer consultation for screening, diagnostic, surveillance and psychological support to their workforce (https://www.mscbs.gob.es/gabinetePrensa/notaPrensa/pdf/25.04260420153138925.pdf).
Once the state of alarm expires, regional health authorities have to guarantee the responsiveness and coordination among public health, primary care and hospital care. Likewise, primary care centres and hospitals should have plans (organization and resources) for rapid response if sudden increases in the number of infected cases occur (Royal Decree 21/2020 https://boe.es/diario_boe/txt.php?id=BOE-A-2020-5895).
On July 16, the Ministry of Health and the autonomous communities agreed a plan for an early response in case of an increase in COVID-19 transmission. The plan foresees strengthening health services preparedness for COVID-19 outbreaks, increasing public health capacity for the early detection and COVID-19 control, and population-oriented preventive measures (https://www.mscbs.gob.es/gabinetePrensa/notaPrensa/pdf/17.07170720140919256.pdf).
In the Interterritorial Council held on September 9, the Ministry of Health and the autonomous communities agreed on developing a common vaccination strategy taking into account bioethics’ experts and scientific societies’ opinions. This common vaccination strategy will be approved in a plenary session of the Interterritorial Council. Autonomous communities will have to provide all the required resources to administer the vaccines that will be provided, in turn, by the Ministry of Health (https://www.mscbs.gob.es/gabinete/notasPrensa.do?id=5048).
Since the second week of March, as a response to the increasing toll of cases, elective surgery and non-urgent consultations have been postponed. In turn, primary care centres have also called off non-urgent consultations, cancelled emergency care except for patients with respiratory symptoms, and implemented an e-prescription mechanism for chronic patients so they can get their prescriptions renewed automatically, and thus avoid a visit to primary care premises. Along the same lines, phone helplines and on-line consultations have been used to deal with non-essential cases.
Since 14 March, after the declaration of the “state of alarm”, the Minister of Health was temporarily entitled to determine the best distribution of technical resources, including those from the military forces, private health sector, and even private business as hotels (Royal Decree 463/2020 https://www.boe.es/buscar/doc.php?id=BOE-A-2020-3692). As a consequence, from March 15, ACs can make use of private healthcare centres (including their personnel) and those of the mutualities for accidents and occupational diseases, if needed. Private hospitals that are treating privately insured patients with COVID-19 are also receiving patients from overcrowded public hospitals or treating non-COVID-19 patients, to release hospital beds and increase physical distance.
In addition, health authorities are entitled to make public or private spaces available (e.g. sports arena) to build ambulatory and hospital care premises (Order SND/232/2020 https://www.boe.es/buscar/act.php?id=BOE-A-2020-3700). So for example, on March 31 there were 16 field hospitals, most of them in Madrid, set up to specifically admit and treat the less severe cases. For example, a temporary field hospital with 1,300 beds has been set up in IFEMA, Madrid’s exhibition centre (https://www.lamoncloa.gob.es/serviciosdeprensa/notasprensa/defensa/Paginas/2020/310320-hospitales.aspx).
Finally, in some regions, hotels have been adapted to allow the recovery of patients and relieve overloaded hospitals (Orden TMA/277/2020 https://boe.es/buscar/act.php?id=BOE-A-2020-4027).
It is also worth noting that the Spanish Government has established legal provisions to ease subcontracting procedures with public sector entities in order to improve the rapid response of public administration entities during epidemics.