Local healthcare services are really struggling. The Lombardy region is facing more issues than any other region, but they are problems that are more or less everywhere in Italy- the shortage of a vaccine for the flu is an example. Recently we, general practitioners, were informed that, if we wanted more doses of the vaccine they could only be delivered by mid December. This is not acceptable, also because in the meantime the people who need the vaccine organise themselves differently, for example by contacting private services that administer it for 50-60 euros. In previous years (differently from today) the vaccine was available at the pharmacy for 15 euros per dose and people who were not referred in by the ATS- due to their good health conditions or young age- could easily purchase it and get it from the GP.
The Lombardy region decided that the “recovery” swab test- the last test that, when negative, allows people diagnosed with Covid to end self-isolation- is no longer necessary after 21 days passed from the first positive swab test and if there have not been further symptoms for at least one week. I think that is wrong. In my experience there are positive swab tests even after a month or longer; therefore people access private services- in this case they do it to protect the community, not themselves- which is something that should be covered by the public healthcare expenditure and be free to the public. The same thing is valid for the close contacts of a positive subject: they are meant to follow a quarantine period of 10 days and have a swab test (which is only available through private services) or only 14 days of self isolation and then the quarantine period is over. However, once again, they might be asymptomatic thus still contagious.
I think that the proposal of the President of the Veneto region, Luca Zaia, to have GPs do swab tests in their surgeries is madness. In the hospital there are two separate lanes- the so-called “dirty” and “clean” lane- to ensure that different environments do not contaminate one another. It is a bit difficult to create two separate lanes in GP surgeries. That would mean causing an outbreak. Patients who need a swab test usually have fever or other Covid symptoms and making them come to the surgery is dangerous. Everyone has expressed various concerns in this regard. A solution would be to create an external gazebo in the open air where GPs could go in turn to do swab tests.
In this period work tends to happen in 12-hour shifts and in stressful conditions. There are operations- such as writing prescriptions- that could be done differently. For example, we could send drug prescriptions for chronic treatments to the IT social-healthcare system of the region and the pharmacists could just find them online, on the file of the citizen, just like the system adopted by the Trentino region. Instead we are burdened with a process that requires us to send the barcode via email or WhatsApp, and whenever the prescription cannot be printed we have to deliver it to the patient- directly to their home if they are elderly.
There is no guideline. We could have done swab tests in people’s homes, together with an ultrasound and a blood draw to diagnose and determine the seriousness of the condition. During the summer we could have learned, with training, how to use the ultrasound machine and this would have allowed us to do more doctor work than admin. In Emilia-Romagna the doctors of the Special Support Units follow this procedure, which was recently described as being more valid for diagnoses than swab tests.
I believe that creating a network is really important. I noticed that patients also feel safer when they know that their GP is in contact with the specialist or even with the pharmacist.
The value of discussion
What is lacking, apart from doctors, is the communication between the decision makers and those who have to apply their guidelines. I believe that when you have to make decisions that concern local services you should consult with the workers of those same services, as they will know exactly what they need. For example, we need someone to arrange swab test appointments; at the moment we, GPs, are doing this. There are days where we have to call twenty different people to check the availability of each person and what date, time and where they can do the swab test. This is admin work, not care work. As GPs we do everything that needs to be done but we would rather dedicate our twelve-hour shifts to urgent home visits and to reassure anxious patients on the phone- particularly needed in this period- (the doctor-patient relationship is all about this). Basically we prefer doing doctor tasks. In my case I decided to work less on bureaucratic/admin tasks and more with patients who come to the surgery instead of going to the A&E. Furthermore, I believe that every group of GPs from the same area should be able to offer patients ECGs, ultrasound scans and spirometry tests, with the help of a nurse.
The GP-nurse-specialist-pharmacist network
Often I call specialists to discuss their patient referrals and I find that they are always extremely happy to be contacted. I am not saying that every single referral should be discussed but I do believe that creating a network is really important. I noticed that patients also feel safer when they know that their GP is in contact with the specialist or even with the pharmacist- speaking of which, last Friday, just after 7 pm, before closing, the pharmacist reassured me that they were going to home-deliver a tank of oxygen to one of my Covid patients). This system will be even more relevant during the “post-Covid-19” period, when patients might be facing the potential aftermath of the disease with the neurologist, the pulmonologist and the cardiologist.