 A very warm welcome everyone to this, the last of the current series of Wonka webinars. Today the topic is research and will be led by Professor Felicity Goodyear-Smith, who chairs Wonka's working party on research. As usual, we have a great panel of experts who will be introduced to you as we go along. But we particularly welcome two past presidents of Wonka, Professor Chris Van Veel and Professor Michael Cade. As ever, we will also be monitoring your questions and comments, and Anastav Dallar, President-Elect, will be putting some of these to the panelists. But before that, I'd like to hand over to Anna for some introductory remarks. Thank you very much, Kors. It's my privilege to greet you all on behalf of our president, Donald Lee, who will join us later. I will now convey his opening remarks. He says, Good day. Welcome to the eighth Wonka webinar. Thank you, family doctors, for sharing the burden of dealing with this COVID-19 global epidemic. Family doctors are continuing with a massively increased workload, but I'm proud of the level of support and collegiality displayed within and across our member organizations, and from region to region. Family doctors all around the world disseminate scientific advice, clinical updates, reflective messages and professional support through their social media links and connections. The Wonka webinar is a platform for all of you to share experiences, relay information and to keep in touch with each other regularly, like family members, urging courage and offering mutual support in these extraordinary times. Next slide, please. To provide essential evidence for informed clinical and health policy decision-making, research is essential. Indeed, one of the objectives of the Wonka working party on research is to support countries and regions in the promotion and nurturing of family medicine general practice primary health care research in their respective nations with the timely translation of its results into everyday clinical service. Today, we have a panel of renowned experts who will share with us some of the studies on COVID-19, as well as other research activities of the working group. So with these words from Donald, we are good to go. I will be moderating the discussion, as Gert said, after each presentation. So please post your questions, share observations and comments, and I will do my best to convey some of them to our panelists. Let me now welcome the chair of the Wonka working party on research. Felicity, could you Smith, we are looking forward to your introduction. Felicity, on the screen is all yours. Thank you very much, Anna. Good morning, good afternoon and good evening, colleagues. And so welcome to this Wonka webinar hosted by the Working Party on Research. I'd like to thank our president, Donald Lee and president-elect Anna Stavdoll for organising this whole webinar series. And also our CEO, Garth Manning, and especially CEO-elect, Harris Legardus, who for all his IT support. So as Anna said, I'm Felicity Goodesmith, the chair of the Working Party on Research. And we're going to address a number of different issues in this webinar. But mostly they're around research projects that members of the Working Party have really quickly instigated since the outbreak of COVID-19. And they're looking both at the primary care response to the pandemic, but also how primary care has been affected by the pandemic. We're also going to cover briefly some of the other activities our groups involve with. In particular, Wonka's role as the founding member of the International Primary Care Research Consortium. And also our new book, which we're editing, in collaboration with the Working Party on Education. This is a guide to primary care educational research. And this will be a companion to our two books, The International Perspectives of Primary Care Research and How to Do Primary Care Research, which you can see on the screen there. We have a panel from around the world to cover some of these issues. And as Anna said, there's an opportunity to ask questions using the chat function on Zoom. And Anna will be posing the questions to our presenters after each presentation. So I just firstly like to introduce our panel to you. First, we have Bob Phillips and Andrew Basimore, who are family physicians from the United States. And they've been involved in research and policy for many years. The Bob's a director of the Centre of Professionalism and Value of Healthcare. And Andrew is the vice president of the research and policy, both at the American Board of Family Medicine. Now they're going to give us some early findings of our International Primary Care Survey. Next, we have Mark Kulkit, a previous president of WOMCA and now Deputy Chief Medical Officer in Australia, who's going to tell us about some of the action research and learnings from the primary healthcare response to COVID in Australia. I'm going to then briefly describe a primary care research project taking place in the US, Canada, and now in Australia and New Zealand, which is monitoring the effect of the pandemic on primary care practice. Another president of WOMCA, Chris Van Weel, will tell us about how primary care presentations have changed in the Netherlands since the advent of COVID-19. Next will come Bob Mesh, who's a family doctor and chair of Family Medicine. It's still in Bosch University in Cape Town, South Africa. Bob's also the coordinator of the Sub-Saharan African PrimaFamily Network, and he's now the founding chair of the International Primary Healthcare Research Consortium, which he's going to tell you about. And lastly, I'd like to introduce Minmit Ackman from Istanbul, Turkey. Minmit's head of the Family Medicine at Mara University. He's also working on the front line dealing with COVID cases in his city. Minmit will be the incoming chair of our working party. We were planning a handover when we meet at WOMCA World in Abu Dhabi in November. However, I come from New Zealand, where we are in the enviable place of almost certainly having eradicated COVID-19 from our country. The downside of this is that international travel is unlikely until there's a vaccine. So sadly, I can't see me traveling to the WOMCA World Conference this year. So I'd like to pass on over now to our presenters. And first, I'd like to invite Bob and Andrew to tell us some hot-off-the-press, very early findings from our WOMCA-endorsed International Primary Care Survey. Thank you. Thank you, Felicity. And Harris, do you mind pulling up the first slide? Thank you. So this study was, as many studies from WOMCA are hatched by Professor Felicity Goodyear-Smith with considerable contribution by Dr. Karen Kinder. Besides Andrew and myself, we were also joined by Christina Manny and Stefan Stridham from South Africa, who have shouldered an amazing amount of the data collection and processing and analysis of the findings. But this incredibly robust study that was fielded in both English and Spanish in the Spanish translation supported by Dr. Juan Ramirez from Mexico with support from Martina's Bianca from the United States through a lot of responses that you'll see in just one moment. Next slide, please. It helped having endorsements from all around the world in getting this fielded. And we're grateful for the various organizations, and particularly WOMCA, for supporting it. Next slide, please. The survey itself had 34 questions that we're really aiming at looking at capturing the strength of primary health care, as well as country responses. And then those were compared to outcomes by country, particularly looking at the acceleration of the rate of deaths from COVID-19. But a number of the questions were really trying to capture how the countries responded with policies such as blocking entry in countries, including things like border control, quarantine, and testing of new arrivals. The second was really looking at reducing the spread, and what was the response of the country and trying to address that. Was it shelter in place? Was it contact tracing? And specifically within this, looking at the variety of ways that primary care and public health, that primary health care was involved in that, and then looking at how they manage severe cases, and really focusing on the acute wave of COVID-19 illness, including hospitalizations, and getting particular things in place in order to handle that surge. Next slide, please. The public health and primary care responses were of particular interest from very simple things like hygiene measures, and particularly having enough personal protective equipment for primary care. The second was its role in looking at person-to-person contact, while some of those are public policies like physical distancing and banning mass gatherings. It was also looking at how primary care responded to work remotely, how they kept their more vulnerable patients away, and how the population and primary care were involved in self-isolation and shutdown. We also looked at some of the impact on the primary care infrastructure. And as Felicity said, there's been a much larger focus on trying to assess that through a separate mechanism now. And then lastly, that critical role of identifying cases and the role of primary care in doing testing and contact tracing or surveillance, or was it really more of a public health function, or was there some evidence of collaboration? Next slide, please. So again, the aim was really to examine the country's characteristics and strategies in dealing with the pandemic from a primary health care perspective and determine if there was any measurable impact on outcomes. So looking at what factors might correlate with the rate of death and what lessons might be learned to better address this in future pandemics. And our method was fairly straightforward. It was primary health care clinicians, researchers, and policymakers who were asked to identify themselves in one or more roles. As I said, it was in English and in Spanish. It was disseminated via the primary health care networks and really took advantage of snowballing to make sure it reached every country that we could. And as I said, the questions address the nature of the primary health care system in each country, how it responded to the pandemic, use of health information technology, particularly with telehealth, and whether their country had a pandemic plan. And I should say within that whether primary health care had a role in that pandemic plan. And then also various strategies employed in response to the pandemic to try and get a sense of how countries may have differentially responded. Next slide, please. So we had participant survey data around country level and primary health care pandemic responses. We used the maximum death rate on a seven day moving average basis as a response variable. And we used participants narratives. We actually captured some qualitative data that was quite fascinating. The analyses were particularly univariate as will be in a upcoming paper, followed by probably a second paper looking at bivariate regression model analyses in the thematic analysis, trying to figure out what could be learned from those responses. Overall, we had 1131 responses from 114 countries. They included low income, middle income, and high income countries, all world regions. We had the highest response rate from Australia. And we had 34 countries with a single respondent from each. The top five with more than 50 responses were Australia and New Zealand, Mexico, Malaysia, and the United States. Almost three quarters were primary care clinicians. It's fascinating. We had so many frontline primary care clinicians, 17% academics, 6% policymakers, and 4% who were other. 92% of the surveys were completed by the English version, and 8% were completed in Spanish. Andrew, I'll turn it over to you. Thank you, Bob. And as Felicity Bob know, this is a work in progress. We have been deeply grateful to Wonka and many of the networks for generating the kind of response that we received with 1131 responses from 114 countries, including open field and text entries. We are just getting started and understanding the meaning from our survey. We can say that we still have holes in our knowledge of a truly multi or truly, again, unifying understanding of how primary health care and country level responses to the pandemic have gone. But you can see from this map that you have reasonable coverage across regions, lower income countries, middle income countries, and high income countries, as Bob noted. I'll go ahead and go to the next slide, though. Our preliminary results are mostly bivariate. We are looking for early correlations and trying to get really an understanding of the highest respondent countries to date. And it's fairly clear that two key areas, testing and movement restrictions, are highly correlated with lower death rates. I think this is not surprising to many that death rates would be less where testing was readily available from the time of the first COVID death, where you had testing on incoming travelers on migration, where you had testing conducted to those who actually had a symptom consistent with COVID-19 and for anyone who was exposed to a COVID-19 positive individual. We also found strong correlations between death rates and physical distancing, vent closures, closures of all but essential services, isolation that was based on contact tracing, self-isolation in households, and quarantine for suspected cases. Less clear was the correlation with what we would have put together as an aggregate measure of a strong primary health care system. We did not find strong correlation between death rates being, again, rated as strong in primary health care, but we are finding interesting patterns, nonetheless, within our data. Speaking as someone coming from the United States, when you look at the higher income countries that are English speaking, there was a very clear correlation between strong primary health care and a lower mortality rate. The scatter of high mortality, strong primary health care, low mortality, less strong primary health care, and the two opposite quadrants are going to be interesting areas to study going forward. We really anticipate some of the richness of our analyses coming out of case studies, understanding a match between these primary care front line perspectives, what we can objectively obtain from literature and web searches, as well as ongoing interviews. We also anticipate doing multivariate analysis and trying to understand where these various elements that might predict death intersect once we get past the early bivariate understandings. And with that, I know we are at time, but please anticipate much more work to come and reporting to come out of this study. And we really are grateful, again, to WANCA for both helping us to gather all these responses, spread the word on the study, and eventually to help with the dissemination of the talents. And I'll turn it back over to Felicity. I think, actually, you're handing over to me. Oh, forgive me, Diana, thank you. That's fine, thank you very much. And thank you for this. I think, actually, I know one of the respondents in this survey, come to think of it. Well, on the chat, just to inform you about that, people are warming up, I think, so attendees around the world. Please post questions and comments. There are so far, and we're used to them coming, warming up a little bit, and there will be more in the time to come. I wonder, I have a question to you. Personal protective equipment has been a hot issue, still is, for healthcare workers and also as a hygienic measure to prevent spread of the virus. Was that at all something you looked into when you created the survey? And that is one question. We can start with that. Anna, thank you for that question. It sure was. The questions ranged from availability and both generally and for primary care specifically. The survey work that Felicity mentioned now across more than five countries is looking even more specifically at that issue for primary care. But for example, in the United States, there was almost no privatization of PPE to primary care. Still, it's still a raging problem for primary care. It's improving, but most of it was dedicated to hospitals and to first responders. So it turns out to be a struggle everywhere, but in particular countries, it really depended on the role of primary care and the response to the pandemic. To me, I mean, we're a global organization. And when I look at the discussions on this specific issue around the world, how much is evidence-based? I mean, the advices and policies worked out and how much is culture and what does it really mean? It isn't just an input from me. I mean, it would be interesting to have a look at also from a research viewpoint. Anyone who wants to comment on that? Any of you on the panel? No, not now. Bob, I'm looking at you. You're smiling, but we'll leave it there. Our next presenter is Michael Kint. He will update us about the work he and his team has been doing in Australia. Michael, it's great to have you here again, back again, as one of our past Wonka presidents. So the screen is all yours. Great. Thank you, Anna. And, Paris, if we can have the first slide, please. Thank you. So what I'm going to tell you a little bit about is about the work that we've been doing in Australia. And I've come back to Australia from Canada to take up this role as Deputy Chief Medical Officer where I'm responsible for the rollout of the national primary care COVID-19 response. And I want to tell you about some of the research which has been informing that rollout, but also the action research which we have underway. So if we can go to the next slide, please, Harris. This is just an update on what's been happening with the pandemic in Australia. And as you can see, like in many countries, we had an initial large number of infections. And then the country went into lockdown. The infections have rapidly reduced. And with the lifting of restrictions, which started about three weeks ago, we've still maintained very low levels of new infections. We've had just over 100 deaths in Australia. And unfortunately, we didn't have overwhelming of our hospital system. Move to the next slide. This is what's been happening in primary care. And in primary care in Australia, we moved very rapidly to adopt telehealth, which was funded by the government to allow the entire population to link with their family doctor and other healthcare providers, particularly as we went into the lockdown phase. We established a large number of general practice or family doctor-led respiratory clinics, which moved the assessment and management of COVID-19 away from regular general practice settings. And they've been established in metropolitan and rural and remote areas right across Australia, as you can see on the map. The next slide. Thank you. So I'm part of developing the National Primary Care Plan. We looked at the evidence of what had happened in past epidemics and pandemics around the world, looked at the role of family medicine, found that in many countries, family medicine had been left out of pandemic responses, and then looked at the roles that we expected that family medicine in Australia was going to play as the pandemic started to come into the country. And these were the four principles that we based our national plan on. Again, based on the evidence from past pandemics. Firstly, recognising that family doctors and family medicine was most likely to be involved in protecting the most vulnerable people in each community, which of course includes the elderly, people with chronic disease, people with immune suppression. Secondly, that it was really important to preserve the functional capacity of family medicine and primary care to ensure that we'd have ongoing healthcare provision for all conditions. And the evidence from past epidemics showing that often more people died as a result of having lack of access to healthcare from other conditions than died from the infectious agent. So very important that we kept the functions of family medicine going. Thirdly, recognising that most people, given that most people with COVID-19 have mild to moderate symptoms and don't actually require hospitalisation. But these people would be cared for by family doctors and other members of the primary care team in their own homes or in residential aged care facilities. And so the importance of being able to support our family doctors to do that. And finally, the principle that people working in primary care and family medicine required access to personal protective equipment just like people working in hospitals. And that the people working in family medicine weren't just there as a source of workforce to boost what was happening in hospitals. We needed our family doctors working in the community and providing the care that they provide. And so this was the basis of Australia's National Primary Care Plan based on the research of what had happened before in the Australian government allocated 1.5 billion Australian dollars to the National Primary Care Plan. It's about a billion US dollars just to the family medicine components of the national planning against COVID-19. Just moved to the next slide, please, Harris. So part of my work working as the Deputy Chief Medical Officer responsible for this work, I had an action research team working alongside me documenting what we're actually doing. And so recording what's happening as part of the primary care response in Australia. And so we have this evidence base that we're building up that we can use in the future and help us to be even better prepared when future pandemics and national emergencies occur. Part of the work of the action research team has been documenting the collaborative work that we've been doing with stakeholders, particularly the professional organisations, including the Wonka member organisations in Australia, the two colleges, to work together on highlighting and getting feedback on the emerging issues which are affecting the healthcare of the people of our country. And also building up an evidence base from the literature specifically targeted to address the different areas which we've been looking at as the pandemic rolls out. And also having the action research team there available to do very rapid reviews. And we had the team doing reviews on guidelines on the use of PPE, advice on the widespread use of masks both by healthcare workers in the community and a number of other areas. Next slide, please, Harris. And this is the final slide which just shows some of the papers which have been developed by the action research team that I have working alongside me. We've had a couple of publications already on the Australian primary care response. We have conducted a number of rapid reviews, as I've mentioned, which are under review or have been accepted for publication. We've looked particularly at occupational health and particularly concerns about healthcare workers attending work when they had symptoms which could indicate COVID-19. And this has been particularly a concern in residential aged care facilities and concerns when people are casual workers and if they don't turn up for work, they don't get paid. And the perverse incentive for people to actually continue working even when they may have symptoms which is very concerning. And also a paper we've written on as industry and business start to react in Australia and the economy starts to get moving again and the healthcare implications are under the new normal for those businesses. Research into telehealth and the implementation and how that's gone and who's missing out in the population on getting access to the benefits of telehealth from their chosen providers and then lessons from primary care from previous pandemics which we hope will help in the future as well as a focus on mental health and a focus on what's been happening in rural areas around the country. So Anna, that's the outline of what we've been doing and happy to field new questions if we have any. Thank you. I have a question for you, Michael. And it's about one of your last points on telehealth. Many countries have exp... or many, many countries, majority of countries maybe have experienced a revolution almost overnight. And you asked the question who's missing out, who's gaining from it and who's not. What is your plan now in your role to assess this and evaluate? Because I think this is extremely important and now is the time to do it. Yeah, that's a great question. Thanks, Anna, and we're looking at this really seriously. When I came to Australia, part of my new role was going to be a 10-year primary health care reform package of which moving to virtual care was going to be part of that 10-year plan. Instead, we implemented the virtual care in 10 days rather than in 10 years. And that rolled out initially to vulnerable people who needed to stay at home, then to vulnerable health care practitioners so that they could be working from home and be safe, and then to the entire population. And that's running now... we'll be running for a six-month program funded with consultations funded by the government. And then at the end of six months, looking to see what we keep and what we don't, and of course, this will depend on what's happening with the pandemic in Australia, but also with what's been working well and what hasn't been working well. So there's considerable work underway and we've got a program of research looking at how that's happened and then looking at what might happen next. Mm-hmm. Good. Thank you. I have a slight problem with my connection here, but you still hear me? You can just nod if you hear me out. Good. There is an overlay from last presentation, but this goes to all panelists. And I think it's really of interest to many of us. To the testing and to the really nitty-gritty thing of testing and tracing. False negative tests and lack of contact tracing has also been attributing to spread. How come testing helps so much? I pose it to you now, Michael. And if anyone here grabs the microphone, maybe you will start. Yeah, I'm very happy to. So the Australian response now is built around three things. Testing everybody who has symptoms, which could be COVID-19, contact tracing and following up with any contacts of people who've been infected. And we also have, as many countries do, an app which we're encouraging people to download on their phones, which records anyone who you've been in close contact with over the preceding two to three weeks. And that's being used by the contact tracers. And then the third feature is being able to move in very quickly and we do get outbreaks. And of course we do expect to continue to have outbreaks occurring and to be able to very rapidly move people into isolation, into quarantine, close down facilities, carry out the testing and then the contact tracing, do the deep cleans of facilities before they reopen. And so this has been happening in schools, it's been happening in businesses, it's been happening where we've had outbreaks occurring in homes as well. And so this is essential. The testing, initially, Australia, like many countries, we didn't have access to enough tests, so they were rationed. Now we have tests available to everyone with respiratory symptoms. And we've performed over 1.4 million tests so far. We also have sentinel testing taking place with high-risk populations and particularly in areas like healthcare workers and residential-age care workers and home care workers for the frail elderly and people with disability. And also for people in a number of populations where we're concerned that we may have community transmission occurring but not picking it up as quickly as we should. So quite extensive and again more research which is underway. We're about to release a report on hidden populations and hidden settings. We're building on the experience of Singapore, where Singapore had a significant resurgence after thinking everything was under control among foreign workers who were living in dormitory accommodation and the infection spread very rapidly amongst that hidden population in Singapore. And so we're very keen to look and see which of the populations we should be targeting and testing. Thank you. And good luck on your work. I'm sure family doctors in Australia are very happy that you took office just because this broke out. But a huge, huge task. So good luck. We're with you. We are going back to Felicity now. She will give you a very short update on the research project that she's working on with colleagues in the US and Canada. And also with Kirsty Douglas who works with Michael Kidd in Canberra. Please, Felicity. Thank you, Anna. Sorry, this is called the Quick COVID Private Care Survey. And the principal investigators Rebecca Etz, who's in the United States. And Sabrina Wong, who's in Canada. And Kirsty Douglas, who's in the Australian National University. Working alongside Michael in some ways. In Australia and myself. University of Auckland in New Zealand. Next slide, please, Harris. And to the original survey was was started by Rebecca. She's in the Larry A Green Centre in the United States. And it's an online survey of primary care doctors. And it takes less than three minutes to complete. To that end, there's four core questions. And then there's between one to three one-off questions. They call them flash questions. And these ones are on pressing information needs. So they're different each time. So she started on the 13th of March. And they're now on their 11th survey. So they're running it every week. And the aim is to understand the impact of COVID-19 on primary care. And so the things that Bob was mentioned, the things that they're looking at includes the availability of PPE and the availability of testing for primary care. They're looking at staffing and finance. A number of practices in the United States have had huge financial difficulties. And some of them are having to declare bankruptcy. They just can't keep going. When they move to remote consultations, they're unable to be paid for their service for their consultations. And they've had to lay off staff and get loans or, as I say, go bankrupt. And that survey is also looking at the impact on patients with non-COVID-19 conditions. It's so important that family medicine keeps happening, that people can still get the care they need when consultations are mostly remote. So next slide, please. So what's important about this survey is that every week the findings are very quickly analysed and they're posted and fed back. And they're disseminated to the sector. They're disseminated on websites and social media sites. But they're also sent to the media and to policymakers. And recently the participants were invited to give comments that were shared with the US Congress. And they're providing, as you can see on the right there, they're providing updates that are really easily able to be assimilated and each of those series, each of the findings are very easily accessible on their website. But it enables monitoring over time so they can see what's happening. Is it getting better? Are practices now getting enough PPE? Do they have any access to any testing? Are they able to coordinate with public health for those sort of things and getting an update every week? So, the next that happened was that in Canada, Rebecca contacted her colleague Sabrina in Canada and they started to run the survey and they've been running it since the 10th of April. I think they're actually up fourth but I think apparently they're now up to their sixth survey and they're doing the similar thing and again they're disseminating their findings. And then about two to three weeks ago Rebecca contacted Kirsty and I in Australia and New Zealand and suggested that we might do it in our countries too so we very quickly got the applications approved and we've just started doing it so our first survey went out on the 22nd of May and it closed on Friday we've just got the first lot of data and we're starting to analyse it so it's too early to give you the results but in another week we'll have the first the very first findings from the survey and then we'll be running another survey. We're doing it fort rightly because both Australia and New Zealand are at the moment we're certainly over the hump and we're not in such difficult circumstances as our colleagues in the United States who really need to look at what's happening weekly as things keep progressing. So each survey is going to form its own country and in New Zealand we're connected to our College of GPs and also the GPNZ network of all our PHO providers and they're going to be helping disseminate the information sending it to the media sending it to Ministry of Health and other policy makers and as well as that because we're doing these studies in parallel we'll be able to do cross-country comparisons and look at what's happening between Australia and New Zealand and between Canada and the US and us as well so that's just a very early update on an ongoing study I'm happy to take any questions. Thank you there is some activity on the chat some of the reflections are going around financial impact on GPs and you were now speaking about US and Bob mentioned something along the same lines do you have any reflections on that? What are we seeing? I mean where doctors are paid for people's service that is the system Are we even in New Zealand? Yes Sure I mean even in New Zealand where we haven't had the major difficulties that might be experienced in the United States the lockdown has put incredible pressure on our practices and they've been layoffs of staff and they've been particularly locums who don't necessarily have a fixed position in a practice and the volume of primary care work has reduced considerably of the non-Covid work so financially in New Zealand it's certainly having an ongoing impact but I think Bob might be able to answer and Andrew might be able to answer more for the United States where I think things are a lot more dire Well would you Doctor? Sure thank you Anna In the United States the response to the Green Centre surveys suggested up to 10% of the practices are not going to be able to keep their doors open the majority have laid off some staff or made other accommodations such as taking reduced pay our concern is that the practices that this is most likely to affect are the small and independent practices are rural practices and that as the subsequent waves of COVID-19 happen that they won't be there to take care of their populations and they're often the only providers in those areas and the second problem we see is that we're starting to realize a lot of those patients with chronic multi-morbid conditions who have not been attended to for some time now many of whom are coming back to our practices in worse shape than they left also won't have that resource in their communities so I think to a point that was made earlier we may see a rise in non-COVID related deaths if that infrastructure is put in too much jeopardy It's a complex issue I mean we are dealing with complex issues here welcome Donald Lee, he just joined us good to see you we are as you can hear in the middle of discussions there's a comment from Spain José Miguel Bueno to the financial impact on chat in Spain most of us are civil servants so we are salaried there is no risk of bankruptcy only the government could decrease our salaries so that's another solution another reflection that this goes to again to all panelists before we move on the combination of a rather high average age of family doctors in many countries the risk of being infected with corona and the introduction of telehealth in large scale do any of you have any reflection of what we are seeing that GPs or family doctors are retiring that they are pulling back from several reasons in this situation that's another question coming up here anyone who wants to respond to that what are we seeing in the workforce of family doctors when we first went into lockdown in New Zealand and we were worried that there was going to be a very large number of cases overwhelming a health system a medical council invited doctors who'd recently retired and nurses if they would like to get back on the medical register and we had a very large number of people who quickly signed up and said they'd help either with contact or long contact duties and in actual fact most of them haven't been needed but we certainly we certainly didn't see people resigning but it may be that the working conditions in the future become too difficult with the financial situation that's another issue thank you let's move on it's now my pleasure to introduce another post president I won't go Christen Wiel he will tell us about his recent research in the Netherlands please Chris thank you Anna and welcome to all of you and I'm happy to contribute to this webinar as you may see on your face or my face on your camera the green that's sticking to me is probably what's happening to you when there's too much wonka in your life wonka green is sticking on you and I'm happy to share with you some the first results of an early study we did in the network and Harris May you move to the next slide from our previous department at the Rotland University that's working there and that is part of the Dutch regular health system so it is playing the first point of contact for patients and it's a network that for a long time is recording all presented episodes of care using ICPCD wonka classification in the Netherlands and the epidemic struck at the last days of February which was a weekend at that time the Dutch college had already put up a regular updating of practices of what would be installed the moment COVID-19 would arrive and from the Monday of the first days of March the network in fact introduced an additional code within the ICPC to record any presentations related to COVID-19 that would be either confirmed diagnosis or suspected diagnosis or reasons for patients to contact concerns of patients worries I present has already been published in the as a paper going prior to a peer review in the Annals of Family Medicine COVID collection so for more details you can look there and Harris please move to the next slide this is mainly what we found on the one hand what we did see was a very sharp increase in regular care you could see it here for diabetes for depression so physical mental health problems a sharp decline in preventive activities on the one hand and on the other hand we saw a sharp increase immediately in number of respiratory symptoms presented much more than in the previous time the year before and COVID related problems became one of the most common presented issues this issue has already been alluded to in the previous presentations but I think this is interesting to look at or a number of reasons the first one is that the effects as we recorded it were instantaneous it was not a development in the cause of a week or the month it was more or less there in the very first week of March as you can see the dark issues on the for diabetes depression and prevention are the context that were based on telephone, email internet and irregular care already some of the care was done that way rather than depending on patients actually visiting practice but the change again in the first week of March was immediate there was an immense activation of distance contacts part of it is very positive because the decrease provided the possibility for practices to re-align their way of practice but more important I think it is a very negative part you see a loss of care in primary care for the most important health issues other than COVID and this happened despite the fact that the Dutch college in the first week of March was in the 8 o'clock news urging patients to make sure that they would use primary care in a rational way that they would make would acknowledge the fact that other issues that COVID would require functioning primary care there was a very strong appeal from the Dutch college to continue regular care yet what we see here is how the public responded and practices ever since been trying to restore contacts with patients with chronic health problems the data show that these efforts have been only come to a limited amount of success and we move to the next slide and I think this is one of the most important learning points for future pandemics the fact that so quickly we lose contact with patients in regular care and probably one of the learning points is how can we manage to do that better in future situations at the same time what the effects in primary care were and I think it's not that much of a difference with other countries what we did see in primary care was a high creativity in how practices could rearrange their practice there was very quick change from in-person to distance contacts practices were able to to segregate patient flows with COVID and non-COVID problems by having different consulting hours or different practice locations and throughout the epidemic we've seen a leading role Dutch college in supporting evidence to primary care to general practice to the public on how to use primary care much more problematic has been the interaction between primary care and hospital care although we have a well functioning state institute for population health that gives guidance and that collaborates with primary care we've seen a single focus on hospital care the most dramatic way is that for at least 8 weeks the 8 o'clock news opened with the situation in intensive care and the number of places available and the struggle to get enough places in hospitals for intensive care for patients how they were managing to do that without any reflection on the fact that the large majority of patients with COVID were not treated in hospitals but they're treated in primary care with that also came a very single focus on access to testing to hospitals access to protective gears most of primary care had to do without testing most of primary care and particularly nursing homes had to do without testing and without protective gears and again that is one of the most important learning points of preparing primary care for a next epidemic Harriswood is the next slide to move to I think that these were my slides and I think that the learning point we have to take is how immediate the impact of an epidemic is even where primary care is well prepared for it and how quickly we lose contact with patients even though primary care has been open and fully functioning and actively engaging with patients throughout the period but particularly when the public information and the 8 o'clock news best example is has a single focus on hospitals that is an implicit health education message to the public and well I think that is the most common and what we should realize is that Covid is the first epidemic we experience in populations where the large number of elderly with chronic health problems and the challenges we are facing for that is the new learning experience here and some of our data give the first struggle with it thank you very much thank you Chris you're really raising a lot of interesting issues for an active practitioner so I have many questions to you but I will leave you with one or two questions we have neglected or we are losing contact with patients in need of chronic care I think that's an experience made in many countries we should look at what we call health literacy and to learn I mean into next crisis might be a pandemic might be something else a health crisis can you reflect a little bit on that what is the role of health literacy are we also neglecting that part I mean in between pandemics or crisis well yes of course I suspect that the people we lose contact with are the people that are the most difficult to engage in the first place where it was probably the most fragile and probably primary care it is very best that they were in contact and able to engage these people in active and proactive care is it the health literacy I think it is at least as important is the person contact the importance not just for the practice not just for primary care but the fact that that should be acknowledged by public health by the public the importance of that and we've given all sorts of if you look back at it difficult advices we've given many people to stay home to abandon contacts with the outer world to abandon physical activities until February when there was no COVID the only advice we would give them was stay in touch with the rest of the world be physically active and no one realizes how poor health that you don't specify is because this will change people's behavior particularly of the people we've had such a big struggle in changing them into a more active physically active mental active lifestyle and I think the challenge is and it's not primary care hospital care this is society how do we give the very sound advice keep distance don't interact you don't have to because of a pandemic and health risk coming from that in a way that you not completely change people from active involvement into people in complete isolation and I think our data illustrate that that change is coming quickly rather than step by step and that the damage is done if you don't do it in an appropriate way early on. Thank you Chris. A lot to discuss here we will move on the working parties they want to tell you a little bit about some of the other activities prior to COVID-19 which are still continuing so I'll call on Bob March from South Africa to tell us a little about the International Primary Health Care Research Consortium please Paul. Thank you Anna great so just at the tail end of this webinar I want to inform you about this new initiative the Primary Health Care Research Consortium next slide so this is as you can see a very new initiative we met for the first time in February 2020 in Delhi we managed to do this just before all of the lockdowns and restrictions on travel and this consortium was established by these particular organizations that you can see so Wonka as represented by Felicity is one of the founding members of this consortium and then Prima Famed which is a network of departments of Family Medicine and Primary Care in Sub-Saharan Africa the George Institute in Indian Australia the International Center for Diarrheal Disease which actually does primary health care research not just diarrheal research in Bangladesh Avi Adni Labs and George Washington University in the USA and the American University of Beirut in Lebanon so this somewhat eclectic group of organizations came together because they responded to a call prior to the establishment of the consortium to look at what are the global gaps in research questions around primary health care so what are the key issues that research needs to address next slide so when we met in Delhi we collectively decided on our vision and you can see that the vision is very much focused on low and middle income countries and how do we strengthen primary health care in these particular countries through and the mission as you can see is to develop, capacitate conduct and disseminate LMIC led research and I think you can see even from this webinar that even within the world of primary care research the capacity and the energy is still very much in the high income countries so this is putting the focus very much on looking at what's happening in LMIC and how do we strengthen them but how do we also get them to lead and to develop capacity so and and beyond that to drive the research findings to action by addressing priority knowledge gaps engaging with policymakers and decision makers and as it says to catalyze that within this consortium the global network of partners that this consortium brings together the global network PrimaFamed is a network within Africa the other organizations also bring in South America Asia and the Eastern Mediterranean so collectively there is a footprint across LMICs across the globe thanks and our slide so within the first two years we had funding for two initial prioritized questions these first two bullet points are the questions that we decided on so sort of pre-COVID so the first one is how are different low and middle income countries implementing primary healthcare teams and integrating those teams to support the delivery of more comprehensive primary healthcare and this would be a mixed method study in India Uganda and Brazil and the second question that we focused on was how do these three low income countries Malawi, El Salvador and Lebanon measure the performance of their primary healthcare systems at the moment at the organization and whole system level and how are they using that information to guide policy at a national level now clearly since we met in February COVID-19 has sort of overtaken the consciousness of the world and we have started to get involved in research that's COVID related I think you saw that the research that Bob and Andrew presented earlier that the consortium was one of the supporting organizations to that and we're now also looking at a study with Penn State University to look more at how communities, how is the public in different LMICs making sense of COVID-19 and what is their intention to comply with public health advice what is their knowledge and how are they how are they intending to behave going forward I think that's my last point thank you very much thank you Bob you are really raising important questions and you say this is apart from COVID-19 to call our attention now with the questions and issues you are raising should be high actuality also in the COVID-19 times driving research to action by addressing priority knowledge gaps a wonderful sentence I think in respect to time we will go on to the next speaker and here's our last speaker it's Mehmet Akman our incoming working party chair over to you Mehmet thank you very much presentation first I would like to say that I'm very happy to be part of this working party and working together with distinguished members in recent years it's very clear that working party on research issued many of its targets under the leadership of Felicity that are already mentioned in the previous talks Felicity with her embracing attitude to everyone set the higher standards during her chair so taking over the chair from her is another but also a challenge in terms of keeping up with her standards so I will do my best actually to bring one step forward the moment to realize during last two terms as the incoming chair under the guidance of Felicity Executive and also with the contribution of other working party members it's very crucial for future development of primary care to generate its own evidence from its state practice so therefore building up the research capacity is a continuous mission for family medicine and working party will continue to contribute this mission in future as it does today I would like to take this opportunity to introduce myself briefly and also describe a little bit what is important for me as a vision for working party on research firstly I am a professor of family medicine working at Marmar University of Istanbul in Turkey well in this slide you might find it a little bit difficult to recognize me on the picture on the right but you will probably have the similar experiences during the recent crisis as primary care workers we all looked alike in our protected personal equipments and no matter what personal deck one we have we all unite and fight against the same enemy so despite this short POI fields of interest I was actually working as a COVID doctor to be honest for the last three months and just looking exactly at this picture at work but what I have done before let me tell you briefly besides publishing many articles I have also contributed some books one of them is international perspectives on primary care research which is edited by Felicity and Bob also as a work of working party on research and my main research and work area in the last five years are mainly chronic diseases management in primary care health systems research with an emphasis on the efficient phase of strengthening primary care and organizing it according to current needs in global conditions also I am teaching medical humanities to undergraduates and using reflective techniques and arts during post-reject training of family medicine residents so medical humanities what we can learn from social sciences is another field of interest of mine next slide please next slide you can see some of the projects I was involved and also my membership to different primary care related organizations one of the recent projects I have a coordinator role is the premora project the premora is aiming to establish a primary care multi-professional research network and I am assigned to write a position paper on organizational primary care under this project and I was involved in this as one of the representatives of EFPC the European Forum for Primary Care in brief what makes EFPC different than most of the primary care organizations is its multi-professional structure and I have been advisory board member for six years there and also still a reactive member in this organization and at the national level besides our national organization I am involved in declaration of a trust for primary care called TAHED Turkish Family Medicine Foundation and still member of this organization as a board of trustees next slide please so as a last word I would like to talk about new book project of the working party this will be the third book initiated by Felicity during her chairing and it will be a sister book to how to do primary care research the title of the new book is a practical guide to primary care educational research this time and the editors are myself professor Valvas the chair of the working party and professor Felicity I am very excited about this book and I believe it will fill a gap of research and education especially for primary care professionals the book will explore the scope of primary care educational research and the current research environment in the context of undergraduate education of graduate training continuous professional development and also the patient education so it will address various issues like interprofessional education participatory research approaches and building research capacity through mentoring I would like to thank Wong Executive for their support to this new book so you don't shout somewhere next year as a new WONCA publication so this is actually the end of my very brief presentation as a final remark I would like to express my enthusiasm once more about the WONCA working party on research so I'm looking forward to seeing new projects coming from our members and I also would like to invite everyone interested in primary care research to join the working party if you are not already a member thank you very much thank you very much Mehmet and good luck on future tasks as chair of the working party panelists we are nearing the end now of this session I would just give you a few comments from the chat there is enthusiasm gratitude operation from attendees because of the work you are doing there is also an interest of being included in the service and the future service like I will read to you one participant says on facebook the challenges we are facing seems to be the same all over the world we should enhance what's good and WONCA should reflect in such a survey during the next month let's say otherwise we might not prove the family care really seems to be the front line and the way this pandemic changed our practice okay from the front line I comment from the front line a question to all of you maybe Mehmet you should go first on that one can we engage more young family doctors in research yes it is a very challenging question well what I find that is helpful when I am entering young doctors in my institution is to make a link between research and then the practice so one can think that I am a young doctor and working my practice why should I be interested in research and why I learn it well it's the first of all you need to learn it to critically apprise the literature and secondly I mean for the development of primary care we need primary care data and we need primary care researchers so it's very difficult to have development in primary care with research from secondary care so at least for them to add data collection so I am just trying to make these links with the daily practice and this helps a little bit to get more involved in research thank you very much I will now in this part of the session thank you all attendees on the chat on Facebook panellists for interesting presentations there are lots of loose threads here to pick up and discuss and I am happy to see that so Donald you are with us and you will now give some concluding remarks yes thank you panellists for leading a wonderful presentation and sharing with us interesting surveys and research I am also quite excited to hear about the future plans of networking new research networks and also publications the first series of the eight Wonka webinars come to an end tonight I hope you have found them informative we will be taking a little time to organize the next series of webinars to watch out for our advertisement we will continue but we want to talk about the topics so I wish to conclude by saying COVID-19 is a pandemic with an unknown end game I wish each and every one of our family doctors well during this time use the best advice available work collaboratively with your teams do the best you can for your patients you should stand proud of your contribution to tackling this world crisis no one knows the pace in the weeks and months ahead but everyone knows enough to understand that COVID-19 will test our capacities to be kind and generous and to see beyond ourselves and our own interests our task now is to bring the best of who we are and what we do to a world that is more complex and more confused than any of us would like it to be may we all proceed with wisdom and grace thank you very much Donald and thanks to Felicity and all of the panel for a really excellent and interesting presentation as Donald has said this is the last in the current series however we are discussing plans for the future so watch this space for future events thanks to everybody for joining us today and a special thanks to our CEO designate for his magical technical skills take care everyone and stay safe thank you very much indeed