Vulnerable Groups in Primary Health Care: Brief Report of a Project Implementation in Lisbon

Gatekeeping has been associated with several benefits [1, 2]. The continuity of care provided by general practitioners (GPs) acting as gatekeepers [3, 4] is represented in countries such as Portugal, Denmark, the Netherlands, and the UK. A positive impact of the gatekeeping function in health systems has been described in outcomes ranging from lower mortality [5] to less health service use [6‒8]. Despite the potential compromise in continuity of care during the recent years [9], patients recognize the relevance of the relationships built with their GP [10, 11]. Lower mortality rates were found for patients accessing their preferred GP [12, 13], and more admissions to health services were attributed to failures in continuity of care [14].

More research is needed on what measures may be undertaken to promote the stability of GPs. The numbers, taken from the Portuguese Statistics Institute and publicly accessible, clarify a phenomenon of change in the public-private pattern of the national health system. Health professionals exist in limited numbers, and the public and private sectors compete for these limited resources. The private sector enjoys greater flexibility than the National Health Service (NHS), namely, through the hiring of professionals and negotiating contracts with complete freedom for each professional, regardless of their status or career [15].

The COVID-19 pandemic had a profound impact on health care resources. Evidence seems to be unanimous regarding the reduction of health care provision in various areas of activity in primary health care (PHC), as the need to respond to the COVID-19 pandemic led to the adoption of measures that conditioned the execution of programmed activity [15]. The trend toward an increase in unmet health needs is higher in Portugal compared to the average values of the OECD, and this differs according to the level of income and health status, particularly in individuals with worse health status and lower incomes [16].

The lack of GPs in PHC in Portugal is a long-lasting problem. However, the situation has worsened since the beginning of the COVID-19 pandemic. It is apparent the need to protect the citizens in accessing health care and continuous assistance is a moral and ethical obligation. However, during the pandemic, GPs were not able to see their usual patients who were already lagging behind, including people with diabetes or those with cardiovascular diseases who needed therapy adjustment and monitoring, nor the first consultations with pregnant women, newborns, or women with contraceptive needs. With this case report, we propose to describe a project taking place in a PHC unit in Lisbon at the beginning of 2022, aiming to monitor vulnerable populations, including children and pregnant women. The project was embedded in the context of the progressive resumption of face-to-face health care activity in a Personalized Health Care Unit in Alcântara (UCSP Alcântara), at the beginning of 2022. This project aimed to provide a rich internship field for the training of essential skills during the Family Medicine residency program.

A descriptive study design based on a case report was conducted. The 4-year Family Medicine residency program includes training with subsequent assessment in various medical areas essential to the provision of health care to the population, such as pediatrics, gynecology/obstetrics, psychiatry, pediatrics, and emergency departments, among others, in addition to Family Medicine. To guarantee the adequate training of these doctors, annual evaluations are carried out comprising written reports, multiple choice exams, and clinical case simulation, which culminate in a sequence of final exams that reiterate the quality of the scientific knowledge and clinical practice of these professionals. This project matched an optional internship, which was made available to complement the training in specific areas, such as the care for vulnerable women and children without an assigned GP. During 2022, the Family Medicine residents in training in the Western Lisbon and Oeiras health care group, in conjunction with the coordinator of UCSP Alcântara, created a schedule for the provision of supervised health care for vulnerable groups of patients. The consultations took place in the functional unit, and the activity was integrated as an optional internship during the residency program, approved by the residency coordinator. The team was composed of the coordinator of UCSP Alcântara who provided supervision to the residents, nurses, and administrative support to schedule and contact the patients. The duration of the activity was different according to the resident interest to stay at the project, ranging from weeks to 1 year. When the residents stayed for longer periods, more opportunities to increase the continuity of care took place. The selection of users was based on the vulnerability (children, pregnant women, women with contraceptive needs), but also for patients with specific diseases such as diabetes and hypertension who were lacking a follow-up.

All regions of the country are affected by the lack of GPs but with very different impacts. In December 2021, more than two-thirds of the total number of people without a GP (780 thousand people) were located in Lisbon and Tagus Valley, which means that 20% of people living in this region do not have a GP assigned. The North has only 2.7% of people without a GP assigned. The most recent data show that today 1.5 million Portuguese do not have a GP to be followed by.

The population pyramid of UCSP Alcântara (as shown in Fig. 1) reveals an increased percentage of vulnerable groups, such as children and young women, which contrasts with other regions with higher percentages of the elderly population [17]. This project allowed for 721 consultations with adults, 237 consultations with children, 125 pregnant women, and 68 women of childbearing age (essentially addressing issues of contraception and cervical cancer screening), between March and August 2022, which corresponds to close to 15% of the total consultations carried out during that period at UCSP Alcântara, with a larger proportion dedicated to the 3 vulnerable groups (as shown in Fig. 2).

Additionally, during the last trimester of 2022, the number of consultations to all the patients at UCSP Alcântara accomplished by supervised family medicine residents reached almost 14% of all consultations carried out during that period at UCSP Alcântara. On one hand, the training of future doctors specializing in Family Medicine can be improved, improving the quality of health services provided at the PHC level, which are considered essential in the Portuguese health system. On the other hand, the problem of inequality in access to PHC is ameliorated, especially in UCSP Alcântara which has a high number of patients without an assigned GP.

This project poses as an optional activity during the residency program, and the major strength is the possibility to present a rich internship field to the training of future doctors specializing in Family Medicine, who provide health services to vulnerable patients. Within the scope of pregnant women and children’s health, access to consultations integrated in health programs ensures their surveillance and early detection of alarm signs. With regard to family planning and cancer screening, these consultations were crucial to ensure adequate access to contraception and cervical cancer screening. Additionally, contact with a multicultural population with diverse socioeconomic problems and low health literacy is a significant opportunity for young doctors to develop interpersonal skills during their residency program.

However, an important weakness is the lack of continuity of care, as longitudinal continuity is not possible if physicians do not remain in their practices over time. When patients have continuous care with the same GP, the foundation is laid for lasting relationships. Over the years, GPs become specialists in their individual patients, rather than their diseases. This is the essence of personal doctoring described by William Osler at the end of the 19th century – “it is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”

This project rises the opportunity to further studies that would clarify if the residents’ competence and satisfaction are improved with educational projects such as this. Studies focusing on skills assessments would be relevant to compare possible training models. As this project allows the residents to provide health services to vulnerable patients, it threats to present an answer to the inefficient management of human resources in the NHS. We reflect that a fundamental solution is needed to the real problem, which this project is not intended to solve.

In order to lead a successful PHC reform, other topics should be considered, such as the promotion of policies to retain professionals in the NHS and the optimization of the debureaucratization of tasks to reduce the professional-bureaucratic conflict that affects GPs [18, 19]. It is crucial to recognize the power to do more so that the Portuguese NHS can be a place of excellence where doctors want to develop their careers and professional paths, with the ability to attract doctors to the NHS as a policy mainstay.

This projects follows on from similar experiences in Almada health center group (Southern Lisbon region), where PHC has been provided to a larger number of people without an assigned GP (more than 50,000 patients) during the last decade. In the near future, the project could potentially be enlarged to include other health care units within the same geographic area and could involve the academic setting, aiming to develop research and knowledge co-creation. In conclusion, optimizing the training of family medicine residents is a possibility that has been successfully implemented at UCSP Alcântara, addressing the health needs of many vulnerable patients.

The authors thank the Family Medicine residents, who kindly started this project and sustained its implementation; the professionals working at UCSP Alcântara who sustained the implementation of the project; all the members of the Family Medicine residency coordination, for creating the conditions for this project to take place; Cecília Shinn, for revising this article; and Alexandra Fernandes, Isabel Santos and Paula Broeiro for leading the way.

Ethics approval was not required.

The authors have no conflicts of interest to declare.

This study was not supported by any sponsor or funder.

Ana Rita J. Maria: conceptualization, formal analysis, investigation, data curation, writing – review and editing, visualization, and project administration. Nuno Basílio: data curation, writing – original draft, and visualization.

Requests to access the data should be directed to the corresponding author.