Creating, repurposing and redistributing hospital beds

While the starting point, for example the number of ICU beds, influences the ability to respond in a pandemic, countries can use several tools to increase capacity rapidly when needed. This was clearly demonstrated during the first wave of the COVID-19 pandemic. Countries rapidly increased their hospital bed capacity for acute and intensive care to accommodate an expected surge of COVID-19 cases. Germany increased its ICU capacity by 20% in the first wave, while Italy and Belgium increased theirs by 65% and 45%, respectively.

Initially, several countries, including Montenegro and Latvia, reported sufficient spare capacity to respond to the COVID-19 outbreak. Countries with a high density of hospital and ICU beds, including Austria, Germany and Switzerland, could use this capacity immediately to absorb increased demand for health services while having the time and flexibility to increase capacity. Often seen as a symptom of inefficient use of resources before the pandemic, spare bed capacity was viewed as an asset. At the same time, treating COVID-19 patients in hospitals regardless of disease severity, as was done initially in many countries, may also be viewed as inefficient. Many of these patients could have been treated at home with outpatient (remote) supervision. This would have put less strain on hospital capacities, and deferring (at least some) elective care for non-COVID-19 patients could have been avoided. Over time, the role of non-hospital settings in the pandemic response, especially PHC, has been strengthened in many countries (see Section 6.2).

Another strategy to increase bed capacity within the standard health care delivery system was the implementation of alternative approaches to using physical infrastructure. Countries quickly implemented or developed emergency hospital plans, most commonly adapting, reconfiguring and designating hospital wards and spaces such as postoperative recovery rooms, acute and intermediate care units, to accommodate critically ill patients with COVID-19. This was possible due to postponing non-urgent and elective procedures. The novel use of physical space to separate patients and create transition areas allowed health care providers to most effectively care for the variety of patient needs (Section 6.2).

At least 18 countries in the WHO European Region created temporary hospitals designated for COVID-19 treatment or to accommodate mild COVID-19 cases or severe cases once discharged (Winkelmann et al., 2021). New physical capacities for the health sector included using existing physical spaces, such as conference venues, stadiums or fairgrounds, as well as newly constructed facilities. In addition, many countries repurposed non-health facilities such as hotels, dormitories and rehabilitation clinics which had been vacated due to lockdown measures into transition centres for quarantine purposes and to accommodate discharged patients requiring low intensity surveillance. In some countries, including areas of the Netherlands, the United Kingdom and the United States, newly created capacities, such as field hospitals, remained unused. This creation of excess capacities needs to be considered in conjunction with the high levels of uncertainty about how both the pandemic and the progression of COVID-19 would develop. Some countries did not have sufficient workforce to operate the new beds.

Tapping resources from other sectors, including the private sector

Available resources in sectors outside the statutory health system, including the private sector and the military, can provide a relatively quick way to scale-up extra capacity. In some countries partnerships between the public and private sectors were common before the pandemic, but volumes increased (e.g. Italy and Spain). At least 14 countries in the WHO European Region used private hospitals as part of the public system and overall COVID-19 response. Largely, countries with a strong private hospital sector and/or those strongly affected by the pandemic employed this approach. For example, Italy used private hospitals to ease pressures on public hospitals, and in the Lombardy region, private hospital beds made up 30% of ICU surge capacity. In Cyprus, during the first wave, patients who could not be treated in public hospitals, due to the closure of wards, could be treated by private providers with the costs reimbursed by the Ministry of Health (Waitzberg et al., 2021a). While private providers sold some services to public payers before the pandemic, the range and volume of services was expanded during the pandemic.

The governments of several countries block booked private hospital capacity (e.g. England, Ireland, Italy, North Macedonia, Spain and the Russian Federation) to have flexible availability throughout the crisis. In countries less affected during the first wave of the pandemic, such as Denmark and Portugal, private hospital beds would be made available in case of need. In many countries, private hospitals provided equipment such as ventilators for treatment of COVID-19 patients.

Not all countries used the available private sector capacity to provide care to COVID-19 patients – others such as England used the private sector to support non-COVID-19 care, such as elective procedures and other activities. The Israeli Ministry of Health’s Central Virology Laboratory partnered with the private company Kandu for surveillance and early warning of SARS-CoV-2 circulation through the monitoring of urban wastewater systems. This collaboration was initiated by Kandu, although in normal times it would have involved a public tender (Tille et al., 2021). Nevertheless, after the initial urgent need, PPPs should be reshaped to comply with good governance practices to avoid negative unintended consequences such as corruption, weakening public structures and market failures such as cream-skimming, duplication of services and access problems (see Section 2.6). Good practices include participation (involvement of stakeholders), decency (undertaking the partnership without harming third parties), transparency (taking and communicating decisions clearly), accountability (being responsible for actions and outcomes of partnership), fairness (applying rules equally to everyone) and efficiency (using human and financial resources without waste, delay or corruption) (United Nations Economic Commission for Europe, 2008).

In several countries, army hospitals were made available to treat the general population and relieve pressure from hospitals. In Belgium, for example, patients with major burns were transferred to military hospitals.

Critical role of the health workforce in surge capacity

Countries prioritized building up physical infrastructure and producing/procuring essential equipment and supplies. Increasing the health workforce capacity at a similar rate is extremely difficult but essential: increasing the number of hospital beds or ventilators is futile if there are not enough hospital staff to operate them. The numerous strategies to expand and retrain the health workforce are discussed in Section 4.1. Some countries developed combined contingency plans that considered the capacity of infrastructure and workforce simultaneously, such as Greece or Romania (Winkelmann et al., 2021).

Redistributing patients

Several countries transferred patients between facilities, regions and even across borders to alleviate pressures in an outbreak area, including as part of the EU Civil Protection Mechanism (see Section 2.9). France deployed high-speed trains, helicopters, private planes and even a warship to move patients to other regions or neighbouring countries, such as Germany. Between 18 March and 19 April 2020, France moved 644 patients across the country. Spain placed trains on standby for transfers within the country that had the capacity to move 24 critical care patients at once. Cross-border transfers have also represented a strong show of European solidarity, with Germany receiving the highest number of patients from other countries during the first wave of the pandemic, likely due to its pre-existing high capacity. By 20 April 2020, Germany had received 229 seriously ill patients from other countries, including from France (130 patients), the Netherlands (55 patients) and Italy (44 patients). In these circumstances, the Commission issued the Guidelines on EU Emergency Assistance in Cross-Border Cooperation in Healthcare Related to the COVID-19 Crisis to inform Member States of the various EU instruments available to support each other and alleviate the pressure on European health systems. Solidarity mechanisms included the coordination of emergency patient and workforce transports through the EU Civil Protection Mechanism, as well as the management of requests for medical personnel and intensive care beds through the Health Security Committee and the Early Warning and Response System. The Guidelines further elucidated the financial and practical arrangements for the provision of health services across borders, while also encouraging Member States to make use of existing regional and local agreements to assist neighbouring regions (European Commission, 2020b).

Scaling-up and redistributing essential equipment and supplies

While several countries had stockpiles of essential materials going into the COVID-19 pandemic, it became clear that scaling-up material capacity, including PPE (e.g. face masks, goggles and other protective clothing to protect the wearer from COVID-19 infection), testing materials (e.g. swabs, reagents), medical equipment (e.g. ventilators) and medicines, presented a substantial challenge for the delivery of care during the first months of the pandemic. This pertained both to the effective delivery of necessary care to COVID-19 and non-COVID-19 patients and the safety of the health care workers who did so.

The combination of increased demand and disrupted global supply chains caused widespread shortages. Countries faced novel situations for paying for materials and determining the appropriate representative in these negotiations, and the EU facilitated several joint procurement initiatives (see Box 3.1). While countries used a number of transitory measures to increase the availability of essential materials, such as temporarily relaxing guidelines for use of PPE, repurposing factories or increasing output of essential materials, or accepting donations from other sectors, the unprecedented strain suggests that the reliance on exports should be reduced. Stockpiles and plans to rapidly increase production might enable countries to meet an unexpected surge in demand. By April 2020, the European Commission had designated €0.38 billion to create a stockpile of necessary equipment (including ventilators, PPE, therapeutics and laboratory supplies) via the RescEU reserve, which is part of the EU’s Civil Protection Mechanism (UCPM) for preparing for and responding to disasters and emergencies. The stockpile is currently hosted by nine Member States, and has distributed large volumes of material to Member States in need. Within the scope of the Next Generation EU package, the Commission has assigned further 2 billion to RescEU for 2021–2027 to expand the reserves of equipment for health and other major emergencies (European Commission, 2020d). In addition, the Commission created the COVID-19 Clearing House for medical equipment, which operated for 6 months starting on 1 April 2020 (European Commission, 2021h). The Clearing House served as a platform for the monitoring of supply chains and shortages, as well as the exchange of information between various stakeholders, including national authorities, industry representatives and manufacturers, on the demands and supply arrangements of key medical equipment in Member States. This service permitted the anticipation of bottlenecks, while also helping Member States rapidly obtain medical supplies by matching them with companies producing and supplying equipment. Further, the European Commission has expressed plans to strengthen the EU’s preparedness and response capacities by creating a new EU authority to deal specifically with cross-border health threats (see Section 2.9).

Box 6.1

Using real-time data systems to ensure adequate distribution of resources.

In addition to increasing capacity, ensuring its appropriate distribution is key. Especially in the context of COVID-19, localized outbreaks have created an uneven situation across Europe and within countries. The availability of up-to-date information about capacity distribution and contingency plans to manage rapid reallocation of resources are critical for effective response, as is the ability to centralize decision-making to coordinate the redistribution of capacity across regions (Section 2.3). Countries with pre-existing monitoring systems fit for supporting an appropriate distribution of resources, such as ICU registries in Finland, the Netherlands, Norway, Sweden and the United Kingdom (England, Wales, Northern Ireland), were at an advantage (Winkelmann et al., 2021), but many countries managed to establish these systems rapidly during the course of the pandemic (Box 6.1).

Disruptions in provision of routine health care services

During the first wave of the pandemic, most countries cancelled or postponed non-urgent care, although decisions on which services to maintain and the duration of these restrictions varied widely. There were large reductions in cancer referrals in many countries (Morris et al., 2021), such as a 24% fall in new referrals in Norway. The number of cancer diagnoses also decreased, especially in the first months of the pandemic. In Catalonia, Spain, 34% fewer cancers were diagnosed than expected between March and September 2020 (Coma et al., 2021). In the Netherlands, non-skin cancer diagnoses dropped 26% while skin cancer diagnoses fell 60% between the end of February and mid-April 2020 (Dinmohamed et al., 2020). Providers in many countries adapted their prioritization of services in response. For example, most facilities treating cancer patients in Italy reorganized their waiting lists, cancelled routine follow-ups and set up teleconsultation services, but continued to prioritize first outpatient consultations (Jereczek-Fossa et al., 2020).

New care pathways to enable dual delivery

After the first wave, non-essential services have largely resumed, albeit often with novel patient pathways that reinforce a dual delivery approach for COVID and non-COVID care. Luxembourg changed its patient pathway so that first primary care contacts occur via teleconsultations; Spain developed a system that uses occupancy rates of COVID-19 patients as a basis for hospitals to determine when to start allowing more elective or non-urgent treatments (Arnal Velasco & Morales-Conde, 2020). Ireland introduced a surge plan to expand community care in winter 2020/21, including home care and rehabilitation services, for both COVID-19 and non-COVID-19 patients thus reducing pressures on hospitals and GPs (HSE, 2020). These tools have been adapted throughout the pandemic as health systems gained experience. In particular, the shift of COVID-19-related care from hospitals to outpatient settings has allowed for new adjustments (see below). Furthermore, some countries have begun to recognize the implications of the longer-term impact of COVID-19 on patients (or long COVID) for service delivery; for example, in Denmark (Sundhedsstyrelsen, 2020). New care pathways for long COVID will require continuous evaluation, as the understanding on the diagnosis and management is still evolving. Multidisciplinary, multispecialty approaches to assessment and management will be required in close collaboration with patients and families (Rajan et al., 2021).

Key role of primary health care

Throughout the pandemic, PHC providers have delivered dual track care to both COVID-19 and other patients. PHC includes family doctors or general practitioners (GPs) who are the first level of professional health care, as well as public and community health providers. The role and models of PHC differ across Europe, but played a crucial role in the COVID-19 response.

At the beginning of the pandemic, many countries emphasized the role of the hospital in planning the response to COVID-19, implementing strategies to surge hospital capacity for treating COVID-19 patients (see Section 6.1). But as more became known about the characteristics of the disease and the number of cases increased dramatically, this approach shifted to managing mild cases at home and only hospitalizing more severe cases. This shift contributed to more appropriate, safer care for COVID-19 patients and, by reducing stress on hospital capacities, allowed elective care for non-COVID-19 patients to resume and expand.

PHC providers often coordinated with public health services in activities related to the COVID-19 public health response (see Chapter 5). Several countries built on pre-existing innovations in primary care in their COVID-19 response. France has over 1 600 multidisciplinary PHC centres that have existing partnerships with municipal community and public health services. This close partnership enabled a more rapid mobilization of the response and exchange of information, enabling a coordinated, holistic response to COVID-19 while maintaining other public health services (André et al., 2021) (Section 5.3). In Catalonia, Spain, existing primary care teams added COVID managers, social workers and administrative staff to manage the new tasks of testing and tracing on top of increased demand and communication of health results to patients (Martí et al., 2021). In Belarus, Greece, Iceland and Spain, testing and medical advice was provided at PHC centres. Slovenia referred all suspected COVID-19 cases to 18 so-called entry points in PHC centres which conducted COVID-19 tests. In several countries, PHC providers provided support and monitored conditions of patients isolating at home. Several countries, including Armenia, Belgium, France and Germany, requested GPs to conduct home visits to perform tests or monitor COVID-19 patients, while most relied on teleconsultation services to monitor and support patients isolating at home. PHC providers also initiated transfers to more intensive care and determined when quarantine periods could end.

Despite the importance of PHC providers to the COVID-19 response, clinical and organizational guidelines about COVID-19 were not always available for PHC providers. In Italy, GPs reported a lack of communication, coordination and leadership related to the emergency response (Kurotschka et al., 2021), and, until May 2020, 44% of all deaths among doctors in Italy were GPs, despite only making up 15% of the total number of doctors (Modenese & Gobba, 2020). Their ability to safely provide the spectrum of care was challenged for a number of reasons, including uncertainty about the suitability of facilities in the light of infection control, the availability of PPE, financing and staff in the light of the focus on hospital care. In addition, patients may have changed their care seeking behaviour, and may not have pursued health services out of fear of becoming infected.

Targeted communication strategies to the public (Section 2.7) about the measures taken in health care settings, including safety and infection control measures, are needed to minimize disruptions and negative health outcomes, particularly as service delivery adapted once again to deliver COVID-19 vaccinations.

Guidelines for treatment and prioritization of care

Treatment guidelines and protocols for patients with COVID-19 changed rapidly over the course of the pandemic, as knowledge about the condition evolved. For example, the Robert Koch Institute, responsible for disease control and prevention in Germany and which has one of the largest inpatient care sectors in Europe, changed its guidance between February and March 2020 from hospitalizing all patients with COVID-19 to hospitalizing only those where treatment at home was not possible. A variety of mechanisms were used to deliver the latest information to workers on the ground, including online training, active feedback and monitoring/compliance systems. Many countries leveraged pre-existing professional bodies to share best practice across clinicians and health care providers. International collaboration has been key in producing updated evidence on COVID-19 treatment options, as exemplified by the COVID-NMA process, which provides a living mapping of COVID-19 trials, and the LIVING project, an ongoing systematic review of randomized clinical trials comparing the effect of all COVID-19 treatments.

At the same time, providers of specialist services often used prioritization recommendations to manage the provision of non-COVID-19 care. In hospitals, essential services maintained throughout the pandemic often included urgent consultations, necessary treatments (e.g. chemotherapy, dialysis) and maternal services. The Netherlands created an “urgency list” of procedures to prioritize when scaling-up regular hospital care after the initial response to postpone; Spain adopted different criteria to prioritize surgery in five potential scenarios depending on the epidemiological situation, prioritizing first consultations over follow-ups; and the German Association for General and Visceral Surgery created a list of prioritized elective interventions. The Association prioritized surgeries of patients with rapidly progressing diseases and manageable comorbidities; however, treating physicians were still responsible for the final decision about postponing for all patients. Italy recommended suspending routine cancer screenings while treating patients with early and advanced cancer in the outpatient setting (Curigliano, 2020). If cancer patients required hospital treatment, they followed a dedicated diagnostic and therapeutic internal pathway to prevent potential SARS-CoV-2 infection. Given the situation, decision-making for all cancer patients was entrusted to multidisciplinary tumour boards, which balanced the risk and benefits of treatment for each specific patient (accounting for the patient’s performance status and comorbidities as well as tumour biology and likely impact of treatment on outcome) in the context of the epidemiological situation.

Scaling-up the use of digital health in delivery of care

Various applications of digital technologies, including remote services, were leveraged during the COVID-19 pandemic to enable access to care and build capacity to respond to surges (European Observatory on Health Systems and Policies et al., 2021) (Table 6.1).

Table 6.1

Example uses of digital technologies to support delivery of care.

While available in most countries prior to the pandemic, remote consultations have been used at unprecedented scales to ensure delivery of care and monitoring for both COVID-19 and other patients across all care levels, but have been most widely employed in primary care. In France, the number of doctors performing remote consultations increased from around 3 000 in February 2020 to 56 000 in April 2020, with GPs billing 80% of all teleconsultations (Richardson et al., 2020). In Lithuania, the National Health Insurance Fund reported conducting 758 000 PHC remote consultations in April 2020, nearly 70 times higher than in April 2019, when 11 000 teleconsultations were conducted (Webb et al., 2021).

Depending on previous infrastructure capacities, established ways of working and patient preference, remote consultations took place on different platforms. Suspected or non-severe COVID-19 cases often received consultations via phone or video link, as did patients requiring more routine care. Compared with the physical capacity requirements of providing care in-person settings, the solutions for remotely provided care are easier to scale. For example, many countries created COVID-19-specific telephone hotlines within weeks of the outbreak of the pandemic. Rapid scaling-up of remote consultations nevertheless required workforce adaptations (see Section 4.2) as well as policy changes to regulation (e.g. removing caps on the number of consultations allowed or enabling more health professionals such as nurses or physiotherapists to provide remote services), changes to reimbursement levels to compensate for lost income, investment in technical infrastructure and training for health professionals in most countries (see Section 3.2). It should also be acknowledged that remote consultations may not be appropriate for some patients and telehealth cannot fully replace in-person consultations.

Digital health tools for the remote management of COVID-19 patients with mild symptoms or those recuperating at home after hospital care went beyond teleconsultations, and included applications for self-monitoring of symptoms as well as remote monitoring using connected devices such as oximeters (European Observatory on Health Systems and Policies et al., 2021).

Beyond the options already discussed, a range of digital applications were leveraged during the pandemic to improve patient care and accelerate progress, providing tenable solutions for a resilient response. Artificial intelligence is being used to provide rapid identification of COVID-19 infections and potential treatments. For example, in initiatives supported by the European Commission, artificial intelligence software has been developed to speed up identification of COVID-19 infections through computed tomography scans, while super computers are being used to identify existing drugs that could potentially be repurposed to treat COVID-19 (European Observatory on Health Systems and Policies et al., 2021).

Provision of mental health services

The uncertainty linked to the COVID-19 pandemic as well as the consequences of measures to stop the spread of the virus affected mental health across multiple groups, including the health workforce (see Section 4.3), people who have or have had COVID-19, and the general population (Moreno et al., 2020). For example, the Italian Society of Psychiatry estimated that 300 000 patients were suffering from post-traumatic stress linked to losing loved ones, financial damage and uncertainty about the future. Provision of mental health services has also been affected. The Technical Advisory Group on the mental health impacts of COVID-19 in the WHO European Region identified three distinct levels of mental health impacts: the population, policy and service level, and individual level (WHO, 2021a), with recommendations for each area.

Efforts have been made to adapt the delivery of mental health care in response to the COVID-19 demands and pressures. Adaptation of services mostly focused on infection control, modifying access to diagnosis and treatment, ensuring continuity of care for mental health service users, and paying attention to new cases of mental ill health and populations at high risk of mental health problems, such as health workers and relatives of those who suffer or died from COVID-19 (see also Section 4.3) (Moreno et al., 2020). Several countries, such as France, Malta and Portugal, established help lines for those in distress. The South West London and St George’s Mental Health NHS Trust in England established a 24/7 mental health emergency department for patients of all ages with a dedicated phone line for admission; the goal was to support people who need urgent mental health care so they could avoid acute hospital emergency departments (CQC, 2021). Mental health care, including individual and group counselling sessions, also transitioned to remote access options to various degrees across countries to respond to existing and emerging needs.

Addressing the needs of vulnerable groups

The COVID-19 pandemic disproportionally affected vulnerable groups, not only in public health (Section 5.1) but also in the provision of care and outcomes (European Union, 2020). In particular, many countries initially underemphasized the need to protect residents in long-term care settings. Preventing infections and managing outbreaks in long-term care settings was a key weakness of many responses and nearly half of COVID-19 related deaths in the first wave in a selection of 26 countries occurred in long-term care facilities (Comas-Herrera et al., 2020).

In many countries, long-term care is organized separately from the health system, and suffers from lack of funding, workforce shortages and fragmentation (Langins et al., 2020). During the first wave of COVID-19, several countries established new governance structures, financing mechanisms and staffing approaches, while changes in care approaches were relatively less common. Some countries, including England, France, Italy, the Netherlands and Norway, explicitly discouraged transfers to hospitals.

“Solutions” to physically distance residents such as no-visitor policies have initial signs of undesired outcomes such as loneliness (O’Caoimh et al., 2020). The WHO Regional Office for Europe released guidelines, including 10 policy objectives, for preventing and managing COVID-19 in long-term care settings (Comas-Herrera et al., 2020; O’Caoimh et al., 2020; WHO, 2020f).