Providing routine primary care during COVID-19

THE risks posed by COVID-19 extend well beyond those of the virus itself – and this was recently highlighted in a statement issued by The Academy of Medical Royal Colleges. It stressed the importance of patients recognising that they must "continue to seek medical assistance if they have symptoms which cause concern, or are already being treated for a serious health condition".

In recent weeks, practices have had to adapt new ways of working to reduce footfall but also ensure that the ongoing medical needs of patients are still being dealt with safely. MDDUS advisers report an increasing number of inquiries from members asking about professional responsibilities in providing routine care in the current situation, where service demand and modes of healthcare delivery are drastically different.

For GPs, this involves considering not only their own areas of responsibility but that of work typically carried out by other healthcare professionals, such as nurses, paramedics and pharmacists, as well as healthcare support workers (HCSWs).

Total triage

In March, most GP practices took steps to move towards a 'total triage system' whereby every patient contacting the practice is first triaged before making an appointment. Patients are then managed remotely (online, phone or video) where possible to minimise practice footfall and help reduce demand for face-to-face appointments. NHS England has noted that early figures suggest that over 85 per cent of GP consultations are now being managed remotely. However, practices must still ensure that they are offering face-to-face appointments where clinical need is determined, following triage.

Controlling physical access/reducing footfall is important but practices must not give the impression of "closed doors"; rather they must ensure that patients are appropriately triaged to the right health professional, via the right channel (e.g. phone or secure video consultation) or in the right location within the practice or at a shared local hub. Moving forward, the public must be reassured that, despite this crisis, GPs are still there to provide routine care as required, even if access is being managed differently.

Some practices are actively identifying patients who will require close monitoring and follow-up. This approach can help to pick up patients who might not otherwise contact the practice – for example those requiring repeat blood samples in order to monitor previous abnormal test results. Specific conditions or treatments, such as diabetes or warfarin therapy, will still require close monitoring.

Working out whether alternative approaches might be trialed, or how you can achieve these tasks safety and with minimal personal contact, will be essential. Some practices, clusters, networks and community organisations are already collaborating in the establishment of centres where different types of patients can be directed for specific services. The BMA’s COVID-19 resource page provides guidance for doctors to help minimise practice footfall.

GP practices are also having to manage a significant increase in home visiting, due to the implementation of public health social distancing measures. Many practices do have access to a home visiting team, specially set up to offer home visits during the current crisis. The demand may increase as patients in high-risk categories are instructed to remain at home, and with the expected increase in patients being discharged from hospitals.

There may also be an option to postpone some specific non-critical interventions, but a reliable system must be implemented to ensure that these patients are not then lost to follow-up when lockdown measures are eased. Practices may also consider whether some activities can be reasonably delegated to other staff in different ways. For example, could a receptionist be trained to check-in on vulnerable patients by phone and determine whether GP review is required? Could healthcare support workers be upskilled quickly and safely to carry out specific tasks not normally within their remit but still appropriate for non-registered healthcare workers? If this is being considered, GMC guidance on Delegation and referral should be followed when implementing any such measures.

Prescribing

Another challenging area is prescription monitoring. Can patients who are on higher-risk medications be identified and monitored as a priority, while deferring monitoring of lower-risk medications until the immediate crisis has passed? Can your practice or local pharmacists assist proactively with this? Could important medications be reviewed over the telephone? It may be that some patients will need testing to check medication efficacy and the management of their condition, and this will require a method for prioritisation, possibly with a set of clear, well-communicated rules for attending patients and the safe handling of specimens.

Electronic prescribing should be the default position for all practices where possible and where clinically appropriate. Patients without a nominated pharmacy should be asked to nominate one. Where a paper prescription is required, you can instruct that it is collected by the pharmacy during pre-agreed and limited collection slots. Patients should make sure they check that their pharmacy offers this service.

It is also recommended that practices avoid giving additional medication to patients, as this could adversely affect the supply chain and possibly lead to shortages. Patients will naturally be concerned about access to medication but overprescribing requests need to be managed with clear guidance about why this may not be appropriate, given the current crisis. It may be helpful to refer to local guidance (e.g. from health boards or CCGs), as some practices are limiting medications to a 28-day supply only.

Communicating with patients

Since the middle of March, the pace of change in service delivery has been exceptional. This has resulted in some confusion about how (and for what) patients should contact GP practices. Moving forward, consider promoting and advertising important changes via your practice website and using text messaging. Perhaps practices could allocate responsibility for this to one or two members of the team, and create a list of channels within which changes could be communicated to ensure clarity and consistency of messaging. The Information Commissioner’s Office (ICO) has recently clarified that it is acceptable to use electronic messaging to inform patients of important public health information and changes to service configuration.

Reception staff should all be aware of day-to-day changes and be prepared with positive scripting to deal with patient queries about access, as they arise. It is recommended that information provided includes a short rationale for changes so that patients are more informed and therefore likely to accept changes more readily, particularly where they see the practice is working actively to protect them and maintain the service.

It’s a well-evidenced fact that patients listen and act on communications presented by engaging staff members, so a short video update on social channels could result in patients feeling more supported and better informed.

In summary

It is important for all clinicians to continue to base decisions on clinical need in the first instance, while minimising the risk to patient safety. Individual practices must make their own judgement about what activities can be postponed, but the BMA has compiled a suggested list of non-urgent work that could be postponed until further notice. This is contained within the guidance referred to above.

ACTION POINTS

• Prioritise urgent care for individual patients, groups and conditions, whilst ensuring patient and team safety.
• Upskill and safely delegate specific activities to nurses, healthcare support workers, paramedics and pharmacists, as appropriate, to help ensure essential tasks are carried out/followed up, and keep track of patients whose care has had to be modified.
• Proactively contact patients needing ongoing care and create positive messaging on access for the rest of your patients.
• Follow evolving guidance concerning clinical matters.

Liz Price, senior risk adviser at MDDUS