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Is COVID-19 changing the priorities of GP practices?

One of the many consequences of the COVID-19 pandemic is how it is changing healthcare provision and, in some parts of the country, the workload of providers.

The government says it is aware that many parts of the health service may be experiencing a surge in patient demand and accordingly, has taken steps to try to ease pressure points.

One in a series of “preparedness” letters from NHS England was issued on 14 April which sets out how surgeries can take various steps to minimise workload on practices such as:

  • deferring routine medication reviews/reviews of frailty/over-75 health checks/annual patient reviews/new patient reviews
  • ‘pausing’ the NHS complaints process to allow all healthcare providers in all sectors to concentrate efforts on COVID-19
  • suspending Friends and Family Test (FFT) data
  • delaying the need to provide access to historic online patient records.

The letter authors Dr Nikita Kanani, medical director for primary care and Gabi Darby, deputy, GP Contract, both from NHS England and NHS Improvement, say: “We trust and support healthcare professionals to use their clinical judgement when applying this guidance in what we appreciate is a highly challenging, rapidly changing environment.”

Time savers?

Allowing practices to pause/defer/suspend these activities might be considered as time-savers and just what practices need at the moment, but managers are unconvinced about just how helpful they will be in reality.

A practice manager from an Essex surgery who wishes to remain anonymous, says: “On deferring complaints, we don’t have that many, so it won’t make any difference. The Friends and Family test doesn’t really matter in the sense that, who even reads them apart from us?

“I don’t think the other deferred things are going to make a huge difference because they are replaced by the many things which they will want for COVID-19 which will make us very busy.”

Helen Oakley, practice manager at The Sherard Road Medical Centre in Eltham, London, adds: “Before we got this latest letter from NHS England, we had already decided that the nurse things we were going to do were D12, contraception, dressings that the patient couldn’t do themselves, child immunisations, any blood tests and any examinations that were clinically required, such as bad blood pressure.

“I’ve got three pharmacists who are all part-time. If they don’t do routine medication reviews, what are they going to do?

“They are employed and why wouldn’t they do routine medication reviews because the patients are still requesting medication. They’re not calling the patients in for routine blood tests but they are still doing routine medication reviews, synchronisations and advice about types of medication.”

Robert Campbell, former GP surgery manager and practice manager consultant, says: “My general feeling is that they have probably chosen things that are not going to make such a vast difference, for instance suspending the friends and family testing – that’s an absolute joke.

“Most practice managers would say that either they don’t do it or it’s of no real value. It does seem to be an awful waste of time and I suspect that lot of practices deal with it with a very soft touch so in that sense, it’s no loss of extra work at all.”

New work tasks

The well-known phrase of ‘no such thing as a free lunch’ quickly springs to mind when you consider that NHS England’s preparedness letter comes with new work expectations.

The letter says practices will be expected to increase the minimum number of appointments that practices must make available for NHS 111 direct booking.

This increases the previously agreed provision from practices being required to make one appointment per 3,000 registered patients per day available for direct booking by NHS 111, to one appointment per 500 registered patients per day during the three-month period of 30 March to 30 June.

In addition, over the same period the definition of “core hours” is to be changed to include bank holidays to allow for a higher than normal incidence of illness.

Practices are also expected to maintain good vaccine uptake and coverage of immunisations, says the letter, as the routine immunisation programme will play a “critical role in preventing ill-health through diseases other than COVID-19”.

If practices experience high demand on services, they should prioritise time-sensitive vaccines for babies, children and pregnant women.

The anonymous practice manager from Essex believes the approach from NHS England is unhelpful, explaining: “We had to run searches for ‘shielded’ patients [extremely vulnerable people most at risk from COVID-19] and that was a lot of work thrown at us. They say in their letters ‘we appreciate you’ and ‘we value you’ but then they say ‘this has to be done now’.

“The shielding thing came in and now everybody is scrambling around on this. We can only do what we can. I don’t think we could do anymore.”

Robert says: “One of the things that worried me [in the letter] was that practices were being expected to switch on their appointment online systems again, so NHS 111 could have access to them.

“A recent survey on Practice Index indicates that well over 90% of practices have switched off their online system because they want people to phone in and they’ll speak to them.

“If NHS 111 is making these appointments, they’re doing so for people for whom you’ve no idea what’s wrong with them. From what I can see, most practices are now shutting their doors and not really letting many people in at all, unless they know that they are apparently coronavirus-free and maybe have another problem that actually needs a physical examination.”

Another manager who wishes to remain anonymous says in a discussion on the issue on Practice Index forum: “Reduce workload! Just come off a PCN [primary care network] meeting about setting up cold hubs etc… and discussing increase of 111 calls to the practices. My head is at exploding point again!”

Helen also has concerns, saying: “On the issue of practices making more appointments available for NHS 111 bookings, this does not affect my practice because its Vision system does not currently allow NHS 111 to directly book GP appointments. It’s the inequity of what the centre thinks should happen, what the centre wants to happen but the reality of what can happen.”

Better solutions

Managers believe other far more helpful steps could be taken to ease pressure on general practice, such as leaving practices to get on with tackling work in the way they consider to be most appropriate.

“The biggest topic at the moment is ‘am I vulnerable’ and ‘am I at very high-risk’?’ says Helen. “What would be really helpful is a definitive list of conditions, a definitive list of patients on certain types of medication, and a seamless process in notifying us of those patients.

“I’ve got patients who have had shielding letters from secondary care, but they’re not on my high-risk list. Patients are also getting letters saying ‘you’re not high risk’ and ‘go and contact your GP surgery’ to find out why.

“This mythical list that is supposed to exist centrally – we’ve not seen it. We had to open on the recent bank holiday and the most phone calls we got on that Friday weren’t patients calling us to book appointments, it was to find out why they weren’t high-risk.”

Robert has heard that some practices have not been sent their QOF aspiration payments for this month, and says: “They need to make sure that these advances are paid consistently and that practice are not expected to reach the [QOF] targets this year. In the next 12 months, they should pay them the normal QOF amounts that they receive and not have them worrying about having to reach all these targets.”

How is COVID-19 impacting on your day to day management in practice? Hop over to the forum and share your experiences.

 

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