As public fears over the COVID-19 virus pandemic continue to grow, GP surgeries are having to undergo significant changes in how they are dealing with patients and meeting demand in different ways. Face to face appointments are fast becoming a rare interaction as telephone and technology must take centre stage in helping practices deal with patients. Will the changes we make, as a result of the demands of the pandemic, mean a long term shift in the way we manage practices?

Naturally, minimising interaction between patients and the practice, wherever possible and safe to do so, has had to take priority. Ensuring anyone with COVID-19 symptoms does not come into contact with others, but while facilitating the right level of care has challenged traditional ways of working.

Changing times, changing practices

Robyn Jackson, Practice Manager at Close Farm Surgery in Bristol, says the way care is being provided has had to change.
“We’ve probably got about 75% less face to face contacts that we normally would have,’ she says. “We used to have a system where we would see most patients face to face and we have gone to 100% telephone triage. All of our GP appointments are by phone appointment first and then the clinician decides if they need to see the patient and whether that should be on site or by home visit.

“All of our long-term condition management – the reviews that our nurses do for things like diabetes, asthma and COPD – are being done over the phone where possible so we don’t bring people in unless we absolutely have to. Medication reviews by our clinical pharmacists have all switched to phones as well.

The practice is still carrying out phlebotomy, dressings, and smears on site but these appointments are being held solely in the mornings.

“That’s because that’s when our telephone triage is going on so there’s no acutely unwell patients in the building so we are minimising the risk of transmission,” Robyn explains. “We have also limited the amounts of bloods that we’re doing. We are doing everything that we can and trying to get as many people as possible to not come into the surgery unless absolutely necessary. We are trying to think of our most vulnerable patients and want to reduce the risk of potential infection as much as possible. We are also trying to increase the use of electronic prescribing.”

Adapting to change

“These are strange times and practices are having to adapt,” says Nicola Davies, Practice Manager at The Roseland Surgeries in Cornwall.
“At our [three] practices, we are very top-heavy with elderly patients. We have many patients with multiple co-morbidities so they are naturally at risk, vulnerable and isolated. They are worried.”

“We’ve seen a huge rise in cancelled appointments. We are offering patients the ability to convert their face to face appointment to a phone appointment and some people are taking us up on the offer.”

Unsurprisingly, the practice is receiving phone calls from patients wanting advice about the virus and asking if they should self-isolate. Staff are directing them to NHS 111 online.

“The doctors have got enough to do,” says Nicola. “They need to crack on and deal with patients who are really ill. I don’t mean that disrespectfully to people who may have Corona, I just mean there are people for whom we are managing ongoing chronic illnesses such as people with brittle COPD, patients with heart disease and the elderly in the end of life. In one way, you can argue that this freeing up of doctor time is allowing them to deal with those patients with a bit more time. The surgeries are half empty.

“I think we just need to have an element of common sense, managing a patient group who naturally panic because that is their natural default setting and then keeping the staff informed. Keeping a sense of perspective as well is really difficult.”

The practice is continuing to operate although some of its staff have now gone into self-isolation.

“There are things that we are postponing for a month or so such as routine checks,” says Nicola. “What we’re looking at now is having spaces between each patient. We’re leaving slots free to reduce the amount of traffic that is coming in and thus reduce risk to those in the building.”

Mark Stubbings, Managing Partner at Portsdown Group Practice in Portsmouth, is also noticing that the way care is being delivered is changing.

“We are moving towards a more consultative role now,” he explains. “We are dealing with a lot of our patients from using eConsult, using telephone triage, and we’re limiting the face to face [appointments] to those to those who really need to be seen face to face.

“We’re lucky in so far as having multiple sites, we are able to designate some to be acute and some to be more routine. From our perspective, we are well placed and continue to be able to deliver care to all the patients.

“We have a centralised contact centre so the volume of calls coming in there hasn’t changed very much, but we are able to deal with a lot more things over the phone than previously that we would have had to deal with face to face.”

Digital care

The government is keen that practices adapt to the changing situation. Health and social care secretary Matt Hancock recently said recently in the House Commons: “We are taking steps to improve access to make sure people can access primary care in the best possible way.”

“I can be clear to the House today that we will take a digital-first approach to accessing primary care and outpatient appointments so wherever clinically and practically possible people can access and should access primary care through phones and digital means.”
That’s fine, but some practices have predominantly older patients who may be less than willing to use such digital technology and not every GP practice will be set up to provide digital consultations.

Protective equipment

Widely reported by practices in the news, and in the Practice Index forum this week, was the concerning discovery that the personal protective equipment (PPE) packs being sent to GP practices contained face masks displaying an expiry date of 2016. Around 20 regions in England were sent face masks past their expiry date with the date covered up with a sticker claiming they were useable until 2021.

Christina Cleworth raised the issue, saying: “Today we received the NHS-supplied PPE for Coronavirus. The masks were of particular interest.”

“Apart from the fact that they are not FFP3, and therefore of little use, I would like to draw your attention to the first picture (before label removed), showing an expiry date of 2021-08. The second picture (after label removed) below shows the same box where, as if by magic, the expiry date is 2016-08.”

“I am assuming, therefore, that, prior to our next CQC inspection, we can simply get some sticky labels to put over any out of date stock.”
Robyn’s practice was recently sent a PPE of which she says: “We have got enough but it is really poor quality. They sent plastic aprons and latex gloves, which we have in practice anyway, and then these masks which have an expiry date on them from 2016.”

However, it turns out that the masks are okay to use. During an evidence session of the parliamentary health and social care committee held on 17 March, witnesses from NHS England were asked about the issue.

Professor Keith Willett, director for acute care at NHS England replied: “We are fully aware of those. They did go through a quality assurance check for health safety. The reason they were re-badged was because that’s what was appropriate. They were tested to ensure that they are of current standard.”

Preparing for the long term?

Calming the public’s fears may be the most difficult thing to achieve in these difficult times, as Nicola concludes: “I’ve been through swine flu and avian flu before in GP practices but this feels a lot worse. It feels like people think we have the plague.

“The media have been inflammatory and this has led to this ridiculous panic buying and queuing outside supermarkets. We need information that we can feed to patients to help them get this into perspective.”

It’s clear that the situation we are facing is something completely alien to all of us, and there will be changes to every aspect of primary care as we try to battle through in the best way we can.  If you are feeling overwhelmed, pop over to the Practice Index forum for support from your fellow PMS or have a look at our Coronavirus resource centre