1. Workload Prioritisation

You will have received the joint guidance from BMA GPC, RCGP and NHSE on what you can safely stop, and what you should continue.

This is a really helpful document that can be found here: workload prioritisation

If you start to approach the point of potential practice closure please ensure you contact the CCG Primary Care Team at capccg.primarycare@nhs.net for advice and guidance as well as the LMC office.

2. Appointments

We recommend that your surgery doors should be closed to patient footfall, and that you operate a model of telephone triage first.

An overwhelming majority of consultations and need can be addressed remotely. A tiny minority of patients may need to come into the surgery on an invitation only basis for a defined appointment and reason.

Appointments should be called by admin teams to advise that they may be subject to cancellation or rescheduling and will take place remotely wherever possible.

A poster to help you is attached here: Practice Poster

3. Remote Consulting

We advocate that you download AccuRx onto your systems. This is a quick and intuitive way to allow ‘Facetime’ consultations without revealing your mobile number, and embedding data into the patient’s medical record. Download from www.accuRx.com using your NHS.net account. It is ridiculously simple. You will wonder how you ever lived without it.

4. Face to Face Appointments

We advocate that you minimise your face to face appointments to the bare minimum. These are those appointments where there is no alternative and the need is urgent. These appointments will need to be carefully triaged first to ensure the patient has no symptoms consistent with Covid-19. If they do, they must follow government advice and self isolate for the next seven days.

If they do not then there will need to be a defined room, with a defined entrance/exit and a defined clinician for these consults. The patient will need to be given a face mask and gloves prior to entering the building. The clinician will need to wear the PPE the practice has available, donning and doffing the PPE in such a manner whereby they practise as if they were in a sterile theatre, with hand washing before and after the consult.  The treatment room can then be cleaned at the end of the day.

An increasing number of patients and staff will be incubating Covid-19 asymptomatically. Everyone should behave as if they have the virus to minimise transmission where possible. Examples of patients you may still want to bring in are: baby immunisations; Zoladex injections; mental health depots; complex dressings; removal of sutures. For some simple dressings, an assistant may wish to video the consultation on AccuRx to share with a next of kin who may be able to continue the dressings at home.

Your at-risk workforce should be kept for remote consulting only.

Suspect Covid-19 Patients:

If Covid-19 patients contact the surgery, either signpost them to 111 online for isolation notes and ongoing self care, or if you are particularly worried about their clinical condition and suspect they may need admission, discuss with your local admissions team at your Trust. Some intermediate patients may need a review. Following clinical triage, you may decide to advise them to contact 111.

Those patients who have a NICE frailty score of 5 or above will not be intubated. A gentle respectful conversation about ceilings of care and potential meds for palliation may be appropriate. A video consultation with a next of kin to ‘see’ the patient will be helpful in the event of their death. Legislation comes into force tomorrow and we will write to you about this anon.

HUC and the CCG are working with us to develop clear algorithms for practices to appropriately manage patients. For now, we recommend you keep your practice a cold site and do not treat or review suspect Covid-19 patients on the premises. Manage them remotely. This advice is subject to change on a daily basis.

5. Prescription Requests

eRDS – Prescribe 6-12 month electronic batches where you can.

Non-EPS Patients – A letterbox should be provided to facilitate urgent handwritten prescription requests from those patients who have not accepted EPS. They will need to be advised over the phone that with immediate effect, they will need to choose a community pharmacy from where they can collect their prescriptions.

Paracetamol/Inhaler/Rescue Pack Requests – Medication stocks are needed for unwell, symptomatic patients. Review your prescribing policy and consider setting up an AccuRx template to handle these requests via SMS. Examples are at the bottom of this email for you to personalise and adapt.

6. Private Medicals e.g. DVLA

The DVLA is soon to be publishing guidance around MOTs, licenses and tests as an interim solution. These requests and others are not to be prioritised above NHS patient care.

7. Referrals, Advice & Guidance

You will have seen the CCG update from the Gateway on Friday co-written by LMC CEO Dr Katie Bramall-Stainer and CCG Clinical Chair Dr Gary Howsam: 

Primary Care COVID-19 daily update – 20 March 2020 (14:10pm)

We have already communicated about changes to Outpatient services – the vast majority of non-urgent clinics will have been cancelled or switched to remote consultations already. Whilst Outpatient activity is greatly reduced, it is vital that GPs can access support from secondary care colleagues, in terms of timely, comprehensive Advice and Guidance and 2WW.

Scenarios:

Knowledge limit reached, expertise needed? Expanded Advice & Guidance – use current systems – expect response within 48 hours. Be clear and concise in question – in return we will expect detailed, pragmatic response without recommendations for additional diagnostics. If the advice is that the patient needs to be seen, you can still refer in to specialist clinics on ERS. These will be restricted and only referrals that have gone through advice and guidance will be accepted. Full guidance will be issued to practice secretarial teams.

Advice needed immediately to avoid admission? We expect GPs to be able to access specialist advice over the phone. More details coming soon.

Referral needed to carry out specific diagnostics ASAP? The ‘need it now’ referral will include 2WWs. Please continue to use the standard 2WW proformas. Where urgent but not 2WW, use Advice & Guidance. Do not be tempted to escalate via 2WW.

Referral needed to carry out specific diagnostics that are non-urgent? Do not refer. We will provide a template letter to give to the patient regarding how at the present time it is safe to wait. We do not intend for practices to carry the responsibility of an audit trail or log of this patient need. We are mindful of the risks in generating task lists that would deleteriously affect your own wellbeing and that of your teams.

Referral due to persistent medically unexplained symptoms and patient demand? We all recognise these cases. This cohort will need to be told firmly that they will not be referred. Sadly, these may represent some of the ‘easier’ difficult conversations we will be needing to have as we move forward.

The key message is that we will be using secondary care to support you in a different way.”

Helpful Hints & AccuRx

Patients requesting MED3s for isolation or being in an at-risk group should download the Isolation Note from: https://111.nhs.uk/isolation-note/

You may want to consider changing those warfarin patients onto a DOAC if it is safe to do so. There is a good patient-decision tool available at:  https://www.hey.nhs.uk/patient-leaflet/patient-decision-aid-for-direct-oral-anticoagulants-doacs-and-warfarin/

Women whose subdermal implant (Nexplanon) or LNG-IUS (Mirena/Jaydess etc) that is nearing expiry can be offered desogestrel as an ongoing safe replacement/cover. With HRT/COCP requests consider issuing an electronic batch for 6-12 months.

With urgent medication reviews consider remote consultations where the patient may have undertaken some home BP readings and document these. Likewise they may have a peak flow meter at home that they can practise in front of you.

You may wish to convert your six week checks to a video consultation postnatal review with the mother which will give you an opportunity to schedule and advise of the new protocol for delivering baby immunisations.

Accurx templates for you to personalise for your practice:

APPT BOOKING

Please contact XXXXXX Surgery on XXXXXXX regarding booking an appointment. Please do not reply to this message.

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ASTHMA REVIEW

You are due for your annual asthma review. Please book a routine appointment, and remember to have all your inhalers and other medicines when we contact you.

SNOMED Code: Asthma monitoring invitation SMS sent

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CHD

You are due for your annual heart review. Please book a routine appointment for a remote consultation.

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CHILD IMMS INVITE

Your child is due for their childhood immunisations. Please call the surgery to book an appointment.

SNOMED Code: Child immunisation invitation first SMS text message

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COPD

You are due for your annual review for your breathing condition (COPD). Please book a routine appointment, and remember to have all your inhalers and other medicines when you are contacted for your remote consultation.

SNOMED Code: COPD monitoring due

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COVID BP CANCEL

We have had to cancel your blood pressure appointment for the foreseeable future. If you can, it may be worth investing in, or using, a home reading machine so that you can forward the results to the surgery. Thank you for your understanding.

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COVID-19 ERDS SWITCH

I have moved you onto repeat dispensing for the next 6-12 months. Your prescriptions will be available as usual from your chemist but you will not need to request them from us as you do now. If any questions, please refer to the linked leaflet. Otherwise, please call and ask to speak to one of the pharmacists working with us.

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COVID-19 NO TO RESCUE PACK REQ

You have requested a “rescue pack”. If you are asthmatic, you don’t need one. Please contact the surgery if you develop symptoms of wheeze or shortness of breath. If you have moderate or severe COPD, you should already have one IF YOU NEED ONE. This will have been looked at by the nurse during your last COPD review.

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COVID-19 PREBOOKED APPTS

You have an appointment upcoming at the surgery, should you have ANY of the following symptoms, do NOT come in for your appointment. Call us on XXXXXXXX to arrange a telephone/video consultation. New/persistent cough Fever/high temperature Breathlessness Or if you have travelled to any high risk country – even if you have NO symptoms. Thanks,

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COVID-19 PREGNANCY INFO

Covid-19 Virus Infection and Pregnancy:�We know this is a very worrying time for you. Here is some information for you about how COVID-19 affects pregnant women and what you can do to look after yourself. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/coronavirus-pregnancy/covid-19-virus-infection-and-pregnancy/

Thanks

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COVID-19 SALBUTAMOL REQUEST WITH NO SYMPTOMS

We are declining your request for a salbutamol inhaler as you have not needed one for a long period of time and haven’t provided any details suggesting you have symptoms at the moment. If you HAVE symptoms of a flare in your asthma or develop any in future, please get in touch via XXXXX (from the front page of our website www.XXXXXX) or by telephone XXXXXXX and we can review the situation.

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COVID-19 SELF ISOLATE (FAMILY)

You have been advised to self-isolate as you or a family member may have COVID-19.  For details on how to self-isolate, seehttps://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-households-with-possible-coronavirus-covid-19-infection .

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COVID-19 SOCIAL DISTANCING ADVICE

You have been advised to apply “social distancing”. Information from the government is available here: https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults

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CX’D APPT

Unfortunately we have had to cancel your appointment. Please call us on XXXXXX to rebook.

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DIABETES REV

You are due for your annual diabetes review. Please call us to book an appointment for a remote consultation, and have your medication easily accessible when the time comes to contact you.

SNOMED Code: Diabetes monitoring invitation by SMS text messaging

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DNA

We’re sorry to see you did not attend your appointment. In future if you are unable to keep your appointment, please make sure to notify the practice in advance so that it may be offered to someone else.

SNOMED Code: Did not attend

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GENERIC CONTACT

Please contact XXXXXXXXX Surgery on XXXXXXX, as we have been unable to reach you by phone. Please do not reply to this message.

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HYPERTENSION

You are due for your annual blood pressure review. Please contact reception to book a remote consultation. If you have a home monitor please start to record your readings so we can talk about them during the appointment.

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MED REV BLOODS

Please book an appointment with reception to have a remote consultation for your medication review. If the clinician feels your bloods are stable you may not need to have a blood test. You do NOT need to fast. Please do not reply to this message.

SNOMED Code: Blood test due

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MED REV DUE

You are due for a medication review. Please book this at the surgery for a remote consultation prior to further repeat medication requests.

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MISSED CALL

We tried to contact you as requested. We will wait to hear from you. Please contact the reception team when you are available if you still need to speak to us. Health information including a symptom checker is available on https://111.nhs.uk/

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NHS HEALTH CHECK

During the Covid-19 Pandemic we are not undertaking routine NHS Health Check. Please call reception to book this later in the year.

SNOMED Code: NHS Health Check invitation SMS sent

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PRESCRIPTION

Please contact XXXXXXX Surgery XXXXXXXX regarding your prescription. Please do not reply to this message.

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RHEUMATOID

You are due for your annual rheumatoid arthritis review. Please book a routine appointment for a remote consultation.

SNOMED Code: Rheumatoid arthritis monitoring invitation