Here are some pieces of what we hope are useful, pragmatic advice for you based on the information shared over the past few days. We will pop this News update and its associated documents on our website tomorrow.
The daily GP Sit Rep
Bank Holiday working
Deaths in the Community
Debriefing – Pastoral Support Team
PCN DES 2020/21
End of Life Update
The daily GP Sit Rep : “How Is Your Practice Doing Today?”
Starting tomorrow (Thursday 2 April), the CCG will be sending you an email each day which contains a link to a Survey Monkey-like platform where you can alert the CCG to a RAG rating (red/amber/green) of:
– how you are coping (coping/stretched/not coping – add details)
– PPE supplies (>3 days/1-3 days/running out today)
– current demand (manageable/at capacity/not managing – add details)
– staffing levels (coping/stretched/not coping – add details)
– any other issues
We would strongly encourage you to complete this daily SitRep for primary care. 111, CPFT, NWAFT and CUH all do this and it feeds into the ‘health gold’ report discussed each morning where capacity across the system is discussed – and general practice needs to be part of this. Please ensure there is someone in the practice who knows where to go each day to complete this, if the usual person who completes the form is incapacitated.
Now the PPE issue is in hand, we are pushing each day for clarity on the need for healthcare worker antibody testing in the community. We will keep you informed.
Bank Holiday Working
We had hoped for some national guidance by now, so we are going to fill the void with some practical advice in the interim.
Practices being mandated to open on Good Friday and Easter Monday forms part of the Covid Act of Parliament, so is completely separate to BMA GPC or the CCG. How you go about arranging this cover in your core hours should be defined by your workforce capacity and the needs of your patients. Whilst your doors may be physically shut to footfall, we know you will be working hard managing them remotely by default, and by appointment when strictly necessary.
GPC is negotiating payment mechanisms to ensure practices are not left out of pocket. We hope that there will be much clearer guidance as we approach the May bank holidays, where the same rule will apply. Parliament will also be looking into how accrued leave of up to four weeks’ duration can be permitted to be ‘rolled over’ to future years. Again, the funding mechanism for this will be negotiated nationally by GPC England, and you have myself and Diana on the committee representing you there.
We recommend that you take a pragmatic approach to these bank holidays. How you decide to rationalise your team on these days will be in your gift. We think it’s important to recognise that these are the early days of a marathon, not a sprint. And so if you are able to step down some members of your team, on some bank holidays, that might be helpful. Any staff that do work the bank holidays may wish to have time back in lieu at a later date, or you may wish to pay an additional amount. Likewise, and separate to the bank holiday issue, is that where you can, you might wish to enable members of your team to work and orchestrate meetings remotely using VPNs and online videoconferencing tools. This may be especially sensible if your premises are confined and stretched.
We recognise that the general public may assume that their practice is closed and contact 111 on the upcoming Bank Holidays, so it may be that we agree to a change to the automated response OOH – to advise patients to contact their surgery in the first instance.
Equally, it may be that one or more of your doctors have committed to shifts in HUC on these days. We would suggest that you look at your workforce needs and make a judgement based on what will make most sense for the practice, in ensuring that you have sufficient cover for the day, before agreeing to release GPs to honour their shifts. What is important is that you think as a team, and support each other in these unprecedented times.
We shared on LMC News (30-3-2020 21:33pm), helpful advice that Dr Stephen Barclay has written on this subject. The BMA guidance (used by the CQC) is quoted, and whilst we fully support this, it is important to acknowledge that the BMA guidance was written for a different time, and we need to be pragmatic about all deaths in the community.
English law does not require a doctor to confirm that death has occurred, and does not require a doctor to view the body of the deceased person. We recommend that at present, the pragmatic solution for expected deaths, would be for the family or the care home to contact the undertaker, who is able to remove the body, and to notify the practice that this has taken place.
A GP can then have a video call with the undertaker to confirm identity of the deceased, and to visibly see the body and discuss necessary additional information, such as the presence of an implantable cardiac device in order to be able to complete the MCCD and cremation administration. Undertakers will be familiar with the Covid-19 risks of handling bodies, and government advice which recommends “placing a cloth or a mask over the deceased” to help prevent the release of aerosols.
The exception to this, is when a patient has not been ‘seen’ (including over a video phone) in the 28 days prior to death by any registered medical practitioner. In this scenario, contact the coroner’s office. They may allow a MCCD to be completed pending the circumstances, but if not, the body will need to be physically seen to be able to complete the MCCD.
If you do need to examine a body, you will need to be mindful of the necessary precautions: https://www.gov.uk/government/publications/covid-19-guidance-for-care-of-the-deceased/guidance-for-care-of-the-deceased-with-suspected-or-confirmed-coronavirus-covid-19
We have attached Dr Barclay’s advice here which includes Cambs LMCs view.
Emma Drew has kindly created an at-a-glance flowchart to make this easier for those of you like me who prefer pictures
Debriefing – Pastoral Support Team
Your LMC has a pastoral support team, here to support you when you need us.
Traditionally this has been an adjunct to stressors aligned with individual performance processes or complaints, and is there to assist with hand-holding and signposting to more formal routes of support such as the GP Health service. Our GPs and exec team have received training from Clare Gerada’s practitioner health unit, and their role in the coming months may also be to chat through some difficult scenarios you may face in this period.
There will be some incredibly challenging scenarios for those of us in the community in the weeks and months to come, and we recognise that a debriefing service may be very much needed. An opportunity to sense check with an understanding non-judgemental peer, and a chance to signpost if more support is needed.
Please contact firstname.lastname@example.org with the subject header Pastoral Support Team and we will allocate you a member as soon as we are able to.
PCN DES & CCG LESs 2020/21
A lot has changed since the original contract was agreed, and the focus of the PCN DES is now to mainly support practices to deal with the national emergency of Covid-19. A two page summary is attached here. Needless to say, the ongoing crisis will mean that general practice will need more support both in the short term and in the medium/long term, and that will remain our focus as we navigate the coming weeks and months. You do not need to ‘sign up’ to the DES per se, as it is an opt-out agreement.
The CCG formally approved the Primary Care Investment Package this afternoon, and you will receive information tomorrow (Thursday 2 April).
As per the explanatory article in our March newsletter, please sign up to these LESs. The CCG has provided contractual assurances covering the Covid-19 period, and these contracts will bring additional financial resources into your practices.
End of Life Update
Over the weekends, and especially over the Easter weekend, we might suggest that you judiciously provide your palliative patients with a number to contact you, in extremis. We recognise that this is not necessarily usual practise for all, but this is an extraordinary time. It may well be that a next of kin would feel much more comfortable seeking advice from a GP they know and trust to feel more comfortable to deliver a prescribed medicine for end of life, which could make all the difference to that family, facing death alone.
Some of you may have missed the post on The Link (contact email@example.com to register if you are a Cambs GP or practice manager) from Dr Stephen Barclay around buccal and sublingual meds in end of life care. The key points are repeated below:
- The buccal / sublingual route would be for those unable to swallow oral meds, as in ‘normal’ palliative care where we would switch to the subcutaneous route. It is likely that syringe drivers will be in very short supply and availability of a clinician to give 4-hourly prn s/c injections may be very limited, so the long half-life of levomepromazine (approx. 18 -24 hours) is particularly helpful. This is also easier for family to administer buccal / sublingual meds, though that needs training and support and careful selection of appropriate people and home circumstances. Family carers may need debriefing afterwards.
- Buccal morphine: this is best being injectable morphine rather than oramorph. If able to swallow and absorb from GI tract, continue using oramorph as usual.
- Buccal midazolam has quicker onset of action of circa 20 minutes compared with sublingual lorazepam of circa 60 minutes. Many people dying with or from COVID have a gradual decline over 24 hours or so that we are familiar with; but some have a rapid decline over hours with delirium due to hypoxia, breathlessness and severe distress for which buccal morphine and midazolam will give rapid relief. The buccal levomepromazine will maintain the sedation after the first two drugs are wearing off. Larger doses of these drugs than we are familiar with may be needed as indicated in the prescribing guidance on the LMC website.
- The 24/7 hospice telephone advice will be there to support and guide health and social care professionals and will be pleased to help. It is hoped that in these exceptional times family carers set up to administer these drugs will be able to access 111 option 4 that is normally reserved for healthcare professionals, but this has not yet been formally agreed. We would reiterate that you will perhaps wish to pass on your contact details in extremis over a weekend, and especially a bank holiday weekend.
- Oxygen can be helpful for breathless COVID patients of which there may well be many, though the logistics of getting this into the home will be challenging, and even more pertinent will be the supply. Oxygen is much less helpful in the less common acute dying phase when sedation is more appropriate.
- A significant number of end stage Covid patients will need to be assisted to be comfortable while they die at home. It is unlikely that O2 therapy will have a beneficial place in their care. Given the resources we have, end of life palliative care will need to concentrate on respiratory distress.
- In due course, the needs of the bereaved will need consideration. In the coming months there will be multiple reasons for death to be much more challenging to process, whether or not a COVID related death. If we have capacity a phone call from the practice is likely to be appreciated.
Likewise you may need a debrief, and the Cambs LMC Pastoral Support Team is here for you.