In this update:
Bank Holiday Working
NHSE’s Covid-19 SOP
Managing patient urgent need
Managing patient ongoing need
Advance Care Planning
Oxygen in non-palliative discharged patients
THE NEW BUSINESS AS USUAL
So, for the foreseeable future, this is the new normal. The social distancing may be starting to have an effect, and we are moving from the initial transformation of patient-facing services into the next phase, of the new business as usual.
Morbidity and mortality associated with reduced access to care during a pandemic can be of equal, if not greater, significance than the impact of the pandemic infection itself. Across Cambridgeshire and Peterborough, attendances at emergency departments and two-week wait referrals have fallen significantly, with hospital colleagues telling us that people, both with and without Covid-19 symptoms, are delaying accessing care leading to very poor outcomes for some, including children.
Just to be clear, you should continue to register new patients. Those needing to prove identity for online access or registration may be invited to have a video call to demonstrate their ID, and potentially use a next of kin to send across an electronic copy for practice records. This is a time for pragmatism, and common sense.
This is partly a result of public anxiety, with people staying at home too long with symptoms. But it’s equally important we don’t compound the problem inadvertently with our own messaging to patients. Where clinically necessary, patients should continue to be assessed physically, in the appropriate safe clinical setting, using the PPE you have – particularly where this could inform the diagnosis of an acute condition or risk of deterioration.
We would continue to advise that wherever possible, a remote consultation over phone or video is used. Where this is not possible, we continue to advise that a process is put in place using the PPE you have to minimise vector transmission, recognising that many staff and patients alike may be asymptomatic incubators. This is why we feel the labels of ‘hot’ and ‘cold’ are ultimately unhelpful and potentially inaccurate. We would advise each practice identifies processes whereby they will be able to manage patients’ urgent needs and patients’ ongoing needs.
Bank Holiday Working – Good Friday & Easter Monday
NHSE have been clear, that under the emergency regulations, the Government expects practices to ‘open as normal’ on Good Friday and Easter Monday, and will likely make the same requirements for the May bank holidays.
Since this is a contractual requirement it means a practice is expected, during core opening hours, “to provide essential services that meet the reasonable needs of its patients, delivered in the manner determined by the practice in discussion with the patient”.
We have been working with the CCG and HUC to ensure that practices only have to provide a ‘light’ service model linked to full HUC provision as detailed in the gateway message of 07.04.2020. We expect the majority of the public to call 111 first, where they will be advised that their surgery will be open. However, if the surgery reaches capacity, further demand is to be directed back to 111. We foresee you needing a receptionist/manager, nurse and a GP. We foresee you continuing to operate your normal ‘remote by default’ service during core hours, bringing minimum patient numbers into the surgery for absolutely essential face to face consultations wearing PPE.
NHSE have only released today, plans for reimbursement of additional staffing costs, in line with capped rates that are unlikely to cover practice costs. We need to see, as a bear minimum, that any necessary additional costs borne by practices will be covered. We do not expect these to be substantial, and we do not expect to make a profit, but neither should we operate at a significant loss for the pleasure of working a bank holiday.
With this in mind we entered into discussions with CCG colleagues over the past week and have today agreed a much simpler reimbursement plan based around £0.37 per weighted patient, whereby practices can submit claims for staff who have worked on Good Friday and Easter Monday up to a ceiling of £7,400 for both days – bearing in mind we are offering a ‘light’ service from practices, with a ‘full’ service from HUC.
Please see the separate Gateway message from the CCG today detailing this arrangement.
NHSE Covid-19 Standard Operating Protocol
The SOP published by NHSE on Sunday evening is a helpful guide, but it not contractual. You may well have examples where your knowledge about an individual patient will form a better risk assessment than that described in the SOP. No one solution fits all in general practice. We maintain, that whilst demand does not outstrip capacity, the safest place for a patient to be managed is by their own practice. We are working with the CCG and Federations to develop plans on standby if and when they are needed.
Patients with urgent needs
These patients will be brought to the surgery following in-house ‘remote by default’ triage. Examples were referred to in our March newsletter, but may include an acute abdomen, a new breast lump, an unwell febrile child, an atypical chest pain that might warrant a baseline ECG. There will be other examples. These are not presentations that would automatically necessitate an admission via ED, or reassurance across a video link. They are judged clinically on an individual basis.
Patients in whom the urgent need is a suspected Covid picture (acknowledging that there may be some overlap and confusion with the history, e.g. 20-30% CV-19 can present with abdominal symptoms) should be managed in accordance with the latest (version 2.0 on 09.04.2020) C&P approved pathway for primary care:
Patients with urgent needs that need a physical assessment will need to phone a dedicated number on arrival outside the premises, where a gloved staff member may pass them a mask. They may be given gloves themselves, or invited to use hand sanitiser prior to entrance to the premises, which we advise should be via a separate entrance/exit, with doors kept open to minimise contaminating handles etc. They will be brought into a specific treatment room where they will be seen by a specific clinician who may be assisted by a specific colleague in the donning and doffing of their PPE for the consultation. The patient will then immediately leave the premises via the separate entrance/exit.
Patients with ongoing needs
Patients with ongoing needs might include antenatal patients needing to see their midwife; newborn vaccinations and baby checks; GnRH analogue injections; antipsychotic depot meds; complex dressings and necessary cervical cytology. There will be other examples. Each patient will need to be triaged the same day in advance of the appointment to ensure that they are not exhibiting symptoms suggestive of active Covid infection, in which case the above pathway applies and their ongoing needs can be deferred to a more appropriate time in the near future when they have made a recovery.
Again, these patients will also need to phone a dedicated number on arrival outside the premises, where a gloved staff member may pass them a mask. They may be given gloves themselves, or invited to use hand sanitiser prior to entrance to the premises, which we advise should be via a separate entrance/exit, with doors kept open to minimise contaminating handles etc. They will be brought into a separate specific treatment room where they will be seen by a separate specific nursing colleague. The patient will then immediately leave the premises via the separate entrance/exit.
What about booster imms?
Routine boosters are recommended to continue, but we would suggest you prioritise primary imms.
What about postnatal reviews and baby checks?
The postnatal review may be conducted via videoconference, and during that consultation, qualitative questions can be asked about any baby concerns, and the process by which they will come into the surgery for first imms. At the time the baby presents for first imms, we would recommend gloves/mask for the parent, and a very focused examination of the baby to be entered onto the child’s record.
What about antenatal clinics?
We hope your midwife has sufficient PPE from their employer. If they don’t you may wish to consider providing them with the necessary supplies whilst they see your patients. You would expect the midwife to telephone triage the patients first, and where there is the capacity for the patients to obtain a home BP meter and online urine reagent sticks to facilitate future video consultations, these should be encouraged. However there will be patients for whom this is not an option and they will need to be seen, and there may be other times when clinical judgement necessitates a face to face review.
What about cervical smears?
NHSE have also produced a helpful guide to assessing the need to undertake cervical cytology. In a nutshell, you may reschedule routine screening for up to 6 months, and up to 3 months for those women on early repeat screening or screening following treatment.
What else should we be doing?
Remember, NHSE and the CCG is supporting you in suspending normal QOF/LESs in fulfilling the guidance we shared last month that was produced by NHSE, the BMA and the RCGP around essential services at this time. Continue to refer to this document together with our advice and you won’t go far wrong.
A smaller practice may wish to use its main entrance and a fire exit. A larger practice may wish to use a treatment room at the main site and a separate room at a branch site. You will know what will make most sense for your premises and patients.
If you reach a stage where your demand looks to start to exceed your capacity, we would strongly recommend you contact and engage with your local Federation colleagues. Even if you are not a member of a Federation, the 3 Feds are looking to support practices across their extended access footprint.
Greater Peterborough Network – Email: firstname.lastname@example.org
West Cambs Federation – Email: email@example.com
Cambridge GP Network – Email: firstname.lastname@example.org
We are working with the CCG and the three Federations to develop a co-ordinated response to support primary care in light of NHSE’s Covid-SOP. This may differ according to each geography, and some discrete areas may wish to develop their own bespoke package according to their own needs – we are working with these areas too. In the meantime, for home visits, we would recommend you use your PPE – that’s what it’s there for – and the CCG is sourcing plastic removable car seat covers to assist with minimising contamination.
You may find your local Federation a helpful touchpoint around issues that arise from the CCG’s daily SitRep and they may proactively contact you if a need for support is flagged. We would strongly encourage you to continue to feed into this daily snapshot across the county.
Advance Care Planning
I spent a frustrating amount of time on call in my surgery on Monday, fielding queries from anxious relatives questioning their decisions to accept ceilings of care on behalf of their extremely frail relatives. As ever, this comes down to common sense and good communication skills, but there are some resources out there to help you:
Our online resources and template letters on
https://www.cambslmc.org/covid-19-updates-and-resources/ are available for you to use on an individual case by case basis.
An article by the well known palliative care doctor and author, Dr Rachel Clarke, was published in Wednesday’s Guardian and articulates beautifully the reality of our intentions which you may wish to share: https://www.theguardian.com/commentisfree/2020/apr/08/do-not-resuscitate-orders-caused-panic-uk-truth
The Training Hub has an excellent link to some very brief (2-3 minute) YouTube videos on using ReSPECT: https://www.cambridgeshireandpeterboroughccg.nhs.uk/health-professionals/news-and-resources/respect/
EEAST, our local ambulance trust has confirmed that electronic signatures will be acceptable for DNACPR forms, whether they are completed remotely or completed on an alternative non-EEAST form (e.g. an Ardens template).
See attachment: EEAST Clinical Update
Oxygen in Non-Palliative Discharges
It is becoming clear that oxygen does not have an active role in EOL management of Covid, but its use is increasing in those patients who are being discharged back into the community under our care. Cylinders are not as useful as concentrators, if in doubt liaise with the community team. Ordering is online through the BOC portal and can be delivered within 4 hours, if needed.
The CPFT community respiratory team has been reconfigured and the on call respiratory clinician can now be accessed seven days a week, 8am-8pm on 07790 571092. Please click this link for the relevant information you will need: www.cptraininghub.nhs.uk/Covid-19-respiratory/
It has come to our attention that patients attending some acute sites for urgent XR imaging are facing difficulties accessing the sites. Please write ‘URGENT’ on all urgent requests and consider sending your patient an SMS message to show as ‘proof’ on arrival
Covid-19 Testing for staff and patients alike is proving to be glacial, and there is a national criteria to follow starting with frontline staff in ICUs and critical care. Carol Anderson, the CCG’s director of quality, patient safety and experience will be co-ordinating the CCG response and we will work closely with her and we will let you know when there is more information to share
Our Cambs LMC Pastoral Support Team is available should any of you wish to use it to debrief or sense-check some difficult scenarios faced at this time, not just for those of us facing professional or personal challenges. Email email@example.com with Pastoral Support your subject header.
We are also aware that our colleagues at the Practitioner Health have set up a website for doctors who need space to reflect, connect, or share with like-minds:
The NHS is also launching a hotline to support and advise all staff during the pandemic, with volunteers staffing the service from charities and hospices. The phone line will be open every day from 0700-2300, with a 24/7 SMS service. See: http://www.people.nhs.uk call 0300 131 7000 or text FRONTLINE to 85258 for 24/7 support via text.
Wishing you all a Happy Easter, and we hope you get an opportunity to sit in the Spring sunshine at some point. I will be manning the phones and keeping an eye on the inbox on Good Friday, and Diana will be doing the same on Easter Monday.
In the meantime, keep safe, keep well
Dr Katie Bramall-Stainer
CEO, Cambs LMC
Tel: 01954 268156
Email firstname.lastname@example.org on Mondays when I am in surgery.