This article was updated on 5 June to include additional advice on shielded patients and to add a link to a new guide on safe video consultations and on 1 June to link of the latest operating procedure; the 'Workload' section and some other sections below have been updated as a result of the new SOP.
This article is based on guidance for England, please see links below for specific guidance for Wales, Scotland and Northern Ireland. Information relating to infection control and much of the information aimed at the public is relevant in all four UK countries:
- Health Protection Scotland guidance for primary care
- Public Health Wales latest information
- Public Health Agency Northern Ireland latest information
Main guidance for primary care
Key guidance GPs in England need to be aware of are:
- NHS England's COVID-19 latest standard operating procedure for general practice (dated 29 May)
- Public Health England's PPE hub
- Public Health England's infection control guidance
- The RCGP is regularly updating guidance for GP practices - more information here.
- GPs in England can also find links to all relevant guidance for primary care on coronavirus on NHS England's website here.
- There is also specific guidance on care of the deceseased with a confirmed or suspected case of COVID-19 here.
NHS England says all practice staff should be made aware of the standard operating procedure, the latest case definitions and guidance on patients at most risk of severe illness as a result of COVID-19, including those advised to shield themselves and other at-risk groups.
The latest operating procedure says that staff, including home visiting staff, should be allocated to either patients with symptoms of COVID-19, or other groups of patients, where possible. Any urgent updates to practices will be provided by the central alerting system (CAS), so practices should ensure the MHRA has an up to date email address that is regularly checked by staff
Guidance from NHS England on 19 March detailed the routine work that practices could suspend in the pandemic and the income protection measures that will be implemented.
A letter to practices on 14 April confirmed the contractual changes that have been made.
Practices should ensure patients have clear information on how to access primary care services and are confident about making appointments (virtual or if appropriate, face-to-face) for current concerns. They should also complete work on implementing digital and video consultations.
Practices are expected to deliver as much routine and preventive work as can be provided safely including vaccinations and screening. The second phase response letter advised practices to 'stratify and proactively contact their high-risk patients with ongoing care needs, to ensure appropriate ongoing care and support plans are delivered through multidisciplinary teams' to mitigate the impact of a reduction in face-to-face patient contacts.
The latest standard operating procedure advises that practices should assess where care has been delayed over recent weeks and now needs to be restarted. It adds: 'as capacity allows, general practice teams should:
- proactively address health needs that may have gone unmet, increased or developed during the pandemic, including health inequalities and mental health issues
- accommodate changes in how patients want to seek healthcareincluding supporting patients with self-care and self-management.'
Practices have been told to increase support for at-risk patients and deliver weekly 'virtual care home rounds' under this second-phase. 'Key elements' of the enhanced health in care homes service specification of the primary care network (PCN) DES have been brought forward to May in order to support care homes. Full details on what is expected from practices and PCNs is here.
The NHS second phases response letter repeats advice for GPs to 'make two-week wait cancer, urgent and routine referrals to secondary care as normal' - and warns hospitals that in addition to restoring urgent and non-urgent procedures, 'referrals, diagnostics (including direct access diagnostics available to GPs) and treatment must be brought back to pre-pandemic levels at the earliest opportunity to minimise potential harm, and to reduce the scale of the postpandemic surge in demand'.
The latest standard operating procedure advises GPs should refer patients 'as usual and as appropriate'.
Symptoms and suspected cases
Fever, cough or chest tightness, and dyspnoea are the main symptoms reported by affected patients.
The latest case definition guidance is here.
Anyone with a continuous cough, fever over 37.8C or anosmia has been advised to self isolate for seven days. Those who remain unwell after seven days should contact NHS 111 online. The four UK chief medical officers added anosmia (loss of taste or smell) to the list of symptoms on 18 May.
Any family/household members of any person displaying symptoms, however mild, should stay at home for 14 days. The person who is symptomatic can end their isolation period after seven days, but all other household members should remain at home until 14 days after the first person became ill, or seven days if they become ill.
- Stay at home: Guidance for people with confirmed or possible COVID-19
- Stay at home: Guidance for households with possible coronavirus infection
Details on how to access testing is here. As of 28 May any symptomatic person in England can access testing, including children under 5.
The government has introduced a test and trace strategy in England as of 28 May, a similar scheme is in operation in Scotland and Northern Ireland and is due to be introduced in Wales shortly.
Patients who receive a positive coronavirus test will be contacted by NHS Test and Trace, a new service, and asked to provide details of anyone they have been in close contact with in recent days. These people will then be contacted by the service and asked to self-isolate for 14 days from when they last saw the individual who tested positive.
Public Health England's PPE hub is here, which includes recommended PPE for primary care.
Advice, and links to videos, on donning and doffing PPE is here.
Triaging patients and appointments
All patients should be triaged either by phone or online before deciding whether they should have a face-to-face appointment. They should be advised to inform staff if they develop symptoms of COVID-19 between triage and attending for a face-to-face appointment. Online bookings should be for telephone or online appointments only.
The latest standard operating procedure advises that all face to face consultations should involve strict infection control procedures.
Practices should also minimise the number of face-to-face contacts that a patient requires 'by co-ordinating care so that as much as possible is done in a single consultation', the operating procedure advises. They should also 'use careful appointment planning to minimise waiting times and maintain social distancing in waiting areas'.
The role of NHS 111
People with suspected early symptoms of coronavirus are being directed to an NHS online advice centre here: www.nhs.uk/coronavirus. Patients can also now obtain a 'self isolation' note if they need to isolate for 14 days online from NHS 111.
According to the latest standard operating procedure the Covid Clinical Assessment Service (CCAS), which is staffed by doctors, will support NHS 111 and in some cases may refer patients back to their practice for a remote or face-to-face assessment (see the operating prcedure for more details including a visual algorithm of how the system should work).
Practices should avoid redirecting patients to NHS 111 if they present in general practice because they can't get through to NHS 111 or beause NHS 111 has directed them to their practice. 'The risk of patients becoming stuck in a loop between NHS 111 and general practice poses a significant risk to unwell patients,' the operating procedure says.
Practices are now contractually required to increase the minimum number of appointments they make available for 111 direct booking until 30 June 2020 to 1 appointment per 500 patients. Although NHS England has recently said that practices can reduce the amount of appointments they make available, providing they keep them under review and increase availability should demand rise.
Patients with symptoms of COVID-19
The standard operating procecdure highlights this BMJ article for guidance on remote assessment and management of patients with symptoms of COVID-19
The operating procedure also includes guidance on seeing possible COVID-19 cases. It says most patients with symptoms can be assessed and managed remotely.
When face-to-face assessment is required this should be done according to the local operating model, which may be via designated sites (either within the practice or as a separate location or 'hot hub'), or home visiting. The CQC may need to be informed about some changes to services. Advice on this from the CQC Is here.
The operating procedure recommends that local areas/practices should allocate staff to patients with symptoms of COVID-19 or other groups, where possible. This should also apply to home visiting teams. However the guidance acknowledges that this may be difficult in some areas.
Staff should wear the currently advised PPE for a possible case of COVID-19 and all PPE should be disposed of as clinical waste.
If a patient is critically ill and requires an ambulance transfer to hospital, the call handler should be informed of the concerns about coronavirus. Any other transfer to secondary care should be discussed with the hospital first.
For guidance on when to consider hospital admission for COVID-19 see NICE's guidance here.
For any face-to-face assessment of a patient living with someone with symptoms of COVID-19, even if the patient does not themselves have symptoms, practices should follow the pathways for patients with symptoms of COVID-19.
NHS England has said that all care that can be done remotely should be done this way.
- NHS England has produced guidance on how to establish a remote 'total triage' model in general practice here. It has also produced guidance for GP practices on remote working here.
- The University of Oxford has produced new guidance on undertaking video consultations in general practice here.
- The BMA has advice on remote consultations and homeworking here.
- New guidance around the principles of safe video consulting in general practice during the pandemic has been produced by the RCGP and NHS England.
All staff should be risk assessed to identify those at increased risk of COVID-19. The Faculty of Occupational Medicine has published a Risk Reduction Framework for NHS staff (including BAME staff) who are at risk of COVID-19 infection here. NHS Employers has also published guidance on risk assessments for staff here.
Practices should display coronavirus patient information posters (which are available here) so that they can be seen before patients enter the surgery. They should also be visible in reception, waiting areas and at patient access points to clinical areas.
Practices should 'designate and prepare' a suitable isolation space, ensuring there is a phone in the room if possible. All clutter and non-essential furniture should be removed. If an isolation room is not possible, practices should identify an isolated area within the surgery that can be cordoned off, maintaining a two-metre space from other patients and staff. The latest standard operting procedure also advises practices to consider allocating a separate toilet for patients with COVID-19 symptoms if possible.
Patients attending the surgery
The following is taken from the latest standard operating procedure
- All patients should be asked if they have any of the symptoms of coronavirus when they attend the surgery.
- If they meet the case definition they should be asked if they feel able to cope at home and if so they should return home and follow the advice on self isolation.
- If no, they should be directed to an appropriate site, if it is easily accessible. If not the patient should be immediately isolated in the isolation room.
- If GPs suspect a patient of having coronavirus during a consultation they should leave the room, wash their hands and conduct the remainder of the consultation by phone if necessary. The patient's belongings should remain in the room.
- If face-to-face assessment is required staff should wear PPE and keep exposure to a minimum. All protective equipment should be disposed of as clinical waste.
After the patient has left the surgery
Cleaning and decontamination should be carried out in line with Public Health England guidance here. Full guidance on management and disposal of healthcare waste is here.
Guidance on home visits is also in the latest standard operating procedure. Remote triage for symptoms of COVID-19 should take place before the visit. If COVID-19 is supsected during a home visit a similar process should be followed as above – the GP should leave the room and conduct the remainder of the consultation via phone.
If symptoms are identified during a care home visit, the local health protection team should be informed.
Practices should ensure that home visit bags have necessary PPE and clinical waste bags in case a patient suspected of coronavirus requires emergency treatment during the visit.
COVID-19 case reporting
COVID-19 is a notifiable disease – PHE guidance on reporting notifiable diseases is here.
Suspected COVID-19 cases should be notified by general practice. Test-confirmed cases will be notified by the laboratory.
Advice on clinical coding for general practice is here.
NICE has produced a range of rapid guidelines in response to the COVID-19 outbreak, including on managing symptoms of COVID-19 in the community and advice on management of patients at risk of complications from the virus. The following are useful for GPs and their teams:
- COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community
- COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community
- COVID-19 rapid guideline: severe asthma
- COVID-19 rapid guideline: community-based care of people with COPD
- COVID-19 rapid guideline: cystic fibrosis
- COVID-19 rapid guideline: dermatological conditions treated with drugs affecting the immune response
The RCGP has also produced a guide to community palliative, end-of-life and bereavement care during the pandemic here.
The British Geriatric Society has a range of guidance on supporting older people with suspected or confirmed cases of COVID-19, including those with dementia, as well as advice on managing patients in care home and medicine advice. This can all be found here.
NHS England has written to patients at most risk from severe complications from COVID-19, asking them to stay at home and avoid face-to-face contact until the end of June at least. An announcement on 31 May said that shielded patients are now able to go outside and to meet one other person from another household, while maintaining social distancing.
The latest standard operating procedure says that all shielded patients should have proactive follow-up to ensure they know how to access care and support. Despite the relaxing of rules for shielded patients, the SOP says that patients who require a face-to-face assessment for any reason this should have a home visit. A separate home visiting service for these patients should be considered.
A letter setting out the support the NHS should provide to shielded patients (dated 4 June) advised that some care could be provided in clinical settings if it was not possible to do so at home. In such cases, practices should 'identify a safe location and ensure the patient has safe "door-to-door" transport.'
There is more advice on how GPs' role in supporting these patients here, including the full list of patients covered by the measures.
- NHS England guidance for GP practices - including template letters and letter dated 4 June.
- NHS Digital guidance on shielded patient lists
- NHS Digital guidance on patients who have self-referred
- Guidance for patients on shielding
Everyone in the UK has been advised to undertake social distancing measures. Anyone over 70, those with underlying health conditions and pregnant women have been advised to be particularly stringent about following these rules. The guidance below outlines which patients should be particularly mindful of the rules.
The government has issued new guidance on death verification during the pandemic. GPs can now verify deaths remotely.
The RCGP and BMA have produced this protocol to help GPs do this.
The CQC has guidance on when it should be notified of deaths related to COVID-19 here. An updated death notification form is here.
Pregnant healthcare staff
GPs who are pregnant should have the choice not to continue in patient-facing roles. Healthcare staff who are more than 28 weeks pregnant, or who are pregnant and have underlying health conditions, should avoid direct patient contact and work from home during the coronavirus outbreak, according to guidance here.
Women who are less than 28 weeks pregnant should can continue working in a patient-facing role if they choose to do so, 'provided the necessary precautions are taken'. Where possible, they should avoid caring for patients with suspected or confirmed coronavirus infection through using PPE and risk assessments.
NHS X, formerly NHS Digital, has produced guidance on information governance during the coronavirus outbreak here. It includes an example supplementary privacy notice to explain how data could be used in the pandemic.
More information on changes to data sharing in the pandemic is here.
Doctors forced to work 'outside their normal scope of practice' during the coronavirus outbreak will have that context taken into account if they face complaints. A joint statement from the GMC, NHS England and the UK's chief medical officers makes clear that while doctors are always expected to adhere to GMC principles and guidance, the difficult context in which they are working will be factored in if complaints arise.
Other key medico-legal questions are answered here.
NHS England and NHS Improvement have introduced an NHS-wide 'pause' on the NHS complaints process. Practices should continue to log complaints, triage them for patient safety or safeguarding issues and take action immediately if necessary. All complaints will then remain open unless an informal resolution is achieved or the complainant chooses to withdraw their complaint.
Terms and conditions of employment
The BMA has produced some useful advice on employment contract terms and conditions for different groups of doctors here. There is information for pregnant doctors in the first section that covers all doctors.
Practices should continue to register new patients, including those with no fixed address, asylum seekers and refugees (absence of photo identification and proof of address is not a reason to refuse registration).
Delivery of application may be by any means, including post and digital, including scanned copies.