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 some 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 24 June)
- 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. A letter to practices on 14 April confirmed the contractual changes that weren made.
A letter to practices on 9 July set out the broad plan for future changes to the GP contract in light of the pandemic. Practices have been asked to restart many of the services that they have suspended. They have also been told to prepare for a major expansion of the flu campaign, while much of the QOF will be suspended for the rest of this year. The quality improvement indicators will be changed, however, and practices will be paid according to achievements in these areas. The letter also set out some of the income protection measures that will be in place. However, full details of the COVID-19 relief fund has yet to be published.
The letter also says that 'digital consultation should be offered as standard unless there are good clinical reasons otherwise'.
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.
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 healthcare including 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'. 'Key elements' of the enhanced health in care homes service specification of the primary care network (PCN) DES have been brought forward in order to support care homes. Full details on what is expected from practices and PCNs is here.
The latest standard operating procedure advises GPs should refer patients 'as usual and as appropriate'.
It says that GPs may be asked to conduct extra tests in primary care when they refer patients with suspected of confirmed cancer in order to help prioritise cases, if they have access to these.
Practices have also been advised to implement effective safety netting for any patient presenting with symptoms that suggest cancer. However, the guidance also says that, after a patient has been referred, it is hospitals' responsibility to ensure they keep track of those whose assessment may be delayed.
Any decision by the hospital to downgrade an urgent referral continues to require consent from the GP who made the referral, the SOP adds.
Symptoms and suspected cases
Fever, cough or chest tightness, and dyspnoea are the main symptoms of COVID-19 reported by affected patients.
The latest case definition guidance is here.
Anyone with a continuous cough, fever over 37.8C or anosmia should self isolate for 10 days. Those who have had a positive test should also self isolate for 10 days from the onset of symptoms. Those who remain unwell after 10 days should contact NHS 111 online.
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. Anyone who has a positive test result should self isolate for 10 days from the onset of symptoms.
The government has introduced a test and trace strategy in England and similar schemes operate in the other UK countries.
Patients who receive a positive coronavirus test will be contacted by NHS Test and Trace 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 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 obtain a 'self isolation' note if they need to isolate for 14 days online from NHS 111.
NHS 111's Covid Clinical Assessment Service (CCAS), which is staffed by doctors, may refer patients back to their practice for a remote or face-to-face assessment (see the operating procedure 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 '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 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 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 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.
NHS England has also published guidance on the use of pulse oximetry in the community to monitor symptoms. This is 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.
The updated operating procedure says that all staff in the shielding group should not see patients face to face. All other staff including BAME staff and people identified as clinically vulnerable should be risk assessed to consider if they should see patients face to face.
Practices have been given until 22 July to complete risk assessments for all staff at potentially increased risk from COVID-19, including those from BAME groups. The letter setting out that deadline here gives examples of good practice in risk assessment.
Patient information posters are available here.
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. You can find all the guidance here, but the following are particularly 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
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.
Aftercare for COVID-19 in-patients
NHS England has published guidance for primary care and community services on the aftercare patients admitted to hospital with COVID-19 may require post discharge.
The guidance says that it is clear that for many patients the virus and the treatment required to combat it will have a lasting impact on their health. It describes the expected immediate and longer-term health needs of patients, focused on new conditions following an episode of COVID-19 and highlights actions to take.
Shielding ended completely on 1 August in England and Scotland and 31 July in Northern Ireland. However, in some parts of England that are subject to local lockdowns or other restrictions, shielding has been maintained and this is likely to be the case in other areas in future. GPs will need to follow local guidance on this issue.
People in Wales have been advised that they will no longer need to shield from 16 August.
GPs will be expected to maintain the shielded patient list in case there are requirements for restrictions to be reintroduced in future.
Guidance from the Royal College of Paediatrics and Child Health has said that that most children on the list who are managed in primary care no longer need to shield. GPs will be expected to remove these patients from the list, following discussions with patients and their parents/carers over the summer.
The chief medical officer and NHS England's medical director wrote to providers on 8 July providing guidance on maintaining the patient list and instructions on removing children from the list.
A letter from the chief medical officer and NHS England's medical director on 22 June includes a list of FAQs that patients may ask about changes to the shielding programme.
The latest standard operating procedure says that if possible care should be provided at home for these patients, ideally be remote or virtual means. A separate home visiting service for these patients should be considered for face-to-face appointments. If care needs to be provided in the practice this should involve strict infection control procedures and take place in a safe location.
- Guidance for patients on shielding
- NHS England guidance for GP practices
- NHS Digital guidance on shielded patient lists
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.
The latest SOP advises practices to ensure their business continuity plans are up to date. These should factor in local outbreak scenarios that could temporarily disrupt services.
'Plans should consider high levels of staff sickness and self-isolation, call handling, staff and patient communication and, ultimately, denial of access to premises for staff and patients,' the SOP says. Full details on what to do in the event of an outbreak are in this letter here (dated 9 June).