This article was updated on 30 November to include details of the COVID-19 vaccine programme, on 27 November to include details of updated advice for shielded patients and on 20 November to include the SOP for pulse oximertry @home, and details of CVD prevention guidance
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 11 August)
- 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 deceased 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.
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
The latest information relating to the England-wide lockdown from 5 November is here.
Information on the tier system being introduced from 2 December is here.
NHS England has published details of the indicative enhanced service specification for delivering the COVID-19 vaccination programme, which could begin as early as December. GPonline has summarised the key points here. Alongside the enhanced service, NHS England has announced £150m of funding to expand capacity in general practice between now and March 2021.
- All information relating to the enhanced service and delivery of the COVID-19 vaccination programme is on NHS England's website here.
- Information for healthcare professionals about the vaccination programme from Public Health England is here.
- A provisional chapter of the Green Book on COVID-19 vaccination is here - this guidance will be confirmed when the MHRA publishes final advice on the priority list and has fully assessed the vaccines.
- PHE has also published training recommendations for COVID-19 vaccinators here. The training programme on e-Learning for Healthcare is here. A vaccinator competency assessment tool is here.
The BMA and RCGP published updated guidance on workload prioritisation in November. This is based on a six-tier response level framework, which depends on the prevalence of COVID-19 in a particular area. You can find the response levels here. The BMA and RCGP also refer to guidance from the first wave of the pandemic on workload prioritisation, which practices may find useful.
The latest standard operating procedure (which is dated early August) says that practices should be 'focused on the restoration of routine chronic condition management and prevention wherever possible, including vaccination, screening and immunisation, contraception and health checks'.
The latest standard operating procedure advises:
- Practices should restore activity to usual levels where clinically appropriate, and reach out proactively to clinically vulnerable patients and those whose care may have been delayed
- Practices should be open for the delivery of face to face care, whilst triaging patients remotely in advance wherever possible.
- An online consultation system is in place to support total triage.
- Remote consultations should be used when appropriate, making reasonable adjustments for specific groups when necessary.
- Video consultation capability should be available and offered to patients when appropriate.
- Patients should have clear information about the new ways of working and how to access GP services; this information should be made available in accessible formats to all patients,
- Practices should work together to safely separate patients with COVID-19 or symptoms of COVID-19 from the wider population. Staff should be allocated to either patients with symptoms of COVID-19 or other patient groups, where possible.
- Communal areas in practices should allow for physical distancing and practices have been advised to follow HSE guidance on making your workplace COVID-secure.
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'. They should also 'use careful appointment planning to minimise waiting times and maintain social distancing in waiting areas'.
Guidance on the QOF confirms that just over half of the 567 QOF points available in 2020/21 will be income protected as part of changes introduced as a result of the COVID-19 pandemic. The number QOF points available for the flu and cervical screening indicators will double to 58 and practices will continue to be paid based on performance. Practices will also be expected to continue work on the QOF's prescribing indicators (worth 44 points) and maintaining disease registers (worth 81 points).
Practices will also be paid based on performance for this year's quality improvement modules, which cover learning disabilities and early cancer diagnosis and are worth 37 points each.
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.
Patients who are not experiencing symptoms but who have had a positive test should self isolate for 10 days. If they develop symptoms in this time they should continue to isolate until 10 days after their symptoms develop.
Any family/household members of any person displaying symptoms or with a positive test result should stay at home for 14 days. If they become ill they need to isolate for 10 days from when their symptoms started.
Details on how to access testing is here. Anyone who has a positive test result should self isolate for 10 days. If they are asymptomatic but then later develop symptoms they should self isolate for 10 days from the onset of symptoms.
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.
Details of how practices can order PPE from the central PPE portal is here.
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.
The operating procedure says practices should 'make nominal appointment sessions available for NHS 111 and CCAS. This will act like a prioritisation list, which may result in a number of different outcomes, including remote management, future follow-up or a face-to-face assessment, which may be at the practice or an alternative local service'.
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.
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 also published guidance on the use of pulse oximetry in the community to monitor symptoms. This is here.
All CCGs have been advised to set up a a pulse oximetry @home service. The standard operating procedure for this is here.
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.
- Guidance on principles of safe video consulting in general practice during the pandemic has been produced by the RCGP and NHS England.
- The BMA has advice on remote consultations and homeworking here.
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.
A letter from NHS England here gives examples of good practice in risk assessment.
As a result of the end of shielding staff who were shielding can return to work, but only if they cannot work from home and their workplace is COVID-secure. If staff can continue to work from home, then they should do so. The BMA is updating its guidance for doctors who have been shielding here.
There is also advice on supporting members of staff who were shielding to return to work here. This also includes advice for individual members of staff.
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. Practices should also consider allocating a separate toilet for patients with COVID-19 symptoms if possible.
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. Any healthcare professional who visits the patient should consider whether they can perform duties of other team members to avoid multiple visits.
Practices should ensure that home visit bags have necessary PPE and clinical waste bags.
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 college has also produced some useful guidance on assessing children and young people with COVID-19 symptoms here. Meanwhile the RCGP has advice on caring for specific patient groups during the pandemic here and managing COVID-19 alongside specific clinical conditions 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.
The Royal College of Obstetrics and Gynaecology (RCOG), Royal College of Midwives, Royal College of Paediatrics and Child Health, Public Health England and Public Health Scotland have produced guidance on COVID-19 in pregnancy, which is regularly update. This can be found here. The RCOG has also produced useful information and FAQs for pregnant woment here.
The Primary Care Cardiovascular Society has produced guidance for primary care teams on CVD prevention during the pandemic, which is 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.
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.
Guidance in light of the lockdown in England which begins on 5 November is here. Updated guidance to reflect the return to the tiered system of local restrictions when the lockdown ends on 2 December is here. This updated guidance also provides advice for shielded patients on 'Christmas bubbles'.
A full list of the conditions covered by the shielded guidance is here.
All patients on the shielded list will receive a letter from the government explaining what the guidance means and the support that is on offer each time the guidance changes.
Patients on the list are expected to stay at home as much as possible, but are encouraged to go outside for exercise and to attend healthcare appointments. Those requiring extra support are dvised to contact NHS Volunteer Responders (details here), or register for support from their council by using an online service on the government website here.
GPs are also expected to maintain the shielded patient list.
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.
- 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 careful about social distancing.
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.
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.
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).