Coronavirus: Key guidance GPs need to know about COVID-19

GPonline provides an overview of the key guidance relating to coronavirus, including links to relevant resources. Last updated: 17 February at 09.50.

(Photo: SOPA Images/Getty Images)
(Photo: SOPA Images/Getty Images)

This article was updated on 17 February to add details about changes to shielding following the introduction of the QCovid model and to add information on the next stage of the vaccination programme and on 12 February to add new guidance on complaints.

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:

Main guidance for primary care

Key guidance GPs in England need to be aware of are:

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

Lockdown and COVID-19 restrictions

Information on the third national lockdown in England that came into force on 5 January is here.

COVID-19 vaccination programme

Shielding

Clinically extremely vulnerable people have been advised to shield again following the introduction of England's lockdown on 5 January. The government's advice on shielding is here. Patients will have access to local support and statuory sick pay if they are unable to work from home. Patients can still go outside for exercise. On 6 February shielding patients were advised that they should continue to shield until the end of March.

A full list of the conditions covered by the shielded guidance is here.

Those requiring extra support are advised 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 most children on the list who are managed in primary care no longer need to shield.

QCovid
On 16 February the government announced that a further 1.7m people would be added to the shielding list following the development of the QCovid tool by researchers. The tool establishes who is at high risk from COVID based on their individual circumstances. This will be done centrally and patients affected will be sent a letter. Around 800,000 of these people have yet to have the vaccine and should be invited for their jab at the top of cohort 6.

The letter to GPs explaining these changes is here. Further information about the QCovid model and how it was developed is here.

NHS Digital has also created a COVID-19 Clinical Risk Assessment Tool, based on the QCovid model, which allows clinicians to assess and individual patient's risk from COVID. Full details on how to use the tool are here.

Workload, routine work and access

The BMA and RCGP published updated guidance on workload prioritisation on 11 January. This is based on a six-tier response level framework, which depends on the prevalence of COVID-19 in a particular area. At present the BMA and RCGP are advising that most practices are operating at a level where a significant volume of, or all, non-essential work has stopped to focus on the pandemic.

The guidance also includes a red. amber, green list of general practice work, covering high priority, medium priority and low priority work, to help practices decide what work can be stopped.

A letter from NHS England on 7 January set out the income protection measures and steps that would be taken to reduce practice workload to help GPs and their teams focus on the vaccination programme. While around half of the QOF was suspsended earlier in the year, the letter confirms that the rest of the QOF for 2020/21 will now be income protected and that appraisals can also be deferred.

Referrals

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 10 days (the self isolation period for close contacts of confirmed cases was changed from 14 to 10 days on 14 December). If they become ill they need to isolate for 10 days from when their symptoms started.

Testing

Details on how patients can access testing is here.

Test and trace strategy

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 10 days from when they last saw the individual who tested positive.

COVID-19 app

Full details of the COVID-19 app are here. Guidance for healthcare workers on using the app is here.

PPE

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 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.

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.

Pulse oximetry

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.

Remote consultations and homeworking

NHS England has said that all care that can be done remotely should be done this way.

Risk assessments

All staff should be risk assessed to identify those at increased risk of COVID-19.

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.

Shielding staff

Shielding has been re-introduced across England in light of the latest lockdown. If staff can continue to work from home, then they should do so. Staff who have been advised to shield should not come to work. The BMA has updated its guidance for doctors who have been shielding here.

Patient information

Patient information posters are available here.

Isolation space

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.

The RCGP has a guide to setting up an isolation room here

Home visits

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.

Clinical guidance

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:

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.

Volunteers

There is further information for clinicians on the use of volunteers here. Clinicians can request volunteer support for their patients here.

Changes to death certification

Updated guidance on death certification is available here.

The MDU has answered key questions about death certification on GPonline here. The RCGP has also produced a learning module on changes to death certification, which you can access here.

Death verification during the pandemic

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.

Information governance

NHS X, formerly NHS Digital, has produced guidance on information governance during the coronavirus outbreak here. An example supplementary privacy notice to explain how data could be used in the pandemic is here.

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.

Patient registration

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.

Business continuity

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).

Complaints

NHS England has produced a new FAQs on NHS complaints for providers and patients. The guidance follows an announcement at the start of February 2021 that NHS providers may take longer than usual to investigate and respond to complaints during the pandemic, in order to allow them to concentrate on frontline care and the vaccination programme roll out.

The FAQs for providers are here. The FAQs for patients are here.

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