NHS England has issued guidance to practices detailing how GPs can manage essential face-to-face consultations during the coronavirus pandemic.
Although practices have shifted rapidly as the outbreak developed to a total triage model, with all patients screened before coming into contact with a doctor and the vast majority of consultations now delivered remotely, NHS England advice highlights that 'it may be clinically necessary to come into direct contact with patients, for example, those identified most at risk'.
This could be at the patient's home, at a GP practice, a local hub or in another community setting. Advice is clear that GPs in each area will need to work out what model suits them best, but NHS England suggests hot sites can operate in a 'zone' within a practice or from a designated specific site covering a local area,
GP hot sites
Stoke-on-Trent was one of the first places in the country to see the opening of a COVID-19 hot clinic thanks to the North Staffordshire GP Federation. A group of over 70 practices, they have already recruited 18 doctors to work at the site - allowing patients with underlying health concerns to be assessed and treated for coronavirus symptoms.
Federation chair Dr Chandra Kanneganti explained why the federation first looked into opening a hot site. He said: ‘We thought there was a gap in services, with practices unable to [safely] see patients who had COVID-19 symptoms and were self-isolating. This meant that patients were not getting the care they needed.
‘Even with video consultations, GPs were finding it difficult [and didn’t] understand the criteria for seeing people who had COVID-19 symptoms while having other medical symptoms. So, that's the reason why we started this.’
Joint clinical director of the federation Dr Malai Veerappan said the main idea behind the hot site was to ‘limit face-to-face’ contact between doctor and patient. He said: ‘What happens is that a patient rings up their own GP surgery, who will try and solve the problem by video or telephone consultation.
‘But if the doctor feels like they can't solve the issue remotely and they believe the patient needs a face-to-face consultation, they will [use the] federation’s EMIS system and put them into the COVID-19 Triage Clinic.
Dr Veerappan stressed that this did not automatically qualify them for a face-to-face consultation. ‘A senior clinician from the federation will then triage them and try to solve the problem using an algorithm - they can finish the session with a phone or video consultation. But if they can't deal with that, they will then organise a face-to-face consultation.'
Patients are given an appointment time and are told how to enter the site. They are given protective equipment to wear during the consultation, protecting both themselves and practice staff.
Last week Public Health England (PHE) updated guidance, instructing GPs to wear eye protection when providing direct care for a patient with confirmed or suspected COVID-19 infection.
Dr Veerappan said the federation supplied doctors with visors from the off, identifying that clinicians working on the hot site were at risk of being exposed to ‘higher viral loads’. ‘We kind of sourced our own visors, sort of making them from the backyard. We bought acrylic and applied velcro to make our own visors,’ he said.
This is what he was wearing. pic.twitter.com/Rqzd3iF9kt— Dr. Chandra Kanneganti #stayhomesavelives (@doctorcm9) March 31, 2020
At present, the hot site receives close to 50 referrals each day, with around 18 going through to face-to-face consultations after triage. The federation leaders said they expected to have ‘a significantly higher’ number of patients this week, but they were ready.
‘We've ramped up our capacity to increase up to three and a half times [this] week, so we can increase face-to-face consultation up to about 50 patients a day. We have the goodwill from the clinicians, so we can expand in a short span of time - we are going to assess this every 24 hours.’
Localised hot site
Surrey GP Dr Dave Triska is currently involved in three hot site projects across his area, including one at CCG level and another in his own practice. However, the most developed of the three is the localised hot site set up by his primary care network, West of Waverly PCN.
Using a space within the community hospital in the network, Dr Triska says the network has been able to run afternoon sessions for those with suspected COVID-19.
‘There is a dedicated entrance for the patient [when they arrive] which leads through to a room with a phone system. This allows them to communicate with a clinician who is based in a separate room, but there is a screen.
‘Most of the consultation is done like this, with the doctor and patient in different rooms. It's only really at the last minute where you finish the consultation and you need to do the exam that you come into the same room.'
Dr Triska explained that patients would only be called for a face-to-face examination when doctors needed to carry out a physical assessment, for example a chest auscultation or an abdominal exam. But he said that the PCN had managed to keep this number to just four a day thanks to a strong focus on remote consulting.
‘We try and do as much remote examination as possible, so it's really reducing risk to patients and clinicians by people who don't need to come in for an examination, they're being dealt with remotely,’ he said.
Dr Triska revealed that plans for the localised hot site had been based on a hospital in Italy, where no members of staff had contracted the virus. He said it focuses around using barrier methods to minimise contact, wearing ‘all the proper protective equipment’ and scrubbing down between patients.
Despite basing their hot site on a successful model, Dr Triska said his PCN was ploughing ahead with plans to further protect patients and staff. ‘We're moving towards having a "no touch" hub,’ he said.
‘Essentially this is where patients use digital monitoring equipment to examine themselves - it’s like a barrier system where there’s a remote examination pod where the GP is next door.
‘As of this week we're going to have a remote stethoscope which you don't need to be in the same room to use. So the patient will put it on their chest and it will transmit across to a set of headphones or bluetooth speaker used by the clinician,’ he added.
Although Dr Triska said the service had been relatively quiet up until now, he stressed it was important that sites were ready and waiting for patients.
‘The thing is you have to set these things up before you need them. You can't do this on the fly as everything's falling apart - your function as a health system is to make contingency plans for that happening.
‘Ideally I'd like them empty, so they just sit there as a contingency. But the contingencies are things like, what happens if the hospital gets overrun or what happens if practices start to close because staff members get sick?’