The latest standard operating procedure for general practice sets out the role NHS 111 will play and how it will link into GP practices during the pandemic. NHS England will also imminently be publishing a new standard operating procedure to fully explain this aspect of its response to the COVID-19 outbreak.
Patients with symptoms of COVID-19 should be directed to NHS 111 online as a first point of access. If a patient calls NHS 111, call handlers should now be traiging patients into three cohorts:
- Cohort 1 - those with severe symptoms who require urgent hospital admission
- Cohort 2 - those who require further clinical assessment.
- Cohort 3 - those with mild symptoms who will be provided with self-care advice and told to contact NHS 111 if symptoms worsen. Practices should receive a post-event message about these patients.
COVID-19 Clinical Assessment Service
Patients in cohort 2 will be referred to a new COVID-19 Clinical Assessment Service (CCAS) for a remote consultation. The service will be staffed by clinicians, including retired GPs who have returned to work and current working GPs who have dedicated time to the service during the pandemic. NHS England has reassured GPs that all staff triaging patients in the CCAS are clincians.
Following this assessment they could be reclassified as cohort 1 or 3, or they could be referred to their GP for either telephone monitoring or a possible face-to-face appointment.
These patients will be booked into practices using the GP Connect system, but they will not be given a specific appointment time. Practices will be expected to triage these cases and then contact the patient to arrange further care based on local systems.
NHS England has been encouraging GPs currently on the performer's list who can offer some of their current time in practice, or additional time for which they would be paid, to work for the service. NHS England has acknowledged that some GPs have encountered problems when attempting to sign up to work for the service, but said the process has been streamlined which should help address this.
Making appointments available to NHS 111
The GP contract has been amended to require practices to make 1 appointment for every 500 registered patients available for NHS 111 to book into between 30 March 2020 and 30 June 2020. This is a change from the 1 appointment for every 3,000 patients practices originally had to make available under the contract.
The changes to the contract also leave scope for the amount of appointments practices have to make available to increase. 'In some cases, this could extend to the whole appointment book', NHS England guidance to GP practices has said.
However, NHS England has stressed that the NHS 111 appointments during the pandemic will work differently to those before the coronavirus outbreak.
During a webinar this week, NHS England director of primary care strategy Ed Waller said: 'These are not the same appointments in form and feel as the one's you're used to allowing NHS 111 to book into. These are simply a way of transferring patients who need contact from their GP into the workflow of GPs in practice. They are not booking people into specific time slots with any expectation that they will turn up in the surgery.'
Practices will be expected to look at the patient's details and then arrange a phone or video consultation to provide advice.
During the same webinar, GP Dr Massood Nazir, director of digital primary care at NHSX, stressed that it was important to look at this as a whole system approach.
He said: 'A lot of patients who would have contacted our surgeries are contacting 111 either by phone or online. Those patients are being assessed and if it's appropriate they are going into an ambulance and in many, many cases simple advice is being given when they are asked to remain at home and self isolate. There's a smaller group in the middle who need a clinical assessment.
'We can reassure you that these patients are being assessed by a clinician and, even in that group, some people will need emergency attendance and some will be able to self care. A smaller number, where the practice knows them better and are able to assess them, are booked into the practice.'
Dr Nazir assured GPs that the clinical assessment by CCAS 'makes all the difference'. 'If there was no clinical assessment you might see a different impact of this programme,' he added.
He also explained that the 1 appointment per 500 patients figure was set because NHS England 'had to start somewhere' and there was no 'absolute formula' to determine what demand would be.
'My own practice has 26,000 patients and 52 slots we need to offer and on most days there aren't any patents,' Dr Nazir said. 'Most of our patients are either making contact with us, or the ones that contact 111 go through the system and don't need to come back to us at all.
'On some occasions they may do. But we had to start [with the 1 appointment per 500 patients] because we don't know the volume for any single practice at any time at all. The main thing is to make slots available so that you can assess patients because you know them better.'
NHS England primary care medical director Dr Nikki Kanani added that the plan was about 'trying to get the system working in a more joined-up way'.
What else do GPs need to know?
GPs have been asked to 'avoid redirecting patients to NHS 111' if they contact the practice because they can't get through to NHS 111 or if NHS 111 has directed them to their surgery. The latest standard operating procedure said: 'The risk of patients becoming stuck in a loop between NHS 111 and general practice poses significant risk to unwell patients.'