Deep cleans and concerning NHS 111 referrals: our practice's Covid-19 experience
Dr Jane Wheatley and Dr Shivangi Thakore
England’s chief medical officer, Professor Chris Whitty, stated last Thursday (5 March) that we've 'moved from a situation where we're mainly in contain, with some delay built in, to we're now mainly in the 'delay’, referring to the Government’s Covid-19 strategy of contain, delay, research and mitigate. Monday’s Cobra meeting resulted in the UK remaining in the contain phase.
In primary care, we’ve understood and been broadly supportive of the strategy, which combines scientific evidence with common sense, encompassing economic considerations and optimal timing for interventions. We welcomed Dr Nikita Kanani’s letter that announced the supply of personal protective equipment (PPE) to all GP surgeries from 9 March.
However – and critically - this support came too late.
GPs have expressed their concerns about the lack of PPE for for four weeks. We’ve struggled to procure our own PPE and, when we’ve requested vital support, we’ve been passed between Public Health England (PHE), NHS England and CCGs. We’ve expressed how, in an era when the public en masse can purchase healthcare equipment online, and when Chinese factories are closing, there’s no place for delayed decisions. Stock shortages of PPE were predictable. Certainly, for at least a week, now community transmission of Covid-19 has become established and primary care clinicians have been left seeing patients with respiratory tract symptoms without PPE. Experience in other countries and previous pandemics tell us that healthcare professionals play a significant role in transmission.
Over the last fortnight, our team of GPs has seen countless patients who have symptoms consistent with Covid-19. Most haven’t had category 1 or 2 travel (based on PHE’s categories) to a risk area, nor any known personal contact with someone who has or has been diagnosed with the virus. However, we’ve felt for weeks now that negative travel or contact history doesn’t mean that the patient has no risk of Covid-19. Community transmission in the UK was only a matter of time.
Government strategy up until now has attempted to divert the highest risk patients away from primary care, but there’s no strategy to divert all patients with the possible symptoms. Our team of GPs has seen such patients as part of our duty of care, but – at risk to ourselves and the wider community - without any protective equipment.
Patients ask us for reassurance, but we’re unable to give it. There’s established community transmission, and absence of widespread access to swabbing, so Covid-19 remains a possible diagnosis for all patients with relevant symptoms. As it stands, NHS 111 has been asking seemingly low-risk patients to contact their GP practice. Last week, a local primary school emailed parents of its pupils to say that a parent had tested positive.
Another parent at the school who had received its email rang our duty doctor to say that they had a child who had been unwell for a week with a temperature and dry cough but had no history of travel to any of the high-risk areas; and that on ringing 111 they’d been advised that the child should see a GP.
After three phone calls with PHE, it was decided not to see the child in our surgery, and that our duty doctor would review the child again by phone. Another patient had a temperature and dry cough, no recent history of travel to affected areas, but had been in touch with two people who had been to a category 1 region. Again, he worried about infecting family members and wanted a test. He had been booked in by 111 to see a GP.
We can’t rationalise our practice needing a deep clean on one hand, and symptomatic close contacts of our colleagues not being tested, on the other
We feel that all patients presenting to 111 with mild and safe respiratory tract symptoms should be asked to self-isolate until better, and that the low Covid-19 risk patients shouldn’t be directed/directly booked in to seek medical attention from primary care services, and should be reminded that GPs have no access to swabbing as things stand.
Two weeks ago, one of our receptionists told us that her younger brother had become unwell after returning from a school skiing trip to Italy (category 2), as had several of his friends, one of whom was tested. He was told initially by 111 that he didn’t need testing. We followed the Government guidance for healthcare professionals at potential risk, and, based upon this, didn’t recommend self-isolation for our receptionist. So she continued to work.
Later in the week, we became increasingly anxious given that her brother’s symptoms weren’t abating and called PHE. We were told to send her home immediately and deep-clean the practice. This information was verified by the local specialist Covid-19 infectious diseases team. We managed to organise overnight deep cleaning, so as not to have to close the practice, and anxiously awaited news on swab results, considering that the entire team had had contact with her. Both she and her brother contacted 111 again - after a few days of waiting for call backs, neither were tested. We can’t rationalise needing a deep clean on one hand, and her brother not being swabbed on the other.
We’ve struggled with deciphering and managing the seemingly conflicting information given by PHE and 111. It’s incurred a heavy time cost, restricting our ability to practice - several GPs have had to dedicate time to strategic planning and lengthy phone calls to PHE, 111 and local infectious diseases specialists.
We’ve invested considerable time and effort to consider how best to minimise the risk of a carrier entering our practice. We’ve followed official guidance at every stage, but late last week decided to take steps ahead on the basis that the current advice is inadequate. We’re now asking all patients about the nature of their appointment request. Anyone consulting us about a possible respiratory tract infection will be managed initially over the phone.
All patients, irrespective of the nature of their request, are to be asked whether they have fever, or dry cough, or feel out of breath at the point of booking, and again if they arrive at the surgery in person. If they confirm respiratory symptoms consistent with Covid-19, they’ll be asked to go home and await a phone consultation.
We strongly believe, based on scientific evidence and our experiences, that the risk has gone past the point of travel and contact histories. We’re going to ask patients who do need to be examined, and who are low risk (but of course as already outlined not no risk), to wait in an isolation room, where they’ll be seen using equipment dedicated to that room, and a clinician wearing PPE once we receive it. We have a duty of care to all of our patients and staff.
Practices wouldn’t cope if staff had to self-isolate. We’re adept at using telephone consultations, and will increase this way of consulting. Dr Kanani’s letter suggests making digital platforms more widely available and this is an avenue we will be pursuing. We believe that questions remain regarding the wisdom of requesting well patients to enter the surgery for health screening and chronic disease checks given that this is a potentially infectious environment, but as yet haven’t been directed to stop our work. We’ve altered how we conduct our weekly visits to nursing homes, given we may be Covid-19 carriers from our work in the surgery.
We feel that much earlier delivery of PPE, and a policy directing and supporting GP practices to implement full appointment triage when complete containment (no community transmission) was first deemed no longer possible would have been prudent at a much earlier date. Specifically, 28 February, the date when the first case of community transmission was announced in the media.
We’re the gatekeepers of the NHS and historically our systems have allowed unmanaged and open access to us. As things stand, in the absence of such policy, each practice needs to consider how best to manage the current risk in line with and ahead of Government guidelines. We mustn’t underestimate the value of our own on the ground knowledge in a fast-evolving situation where national policies, guidelines and actions may not keep pace. We’re the eyes and ears of the NHS in the communities in which we work.
Dr Jane Wheatley and Dr Shivangi Thakore are an associate GP and GP partner in North London respectively