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The waiting game

NHS advises 'total triage' as GP groups look to limit patient demand

Exclusive NHS England has issued advice for practices to move to a 'total triage' services, as LMCs and CCGs are implementing radical changes to GP access.

An email sent by NHS England director of primary care Dr Nikita Kanani said that practices should start 'moving to TOTAL triage system (whether by phone or online)', as well as undertaking all care that can be done remotely through remote means. 

At the same time, LMCs and CCGs have been advising GPs to take other actions, including cancelling routine appointments and cancelling online bookings.

The email sent by Dr Kanani advised that when patients present as potential coronavirus cases, and are unwell, GPs should: 'Use PPE as per PHE guidance for possible cases i.e. gloves, apron, mask; isolate the patient; if acutely unwell treat; if not then ask them to ring 111 from the room and leave; decontaminate as per the SOP.'

She added: 'In the meantime, practices should start:

⁃ Moving to TOTAL triage system (whether by phone or online)

⁃ Undertaking all care that can be done REMOTELY through remote means, being guided clinically and we will support those decisions

⁃ Agreeing locally which sites and staff could manage face to face assessments of any possible COVID-19 cases

⁃ Agreeing locally a plan to support patients who are particularly at risk of COVID-19 complications, including considering co-ordination of their care if in future advised to stay at home

⁃ Confirming business continuity plans, with a view to cross practice resilience.'

Pulse reported on Friday morning that GP practices in Derbyshire are poised to suspend all routine appointments in response to the coronavirus (Covid-19) outbreak, following advice from their LMC.

This afternoon, Cambridgeshire LMC issued the same guidance, Pulse has learnt.

Meanwhile, Doncaster CCG said that local practices are authorised to switch off online bookings ‘completely’ if this is their ‘preferred approach’.

An email sent by the CCG and seen by Pulse said measures can include:

- ‘Switching off online appointment booking completely if this is the practice’s preferred approach

- ‘Accepting prescription requests by telephone where the patient isn’t willing to register for/able to use online services

- ‘Moving an increasing amount of clinical care to telephone/video/online consultations where this is safe to do so and within the competence of clinicians

- ‘Changing your Proactive Care service to a predominantly telephone-based service alongside suspension of routine face to face external MDT meetings. As well as releasing capacity this should help reduce risk of rapid spread to a particularly vulnerable cohort of patients who don’t have a pressing clinical need

- ‘The previous point also relates to other proactive in-reach work such as routine ward rounds with care homes for the same reasons. Practices will need to agree with the care home managers how clinical input and support to these homes will continue during this period.’

Lancashire and Cumbria LMC chief executive Peter Higgins said the LMC has advised practices to start triaging all patients remotely and ‘undertaking all care that can be done remotely through remote means, being guided clinically’.

However, Mr Higgins told Pulse that he had decided not to advise practices to suspend all routine appointments.

He said: 'I'm not doing it and it's not because I don't think they should do that, but what I'm pressing for is a local tactical operational group working across the whole health system that will advise when it's appropriate to do what.'

The chief medical officers of all four UK countries said that expectations on routine GP services will be relaxed if the spread of coronavirus becomes a ’significant epidemic’ in the UK.

A Pulse survey revealed that two out of five GPs have still not received any personal protective equipment against coronavirus.

Meanwhile, GPs have been forced to draw up their own emergency plans amid a lack of guidance from NHS England on how to manage patients turning up with respiratory symptoms.

As of 13 March, 32,771 people have been tested in the UK, of which 31,973 were confirmed negative and 798 were confirmed as positive. 10 patients who tested positive for COVID-19 have died.

Readers' comments (22)

  • I would be interested to know people's position on home visits for patients with symptoms of COVID-9 who are high risk for admission. Do we visit with PPE, or ask them to liaise directly with 111 all the time?

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  • @Andrew Hills - I haven't seen a single useful bit of guidance from NHS England, Scotland, government, even local clusters/LMCs about this conundrum. Would be interested to know what on earth we're meant to do - especially care homes/nursing homes lacking in ANPs/clinical staff.

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  • My approach has been i can offer abx over the phone but if that poorly i advise to contact 111/999 as appropriate. given my practice has substandard ppe then face to face from ourselves is not an option at this point

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  • My understanding, and I may be wrong, is that the patient should still be using 111 and that assessment / admission to an appropriate unit would be managed by the ambulance service. As the CHMS become active, it will be taking over this role from the ambulance service

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  • And not at all clear what to do if someone self-isolating develops symptoms unrelated to Covid-19, for example, abdominal pain, which requires examination.

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  • and i realise abx is not needed for viral illness but i cant offer anything else to those with underlying resp disease but not in difficulty to prompt acute admission

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  • Absolutely agree with above. Patient just had appointment; reception staff gave entirely logical advice for viral symptoms, 111 triage told see GP as not Coronavirus so they walked in asking which side room to use! Clearly missing Boris's latest advice and then had a rant (including can't possibility self isolate as inconvenient) at GP when pointed this out!

    Neither any PPE or the great British Public were harmed in this consultation, and clearly wasn't that SOB so I'm off home soon for a stiff G&T.

    Cant wait for next few weeks!

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  • Had lots of calls from parents worried about febrile children - the usual concerns regarding is it an ear infection, tonsillitis, chest infection etc.

    Also adults patients turning up still at reception asking to be seen with cough or fever despite mass texting, website link to NHS information, a big sign at gate with advice not to come into surgery and leaflets/signs everywhere in building.

    Our poor duty GP has been left trying to manage these patients including one who contacted oncology and 111 and was told to go to GP practice. We have limited supplies of PPE but could potentially go through it within one afternoon.

    Things need to be black and white. We either are responsible for managing patients who should be self isolating with full supplies of adequate PPE and access to testing or we should be able to direct to a different service with adequate resources. Apparently local OOh provider has contract for COVID response in community by I can't see them being able to cope with all the demand.

    There is a clinical risk that patients who are ill with something that isn't coronavirus doesn't receive adequate assessment or treatment and die.

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  • There must come soon some civil action against wilful spreaders / attendees, as Corona Charlies replace Typhoid Marys in history; we may prepare a leaflet along the lines of "you have it, you shouldn't be here, go home and may your God go With You."

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  • carfentanyl | GP Partner/Principal13 Mar 2020 6:13pm

    'Corona Charlies' - LOL! Unfortunately for them there will be too many for these individuals to achieve the same notoriety/immortality as Typhoid Mary.

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