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NHS England's 19 March update to GP practices on Covid-19

NHS England’s letter to GPs and their commissioners

19 March 2020

This is the third of a series of regular updates to general practice regarding the emerging COVID-19 situation. An electronic copy of this letter, and all other relevant guidance from NHS England and NHS Improvement can be found here: https://www.england.nhs.uk/coronavirus/primary-care/

Dear GPs and their commissioners,

NEXT STEPS ON GENERAL PRACTICE RESPONSE TO COVID 19

We recognise the intense pressure that general practice is under right now as the pandemic increases rapidly.

On 17 March you received Next Steps on the NHS response to COVID 19.

This letter now describes the service delivery consequences for general practice and further steps we are taking nationally to manage the workload consequences and ensure that income can be protected if other routine work has to be substituted.

Supporting staff to stay safe and well at work is a critical immediate priority, including through expansion of testing, and supply of PPE. An issue of protective kit commenced on 9 March 2020. If any general practice has concerns around the kit, please contact our National Supply Disruption line on 0800 915 9964 or email supplydisruptionservice@nhsbsa.nhs.uk who will be available to help, Monday to Friday 08:00-18:00.

1. Advice and guidance on coronavirus

Up-to-date advice from Public Health England, including the latest case definition, can be found here and the latest NHS England guidance can be found here.

Anyone who is unwell should go to NHS111 online first for advice, rather than approaching their GP practice. If a case comes to the surgery or extended hours hub:

• If the patient is WELL then:

- they should go home immediately and self-isolate

- use nhs.uk/coronavirus for advice and guidance.

• If the patient is UNWELL then:

- use PPE as per current PHE guidance for possible cases

- isolate the patient

- if acutely unwell treat as appropriate

- if not then ask them to use NHS 111 online or ring NHS 111 from home or the isolation room

- decontaminate as per the standard operating procedure (SOP).

2. Service implications and priorities

Responding to COVID-19 is already necessitating major immediate changes to how general practice works.

Right now, all practices and their commissioners are asked to focus on six urgent priorities:

1. Move to a total triage system (whether by phone or online). This does not mean not advising/treating patients for other health issues, where there is clinical need, or unilateral closing of practices doors, rather ensuring that patients are appropriately triaged to the right health professional setting. The upsurge in telephone calls to general practice means that providing a reliable and timely response for patients has already become a vital operational priority.

2. Agree locally with your CCG which practice premises and teams should be used to manage essential face-to-face services.

3. Undertake all care that can be done remotely via appropriate channels, guided by your clinical judgement. We ask you to read the guidance note at annex A.

4. Prepare for the significant increase in home visiting as a result of social distancing, home isolation and the need to discharge all patients who do not need to be in hospital

5. Prioritise support for particular groups of patients at high risk. Next week the NHS will be writing directly to all patients in this category, and you will receive further advice shortly

6. Help staff to stay safe and at work, building cross-practice resilience across primary care networks, and confirming business continuity plans.

To reduce the risk of respiratory disease, protect those most vulnerable and reduce pressure on health services, please can you also ensure that you have ordered sufficient stock of the recommended adult flu vaccines for 2020/21* to meet your local needs before the 31st March 2020. In summary these are:

• For over-65s aTIV

• For under-65s at risk, including pregnancy women either QIVc or QIVe.

3. Arrangements to free up capacity and protect income

We will seek to do all we can to support practices to manage inevitable increases in workload at this extremely difficult time. Patients will be clearly advised to visit the NHS coronavirus page in the first instance and not to visit their practice, if they have relevant symptoms.

The key principle is that we free up practice capacity to prioritise workload to both prepare for and manage the COVID-19 outbreak. All routine CQC inspections have been cancelled and advice is being issued on suspension of appraisal and revalidation activities.

We ask all practices to consider stopping any private work they are doing to help free up capacity.

We will make sure that funding does not influence clinical decision making by ensuring that all GP practices in 2020/21 continue to be paid at rates that assume that assume they would have continued to perform at the same levels from the beginning of the outbreak as they had done previously, including for the purposes of QOF, DES and LES payments.

This section:

• outlines the actions we are taking nationally now to support practices to free up capacity – see table 1

• identifies activities that practices can suspend in the circumstances set out where this is necessary to free up capacity to support the COVID-19 response – see table 2. This may be added to or amended in due course as required

• recommends that commissioners suspend their locally commissioned services, schemes and pilots unless these will directly support the response to the Covid-19 outbreak – see table 3.

From the date of this letter until a new announcement is made, a practice is not required to provide the activities set out in table (ii) where this is necessary as a result of work generated by the COVID-19 response and where that would be clinically appropriate as part of clinical prioritisation.

Commissioners are expected not to take remedial action under the contract in such circumstances and swift changes to Regulations are expected to give statutory force to this position. We will update practices once these Regulations come into force.

4. Further communications

We will continue to send regular updates, hold regular webinars and share information as the situation unfolds. On Thursday 11th March we held two webinars. The first discussed the move from the contain to delay phases, and support in place for colleagues and patients. The second discussed how to use remote triaging and online consultations in managing COVID-19. Although more than 1,000 people attended each webinar, we recognise that not everyone who wanted to attend would have been able to. They will be uploaded to our website on the NHS general practice page.

The next webinar will be held today (Thursday 19 March), at 5pm. To join either:

Call one of the dial-in numbers before the start time (0800 121 4113 or 01296 480 180), follow the instructions provided and when prompted, enter passcode: 944 128 72#

We will use a variety of additional methods to keep you informed of the emerging situation, alongside Royal Colleges, regulators and professional bodies, and through formal and informal networks including social and wider media. You can follow these Twitter accounts to keep up to date:

• NHS England and NHS Improvement @NHSEngland

• Department of Health and Social Care @DHSCgovuk

• Public Health England @PHE_uk

Again, thank you for your incredible commitment and patience in this rapidly evolving situation.

Dr Nikita Kanani - Medical Director for Primary Care Director, Primary Care Strategy and NHS Contracts, NHS England and NHS Improvement

Ed Waller - Director, Primary Care Strategy and NHS Contracts, NHS England and NHS Improvement

Table: Actions we are taking nationally to free up capacity in general practice

     
 Activity Update   
 QOF for 2019/20

QOF activity for 2019/20 is largely complete and QOF calculations will be made as usual.

However, given the priority that may need to be given to COVID-19 work, we will undertake a piece of analysis to confirm the impact and will make a one-off adjustment for practices who earned less in 2019/20 than 2018/19 as a result of COVID-19 activities.

 
 QOF for 2020/21  We will protect QOF income as necessary to respond to COVID-19.  
 Dispensary Services Quality Scheme (DSQS) payments For dispensing practices only, the DSQS will be suspended with immediate effect, with income protected. This includes ceasing DRUMs with immediate effect. Medication review should continue if essential.  
 Investment and Impact Fund (IIF)  We will defer the introduction of an incentive scheme for at least the first half of 2020/21. Investment for the first two quarters of 2020/21 will not be lost to PCNs.  
 Network Contract DES service requirements  The funding attached to the PCN DES in 20/21 will continue to be available to practices signing up. The introduction of the Structured Medication Review and Medicines Optimisation Service Specification will be postponed, in the first instance until October 2020. Networks should make every possible effort, to begin work on the early Cancer Diagnosis specification as planned, unless work to support the COVID-19 response intervenes. People who are concerned about any symptoms related to suspected cancer should still contact their GP and GPs should make sure they continue to refer those for suspected cancer for diagnostic tests as normal.Given the importance of delivering a coordinated service to care homes, the Enhanced Health in Care Homes service requirements will continue in line with the dates set out in the 2020/21 GP contract deal, and we will ensure alignment with COVID-19 pathways.  
 Network Contract DES: workforce returns  The additional workforce under the ARRS will be critical to the COVID-19 response. However, we recognise that PCNs may need more time to consider their workforce needs.We will therefore delay the deadlines for the workforce planning templates from 30 June to 31 August 2020, and the associated requirements on CCGs to redistribute unused  
Appraisals and revalidation We strongly recommend that appraisals are suspended, unless there are exceptional circumstances agreed by both the appraisee and appraiser. This should immediately increase capacity in our workforce by allowing appraisers to return to clinical practice.Until reinstated, responsible officers should classify appraisals which are affected as ‘approved missed’ appraisals. For clarity, affected appraisals will be regarded as cancelled, not postponed.Separate advice on revalidation is being issued.In the meantime, for those doctors where appraisal has been cancelled and a recommendation is due, responsible officers are reminded that they may make a positive recommendation if the required supporting information has otherwise been presented earlier in the doctor’s revalidation cycle.At the same time, if needed, doctors can be reassured that deferral is a neutral act and has no impact on their ability to practice as normal.  
Scale down of CQC inspections CQC has announced that from 16th March routine inspections will be suspended.  

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Readers' comments (9)

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  • Someone listened to the action points. Thank you.
    Some more nocturnal ideas:

    1. Address stockpiling of inhalers - thousands of calls and falling reserves - guidance and rules required.
    2. Need alcohol gel and cleaning products to be sent to General Practice too. You have left this slide.
    3. Remove this silly QOF of offering smoking cessation advice. It's annoying. The nanny state has expired and responsibility is now.
    4. State clearly that practices can shut their door with the triage system in place and lines open to protect staff from lawless public and the inconsiderate risking our exposed front line.
    5. Create a proper NHS staff rewards and appreciation page with discounts and concessions. You will need it when staff fatigue. Plus it will aid recruitment.
    6. Tell council's to issue doctors with parking permits free! It is an absurdity in 2020.

    Fingers crossed.

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  • Thanks Nikki for the placebo. Have you seen what the German doctors are wearing? Can doctors not spread it to staff and patients?

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  • Can we please have testing of GPs, otherwise we do not know who has had it already !

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  • I agree with all of the above. Last week were told that there would a dedicated community service for covid patients; what happened to that? Let me guess, the OOH service said no. So now we are being thrown to the wolves. Why are you not pushing for proper PPE and testing of health care workers? What are you going to do when large numbers of healthcare staff become ill? We are now being asked to create “hot” and “cold” areas within the practice to see covid and non covid patients. What exactly do you hope to achieve with that? To spread the virus even more?? Have you seen the images from Italy lately?? I mean do you realise how infectious this virus is and that it can survive on surfaces for days ?? I’ve also been told that we need to do the decontamination ourselves!!! What a joke!! The truth is that there is no plan and no preparedness. We need proper leadership and action to safeguard patients and staff.

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  • Problem with this is-???? " ring NHS 111? "-as per my experience yesterday(below) I was on hold for 1 hour 45 minutes calling to get a blue light ambulance for a patient and that was just the call to get through -not the ambulance wait time!!!
    They have no idea of the reality of practice.......
    it’s actually not safe!
    They want us GPs visiting the sick Covid cases-
    I have experienced this today-( LONDON GP)
    A pregnant patient, high fever and short of breath- couldn’t get a response from 111 yesterday and finally they told her to call her GP. I visited her this morning- assessed her: temp 39.5. sats 94 p 106-
    I Even did bloods- got them back a few hours later.....
    CRP 110 with normal white cell count- was sure it was Covid
    Discussed with med registrar in local big LONDON hospital - “ send her to A&E they’ll triage and call me if we’re needed”- I was gob snacked- pretty sure you’ll be needed mate! I called A&E- to confirm this was the right route....- it was! they have a red and a green zone and she could “go wait in the red zone”. The 999 ambulance call to send her to A&E had us on hold for 1 hour and 45 minutes. I then had to leave to see the next patient- she sent me a message that’s she’s still in A& E waiting to be seen having taken a taxi as couldn’t get through to blue light 999 ambulance! This is the reality! The service is not functioning- god help anyone having a stroke- never mind Covid death rates - what are cardiovascular death rates??? No one left to do normal stuff- all overwhelmed already! There will be hot and cold spots in practices for people to be assessed-just like in A&E already- its overwhelmed....

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  • Government knows the system will fail. All the guidance is intended to give the impression of control - no government could do otherwise. Telling the front line to expect significant increases in visiting is just being seen to say the right thing. From the comments elsewhere it seems this single expectation will bring an end to many careers - I will not be spending the day driving from high risk to high risk household, accumulating risk and casually spreading it round the needy, the clueless and desperate. They will get a phone call. That is all.

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  • Nikita
    In your eminent position , would you be able to talk to anybody in charge , who may be able to initiate / set up some sort of public service broadcast , TV programme , podcasts etc on regular , at least daily basis to inform the punters of dos and don’ts . This may curb at least some of the unnecessary and rubbish calls and overinflated workload .

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  • Can not trust guidance from NHSE or PHE- they are weeks behind reality. And in these circumstances GMC guidance is very nice, and I will read it when I have time... Look after yourselves, and by doing so you will be helping your patients. Get your own PPE, drugs to help the dying, oxygen etc, don't expect that regulators will produce adequate guidance in time.

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