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​GPs go forth: Has the Government’s strategy put GPs at risk?

‘It is like walking into no-man’s land with a machine gun blasting at you without any body armour,’ says Dr Zishan Syed, a GP and LMC member in Kent.

Dr Syed is not the only one feeling unsafe. A major survey by Pulse of 675 GPs conducted between 17-21 April reveals that three-quarters fear for their health or lives.

This comes as little surprise. The UK Government had an aim to limit deaths from Covid-19 to 20,000. Sadly, that number has already been surpassed, and that is not including community settings and care homes.

Tragically, a number of healthcare staff are dying, including GPs. GPs and other health workers are, literally, risking their lives in order to do their job.

Central to many of their worries is, of course, PPE. This has been exacerbated by the NHS’s admission that GPs can now expect to see a number of potential Covid-19 patients face to face– potentially in their own surgeries. Antibody testing of healthcare workers would give reassurance to healthcare workers, and even antigen testing may give GPs a boost through allowing more staff to be in practices. But the Government was slow to implement testing processes.

So GPs and their teams are putting themselves at risk to care for their patients. Is this simply an inevitable consequence of a deadly pandemic, or should we be asking to what extent it is due to the Government’s response to the Covid-19 outbreak here? Can GPs have faith in the Government’s cunning plans to protect them in the months to come?

The kids wear better protection for painting

Dr Tracey Turpin

For GPs, the biggest concerns continue to be around PPE. Pulse’s April survey reveals that only a third had received an adequate supply of facemasks and worse still, just 13% and 12% said they had received an adequate supply of gowns/aprons and eye protectors respectively. As a result, more than half of respondents – 52% – said they felt unsafe.

Most worryingly, a quarter of GPs said they had conducted face-to-face consultations with potential Covid-19 patients without PPE. Many of these took place when travel history was – incorrectly in hindsight – treated as the main determinant of risk. But others point out that, since then, they have seen asymptomatic patients who developed symptoms soon after the consultation.

A number of respondents to the Pulse survey said they had been forced to source PPE from unlikely avenues. As Dr Tracey Turpin, a salaried GP in Durham, puts it: ‘We have no gowns, just plastic mini-pinnies. My kids wear better protection for painting. We have eye goggles but only because they were donated by a school.’

For GPs who need PPE, the options are shrinking further. The hotline set up in England advised them to go through their ‘normal channels’ – ie, go back to their suppliers. Then they were told to try resilience forums run by councils – but authorities in Birmingham warned they were running out. The devolved nations have no central hotlines, with much depending on the ability of local health boards to procure protective equipment.

The CCG asked if we would send gowns back to be used in secondary care

Dr Emily Armitage

The problems extended to Covid hubs in secondary care, with health secretary Matt Hancock admitting that gowns were running out and the BMA calling the whole situation ‘shameful’. In response, Public Health England’s highly questionable short-term fix was to change its guidance to advise the re-use of PPE in certain situations.

The Government’s long-term approach is twofold. The first strand is procuring from abroad, with Mr Hancock announcing on 21 April that the Government was working directly with factories in Asia to ensure the UK could obtain PPE without intermediaries, after the delaying of a shipment from Turkey revealed the problems with middlemen. The second part of the plan is ramping up home production; the health secretary said the Government had engaged 159 UK manufacturers to step up production.

But the inescapable issue is the sheer amount of PPE needed. Mr Hancock conceded that the ‘unprecedented scale and complexity’ of the situation called for ‘billions of items per month’. To put that in context, the Government had delivered one billion items in the three months up to mid-April. Mr Hancock said this came down to a ‘global shortage’.

These numbers mean GPs may find themselves down the queue. York GP Dr Emily Armitage said NHS Vale of York CCG had asked whether some of the practice’s gowns could be given to secondary care. She tells Pulse: ‘We sourced some gowns (not many) via a PCN contact and claimed the cost from the CCG. So knowing we had some, the CCG asked if we would send them back to be used in secondary care – which is obviously in great need – which we did.’

Dr Syed points out that the PPE guidance prioritise medics performing aerosol-generating procedures (AGP). He adds: ‘It creates a divide between primary and secondary care, with arguments of AGP being done predominantly in secondary care and not in primary care. This means that hospitals are prioritised for provision of FFP3 masks, etc.’

London GP and chair of grassroots group GP Survival Dr Nick Grundy says Mr Hancock’s calculations are off: ‘A billion items a month would mean 166 million patient contacts, each using two gloves, apron, mask, visor. This equates to 5.5 million a day, which seems unlikely. Anyway, why is the Government only discovering this now when it’s their job to know how many items/month they’d need in a pandemic?

‘Of course primary care is behind secondary care in the queue but the fact that there is a queue is inexcusable, and the health secretary saying ever-larger numbers doesn’t get around that.’

GPs not being prioritised is all the more dangerous when considering changes to guidance on seeing Covid-19 patients. GPs had been reassured at the beginning of the crisis that they could divert any potential cases to NHS 111 or local Covid-19 centres – be they hospitals or ‘hot hubs’. But there was tacit acknowledgement that this was no longer possible when NHS England suggested last month that practices may wish to set up ‘hot zones’ for cases where ‘patients with symptoms of Covid-19 require face-to-face assessment’. The type of patient who may require a face-to-face consultation in a GP surgery were not defined, however. And fears grew even further with the announcement that practices should reserve slots for NHS 111 referrals, potentially overriding the safe triaging practices had been encouraged to set up.

We took a Covid swab but the lab refused to process it as it was “outside the protocols”

Dr Jonathan Heatley

The bigger elephant in the room is that every patient potentially has the virus. As a result, doctors’ leaders are instigating a ‘no PPE, no see’ policy. In a communication to practices, Berkshire, Buckinghamshire and Oxfordshire LMC chief executive Dr Matt Mayer said: ‘There are limits to the risks you can be expected to expose yourself to. You are not under a binding obligation to provide high-risk services where [you are not provided with] appropriate safety and protection.’ The Royal College of Surgeons and the Royal College of Anaesthetists also advised members on a similar policy.

Most GPs – 61% – told our survey they were taking a ‘no PPE, no see’ approach. The BMA is not yet going as far as the RCS and RCA, simply advising: ‘You can refuse to treat patients if your PPE is inadequate, you are at high risk of infection and there is no other way of delivering the care.’

Yet there is no doubt GPs are in the firing line. One in five GPs say they have had suspected or confirmed Covid-19, with a further one in five saying they are not sure. And the Government has been widely lambasted for its poor response to the World Health’s Organization’s repeated advice to ‘test, test, test’.

This lack of action directly affects the workforce, increasing the risk for GPs. One in four said they have had to self-isolate. Of those, only 24% had both a cough and a fever: a third were only isolating because members of their household were displaying symptoms.

In the case of Sussex GP Dr Jonathan Heatley, this had repercussions for the wider NHS: ‘Three NHS workers (two doctors) in our household had to self-isolate for two weeks due to a daughter-in-law’s cough. We took a Covid swab to try to prove it was nothing so we could all go to work but the lab refused to process it as it was “outside the protocols”.’

There’s no doubt GPs’ fears are justified but their views on the Government’s handling of the crisis are more evenly split than you might think: 36% had a negative view, 39% were neutral, and 25% had a positive view.

How this changes over the coming months will depend on whether the Government finally delivers adequate PPE and testing. For now, however, in the words of Captain Blackadder, it remains a case of ‘good luck, everyone’.