Covid infections are increasing daily and there are fears of what the winter will bring, but GPs are warning measures to counter this could lead to even greater patient harms. Beth Gault reports
When Covid-19 first hit the UK, it was estimated that if the virus was left unchecked, more than half a million people would die. Eight months later, we have seen the damage it can cause, even with the severe measures of reconfiguring the health service and the various forms of lockdown.
As Pulse went to press, the UK was approaching 60,000 deaths with the virus. And we are seeing longer-term effects, in the form of ‘long Covid’.
As the UK enters its first Covid winter, infections are already rising steeply and the current reproduction (R) rate is between 1.3 and 1.5. In July, scientists predicted if the R number reached 1.7 by September there would be nearly 120,000 hospital deaths by June 2021.
No one doubts further steps must be taken. We have seen the Government in England introduce its ‘three-tier’ system of localised responses, although the devolved nations are showing signs of dissent, with Wales and Northern Ireland favouring temporary national lockdown. Plans are being considered to reconfigure the health service again to free up ICU space and redeploy secondary care staff.
But this throws up an impossible dilemma for health leaders. Such measures result in health harms for the general population, with some arguing these are worse than those of Covid.
GPs are at the centre of this dilemma – and their response is informed by knowledge gained during the first lockdown earlier this year.
These experiences led 66 high-profile GPs – including media doctor Dr Ellie Cannon and Professor Sir Sam Everington, chair of London’s 32 CCGs – to sign a letter to the health secretary last month warning of the dangers of putting too much emphasis on Covid. It said: ‘We are concerned due to mounting data and real-world experience, that the one-track response threatens more lives and livelihoods than Covid-lives saved… Now is a critical pivotal point: we must recognise our duty to do no harm.’
Surrey GP Dr Martin Brunet, who signed the letter, says: ‘There have been lots of excess deaths that are not Covid deaths, and the prospect of all routine operations being stopped again and hospitals not seeing patients face to face when some people just need to be seen – that would just be awful.’
We now have the data from the lockdown measures this year. Office for National Statistics figures reveal there were 311,000 deaths in England and Wales between March and August this year, compared with 252,000 in the same period last year. Of these, 48,000 died with Covid – meaning there were 11,000 excess deaths year on year above and beyond those caused by Covid.
But this 11,000 figure doesn’t tell the full story, as many of the 48,000 who died of Covid would have been palliative and thus likely to have been part of the ‘normal’ 250,000 deaths as occurred last year. And it is notable that April – the first full month of the Covid response – saw more than double the number of deaths than April 2019, with Covid-related deaths only accounting for two-thirds of this extra mortality.
Secondary care support
But it is not just mortality. As soon as the UK went into battle mode in March, GPs began to see the effects of reduced secondary care capacity. And now, official figures reveal the scale of the problem and the resultant backlog. NHS England and NHS Improvement statistics on referral to treatment (RTT) waiting times for consultant-led elective care show 46% of patients still waiting for routine treatment had been waiting for longer than 18 weeks at the end of August 2020. This was against a target of 8% and compares with 15% in August 2019.
Dr Satpal Shekhawat, GP and medical director at NHS North Lincolnshire CCG, says this forces GPs to change the options they give patients: ‘I am aware of the delay so if I’m consulting with a patient then subconsciously it will play a part in the options I offer. If I’m thinking the patient needs an MRI but I know the MRI won’t happen for the next four months because of the backlog, then I’m almost changing the way I treat the patient.’
This sometimes means putting patients on medication for longer than they would usually need. ‘We have to manage with pain control and physio but that’s delaying the treatment rather than fixing the problem,’ he says.
At the same time, more workload is being dumped on GPs. Dr Shekhawat says: ‘We’re getting a lot more letters from hospitals asking us to do bloods for them.’ And this was before all the problems with Roche testing.
The pressure on secondary care is also affecting communication between hospitals and GP practices. Cambridgeshire LMC noted the ‘potential downgrading of two-week-wait referrals without notice to either the patient or the practice’ in its September newsletter.
The original pandemic measures also affected cancer referrals. Performance against the national two-week-wait target in the first half of the year remained about the same as at the start of lockdown, at around 91.5%-92%. But alarmingly, NHS England data show that from April to June 2020, hospital specialists saw 340,000 urgent cancer patients – a 43% dip on the same period in 2019. Cancer Research UK says around 31,000 fewer patients started treatment between April and July compared with the same time in 2019, a reduction of 26%.
London GP Dr Murray Ellender, says: ‘It’s not like there’s less cancers out there, it’s clearly as a health service we’re not picking them up as well as we were. I’m definitely seeing a backlog now.’
Health authorities’ plans to support GPs experiencing reduced access to secondary care involve little more than ‘advice and guidance’.
Over the summer, NHS England stressed in its Covid standard operating procedure guidance that it wanted to see GP practices use the advice and guidance route to ‘keep patients away from hospital settings unless a referral is necessary’.
But in some cases hospitals are now insisting most referrals go via advice and guidance first.
Birmingham LMC chair Dr Gavin Ralston says this creates a ‘barrier’ to scans at his local trust: ‘You have to ring between 1pm and 3pm to have a referral triaged, which I think is a poor system.’
Direct effects of lockdown
As well as the impact of reconfigured services, the lockdown restrictions themselves had a direct effect. First, patients’ concerns made them less keen to use healthcare services.
This shows up in the number of general practice appointments made by patients during the first peak – just 16.6 million in England in April – a drop of almost a third on February’s figure.
But second, the restrictions are having an effect on people’s mental health – those with existing problems, but also those who had no existing problems. These are having to be managed by GPs.
Dr Shekhawat says: ‘This pandemic has meant some who had no mental health problems are developing them.’
A study in The Lancet Psychiatry in July found UK prevalence of clinically significant levels of mental distress rose from 18.9% of adults in 2018/19, to 27.3% in April 2020, one month into lockdown.
The study says: ‘Early indications suggest a serious impact on employment and livelihoods, income, and personal debt. Coupled with a substantial amount of worry about future insecurity, there are increasing concerns about the mental health sequelae of the pandemic.’
An Office for National Statistics survey also found almost one in five adults was likely to have some form of depression in June, almost double the pre-Covid level. GP and clinical lead for mental health at NHS North Hampshire CCG Dr Tim Cooper says: ‘With a challenging winter ahead, it is right to flag the impact of further disruption, lockdowns and job losses on the prevalence of depression, particularly in those areas already facing substantial health inequalities.’
And as Pulse columnist Dr Shaba Nabi points out, there is also
a potential ‘pandemic’ of domestic violence. This has increased under the pressures of lockdown, with victims having reduced access to support.
A deadly disease
The GPs who signed the letter offered no recommendations beyond concluding ‘Covid deaths alone can no longer be used as the unilateral measure of harm’.
Yet there are moves to address the potential harms of prioritising Covid. Acknowledging its effect on vulnerable women and children, Public Health England last month wrote to nursing directors to say professionals supporting children and families should not be redeployed to other services this winter.
And NHS England has invited private providers to apply to a new £10bn procurement framework, as part of plans to outsource routine activity.
GPs do acknowledge the challenges. Doncaster GP Dean Eggitt says: ‘Lockdown is an incredibly difficult decision.’
Part of the problem is the Government’s track and trace system, he says. ‘At the moment it is just a political pawn for votes. Unless we quarantine everyone with minor symptoms, which we’re not, we’re probably just allowing the disease to spread anyway.
‘This is a war. We should be fighting it like one and we’re not.’
Advice and guidance being ramped up
Advice and guidance services have been on offer for years, giving GPs the option to receive a consultant’s advice about a patient without referring to an outpatient clinic.
But since the virus outbreak, hospitals have begun to use the services to triage all GP referrals across certain specialties and limit those attending clinics, backed up by NHS England’s direction to use advice and guidance to ‘keep patients away from hospital settings unless a referral is necessary’. GPs say hospitals’ approach is creating extra work and responsibility for general practice.
Dr Kieran Sharrock, medical director at Lincolnshire LMC, says in his region the CCG asked practices to do ‘all referrals for cardiology via advice and guidance’. He says: ‘What we don’t want is that to result in the consultant saying “can you arrange test x and test y”. That’s not my responsibility.’ NHS Lincolnshire CCG said cardiologists and GPs were working together ‘to ensure [the service] continues to evolve and develop to support GPs’.
Birmingham LMC chair Dr Gavin Ralston said University Hospitals Birmingham started to move most specialties to the system in April, but with no extra money for GPs.
He says: ‘[For radiology] you have to ring between 1pm and 3pm to have a referral triaged, which I think is a poor system… general practice should get extra funding.’ The trust has said this is a temporary measure.
In the Black Country, the local hospital plans to use advice and guidance as a compulsory route. Walsall LMC medical secretary Dr Uzma Ahmad says: ‘They want it as an entry point and then to use referral assessment for who to see and who to give back to GPs. We are not experts.’