GPs should consider long Covid referral after just four weeks, says final NICE guideline

GPs should consider referring patients with long-term symptoms of Covid-19 to specialist clinics as soon as four weeks after acute infection after ruling out other diagnoses, NICE has recommended.

Referrals should be made on the basis of ongoing symptoms and impact on the patients’ life, not the severity of the initial illness or a positive SARS-COV2 test, the final guideline developed with the Royal College of GPs and Scottish Intercollegiate Guidelines Network states.

NICE also makes the case for proactively identifying at-risk and vulnerable groups in primary care who may have more difficulty accessing services for longer term monitoring.

It comes as NHS England said there were now 69 long Covid clinics in place around the country with more sites expected to open in January.

But only one fifth (21%) of GPs responding to Pulse’s December survey said they currently had access to a long Covid clinic in their local area.

Patients with long Covid often present with clusters of overlapping symptoms which can affect any system in the body and fluctuate and change over time, NICE said

Figures published by the Office for National Statistics this week suggest a fifth of people still have coronavirus symptoms five weeks after being infected with half of them – currently around 186,000 patients – having problems for 12 weeks or more.

NICE has split long Covid into two categories after the initial acute infection phase – ongoing symptomatic Covid-19 which can last from four to 12 weeks and post-Covid-19 syndrome defined as longer-term symptoms not explained by another diagnosis.

Some patients, including the elderly and children, may not present with the most common symptoms of the condition, which include breathlessness, chest tightness or pain, palpitations, fatigue and ‘brain fog’, the guidelines said.

GPs should urgently refer any patient that has potentially life-threatening complications such as cardiac chest pain, signs of severe lung disease or oxygen desaturation on exercise.

Tests should also be done in primary care to rule out other possible diagnoses including blood tests, exercise tolerance testing, chest X-rays and lying and standing blood pressure and heart rate recordings, depending on the patient’s symptoms.

Patients should be given advice on self-management as well as being referred to an integrated multidisciplinary assessment service where available, the guidelines said. 

NICE concluded that more research is needed on how to identify and manage long Covid but said the recommendations would be continuously reviewed and updated as new evidence emerged.

Paul Chrisp, director of the Centre for Guidelines at NICE, said the guideline highlighted the importance of good information for patients after Covid-19 so they know what to expect and when to seek medical advice.

‘This could help to relieve anxiety when people do not recover in the way they expect, particularly because symptoms can fluctuate and there are so many different symptoms reported,’ he said.

‘Because this is a new condition and there is still much that we don’t know about it, the guideline will be adaptable and responsive as understanding of the condition grows and new evidence about how to manage it emerges.’

RCGP chair Professor Martin Marshall said they had also produced a booklet for patients to help them understand their illness as part of the guideline development.

‘It’s been a rapid but rigorous process, during which we have listened to both clinicians and patients who have had ongoing symptoms as a result of Covid-19 to ensure the guidance is as holistic and comprehensive as possible given what we know.’

He added that the ONS stats on long Covid showed it could be a debilitating illness for a significant number of patients and GPs needed referral pathways in place.

‘It’s vital that GPs and our teams have the resources to deliver care to patients with long Covid – and access to dedicated services in the community for these patients, so they can get the specialist care they need to manage and treat the condition.’

Professor Azeem Majeed, professor of primary care at Imperial College London, said local services for people with long Covid were currently very variable across England.

‘As well as a lack of services in some parts of England, there is also variation between specialist providers in how these patients should be investigated before referral.’

He said guidance on what should be on offer as well as pre-referral investigations should lead to more standardised care for patients.

‘For primary care, one caveat about the guidance is that the number of people who have experienced a Covid-19 infection continues to grow rapidly (over 25,000 positive tests in the UK on 16 December) and will continue to do so until the vaccination programme has some effect on curbing infection rates.

‘Hence, primary care teams will be faced with a lot of extra work in managing patients following a covid-19 infection, something they will need to do on top of all their usual work, as well as the expanded flu vaccine programme and the covid-19 vaccine programme.

The news comes as a rapid guideline produced by NICE published yesterday did not find sufficient evidence to recommend vitamin D supplements solely for the purpose of preventing or treating Covid-19.

Pulse asked 854 GPs on 4 December if they had a long Covid clinic in their area and 21% said yes while 50% said no and 29% didn’t know.

COVID-19 rapid guideline: managing the long-term effects of COVID-19

There are three phases following Covid-19 infection:

• Acute Covid-19 lasting up to four weeks
• Ongoing symptomatic Covid-19 lasting from four to 12 weeks
• Post-Covid-19 syndrome where symptoms continue for more than 12 weeks

1.1 Patients with suspected or confirmed acute Covid-19 should be given advice on symptoms, what to expect during recovery and how to manage any ongoing symptoms

1.5 Consider using a screening questionnaire to capture all the symptoms in patients with ongoing problems but only alongside clinical assessment

1.6 Be aware that some people (including children and older people) may not have the most commonly reported new or ongoing symptoms

1.8 Support access to assessment and care for people with new or ongoing symptoms after acute COVID‑19, particularly for those in underserved or vulnerable groups who may have difficulty accessing services

2.1 For those with long Covid who need an assessment include a comprehensive clinical history and appropriate examination that involves assessing physical, cognitive, psychological and psychiatric symptoms, as well as functional abilities.

2.3 Symptoms can be wide-ranging and fluctuating.

2.7 Do not predict whether a person is likely to develop post‑Covid‑19 syndrome based on whether they had certain symptoms or were admitted to hospital 

3.2 Offer tests and investigations tailored to people’s signs and symptoms to rule out acute or life‑threatening complications and find out if symptoms could be a new, unrelated diagnosis.

3.10 After ruling out acute or life-threatening complications and alternative diagnoses, consider referring people to an integrated multidisciplinary assessment service (if available) any time from 4 weeks after the start of acute Covid‑19.

3.11 Do not exclude people from referral or specialist input based on the absence of a positive SARS‑CoV‑2 test.

4.2 Think about the overall impact their symptoms are having on the patient’s life, even if each individual symptom alone may not warrant referral

Source: NICE