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.
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 firstname.lastname@example.org 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.
• 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
|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.|