Covid-19 primary care operating model and implementation
A letter from NHS England, sent on 27 March, said –
On 19 March you received a letter setting out the next steps in the general practice response to Covid-19. This letter builds on that guidance as we deliver care in an ever-changing environment.
The principles set out in this letter are intended to help achieve three key aims:
1. successful shielding of those identified as most at risk from complications of Covid-19 and actively managing their ongoing, often significant, health and care needs
2. supporting the rest of the population, including those who you suspect have Covid-19, by delivering primary care services, including to those discharged from hospital
3. minimising health risks to yourselves, your practice staff and your local multidisciplinary teams.
The system will need to work to the following principles:
I. Utilising NHS 111 online as the first port of call for people with Covid-19 symptoms rather than approaching their GP practice.
II. Prioritising support for those patients identified as being at the highest risk from Covid-19 and who have been advised to shield themselves, proactively managing a comprehensive medical support package drawing on volunteers and wider services.
III. Adopting remote triage as the default and delivering care and treatment remotely wherever possible and appropriate, based on your clinical judgement, as well as home visits whenever clinically necessary.
IV. Managing essential face-to-face services (including home visits) by designating facilities/premises and teams to minimise the spread of infection to those who are suspected non COVID-19, particularly those most at risk and our healthcare workers.
The next version of the standard operating procedure (SOP) will give further guidance on implementation, but the principles are fleshed out below.
Utilising NHS111 online as the first port of call for people feeling unwell with possible COVID-19 symptoms, rather than approaching their GP practice
NHS 111 has been commissioned nationally to provide a dedicated Covid-19 response service to free practices to focus on managing those most at risk of complications from Covid-19. A consistent algorithm will be used to stream patients into the following cohorts:
• Cohort 1 – patient demonstrating severe symptoms, requires treatment in hospital and will likely require an ambulance response
• Cohort 2a – symptomatic patients requiring further clinical assessment before final disposition is decided (these are referred to the Covid Clinical Assessment Service or CCAS)
• Cohort 2b – patient exhibiting mild symptoms but has self-declared high atrisk status, having received a letter from the NHS – a post-event message recording this contact will be sent to registered GP for information
• Cohort 3 – patient is showing mild symptoms and advised to self-isolate at home and to reassess via NHS 111 (online whenever possible) if symptoms deteriorate (GP informed via a post event message).
To deliver this service we are mobilising additional workforce, including from the experienced retired doctors’ community. They will be immediately employed to remotely support CCAS ensure high quality clinical triage on which practices will be able to rely. The reliance on NHS 111 online will minimise the number of patients contacting their practice for advice unless they have been triaged as requiring it.
Where CCAS assessment is required, this will result in one of the following outcomes:
• reclassification as Cohort 1 – patient demonstrating severe symptoms, requires treatment in hospital and will likely require an ambulance response
• reclassified as Cohort 3 – patient is showing mild symptoms and advised to self-isolate at home and to reassess via NHS 111 (online whenever possible) if symptoms deteriorate (GP informed via a post-event message and call closed)
• requires proactive action from practice – eg telephone monitoring
• requires face-to-face assessment in primary care; message sent to appropriate service to arrange.
In a small number of cases, the patient cannot be managed remotely and requires face-to-face assessment by local primary care services. To implement this, the National Covid-19 Response Service will transfer the last two categories of patient to general practice for follow-up.
Practices must therefore:
• Enable GP Connect for both appointment booking and record access – guidance on doing so can be found at: https://www.emisnow.com/csm?id=kb_article_view&sysparm_article=KB0063 466
• Ensure nominal appointment slots are always available into which the National Covid-19 Response Service can ‘book’ patients into a work list. Patients will be told that they will be contacted by their practice with further information about the follow-up, not given a specific appointment time. No additional clinical triage will be required, but practices will decide how to deliver the appropriate care to each patient according to the record of the assessment already made and the local delivery model.
Swift changes to regulations are expected to give statutory force to this position. We will update practices once these regulations come into force.
In some case it may be necessary for the NHS 111 clinician to speak directly to the GP or the out-of-hours primary care service about a patient: for example, to inform them of the case.
Prioritising support for those patients identified most at high risk and proactively managing a comprehensive medical support package drawing on volunteers and wider services as required to meet their wider needs
By now you will have been notified of those patients most at risk from infection who are registered with your practice: https://www.england.nhs.uk/coronavirus/publication/guidance-and-updates-for-gpsat-risk-patients/ and these patients will have been written to. There is scope for GPs to add to that list based on local knowledge in line with the guidance.
However, please carefully consider who to add – the RCGP issued further guidance on this: https://www.rcgp.org.uk/-/media/Files/Policy/A-Zpolicy/2020/covid19/RCGP%20guidance/202003233VulnerablePatients%20TheRole GeneralPracticeduringCOVID19%20FINAL
Specialist consultants have also been written to advising them of next steps.
The action required by GPs includes:
• Reviewing their care plans, adapting them where needed or appropriate, including undertaking any essential follow-up. This should be done remotely where possible.
• Helping patients receive their medicine supplies regularly by helping them to arrange electronic repeat dispensing and enlisting the support of local resource (this could be co-ordinated through your social prescribing link worker or equivalent) and voluntary sector partners to collect and deliver. Those people most at risk have been advised to access help by visiting www.gov.uk/coronavirus-extremely-vulnerable. You can refer people to receive the support of an NHS volunteer responder via www.goodsamapp.org/nhs. We have had a fantastic response from the public and we strongly encourage you to use this service.
• Speaking to patients (remotely where possible) who have an urgent medical question relating to their health and/or pre-existing condition (they may also need to contact their specialist consultant directly).
We would like you to complete your review of (i) which patients are at most risk, and (ii) their care plans, by the end of March.
Some of these patients may have additional needs including mental health needs, learning disability or autism. Their needs may be exacerbated by the impact of shielding and subsequent reduction in social contact and support. Social isolation, reduction in physical activity, unpredictability and changes in routine can all contribute to increasing stress and subsequently mental health needs
Adopting remote triage as the default and delivering care and treatment remotely where appropriate and based on your clinical judgement
In line with previous guidance (19 March letter), GP practices should adopt a full triage-first model that supports the management of patients remotely where possible. This should be at the point of access by patients to general practice. In practice, this means GP practices using telephone, video and online consultation technology, potentially supplemented by any remote monitoring, available to the patient in their home (eg temperature, blood pressure) or provided as part of the local model.
There is support available for GP practices to establish a remote ‘total triage’ model using online consultations. A blueprint guide has been developed – this is contained in a separate accompanying document (Remote Total Triage Blueprint). There has also been a rapid procurement exercise via the dynamic purchasing system (DPS) framework so that any commissioners who do not have a contract for an online consultation system that enables total triage can immediately call one off. These systems will be centrally funded. Please contact your regional NHS England and NHS Improvement team to take this forward, ensuring you have a solution by 3 April 2020 at the latest.
It is also essential that all practices have a video consultation system to support remote management of patients. Advice from NHSX on using free solutions has been published; all relevant products on the Digital Care Services Framework (GPIT Futures) have now been assured, and the rapid procurement via the DPS has also created an approved video consultation supplier list. Video consultation systems from the DCSF or DPS will be centrally funded.
This means there are a variety of options available for practices to use and commissioners should support practices to put these in place immediately where there is no video system currently available.
NHS England and NHS Improvement are also working with CCGs to enable secure remote working options for GPs and practice staff including social prescribing link workers that are supporting practices. The priority is to ensure secure NHS laptops and equipment are supplied where possible. Annex A sets out some further information including temporary solutions that can be implemented in the interim.
Manage essential face-to-face services (including home visits) through designating facilities/premises and teams to minimise the spread of infection to those who are suspected non-Covid, particularly those most at risk
It may be clinically necessary to come into direct contact with patients, for example, those identified most at risk, to provide them with the necessary treatment and care in a range of settings including the person’s own home, the GP practice, a local hub or an alternative care setting in the community.
To manage this effectively and avoid any risk of cross-infection, there will need to be separation in terms of how services are configured, staffing and patient flow management. This principle applies equally to providers of community services and social care.
In practice, the vast majority of patients with Covid-19 symptoms can be assessed and managed remotely. Routine care for these individuals can usually be postponed to a later date. However, there will be cases where face-to-face assessment is required (eg COVID symptoms with an acute abdomen). These would need to be carefully managed either in a designated way on premises set up to deliver these services or by home visit, always with appropriate precautions and PPE.
Some practices may wish to separate services for those with urgent care needs (red or hot sites) from routine but essential care (green or cold sites, eg childhood imms), making provision for anyone with Covid symptoms.
Each local area will need to consider and agree with their CCG, the model that best suits their local context and arrangements. It might be necessary to change and/or flex the chosen model depending on changes in demand and workforce capacity/availability.
For example, a scenario may arise in which a practice has to temporarily close its premises for contamination reasons, or due to a lack of workforce (any closures are subject to CCG approval) – in this event, the model would need to be flexed so that services to its patients using available staff can continue to be delivered from another site.
Options for managing face-to-face appointments
Option 1 – Zoning
Manage patients within practices but with designated areas and workforce to maintain separation.
This may characterise the model that practices have implemented immediately to manage the risk of contamination. In practice, it requires designating a specific zone/area within each practice to treat patients triaged as ‘amber-red’. This option reduces the need for significant reconfiguration of existing patient flows.
However, the interface between the redamber and green zones would need careful management to minimise crosscontamination with strict decontamination protocols in place – this would need to be extended to staff to maintain a ‘COVID-19 free’ home service for ‘green’ patients including those most at risk. Not all premises are likely to have separate entry/exits point to help maintain this kind of separation.
The principles of this model could be extended to walk-in centres.
Option 2 – Practice designation
Designate practices, across a PCN footprint, to either treat those with suspected Covid-19 needing further face-to-face contact (rare) or those patients without Covid-19 symptoms needing essential care.
Practices may wish to adopt such a model to better manage increasing demand as infection rates increase.
Those sites that treat those without Covid-19 symptoms will need protocols to ensure patients remain symptom-free before contact. These sites may also carry out other essential work such as childhood vaccines and immunisation. This option is likely to be the most effective option in managing cross-contamination.
Workforce capacity constraints mean pooling may be required. Additional support will be needed for those staff working in sites dealing with those with suspected Covid-19 symptoms – these cases should be rare.
Walk-in centres could follow this same designation model, which could be particularly useful when demand from those showing symptoms surges.
Any sites treating those without Covid-19 symptoms that become compromised would need decontaminating.
Home visiting can be organised at network or place level to deliver care at home to the most at risk of complications due to COVID-19, and these will be needed in either model.
In all variations, it will be vitally important to have strict infection control and decontamination proposals to minimise the risk of onward transmission from patients to healthcare workers and vice versa. That principle applies equally to home visits. The standard operating procedure will set out more detail about how this should work in practice from pre-contact to discharge. We will also write to you shortly setting out the principles and arrangements for workforce testing.
It might be the case that you need to use additional estate capacity in a way that supports your model for managing face-to-face services as outlined above. NHS England and NHS Improvement have been working in collaboration with both NHS property companies (NHS Property Services and CHP) and external landlords to identify suitable vacant estate that could provide additional capacity on a temporary basis. The NHSPS and CHP availability has now been mapped on to the SHAPE atlas https://shapeatlas.net/ for ease of use.
In most circumstances, it has been agreed that these premises will be let on a costonly basis for a fixed, short-term period. For use of these spaces, it has been agreed in these circumstances to allow commissioners to enter into the agreements either through a tenancy at will or a license for occupation. It will also be necessary to record the occupations on a central register. If a commissioner takes out an agreement, they will be required to update any documentation.
For further advice on this, please contact: firstname.lastname@example.org
Source: NHS England, Preparedness update letter for general practice: 27 March 2020 [published 27 March]