When the Covid-19 pandemic started the CCGs and STPs/HCPs seemed to go into a ‘command and control’ strategy in terms of the primary care response to it: likely based on previous plans laid out regarding pandemic influenza. These strategies involved the setting up and establishment of Covid-19 ‘hot sites’ or ‘hot hubs’ in each CCG region, with the plan that 111 and/or local GP practices could refer patients with ‘suspected coronavirus’ there for further assessment.
As they stand, if 111 or a GP practice has done a triage and referred a patient to the ‘hot site’, it seems a second triage is then be done; however, as the individual with symptoms has already been triaged once as needing further assessment, it is fairly likely that a face-to-face clinical encounter will then ensue.
These hot hubs have now been set up in most CCG areas, and follow a variety of models: some are more like outside assessment areas, for instance in car parks, with oxygen saturations monitoring and basic observations: sometimes done whilst a patient is still in the car: ‘drive-thru’ oxygen sats monitoring if you will. This seems to be a good model in terms of reducing the risk of environments with high viral loads and vector enhancement, and appears to be working quite well where this has happened, although staffing these has meant taking frontline workers away from their own GP surgeries in some instances, which can cause its own problems.
Other models however seems to be in buildings: contained and enclosed environments where social distancing may be more difficult to adhere to and the buildings may be old with poor ventilation with possibly the potential of causing high environmental viral loads and increased risk of viral contagion and transmission to people in the vicinity of the building, especially as now many people regard Coronavirus as effectively ’airborne’ transmission and not just droplet spread. Some CCG areas have established ‘hot’ and ‘cold’ clinics also, although it is argued that as large numbers of individuals seem to be asymptomatic with Covid-19, the ‘hot’ and ‘cold’ terminology may not be useful or appropriate.
One point regarding the second type of hot hub that I mentioned, which is more building based is that one of the features of Covid-19 is that the severity of illness seems to be linked to the exposure to higher viral loads: the ‘viral load theory’. It is speculated that in the Bergamo region of Northern Italy, the catastrophic and terrible consequences of the pandemic in that area were possibly linked to a Champions League football match where tens of thousands of football fans, clearly many of whom were carrying the virus, were brought together; there were lots of people in an enclosed space with very high viral loads and there was a ‘biological bomb’ effect which were ideal conditions for transmission and propagation of the virus.
The hot hub strategy has lots of unanswered questions
So we have to be very careful about not generating a situation that we definitely do not want: large numbers of people with mild/moderate disease not needing admission; a small area of clinical assessment; difficulty adhering to social distancing measures; inadequate PPE and large viral loads.
The hot hub strategy also has of course lots of unanswered questions:
- Is it worth taking staff away from GP surgeries if hot hubs are poorly attended?
- How long will they last? For the duration of the pandemic which may mean over 12 months or longer?
- How will they be funded?
- Is there extra funding or will this be coming out of GMS and normal contract payments?
- Is there a Covid-19 ‘fund’ covering all these expenses?
- Will these hot hubs lead to an erosion of practice based care?
- Will hot hubs actually create more work?
- Is it right to refer a patient to a hot hub on the other side of the CCG area, when they live around the corner from their GP practice?
- Is doing ‘drive-thru’ observations such as oxygen saturations a good enough form of assessment?
- Is actually knowing your patients and their medical histories useful when it comes to assessment?
- Should assessment for Covid-19 be done more at a practice level with remote consultations (video and telephone), backed up by home visiting and face to face assessment as needed?
In terms of the funding it seems that in most areas the money is coming out of normal contract payments, although some CCGs have assured practices that ‘their costs will be covered’.
Without taking anything away from the dedicated GPs and other members of the primary care team who have helped establish the hot hubs, with of course the right intentions, it is however argued that there should be a more ‘practice first’ model of care during the pandemic: some patients will definitely need urgent face-to-face assessment, but this is may be best done at the patient’s home where they are in isolation, or if necessary in a specified room at the GP surgery.
The viral loads will be lower compared to the ‘centralised’ CCG hot hub strategy, the exposure less, the risk to other people and HCPs diminished with just as good if not better medical care and assessment of individuals who have likely Covid-19. It may be safer for everyone, and the questions listed above regarding Hothubs, will then become largely irrelevant and the GP practice-based care that has served us so well for decades will be supported and consolidated.
It’s almost that with the top down pressure from CCGs to create hot hubs when the pandemic started, that NHSE and some CCGs did not trust individual GP practices to look after their own patients with Covid-19? What a shame.
The solution in the majority of cases of Covid-19 is: supported self-care, telephone and video reviews and face-to-face appointments as required and home visits. Face-to-face appointments if necessary can be near the back door at the GP surgery, with quick in/out access and easyclean: viral loads may be less and risk diminished. In particular, the GP-led triage will be for the surgery’s own patients who they know, the medical records will be easily available and it will be likely more accessible to the local population.
There are no easy answers: we are in uncharted waters. The ‘hot clinics’ solution looks good on a strategic level, but when we look back at this time years ahead, the main thing that we do not want to find is that the ‘Covid-19 hot sites’ became in fact ‘Covid-19 hot spots’ that in fact led to continued viral transmission mapped back to them as it was the case with the football match in Milan.
Dr David Mummery is a GP in west London and academic clinical research fellow at Imperial College London