This article was updated on 6 April to update the link to the latest standard operating procedure for general practice (many of the sections below have also been updated as a result of this)and to include links to NICE clinical guidance; on 1 April with details about the use of volunteers in the NHS; and on 30 March to update links to RCGP guidance.
This article is based on guidance for England, please see links below for specific guidance/information for Wales, Scotland and Northern Ireland. Information relating to infection control and much of the information aimed at the public is relevant in all four UK countries:
- Health Protection Scotland guidance for primary care
- Public Health Wales latest information (Public Health Wales refers healthcare professionals to Public Health England's guidance, which much of this article is based on)
- Public Health Agency Northern Ireland latest information (The Public Health Agency also refers health professionals to Public Health England's latest guidance)
Main guidance for primary care
Key guidance practices need to be aware of are:
- NHS England's COVID-19 standard operating procedure for general practice (dated 5 April 2020)
- Public Health England's infection control and PPE guidance
- The RCGP is regularly updating guidance for GP practices - more information here.
- GPs in England can also find links to all relevant guidance for primary care on coronavirus on NHS England's website here.
NHS England says all practice staff should be made aware of the standard operating procedure, the latst case definitions and guidance on patients at most risk of severe illness as a result of COVID-19, including those advised to shield themselves and other at-risk groups.
The latest operating procedure says that staff, including home visiting staff, should be allocated to either patients with symptoms of COVID-19, or other groups of patients, where possible.
Any urgent updates to practices will be provided by the central alerting system (CAS), so practices should ensure the MHRA has an up to date email address that is regularly checked by staff.
Guidance from NHS England on 19 March detailed the routine work that practices can now suspend and the income protection measures that will be implemented. The RCGP has produced guidance on workload prioritisation to support this guidance. This is intended to be read in conjunction with guidance from the BMA here.
Symptoms and suspected cases
Fever, cough or chest tightness, and dyspnoea are the main symptoms reported by affected patients. PHE guidance says that COVID-19 may cause mild to moderate illness as well as pneumonia or severe acute respiratory infection.
The latest case definition guidance is here.
Anyone with a continuous cough or a fever over 37.8C has been advised to self isolate for seven days. Those who remain unwell after seven days should contact NHS 111 online.
Any family/household members of any person displaying symptoms, however mild, should stay at home for 14 days. The person who is symptomatic can end their isolation period after seven days, but all other household members should remain at home until 14 days after the first person became ill, or seven days after their own symptoms resolve if they become ill.
The current position is that those people who are self-isolating in the community will not be tested for coronavirus – at present, testing is focused on patients admited to hospital. This also currently applies to healthcare professionals.
Guidance on self isolation
PHE has produced guidance for patients who are advised to self isolate due to experiencing symptoms and for families/households that are all self isolating:
- Stay at home: Guidance for people with confirmed or possible COVID-19
- Stay at home: Guidance for households with possible coronavirus infection
The role of NHS 111
People with suspected early symptoms of coronavirus are being directed to an NHS online advice centre here: www.nhs.uk/coronavirus. Patients can also now obtain a 'self isolation' note if they need to isolate for 14 days online from NHS 111.
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.
According to the latest standard operating procedure a consistent algorithm will be used to stream patients into four cohorts. A new Covid Clinical Assessment Service, that will be staffed by doctors who have come out of retirement, among others, will support NHS 111 and in some cases may refer patients back to their practice for a remote or face-to-face assessment (see the SOP for more details including a visual algorithm of how the system should work).
Practices should now avoid redirecting patients to NHS 111 if they present in general practice because they can't get through to NHS 111 or beause NHS 111 has directed them to their practice. 'The risk of patients becoming stuck ina loop between NHS 111 and general practice poses a significant risk to unwell patients,' the standard operating procedure says.
Practices should follow the system for seeing patients with symptoms in their local area (see below).
Patients with symptoms of COVID-19
The standard operating procecdure highlights this BMJ article for guidance on remote assessment and management of patients with symptoms of COVID-19
The operating procedure also includes guidance on seeing possible COVID-19 cases. It says most patients with symptoms can be assessed and managed remotely.
When face-to-face assessment is required this should be done according to the local operating model, which may be via designated sites (either within the practice or as a separate location or 'hot hub'), or home visiting. Details of the possible operating models are set out in the operating procedure.
The operating procedure recommends that local areas/practices should allocate staff to patients with symptoms of COVID-19 or other groups, where possible. This should also apply to home visiting teams. However the guidance acknowledges that this may be difficult in some areas. 'If it is not possible to fully separate staff groups on a longer-term basis, consider seaparation on a day-to-day basis,' the guidance says.
Routine care for patients with symptoms should, where possible, be delayed.
Staff should wear the currently advised PPE for a possible case of COVID-19 and all PPE should be disposed of as clinical waste.
If a patient is critically ill and requires an ambulance transfer to hospital, the call handler should be informed of the concerns about coronavirus. Any other transfer to secondary care should be discussed with the hospital first.
For guidance on when to consider hospital admission see NICE's guidance here.
Public Health England guidance on infection prevention and control, including recommended PPE for primary care, is here.
All patients should now be triaged either by phone or online before deciding whether they should have a face-to-face appointment. They should be advised to inform staff if they develop symptoms of COVID-19 between triage and attending for a face-to-face appointment. Online bookings should be for telephone or online appointments only.
Remote consultations and homeworking
NHS England has said that all care that can be done remotely should be done this way.
- NHS England has produced guidance on how to establish a remote 'total triage' model in general practice here.
- The University of Oxford has produced new guidance on undertaking video consultations in general practice here.
- The BMA has advice on remote consultations and homeworking here.
Practices should display coronavirus patient information posters (which are available here) so that they can be seen before patients enter the surgery. They should also be visible in reception, next to any patient touch screen booking-in, waiting areas and at patient access points to clinical areas.
Practices should 'designate and prepare' a suitable isolation space, ensuring there is a phone in the room if possible. All clutter and non-essential furniture should be removed. If an isolation room is not possible, practices should identify an isolated area within the surgery that can be cordoned off, maintaining a two-metre space from other patients and staff.
Patients attending the surgery
The following is taken from the latest standard operating procedure
- All patients should be asked if they have any of the symptoms of coronavirus when they attend the surgery.
- If they meet the case definition they should be asked if they feel able to cope at home and if so they should return home and follow the coronavirus advice.
- If no, they should be directed to an approriate site, if it is easily accessible. If not the patient should be immediately isolate in the isolation room.
- If GPs suspect a patient of having coronavirus during a consultation they should leave the room, wash their hands and conduct the remainder of the consultation by phone if necessary. The patient's belongings should remain in the room.
- If face-to-face assessment is required staff should wear PPE and keep exposure to a minimum. All protective equipment should be disposed of as clinical waste.
After the patient has left the surgery
Cleaning and decontamination should be carried out in line with Public Health England guidance here. If practices need to close temporatily for cleaning of communcal areas, usual business continuity arrangements should be followed.
Guidance on home visits is in the latest standard operating procedure. Remote triage for symptoms of COVID-19 should take place before the visit. If COVID-19 is supsected during a home visit a similar process should be followed as above. The GP should leave the room and conduct the remainder of the consultation via phone.
If symptoms are identified during a care home visit, the local health protection team should be informed.
Practices should ensure that home visit bags have necessary PPE and clinical waste bags in case a patient suspected of coronavirus requires emergency treatment during.
If a home visit is required for a patient who is already self-isolating, the practice should speak to the health protection team about this.
NICE has produced a range of rapid guidelines in response to the COVID-19 outbreak. The following are useful for GPs and their teams:
- COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community
- COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community
- COVID-19 rapid guideline: severe asthma
Anyone over 70, those with underlying health conditions and pregnant women have been advised to undertake social distancing measures. This means that they should avoid contact with anyone displaying symptoms, however mild, work from home where possible, avoid non-essential use of public transport, avoid large gatherings and pubs, restaurants etc and contact their GP practice by phone. The guidance below outlines which patients this affects.
NHS England has written to patients at most risk from severe complications from COVID-19, asking them to stay at home and avoid face-to-face contact for the next 12 weeks. GP practices are being asked to ensure the list is correct.
An FAQ for GPs here explains the process for adding other people to this register. Patients are also being asked to self identify on the government website and practices will receive a list. They should add appropriate patients to their register by flagging their record and sending them a letter (see link below).
If patients who are shielding require a face-to-face assessment for any reason this should be done in the patient's home, and involve strict infection control measures, according to the latest operating procedure. A separate home visiting service for these patients should be considered. The number of healthcare professionals visiting a patient's home should be limited as much as possible. Shielded patients with symptoms of COVID-19 should be referred to the most appropriate service, depending on local arrangements.
The full list of patients covered by the measures along with the steps practices are required to take are detailed in the NHS England guidance below.
There is more advice on how practices should support these patients here.
- NHS England guidance for GP practices - including template letters.
- Guidance for patients on shielding
- RCGP e-learning module on shielding
Pregnant healthcare staff
GPs who are pregnant should have the choice not to continue in patient-facing roles. Healthcare staff who are more than 28 weeks pregnant, or who are pregnant and have underlying health conditions, should avoid direct patient contact and work from home during the coronavirus outbreak, according to new guidance.
Women who are less than 28 weeks pregnant should can continue working in a patient-facing role if they choose to do so, 'provided the necessary precautions are taken'. Where possible, they should avoid caring for patients with suspected or confirmed coronavirus infection through using PPE and risk assessments.
Changes to death certification
The latest operating procedure says updated guidance on death certification will be published shortly.
NHS X, formerly NHS Digital, has produced guidance on information governance during the coronavirus outbreak here.
Doctors forced to work 'outside their normal scope of practice' during the coronavirus outbreak will have that context taken into account if they face complaints. A joint statement from the GMC, NHS England and the UK's chief medical officers makes clear that while doctors are always expected to adhere to GMC principles and guidance, the difficult context in which they are working will be factored in if complaints arise - and that for junior doctors or students stepping up, 'we are determined to ensure the long-term prospects...are not compromised'.
Other key medico-legal questions are answered here.
If health workers fall ill
Practice staff should follow the Stay at home advice if they have a continuous cough or a fever of over 37.8C.
Practices should continue to register new patients, including those with no fixed address, asylum seekers and refugees (absence of photo identification and proof of address is not a reason to refuse registration).
Delivery of application may be by any means, including post and digital, including scanned copies.
The latest standard operating procedure has advised practices to work together to 'maximise clinical capacity and provide business continuity resilience'. More detail on how they should do this is here.
Medeconomics has the following resources to help you with your business continuity plan:
- Business continuity checklist
- Business contiunuty: Risk assessments and impact analysis
- Downloadable policy: Business continuity plan