Implications of changes to routine service provision
Under the GMS contract, practices have a responsibility to provide services to your registered patients and it is for practices to decide how best to do so. COVID-19 does not in any way negate this requirement.
General practice has rapidly, and rightly, changed its working patterns in order to cope with this national emergency, and demand on general practice for routine care has changed.
There are early signs that a short-term reduction in routine clinical activity, although replaced by significant work on system change, is now reversing as patients begin to contact their practices more frequently again. This will lead to routine clinical work returning more toward normal, in addition to increased workload to manage the COVID emergency.
New ways of working
Practices are responding to the needs of patients with, or suspected of having, COVID-19, by admitting them when clinically appropriate and managing them in the community. This is in the way you would for many other patients (including palliative care), often supported by community nursing and other primary care teams.
These arrangements, including the establishment of hubs or zoning in a practice building, have been established by practices to manage patients to whom you have a responsibility to provide essential services.
Remote working reduces the risk of contracting or spreading COVID-19, and should be considered the default for staff as part of a safe delivery of clinical services. However, there will be instances where a face to face consultation is required. Practices who do not do so may make clinical errors and therefore could be open to medico-legal and contractual risks. Practices need to ensure patients can access services appropriately.
Face to face work should be allocated equitably across clinical staff, taking into account individuals’ risk factors. Higher risk work should not be solely allotted to a specific type of contract.
Funding for COVID-related care
NHS England has committed to maintaining practice income while practices replace normal routine care with new ways of providing this care, and provision of COVID-related care.
Additional costs accrued by these new models should be covered by additional funding from the national COVID-funding announced by Government. Many CCGs are also providing additional support.
For example, if the system deems that a group of people (eg shielding patients) who are not normally housebound must be visited, then that should trigger a discussion about how that new additional work is paid for or commissioned.
Practices in Scotland have received advance funding against anticipated higher costs associated with the current outbreak. A revised SFE has been agreed for the duration of the outbreak which sets out details of additional support that practices can anticipate.
If further funding advances are required, practices are able to request these from their health board. A guarantee has been agreed that no practice in Scotland will lose out financially as a result of COVID-19.
For patients who require care not related to COVID-19 (whether they don’t have COVID-19, they are asymptomatic, they are shielding, or they have COVID-19 but have other health needs) – practices will provide the routine care to their patients in the way they decide is clinically appropriate.
If the patient is already under specialist care (ie not general practice care) for specific health needs, then this specialist care should continue to be provided.
For patients who require care not related to COVID-19 and are not suspected of having it, practices will continue to provide routine care in the way that they decide is clinically appropriate.
Patients who are either suspected or confirmed as having COVID-19 but require unrelated routine primary care may be required to access this via the hub or CAC (COVID assessment centre). Delivery of specialist care provision to patients who are shielding or isolating remains the responsibility of specialist services.
COVID-related care in the community
For patients who require COVID-related care in the community, NHSEI has stated that it is for the locality to agree how this is to be delivered – with input from all providers within the locality.
A practice cannot be forced to operate in a specific way, or deliver care that is outside their scope of expertise, but we would expect all parties to work collaboratively to ensure patients receive appropriate care.
Localities may agree additional funding is required, especially if the new model of care delivery creates additional costs to practices.
In Scotland, hubs and CACs have been established to cohort COVID-related care away from wider general practice.
- At least one hub and CAC has been established in each health board.
- The role of hubs is to remotely triage potential COVID-19 cases for further assessment at a CAC.
- The role of the CAC is to assess whether hospital admission is required.
- Hubs and CACs are health board operated and their staffing is made up of clinicians from primary and secondary care.
Routine care and your requirements
England and Wales
We advise that all non-urgent work be postponed until further notice. This might include:
- travel advice and travel vaccinations
- new patient reviews
- over-75 health checks
- minor surgery
- clinical reviews of frailty
- friends and family tests
- engagement with PPGs
- phlebotomy (non-essential to be suspended)
- dispensing services quality scheme to stop (with funding protected)
- dispensing list cleansing
- routine medication reviews (essential ones to be conducted by phone)
- all other non-urgent provision (DESs and LISs/LESs) to be postponed until further notice
- funding will be protected for practices
- audit and assurance activities
- data collection requests (unless considered essential to support the COVID-19 efforts)
- all other routine nurse appointments will be subject to telephone triage by nurses
- appraisal and revalidation
- all routine CQC inspections (already enacted)
- all non-essential paperwork.
- Essential services as determined clinically relevant by the practice and based on the available workforce, capacity and PPE.
- Immunisations for children, influenza and pneumococcal infection.
- All staff are covered by the full CNSGP indemnity scheme currently.
We have published similar guidance on activities to continue in Wales.
We have also published guidance on video consultations and home working.
These should be read alongside guidance from the RCGP on workload prioritisation and NHS England guidance and standard operating procedures.
Guidance for practices in Scotland has been co-produced by the BMA, RCGP and Scottish Government. It recommends a number of steps for practices, including triage of patient appointments and services that can be paused to free up capacity.
Patients on the shielding list
Practices must review the list to ensure it is accurate.
NHSE has used various data sources and codes to extract the list and we are aware that the second list provided on 10 April may have included more inaccuracies.
We have prepared guidance on the list of at-risk patients and shielding arrangements.
Practices should do what they can to ensure the list is appropriate and updated so that patients can get access to the necessary services.
Hospitals are also able to add to the list of patients shielding and this is to be done directly by them through a separate process. Practices will be notified of additions to the list as appropriate.
Unfortunately, a large number of patients did not receive letters, and may be in contact with practices. GPs are able to issue the letter if they think appropriate to do so and in agreement with the patient.
Practices have been asked by the Scottish Government to assist with identifying patients who fall into the highest risk groups who have not been identified centrally.
Practices have been asked to contact these patients to update anticipatory care plans and key information summaries. Shielding patients will fall into one of seven groups and practices are asked to notify the health board of the CHI number and category number of any patients identified as being in the highest risk group who have not been identified nationally.
The Scottish Government has developed guidance on what it is asking practices to do to support shielding.
NHS111 and CCAS direct booking into practices
NHSE has announced that the CCAS (COVID clinical assessment service) will be able to book patients, who have been appropriately clinically triaged, directly into practices, at a rate of 1 appointment per 500 registered patients.
This is intended to be a hand-off of patients from CCAS, rather than a booking into an appointment and should operate as a worklist for practices to manage in they way they see fit.
From 30 March until 30 June 2020 all practices in England must make one appointment per 500 registered patients per day available for direct booking by NHS 111. This supersedes the previous requirement of one appointment per 3,000 registered patients and is not in addition.