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.
Routine care and your requirements
As the workload pressures caused by the pandemic grow, and as practices engage in the COVID vaccination programme, practices will need to continue to prioritise their work.
Accordingly, we have agreed a number of additional measures with NHS England to support practices during this time, detailed in a letter to practices and outlined below.
NHS England has instructed CCGs to take a supportive and pragmatic approach to minimise local contract enforcement across routine care. This will allow practices to decide how best to allocate practice and PCN resources.
In light of this, the GPCE and RCGP have published updated joint guidance to help practices to prioritise the clinical and non-clinical workload in general practice.
All other provisions put in place by the NHS (amendments relating to the provision of primary care services during a pandemic) Regulations 2020 should continue until 30 June 2021 for GP practices in England.
We advise that all non-urgent work be postponed until further notice. This might include:
- travel advice and travel vaccinations
- friends and family tests
- 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)
- 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 (unless requested by the appraisee)
- all routine CQC inspections (already enacted)
- all non-essential paperwork (such as insurance reports and DVLA medicals for non-essential workers)
- new patient reviews (including alcohol dependency)
- routine medication reviews
- over-75 health checks
- clinical reviews of frailty
- routine call for shingles vaccination programme
- engage with and review feedback from PPGs (conducted remotely)
- list cleansing activities - this is considered particularly important ahead of the planned migration of GP payments from NHAIS to PCSE online later in 2020
- standard complaints activities.
- 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.
- Work related to QOF indicators not otherwise protected (flu immunization, cervical screening and registry management).
- Work related to IIF indicators.
- Medical assessments that are part of the adoption and fostering process - see our statement with RCGP.
The BMA and the DWP (Department of Work and Pensions) have agreed that until further notice, fit notes may be issued remotely and sent to patients electronically.
A properly signed and scanned fit note sent via email to the patient will be regarded as 'other evidence' and will be accepted by DWP for benefit purposes.
You should send the scanned document to the patient who can then share with either their employer or DWP. The original hard copy does not need to be retained if there is an electronic copy of the fit note in the medical record.
If the patient is unable to receive their fit note electronically then they will be required to collect a hard copy from the practice or it will need to be posted to them, at the practice’s discretion.
DfE has confirmed in their guidance to schools that they should not encourage parents to generally request doctors’ notes from their GP when their child is absent from school due to illness. If evidence is required, it can take the form of prescriptions, appointment cards, text/email appointment confirmations etc. Input from GPs should only be sought where there are complex health needs/persistent absence issues.
Due to added pressures caused by the pandemic, a decision was taken by DVLA in April 2020 to waive the medical requirement for a D4 licence renewal application for those aged 45 and over. Applicants were instead issued with a single, one-year licence.
After talks with the DVLA, the BMA has agreed to aim to accommodate D4 medical appointments for working drivers to make sure that drivers are available to the transport industry. Further information and guidance on this can be found on the DVLA website.
We would therefore encourage practices to enable relevant drivers to have D4 medical examinations for working drivers as much as public health guidelines and individual priorities allow. This excludes car driving licence renewals with small lorry (C1, C1E (107)) and minibus (D1 (101) and D1 (101,119)) entitlements issued before 1997 where these entitlements are used for driving large recreational vehicles rather than for working in the transport sector.
Practices are reintroducing elements of routine care which were suspended. There are still likely to be significant restrictions, taking account of social distancing, estates issues and PPE/cleaning requirements of F2F delivery.
The reinstatement of contractual requirements does not set out an expectation that all services will return to normal within that timescale. The reintroduction of services must be considered carefully according to local circumstances and in discussion with health boards and local medical committees.
Welsh Government have published guidance outlining principles for the safe return of general practice to routine arrangements.
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.
Changes to routine service provision
The only QOF indicators which are not currently income protected are those related to flu vaccination and cervical screening, and register maintenance.
Read more about QOF indicators and points in COVID.
DESs, LESs/LISs and local pilots
Local commissioners have been asked to suspend any locally commissioned services from January to March 2021. Except, where these are specifically in support of vaccination, or other COVID-related support to the local system, eg wherever they contribute to reducing hospital admissions or support hospital discharge.
The minor surgery DES (directed enhanced service) will be income protected until March 2021 and a similar provision will be made for the additional service income related to minor surgery within the global sum.
DSQS (dispensary services quality scheme) (for dispensing practices)
DSQS was reinstated from 1 August 2020. GPC is currently in discussion with NHS England about further measures.
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 hubs or zoning in a practice building, are 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. 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 across clinical staff, taking into account individuals’ risk factors. Higher risk work should not be solely allotted to a specific type of contract.
The successful management of demand will rely on sustaining the transformations delivered during the first phase. These transformations include local system working, total triage, remote working and consultations.
Responding to local outbreaks
Managing any local outbreaks, CCGs may need to order a further suspension of activities which are now being reintroduced across affected practices.
CCGs will need to submit a request to NHSE/I to suspend any contractual requirements. If a request is approved then NHSE/I will write directly to the affected practices setting out the agreed changes.
CCGs may also be able to offer some flexibility to hard hit practices during a local outbreak who may not be able to meet patient demand, eg if there are resulting high levels of staff absence.
COVID PCR swab testing results
Results from national PCR swab testing will appear in patients' records. Results predating the national test and trace regime will also appear in patients' records where an NHS number has been identified.
There is no action required of practices as the patients will have already received their results and they should have been communicated to PHE.
PPV was reinstated from 1st October 2020.
Some practices will have had changes in capitation in the last 12 months and potentially will see increases in required provision of enhanced services when compared to historical figures. To protect against these fluctuations, amendments against the SFE directions have been agreed.
England and Wales
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.
Managing long-term conditions remotely
Most conditions lend themselves well to remote assessments and could actually be enhanced. Remote management could create an easier opportunity to share care plans, information and guidance through links to websites and shared documents.
See below a list of conditions and how they can be managed remotely.
This can be monitored by patients using their own home monitors and results fed into the patient’s record electronically or by telephone. This may lead to a reduction in white coat hypertension and enable better control.
The review could be carried out remotely but would benefit from a video consultation to be able to see the patient and observe their respiratory rate and function. Spirometry should not be attempted during the pandemic. Indicators in QOF 20/21 have changed to include the following:
- Patients could have a review including smoking status, a record made of the number of exacerbations in the last year, as well as MRC dyspnoea scale completion. Patients could have medication reviews and altered if control has altered significantly over the year.
A remote review is possible. The practice could consider online assessments including inhaler technique. Patients who do not already have a peak flow meter at home could be prescribed one.
In line with QOF 20/21 the patient should have an assessment of control using a validated asthma control questionnaire, recording of number of exacerbations and a personalised written plan.
The plan could be sent electronically, and the control and exacerbation could be collated using an online self-assessment.
Practices could consider remote review of shielded patients first including a functional review and medication review to ensure dose optimisation. Home blood pressure monitoring could be done when medication is titrated upwards.
Practices could consider remote review and complete most aspects of the annual review this way.
Consideration needs to be given to those patients that would most benefit from checking their HBA1c, reducing this physical contact to the minimum.
A partial foot assessment could be done via video, looking for signs of ulceration and reviewing their risk status.
Serious mental illness
Patients with serious mental illness should be reviewed remotely were possible and with the support of mental health services when relevant. Patients may need additional support during COVID-19.
COVID 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.
The Welsh GP committee were approached by Welsh Government to review and repurpose the existing care home DES. Feedback from the care home sector suggested that whilst we were operating in a pandemic, the pressing needs of those working in very challenging and difficult circumstances in care homes were different to those before COVID. They felt the current agreement was no longer fit for purpose.
After significant renegotiation of the original Welsh Government draft, we have agreed a time limited COVID-19 revision to the DES to March 2021. This will involve:
- care homes being given a direct number to contact the practice when an urgent problem arises - an urgent response and advice will be given by the practice
- weekly ward rounds with a suitable clinician from the practice team to discuss residents’ concerns and proactively deliver care in a timetabled fashion
- in order to free up GP time the requirement for two structured clinical reviews each year has been replaced with the ‘ward round’ based review system
- enhanced medication reviews will still be undertaken annually
- the ‘unscheduled care reviews’ will be replaced by ‘mortality reviews’ where deaths will be explored for future learning and reflection.
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.
NHS111 and CCAS direct booking into practices
The CCAS (COVID clinical assessment service) is 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.
All practices in England must make a maximum of one appointment per 500 registered patients per day available for direct booking by NHS 111. However, the actual number will depend on demand, which should be reviewed regularly. This supersedes the previous requirement of one appointment per 3,000 registered patients and is not in addition.