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 continue, practices will need to continue to prioritise their work.
NHS England and NHS Improvement has now set out plans for an acceleration of COVID-19 vaccination following the emergence of the omicron variant.
They have written to practices setting out further details of actions to support GPs, primary care networks and their teams to expand the vaccination programme alongside patient access this winter.
GPCE and RCGP have published joint guidance to help practices to prioritise the clinical and non-clinical workload in general practice.
The following changes will apply to IIF for 2021/22, implemented via a forthcoming variation to the network contract directed enhanced service.
- The three flu immunisation indicators, and the appointment categorisation indicator (as the work is complete), will continue to operate on the basis of PCN performance in 2021/22.
- The remaining indicators will be suspended and the funding allocated (worth £112.1m) repurposed.
- £62.4m of the funding allocated to these suspended indicators will instead be allocated to PCNs via a PCN support payment, to be paid on a weighted patient basis, subject to a simple confirmation from the PCN that it will be reinvested into services or workforce.
- £49.7m will be allocated to a new binary IIF indicator. This is paid on the basis of all practices within a PCN being signed up to phase 3 of the COVID-19 vaccination enhanced service as at 31 December 2021, remaining signed up until 31 March 2022, and actively delivering the programme.
Practices not signed up to the phase 3 enhanced service needed to opt in by 10 December 2021, be assured to go live in early January, and continue to participate in the enhanced service until 31 March 2022.
Payment for this indicator will be made on a registered list size basis after the end of the financial year.
Where, in exceptional circumstances, the commissioner agrees with one or more practices that they should not participate in the enhanced service (as a result of wider access, performance or patient safety issues) then the PCN may still receive payment with those practices excluded.
The payment will not apply if any practice in the PCN otherwise declines to participate in the programme.
- As with QOF, CQRS will continue to operate in 2021/22 and achievement data will be collected and reported for all indicators. Recording of activity should continue.
Payment for IIF may be made later than usual for 2021/22, given that the proposed changes to the scheme are being made towards the end of the year.
- IIF will recommence in full from April 2022.
- If participating in the vaccine programme, income protection for the minor surgery DES will apply from 1 December 2021 until 31 March 2022.
Local commissioners should make the monthly payments to practices for the minor surgery direct enhanced service that they made for the corresponding period from 1 December 2018 to 31 March 2019.
No contract enforcement will be taken where no activity is done under the minor surgery additional service from 1 December 2021 to 31 March 2022. Capacity released must be redeployed to vaccination.
- From 1 December 2021 to 31 March 2022, where contractors consider it clinically appropriate and they are participating in the vaccine programme, routine health checks on request for those over 75 who have not had a consultation in the last 12 months, and for new patients may be deferred.
- The dispensary services quality scheme will be amended to reduce the requirement for medication reviews from a minimum of 10% of dispensing patients to a minimum of 7.5% for 2021/22.
Practices will be asked to prioritise patients who they consider to be higher-risk or would benefit most from a review.
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.
In consultation 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.
The temporary scheme to issue one year lorry and bus licences to drivers aged 45 and over without a D4 is ongoing for drivers who are unable to get a D4 medical examination.
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 expected to continue to provide routine care arrangements, while retaining the telephone first triage model which was brought in at the begging of the pandemic.
There are still likely to be significant restrictions, taking account of social distancing, estates issues and PPE and cleaning requirements of face to face delivery. Practices should consider the principles outlined in Welsh Government’s operational guide for the safe return of general practice to routine arrangements.
Welsh Government confirmed that many of the contractual relaxation measures are extended until 30 September 2021.
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 NHSE/I letter on 7 December made a number of changes to QOF. It outlined measures to balance GP resources against the urgent needs of patients, the management of long term conditions, and vaccination and public health, which are set out above.
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.
Remote working reduces the risk of contracting or spreading COVID-19. Practices practices should continue to provide consultations remotely when appropriate but also ensure patients can access services appropriately face to face is there is a clinical need.
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 an appropriate balance of 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.
It has been agreed that the current contract relaxations measures of enhanced services will be extended to the end of September 2021. We have set out our full enhanced services position.
In-hours access standards
Recognising the fact that he last year has not provided a true platform to show how the current standards have improved access, Welsh Government have agreed that a further year of the current standards to 31 March 2022 will allow the measures to embed.
The achievement for access standard 2 (calls answered) at the end of March 2021 will be carried forward. Achievement for this standard is being counted the same as at March 2020, with practices retaining the ability to evidence achievement if they didn’t last year.
This will provide some financial stability to practices who are facing mounting workload demands.
Only active clinical indicators, two QI projects from the original QI basked and the cluster indicator requirements which have remained active, will be measured for achievement at the end of the current QAIF cycle (end of September 2021).
The deadline for completion of the information governance toolkit and CGPSAT tool has been brought into line with this QAIF cycle.
The requirement for GMS contractors to operate daily community huddles alongside their district nursing teams and community allied health professionals, introduced in January 2021, has now been removed.
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
It is for practices to determine how best to care for patients with long term conditions. Many will be seen face to face in the practice but it is also possible to carry out remote assessments and in some cases could be better.
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 21/22 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 21/22 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 could be reviewed remotely 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) has now been stood down.
Over the pandemic, practices were required to make a maximum of one appointment per 500 registered patients per day available for direct booking by NHS 111. In October 2021, this reverted to the existing contractual requirement of 1 per 3000 registered patients.