Visits to surgeries for one-to-one consultations with GPs have long been the traditional starting points for people with health concerns.
As with so many other aspects of everyday life that were once taken for granted, COVID-19 has transformed the way general practice operates and provides care to patients in the communities it serves.
While the pandemic has undoubtedly created challenges for GPs, it has also presented opportunities for change and improvements in the way care is delivered through innovations such as telemedicine and collaborative working.
‘It’s hard to know where to start,’ explains Sam Wessely, a partner at Amersham Vale practice in New Cross, London.
‘It [the pandemic] has seen a wholesale transformation of how we work.’
Like thousands of practices across the country, Amersham Vale has had to change its model for providing care to deal with the health needs of COVID-19 and non-COVID-19 patients while protecting staff and patients from the risk of infection.
A component of this has been the use of telemedicine.
Prior to the pandemic, Dr Wessely says a typical session for a GP at his practice would see doctors having 13 to 14 face-to-face consultations with patients, along with three to four pre-arranged follow-up phone calls.
Patients with urgent problems would be added to a list to be followed up on by phone by a duty doctor, although Dr Wessely says that system would often be overwhelmed by patient demand.
‘We’re now completely triage first,’ he says.
‘We now discourage patients from physically entering the practice asking for an appointment, now the two main ways to contact the practice are by phone or through filling in an online consultation form.
‘We can get back to patients by phone, text message, email or through a video consultation and can often deal with their problems that way.’
Dr Wessely says SMS-based services such as AccuRx, which enables practices to contact patients via text, have proved to be invaluable during the COVID-19 crisis and are something his practice will be continuing post-pandemic.
‘AccuRx has been absolutely fantastic,’ he says.
‘They’ve done incredibly useful things in developing their messaging app. You can now do things like arrange a video consultation with a patient and also allow patients to get back to you.
‘These sound like really small things, but they never existed before and they’ve completely transformed things.
‘Previously we would have to make a note to call back a patient and check they were OK.
‘It takes time to do that, the patient might not answer or they might end up talking about two or three other problems – it’s messy. Now you get the information you need back from the patient in an automated way within seconds and added to the patient record.’
Another change embraced by the practice in response to the pandemic is the decision to dispense with GP sessions, something that Dr Wessely says has led to a more collaborative approach to providing care.
‘Doctors for decades have worked on a sessional basis,’ he says.
‘Whenever we’ve done workforce planning “the session” has always been the unit of work, but because patients are no longer waiting in the waiting room to be seen there and then, it makes a nonsense of the idea of sessions – you simply have a list of patients that have to be contacted.
‘We’ve now got one giant list of patients that we all do together, and when we get to the bottom of the list the acute work is done.
‘That’s been quite revolutionary for us, it’s resulted in a huge amount of teamwork and seen us move from quite an isolated approach of individual sessions to a situation where we’re now talking more as a team and working more collaboratively.’
The value of collaborative working in the face of the unprecedented challenge of COVID-19 is something East Sussex GP Jason Heath knows all too well.
A partner formerly at St Andrews surgery and now at the Foundry, a PCN (primary care network) made up of three practices in Lewes, Dr Heath says that combining the resources of three local practices has bolstered the response to the virus.
‘I have no doubt that the work we’ve done to become a PCN has massively helped us during the COVID crisis,’ he says.
‘COVID has required really rapid decision making on where services are going to be placed, whether COVID or ongoing, like where we’ll deliver services such as necessary routine blood tests, diabetic reviews, childhood vaccinations etc. All that is going to need to be streamlined. Instead of having to work out for three or four sites how you’re going to do that you just do it all in one place.
‘Had we had to organise all that as three or four individual practices you’d have to make the same decisions three or four times over.’
Prior to the pandemic the Foundry had introduced a system which filters patients into one of three workstreams based on their needs.
These include patients with overall good health who present with an acute need, patients with known conditions requiring continuing care and those patients with multiple conditions and complex
Early on in the pandemic, the Foundry was able to set up a hot site exclusively for treating patients with the virus and two cold sites that cater for non-COVID-19 patients with continuing care needs including cancer and mental health.
‘We’d already designed our services to deliver acute care from a centralised phone hub with consulting rooms we can bring patients to,’ he says.
‘COVID has actually fitted very easily into our existing model of working and organised phone triage system bringing [COVID-19] patients to one place.’
Despite their well-organised set up, Dr Heath admits that many patients with ongoing health issues are isolating themselves and avoiding face-to-face contact with medical services. He says it is in these cases that telemedicine services such as AccuRx for video calling are proving vital.
‘Paradoxically we’ve seen a significant reduction in the day-to-day demand for bread-and-butter primary care services,’ he says.
‘People have got the message that we’re reducing face-to-face contact. We’ve been able to rationalise a lot of the work we’ve been doing yet it’s really important we minimise the risk of missing important non-COVID pathology.
‘New staff appointments facilitated by PCN opportunities like community prescribers and in-house senior pharmacists and paramedics have proved their worth.
‘The next challenge as we move into the “post-peak” phase is how we safely reintroduce ongoing work while trying to keep patients and staff safe. The flexibility across sites and staff mix that a PCN brings is invaluable. Good teamwork and mutual trust is the key.’
BMA GPs committee chair Richard Vautrey says COVID-19 has forced GPs to revolutionise how they work in ‘just a few short weeks’.
‘Practices have rapidly moved both to protect patients and staff, and support social distancing, by introducing total triage arrangements with the vast majority of consultations now taking place by telephone or video, with face-to-face consultations either in the practice or at home only taking place when clinically necessary,’ he says.
Greater reliance on remote working and technology in delivering healthcare in the face of having to reduce personal interaction have been revolutionary for GPs, but Dr Wessely warns there are also drawbacks that have to be considered.
‘You can’t form a human relationship as effectively on the telephone as you can face to face,’ he says.
‘I feel like I am continuing decent care for patients I know well already, but I can’t easily initiate a relationship with a new patient using telemedicine.
‘At the moment a patient contacts us with a problem. We deal with that problem in a way that minimises harm and causes the least risk of infection to the patient or the practice staff, but that’s not necessarily the best way to practise medicine.
‘We don’t, for example, have the opportunity to pick up on cues and when you’re not face to face with someone, you might not notice certain aspects of their appearance or behaviour that you might have noticed face to face.’
While a remote consultation will suit some patients, Dr Wessely says that telemedicine is often less suitable for the very elderly or vulnerable patients and those with multiple health issues.
He says that there would need to be at least a partial resumption of physical face-to-face consultations post-pandemic but stresses that he is confident that the majority of changes to general practice brought about by COVID-19 would remain in place.
‘If, before the crisis, a partner had gone to the team with proposals to change the way we practise to the way we are practising now, ie triaging patients first and having a greater reliance on technology, there is absolutely no way that it would have been taken on without a huge amount of resistance and a huge number of questions,’ he says.
‘Whatever we’re doing now is going to carry on to a large degree and it seems likely that similar changes are going to be replicated [by GPs] across the country.’