In England, led by Public Health England (PHE), we are attempting to contain and delay the spread of covid-19. In parallel, surveillance systems look for evidence of spread across the general population, to indicate as to whether this strategy is effective. [1]

It is vital that primary care services are well prepared to manage the outbreak. Here we make some suggestions on how primary care should better prepare. This is based on the assumption that covid-19 will have peaked and started to remit within six months. We may find ourselves in an unprecedented situation with this outbreak, and while there is not yet evidence on how best primary care should prepare, these are some strategies that we believe deserve consideration.

(1) Creating capacity to implement the plan by stopping a range of non-urgent work
The goal is to create time and space to enable other preparations to take place, as well as reduce the risk of unnecessary exposures. Elements of clinical and non-clinical work could be stopped in primary care. We propose that much of the routine chronic disease management in low-risk people could be suspended for a few weeks or months, these include hypertension, hypothyroidism, and mental health reviews where there has been no change over the last year. However, it is important to consider the potential harms that could occur if some of this support is withdrawn temporarily for patients with long term conditions, so these decisions would need to be carefully balanced. For example, revalidations, appraisals, Care Quality Commission (CQC) visits and the pay-for-performance (P4P) schemes could also be suspended, with this year’s remuneration, where relevant, rolled forward.

(2) Working to keep minor illness self-isolated at home
To slow the spread of disease, we should give much greater encouragement for the self-management of minor infections at home. There needs to be a national emphasis on people with minor illness staying at home, and some simple thresholds of when escalation/further advice would be needed. This could also be partly managed by a much greater utilisation of alternatives to face-to-face consulting, such as remote consulting or telephone triage. And since these alternative access arrangements are likely to happen variably across practices, some controlled evaluations of these ad-hoc strategies should be planned to gain as much as possible from the natural experiments that will occur. “Sick notes” (medical sickness certificates) which are paper should be made capable of electronic issue and self-certification temporarily extended to two weeks for those who self-quarantine.

(3) Optimising the management of people who may be most vulnerable to covid-19
Experience with influenza in years where there has been vaccine mismatch may provide insights. [2] Influenza often affects older people with co-morbidities and respiratory disease. Practice time, freed up by removing work, listed in section 1, should be spent optimising the care of people classified as “severely frail” and those with respiratory illness. [3] Areas to audit might include – ensuring those with asthma have preventive immunisations and inhalers and seeing that patients with any history of exacerbations have “survival kits” of antibiotics and steroids.

(4) Leveraging technology to reduce footfall into practices
There are two areas we recommend focusing on: (1) Electronic prescribing, including repeat dispensing. Nearly all prescriptions should be issued electronically. We should look to reduce as far as possible paper repeat and acute prescriptions. Repeat dispensing authorises pharmacists to repeat prescriptions. (2) As many patient enquiries as possible should be moved to email or online Apps.

(5) Preparing the practice team
Practice teams need to develop resilience plans, while electronic systems and reducing footfall are key to these, there also needs to be established methods for sharing information and meeting without being face-to-face. Day-to-day running plans need to include redundancy with at least one member of each element of the team (e.g. GPs, nurses, other health care professionals, managers, reception) working remotely. Resilience plans should include preparation for limitations on movement in either a locality or region.

(6) Build up the sentinel system to provide more granular information about the spread of covid-19.
Primary care data from sentinel general practices is currently a key source of national influenza surveillance data for Public Health England (PHE), provided through the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) for over 50 years. [4] We suggest that this network could expand to help research the impact of any natural experiments (e.g. dealing with respiratory disease on the phone) and to feedback to practices via dashboards on their progress.

Key to monitoring covid-19 is having high-quality primary care computerised medical record (CMR) system data to better understand what is going on, to monitor spread, and to know when covid-19 peaks and when it remits. For primary care in the UK, there is advice on coding covid-19, which practices should follow. [5] Key is coding influenza-like-illness, upper and lower respiratory infections as “problem” in CMR systems.

Covid-19 infections are very likely to accelerate in the UK. If they do, we need to be better prepared. If the epidemic occurs, we know it is likely to be a minor illness for 80%, with most risk among frail older people and those with respiratory illness. Primary care could have a unique role in better preparing those at most risk by reducing practice time spent on less essential clinical work. This may slow the spread of covid-19 and help reduce the risk of secondary care, especially intensive care, being overwhelmed.

Even if covid-19 peters out early in the UK, we will have created better research capacity for future epidemics and enabled rapid natural experimentation on alternate models for GP access that might inform future re-configurations of healthcare. The time to act is now.

Simon de Lusignan, Professor of Primary Care & Clinical Informatics, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford UK. Director Royal College of General Practitioners Research & Surveillance Centre, London, UK

Ben Goldacre, Director, EBM Data Lab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford UK

Manasa Tripathy, Research Officer, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford UK

Richard Hobbs, Professor of Primary Care and Head Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford UK

Competing interests:
SdeL has no competing interests relevant to this article. His role as Director of RCGP RSC is part of his academic post in Oxford. He is a partner at Woodbridge Hill Surgery. He, through his University has had influenza/influenza vaccine studies funded by Seqirus and GSK, and been members of advisory boards for Sanofi, Seqirus and GSK.

BG has received research funding from the Laura and John Arnold Foundation, the Wellcome Trust, the Oxford Biomedical Research Centre, the NHS NIHR School of Primary Care Research, the Health Foundation, and the World Health Organization; he also receives personal income from speaking and writing for lay audiences on the misuse of science and is Chair of the Health Tech Advisory Board, reporting to the Secretary of State for Health and Social Care.

MT no competing interests

RH is Director of the National Institute for Health Research (NIHR) School for Primary Care Research.

References:

1] de Lusignan S, Lopez Bernal J, Zambon M, Akinyemi O, Amirthalingam G, Andrews N, Borrow R, Byford R, Charlett A, Dabrera G, Ellis J, Elliot A, Feher M, Ferreira F, Krajenbrink E, Leach J, Linley E, Liyanage H, Okusi C, Ramsay M, Smith G, Sherlock J, Thomas N, Tripathy M, Williams J, Howsam G, Joy M, Hobbs R.  Emergence of a Novel Coronavirus (COVID-19); A Protocol for Extending Surveillance Used by the Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) and Public Health England (PHE). JMIR Preprints. 07/03/2020:18606. DOI: 10.2196/preprints.18606. URL: https://preprints.jmir.org/preprint/18606

2]  Pebody RG, Green HK, Warburton F, Sinnathamby M, Ellis J, Mølbak K, Nielsen J, de Lusignan S, Andrews N. Significant spike in excess mortality in England in winter 2014/15 – influenza the likely culprit. Epidemiol Infect. 2018 Jul;146(9):1106-1113. doi: 10.1017/S0950268818001152.

3]  Clegg A, Young J, Iliffe S, Rikkert MO, Rockwood K. Frailty in elderly people. Lancet. 2013 Mar 2;381(9868):752-62. doi: 10.1016/S0140-6736(12)62167-9.

4]  de Lusignan S, Correa A, Smith GE, Yonova I, Pebody R, Ferreira F, Elliot AJ, Fleming D. RCGP Research and Surveillance Centre: 50 years’ surveillance of influenza, infections, and respiratory conditions. Br J Gen Pract. 2017 Oct;67(663):440-441. doi: 10.3399/bjgp17X692645.

5]  Clinical Informatics and Health Outcomes Research Group.  COVID-19 dashboard. Nuffield Department of Primary Care Health Sciences, University of Oxford. URL: https://clininf.eu/index.php/cov-19/