Rebecca Fisher: general practice in the time of covid-19

General practice has been forced to change rapidly to meet the challenges of coronavirus. Rebecca Fisher gives us further insight into how staff have adapted, and the caution that is needed moving forward beyond the pandemic.

If you had told me two months ago how I’d have spent today, I wouldn’t have believed you. I’m still a GP—in fact, I’m doing more clinical work now than I have done in years. But I’m practising in a way that would have seemed impossible to imagine just a few weeks ago.

My surgery is in an urban, highly-deprived area and feels more like a ghost ship than the bustling hub it usually is. We’re seeing as few people face to face as possible, and everyone gets a telephone appointment first. Bringing patients to the surgery puts them—and us—at risk, so we’ve had to make some tough decisions. We’re still doing things we consider absolutely vital—emergency appointments, urgent blood tests, and scaled back antenatal care for example, but we’ve postponed lots of our “routine care.” This means it’s harder to improve the management of our patients with long-term conditions like asthma, COPD, and diabetes. Our local hospital, a major tertiary centre, stopped accepting all routine referrals several weeks ago.

The way I’m interacting with patients has changed radically. We introduced e-consultations months ago, but the number of patients using them has shot up in past weeks. Video consulting already seems like a normal adjunct to our days. All of which makes the next adjustment to my working week doable. As I’m now spending the rest of my week working in our “covid hot hub,” I’m not physically in my own surgery. Equipped with a new laptop; I’m working remotely from home, so that our practice and patients are protected from contact with the virus.

I’ve no doubt that these patterns are being replicated across the country. Digital first primary care—a longstanding goal for policymakers—has arrived although in circumstances none would have wished for. General Practice has proved that it can innovate and adapt, and can do so despite well-acknowledged workforce and workload challenges. It’s early days yet, but worth reflecting on some of the changes we’re already seeing.

  • Ways of working can be changed quickly. It requires vast amounts of effort and teamwork but can be done. GPs often get the limelight but other roles are just as important. Our practice manager and reception team have smoothly transitioned to a whole new way of working and simultaneously helped our patients to navigate this brave new world. Our GP Federation has led a city-wide effort to get covid hubs and a covid home visiting service up and running.  
  • GPs are embracing change. We’re adopting new ways of consulting (video), new apps (for telephone triage and for sending information to patients), and whole new ways of working (e.g remote triage from home rather than the surgery). We’ve struggled to recruit for years, but now numerous colleagues are offering extra sessions to cover sickness absence and our covid-19 hubs. Some are returning early from parental leave, postponing retirement or other work commitments to do so. The NHS comes first for now. 
  • Patients are receptive to change. Several years ago we switched from a ‘first-come, first-served’ on the day appointment booking system to one where all appointments were pre-bookable. That took months of negotiation with the same group of patients who have, on the whole, been very accepting of the even greater changes we’ve made in the past few weeks. 
  • GPs are sharing resources—within practices, but across the country too. WhatsApp groups, which had sprung up to share ideas and information between the fledgling Primary Care Networks, have been re-purposed for covid-19. GPs from Shrewsbury are asking questions that get answered by GPs from Hull. Protocols for anything from how to manage patients on particular medications, to how to set up entirely new covid-19 hubs are being shared. It’s not gold standard evidence-based medicine, but it is medicine in the time of pandemic – and it’s collaborative and co-operative. 

But, there are some aspects of this that make me uneasy. The pace and scale of change, and absence of counterfactuals, means that we’re missing opportunities to monitor the outcomes. We’ve been so busy doing and acting that there has been little planning and even less studying. But tracking what is happening, outcomes and learning is important. To this end the Health Foundation will be supporting work focused on understanding GPs’ lived experience of the pandemic as it unfolds.

It’s hard to picture how we’ll move back from pandemic mode to “business as usual.” Widespread adoption of digital first primary care has been driven by the need to drastically limit contact. We don’t know how acceptable these new ways of working will be to clinicians and patients once restrictions are lifted, and how much of what is new will be kept. Ideally, we’ll be able to choose what to keep and what to discard based on evidence, but the current circumstances make that evidence harder to gather.

We also have to remember that the conditions we’re innovating in now aren’t reflective of usual clinical care. Many of us worry that there’s a lot of currently unmet need—problems storing themselves up, while attention is diverted to a more immediate, but not necessarily more severe threat. New practices that seem to be working well now may not once this is over—either because needs have changed, or because unintended consequences of the way we are currently working become more apparent. And although I’ve been pleasantly surprised by the ease of adopting video consulting, it doesn’t work well for everyone. Lots of my elderly patients only have landlines, plenty of others don’t have smart phones, and not everyone can cooperate to the required degree (trying to see the tonsils of a small child with autism was a long shot, despite the best efforts of his mum). 

For general practice the covid-19 crisis won’t be over once lockdown is lifted or covid-19 incidence declines. We’ll need to deal with everything we’ve postponed, and the repercussions of having to postpone care (sadly likely to include disease progression and worse clinical outcomes for some). The number of people with mental health conditions is likely to rise, and as the economy suffers so too will the overall health of the nation—a burden likely to be felt disproportionately by those already most deprived. 

All of that is a daunting prospect. General practice in England, overworked and overstretched before covid-19, will only be more stretched in its wake. But it will also have learned some key lessons: that it can adapt and change, and can do so at pace. That it can make limited resources stretch further in collaboration rather than competition. And that in general practice, just as across health and social care, the commitment of front-line staff is a currency that defies quantification.

Rebecca Fisher, GP and policy fellow, Health Foundation, UK

Competing interests: none declared