It was a patient who I visited at home that made me think about how GPs could improve on the care that is offered to patients with covid-19. The patient was older, frail, with multiple morbidities and had tested positive for covid-19. She lived with her family. Her symptoms became worse and she was adamant that she did not want to go to hospital. I visited and agreed to provide support, and eventually her condition improved.
I have become aware of many of our older patients who have died of covid-19 in hospital. A review of their records showed that very few of them consulted their GP before they were admitted. How many of them would have died in hospital without the support of their families and loved ones? The campaigning group In My Own Bed Please (IMOBP) has begun to outline how patients with severe covid-19 might be managed at home.
In the first wave of the pandemic, there was some logic in the centralised, hospital-based approach to the management of patients with calls from patients about covid-19 directed to NHS 111. However, is there now a case for making primary care the central port of call for patients who are developing worsening symptoms of covid-19?
In making decisions about a patient, GPs bring to bear the wealth of knowledge that we have accumulated from the patient record, past history, knowledge of their family, and their social circumstances. Faced with the same situation, the clinical advisors manning NHS 111 (although experienced GPs and nurses) are relatively speaking, blind. It’s not surprising that in such situations, faced with a patient with worsening symptoms, a choice is made to refer them to the emergency department, with the inevitable waits and unintended consequences of a hospital admission. We can’t know who is going to deteriorate rapidly, but many patients, even though made aware of this uncertainty, would still prefer to remain at home.
I have been told by some of my patients that they do not want to go into hospital under any circumstance, even if they develop severe covid-19. Why shouldn’t GPs, working with the wider primary care team, take the lead in looking after patients who choose to stay at home, prescribing steroids, oxygen, pain relief, and other forms of palliation?
The strength of the NHS has always been the relationship-based care that general practice can provide. It is true that innovations such as “virtual covid wards” may help ease the burden on hospital care by allowing more patients to stay at home. However, unless general practitioners are closely involved with patients in making decisions about hospital admission, the full potential of such initiatives will not be realised.
In a situation where the virus is endemic and with the relative protection offered by the vaccine, perhaps we can rekindle the promise of general practice to provide outstanding relationship-based care for our patients. There are already models of good home-based palliative care—for example, in Airedale NHS Foundation Trust—which could be modified for use in general practice. NHS 111 would be able to identify patients who request end of life care at home or who are at the end of their life (having been informed already that patients had made an advanced care plan). NHS 111 would then be able to contact the patient’s on-call GP, who would be on a rota of GPs dealing only with that select group of patients. This would be the sort of on-call commitment a consultant may have, in which only the most complex issues would disturb his or her night’s sleep.
For some patients, treatment at home with their families and with the help of the wider primary care team might be the best option and may even have the best outcome. As we move towards a new norm where covid-19 is endemic and will have repeated surges in the winter months, primary care should fulfil its role as the lynchpin of the NHS.
Aneez Esmail is a practicing GP and Professor of General Practice at the University of Manchester.
Competing interests: none declared.