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LMC weekly update 17 April 2020

PPE update

The BMA continues to put pressure on Government to provide adequate and sufficient PPE for all healthcare workers, which as shown by the results of our survey, are still lacking and most doctors do not feel safely protected from COVID-19 where they work. These results will be updated by our second tracker survey published tomorrow.

This situation comes despite repeated assurances by the government that additional stock is being delivered to practices, but many areas across the country are still lacking the necessary equipment. We have raised this again with NHS England and Government ministers and have been told there now should be enough supplies available within the wholesale system. However this does not yet match the experience of practices across the country.

NHSEI has now set up a PPE supply page which includes options available for primary care, via wholesalers that routinely supply to GPs or through Local Resilience Forums. Other systems are being rapidly tested.

Public Health England’s PPE guidance advises that in primary care PPE should include eye protection and should be worn for all contacts. All patients must be assumed to have COVID-19 infection, and it is recommended that they should wear a mask during any face-to-face consultation. We will continue to work hard to ensure that everyone gets the necessary PPE that they need to work safely. Read the latest BMA guidance on PPE here and the BMA calling for urgent supply of PPE

PPE media

I appeared on LBC on Saturday evening to talk about PPE and on Tuesday our survey and my comments led BBC Look North. This morning I was interviewed about testing and PPE availability on TalkRadio. Phil White, Chair of GPC Wales, was interviewed on BBC Radio Cymru, about PPE (from 25 mins in). Alan Stout, Chair of NIGPC, said to Irish News that there is enough PPE available for GPs in Northern Ireland, following concerns from both health workers and patients about lack of PPE.

Identifying high risk patients and shielding

As you will be aware, last week NHSE/I and NHS Digital informed practices how to complete the process of identifying patients at highest clinical risk, as set out in the CMO letter and subsequent NSHEI guidance, and where practically possible, to do this by the end of 14 April or soon thereafter.  

Many practices will have already completed most of this work using previous data provided and may only have needed to check the most recent lists provided to them via system suppliers to ensure they are as accurate as possible. However, some of the work of keeping clinical records up to date will be an on-going task should further information about individual patients be provided by hospital specialists or if patients develop new conditions that require them to shield.  Find more information in this letter from NHSEI and NHS Digital. If you have any questions, contact the NHS Digital Shielded Patients List Hub: splquery@nhs.net

We have published guidance for practices about steps to take about the list of shielded patients and those that have self identified through the Cabinet office site.

The Government’s COVID-19: guidance on shielding and protecting people defined on medical grounds as extremely vulnerable has been updated today.

Social distancing

I spoke on Talk Radio to discuss the Governments latest guidance on social distancing (start listening between 8:30am and 9:00am).

Testing of healthcare workers

We continue to push for testing of GPs and their staff to be rolled out across the country as a matter of priority, following the NHSEI advice that staff in initial priority groups such as critical care and emergency departments would be tested first. The NHSEI bulletin advises that plans have been outlined on widening testing of COVID-19 for primary care staff and household members including primary care staff, this should now be available in testing sites across the country. Access to this is being coordinated by CCGs and practices are advised to contact their local lead if testing is required.

Widening access to testing sites

I raised the importance of widening access to testing with Health Minister, Jo Churchill MP, today. A number of sites are now operating and there are plans to rapidly increase the number of sites to 50 by the end of April.  These are open to both primary care and care home staff. CCGs should be contacted to book appointments and CQC are also supporting access for care home staff.

The current live test sites are Birmingham (Edgbaston), Chessington, Gateshead, Gatwick, Haydock, (Liverpool/Warrington), Leeds, Manchester, Midland Metropolitan, Nottingham, Plymouth, Stansted, Wembley (IKEA), Worcester, Aberdeen, Belfast, Edinburgh, Greenwich, Preston

Sheffield, Twickenham.

Impact on GP services

The Mirror reported on the pressures that GPs are under, and I commented: “We will need to stop doing much of the routine work that we do week-by-week to enable us to focus on the sickest patients and prioritise those who most need us. Practices that are routinely doing routine health checks, assessing blood pressure, diabetic control, and long-term problems with heart and lung disease - those routine checks will need to stop."

BMA COVID-19 contract for temporary engagements

The Sessional GP Committee, working with GPC and BMA Law, has produced a model contract with terms for the engagement of a GP providing temporary COVID-19 services. The model terms are intended to provide practices with the ability to flexibly employ additional GPs to deal with the demands of responding to COVID-19. In particular, it is aimed at locum GPs in order to provide access to employment benefits such as maintaining continuous coverage of death in service benefits while supporting COVID-19 services, and access to the employer’s occupational sick pay and annual leave entitlements.

NHS111 CCAS appointments

The latest NHSEI preparedness letter (14 April) highlights that the recent amendments to the GMS regulations, will increase the minimum number of appointments that practices must make available for 111 direct booking and all practices in England must now make a minimum of 1 appointment per 500 patients available for direct booking from NHS 111 through the CCAS clinical triage service.

We have raised concerns with NHSEI and NHS Digital about these figures and the proposed process, and they have clarified that there is a difference between the current local NHS111 appointments, which were used to book in to practice appointment systems for patients that don't have COVID-19 related symptoms, and the new national CCAS which is staffed by clinicians, including returning GPs, and which is intended to take the pressure off practices by dealing directly with many of their patients with COVID-19 related symptoms. The CCAS service is additional capacity to support your practice, and should reduce the number of patients the practice has to deal with directly.

Patients should not be told by CCAS that they will be phoned back at a particular time, as per the nominal appointment slot they may have been put in to. The appointment slots are just a technical way of transferring patients from CCAS to the practice. It is for the practice to determine how they respond to the patients who have been transferred to them. Practices may therefore set up a separate triage list that they monitor during the day alongside whatever their normal arrangements are for managing patients who have contacted the practice directly.  In most areas the numbers transferred will be far fewer than were originally modelled, and which led to the 1 in 500 figure.

Returning GPs

The GMC have now granted temporary registration to retired doctors so that they can return to practice and help with the coronavirus pandemic. However, we are aware that due to overwhelming number who have applied to get involved, there have been delays to returners being added to the system after relicensing and we are working with NHSE/I and government to encourage them to speed this process up as much as possible.

The significant numbers expressing the intention to get involved has overwhelmed current systems and processes, and we know that many are currently waiting for the next steps. Both the BMA and the RCGP are working to try and speed up the process as much as possible, and on additional guidance which is currently being finalised.

The BMA has published a joint letter with RCGP regarding returning GPs as well as guidance for returners. Please share these with colleagues who are intending to return.  For any retired doctors joining the BMA or any current retired members who are returning to work to support the fight against COVID-19, we are waiving their membership fees until 1 October 2020. You do not need to do anything to update your membership. You will make no further payments until 1 October 2020 and we will email you to confirm. If you have any questions please email membership@bma.org.uk

GP Induction and Refresher scheme and International GP Recruitment Scheme

As we reported last week, new regulations have been published which enable medical practitioners who are not on the performers list to provide GP services during the pandemic. In addition to GPs on a devolved nation performers list being able to apply to be included on the Performers List in England, those on the GP Induction and Refresher (I&R) or International GP Recruitment (IGPR) schemes, can also use the Fast Track COVID-19 application process to seek approval to be added to the Performers List for the duration of the COVID-19 crisis.

Some doctors who had been pursuing the I&R and IGPR routes into general practice had been left unable to work due to the cancellation of the MCQ and Simulated Surgery Assessments.

The online application form can be accessed here while questions about the application process should be directed to the NHS England national team using england.ftc19@nhs.net. NHS England will be contacting all scheme applicants and inviting them to make a Fast Track application.

If a doctor decides to pursue this route they must continue with their standard application alongside the Fast Track process. The evidence obtained during the COVID-19 period may be used to support full inclusion on the Performers List. While this may negate the need for any additional assessment or supervised placement, some doctors may be asked to complete the standard programme when the COVID-19 crisis period is over.

The Fast Track route will only be available to doctors who are considered by Health Education England / NHS England leads to be safe to start a clinical placement without completing the MCQ and simulated surgery assessments. The Fast Track process is also open to applications from MoD GPs, performers on the respective lists in Wales, NI, Scotland, Isle of Man and the Channel Islands, private GPs and NHS GPs who wish to return to work as a general practitioner having been off the performers list for more than 5 years. 

GP retention scheme (England)

NHSEI has extended the relaxation of the maximum number of in-hour sessions retained GPs can conduct until further notice so they can contribute to the COVID-19 response.  For the retained GPs due for their scheme annual review, CCGs will now be able to:

·         agree with retained GPs, who are due for a scheme annual review before the end of September 2020, to defer their annual review until a later date

·         consider granting retained GPs, who are approaching the end of the scheme (e.g. those in their final three months of the scheme), with a scheme extension until the end of September 2020.

Retained GPs are encouraged to contact their HEE local scheme leads if they require any support.

Death certification and verification of death

This complex area continues to be the subject of intense work between BMA, RCGP, NHSE and CQC. We will be publishing updated guidelines on all death related matters in the coming days. In the meantime there are specific updates in relation to:

Verification of death

London Coroners wrote an open letter on Tuesday 14th April. The text can be found here. We have challenged this position and our response can be read here.

Certificate of death

Following the relaxation of certain aspects of the rules around the completion of death certificates the BMA has written to the government to ask for further changes to fit more closely with the working patterns in general practice and to streamline the system.

Ethical considerations advance care planning

The BMA issued a joint statement last week about the importance of continuing with advance care planning during the COVID-19 emergency. I was also interviewed by BBC Radio 4 about the ethical considerations around COVID-19 end of life care – listen here (from 2:39:30 onwards)

JCVI statement on immunisation prioritisation

The Joint Committee on Vaccination and Immunisation (JCVI) has published a statement on the importance of maintaining immunisation services to reduce the risk of vaccine-preventable disease during the COVID-19 outbreak. This will provide important protection to children and other vulnerable groups and will also avoid increasing further the numbers of patients requiring health services because of vaccine-preventable diseases. Read the full statement here

Dispensing delivery services (England)

The letter on Home delivery of medicines and appliances service during the COVID-19 outbreak from the Chief Pharmaceutical Officer and NHSEI, outlines changes of essential services for dispensing doctors in England. Due to the emergency changes to GMS contract regulations, from 9 April, community pharmacies and dispensing doctors provide a home delivery option service for shielding patients.

Community pharmacies and dispensing doctors have to ensure that medicines are delivered to people at high risk of complications from COVID-19 who are advised to isolate at home for 12 weeks and meet the 'shielding' criteria if these medicines cannot be collected and delivered by a family member, friend, carer or volunteer. The funding of these services will be in addition to the current contractual agreement for both pharmacies and dispensing doctors.

Referrals to secondary care

Following concerns GPCE has been raising about the risks to patients of practices not being able to make referrals when necessary, yesterday’s NHSEI Primary Care bulletin advises that GPs should continue to refer patients to secondary care using the usual pathways and to base judgments around urgency of need on usual clinical thresholds. GPs should also continue to use specialist advice and guidance where available to inform management of patients whose care remains within primary care including those who are awaiting review in secondary care when appropriate. Further NHS guidance will be published shortly advising secondary care to accept and hold clinical responsibility for GP referrals.

Laptops for use in general practice (England)

Following GPCE highlighting the difficulty many practices have had enabling staff self-isolating at home to continue to work,  NHSEI has now confirmed that 9,500 laptops have been sent to CCGs this week for use in general practice, and 13,000 more laptops to be sent over the next few weeks. Practices should contact their CCG to request a laptop when this is needed.

NHS staff absence tracker

NHSEI has launched a new staff absence tracker service, which is a tool for staff and managers to report COVID-19 related absence from work and subsequent return to work. It will provide a source of national data on the absence rate in general practice that will allow them to better target support. Staff can register using their NHS email address and if they provide the details of their practice manager or rota manager, they will be automatically informed of the absence. Although there is no obligation for practices to use this service, this would be a way to demonstrate the pressures on general practice.

NHS Volunteer Responders: open to referrals from health professionals

NHSEI has published guidance for health professionals about the NHS Volunteer Responders programme and how to refer patients for support who are considered to be vulnerable and at risk.

Any member of practice staff, not just GPs, can make the referral, by using their nhs.net address. You can refer people who are at very high risk from coronavirus where no local support is available, for example if they have been asked to self-isolate and ‘shield’, if they are over 70 and have underlying health conditions, or if they are self-isolating and you consider them to be especially vulnerable. You can continue to use your local schemes where they exist and please speak to your patients if in doubt about whether they require support.

Requests can be made via the NHS Volunteer Responders referrers’ portal or by calling 0808 196 3382. Read more about how the referrals work here

BMA COVID-19 webpage and guidance

The BMA COVID-19 webpage is updated daily with guidance and links to official information:

The BMA has published ethical guidance on COVID-19.

If BMA members have any specific concerns or issues related to COVID-19 please contact the BMA’s advisers on 0300 123 1233 and support@bma.org.uk.

Wellbeing

At times of crisis it is also vital that we all look after our emotional as well as physical health and the BMA has a range of wellbeing services including 24/7 counselling, available to ALL doctors and medical students (not just BMA members).

If practices or LMCs would like hard copies of our Wellbeing poster, with tips for doctors supporting each other during the crisis, please email wellbeingsupport@bma.org.uk.

PHE have launched a new campaign to support people to manage their mental wellbeing during the pandemic, using Every Mind Matters self-care resources.

Other COVID 19 resources

BMJ – news and resources

RCGP COVID-19 information

NHSE/I daily primary care bulletins on COVID-19

NHSE/I COVID-19 webinars

COVID-19 Google Drive resource

Primary Care Pathways COVID-19 resource centre

NICE resources on COVID-19   


Condolences

We will all be aware of increasing numbers of our patients who have sadly died as a result of COVID-19. However this now also including some of our colleagues. On behalf of the profession I would like offer our condolences and pay tribute to four dedicated and courageous GPs who have died whilst supporting the nation’s battle against COVID-19. They are Dr Habib Zaidi, Dr Syed Haider and Dr Kamlesh Masson who were still working actively as GPs, and Dr Fayaz Ayache, who had retired but returned to practice following the outbreak.

They will be missed not only by their family, friends and colleagues, but also by their patients to whom they dedicated many years of service and care.

See this week’s GP bulletin here

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