Author: Professor Kamila Hawthorne, Bevan Commissioner
Published: June 09, 2020
Covid 19 burst onto all our worlds in mid-March 2020. We had known it was coming – we could see what was happening in China, and then in Italy, but we were still unprepared.
The number of patient contacts reduced dramatically – in fact, from being a very busy surgery, it became eerily quiet. Many patients said they were afraid to go outside. It was interesting how most patient requests could be dealt with over the phone, and we started some video consultations. Patients helped out with their own thermometers and blood pressure monitors. A few bought pulse oximeters to check their oxygen levels!
Over the weeks of lockdown, we puzzled over the right level of PPE, as the guidance kept changing and there was no initial guidance on what PPE was needed for home visits, or what PPE reception staff should be wearing.
What have we learned, both good and bad, from the Covid 19 crisis?
Primary Care – Cluster communication and working together
Clusters have come together as never before, to determine their response to the Covid threat. On newly formed WhatsApp groups, they discuss PPE, service provision, information received from the Health Boards, and how to deal with difficult situations (anonymised of course). Relationships are being built between practitioners that will be useful for future collaboration and development of Primary Care.
At the same time it is becoming clear that clusters have not been used to their full advantage during the Covid 19 crisis. In some Health Boards, they have not been present or represented in key planning groups and invited to Bronze level meetings at a relatively late stage. The whole response to Covid 19 therefore has been from a secondary care lens and may have contributed to reasons why care in the community for vulnerable patients has been so lacking.
Primary Care, an obvious resource, has not been used at all in the test/ trace/ isolate chain. They are an obvious resource that has been untouched, particularly since patient contacts have reduced dramatically during the crisis and they do have more time than in pre-Covid times.
Video and telephone consultations/ electronic prescribing
General practitioners and their teams are now dealing with most patient contacts by telephone, video and email. Patients and Primary Care Teams have taken to this mode of communication rapidly and easily, with very few patients still needing to be seen face to face. I can see that perhaps 50% or more contacts will henceforth become virtual contacts. This also has positive implications for sustainability (less time and energy spent coming to surgeries to see healthcare staff or pick up prescriptions), and safety (using validated algorithms that ensure important questions are not left out of consultations).
However the remote consultation is not a panacea. Patients with poor hearing or poor vision are at a disadvantage, as are those who cannot speak English, don’t have a Smart Phone, or have limited broadband access. Also, there are still too many technical problems. We will need to review our virtual consulting skills to ensure that the essential values of the Dr/Patient relationship are retained and maintained.
The way patients use the practice/ pharmacies
Many surgery premises are not large enough to distance patients, if they presented in pre-Covid numbers. For example, our practice can only manage 2-4 patients waiting at any one time.
Reduced but longer consultations – face to face consultations are longer, not only due to PPE requirements, but also because patients raise more issues in this type of consultation than they do in telephone and video consultations.
Visiting patients at home is fraught with additional complications associated with use and disposal of PPE.
The lack of electronic prescribing in Wales continues is a missed opportunity, as practices and pharmacies develop close working relationships.
Care for vulnerable patients in the community
The Covid 19 pandemic has revealed the extent to which vulnerable patients, particularly the elderly, but also those with physical disabilities and learning difficulties are exposed. These deficiencies in care provision were masked pre-Covid, as services generally managed to patch up the ‘holes’ in so-called ‘seamless care’ to vulnerable people. I think it will come to be seen as one of the great scandals of the early part of the 21st century. We must acknowledge that we have an out-of-date model of care that doesn’t work and prioritise remedies:
- Care for the elderly at home. Slow responding or insufficient support to patients and their family’s means that in a crisis, they can’t cope. This has sometimes meant the only recourse we have is to admit them to hospital, just where Covid is most prevalent!
- Care for the elderly in care homes – the Covid crisis shines a light on the deep commitment and excellent care staff give to their residents. The lack of PPE supplies to care homes in some instances has been terrible. The separation of families from their relatives, resident in care homes, has been a cruel endurance for many.
The human cost of Covid 19
Shielding letters and their effects on patients. Many patients have felt their shielding letter victimises, rather than protects them. They call it a ‘death letter’. In addition, some shielding letters (generated from a central database) have been wrong, giving some patients unnecessary worry.
Giving people impossible choices – if you fall ill with Covid-19, how would you like to die? At home or in hospital? In pre-Covid palliative care consultations, there is usually time to discuss these choices carefully. With Covid-19, previously healthy, though frail people did not have time to adjust to the new reality when faced with these choices.
Families separated from their dying loved ones – either in hospital or in care homes. Is this really necessary? We need to rethink what is possible, and how we express compassion in dire situations.
Mental and social health – many people with mental health problems have suffered from living in lockdown. For those who live with domestic violence, the fear of harm is difficult to imagine. We have had many conversations with patients whose anxiety symptoms are too difficult to handle, especially after many weeks of lockdown.
Hidden health issues/ missed early diagnoses –the dramatically reduced footfall in general practices has meant that opportunities for early diagnoses of cancers and other serious conditions are being missed (it is estimated there is an 80% reduction in cancer presentations during the Covid crisis).
More positively, the Covid 19 crisis has accelerated the use of social prescribing and self-help, as there are fewer statutory community services available and some fear coming into GP surgeries.
So, how do we build a healthier future, that strengthens general practice and community health? We need a clearer political commitment to rebalancing health and social care policy towards a more prudent, social model of health and care.
- We should use and strengthen Primary Care cluster structures, giving them more autonomy and resources, and build better digitally enabled communications within Health and Social Care, Public Health Wales, and Third Sector organisations. This will enable faster, co-ordinated and more effective responses to future health crises and ‘real’ engagement with people and communities.
- Lockdown has brought the concept of social prescribing to the fore, as many people have had to find their own solutions to stay safe and healthy – daily exercise, arts and crafts, and giving to, and receiving from others.
- IT has shown how rapidly it can develop. We have a great opportunity to use this potential to develop a unified medical record, allowing safer and more efficient use of medical information, and empowering patients to control their own health.
- Video, telephone and email consultations are here to stay – they have proven their worth and ability to handle the majority of patients presenting during the Covid crisis.
- We will need to work on ways to maintain that most valuable and ephemeral concept, the ‘Dr/Patient relationship’ in a virtual context.
- Difficult communications, such as the system for discussing and developing acute care plans, need to be much more sophisticated, and part of routine consulting (in the same way as the ‘opt in’ organ donor card).
- The way GP practice premises are used will change to accommodate social distancing rules. The reduced footfall may result in premises being repurposed to include ‘diagnostic hubs’, that keep patients out of hospitals, and community-based healthy lifestyle activities.
- The role of pharmacies in the health-provision chain will be strengthened, and the need for electronic prescribing to enable this has been highlighted.
We must re-define the way we care for our elderly communities and their carers, valuing and supporting them, and providing them with the resources they need, much more than we appear to do currently.
In place of fear, let’s build a healthier future and strengthen general practice and communities. This requires acknowledging those things we didn’t do well, and how to do them better in the future, as well as retaining some of the new practices that have emerged in the immense efforts to contain the pandemic. Above all, I hope that the lessons learned about the serious gaps in social care and the gaps between primary and acute care will result in a very different public perception of the needs of the vulnerable in our communities and much more pressure on our politicians and health policy designers to institute rapid changes to the way we run and value these services.