Covid-19: how coronavirus will change the face of general practice forever
BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1279 (Published 30 March 2020) Cite this as: BMJ 2020;368:m1279Read our latest coverage of the coronavirus outbreak
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Dear Editor,
As a healthcare investor and entrepreneur with a large family who have used the NHS and many other health services around the world significantly, I have been giving some thought to how much our primary care needs to change, and have concluded that we can - and should - close all GP surgeries. In a world in which almost everyone has a smartphone, there are much better ways to do this, and while the elderly are on lockdown, this is the perfect chance to make those changes stick.
Full article here: https://medium.com/@bglegg/should-we-shut-down-gp-primary-care-surgeries...
Feel free to challenge - I am sure my proposal is too simplistic.
Ben Legg
Competing interests: No competing interests
Dear Editor
Communication in medicine is being transformed as smartphone applications, mobile messaging and video consultations are becoming a major part of doctor-patient interactions (Martinengo et al, BMJ). Coronavirus may change the face of general practice forever (Jaqui Thornton, BMJ). It has certainly accelerated this process considerably, with clinicians and their patients adapting to alternatives to face to face consultations. However, it is imperative to remember that some of the population do not have smartphones, cannot use the internet and have to ration their telephone use due to cost. This group includes some of the most vulnerable, medically and socially, in our society - such as migrants, the elderly, the homeless and those with learning difficulties.
As clinicians working with vulnerable migrants we have noted an increase in the number of clients expressing anxiety and frustration about their inability to access healthcare services due to a language barrier. Where remote consultations are taking place, many have reported GPs being unwilling or unable to use interpreters for telephone consultations. The technology to do this is simple and is widely available in both primary and secondary care settings. It is imperative that all consultations can be understood by both doctor and patient, particularly when non-verbal prompts are not possible. Not providing alternative or reasonably adjusted methods of communication for such patients risks widening health inequalities and jeopardising both individual and public health.
Yours sincerely,
Dr Jane Hunt
GP and Senior Medical Advisor, Helen Bamber Foundation
Professor Cornelius Katona
Psychiatrist and Medical and Research Director, Helen Bamber Foundation
Dr Silvana Unigwe
GP and Head of Doctors, Helen Bamber Foundation
References:
Mobile messaging with patients, Martinengo et al, BMJ 2020;368:m884
How coronavirus will change the face of general practice for ever, Jaqui Thornton BMJ2020;369:m1279
Competing interests: No competing interests
Dear Editor
The ‘Hot Hubs’ being set up for the management of Covid-19 patients in primary care are well-intentioned, but inadvertently undermine the greatest strengths of our GP system and are generating unnecessary increased risk to both staff and patients.
A straw poll of local colleagues in inner London practices suggests that most of us currently have capacity to see sick patients. We have suspended the majority of routine care and are providing a much reduced offer of phone and video consultations. Even if some colleagues are off sick or self-isolating, most group practices have enough clinicians still working to manage the diminished workload comfortably.
GPs are the best-placed doctors to assess our own suspected Covid-19 patients, both remotely and in person. We are based close to their homes and understand their medical histories and psychosocial contexts, after years of continuity of care. If they need urgent assessment, we can arrange to see them in a ‘hot zone’ in the practice or offer home visits with appropriate PPE. We can help our frail and vulnerable patients to make sense of the current crisis and we are the most appropriate doctors to have end of life conversations with those who may not be suitable for hospital admission. At the level of the individual practice, this workload remains manageable.
Hot Hubs in centralised locations require sick patients to travel larger distances to be seen, with greater concomitant risk of viral transmission. The model gathers high-risk patients together in one location, placing those who turn out to be Covid negative at much increased risk. A home-visiting ‘car doctor’ seems particularly likely to spread infection. If GPs from local practices take part in the rota, they risk carrying infection back to their own practices. Conversely, if the Hub relies on locums, paid higher rate ‘danger money’, then effectively GP partners are avoiding their own relatively low risk of exposure by expecting colleagues (whose usual GP locum work has dried up) to face much higher risks.
The Hot Hub model sidesteps our GP Duty of Care. It should be replaced by emergency ‘back-up clinics’, to provide urgent care across the whole range of primary care presentations to the patients of those practices that have to close due to clinician or staff sickness. GP practices with the capacity to do so should step up and provide emergency medical care to their own patients, including those with suspected Covid-19. Otherwise, when this crisis is over, we will be remembered as the NHS doctors who locked our doors and chose not to look after our own sick patients.
Yours faithfully
Dr Jim Boddington
GP Partner
Shoreditch Park Surgery
Competing interests: No competing interests
Dear Editor,
Many forward thinking practices had already moved away from face to face consultations towards telephone triaging and increasing the use of digital services. It will be interesting to see once the pandemic has “gone”, whether people revert back to the old ways of working. I am doing very very few video consultations. The need is not great though it is being lauded as transformative in general practice. It has helped to reduce the need further for face to face appointments. There has been a big increase in telephone triaging but we were doing this anyway.
A video that I put out for all our patients who have yet to sign up for full records access. It includes how to get an appointment or how to ask for an administrative query by providing a very comprehensive medical history via Engage Consult. It offers the opportunity to receive rich multimedia content via messages. We are sending messages to individuals to groups of patients via MJOG Messenger. The practice-based web portal signposts patients and carers to trusted information about how the practice and local neighbourhood is supporting patient care.
Over 150 new people have completed the Records Access and Understanding Safety Checklist questionnaire in the last 2 days. We are now busy ploughing through them because once the pandemic is over, they will be the ones who continue to enjoy a new paradigm shift in healthcare where they feel much more in control of their own healthcare needs, improve their health literacy and are not just waiting for a doctor to video call them.
The real story is about how normal this has been for those of us with the foresight to know and the opportunity to bring others along. However, if we realise people can do a video consultation in their own home - which is the safest place for people to be - and not in GP surgeries, community clinics or hospitals - then we can start to build systems and processes that encourage and support people to self manage more at home with their families. There has never been a better time to do this than now whilst people are social distancing and self-isolating and shielding.
Competing interests: No competing interests
Dear Editor,
Mark Porter reports satisfaction with the use of non face to face consultations. Patient On Line services have been promoted by the NHS and NHS App. Evergreen-Life report (personal communication) an increase in the use of on line consultations by patients. Patient On Line may also see an increase after the COVID 19 pandemic.
Non Face To Face consultations and Patient On Line have positive effects on sustainability as well as on General Practice capacity, as shown by our study in the International Journal of Medical Informatics:
"Accessing personal medical records online: A means to what ends?"
Syed Ghulam, Sarwar Shaha, Richard Fitton, Amir Hannan, Brian Fisher, Terry Young, Julie Barnet
International Journal of Medical Informatics, 84(2), 111-118. https://doi.org/10.1016/j.ijmedinf.2014.10.005
and in the London Journal of Primary Care:
"The impact of patient record access on appointments and telephone calls in two English general practices: a population based study"
Caroline Fitton, Richard Fitton, Amir Hannan, Brian Fisher, Lawrie Morgan, David Halsall
London J Prim Care (Abingdon). 2014; 6(1): 8–15. doi: 10.1080/17571472.2014.11493405
Competing interests: No competing interests
Dear Editor,
I read the Feature "Covid-19: how coronavirus will change the face of general practice forever" with interest having worked in general practice in the 'pre-Covid' era. [1]
Back in those simpler times a 'good luck' would admittedly be unusual but a 'thank you' would not. I suspect the people who were polite and understanding of the service pressures on the NHS are still the same now. The current pandemic merely intensifies what has been global creeping trend in medicine in the United Kingdom felt sharpest in general practice: gutting and trimming away of what are deemed 'non-essential' services. General practice disproportionately bears the brunt of broader social and economic trends.
The measures being put in place are necessarily unsustainable - by definition the health service is kicking into a gear it could not maintain indefinitely.
War-time spirit may sustain us for now but when we emerge blinking into a stark new 'Post-Covid' world (should such a thing be realisable) our dysfunctional social and economic inheritance, with interest to pay, will fuel a further catastrophe in primary care. It is not difficult to predict what a further economic recession - and likely depression - will have on the waiting rooms of surgeries across the country. We will need all the 'good lucks' we can get as coronavirus will indeed change the face of general practice forever.
References:
1. Thornton J. Covid-19: how coronavirus will change the face of general practice forever. BMJ 2020;368:m1279
Competing interests: No competing interests
Re: Covid-19: how coronavirus will change the face of general practice forever
Dear Editor
The recent rapid changes in primary care will probably be long lasting and may well lead to needing less bricks and mortar BUT we don't know the consequences of this.
Multiple morbidities, medically unexplained symptoms, the anxious well, the ill child, the socially isolated, those with psychological and or mental health concerns may all be having worse outcomes without direct face to face care. The young, those with single easy to signpost problems can exist without F2F (face to face in the flesh) consulting, though somebody will need to pay for the care they then get. There is good outcome data, though, that a GP hunch for a sick child or cancer is important for early pick ups. The flaws shown in some of the on line triaging are ridiculed away by their promoters currently and only time will tell what the best health care solutions will be. With a health minister sold on electronic health care, the odds don't seem exactly equal though.
One can hope that remote care may lead the UK population to start monitoring their own health more and be aware of their blood pressure, cholesterol, weight and exercise targets much more then it seems most do currently.
Competing interests: No competing interests