"General Practice after COVID-19" (Dr. Thomas Micklewright)

"In the midst of winter, I found there was, within me, an invincible summer"
Albert Camus
The reality of working at a General Practice COVID hot hub only sunk in when I entered my consulting room for the first time. For GPs, this is usually a time of giddy excitement. Your room, with its desk, leaflet stands, equipment cupboards and examination couch, becomes a steadfast partner throughout your career. Not in the hub. A smell of disinfectant, a box of PPE and a large TV with a webcam had replaced the usual, friendlier amenities. This was General Practice at war.
 
The hot hubs across the country epitomise the rapid change occurring in general practice. Patient empowerment, self-monitoring, remote consultation and hub-based working are not new ideas. However, the speed of their adoption in recent months has been unprecedented. Now as lockdown begins to ease, 3 questions about these changes have become pressing:
  • Which of these will stay?
  • Which will go?
  • And which will continue to evolve?

Welcome to General Practice post-COVID-19.

Remote consultations post-COVID
Remote consultations in General Practice after COVID Since the COVID-19 outbreak, the number of face-to-face General Practice consultations has plummeted from 80.8% to just 7-8%. Almost all of these are now triaged beforehand. Online consultations are now available in all GP surgeries in England and GPs are having to reconsider the role of clinical examination. Which bits are needed? What can the patient do (I’ve previously covered this in a video)? And how do I manage the unknown?

As GPs warm to this new digital paradigm, they will manage more patients by video, email and signposting to other services. NHS England still advise “you don’t need a video consultation if a phone call will do”. Many still hold this attitude. But the huge time and cost saving to running an entire GP appointment list by video, rather than individual appointments, has yet to be realised. With time though, online consultations will only become more embedded in practice.

Remote consultations: beyond GPs
I believe that allied health professionals will soon go digital as well. Once the limitations of telephone appointments becomes apparent, we will see mental health therapists, specialist nurses, dieticians, physiotherapists and health coaches start to adopt these technologies too. Patients will also become more heavily involved in their care (more on this below).

The increased uptake of health apps strongly supports this. ORCHA, the Organisation for the Review of Care and Health Apps, has reported a 6500% increase in health app recommendations from health and care professionals. The next radical leap though, will be devices that enable remote measurements to be taken. “If only he could measure his own oxygen levels”, I’ve heard many a colleague vent. “Then I wouldn’t need to see him at all”. In fact, we built General Practice COVID hot hubs because of this particular thorn. There is an enormous demand for mobile technology that can record blood pressure, 02 saturation, heart sounds, respiratory rate, ECG and more, especially during COVID-19. This is fertile ground for innovation. With companies like Fitbit exploring  02 monitoring in their devices and Public Health Wales recently announced an online home STI testing service, I expect much more to enter this space soon.

Patient Empowerment post-COVID
After remote consulting, the second biggest change will be in the relationship between patients and healthcare. Within days of the announcement that fever and a new cough were indicative of COVID-19, thermometers disappeared off the shelves. Once asthmatics were marked as ‘high risk’, inhalers and peak flow monitors began to disappear too. Many patients I now consult with have already measured their pulse, temperature and blood pressure on their home devices. I believe this represents a paradigm-shift. The public are taking back responsibility for their health. Of course, they’ve had little choice. Government guidance has put the onus on patients themselves to recognise symptoms, identify risk factors and self-isolate appropriately.

I believe this will lead to an increase in the use of home devices, wearables and health apps that patients use. The pressure to take more responsibility has been even greater when we consider the utilisation of digital first services. The pandemic has birthed online isolation notes, 111 online, online COVID test requests, the NHS Contact Tracing app and a plethora of new online consultation providers. The message appears to be: if you want healthcare, get online. We must also determine the impact of this on equality of access in the coming months.

Hub-and-spoke working in General Practice
After the sluggish development of Primary Care Networks (PCNs), the rapid formation of COVID hot hubs is impressive. Within just a few weeks, practices have come together to create networked clinical systems and agreements to share staff, data, governance and facilities. So with all of this infrastructure already set up, I expect this will form the model for future PCN working. And will we ever go back to having one waiting room for both our Flu patients and our Chemotherapy patients? Not likely. Hub working is here to stay.

Care Homes after COVID
Care homes and general practice after COVID Care staff have struggled to obtain PPE, often at inflated prices. 25,060 residents, in just one month, were discharged back into care homes from hospital, without any routine COVID-19 testing during the pandemic. The care sector remains separate from the health sector and the new PCN DES alone will not solve this.

Care home staff need training, rapid access to clinical support and a line of communication into the leadership of the local health economy. Better joined up care will gain even greater attention post-COVID and digital solutions, like virtual ward rounds, will help.

Professional Development and Support
Facing a tidal wave of mixed messages and conflicting guidelines from multiple agencies, GPs took matters into their own hands. Social media has proven the most effective way for local GPs to keep each other up to date on COVID-19. Powerful digital networks have formed, for learning, planning and rapid information sharing.

I believe that General Practice will continue to use these post-COVID. They may even expand to invite secondary care colleagues, bridging gaps at the interface and moving 1:1 e-advice into a collaborative, shared setting. Software that enables this to be done securely, like Figure 1 for image sharing, will become more commonplace.

Conclusion: General Practice after COVID-19
Let’s return to our 3 questions: which changes will stay? Which will go? And which will continue to evolve? Remote consulting is certainly here to stay and will continue to evolve. Opportunities for remote examination and patient health apps will only grow exponentially. Whether the public will retain their sense of agency and responsibility for their health remains to be seen.

The response of General Practice to COVID-19 has also given us a teaser of the future of PCNs; a hub-and-spokes model that can integrate the care sector and sustain professional clinical communities, whether online or face to face. We must remember though, that this has come at a terrible cost. The loss of thousands of lives and livelihoods, across the country.

For the sake of our patients, we have a responsibility to rise from this with a renewed vision for General Practice. Let’s build a system that is stronger and more resilient than ever before.