After a shambolic start, last week’s announcement by the chancellor that the government has finally secured a steady supply of personal protective equipment for the NHS and has promised a further £10bn for a “test, track and enable” system is welcome: a winter second wave of Covid-19 is a distinct possibility and the NHS needs to be prepared.
In our large practice we now run a complex rota with staff allocated to different roles and rooms or working from home. Earlier PPE shortages have thankfully been resolved and we are lucky to have a great management team who try and keep abreast of the daily changes and updates that we receive from various NHS bodies. I am cautiously hopeful that we are as prepared as we can be for now.
A few weeks ago we were only carrying out urgent work as, nationally, routine work was suspended as part of the Covid-19 response. As the country slowly comes out of lockdown with a return to some level of normality, within primary care we have slowly been undertaking more routine work. In those early weeks there was mainly a telephone triage service and video consultations. Those patients requiring a face-to-face appointment were seen in designated Covid-19 or non-Covid areas of the surgery. We also did virtual ward rounds (through video consultations with residents) in care homes to prevent the spread of infection and most clinical and non-clinical staff worked from home, apart from a handful doing urgent face-to-face work. The pace of digital change implementing all this was so accelerated that in any other circumstances it would have taken years of NHS bureaucracy to implement.
Although we have now started seeing more patients face to face, this is based on clinical need and we still use a triage-first model, managed virtually if at all possible. We can arrange blood tests, X-rays, receive and send information to patients via texts and e-consultations, and book them in for appointments remotely.
But this is not without its challenges. What has quickly become apparent is that the process of running a clinic even with just a few patients is much more wearing and time-consuming when you add in changing PPE, and cleaning the equipment and room after each patient consultation.
We have had to make the time between appointments longer, meaning we can see fewer patients. We have to factor in the length of time patients are kept waiting – currently 2 metres apart in the car park, which is closed to cars, as well as special appointment slots for shielding patients.
Meanwhile, the impact of the pandemic continues: we are now managing a cohort of about 20 patients with prolonged Covid-19 symptoms or those needing aftercare after hospital admissions. Patients like Wendy who had Covid-19 in March and still suffers from bouts of breathlessness and overwhelming fatigue which has led to psychological distress. It is all uncharted territory as we learn more about the virus and try to help them, with no local specialist service for aftercare.
For these and other patients, access to tests and specialists remains difficult. During the height of the pandemic, hospitals prioritised urgent cases. Until this week, all routine diagnostic tests apart from X-rays were suspended unless it was for urgent or suspected cancer diagnosis, with strict triage thresholds in place.
This has been difficult as there is still a big group of patients who need secondary care referrals for their medical conditions. But they do not meet the strict criteria to be seen under the urgent care pathways. My patient Jill rang to tell me that her knee replacement was cancelled, and although she was disappointed, she understood why hospitals still need to prioritise patients with probable cancers or other life-threatening conditions. I have had many such recent conversations.
Now routine diagnostic tests are starting again, there is a big backlog to clear and we are being asked to manage patient expectations of likely waiting times. Some referrals are even being returned following hospital triage. Owing to capacity issues in hospitals, there are now thresholds in place for routine referrals as well.
I have also seen a big rise in the mental health burden of Covid-19 through isolation, financial hardship and the cessation of many face-to-face health and support networks for individuals, which previously offered them a lifeline. All our recent mental health appointments have been done virtually and we are working to move towards consultations in a socially distanced way (outdoor settings or shorter face-to-face contact) but without the use of PPE, as this can potentially detract from the therapeutic relationship.
Despite everything, this pandemic has strengthened the bonds between colleagues and patients. We have maintained morale and resilience through our daily morning and lunchtime huddles (albeit at 2 metre-distance) which remote staff can join and an opportunity for everyone to work flexibly. Above all, there has been humour and sheer hard work to get through the stress test that has been Covid-19.
More money and PPE for the NHS is all well and good, but now the government needs to listen to its workforce and public health experts, not blame them, if GP surgeries like mine are to cope with any second wave of coronavirus.
• Zara Aziz is a GP partner in Bristol