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Dr Rebecca Fisher gives the lowdown on why maintaining general practice as a ‘front door’ to the NHS that is safe for both GPs and patients is not easy. It’s fair to say that Matt Hancock’s pronouncement that henceforth all consultations should be “teleconsultations unless there’s a compelling reason not to”, has not been universally welcomed in general practice. In my surgery, practicing in a pandemic has seen us change our ways of working beyond imagination. In March, like many other practices, we shifted overnight to a “telephone first” approach. And whilst at peak-pandemic we kept face-to-face consultations to a minimum, we’re now seeing more and more patients in person again. Although many consultations can be safely done over the phone, we’re very clear that there are some patients – and some conditions and circumstances – where a patient needs a face-to-face appointment with a GP. NHS England have also been clear that all practices must offer face-to-face consultations if clinically appropriate. But maintaining general practice as a “front door” to the NHS that is safe for both GPs and patients is not easy. Options to quarantine and pre-test patients set out in national guidance and intended to help protect secondary care cannot be deployed in primary care. Other national guidance – for example regarding wearing masks in clinical sites – often seems to be issued with secondary care in mind, with little or delayed clarity for primary care. Measures like maintaining social distancing are also likely to be harder in general practice, where the ability of a surgery to physically distance staff from each other, and patients from each other and staff, is in part dependent on physical factors. Options to quarantine and pre-test patients set out in national guidance and intended to help protect secondary care cannot be deployed in primary care Things like the size and layout of a practice, or the availability of a car park for patients to wait in are hard to change quickly. Stemming from those challenges are ones related to staffing; how to keep practice staff safe from covid-19? NHS England and the British Medical Association have stated that staff should have rigorous, culturally sensitive risk assessment and consider ceasing direct patient contact where risks from covid-19 are high. The risk of catching COVID-19 – or dying from it – is not equally distributed amongst GPs. Age, sex, ethnicity, and underlying health conditions are all important risk factors. New Health Foundation research finds that not only are a significant proportion of GPs at high or very high risk of death from covid-19 (7.9 per cent), but one in three single-handed practices is likely to be run by a GP at high risk. If those GPs step back from face-to-face consultations we estimate that at least 700,000 patients could be left without access to in-person appointments. Even more concerningly, there’s a marked deprivation gradient. If GPs at high risk from COVID-19 step back from direct face-to-face appointments, and gaps in provision aren’t plugged, the patients likely to be most affected are those in deprived areas – the same people who have already been hardest hit by the pandemic GPs at high risk of death from covid are much more likely to be working in areas of greater socioeconomic deprivation. And single-handed practices run by GPs classed as being at very high risk from covid are more than four times as likely to be located in the most deprived clinical commissioning groups than the most affluent. If GPs at high risk from COVID-19 step back from direct face-to-face appointments, and gaps in provision aren’t plugged, the patients likely to be most affected are those in deprived areas – the same people who have already been hardest hit by the pandemic. Where do solutions lie? Ultimate responsibility for providing core general practice services to populations lies with CCGs. In some areas, collaborations between practices (such as GP federations and primary care networks), may be able to organise cross-cover to surgeries where face-to-face provision is not adequate to meet need. But these collaborations have not developed at equal pace across the country, have many demands on their capacity and may not be sufficiently mature to take on this challenge. These local factors – including the availability of locums – will need to be considered by commissioners. It’s vital that CCGs act quickly to understand the extent to which the concerns around GP supply highlighted by our research apply in their localities. In some cases, additional funding will be needed to enable practices to ‘buy in’ locum support for face-to-face consultations. This should be considered a core part of the NHS covid response. Face-to-face GP appointments remain a crucial NHS service, and must be available to the population in proportion with need. Just as in secondary care, protecting staff, and protecting patients in primary care will require additional investment. Failure to adequately assess the extent of the problem, and to provide sufficient resource to engineer solutions is likely to further exacerbate existing health inequalities. Original Source: The HSJ

I fell sick on 25 March. Four months later, I’m still dealing with fever, cognitive dysfunction, memory issues and much more I just passed the four-month mark of being sick with Covid. I am young, and I had considered myself healthy. My first symptom was that I couldn’t read a text message. It wasn’t about anything complex – just trying to arrange a video call – but it was a few sentences longer than normal, and I couldn’t wrap my head around it. It was the end of the night so I thought I was tired, but an hour later I took my temperature and realized I had a fever. I had been isolating for 11 days at that point; the only place I had been was the grocery store. My Day 1 – a term people with Long Covid use to mark the first day of symptoms – was 25 March. Four months later, I’m still dealing with a near-daily fever, cognitive dysfunction and memory issues, GI issues, severe headaches, a heart rate of 150+ from minimal activity, severe muscle and joint pain, and a feeling like my body has forgotten how to breathe. Over the past 131 days, I’ve intermittently lost all feeling in my arms and hands, had essential tremors, extreme back, kidney and rib pain, phantom smells (like someone BBQing bad meat), tinnitus, difficulty reading text, difficulty understanding people in conversations, difficulty following movie and TV plots, sensitivity to noise and light, bruising, and petechiae – a rash that shows up with Covid. These on top of the CDC-listed symptoms of cough, chills and difficulty breathing. Read the full article here.

Up to half a million Britons are suffering the effects of "long Covid", MPs have been told, with some doctors dismissing many of the long-term symptoms suffered in the wake of coronavirus as ME.... Paywalled article in The Telegraph.

As part of a £160m initiative, the NHS will look to roll out and expand ‘Covid-friendly’ cancer treatments which are safer for patients during the pandemic, the health service’s Chief Executive Sir Simon Stevens has announced. The funding will help pay for drugs which treat patients without having as significant of an impact on their immune system, or which could offer other benefits such as a reduced number of hospital visits. Almost 50 treatments have been approved for use as ‘swaps’ for existing drugs, with thousands of patients having already benefitted, and more are expected to be made available this week as part of deals struck between the NHS and pharmaceutical companies. Within these treatments include options which allow patients to take tablets at home or receive medicines with fewer side effects rather than undergoing hospital-based treatment which can leave them more susceptible to coronavirus and other infections. Sir Stevens said: “Since the first case of Covid in England six months ago, NHS staff have fast tracked new, innovative ways of working so that other services, including A&E, cancer and maternity could continue safely for patients and it is thanks to these incredible efforts that 65,000 people could start treatment for cancer during the pandemic. “We are now adopting new, kinder treatment options which are not only effective but safer for use during the Covid-19 pandemic and more convenient for thousands of patients, who can take medication at home or be given medicines with less harmful effects on their immune system.” Read full story Source: National Health Executive, 3 August 2020

The coronavirus lockdown has provoked a mental health crisis among the LGBTQ community, with younger people confined with bigoted relatives the most depressed, researchers found. A study of LGBTQ people’s experience during the pandemic, by University College London (UCL) and Sussex University, found 69% of respondents suffered depressive symptoms, rising to about 90% of those who had experienced homophobia or transphobia. Almost 10% of people reported they felt unsafe in their homes. The study called for more government support for LGBTQ charities, which have experienced significant rises in demand since the start of the pandemic. It warned: “Poor LGBTQ+ mental health may remain unchecked without a substantial policy commitment and funding directed to ameliorating health inequalities exacerbated by the pandemic.” Read full story Source: The Guardian, 5 August 2020

Trusts have been set a series of “very stretching” targets to recover non-covid services to nearly normal levels in the next few months, in new guidance from NHS England. NHS England and Improvement set out the system’s priorities for the remainder of 2020-21 in a “phase three letter” sent to local leaders. It said the NHS must “return to near-normal levels of non-covid health services, making full use of the capacity available in the ‘window of opportunity’ between now and winter”, when further emergency and covid pressures are anticipated. In recent weeks providers have found it very difficult to resume many services, with many running at well below normal capacity, due to infection prevention measures, staffing gaps, and other covid-related barriers. The targets in the new guidance for phase three of the NHS’s covid response include: In September trusts must deliver “at least 80 per cent of their last year’s activity for both overnight electives and for outpatient/daycase procedures, rising to 90% in October (while aiming for 70% in August)”; “This means that systems need to very swiftly return to at least 90 per cent of their last year’s levels of MRI/CT and endoscopy procedures, with an ambition to reach 100 per cent by October.” “Trusts must hit 100 per cent of their last year’s activity for first outpatient attendances and follow-ups (face to face or virtually) from September through the balance of the year (and aiming for 90 per cent in August).” Read full story (paywalled) Source: HSJ, 31 July 2020

A healthy population is one of any nation’s most important assets. We have known for a long time that not everyone has the same opportunity to access the things they need to lead a healthy life, such as good quality work and safe secure stable housing. Now we can see that the COVID-19 pandemic is replicating and exacerbating deep-rooted health inequalities. Without concerted action, this health crisis will also become a health inequalities crisis. The COVID-19 pandemic has brought health inequalities into sharp focus. While every part of the population has been affected by the current crisis, some communities have been hit much harder both by the virus itself and by the measures taken to control its spread. Evidence is starting to emerge, for example, of the unequal impact of the shutdown of the economy. For example a recent survey of UK households found that the lowest earners have been worst hit by loss of earnings, with the most severe losses for single parents. The uneven impact of COVID-19 has also highlighted the inequalities faced by Black, Asian and minority ethnic communities. Recent data shows that some ethnic groups are at much higher risk of dying from COVID-19 than the rest of the population (e.g. Black men are four times more likely to have died of COVID-19 than their White peers). Read full article here.

New analysis by the Health Foundation reveals the devastating impact the pandemic has had on social care in England. The independent charity says the findings provide further evidence that the government acted too slowly and did not do enough to support social care users and staff, and that protecting social care has been given far lower priority than the NHS. The Health Foundation finds that policy action on social care has focused primarily on care homes and that this has risked leaving out other vulnerable groups of users and services, including those receiving care in their own homes (domiciliary care). It also notes that the shortcomings of the government’s response have been made worse by longstanding political neglect and chronic underfunding of the social care system. Since March there have been more than 30,500 excess deaths* among care home residents in England and 4,500 excess deaths among people receiving domiciliary care. While high numbers of excess deaths of people living in care homes have been well reported, the analysis shows there has been a greater proportional increase in deaths among domiciliary care users than in care homes (225% compared to 208%). And while deaths in care homes have now returned to average levels for this time of year, the latest data (up until 19 June) shows that there have continued to be excess deaths reported among domiciliary care users. The Health Foundation says that decades of inaction by successive governments have meant that the social care system entered the pandemic underfunded, understaffed, and at risk of collapse. Read full article here.

Initial data from the COVID-19 Infection Survey. This survey is being delivered in partnership with IQVIA, Oxford University and UK Biocentre. Full article here Table of contents in the report: 1. Main points 2. Number of people in England who had COVID-19 3. Regional analysis 4. Incidence rate 5. Test sensitivity and specificity 6. COVID-19 Infection Survey data 7. Collaboration 8. Glossary 9. Measuring the data 10. Strengths and limitations 11. Related links

People are being warned to familiarise themselves with the symptoms of sepsis after a study found that as many as 20,000 COVID-19 survivors could be diagnosed with the condition within a year. One in five people who receive hospital treatment for the coronavirus are at risk, according to the UK Sepsis Trust. Sepsis is triggered when the body overreacts to an infection, causing the immune system to turn on itself - leading to tissue damage, organ failure and potentially death. If spotted quickly, it can be treated with antibiotics before it turns into septic shock and damages vital organs. Read the full article here.

More than a quarter of black, Asian and minority ethnic NHS staff had not yet had a risk assessment in relation to their exposure to coronavirus, according to the latest data collection by national NHS leaders. Full article here on the HSJ website (paywalled)

One of the world’s foremost virus experts has said survivors will be living with the effects of Covid-19 for “years to come” after he was struck down by a severe infection, and called for added support for those who have recovered from the disease. Professor Peter Piot, who as director of the London School of Hygiene and Tropical Medicine has been at the forefront of the academic response to the pandemic, has spent his entire career studying viruses such as Ebola and HIV. Prof Piot spent a week at the Royal Free Hospital in London in early April after contracting the disease. “I spent a week in isolation on a ward with three other men. I couldn’t leave the room. When I came out the thing I remember most is seeing the sky. London was deserted - it was in acute lockdown,” he said. The fever and splitting headache he had felt before being admitted were gone and apart from chronic exhaustion he was feeling better, he said. Getting out of bed was a struggle and he had to take rests when going up the many flights of stairs of his tall Georgian townhouse. But a week later he took a turn for the worse - he became breathless and his heart rate shot up to over 100. Read the full article here

The Centers for Disease Control and Prevention acknowledged last week that a significant number of COVID-19 patients do not recover quickly, and instead experience ongoing symptoms, such as fatigue and cough. As many as a third of patients who were never sick enough to be hospitalized are not back to their usual health up to three weeks after their diagnosis, the report found. Read the full article here

To help stop the spread of the coronavirus that causes COVID-19, the majority of hospitals have stopped or severely restricted visits. This article explains how you can still help a loved one even when you can't see them face to face. During the coronavirus crisis, most hospitals and care homes in the UK have stopped visits. If you have a loved one in a healthcare setting, not being able to go to see them will be incredibly difficult. But these temporary measures have not been taken lightly. Restricting visits to hospitals and care homes is important to reduce the spread of the virus that causes COVID-19 as much as possible. This way hospital and care home residents, and healthcare staff, can be better protected during the pandemic. Read the full article here

Healthcare staff working at the height of the covid-19 pandemic in England were not properly protected and were forced to work in an unsafe environment, MPs have been told. Appealing before the health and social care committee on 21 July, experts criticised the government and NHS management for their failure to provide staff with sufficient testing and personal protective equipment (PPE). The committee was gathering evidence for its inquiry into the management of the COVID-19 outbreak. Paul Nurse, director of the Francis Crick Institute, said he believed that the failure to implement better testing systems in the early days of the pandemic had contributed significantly to the problems. He said, “At the height of the pandemic, our own research—which backs up what’s been done elsewhere—found that up to 45% of healthcare workers were infected and they were infecting their colleagues and infecting patients, yet they weren’t being tested systematically. “In the healthcare environment we weren’t providing proper protection, and it’s important because it protects the most vulnerable in our society and it protects our healthcare workers. They deserve to work in a safe environment, and some of them are dying because of what they do. They deserve better.” Read full story Source: BMJ, 22 July 2020

More than 4 in 10 anaesthetists are not convinced their hospitals would be able to provide safe services should there be a second wave of COVID-19, a new survey has indicated. A survey of members of the Royal College of Anaesthetists (RCOA) showed 44% of respondents were not confident their hospitals would be able to provide safe covid and non-covid services should there be a second surge of infections. The survey also showed levels of mental distress and morale were worsening among anaesthetists – many of whom were drafted into intensive care units during the first wave. Almost two-thirds of respondents (64%) said they had suffered mental distress in the last month due to the pressures faced during the COVID-19 pandemic. Now the college is calling on the NHS to plan intensively for a second covid wave and to identify, train and maintain the skills of cross-specialty “reservists” – including current clinicians, recent retirees and senior trainees — who can support the health service in the event of future surges. One anaesthetist told the RCOA they were “exhausted with constantly having to think about covid and protecting yourself” and “struggling with the realisation that PPE is here to stay for some time.” Another said: “We have burned out our human resource. We need a period of rebuilding or patient harm will result.” Read full story (paywalled) Source: HSJ, 22 July 2020

About 3,500 people in England may die within the next five years of one of the four main cancers – breast, lung, oesophageal or bowel – as a result of delays in being diagnosed because of COVID-19, say the researchers in the Lancet Oncology journal. “Our findings demonstrate the impact of the national Covid-19 response, which may cut short the lives of thousands of people with cancer in England over the next five years,” said Dr Ajay Aggarwal from the London School of Hygiene & Tropical Medicine, who led the research. Routine cancer screening was suspended during the lockdown, the authors said. So was the routine referral to hospital outpatient departments of people with symptoms that could be something else but also might possibly be cancer. Only those deemed to need emergency care by the GP or those who go to A&E are being picked up. Inevitably, those are people with more advanced cancers. If cancer is picked up at an earlier stage, successful treatment and survival are much more likely. “Whilst currently attention is being focused on diagnostic pathways where cancer is suspected, the issue is that a significant number of cancers are diagnosed in patients awaiting investigation for symptoms not considered related to be cancer. Therefore we need a whole system approach to avoid the predicted excess deaths,” said Aggarwal. Read full story Source: The Guardian, 20 July 2020

Matt Hancock has ordered an urgent review into how Public Health England (PHE) calculates daily COVID-19 death figures. It comes after scientists said they believed PHE was “over-exaggerating” the daily coronavirus death toll, by counting people if they die of any cause at any time after testing positive for the disease. Professor Yoon K Loke, of the University of East Anglia, and Carl Heneghan, professor of evidence-based medicine at the Nuffield Department of Primary Care, said on Thursday night that a “statistical flaw” in the way PHE compiles data on deaths created a disparity in figures published by the different UK nations. “It seems that PHE regularly looks for people on the NHS database who have ever tested positive, and simply checks to see if they are still alive or not,” they wrote. “PHE does not appear to consider how long ago the Covid test result was, nor whether the person has been successfully treated in hospital and discharged to the community. Anyone who has tested Covid-positive but subsequently died at a later date of any cause will be included on the PHE Covid death figures.” Read full story Source: The Independent, 17 July 2020

There are "deep concerns" for brain injury survivors after many reported losing rehabilitation services during the COVID-19 lockdown. A survey by the charity Headway found 57% of people, injured since 2018, had seen face-to-face services stopped. The first two years of recovery are crucial in regaining skills, such as talking, with fears this could affect future independence. The government acknowledged it had been "a challenging time". Headway conducted its survey across all brain injury rehab services, with 1,140 respondents. It found about 60% of those were frustrated by the situation, their anxiety and depression had increased and they felt more socially isolated. Read full story Source: BBC News, 17 July 2020

Every child in Scotland will need additional mental health support as a consequence of measures taken to tackle the coronavirus crisis, according to the country’s children and young people’s commissioner. Speaking exclusively to the Guardian as he publishes Scotland’s comprehensive assessment of the impact of the pandemic on children’s rights – the first such review undertaken anywhere in the world – Bruce Adamson said the pandemic had sent a “very negative” message about how decision-makers value young people’s voices. He said Scotland has been viewed as a children’s rights champion but that efforts to involve young people in the dramatic changes being made to their education and support “went out the window as soon as lockdown came along”. There have been escalating concerns across the UK about children’s mental health after support structures were stripped away at the start of lockdown. Earlier this week, the Guardian revealed that five children with special educational needs have killed themselves in the space of five months in Kent, amidst warnings over the impact of school closures on pupils. Read full story Source: The Guardian, 16 July 2020

Around 5000 fewer people were admitted to hospitals in England for acute coronary syndrome than expected from January to the end of May this year, an analysis has shown. The results, published in the Lancet, indicate that many patients have missed out on lifesaving treatments during the COVID-19 outbreak. This decline started before the UK lockdown began on 23 March and “was qualitatively similar throughout the country, with only minor variations … in different demographic groups,” the authors wrote. Among patients admitted to hospital with acute myocardial infarction there was a “sustained increase in the proportion ... receiving [a percutaneous coronary intervention (PCI) for acute myocardial infarction] on the day of admission and a continued reduction in the median length of stay,” they added. “The reduced number of admissions … is likely to have resulted in increases in out-of-hospital deaths and long-term complications of myocardial infarction and missed opportunities to offer secondary prevention treatment for patients with coronary heart disease,” they concluded. Read full story Source: BMJ, 15 July 2020

The NHS is losing more than 3.5 million days of work because of staff sickness linked to mental health problems, it has emerged. New data from NHS England shows the problem is getting worse with an increasing number of days and proportion of staff off sick for mental health reasons. The data runs from March 2019 to February 2020, before the coronavirus crisis. It is feared the pandemic could lead to lasting mental health issues for some NHS workers. Layla Moran, a Liberal Democrat MP who obtained the data through a parliamentary question, said: “These incredibly worrying figures show the mental health of NHS workers was already at a tipping point before the pandemic struck." Read full story Source: The Independent, 14 July 2020

Health Secretary Matt Hancock admits he is "worried" about the long-term impacts of coronavirus on those who have been infected. Mr Hancock said a "significant minority" of people had suffered "quite debilitating" conditions after contracting COVID-19. It comes after Sky News reported on how psychosis, insomnia, kidney disease, spinal infections, strokes, chronic tiredness and mobility issues are being identified in former coronavirus patients in northern Italy. Asked about the long-term impact of the disease on patients, the health secretary told Sky News: "I am concerned there's increasing evidence a minority of people - but a significant minority - have long-term impacts and it can be quite debilitating. "So we've set up an NHS service to support those with long-term impacts of COVID-19 and, also, we've put almost £10m into research into these long-term effects." Read full story Source: Sky News, 15 July 2020

A wide disparity in coronavirus mortality rates has emerged in English hospitals, with data seen by the Guardian showing that one hospital trust in south-west England had a death rate from the disease of 80% while in one London trust it was just 12.5%. The figures, which NHS England has compiled but never published, show the age-standardised mortality rates that all of the country’s 135 acute hospital trusts have recorded during the pandemic. Doctors regard age as the single biggest predictor or risk factor for dying from COVID-19. They cover the period from the start of the coronavirus crisis in March, through its peak in late March and April, up until 15 May, by which time 42,850 (85%) of the 50,219 deaths so far in all settings had occurred in England and Wales. It is the first such data to emerge about how many people have lived or died in each trust after being treated there because they had been left critically ill by the disease. They are based on patients who were treated in an intensive care or high-dependency unit or on a ward. Senior doctors said the dramatic gap in death rates of 67.5 percentage points between the trusts with the highest and lowest rates was notable and may mean that some hospitals needed to learn lessons from others. Read full story Source: Guardian, 14 June 2020