GP Frontline: Autumn 2020

M A GA ZI NE O F TH E R CGP  I SSU E 18  A U TU MN 2 020

CONTENTS 03 | NEWS 03

COVID-19: the RCGP response

04

Devolved Councils: pandemic response

05

Continuing to learn

06

The vital ‘PRINCIPLE’ of research

07 | OPINION 07

Sigi Joseph on being a BAME GP during COVID-19

09 | STORIES FROM THE 09

FRONTLINE

Returners to the rescue

10

Different directions

11

Starting out during a pandemic

12-13

Tackling COVID around the world

15

The patient perspective

16

Compassion to the end

CHAIR’S WELCOME The NHS has been through one of the most difficult periods in its entire history, and for general practice it’s certainly not over. As well as being at the forefront of tackling the second wave of COVID-19, GPs and our teams are leading the rehabilitation of our communities after the first. We are supporting patients with long-term symptoms of the virus and psychological effects of the pandemic; managing the backlog of patients who chose not to seek care during lockdown; and delivering the biggest and most complicated mass flu vaccination programme ever. We’ll also be continuing to deliver care to around a million people every day who have conditions unrelated to COVID-19.

I have no doubt that as a profession we’ll overcome our new challenges, along with existing ones. Just as we have overcome the difficulties posed by coronavirus so far. We will certainly need resources to do so, and the College is committed to privately and publicly lobbying government and key stakeholders to ensure the profession has the necessary support to make general practice ‘doable’ and deliver high quality patient care.

Ironically, the crisis has also provided an opportunity for positive change. Different ways of

working, particularly the reduction in bureaucratic demands, could mean a more manageable workload, permitting more time forpatient centred care. There is also an opportunity to harness the technological gains that have been made – gains that pre-pandemic were considered a pipe dream. As a College, we want to make sure that any positive changes are permanently retained.

This edition of GP Frontline is dedicated to showcasing the inspiring response of general practice to the pandemic, from FY doctors and trainee GPs who were thrown in at the deep end to the retired colleagues who came back in their thousands to help - and everyone in between.

I am so proud to be Chair of this College, and perhaps never more so than over the past few months. We know there is further adversity to come, but the College will be here to support you all the way.

Thank you all for your dedication to delivering patient care, and for your professionalism and courage in the face of one of the greatest challenges to face the NHS. Finally - and sadly – I wish to pay tribute to the 13 GP colleagues we have lost to this terrible virus. Our condolences go to their families and loved ones, and to their GP colleagues and practice team members still working on the frontline of patient care.

Martin Marshall

Staff editors: Daniel Openshaw, Gillian Watson Reporters: Amy Boreham, Kristy Ebanks, Emily Brewer, Lizzie Edwards

Clinical editors: Professor Martin Marshall, Dr Laurence Dorman, Dr Mike Holmes, Dr Mair Hopkin, Professor Amanda Howe, Dr Gary Howsam, Dr Jonathan Leach, Dr Carey Lunan, Dr Steve Mowle, Dr Michael Mullholland, Professor Peter Saul, Dr Victoria Tzortziou-Brown Cover cartoon: Martin Rowson

Inside cartoon: Kipper Williams Design: Aura Creative Ltd

Feedback: can be emailed to gpfrontline@rcgp.org.uk or tweeted using #gpfrontline. You can also write to us at GP Frontline, 30 Euston Square, London, NW1 2FB

02 | CONTENTS

General practice has an excellent track record of achieving high uptake rates of the influenza vaccine every winter. This year, to help minimise the impact of a second wave of COVID-19, the vaccination programme has been expanded to include 50-64-year-olds and Year 11 children.

The College has drawn on military experience to develop guidance on how to deliver the flu vaccine successfully at this scale while considering social distancing as part of infec-

tion control measures. It explores alternative locations for flu clinics, equipment needs, and how to implement appropriate safety measures to protect staff and patients from and minimise the spread of COVID-19. The College has also been lobbying government for assurances that there is enough supply of vaccines for the expanded cohort of patients – and if not, for guidance for GPs on who to prioritise outside of at-risk groups.

COVID-19

THE RCGP RESPONSE W

hilst much of the political and media narrative around COVID-19 has been focused on the efforts of ICUs, GPs and their teams have been busy throughout, radically transforming the way they deliver care, and continuing to deliver the vast majority of NHS patient contacts.

The College has responded to support members and their teams in myriad ways, not least in being the ‘voice’ of general practice.

A series of open letters to the Government and political leaders has achieved widespread national media attention on issues such as the need for clarity on PPE use in general practice; for targeted COVID-19 testing at a community level - and for GPs to have access to testing; for action to address the disproportionate way Black, Asian and minority ethnic people have been affected by the

A NEW COLLEGE EXAM IN 10 WEEKS! The College cancelled the Clinical Skills Assessment and sittings of the Applied Knowledge Test in mid-March following Government guidance – but thousands of trainees were due to CCT during the summer.

The solution was the development of a completely new exam that would appropriately test the clinical expertise of candidates, while keeping them, examiners and patients safe.

The process from concept of the new Recorded Consultation Assessment to delivery was 10 weeks! This included tendering for a provider, design of the assessment, GMC approval and a pilot.

pandemic; for strict controlled drug laws to be temporarily relaxed to allow optimal end of life care; for assurances around flu vaccine supplies; and for the cap to be lifted on medical school placements following the A-levels fiasco. These letters have led to tangible change, for example with Health Secretary Matt Hancock singling out the College’s letter as a reason for honouring all offers made to students about to start medical training, based on their predicted grades.

The College has called for support to deliver care to patients with long-Covid, clarity around shielding guidance, and for technological barriers to delivering remote care to be addressed.

It has also been at the forefront of making clear that general practice is open - defending the profession against claims to the contrary - and encouraging patients who are concerned about serious health concerns to seek medical care. Crucially, the College campaigned for the temporary suspension of appraisals and practice inspections to enable GPs to focus on frontline patient care.

The College has received more than 17,000 mentions in the media during the pandemic – almost 1000 in national print and broadcast outlets. Martin Marshall has appeared on BBC Radio 4’s influential Today Programme 10 times, as well as BBC’s Newsnight, Sky’s Sophy Ridge on Sunday, and featuring on all other major news broadcast stations.

As well as private and public advocacy on behalf of GPs, the College has produced CPD and education resources to keep GPs up to date in the fast moving landscape of COVID-19 (see p5)and has been at the forefront of research into the virus through its Research and Surveillance Centre (see p6). A series of #RCGPTogetherLive webinars covering topics such as technology, health inequalities, and relationship-based care, have been viewed by over 4,000 people.

Whilst supporting GPs through the pandemic, the College has also been looking to what the post-pandemic landscape will mean for the profession.

General Practice in a Post-Covid World was published in July, featuring on the front page of The Times. 

Deaneries identified those who needed to CCT quickest, and candidates submitted over 700,000 minutes of recorded consultations, equalling 11,666 hours and 486 days.

‘Emergency’ sittings for the Applied Knowledge Test were also arranged for July and August, with reduced numbers and social distancing measures in place.

College Chair, Professor Martin Marshall, said: “This was an extraordinary achievement for the College and for our trainees who had to deal with the worry and uncertainty of having their MRCGP cancelled.

"My thanks to Vice Chair of Professional Development Michael Mulholland and Chief Examiner Mei Ling Denney for their incredible leadership, as well as our examiners and staff teams who worked non-stop

to enable nearly 2,000 trainees to CCT as planned and provide a much-needed boost to our GP workforce.” 

NEWS

| 03

DEVOLVED COUNCILS: PANDEMIC RESPONSE

NORTHERN IRELAND From the start of the pandemic, RCGPNI Chair Dr Laurence Dorman has worked closely with government officials to shape decision making for the management of the spread of COVID-19 in the community. Regular meetings have also been held with the Health Minster, and Laurence has been a consistent presence in the NI media, advocating for general practice and recognising the efforts of GPs and their teams.

RCGPNI established pathways for GPs working in COVID-19 centres to get appropriate PPE and rapid access to COVID-19 diagnostic tests. It also played a key role in promoting public health messages, reminding parents of the importance of childhood vaccinations and encouraging patients to contact their GPs with cancer concerns.

Throughout the pandemic, RCGPNI actively supported members through virtual zoom meetings and webinars.

Laurence said: “GPs in Northern Ireland excelled in their response to COVID-19. Their ability to adapt and deliver entirely new services ensured our health service did not collapse. This earned respect and high praise from all levels of government – and patients who showed their appreciation for all healthcare workers with a weekly round of applause.

“RCGPNI was involved at the highest level of discussion and planning, and was able to influence key government policy, highlighting members’ concerns and advocating for best quality practice". 

04 | NEWS

WALES RCGP Wales put general practice at the heart of Welsh Government by organising regular meetings with decision makers.

The College advocated for PPE and clarity over the 111 online system, successfully campaigning for the inclusion of a link to the NHS Wales Covid symptom checker on the NHS England website, meaning patients across the UK could quickly access information and reducing unnecessary calls to 111.

Weekly blog and video Q&A sessions ensured that co-Chairs Dr Mair Hopkin and Professor Peter Saul kept members in the loop with latest updates and developments. The Members Forum has also shared best practice and provided peer support. Throughout the crisis, RCGP Wales became a go-to source for BBC Wales, ITV and S4C, a popular Welsh language TV channel.

Peter said: “It was vital to keep members informed in what the College was doing, as well as taking feedback from the frontline and making sure the big questions reached the right people as the profession rapidly responded to COVID-19. It has been a team effort.” 

SCOTLAND RCGP Scotland has worked closely with the Scottish General Practitioners’ Committee of the BMA (SGPC) and the Scottish Government to ensure a unified and joined-up response.

The College has also been involved in the production of crucial guidance for GPs and practice teams - including three sets of FAQs on care homes for residents, staff and GP practices.

Dr Carey Lunan, RCGP Scotland Chair, appeared as the face of general practice in a Scottish Government TV campaign ‘NHS is open’, She also achieved an RCGP ‘first’, appearing on Debate Night – BBC Scotland’s version of Question Time - where she discussed health inequalities, which remained a key priority for RCGP Scotland throughout the crisis.

The College helped to produce guidance for GPs caring for patients in deprived areas and Carey also conducted an interview with Professor Sir Michael Marmot on health inequalities in the COVID-19 landscape.

Carey said: “This pandemic has shone a light on the impact of worsening health inequalities across society, with those living in the most deprived areas being disproportionately affected.

I have always believed that general practice, based in communities, offering continuity of care, coordination of care, and advocacy for our patients, has a vital role to play in addressing health inequalities and during my time as Chair of the College in Scotland I have worked to ensure that our role can be better understood and strengthened.”

CONTINUING TO LEARN The pandemic has led to high demand for educational resources and guidance to support GPs and primary care teams in delivering the best possible care for patients with COVID-19. specific tips to obtain physical signs, in the absence of the ability to physically see or examine the patient. The hub has provided a useful 'go to' site that I have also directed colleagues to,” she said.

The College’s entire eLearning offer has been made freely available, in part to support returning GPs and primary healthcare professionals in the response to COVID-19.

Meanwhile, College clinicians and Officers worked quickly to ensure that events could be delivered online. The first free COVID-19 webinars looked at the disease trajectory and clinical symptoms, as well as the impact of the pandemic on mental health and managing

Dr Anne Connolly speaking at an ODE event last year - Grainge photography

F

ollowing the outbreak of COVID-19, the College responded quickly and launched the dedicated COVID-19 Resource Hub with clinical modules to enable the identification and management of coronavirus symptoms, as well as advice on approaching difficult conversations, ethical quandaries GPs may face and guidance on changes to death certification.

Other resources have addressed the needs of specific patient groups, such as shielded patients, those with learning disabilities, and PTSD as a result of trauma experienced during the pandemic.

Guidance was also developed on working in settings such as care homes, as

"The hub has provided a useful 'go to' site that I have also directed colleagues to."

Dr Zarina Beg

well as managing ongoing services such as contraception, postnatal infant and maternal care, and cancer prevention and screening, through the outbreak and beyond. To date the hub has been visited by nearly 30,000 users.

Dr Zarina Beg, locum GP and faculty education lead for Vale of Trent, found the podcasts and videos on remote consulting helpful during the initial move to remote triage consultations. "My practice benefited from a refresher on telephone triage consultations, including the concept of a ‘verbal examination’ using

Screenshots from ‘COVID-19: the patient journey from rehabilitation to recovery’ webinar

drug and alcohol problems in lockdown.

Several Faculties - including East Anglia, Midland, South East Thames, SYNT, Thames Valley and Vale of Trent - ran virtual meetings supporting more than 200 late career and retired GPs who were considering returning to practice. These covered topics including the impact of COVID-19 on paediatrics, preparing for a second wave and new ways of working, as well as offering practical and emotional support.

The focus of these webinars has now broadened to support many other vital topics for general practice. The popular face-to-face One Day Essentials conferences have been repurposed as One Day Essentials online conferences complemented by shorter clinical webinars - the Essentials Webinar Series. Both continue to feature leading experts. Events over the summer covered neurology, dermatology and ENT. Plenty of time is built in for questions, and participants can access the recordings and slides for six months from the broadcast date. Members receive up to one-third off the price of the online events.

Dr Anne Connolly is RCGP clinical champion for women’s health and clinical lead for the Menstrual Wellbeing Clinical Spotlight project. She previously chaired

the regular face-to-face One Day Essentials event on women’s health (pictured) and has recently spoken at the Essentials Webinar on Menopause management: The how-to guide for remote consultation, chaired a webinar on managing bleeding problems remotely in primary care, and will chair the December online One Day Essentials sexual health conference.

“Women’s health concerns are a common concern, but are often hard to explain over the phone,” she says. “Menstrual or menopausal issues are often raised when women are attending an appointment for another reason. Many problems can be dealt with via a remote consultation but require a careful history and an understanding of the risks associated with the problem to determine whether an examination, investigations or referral is required.”

Other forthcoming College webinars and online conferences include epilepsy, the cardiovascular effects of cancer treatment, mental health, ophthalmology and men’s urology.  Access the COVID-19 Resource Hub, including an archive of recorded webinars, here

NEWS

| 05

THE VITAL 'PRINCIPLE' OF RESEARCH

S

uccessfully tackling – and eventually eradicating - COVID-19 will depend on high-quality research to help us understand the virus. Across the globe, researchers have turned their efforts towards developing interventions to help ease its symptoms, treat those who contract it, and potentially vaccinate against it. The College’s Research and Surveillance Centre (RSC), based at the University of Oxford, has a proven-track record in virology surveillance and turned its attention to COVID at the start of the pandemic.

COVID-19 research is being prioritised by the UK Government and the RSC is involved in one of the country’s three national priority clinical trials on COVID: the Platform Randomised trial of INterventions against COVID-19 in older peoPLE (PRINCIPLE).

PLATFORM RANDOMISED TRIAL OF INTERVENTIONS AGAINST COVID-19 IN OLDER PEOPLE PRINCIPLE, the first trial of COVID-19 treatments to take place in primary care is widely considered to have historic potential as it represents a significant step in tackling the virus. It is 'one of the largest' COVID trials in the world in terms of its infrastructure and enables researchers to swiftly and easily assess a variety of treatments that may ease COVID symptoms in vulnerable and older people at a community level.

General practice has played a crucial role in keeping people safe and well in the community, helping to ensure the NHS doesn’t become overwhelmed during the crisis, and this trial has the same aim – focussing on the most vulnerable patients, including those who are most likely to be admitted to hospital with COVID, to find a treatment that can be prescribed by community-based GPs and ultimately benefit patients with the virus.

06 | NEWS

RESEARCH AND SURVEILLANCE CENTRE

TREATMENT EVALUATION

The trial aims to recruit more than 3000 patients and the RSC’s established and vast network of practices is playing a key part in this recruitment.

The RSC provides the PRINCIPLE trial with COVID surveillance information, therefore aiding patient identification.

The RSC also extracts and processes the study data as well as acting as a vehicle for the monitoring and following-up of participants throughout the course of the trial.

Following a nationwide call for participants, PRINCIPLE has just reached the landmark 1000th recruit and is open to all GP practices across the UK. Patients are recruited remotely, directly by the study team or via their GP surgeries. It is open to patients with COVID-like symptoms who are over 65 years of age or aged 50-65 with underlying health conditions.

The trial started with the evaluation of the malaria drug Hydroxychloroquine as some evidence suggested it might help to prevent hospitalisation of patients with COVID-19. The drug became prominent at the height of the pandemic but PRINCIPLE is no longer evaluating its potential impact on COVID symptoms because new evidence suggests it may not be an effective treatment within primary care settings. The trial has since gone on to evaluate the antibiotics Azithromycin and Doxycycline. Unlike most traditional clinical trials where a single treatment is evaluated, the design of the PRINCIPLE trial allows for the evaluation of several potential treatments at the same time and presents an opportunity for more patients in the trial to get the most effective intervention possible.

PRINCIPLE is ground-breaking in its infrastructure. The platform allows for quick and easy testing throughout the country and the College looks forward to seeing the potential of more interventions as they are added to the platform.

Dr Nicholas Thomas, RCGP clinical lead for research, said: “Research as a discipline has robustly responded to the challenge of the pandemic, and the RSC’s unique infrastructure and UK-wide coverage has put it in a fantastic position to try to identify a treatment for the virus.

“The PRINCIPLE trial is one of the largest acute care treatment trials in the world and we should celebrate the 1000 recruit milestone. The research being carried out promises to play an integral role in increasing the profession’s understanding of COVID-19 and primary care has a key part to play in this. I would encourage all of our members to take part in PRINCIPLE and contribute to this vital work.” 

"The PRINCIPLE trial is one of the largest acute care treatment trials in the world“ Dr Nicholas Thomas

SIGI JOSEPH

OPINION

Dr Sigi Joseph is RCGP Scotland Executive Officer for Professional Development. Here she reflects on being a BAME doctor during COVID-19...

I

trust I am not alone when I say that in early 2020 watching the emerging data on COVID-19 sweeping across the nations, I held my breath. The words “brace brace”, usually reserved for in-flight safety briefings seemed more important than ever.

Staring down the barrel of an inevitable pandemic and the likely repercussions was certainly a new experience in my 20 year career.

Reflecting seven months on, I feel a huge sense of pride for my practice team who swiftly shifted the way we consult; responding calmly with dignity and safety at the forefront of our minds.

The impressive guidance instigated by our LMC and the huge amount of policy work undertaken at RCGP Scotland, led by our indomitable Chair, Dr Carey Lunan has certainly helped to support practice teams across Scotland to navigate the pandemic. There is some trepidation as we look forward as the pent up pre-COVID workload reappears and a degree of emotional fatigue as the COVID-19 finish line moves further into the horizon.

Primary care has shone as a beacon of good practice with flexibility and a positive attitude. Contrary to some reports in the press, general practice has very much remained open throughout COVID-19, many of us working additionally in COVID-19 clinics and continuing to train our GPSTs and support our staff and families at home.

Remaining calm in a crisis has always been my approach and I think as clinicians most of us are intrinsically like this. However, as a BAME clinician I would be lying if I didn’t admit to an added level of worry.

In the early pandemic days, I was devouring every bit of news, social media and research I could find on COVID-19.

The apparently disproportionate number of Black Asian and minority ethnic colleagues dying heightening this further, not least because I come from a family of five BAME NHS doctors. This emerging worldwide data alongside the findings of Public Health England’s report

by Professor Kevin Fenton make this a poignant time to reflect on the impact of COVID-19 on our BAME colleagues.

Considering areas such as risk stratification for minority groups, position and value within the workforce and deeper

"As a BAME clinician I would be lying if I didn't admit to an added level of worry" difficult issues such as systemic racism.

The simultaneous worldwide Black Lives Matter protests alongside the COVID-19 related BAME issue coming to the fore gives us no better time to think about our BAME colleagues and what we are doing at RCGP to support and celebrate the diversity in our workforce. I was delighted to see the production of the RCGP BAME action plan and in particular some of its recommendations, for example, increasing diversity

in leadership positions and examiners, championing Faculty Education Leads, tailored risk assessment for safe working environments and CPD. In Scotland we have the excellent STEP Programme (Scottish Trainee Enhanced Programme) for our International Medical Graduate trainees.

We need to recognise that true inclusivity requires a cultural shift away from tokenism into full and proper inclusion of BAME colleagues, at all levels of the decision-making hierarchy.

Amazing initiatives such as Dr Omon Imohi’s Black Women in Health Initiative and increased recognition by our non BAME colleagues that things have got to change are very heart warming.

For me, strong role modelling has truly helped me to understand what is achievable in a GP career. These people have celebrated my strengths and helped me to push myself in taking additional roles. Such role models do not have to be BAME but they must be truly supportive and encouraging of BAME colleagues at all levels.

The 10th anniversary of the Marmot Review exposes our lack of progress in many areas of tackling health inequalities and I truly hope we will not be looking at a COVID-19 report in ten years’ time and finding nothing has changed for our BAME workforce. With the right policy changes and true recognition of the elephant in the room, this can be avoided. 

Read about the RCGP’s work to create an inclusive culture here

OPINION

| 07

RETURNERS TO THE RESCUE It was clear from the onset of COVID-19 that for the NHS to successfully manage the pandemic, reinforcements would be required.

More than 15,000 retired GPs from across the UK answered the call to return to the workforce to help with the pandemic response. They received temporary registration from the General Medical Council and were reinstated on the Medical Performers List. Amy Boreham caught up with two retired GPs about their different contributions to the pandemic effort.

England. She said: “I didn’t have the time to be nervous. This was a new virus, and initially there was limited information available, I knew I had to do some research.”

After setting up regular COVID-19 study meetings with fellow returning GPs on Zoom, Jo was on the remote

frontline during the height of the pandemic. “I enjoyed exercising my clinical skills again and speaking with patients, it was also interesting to get a detailed overview of the intricacies of the NHS 111 service, although I missed the continuity of care that comes with working in general practice,” she reflects.

Although Jo has no plans to return permanently to the workforce, she has been on a reserve list for the COVID Clinical Assessment Service and is now preparing to return to help with the current upsurge in demand. She has also resumed her volunteer work for asylum seeker charity Freedom from Torture as a medical report writer.

Jo describes her unexpected return to the workforce as ‘a privilege’.

"I am extremely grateful to the NHS for creating safe and suitable ways for retired GPs to aid the pandemic efforts, and for creating a selection of roles that ensure all skill sets can be directed to provide the greatest benefit,” she said. 

essential peer support to frontline GPs and other healthcare professionals, particularly with the new and intense pressures resulting from COVID. Post-pandemic, Anita is going

to continue her work at Practitioner Health, in anticipation of a significant increase in healthcare professionals requiring the service. She believes that the training and coping mechanisms GPs have used during the pandemic are short-term, and that many GPs will want to revisit and properly address the challenges and difficult circumstances they have recently encountered.

"Supporting colleagues throughout the pandemic has been exceptionally important work and is still ongoing. Many GPs will want to reflect and learn both personally and professionally.

"I am grateful to the NHS for acknowledging that not everyone will have been able to provide a clinical contribution to the pandemic, and for creating safe alternative opportunities,” says Anita. 

Dr Jo Buchanan, from Sheffield, had been retired from general practice for 18 months when in early March, she received an email asking if she was prepared to return to the workforce.

Jo successfully secured a clinical advisory role, assessing and supporting triaged patients with potential symptoms of coronavirus at an NHS 111 clinical assessment service, established

by South Central Ambulance Service Foundation Trust on behalf of NHS

Dr Anita Campbell, a retired GP from Yorkshire was drafted into Practitioner Health, the NHS programme supporting the mental wellbeing of doctors and dentists across the UK. With strong coaching skills and experience of working for local GP mentor programmes, Anita decided her skill set would be best suited to providing

STORIES FROM THE FRONTLINE

| 09

DIFFERENT DIRECTIONS Dr Simon Hodes safely transformed his GP practice in Zones to use as COVID-19 'hot hubs'.

“The initial outbreak sparked a practice ‘COBRA’ meeting,” explains Simon who practices at Bridgewater Surgeries, Watford. “We are very patient centred, and continuity of care is important to us. We knew we wanted to remain as visibly open as possible, and to protect our patients and staff.”

Like many GP practices across the UK, the surgery adopted a telephone triage service, with most patient care being delivered remotely, but with face to face appointments for those patients who needed them.

“We were lucky, our practice is over three sites – we closed one as a clean ops centre; the main site is extremely spacious, so we were able to segregate the ground floor for patients presenting with potential COVID-19 symptoms and the first floor for patients without symptoms. We also set up a 'Hot Clinic' at our branch surgery with a one way flow using the fire exit.

"Upon arrival, any patients seen were handed masks through a window to wear before entering the practice.

Appointments were strictly for patient examination only, with conversations on diagnostics and treatments delivered via phone to limit the amount of close contact between GP and patient.

Doors and windows were kept open to maximise ventilation as we had understood this reduced risks."

Like other GPs they were only provided with basic PPE, which they were concerned did not meet WHO guidance, so investments were made to acquire more sophisticated kit that included goggles, full head covering masks and full length, arm covering single use surgical aprons, which ’defi-

10 | STORIES FROM THE FRONTLINE

nitely made us feel safer’, says Simon.

Another challenge was staying updated with all the latest clinical guidelines, which at times were changing daily, and ensuring they were adopted in the practice.

Bridgewater Surgeries’ temporary hot hub was in operation until an official centre opened in the area. But Simon was also aware of the strain the pandemic was having on wider NHS services and was keen to support them.

He launched #TeamGPvCovid, with the support of Dr Nikki Kanani, Director of Primary Care at NHSE England and Iain Pickles, Lead for NHS Clinical Review of Standards, to recruit volunteer GPs to reinforce NHS 111 and 999 services.

The campaign was a huge success: within 48 hours, 300 GPs had signed up. In total over 800 signed up to volunteer.

“Primary care should be exceptionally proud of what it has achieved during these unprecedented times. We have been the epitome of keeping calm and carrying on. We've reconfigured, maintained a service and adapted to new technologies” said Simon. 

Emerging from the Costa Rican jungle after a 10-day expedition, Dr Hareen De Silva’s phone was alight with notifications on the rapid global escalation of the COVID-19 crisis.

On arrival back in the UK, the country entered lockdown. Hareen, who usually practises in Doncaster, began to look for locum GP work but changes to the way general practice was working, meant few vacancies were available.

A social media post advertising a six-week contract as a ward doctor at the Nightingale Hospital, the temporary COVID-19 hospital at the Excel Centre in London caught his attention and he applied.

Hareen received training on how to work technology on the wards and several days later, started his first 12-hour shift. “I felt incredibly nervous, it was like I was starting my first F1 placement all over again. One thing that initially struck me was the sheer vastness of the Excel centre. Each bed has a computer, ventilator, obs machine, a dedicated clinical support worker and nurse, and is overseen by an ITU nurse.”

He was initially allocated six patients to monitor: “There was a real sense of staff collaboration and a fighting spirit from the clinical support workers to more senior members of the team. Our uniforms were colour coded to make everyone’s roles easily identifiable.”

He saw the devastating effects of COVID-19, first-hand. “As a GP you develop strong palliative care skills, particularly when doing home visits to terminally ill patients. We were surrounded by critically ill patients and I was able to deliver this care to these patients and provide support to their families during the brief moments they were allowed to visit to say goodbye.

“The hospital made a real effort to keep up staff morale. Companies donated food, some hospital walls were decorated with drawings from local primary schools and there was always an onsite psychologist or member of the wellbeing team to chat to.”

Hareen summarises his work at the Nightingale as ‘harrowing but incredibly humbling.' He says: “COVID-19 has shown me the sheer power of nature, but I feel that the skills I have acquired in general practice have allowed me to cope well in these uncertain times.”

Hareen has been awarded a British Empire Medal in the Queen's Birthday Honours for his work. 

STARTING OUT DURING A PANDEMIC Embarking on a medical career is always full of new experiences but what happens when it coincides with a global health pandemic? F1 doctor Shamarah Mathurin-Charles and GP trainee Muddassar Ahmed share their experiences.

Dr Shamarah Mathurin-Charles was a final year medical student shadowing an F1 doctor at Medway Hospital in Gillingham, in preparation for her own F1 placement, when she heard the news that 5,500 medical students would be graduating early to aid the COVID-19 pandemic response.

After volunteering, Shamarah was drafted into a COVID-19 ward as Final Year Medical Student COVID Support.

Her primary role was to teach staff how to safely put on PPE equipment.

In April, following an understated and remote graduation, Shamarah transferred to the COVID-19 high dependency ward, where she worked at the height of the pandemic, helping with clinical jobs such as taking blood samples and fitting cannulas.

“It was an unexpected and extreme dynamic, but it helped that I was familiar with the clinical supervisors and hospital consultants, and the higher ratio of clinicians on wards compared to patients enabled me to ask more questions and further develop my clinical skills; something that I might not have had as much of an opportunity to do if I had been working under more normal circumstances.”

In May, Shamarah’s official Interim FY1 placement in one of the designat-

ed COVID-19 wards at King's College Hospital London began. At the time, the news agenda was dominated by the Black Lives Matter movement, and the publication of data that indicated patients from Black Asian and minority ethnic communities were more susceptible to contracting the virus.

She found it to be a particularly emotional time: “I felt I had a special connection with patients admitted onto the ward from BAME communities. I think it made me even more compelled to deliver the best possible care to all patients,” she reflects.

Since then, Shamarah has joined the College’s BAME working group.

She summarises her unprecedented career start as an ‘invaluable experience’ but also a ‘steep learning curve’. “I’m grateful to King’s College for their support, and to the NHS for providing free accommodation, which instantly alleviated any of my worries about spreading COVID-19 to my grandparents, who I normally live with,” she says. 

GP registrar and Vice Chair of the RCGP AiT committee, Dr Muddassar Ahmed, managed to complete his MRCGP before exams were suspended due to COVID-19, and whilst waiting for his results, spent

the pandemic practising at the GP practice in Peterborough where he was training.

His initial challenge was becoming accustomed to the new ways of working in general practice, particularly the move to remote consultations, something he had little previous experience of. “Most of my training involved seeing patients face to face, so delivering care via telephone was initially a struggle. At first, I was ringing patients a couple of times after their consultation to check they were okay. I thought having video consultation equipment, would enhance the quality of care we were able to provide. I raised this in a practice meeting, and cameras were ordered and installed, which made me feel a lot more confident.”

Limited PPE and media speculation on its effectiveness left Muddassar feeling concerned, not only for his safety but his friends, family and patients. “When arriving home from work, I was practising an extensive hygiene routine and having to socially distance from close family members. I made the decision to temporarily live alone. I felt quite isolated and hugely benefited from colleague support at the practice.”

Muddassar also found time to volunteer with the Ahmadiyya Muslim Association and Ahmadiyya Muslim Medical Association, to help and support vulnerable members of the community during lockdown, as well as setting up a remote online clinic for patients in Pakistan, who were unable to access COVID-19 medical care.

Despite COVID-19 presenting clinical and mental challenges, he says it also helped to build his confidence and reminded society of the importance of kindness and communication. 

STORIES FROM THE FRONTLINE

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TACKLING COVID AROUND THE WO

South Korea’s pandemic response has, so far, prevented a national lockdown and significantly minimised the spread of COVID-19 across the country, with fewer than 450 deaths recorded. Its quick response and high capacity testing system has received worldwide recognition, being attributed by some to lessons learnt from the outbreak of Middle East Respiratory Syndrome (MERS) in 2015.

Dr Chu Hyein, 43, a family doctor in a clinic located in north west Seoul, highlights the extensive and important role family doctors have played in South Korea’s pandemic response.

The doors to most family medicine clinics have remained ‘firmly open’ throughout the crisis, with a primary responsibility of triaging and assessing patients with COVID-19 symptoms, to determine if a referral is required for a free screening test. “All public screening tests are free of charge. We can refer patients who need tests to screening clinics without any hesitation,” Hyein explained.

“Patients who test positive are referred to the Central Disaster and Safety Headquarters, who in turn refer them on to an ICU, a ‘negative pressure ward’ (special wards pumped with negative pressure to prevent the transmission of infectious diseases), or a ‘living treatment facility’ (with onsite nurses, for patients who are asymptomatic or have mild symptoms to

12 | STORIES FROM THE FRONTLINE

and were quarantined in hospitals and living treatment facilities,’ she said.

Hyein says the spread of ‘fake news’ by political groups suggesting a government exaggeration of the severity of the virus is now causing widespread confusion, making patients more reluctant to quarantine and putting vulnerable groups such as the elderly at risk.

She says that family doctors are playing an important role in the fight against propaganda by educating patients with key public health messages to maintain community safety against the virus.  Doctor Mike, Instagram

SOUTH KOREA

self-isolate in). Referrals depend on the severity of initial systems, as well as other risk factors such as any underlying health conditions or a patient’s age.

“People could count on us during the pandemic,” she said, “not only to help with physical symptoms of the virus but to also provide lots of reassurance to our anxious communities whenever they felt scared or depressed by the coronavirus” Family doctors worked Monday to Saturday, offering support to patients remotely on the phone who were concerned about their symptoms or had fears of coming to visit the medical centre. “Of course, we were also continuing to manage other chronic diseases such as hypertension, diabetes and asthma too,” she says.

At the start of the pandemic, Hyein also volunteered at the Public Community Health Centre for COVID-19 screenings after work and at weekends, assessing potentially symptomatic patients, and conducting tests. Her experience emphasised the incredibly low prevalence of COVID-19 in the community. “Out of the hundreds that I tested, only two patients were confirmed positive cases of COVID-19

NEW YORK, USA New York was one of the first hit areas in the United States, and one-time epicentre of the pandemic. Dr Mike Varshavski lives in New York and practises family medicine in New Jersey.

He says that people saw COVID-19 as a ‘New York problem’, not recognising the seriousness of the pandemic at a national level.

“I don’t think you can fully prepare for a pandemic and there are things at a federal and state level that I think we could have done better. It’s important we look back and assess this – we’ve been doing that in New York and can give advice to states that are hardest hit now.”

ORLD Mike describes ‘a period of quick adaptation’ professionally. “In the healthcare space we’ve tried to do the best with what we could. At one point we were being asked to take care of people without the proper protective equipment. In late March we switched completely to telemedicine because the virus was just peaking and we couldn’t have patients come in unless it was an emergency. It’s been difficult, and confusing for patients, first telling them they can’t come in and then, once safety protocols were in place, saying it’s safe. “It’s shown how quickly the medical field can come together and really do something special because our primary motive is to care for our patients.”

Whilst Mike has mainly worked remotely during the pandemic, his views on telemedicine are mixed. “There are plenty of instances where it does a great job in helping patients access care, but we have to be honest about its shortcomings. There’s no substitute for being in a room with a patient, reading their non-verbal cues, doing a proper physical exam, listening to their heart and lungs.”

Doctor Mike has also been busy maintaining his social media outlets, which have a combined audience of more than 10m.

“There have been so many outlandish things being said about COVID-19, but also a lot of believable things that are horribly inaccurate, which are more dangerous as they’ll have bigger impact. It creates fear and panic.

“I’ve focussed on delivering accurate information, and challenging misinformation, in a way that’s easy to understand. I’ve done some content teaching people how to safely put on masks. I also did a video interviewing 106 physicians from all over the world on how they’re coping - all different but all thinking about the same thing in unique ways. It was powerful.

“The amount of views we’ve been getting for our videos [during the pandemic] is amazing, they’ve been rivalling some of the major press outlets here in the US.” 

“I’ve been impressed by the discipline that high-risk patients have shown, they have isolated themselves and followed official guidance diligently.”

SWITZERLAND Dr Christian Fahe practises in Muhen - a town in central Switzerland with a population of approximately 4000.

“In Switzerland each canton [the country’s administrative subdivision] issued COVID-19 guidance for its territory. The majority of my patients are not considered extremely vulnerable, their average age is 51, but in Muhen from around mid-March, GPs were advised to only see patients in need of emergency assistance, so all routine appointments were cancelled. Masks were strongly advised for patients but mandatory for general practice staff,” says Christian.

“However, by the end of April, we were back to normal and GPs started seeing all patients again. At no point did we adopt a primarily remote service because this wasn’t something the canton advised. Our patients understood the reasons for general practice being an emergency only service for a period of time,” he says.

In preparation for a second wave Christian explains: “I have a large reserve of protective equipment [PPE] that meets safety standards, we’re still

very strict regarding social distancing and carry out deep cleans on the premises several times a day.”

Christian also notes that COVID-19 has led to a spike in the number of people wanting the seasonal flu vaccine.

“Last year I ordered enough to vaccinate 300 people, which under normal conditions would have been a good amount, and we only used half.

This year I’ve had to order well over 300 vaccinations - it will be interesting to see how patients respond to the COVID-19 vaccine once it’s available,” he says.

Commenting on Switzerland’s overall response Christian says: “I’ve been impressed by the discipline that highrisk patients have shown, they have isolated themselves and followed official guidance diligently. We are dealing with a health issue, so having to follow the advice of politicians in this area has been unusual but I believe good decisions are being made with the information available at any given time.”  All information was correct at time of publication.

"It’s shown how quickly the medical field can come together and really do something special because our primary motive is to care for our patients.”

STORIES FROM THE FRONTLINE

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Specialist financial advice for GPs and their practices

A THOROUGH EXAMINATION IS ALWAYS A GOOD IDEA Examining your financial concerns At Wesleyan Financial Services, we’re happy to be working with the RCGP as their exclusive financial advice provider.

Whether you’re just starting your career, approaching retirement or somewhere in the middle, we can help you with: u

Retirement and Inheritance Tax planning

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Saving and investing for your future

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Protecting yourself and your loved ones

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Advice on finding the best mortgage

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Ensuring your practice runs smoothly

Let us help you feel better about your finances this autumn You can speak with your local Wesleyan Consultant from the comfort of your own home via telephone, video call or face-to-face.

To arrange your review, or for further information on the range of services we offer, visit

wesleyan.co.uk/RCGP

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Your mortgage is secured on your home. Your home may be repossessed if you do not keep up repayments on your mortgage.

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Advice is provided by Wesleyan Financial Services Ltd. ‘WESLEYAN’ is a trading name of the Wesleyan Group of companies.

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GP-AD-3 09/20

THE PATIENT PERSPECTIVE GPs had to transform their ways of working almost overnight and patients have also had to adapt. Kristy Ebanks writes about some of their experiences.

“I wasn’t considered clinically extremely vulnerable but I do have a chronic disease, and I’m also a key worker so even though I wasn’t advised to shield, my role put me at a high risk,” said Keri Rose, 34, who lives in Romford.

At the start of the pandemic, Keri contacted her GP for advice about the risks presented by her key worker role.

She was concerned about how long it would take to get an appointment and whether she would be asked to come in for a face to face consultation.

“I don’t want to catch the virus and I was worried about going into the GP practice but my doctor called me back the same day and was happy to have the appointment over the phone,” she explained.

“He agreed that I should limit contact with people outside of my home and issued me a certificate via email, which is good because that helps to save the planet,” she said.

Keri – a patient at North Street Medical Care – was impressed by how easy the processes have been and, as

someone who has regular contact with her GP, would like remote consultations to remain an option post-COVID. “I work nine to five and my condition means I’m often at the doctors, so if I could have these appointments over the phone then I wouldn’t have to take time off work,” she said.

Elsewhere, in Enfield, North London, Selina Robinson was experiencing flu-like symptoms and despite testing negative for COVID-19, she needed advice from her GP and was impressed at how easy it was to get help.

“I’d love to have the option of a telephone appointment in the future.

Sometimes you just need reassurance or advice on how to administer selfcare,” said Selina, a patient at at the Town End surgery.

Nathan Ballin and his son Cole attended a face-to-face appointment at the at Spring House Medical Centre in Welwyn Garden City for pre-school booster vaccinations.

“There was no waiting room –

we arrived outside and I spoke to the receptionist through a window, then we were let in when they were ready for us,“ said Nathan.

“Once inside, no one else was there and it was all very relaxed. We all wore masks, even before masks were made mandatory.”

Owen Richards, Lay Chair of the RCGP Patient & Carer Partnership Group, said: “Patients and their carers understand the need for the new ways that primary care has been operating throughout the pandemic, but, as the College has pointed out, face to face consultations remain essential for some patients.

“Some people may not be confident with technology and some just prefer seeing their GP face to face – there is no such thing as an ‘average patient’.

“Looking to the future, there’s a real opportunity for patients and their carers to work with GPs to develop a truly personalised-care approach to access.” 

THE LETTER OF DOOM “When my friends and I received shielding letters, we all felt as though we had been delivered a letter of doom,” said Ingrid Brindle.

Ingrid from Manchester is 76 years old and said: “I interpreted the letter as meaning that if I was hospitalised I wouldn’t be given any ventilation equipment and if it came down to it I would not be resuscitated – I was worried,” she said.

However, Ingrid’s views changed when her local GP practice, the Haughton Thornley Medical Centre, stepped in. “The support I received from my GP practice was marvellous. I need to have regular contact with my practice because of my complex medical histo-

ry and I’ve been keeping in touch with my GP via email, which is very beneficial,” she said.

Ingrid explained that while a lot of her face to face appointments were initially cancelled, she was able to stay involved using Engage Consult, the online app offered by her surgery for routine medical conditions or admin questions.

“I have full access to my records and blood test results, and I’m able to ask questions about anything that is not clear – it’s terrific. There’s a lot of advice available. My friends have also made use of this service. We all feel extremely supported,” she said.

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Dr Catherine Millington-Sanders - Channel 4 News

COMPASSION TO THE END

COVID-19 has led to more than tens of thousands of deaths across the UK. Many of those who died were living at home or in care homes in the community.

“Many people have died, who before the pandemic, were not expected to die so soon”, says Catherine Millington-Sanders, RCGP and Marie Cure clinical champion for palliative and end of life care.

One consequence was that access to medication to alleviate some of COVID-19’s most severe symptoms, such as extreme breathlessness, became difficult due to increased demand for strictly controlled drugs such as morphine. In response, College Chair Martin Marshall wrote to Home Secretary Priti Patel urging a temporary relaxation of rules around controlled medications and to prevent them being destroyed if they could not be used for the patient they were originally prescribed for.

His letter featured on Channel 4 News and in the Financial Times.

Subsequently, rules were temporarily relaxed in care homes and hospices, speeding up the process for patients who needed the drugs and easing supply issues for patients in other settings, such as their own homes.

Delivering care to patients in care homes, whilst also maintaining infection control, has been a particular challenge for GPs. The College called for adequate PPE for care home staff and appropriate testing for staff and patients early on in the pandemic – and hosted a webinar for members to share best practice to deliver care in care homes, both in person and remotely, as well as producing other resources.

Another consequence of increased death during the pandemic, Catherine

16 | STORIES FROM THE FRONTLINE

explains, was that for many it “brought forward the need for doctors and patients and their families to have difficult conversations about death and dying that were unplanned, given the nature of how the virus quickly affected patients.

“It’s highlighted that these conversations aren’t just for the dying. We need to be more open as a society about discussing death and as GPs, about finding out what matters most to patients including advanced decisions with patients so that their wishes can be respected if they do become ill and unable to make their own decisions.”

Catherine is now collecting GPs’ stories of dying, death and grief for a book aimed at helping other GPs make sense of their experiences of loss in the everyday world.

The responses she has received so far, focus on learnings from GPs’ own experiences of loss and how they have applied these to their own practice.

One says: “The constant challenge of medicine isn’t keeping up with the rapidly evolving science and evidence, it’s holding on to our humanity, being kind, being empathic, allowing patients and families to share their darkest thoughts and worries. Then being able to return home at the end of the day and not incorporate the suffering of others into our own lives.” 

If you wish to share your own experiences with Catherine, email her at catherine.millington-sanders@ rcgp.org.uk.

Dr Victoria Tzortziou-Brown

The challenges of delivering good end of life care have never been greater for GPs.

Verifying deaths during COVID Throughout the COVID pandemic the way in which GPs have registered and managed deaths outside of a hospital changed in order to ensure that, despite unprecedented circumstances, the deceased and their families are treated with the utmost respect.

Very early into the pandemic, the College became acutely aware of the challenges around remote death verification via our dedicated feedback email and members’ forum. In response the College, along with the BMA, produced guidance for the verification of expected death with the remote assistance of other workers.

Influenced by the RCGP/BMA’s guidance the Department of Health and Social Care went on to update their own guidance in this area.

Dr Victoria Tzortziou Brown, RCGP joint Honorary Secretary who led this work for the College, said: “Developing this guidance, as well as an e-learning module, was crucial as it ensured that the death verification process could be completed by a clinician safely without delays or potential exposure to COVID-19. It meant that at the peak of the pandemic bereaved families would not face unnecessary delays whilst GPs could continue working on the frontline minimising the spread of the virus.” 