Primary care transformed due to ‘collective urgency’
Blog posted by: Dr Ian Pawson, 08 June 2020.
Dr Ian Pawson
I am a GP partner at Brownlow Health, which has four practices in Liverpool city centre serving a combined population of just over 60,000 patients. As with many inner city practices our patient group is very diverse and the needs of different patients can vary widely.
Most of our practices and staff have been very familiar with telephone triage, having used this for some years, and last year began using email consultation as part of a total triage approach for two of our practice sites.
When the COVID-19 outbreak hit and lockdown was implemented we experienced an initial dip in contact from our patients. I know many GP colleagues commented that patients were reluctant to make contact with healthcare providers, even when there may have been a pressing need. This has certainly changed now, those who need help have begun contacting us again and our volume has returned to normal.
How things changed overnight
When COVID hit we responded rapidly: we shut the physical doors of our practices and ensured all access to the practice was handled remotely, using phone and email. For some of our vulnerable groups, such as our homeless patients and care home residents, additional forms of support were put in place.
We went from seeing around 50 per cent of patients presenting to us to dealing with around 95-98 per cent remotely, almost overnight.
Having systems already in place for remote consultations certainly helped but this was still a massive shift in the way we worked.
These changes were made possible because we quickly had access to improved remote tools, including enhanced patient texting and video consultation. To be honest, we weren’t convinced of the value of video consultation before COVID-19, the majority of the time a telephone call or email consultation alongside a photo usually being adequate to make a decision. COVID-19 has shown there are some situations where video can help resolve a consultation remotely, including for managing patients in care homes, those with musculoskeletal conditions and mental health problems.
The speed of response from the providers of the remote tools we use, such as AccuRx and eConsult, has been outstanding. Within days of COVID-19 lockdown they were providing additional functionality that has enabled us to operate a remote model reliably, ensuring our clinicians were provided with enough information to make safe clinical decisions: The impact of this cannot be underestimated, enabling the sustainability of general practice and so alleviating pressure on other parts of the healthcare system.
Impact on GPs
In our practices we have developed green and red zones – green for non-COVID, red for COVID and we have clinicians in each zone. We set up this process as soon as it was clear that there was a real risk of our patients being vulnerable if coming to the practice. We will only ask patients to come into the practice once they have had a triage consultation and it is clear that they need examination to decide on management. Following this we aim to ensure the patients are in and out of the practice as quickly as possible and we manage our appointment times to minimise multiple patients being in the waiting room at the same time.
Our team has developed extensive processes to ensure that our patients and staff are as safe as possible, and the way our team have pulled together to make this work has been exceptional.
We would normally have had 25 to 30 clinicians in person based across the practices; now a minority of the team work within the practice on any given day and the remainder work remotely, with the ability to come in if needed.
Despite managing the majority of our patients remotely our workload remains intense. One of the things we have experienced with total triage is that, while it is efficient, it can increase the acuity and complexity of what you are then seeing face to face. Prior to COVID, when triaging, we would always have the option of asking a patient to come in face-to-face to review, not having this option has certainly stretched us to consider new options; in the long run this will be positive, but it has also been very hard work and pushed us out of our comfort zone at times.
The amount of effective change we have seen in such a short space of time and the ability to work in new ways has felt like a breath of fresh air.
We are having conversations about how we use this opportunity to shape how we work in the long term and ensure we make general practice sustainable.
The big responsibility we feel right now is how to use this opportunity well; this is a time for ‘blue sky thinking’, redefining general practice in a post-COVID world while retaining the distinctive features which make it special: Continuity of care, integration in the community, relationship with patients.
Many of us have felt benefit in the so called ‘red tape’ not playing a significant part in the decision making processes at practice level during COVID-19; the majority of decisions have been driven by what is absolutely necessary for the patient in front of you. There has been an ability to accelerate the pace of change as required - at times this has been from one day to the next.
Collaboration has been accelerated
We are part of Central Liverpool Primary Care Network which has nine practices with just over 100,000 patients in the city centre of Liverpool. As well as the significant amount of practice-based work much has been done in collaboration with our primary care network (PCN) colleagues. We came together to run a collaborative hot hub for all our ‘red patients’. It has been challenging, PCNs being relatively young organisations.
To begin integrating and seeing each other’s patients within a matter of weeks was a massive undertaking but we have stood up to the challenge and have learned a lot and going forward we hope our relationships and network are stronger as a result.
We now have one hot hub seeing patients from nine different practices, and have set up robust processes to ensure smooth patient flow through this system as well as regular review to ensure we optimise the system. This has enabled the nine practices to focus on managing their other non-COVID workflow in-house without having to develop separate patient flows for their own red patients.
We’ve had really positive conversations and valuable constructive criticism from network colleagues at each step, building on good network relationships - trust has been vital.
As we look forward there are opportunities which we are now viewing in a new light, such as enhanced access. As we have successfully begun to send our patients to a hot hub to be reviewed by network colleagues, we are asking what other work we could effectively share. The COVID experience has probably accelerated these conversations by more than 12 months.
We are moving from the visionary stage to getting the practicalities down on paper now. The changes have to be in the best interests of patients but there is likely to be a way we can improve working practice for everyone - patients, staff and practices. Can we make sure that the regular working day for our general practice teams is satisfying, because it continues to provide exceptional care for our patients, whilst also safeguarding a healthy work-life balance for our staff and making general practice an attractive place to work for years to come?
We need to ensure that young GPs, practice nurse and administrative staff coming into the profession can look forward to completing their working life in the role without the risk of burn out, with options to have a satisfying and varied role.
When reflecting on the last few months it has been interesting to consider what has been stopping us from making some of these practical changes earlier.
On reflection, I’m not sure that it really was ‘red tape’ or contractual restrictions, although these definitely can be factors, I think that the biggest issue is that there just wasn’t the collective urgency for it.
At present we have the impetus of this collective urgency. We must grasp the opportunity to shape the future of general practice to benefit our patients; involve patients in a conversation about what general practice can and should offer, while not allowing gaps of health inequality to widen. There is clearly still a lot of work to do moving into the ‘new normal’.
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