Rapid changes are taking place across general practice as a result of the covid crisis.  Do these pose a long term threat to the profession, or are they an opportunity?

It is hard to over-exaggerate the level of change taking place in general practice right now.  The shift to telephone consultations, video consultations and remote working, borne out of necessity, is happening at a pace and a scale never previously seen.  Shared models of service delivery across practices within networks and boroughs are being developed and operationalised in a matter of days.  Models include covid face to face sites (“hot” clinics), covid and non-covid visiting services, and even non-covid face to face services, including essential services such as childhood immunisations and routine injections.

Such changes have raised concerns in some quarters of the profession.  Will general practice ever be the same again?  Once this is all over, will things be able to return to the way they were, or are we saying goodbye to general practice as we knew it forever?  The worry is that the scale and pace of the changes being introduced right now will have an impact on the profession way beyond being able to cope with the crisis that is front and centre right now.

It is, however, worth bearing in mind that all was not well in general practice before the current crisis.  The GP Forward View, and then the five year contract introduced last year, were put in place to help a profession that was facing significant workload, workforce and financial challenges.  Some areas had been making changes in an attempt to meet these challenges.  These changes largely focussed on new ways of working, working at scale, introducing new roles, and building stronger partnerships with the wider system.

What the current crisis is providing is a unique opportunity to test out these changes.  The rationale for making these changes is stronger than ever.  Rather than the changes relying on a critical mass of practices having reached the point of enough being enough, when in reality some practices were getting there while others were managing to find a way through, now the need for change is clear.  The safety of staff, and limiting exposure to the virus, requires virtual appointments and centralised models of face to face delivery.  This, alongside the limited supplies of PPE, means these models have had to be put in place very quickly indeed, when previously such changes would have taken months or even years to put in place.

At the same time, the system is providing resources to general practice to make these shifts in ways that it never has done before.  On the podcast Dr Ravi Tomar describes the advantage practices have in making the shift to remote working now compared to when his practice made it 18 months ago.  Laptops, dongles, tokens are all being made readily available to practices.  In many areas centralised models of service delivery for covid patients are being directly funded by the local CCG.

The need for rapid change right now, and the support and resources available to make this happen, represent much more of an opportunity than a threat to general practice.  Once all this is over general practice can choose the parts of the changes they want to keep and the parts they do not.  But right now there is a unique opportunity for general practice, a profession that has been in urgent need of resuscitation, to test out new ways of working.  These changes may not only help it get through the current crisis, but also enable it to thrive into the future.

A big part of this week has been about PPE (personal protective equipment).  GPs need it.  They need it to see covid/suspected covid patients, and, increasingly, they need it to see everyone because right now who isn’t suspected covid?

The problem is that the supplies have not been there.  Initial supplies were sent to GP practices in early March.  But these supplies are widely regarded to be inadequate for what is required, and are rapidly running out (if they have not already done so).  Last week GPs were informed that a hotline had been established (0800 9159964 in case you don’t have the number), and for GP practices ringing the hotline that kit would be arranged within 72 hours.  So far (as of the weekend) reports are that problems remain.

As a result, GP federations and organisations have been working to see if they can secure supplies on behalf of their member practices.  Supplies do exist, but they are primarily in China.  But as we have been discovering this week, there are a number of problems dealing directly with suppliers in China.

First, the products need validating.  Just because the supplier says the masks are FFP3 masks does not mean they are.  Someone needs to go and check the products.  But finding someone you can rely on to carry out the validation is difficult.

Second, the PPE products need to be transported from China to the UK.  The cost of air freight is eye-watering.  On top of that the exporters need to have all the correct licenses to be able to ship products to the UK.   There are reports that hand sanitisers and overalls are being stopped at the UK border, and being returned to China as the importers did not have an alcohol or medical supplies licence.  This urgently needs to be addressed, but it falls within the remit of government and is out of the control of GP federations.

Third, the products are expensive.  They are not just expensive – prices are escalating on a daily basis, as the worldwide demand for the products soars.  Not only are they expensive, the Chinese suppliers demand payment upfront.  They hold products that everyone wants, so they can set their own terms.  Their terms are that they will only sell to those who are pay upfront.  Some will only sell to those who provide cash upfront.

However, the NHS does not work that way.  The NHS will not make payment up front ahead of supply.  It, understandably, does this on the basis that any supplier not prepared to extend credit to a state backed entity is a much higher risk of fraud.

So here comes the dilemma. How much financial risk is it reasonable to take to secure PPE supplies for GP surgeries?  Because ultimately we are weighing that risk against the health and lives of our GPs and their staff.  Should the NHS be prepared to say that in these exceptional circumstances we will take risks that normally we would not take, because these are not normal times?  Should government be encouraging and enabling NHS organisations to take these risks?  Or is the financial risk not worth it?

Whatever the view of the wider NHS, a number of GP federations think it is a risk worth taking.  If at the end of the day the PPE isn’t what they said it was, or it doesn’t arrive, they view it as a risk worth taking, because ultimately what we are actually risking is the health and lives of those we are asking to deliver care.

I spend most of my time at present working with a GP Federation in North East London.  What has become clear in recent days is that the crisis we are in is a key moment for the federation.  The role of the federation is, and always has been, explicitly to support member practices and delivery of care to their practice populations.  If the federation cannot support practices right now at the time when they need it most, I don’t think it ever will be able to.

This situation is not unique to the federation I am working with.  I think the challenge equally applies to other federations, to super-partnerships, and even to Primary Care Networks.  If there was ever a time when working together could add value, then it is now.

Individual practices are working extremely hard.  They are trying to get to get to grips with whole new ways of working – some practices have had to move to full telephone triage in a week, when many practices have taken years to make such a shift.  Every day there is a new challenge, with different staff off sick or isolating.  The priority is simply to make it through to the end of each day.

What is the role of at scale general practice?  Things are changing at such a pace that what is needed today might be completely different to what is needed in only a couple of weeks’ time.  But for right now, the role appears to be threefold.  First, identifying what immediate support can be provided to practices.  That could be help with ordering equipment, setting up IT equipment or establishing remote working, help obtaining locums, and directly helping when a practice goes into crisis (as some practices inevitably will).

Second, preparing for what is coming next.  We know the scale of the challenge will increase week on week, certainly for some time to come.  What worked last week may not work next week.  Local at scale general practice has to think about what is coming next, and what needs to be put in place to enable practices to cope.  This might be ensuring robust escalation processes are in place between and across practices, the introduction of “hot” sites, establishing an at-scale visiting service, plus things we have not even thought of yet.  Practices are (rightly) focussing on today, so at-scale general practice has to make sure it is doing the thinking about tomorrow.

Third, ensuring there is two-way communication with practices.  Practices need to have the up to date information on what is happening locally, and at the same time need somewhere to raise questions and concerns.  At-scale practice needs to provide that visible local leadership for practices which is so critical at a time when individual practices could easily feel isolated and alone.

But the challenge this presents for the at-scale organisations themselves should not be underestimated.  They often operate with a very limited number of staff, and clinical leaders in more or less full time roles in practices themselves.  They will also have their own internal challenges with sickness and isolation.  Meeting this challenge will not be easy.

In the coming weeks on the podcast I am going to be talking to Tara Humphrey who is working with a PCN, and we will both share our experiences of working with a PCN and a federation to see whether at scale general practice is able to rise to the huge challenge ahead.

We have had quite a week in general practice.  The LMC conference voted to “reject the PCN DES as it is currently written” and yet, frankly, it feels like an irrelevance given the unfolding situation with regards COVID-19.

The irony of course is that, just when the profession has chosen to reject PCNs, the need to work in groups of practices has become more important than ever before.  The reality is that many practices will have to close for periods of time over the coming weeks, and so right now need to be working and planning with their neighbouring practices to be prepared for when the time comes.

In turn, this reinforces the point that those who voted against the PCN DES were making.  If Primary Care Networks were genuinely about strengthening core general practice (and there is no better example of the need for this than right now) they would have voted for them.  It is the sense that, as the LMC motion put it, they are “a trojan horse to transfer work from secondary care to primary care” that has caused the disillusionment, not the idea of PCNs or working together per se.

Let’s see where we end up, but it may be that when all this is done and dusted we have much stronger, supportive networks of practices, regardless of whether or not they have signed up to the PCN DES.

At the same time practices have been asked to move to a total triage system (whether phone or online), and to undertake all care that can be done remotely through remote means.  The threat caused by coronavirus means that practices are very keen to move to such a system, to reduce the risk to their own staff as much as they can.

Now this is in sharp contrast to the situation we have had previously, where there has been a relatively slow rollout of first telephone triage and then e-consultations.  What situation will we be in a few months down the line when practices have grown used to operating primarily via remote consultations?  Even at this early stage it is hard to envisage a full regression to the point we were in maybe only as recently as last week.

So right before our very eyes general practice is changing at a pace that it has never changed at before.  It is change borne out of the necessity and challenge the current crisis is placing upon us.  What the service will look like once the dust has settled none of us know, but my guess is general practice will never look the same again.