Practice and participant characteristics
87 interviews were conducted with 21 GPs, 11 practice managers, and 9 nurse managers from across 21 practices, which covers 25% of the CCG’s practices. Practice and participant characteristics are shown in Table 1.
Table 1
GP Practice and participant characteristics
GP practice | Patient List Size * | Indices of deprivation quintile ** | Interview participants |
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| | Round 1 *** 13–27 May | Round 2 28 May − 13 Jun | Round 3 15 Jun − 2 Jul | Round 4 3 Jul − 27 Jul |
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1 | Medium – Large | 1 | GP1, PM1 | GP1 | GP1 | NM1 |
2 | Small – Medium | 2 | GP2, PM2 | GP2 | GP2 | GP2 |
3 | Medium | 3 | GP3, PM3 | NM9 | GP3 | NM9 |
4 | Medium – Large | 5 | GP4 | GP4 | GP4 | NM2 |
5 | Small | 1 | GP5, PM4 | 0 | GP5 | NM3 |
6 | Very Large | 5 | GP6, PM5 | GP6 | GP6 | GP6 |
7 | Medium | 5 | GP7 | GP7 | GP7 | GP7 |
8 | Small – Medium | 5 | GP8, PM6 | GP8 | NM4 | GP8 |
9 | Very Large | 5 | GP9 | GP9 | GP9 | NM5 |
10 | Small – Medium | 5 | GP10, PM7 | GP10 | GP10 | GP10 |
11 | Small | 1 | GP11 | GP11 | GP11 | GP11 |
12 | Very Large | 3 | GP12 | GP12 | GP12 | 0 |
13 | Small | 5 | GP13 | GP13 | GP13 | GP13 |
14 | Medium | 5 | GP14, PM8 | GP14 | GP14 | NM6 |
15 | Small | 5 | 0 | GP15 | GP15 | GP15 |
16 | Small | 3 | 0 | GP16, PM9 | 0 | GP16, PM9, NM7 |
17 | Small – Medium | 3 | 0 | GP17, PM10 | GP17 | GP17 |
18 | Small | 1 | 0 | GP18, PM11 | GP18 | GP18 |
19 | Small – Medium | 2 | 0 | GP19 | GP19 | GP19 |
20 | Medium | 2 | 0 | GP20 | GP20 | GP20 |
21 | Small | 1 | 0 | GP21 | GP21 | NM8 |
Total interviews | | | 22 | 23 | 20 | 22 |
* Small: < 10,000 patients; Small-Medium: 10–15K patients; Medium: 15-20K patients; Medium - Large: 20-25K patients; Large: 25–30K patients; very large: 30K + patients |
** Index of Multiple Deprivation (IMD) quintile 1 = most deprived and 5 = most affluent. |
*** GP = general practitioner; PM = practice manager; NM = nurse manager, advanced nurse practitioner or senior nurse. |
When face-to-face contact was necessary
Face-to-face contact remained necessary for multiple reasons. Firstly, there were non-clinical reasons to see some patients face-to-face, such as when patients lacked access to technology or were not able to communicate effectively remotely.
“I know that is a bit of a risk [bringing patients into the practice], but we deem it an acceptable risk, and the patient will often deem it an acceptable risk. So, we probably have a lower threshold to bring in those who struggle with English as a first language, those who are more elderly and maybe have a range of symptoms which is hard for them to articulate.” (GP, Practice-18)
Beyond this, the circumstances where face-to-face contact was necessary included both routine and acute care.
Routine care
All practices maintained contact with patients with long-term conditions, prioritising face-to-face contact with those who needed examination or treatment and dealing with others remotely. Typically, this meant focusing face-to-face contact on patients with poorly controlled conditions, such as those “not responding to a change in medication or [who] we thought they were sicker” (NM, Practice-14), as well as patients with multiple conditions and patients “most at risk of both complications from the[ir] condition but also complications of COVID[-19] if they get it” (GP, Practice-12). To prioritise patients, some practices sent questionnaires (by SMS text message, post and email) to assess the needs of their patients with long-term conditions and identify those needing face-to-face assessment.
Other routine face-to-face activities also continued for those most in need, in line with BMA and RCGP guidance. The ability of practices to continue routine work varied according to their circumstances. For example, all smear tests and long-acting reversible contraception (LARC) services were cancelled at one practice because they initially had problems obtaining PPE, whereas another practice decided to continue LARC services (despite it being advised to pause them) because they had patients who were “vulnerable sex workers” (PM, Practice-18).
Acute care
Staff commonly noted that face-to-face contact was required for patients with urgent or acute problems that required a physical examination, such as abdominal pain, or where GPs needed more holistic non-verbal information about a patient.
Face-to-face contact was also thought necessary when there was a suspicion that a patient may need admitting to hospital, but it was not possible to “make that judgement over a phone call.” (GP, Practice-12). Equally, face-to-face contact often
became necessary to resolve GP uncertainty following one or more remote consultations.
“[A colleague] was saying, ‘I’ve kicked the can long enough down the road with these people. I’ve tried the stuff that I wanna go through with them but now I do need to press the flesh and satisfy myself that I’ve done everything.’ […] ‘I’ve tried the telephone, I’ve tried the video, and what I thought might work hasn’t worked, so let’s get [the patient] in and go into it a little bit deeper.’” (PM, Practice-6)
Here a GP is reported as wanting to see the patient because face-to-face contact was needed to provide more clinical or diagnostic information. Other GPs decided face-to-face became necessary because patients “[were] not feeling reassured enough by the examination over a video link or the telephone call.” (GP, Practice-12).
Decision-making process for booking a face-to-face appointment
Views about when face-to-face contact was necessary were reasonably consistent (as above), however, GPs found it challenging to establish when the benefits of face-to-face contact outweighed the risks..
“I am weighing up the trade-offs of whether she [patient] has anything to gain by me seeing her or not […] it’s emotionally quite difficult to be in a situation where you seeing someone face-to-face may actually be harmful for them. […] ‘I want to help you and me seeing you may not help you![…] It may actually harm you.’” (GP, Practice-15)
In some practices, the process of double-checking with colleagues was introduced to help clinicians make these decisions consistently.
“If any of us want to see a patient face-to-face we send a quick pop up around to our colleagues that are working that day, not so much to ask permission but just saying, ‘do you think it’s reasonable? Can you think of any other way we can manage this?’ Just so we’re not getting one doctor who is doing things differently from everyone else.” (GP, Practice-9)
GPs also recognised that minimising face-to-face contact to the degree achieved in March to May 2020 was an “extemporising” (GP, Practice-19) and temporary measure. As infection rates reduced from June to July GPs increased face-to-face contact “particularly in cases where the clinical risk is maybe moderate to high, rather than it was just high before” (GP, Practice-2). GPs also reported relying more on their own judgement for when face-to-face contact was necessary rather than double-checking with colleagues.
“We’ve relaxed our rules a little bit [...] we had this protocol where we would check with anyone else before bringing someone in, and we’re not doing that anymore, we’re bringing them in ourselves.” (GP, Practice-9)
In part, this was due to infection control procedures becoming embedded leading staff to “feel that we know what we’re doing.” (GP, Practice-7). Equally, GPs were aware that problems may be being missed and the balance between infection risks and risks of remote management were shifting, making it increasingly important to re-establish face-to-face contact. As one GP described, “we can’t wait on this anymore, let’s [...] have a look at them face-to-face.” (GP, Practice-9).
How face-to-face contact was made possible
To make face-to-face contact as safe as possible for staff and patients, practices adapted their buildings and processes to increase infection control measures, particularly for shielding patients.
Zones
Different ways of ‘zoning’ practices were used to separate patients with or without suspected COVID-19. For practices with multiple sites, this separation was sometimes achieved by establishing dedicated ‘hot’ sites for suspected COVID-19 patients and ‘cold’ sites for patients without COVID-19 symptoms.
“our hot site [is] where we will only see patients with respiratory symptoms. [...] Therefore, that has made all our other sites what we call cold sites, where we are not seeing respiratory symptom patients. So then we minimise that risk for patients who have got non-respiratory type symptoms.” (GP, Practice-6)
Hot and cold sites could also allow routine care to continue by dedicating some sites to specific tasks such as blood tests for shielding patients.
“[shielding patients] go to one of our sites, which is specially designated as a clean site […] they’re just doing shielded bloods.” (GP, Practice-9)
Single-site practices often introduced hot and cold zoning within buildings, exploiting features like multiple floors or multiple entrances to control patient movement within the practice building. Not all practices had these options however, and instead (or as well) practices ‘zoned’ their hours to keep patients (in particular, those shielding) temporally separate.
“our building hasn’t got another door! […] what we have done is bring our shielded patients in by appointment, first thing in the morning, so the building has just been cleaned. They are separated out by quite a lot of time” (GP, Practice-13)
Building modifications
Many practices made significant modifications to their buildings. For instance, one practice had “clinical flooring installed …[to create] our ‘dirty’ zone” (GP, Practice-4), another had “a new tarmac path [...] around the side of the building […] to provide safe access for patients” and new stud walls to divide a large treatment room in two, and many others installed perspex screens at reception. Furthermore, to facilitate social distancing, practices took measures such as “strip[ping] consulting rooms bare” (GP, Practice-4), reorganising desks in reception areas and having minimal chairs for patients in waiting areas.
Outside spaces
Outside spaces were used to keep patients separate. Many practices used their car parks as a waiting area, either by “calling [waiting patients...] straight in from the car” (GP, Practice-9), or adding seating outside. Practices also used their car parks as treatment areas by erecting gazebos and creating private areas within these for simple assessments and taking blood. These measures were used for both acute and routine clinical activities, including for shielding patients, and created, for staff, a safer alternative to home visits.
“it’s just the additional risk COVID-wise going into someone’s house, so we’re happier to do it in the car. So if we can get people to come to the car park, coming to the sectioned off bit, so there’s patient privacy, and then doing their bloods in the car.” (GP, Practice-17)
Home visits
Home visits were used as another way to maintain necessary face-to-face contact, especially with vulnerable or shielding patients. Although home visits were noted as being more time consuming, visits to shielding patients were used when it was difficult to minimise the infection risks of coming to the practice (for example, where it was not possible to repurpose car parks, or where practice buildings lacked multiple entrances), or when particular patients were anxious about leaving their house, or unable to arrange transport. Many practices also had nurses doing home visits for shielding patients, even in practices with little history of nurse visits, for example, to change dressings or take blood.
Rationalising appointment processes
The reconfiguration of practices was accompanied by new appointment processes to further minimise the number of people in the building at one time and to allow for extra cleaning and changing time (into and out of PPE) between appointments.
“We’ve spaced out the appointments [...] spread throughout the day so we haven’t got too many people in the waiting room. And we’ve adjusted our rotas so we’ve got no more than two nurses in at any one time.” (PM, Practice-16)
As demand for routine appointments increased and became more challenging to manage, some practices established clinics for seeing certain types of patient in dedicated blocks.
“we’ve got less appointments on the system ‘cause the appointments are longer. So, I think what we’re gonna do is we’re gonna actually have a HCA doing a blood clinic every day, so that simple bloods can just go into that […] otherwise we’re not gonna be able to churn through the number of just bloods that we need to do” (GP, Practice-7)
A further innovation to improve the efficiency of face-to-face contact was to combine as many tasks as possible when patients visited, creating a “one-stop shop” (GP, Practice-1). For example, taking blood from patients immediately following a GP consultation; combining multiple long-term condition reviews that a patient may need; and doing the face-to-face components of overdue or upcoming long-term condition reviews if a patient visited for a routine blood test.
“when someone comes in for a blood test, the nurses are now looking up at the pop-ups to see what other things are due. […] Basically, what we’re trying to do is everything that that patient may need. […] We’re just trying to minimise people coming down and if you’re coming down why not have everything done that you need to have done” (GP, Practice-7)
Practices also adopted strategies to reduce unnecessary face-to-face time during visits. This was often achieved by separating long-term condition reviews into the physical exams, which were done face-to-face, and the subsequent discussions that could be done remotely.
“[patients with diabetes] come in for their blood test. They’re weighed and measured. […] We try and do everything as a oner and then, unless there’s some pressing reason, usually they go home then. Then the nurses can speak to them a couple of days later to go through the results and hopefully try and get control of their HbA1c or blood pressure, or whatever that might be.” (GP, Practice-18)
Challenges as demand increased
The time taken to follow new infection control procedures reduced practice’s capacity to meet increasing demand. As the first wave of the pandemic passed and the number of COVID-19 cases in the South West remained low, COVID-19 zones within practices needed to be reclaimed for the care of non-COVID-19 patients.
“we need our ‘hot room’ back, we can’t function without that room as things get busier. So, we’ve had to make a ‘hot room’ with a temporary structure in the garden. […] we simply haven’t got the space to not do that and increase up to our normal functioning.” (GP, Practice-13)
The need to divert clinician time to new tasks, such as additional home visits (noted as being particularly time consuming due to infection control measures) or allocating a doctor to suspected COVID-19 patients, was a further barrier to meeting increasing demand for non-COVID care (while also adjusting to ‘total triage’ access models).
“we have had to take someone out to do the COVID work. That GP may only see three or four patients in the course of the day. We have also taken out a GP to do all our home visiting [...] having taken those clinicians away from perhaps being able to churn through the bulk of our clinical work has also led to a bit of pressure as well.” (GP, Practice-12)
Moreover, many existing tasks took longer because of the new processes in place. For example, lengthened appointment times, particularly for nurse appointments, meant an overall reduction in the number available.
Measures adopted to make face-to-face contact possible are summarised in Table 2.
TABLE 2: Measures taken by practices to make face-to-face contact possible
Measures taken by practices
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Examples
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Zones
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Physical zoning
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Areas of buildings (‘red zones’) used only for suspected COVID-19 patients.
Areas of buildings (‘green zones’) used only for patients not suspected of having COVID-19.
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Temporal zoning
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Shielded patients seen first thing in the morning, before any other patients enter the building.
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Building modifications
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One-way systems
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Routes within practices that avoid staff and patients meeting in corridors where distancing cannot be maintained.
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Use of multiple entrances and exits
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Side entrances used for access to ‘red zone’, minimising interaction between suspected COVID-19 patients and other patients, and reducing the amount of space necessary to create red zones.
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Repurposed spaces
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Stripping bare clinic rooms for easier cleaning and
semi-permanent changes to buildings (new flooring to expand clinical spaces, new walls to divide larger clinical rooms).
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Home visits
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Home visits
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Shielded or vulnerable patients visited by GPs and nurses, for acute and routine care.
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Outside spaces
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Use of practice car parks or gardens
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Sections of car parks used as waiting or treatment areas.
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Rationalising appointment processes
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Longer appointments
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Adding five minutes before and after treatment room appointments to allow staff to change into PPE beforehand and clean room afterwards.
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Consolidation of face-to-face tasks
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Opportunistically doing patients’ blood tests or reviews of long-term conditions if they visit the practice for other reasons.
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Segmentation of reviews of long-term conditions
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Conducting only essential physical exams or observations face-to-face then completing review remotely.
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