How a Nurse-led General Practice adapted to Covid-19: A Reflection
23 June 2020 | Carol Sears
Nurse Practitioner Carol Sears writes about how her Practice adapted to the Pandemic
Arriving home from New Zealand at the end of February after a wonderful four-week holiday visiting our daughter we were of the general concern about the ‘flu’ in China, but it all seemed a long way away and we had no real understanding of what was about to happen. However, I was not back at work at the Cuckoo Lane Practice in Ealing for very long when the coronavirus pandemic reared its ugly head in the UK.
My overwhelming recollection of those early days is of the sheer volume of communications as the NHS geared up for the trial ahead. My business partner Julie and I, as well as the rest of our team, were hit with a bombardment of information emails and meeting invitations about how we were going to manage the pandemic, who might be ill, how we could keep the practice open if a large number of our staff were unwell, how we could protect ourselves and how our practice could carry on providing Primary Care to our 6000+ patients in Hanwell and West Ealing!
It soon became clear that we needed a completely new approach to general practice, and we started preparing to telephone triage all our patients. We have previously offered telephone appointments, but like most of general practice, the vast majority of our consultations were face-to-face. However, we were advised that no one was to come into the building if they might have the virus, e.g. if they were showing symptoms such as a temperature and/or a cough.
Fortunately, we were not facing these new challenges alone. Our primary care network quickly established a WhatsApp group to share information and give guidance on how to manage general practice in the pandemic. Very quickly we worked up alternative ways of providing primary care and of triaging and assessing ill patients who presented with Covid-19 symptoms. This was supported by numerous webinars from the consultants at Imperial and Ealing hospitals on how to manage these patients and how to assess their condition remotely.
As in the wider NHS, the pace of change in general practice over the last few months was remarkably swift in response to the pandemic. Although this was clearly necessary, we all felt a sense of hurry and rush and a slight background anxiety about how we would manage the challenges of assessing patients remotely. We quickly enabled new software on our computers so we could begin video consultations, which would clearly give us for more information about our patients than just using the telephone.
It was about this time that I began to feel unwell and developed a temperature and a cough and so had to isolate for at least seven days. This turned into an illness that was quite debilitating for about 21 days, the worst of which was the middle week. During the last week I was able to work safely from home and it was then that I started video and telephone consultations on my laptop to support my colleagues at the practice, some of whom had also gone down with Covid-19. With goodwill and flexibility across the team we maintained services through a mixture of home working by those with symptoms and staffing the surgery by those without.
By early April, I was well enough to go back to the practice and the Covid-19 pandemic was at its peak. Patients were being admitted into ITU and we were aware that some of our patients, including some young people, were very unwell. We were not only worried about them, but we were trying our best to support their families, working in a pressurised environment providing remote consultations, having completely embraced the new technology to enable us to make video calls. However, we still saw some patients face to face and had the pressure of obtaining PPE and learning how to use it. The priority of course was to ensure that patients with Covid-19 symptoms did not attend the surgery if at all possible.
The CCG quickly put into place a ‘Hot Hub,’ which was in a local larger practice where we could refer a patient if we felt that they might need a trip to hospital. Most people were desperate not to go to hospital and very much wanted to stay at home. The most accurate way, we were told, of assessing a patient’s need for hospitalisation was their peripheral oxygen saturations. Of course, not many people had access to a pulse oximeter in their own home, but the Hot Hub could check a patient’s oxygen levels and make a better assessment of whether they needed to go to hospital or not and this proved very useful at that stage in the pandemic.
One of the biggest challenges was continuing to provide routine primary care to our patients, to reassure them that we (and the NHS in general) were still open for business.Carol Sears
At the same time, as well as assessing patients, we were still receiving regular updates on what to do, what PPE to use, how to assess patients with diabetes, hypertension, asthma and COPD, and how they might be affected by Covid-19. There were numerous webinars and online lectures to attend and ensure that we were aware of developing thinking and procedures. As well as this we had our weekly Council of Members meetings, which were all online, but which it was really important to attend to keep up to date with what was going on. These were usually held at 7 o’clock at the end of a long busy day!
One of the most challenging tasks was contacting our patients whom NHS Digital had identified as needing to be shielding. Some were anxious and pleased with the support, but others could not understand why they had been identified. We were also contacted by patients who thought that they should be shielding despite not meeting the criteria! Some patients wanted to go to work when they really shouldn’t, and others had genuine concerns about working, but did not fit the formal shielding criteria. It was a very confusing time for both us in general practice and our patients.
We therefore had to explain to patients why they should be shielding, making sure they had suitable welfare provisions in place, that we had details of their next of kin and also raising the issue of advance care planning.
This was challenging in itself over a telephone or video call, but it had to be done and we were being encouraged to take a proactive approach against a background of negativity about advance care planning in the press, so we were very cautious. Personally, I came across some patients who were keen to discuss this subject and welcomed the opportunity and others who were not, so we took the lead from them and treated every case as an individual.
A particularly poignant moment was speaking to a patient I have known for many years who was near the end of his life, organising advance care planning for him over a video consultation. This was the last time I saw him alive. He died comfortably and peacefully in his own home surrounded by his family which was a blessing to him and them.
As time passed through May and into early June, there was a reduction in the number of patients calling us about Covid-19 related symptoms. However, we began to see an increase in patients who perhaps had become unwell, sometimes with early sepsis, but who were not keen to go to hospital. We had lots of difficult consultations and did many home visits for such patients. There was and still is a lot of fear and concern from patients about going into the hospital environment and we spent a lot of time trying to reassure patients about the Covid-19 precautions in place across the NHS.
One of the biggest challenges was continuing to provide routine primary care to our patients, to reassure them that we (and the NHS in general) were still open for business. It is critically important, for example, to maintain immunisations during the pandemic as we certainly don’t want a national epidemic of measles as we emerge from Covid-19, so our practice nursing team took a proactive approach to scheduling vaccinations. By and large we have been successful in encouraging young parents and their babies to attend for their vaccinations. We even produced a video to reassure patients of the measures that we were taking for both their protection and ours during the pandemic and posted this on social media. We made every effort to encourage patients to attend if needed, to reinforce the message that we are still here and happy to help. We stressed that although our service is provided in different ways, it will still meet their needs and those of their families. We also promoted the giving of pneumococcal vaccination to those in the ‘at risk’ groups because in the past we have held clinics that have been well attended.
We are now entering the stage where we are embedding the new ways of working prompted by the pandemic into our routine practice, recognising that there are many advantages to these. Many patients have benefited from the remote consultation, as it’s often more convenient for people to sit in the comfort of their own homes having a good discussion over video or telephone and this is an approach that we will certainly continue to use. I know that this positive experience of remote consultation has been repeated across Primary Care and will become part of our regular working practice.
The pace of change has slowed and although we are now only having fortnightly Council of Members meetings, we are still regularly updating ourselves regarding other issues that have been of concern during the pandemic. Particularly important is the increase of domestic violence and safeguarding concerns in children and young people and the challenges of looking after and empowering people with long-term conditions who need to continue to care for themselves.
Julie, my fellow nurse practitioner, set up a remote ‘Good to Talk’ event particularly to address loneliness and isolation and despite some teething problems with IT, this was a successful innovation. We are considering setting up working groups to look at how we care for patients with diabetes and hypertension. We are proactively sending out questionnaires to all our asthma patients to get them reviewed and to make sure by remote video consultations that their asthma is as well-controlled as it possibly can be.
We have learnt so much during the pandemic about how to take general practice forward and I am personally very proud of how our small team have embraced change, constantly tweaking new ways of working to ensure that services to patients are maintained. The challenge has brought out the best in my colleagues, morale is good and there is always time for a smile and a joke keep up our spirits.
Carol Sears, Queen’s Nurse
Nurse Practitioner and Clinical Lead
The Cuckoo Lane Practice