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This Guidelines summary outlines key principles and standard operating procedures for general practices in the context of COVID-19. It does not include information on:

  • patients at increased risk of severe illness from COVID-19
  • infection prevention and control
  • technical and regulatory considerations for general practice in the context of COVID-19

For information on these areas, please refer to the full guideline.

This summary is correct at the time of publishing. However, as it is subject to updates, please refer to the full guidance to confirm the information you are disseminating to the public is accurate.

Key principles for general practice

  • All patients should be triaged remotely
  • Remote consultations should be used when possible. Consider the use of video consultations when appropriate
  • Practices should work together to safely separate different patient cohorts: patients with symptoms of COVID-19; shielded patients; and the wider population
  • Staff should be allocated to either patients with symptoms of COVID-19 or other patient groups, where possible
  • In order to protect our workforce, staff should be risk assessed to identify those at increased risk from COVID-19 and the shielded group, which includes those at highest risk from COVID-19
  • Dedicated home visiting services should be considered for shielded patients
  • Access to urgent care and essential routine care should be maintained for all patients
  • All patients without symptoms of COVID-19 booked for any face-to-face contact should be advised to inform staff if they develop symptoms, and rescreened prior to consultation
  • Patients with symptoms of COVID-19:
    • will be directed to NHS 111 (online, telephone if necessary) in the first instance
    • may make direct contact with general practice or be referred by NHS 111/the COVID-19 Clinical Assessment Service (CCAS)
    • avoid redirecting patients to NHS 111 if they present to general practice either because they cannot get through to NHS 111 online/by telephone, or because an NHS 111 clinician has directed them to their GP: the risk of patients becoming stuck in a loop between NHS 111 and general practice poses significant risk to unwell patients. Further information on the interface between NHS 111 and general practice is available in the full guideline
  • For any face-to-face assessment, patients living with someone with symptoms of COVID-19, even if they do not themselves have relevant symptoms, should follow the pathways for patients with symptoms of COVID-19
  • For all face-to-face consultations, infection prevention and control measures should be followed rigorously

Standard operating procedure for general practice

Practice staff are to be made aware of this standard operating procedure (SOP), the COVID-19 case definition, and the guidance on patients at increased risk of severe illness from COVID-19, including those advised to shield themselves and the wider group of patients at risk.

Operating model for general practice in the context of COVID-19

As the COVID-19 pandemic escalates, collaboration between GP practices within primary care networks (PCNs) and federations, and the wider healthcare system will be crucial. General practice, pharmacies, and community services need to work together to deliver the best care for patients. Local health systems should ensure clear leadership, robust workforce planning and appropriate data sharing and patient record sharing are established.

Operating model

Most patients presenting with symptoms of COVID-19 can be assessed and managed remotely. When face-to-face assessment is required, this will need to be managed either through use of designated sites (whether within practices or as separate locations, for example, hubs) or through home visiting services.

As well as separating services for patients with symptoms of COVID-19, and for shielded patients, some practices may wish to separate services for patients without symptoms of COVID-19 into those with urgent care needs and those for essential routine care (for example, childhood immunisations). Routine care should be delayed where possible for patients with symptoms of COVID-19.

Where possible, staff should be allocated to either patients with symptoms of COVID-19 and those living in a household with someone who has symptoms, or patients who do not have symptoms of COVID-19. We recognise that this may be challenging and will depend on staffing levels in a local area footprint. If it is not possible to fully separate staff groups on a longer-term basis, consider separation on a day-to-day basis.

Local areas will need to consider, with their clinical commissioning group (CCG), the operating model that best suits their local context and arrangements. The model should be able to adapt to changing circumstances, for example if a practice needs to close due to workforce issues.

Patients, communities and local systems (including NHS 111, directory of services leads, pharmacies, community and secondary care services) will need to be kept up to date with changes to the configuration of general practice.

Reference to the standard operating procedures for community pharmacy and community services may be helpful to ensure joined up working.

Signage and clear communication must clearly direct patients to the appropriate service. See the full guideline for advice on preparing practice spaces for face-to-face review of patients with symptoms of COVID-19.

Home visiting can be organised at network or place level to deliver care at home to shielded patients, and this will be needed in either model.

If local systems make provision of separate spaces or sites (for example, hubs) impossible, consider separating clinics into patients with symptoms of COVID-19 and patients without symptoms of COVID-19 at different times of the day. If local systems make separate home visiting services impossible, consider seeing patients with symptoms of COVID-19 at the end of visits, to reduce risk of cross-infection.

Whatever model is used, rigorous infection prevention and control procedures must be followed for any face-to-face consultation.

Table 1: Options for managing face-to-face appointments

Option 1–zoningOption 2–practice designation

Brief description:

Manage patients within practices but with designated areas and workforce to maintain separation

Brief description:

Designate practices, across a PCN footprint, to either treat those with symptoms of COVID-19 needing further face to face contact or those patients without symptoms of COVID-19 needing essential care

Considerations:

This may characterise the model that practices have implemented immediately to manage the risk of contamination. In practice, it requires designating a specific zone/area within each practice to treat patients triaged as urgent, separating into those with and those without symptoms of COVID-19, and routine, for those without symptoms of COVID-19. This option reduces the need for significant reconfiguration of existing patient flows

 

The interface between would need careful management to minimise cross contamination with strict decontamination protocols in place – this would need to be extended to staff to maintain a ‘COVID-19 free’ home service for shielded patients. Not all premises are likely to have separate entry/exits point to help maintain this kind of separation

 

The principles of this model could be extended to walk in centres

Considerations:

Practices may wish to adopt such a model to better manage increasing demand as infection rates increase

 

Those sites that treat those without symptoms of COVID-19 will need protocols in place to ensure patients remain symptom-free prior to contact. These sites may also carry out other essential work such as childhood vaccines and immunisation. This option is likely to be the most effective option in managing cross contamination

 

Workforce capacity constraints means pooling may be required. Additional support will be needed for those staff working in sites dealing with those with COVID-19 symptoms

 

Walk in centres could follow this same designation model which could be particularly useful when demand with those showing symptoms surges.

 

Any sites treating those without symptoms of COVID-19 that become compromised would need de-contaminating

Practice resilience

During the COVID-19 pandemic, it is likely that members of staff (both clinical and non-clinical) may be off sick, self-isolating, may need to work remotely, and may be working under increasing patient demands. To maximise clinical capacity and provide business continuity resilience, the following principles should be incorporated into local plans. They can be at a PCN level, Federation or other agreed geographical area according to local need and should be agreed with commissioners:

  1. establish which practices are going to work together as part of any escalation response to maximise clinical capacity and support your business continuity
  2. appoint a clinical and managerial lead (and deputies) who will oversee and manage any difficulties including reporting/escalation to CCGs in line with local processes
  3. ensure a baseline number of clinical staff, administrative staff and others including part-time and full-time members
  4. establish a daily reporting system mechanism for your workforce issues (sickness absence, home isolation) – some national tools will soon be available to support
  5. ensure the directory of services is kept up to date with any significant changes to services as this is important for NHS 111 pathways
  6. CCG and/or commissioning support unit (CSU) to support shared access administration, GP Connect, and continue to support enabling remote working for more staff
  7. CCG/CSU to help co-ordinate personal protective equipment (PPE) for practices

The role of the clinical and managerial leads is to ensure local mitigating actions are identified and taken in response to capacity concerns, including possible reconfiguration agreed with the CCG to ‘flex’ clinical and administrative capacity which could include from one location to another according to need. A key enabler will be ensuring that staff can access GP computer systems from locations other than their usual or base location. This will facilitate remote consultations and administration.

Separating patient cohorts: practical advice

To reduce the risk of patients presenting with symptoms of COVID-19 at a healthcare setting where this is not appropriate or being seen by a home visiting team designated for patients without symptoms of COVID-19 (for example, for shielded patients) all patients should be triaged before any face-to-face appointment is booked. Patients should be advised to inform staff if they develop symptoms of COVID-19 in the interim between remote contact and face to face assessment.

On arrival at healthcare setting:

Signs and posters should be prominently displayed at site entrances with key information.

All patients presenting to services for patients without symptoms of COVID-19 should be screened on arrival by reception staff to ensure they have not developed symptoms of COVID-19. If they meet the case definition, they should be asked:

‘Do you feel you can cope with your symptoms at home?’

If they answer yes, ask the patient to go home and follow the NHS coronavirus advice.

If they answer no, the patient should be directed to an appropriate site, if easily accessible.

If this is not possible, the patient should be immediately isolated in an isolation room away from other patients and staff and triaged remotely by a clinician in the practice.

If face-to-face assessment is required, follow face-to-face assessment of patients with symptoms of COVID-19.

Home visits:

All home visit requests should be triaged in the same way as requests for ambulatory patients. The same principles for PPE apply, and resilience is likely only to be achieved by practices working together and with community partners.

Home visiting teams should screen patients, carers and household members for symptoms of COVID-19 on arrival at the patient’s home. If they meet the case definition, further management should depend on the acuity of the situation. Where possible, the patient should be seen by the most appropriate review service, depending on local arrangements. If face-to-face assessment is required, see page 16 of the full guideline for advice on home visits for patients with symptoms of COVID-19.

Patients with symptoms of COVID-19

For the purposes of this document, anyone living with someone who has symptoms of COVID-19 should follow the pathways for patients with symptoms of COVID-19.

COVID-19 case reporting and coding

COVID-19 is a notifiable disease; this applies to all test confirmed cases. Additionally, the local PHE Health Protection team should be informed of patients with symptoms of COVID-19 in the following settings:

  • any case from a long-term care facility
  • any case from a prison or prescribed place of detention
  • any outbreak in a hospital or healthcare setting
  • schools
  • other unusual scenarios

NHS 111, COVID-19 Clinical Assessment Service and GP interface

Patients with symptoms of COVID-19 are directed to NHS 111 online as a first access point for urgent medical concerns. If patients with symptoms of COVID-19 contact their GP practice, either because they are unable to speak to an NHS 111 clinician or because they have been advised to do so by NHS 111, they should be assessed rather than directed to NHS 111.

NHS 111 clinicians may need to speak to the patient’s GP practice or the local out of hours service directly during or after assessment. Some patients will need input from their general practice team following clinical assessment through NHS 111.

For information on NHS 111 triage for patients with symptoms of COVID-19 Clinical Assessment Service and GP interface, see the full guideline.

Remote assessment of patients with symptoms of COVID-19

  • Patients with symptoms of COVID-19 may make direct contact with their GP practice rather than NHS 111; avoid redirecting patients to NHS 111 where possible
  • Guidance on remote assessment of patients with symptoms of COVID-19 can be found on the BMJ website
  • Guidance on diagnosis, assessment and management of COVID-19 pneumonia in the community can be found on the NICE website (NICE guidance NG165)
  • In deteriorating patients with symptoms of COVID-19, clinicians should be alert to potential alternative diagnoses

Face-to-face assessment of patients with symptoms of COVID-19 following remote assessment

If patients with symptoms of COVID-19 require face-to-face assessment, they should be managed depending on local system provision. See the full guideline for advice on preparing practice spaces.

  • Staff should wash hands, don and doff PPE for patient assessment and keep exposure to a minimum. All PPE should be disposed of as clinical waste. Further guidance is available on the gov.uk website
  • If the patient becomes critically ill and requires an urgent ambulance transfer to a hospital the practice should contact 999 and inform the ambulance call handler of COVID-19 concerns
  • If non-ambulance hospital transfer is required, see the hospital admission for patients with symptoms of COVID-19 section on page 16 of the full guideline 
  • Spaces should be decontaminated as described in PHE guidance

Patients presenting with symptoms of COVID-19 during a face-to-face consultation

If COVID-19 is first suspected when an appointment is in progress:

  • close the consultation at a suitable point, withdraw from the room, close the door and wash your hands thoroughly with soap and water
  • assess the patient remotely where possible
  • if face-to-face assessment is required, follow face-to-face assessment of patients with symptoms of COVID-19
  • decontamination should be carried out in line with the government’s guidance on COVID-19 infection prevention and control

Home visits for patients with symptoms of COVID-19

Before visiting:

  • remote triage for symptoms of COVID-19 should take place before a home visit is arranged. Where possible, remote consultation should be used rather than visiting
  • staff planning a home visit should follow the infection prevention and control measures as outlined on the gov.uk website, including use of PPE
  • consult the infection prevention and control guidance before visiting a patient with symptoms of COVID-19 who is on home non-invasive ventilation, as additional precautions must be taken
  • ensure that ‘home visit’ bags contain necessary additional PPE and clinical waste bags

During a visit

Infection prevention and control measures, including handwashing and the use of personal protective equipment, should be used for home visits.

If symptoms of COVID-19 are identified during a home visit, staff should ensure they have the patient’s (or carer’s) telephone number. Staff should then withdraw from the room, close the door and wash hands thoroughly with soap and water. Further communication should be via telephone. If face-to-face assessment is required, PPE must be used.

If symptoms of COVID-19 are identified during a care home visit, please inform the local health protection team.

Hospital admission for patients with symptoms of COVID-19

For guidance on when to consider hospital admission for patients with symptoms of COVID-19, please refer to the NICE COVID-19 rapid guideline: managing suspected or confirmed pneumonia in adults in the community.

If an ambulance is required, the call handler should be informed of the risk of COVID-19.

If an ambulance is not required, the admission should be discussed with the relevant hospital team first, to inform them of the risk of COVID-19 and agree method of transport to hospital:

  • patients can travel by private transport, accompanied by a family member or friend if they have already had significant exposure to the patient and are aware of the risk of COVID-19
  • otherwise, hospital transport should be arranged.
  • patients should not use public transport or taxis to get to hospital

For information on hospital discharge for patients with COVID-19, see the full guideline.

Full guideline:

NHS England and NHS Improvement. Guidance and standard operating procedures: general practice in the context of coronavirus (COVID-19). NHS, 2020. Available at: england.nhs.uk/coronavirus/publication/managing-coronavirus-covid-19-in-general-practice-sop/

Published date: February 2020.

Last updated: 06 April 2020.