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This Guidelines summary outlines key principles and standard operating procedures for general practices in the context of COVID-19, covering key principles for general practice, managing patients with COVID-19 symptoms, staff at increased risk from COVID-19shielded patients at highest clinical risk from COVID-19, and considerations for general practice. It does not include information on:

  • other guidance for staff
  • case reporting
  • employment guidance 
  • marginalised groups
  • care homes
  • advanced care planning.

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 guideline to confirm the information you are disseminating to the public is accurate.

Introduction

We are now in the second phase of the pandemic response following NHS England’s 29 April letter. Practices should be focused on the restoration of routine chronic condition management and prevention wherever possible, including vaccination and immunisation, contraception and health checks, in the context of the following advice.

Key principles for general practice

  • All patients should be triaged remotely
  • Ensure that an online consultation system is in place to support total triage
  • Remote consultations should be used when possible, making reasonable adjustments for specific groups when necessary
  • Ensure that video consultation capability is available and that video consultations are offered to patients when appropriate. NHS England and NHS Improvement have published some principles on safe video conferencing which may be helpful
  • Ensure patients have clear information on how to access GP services; this information should be accessible to all patients, including those who do not have digital access, and those who have English as a second language
  • Where possible, staff should be enabled to work remotely
  • 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
  • Practices should work effectively with community care by building on existing MDT working arrangements and encouraging primary care professionals to work across organisational boundaries to help manage pressure points in delivering essential services to people
  • To protect our workforce, staff should be risk assessed to identify those at increased risk from COVID-19: see Staff at increased risk from COVID-19
  • Ensure staff are trained in relevant infection prevention and control guidance
  • Access to urgent care and routine care in general practice should be maintained for all patients, and practices should assess where care has been delayed over recent weeks and now needs to be restarted
  • As capacity allows, general practice teams should:
    • proactively address health needs that may have gone unmet, increased or developed during the pandemic, including health inequalities and mental health issues
    • accommodate changes in how patients want to seek healthcare including supporting patients with self-care and self-management
  • Referrals should continue to be made as usual and as appropriate
  • Patients should be involved in all decisions about their care. Shared decision-making about treatment escalation and advance care planning are particularly helpful
  • Shielded patients should have proactive follow-up to ensure they know how to access care and support; those requiring face-to-face assessment should be seen by home visit wherever possible, unless an alternative care setting is clinically indicated and follow infection prevention and control guidance. Further advice can be found here
  • Patients without symptoms of COVID-19 booked for face-to-face contact should be advised to inform staff if they develop symptoms, and asked again before consultation
  • Patients with symptoms of COVID-19: 
    • will be directed to NHS 111 in the first instance 
    • may make direct contact with practices, or be referred to general practice by NHS 111/the COVID-19 Clinical Assessment Service (CCAS)
    • avoid redirecting patients to NHS 111 if they present to general practice: this poses significant risk to unwell patients
  • Ensure that an adequate assessment is undertaken to exclude alternative diagnoses in patients with symptoms of COVID-19
  • For any face-to-face assessment of a patient living with someone with symptoms of COVID-19, even if the patient does not themselves have relevant symptoms, GP staff should follow the pathways for patients with symptoms of COVID-19
  • For all face-to-face consultations, infection prevention and control guidance should be followed rigorously 
  • Minimise the number of face-to-face contacts that a patient requires by co ordinating care so that as much as possible is done in a single consultation
  • Use careful appointment planning to minimise waiting times and maintain social distancing in waiting areas

Options for face-to-face patient assessment

  • When face-to-face assessment is required, consider the following options for cohorting patients:
    • separate patient cohorts within practices, using designated areas and workforce
    • separate patient cohorts across a PCN footprint using designated GP practices or other sites, as appropriate
  • Avoid using GP practices that are co-located with pharmacies to deliver services to patients with symptoms of COVID-19. If this is not possible, cohorting with strict infection control and cross-contamination protocols must be in place between the GP practice and the pharmacy

Home visits

  • Home visiting can be organised at network or practice level to deliver care at home to shielded patients
  • For home visits, the number of healthcare professionals visiting the patient’s home should be limited as much as possible, particularly for shielded patients
  • Where possible, liaise with the wider community care team looking after the patient to ensure that the visit is carried out by the most appropriate professional
  • Any healthcare professional who visits the patient should consider whether they can perform duties of other team members to avoid multiple visits
  • Follow infection prevention and control guidance and be aware of any additional precautions required (eg if patient is on home non-invasive ventilation); ensure visit bags contain necessary PPE. Clinical waste and PPE should be disposed of as set out by the Environment Agency (England) and PHE

Preparation of sites for COVID-19 face-to-face consultations

  • Use clear signage to direct patients to the appropriate site/space
  • Ensure alcohol gel/handwashing facilities are available for patients and staff
  • De-clutter communal spaces and clinical rooms to assist decontamination
  • Ensure clinical rooms have the necessary equipment for patient examination readily available, and adequate and accessible provisions of PPE and clinical waste bins
  • If possible, identify toilet facilities for the sole use of patients with symptoms of COVID-19

Outbreak management in the context of COVID-19

General practices will have business continuity plans to ensure arrangements are in place to minimise the impact of a local incident, including pandemic influenza, on services.

These may have been updated so they are appropriate to the COVID-19 pandemic. It is recommended that plans are reviewed to capture the risks of COVID-19 and plans to maintain services. This should include local outbreak scenarios that could temporarily disrupt delivery of services from practice premises (eg to allow effective cleaning) or disrupt staff availability (eg if staff become poorly or are required to isolate) following NHS Trace and Test contact. Plans should consider high levels of staff sickness and self-isolation, call handling, staff and patient communication and, ultimately, denial of access to premises for staff and patients.

Business continuity arrangements will be able to recognise the opportunities to maintain patient services through remote working and support from local PCNs; consider the use of buddying systems. Using clinical judgement and experience of recent months, general practice teams may need to consider how to prioritise their workload to deliver the best possible care to their population. In the event of an outbreak impacting the delivery of services, practices should:

inform their local commissioner in line with local reporting/escalation processes and as detailed here

follow PHE guidance on communicable disease outbreak management

communicate service changes to patients and update the NHS 111 DoS.

Staff at increased risk from COVID-19

The government has issued guidance on shielding for people defined on medical grounds as extremely clinically vulnerable from COVID-19. Staff who fall into these categories should not see patients face to face; this takes precedence over any other risk assessments.

All other staff including BAME staff and people identified as clinically vulnerable who are asked to apply stringent social distancing should be risk assessed to consider if they should see patients face to face. The Faculty of Occupational Medicine has published the Risk Reduction Framework for NHS staff (including BAME staff) who are at risk of COVID-19 infection. NHS Employers has also published guidance on risk assessments for staff. Staff may be referred to an occupational health professional for further advice and support (contact your commissioner for details of your local occupational health service if not known).

Managing patients with symptoms of COVID-19

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

Algorithm 1: Flowchart for NHS, 111, Clinical Assessment Service, and GP interface

Flowchart for NHS 111, CCAS and GP interface

NHS England & Improvement Flowchart for NHS 111, CCAS and GP interface

  • GP practices should make nominal appointment sessions available for NHS 111 and CCAS. This will act like a prioritisation list, which may result in a number of different outcomes, including remote management, future follow-up, or a face-to-face assessment, which may be at the practice or an alternative local service
  • Note that patients referred from CCAS may have alternative diagnoses, as symptoms of COVID-19 are non-specific
  • To facilitate direct booking into GP practices, GP Connect needs to be enabled. Guidance to support set-up of GP Connect is available on NHS Digital’s website

Assessment and management of patients with symptoms of COVID-19

Children with symptoms of COVID-19

  • COVID-19 tends to be a mild, self-limiting respiratory illness in children
  • Prolonged illness and/or severe symptoms should not be attributed to COVID-19 and should be evaluated as usual
  • The threshold for face-to-face assessment in general practice and for referral to secondary care should not change during the COVID-19 pandemic
  • Where available, GPs should use secondary care consultant advice via ‘consultant hotlines’ for support as needed

Access to medication for patients with symptoms of COVID-19

  • Patients with COVID-19 symptoms should be advised not to go to community pharmacies; if they require a prescribed medication, this should be collected by someone who is not required to isolate themselves due to contact with the patient—e.g. neighbour or relative not in the same household—or through NHS Volunteer Responders, and delivered to the patient’s home

Shielded patients at highest clinical risk of severe illness from COVID-19

  • Ensure the situation is clearly flagged in the patient’s healthcare records and visible to all teams involved in the patient’s care
  • Ensure a named, lead co-ordinator is in place, either in primary or secondary care
  • Review and update personalised care plans and undertake any essential follow-up
  • Support patient self-management
  • Support patients with urgent medical needs (note that patients may also need to contact their specialist consultant directly)
  • If the patient needs face-to-face assessment, they should be seen on a home visit wherever possible, ideally by a dedicated team, and not brought into general practice premises unless clinically indicated and follow infection prevention and control guidance. Further advice can be found here
  • Ensure that there has been at least one contact by the practice with all its registered patients on the shielded list, as a follow-up to the original letter and follow up as required. Make every contact count
  • Help patients secure their medicine supplies regularly by ensuring electronic repeat dispensing is used for all suitable patients, and ensure they know how to access information about how they can have their medicines delivered
  • People in shielded groups may be particularly affected by mental health issues. GPs should work with local mental health, learning disability or autism services to review patients receiving care from these services

Considerations for general practice in the context of COVID-19

Patient registration and access

Identifying patients at risk of deterioration from other conditions

  • General practices should consider how to work with their local populations to signal that they should continue to seek help and advice for urgent and essential health concerns
  • Practices should now be offering routine care as usual, wherever safe, making use of virtual options wherever that is possible

Specialty referral pathways

  • GPs should continue to refer patients to secondary care using the usual pathways and to base judgements around urgency of need on usual clinical thresholds (taking into consideration need for non-face-to-face consultations, likely delays in restarting routine elective activity, and communicating likely delays to patients at point of referral)
  • NHS Digital has produced guidance on the NHS e-Referral Service (e-RS) in this context

Medicines and prescribing

  • Practices should not increase repeat prescription durations and should not routinely authorise repeat prescriptions before they are due as this could create pressure on the medicines supply chain; consider the use of electronic repeat dispensing instead

Mental health, dementia, learning disability, and autism

Full guideline:

NHS England & NHS Improvement. Guidance and standard operating procedures: general practice in the context of coronavirus (COVID-19): version 3. NHS, 2020. Available at: england.nhs.uk/coronavirus/publication/managing-coronavirus-covid-19-in-general-practice-sop

Contains public sector information licensed under the Open Government Licence v3.0.

Published date: 19 March 2020.

Last updated: 24 June 2020.