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‘How is it on the front line?’

Dr Charles Parker

Dr Charles Parker is a GP Partner at Topcliffe Surgery near Thirsk. He is the Clinical Chair of NHS North Yorkshire Clinical Commissioning Group (CCG). In his first post for a new CCG blog called ‘Doctor Diaries’, Charles speaks about the impact Covid-19 has had in primary care.

I’m often asked: “How is it on the front line?”

My thoughts invariably turn towards the NHS doctors and nursing staff who have been working relentlessly and tirelessly in the North Yorkshire hospitals’ Covid wards – and those colleagues who have been exposed to this virus and lost their own fight for survival. This is the front line.

In General Practice, we’ve been spared the heaviest toll that comes with front-line exposure to this pandemic. But we are certainly not spared the grief. Every person who dies belongs to a GP surgery. They are not just a number that makes up a grim daily statistic. They are our patients. Friends. Even family. They are faces who are familiar to us and we’ve been there for, through thick and thin. And when news reaches us they have died from Covid-19 – many before their time – we mourn their loss.

Yes, I’m grateful that NHS England has not put General Practice on the front line in the fight against coronavirus, but this terrible pandemic is touching us all, right across the health and care system.

As GPs, we’ve had to adapt the way we work and how we ‘see’ patients in ways I would have thought scarcely possible a year ago. And I’ve had to re-evaluate some of my own perceptions along the way.

Over the last three months I have developed a deep gratitude for the work of NHS 111 and the responsibility its staff have shouldered. I have also surprised myself with how much I approve of NHS 111 online.

I have always been proud of the access to a GP that we have been able to maintain at my surgery in Topcliffe. It has always been “do today’s work today” and not push appointments forward if possible. So, making the decision to shut and lock the patients out was very difficult. And we did have to lock them out. At first we put up a six foot banner in the doorway, asking them not to attend the surgery without an invite, but people just squeezed past it, so Chubb was put into action. That is just one of the changes that happened in days rather than the normal months or years. And the changes keep on happening.

At the end of March the practice moved to a system of ‘total triage’. This has worked really well, with patients being spoken to on the phone or via a video app. The real difference is the speed in the response to patients, mostly within 30 minutes. Reduced demand has helped. The speed of our response has caught a lot of patients by surprise, so they were unable to take the call. It is now possible to pre-book a call with a GP. This is how it has been, with problems being identified and rapid solutions or revisions being applied. It has been an excellent time for the “Plan, Act, Study, Do” cycle to come into its own.

As a practice we had finally signed up to electronic prescribing and had a date to start in May, all planned before Covid-19 hit. The NHS England team was brilliant and it brought the introduction forward, completed the training, so we were up and running in the practice within a week. That has helped reduce delays for those close to a pharmacist as the scripts were only collected twice a week by the pharmacies. It also reduced workload for the team, with those 10 per cent of scripts disappearing into the ether, as well as reducing risk to staff on both sides.

Everyone has been talking about PPE and the shortage of supply. It dawned on me that I have not worn scrubs or a mask this century. The challenge of the don and doff is all very well in the surgery, with a lovely diagram to follow, but what about on someone’s doorstep? Putting it on is not so bad, except that plastic pinafore and strong wind is not a great mix. This is a new skill that it is taking a while to learn, for instance making sure the bin is out and ready, and that the bin for the bin is out and ready for the first bin and the second pair of gloves. You can see why it is taking time to learn.

Our latest challenge in General Practice has been “Test and Trace.” Our Business Continuity Plan allowed for 25 to 30 per cent of staff to be off ill at one time. Business Continuity in Pandemic Flu did not plan for contacts to be sent home even if they were well. I suspect we are not alone in having to revise our plans. In a small surgery with a small team, that are almost like family, it is difficult to achieve the rules of social distancing. We have recently taken on a new member of the reception team. How do you train someone in such a varied role without being close? We are hastily creating “bubbles” to avoid putting the whole reception and dispensary teams at risk. Individual risks have also had to be assessed for all members of the team, and adjustments made to working patterns for those at higher risk.

Having said all of that, the sudden removal of barriers to change and the belief that we do not want to go back to business as usual has been refreshing. I have adjusted to working from home for NHS North Yorkshire Clinical Commissioning Group (CCG), being part of new “Teams” revolution and not dashing around the county and region in my car.

The latter is an exaggeration as my children always accused me of driving like someone born at a more comfortable distance from the apocalypse. The tandem has come into its own on quiet roads, and the weather has been an unexpected blessing. With the human toll of this virus continuing to rise, albeit it at a much slower rate now, there are times I feel guilty for feeling positive, but I remind myself it was good judgement to come and work in England’s best county.

Like many people, I still worry about the possibility of a second coronavirus wave – and the impact that would have on our communities and local health and care systems – but, as we begin to fire up the boilers of the NHS and start bringing back on stream the services we had to pause, we’re in a much more mature place than we were three months ago and I’m incredibly hopeful that some of the changes that have taken place, borne out of necessity, have improved the way we look after patients and will be here to stay. In the meantime, the partnership working across the whole system has shown itself to be a formidable force and in NHS North Yorkshire CCG and primary care we remain alert and ready to support our front-line colleagues in health and social care.

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