General practice raises ethical dilemmas but never more so than during a health crisis

Everyone is moving at pace. Everyone is trying to do the right thing for their patients, and that can result in decisions which in retrospect look insensitive. We have seen that around advanced care plans this week.

In response, the College has issued a joint statement with the BMA, Care Quality Commission and Care Provider Alliance. Making clear that it is unacceptable for advanced care plans to be applied to groups of people. That these decisions must continue to be made on an individual basis according to need. You might also want to look at these FAQs on how Advance Directives to Refuse Treatment (ADRTs) might be affected by COVID-19. Written by our Palliative and End of Life Care Lead Catherine Millington-Sanders.

Ethical guidance

We have also just published ethical guidance for GPs. This piece of work has been led by joint Honorary Secretary Victoria Tzortziou-Brown and involving the College’s Ethics Committee and others. Which focuses on practical answers to ethical questions that have been posed to us by members around COVID-19.

In such a fast-moving situation, thinking and evidence around COVID-19 is changing all the time. This week we issued clarification that the College does not support the Roth score in assessing breathlessness for patients suspected of having the virus. Which had previously shown some promise in this regard. Trisha Greenhalgh from the University of Oxford has published an excellent paper on the use of Roth scores in the assessment of patients with potential COVID-19. Which includes suggested alternatives.

Personal protection equipment

Last week I wrote to Matt Hancock, Secretary of State for Health and Social Care, highlighting some of the issues you have been telling us you’ve been having with PPE – and calling for urgent clarity on how and when GPs should be using it. This week, we have welcomed new guidance from Public Health England and NHS England, which provides that clarity. We still have some questions, for example about the type of PPE we should be using when seeing acutely ill patients in acute hubs and whether nebulisers are classed as aerosols - but rest assured we will still be raising them, as well as ongoing issues around supply, at the highest levels.

We want to continue hearing your feedback so that we can lobby Government and decision-makers on the things that matter most to you. We have heard that some members are having technical problems. Particularly when working remotely, and we want to understand these better. Please take a few minutes to complete this short survey, if this applies to you.

Testing

Another issue the College has campaigned hard on is increasing testing, particularly for healthcare professionals. Yesterday, we heard Mr Hancock’s pledge, to be doing 100,000 COVID-19 tests a day by the end of the month. To increase testing of frontline NHS staff. This is welcome, both in understanding the virus and increasing capacity of general practice and wider NHS workforce. But it will be a huge challenge, and something else we will be holding the Government to account on.

From our end, the College is continuing to update our dedicated COVID-19 resource portal, full of advice, tools and guidance for our members. This week, we have published new guidance on the use of the NEWS2 score to assess unwell patients in primary care, we’ve produced eLearning on changes to recording deaths that have come out of the Coronavirus Act 2020 and managing COVID-19 in secure environments.

In order to provide timely support to you during the pandemic. The Professional Record Standards Body and NHS Digital have shared clinical guidance on how to code cases of COVID-19. Which will help you manage clinical information that improves patient care.

Continuing education

I would also like to thank Mike Holmes for his work addressing the impact COVID-19 has had on undergraduate learning and development. To help continue the education of students, we have been working closely with the Society for Academic Primary Care to provide a helpful Learning General Practice resource for tutors and students.

We’ve also updated our FAQ section for doctors who are:

• retired,
• working non-clinically,
• in less than full time training (LTFT).

In order to support and guide those who wish to return to general practice or work extra sessions. I’m hugely appreciative of all those who are returning to the NHS to support us during this time, and I hope this guidance will be useful.

We’re updating the website all the time, work led by Vice Chair Michael Mulholland, and we are expecting updated guidance on delivering care to vulnerable patients in general practice very soon.

Above and beyond

Thank you to all of you for the work you are doing. You are truly going above and beyond for your patients and together we will get through this. While the world is focussed on COVID-19, our patients do not stop having long-term conditions or becoming sick from non-COVID illnesses, and you are at the forefront of ensuring these patients receive the care they need – it’s an issue I discussed on CNN earlier this week.

You’ll have had a taste of just how much the public recognise our contribution – along with other key workers – from the clapping yesterday at 8 O’clock, and I can tell you that this appreciation is shared among policy-makers, politicians and all of us at the RCGP.

Many of you are also working in NHS 111 centres during the pandemic. The work they are doing in the face of extreme pressure is outstanding, but they wouldn’t be able to do it with the clinicians to support them. If any of you are able to offer additional time to the service, please do sign up to the COVID response service that is supporting NHS 111 – it would be hugely appreciated. We are actively supporting as many as possible of the retired returning GPs to work in 111, as this is a top priority for the NHS at the moment.

Finally, in these difficult times, peer support is so important, so please do join our members’ forum, as well as discussing the issues most pressing for you around COVID-19, you will also be able to share examples of best practice and support each other.

About the writer

Professor Martin Marshall is a GP in Newham in east London and Professor of Healthcare Improvement at UCL, Programme Director for Primary Care at UCLP Partners. He leads Improvement Science London, an initiative to promote and embed the science of improvement across the health service and academic sectors. He is immediate past Vice Chair (External Affairs) of the RCGP.