COVID-19 GP diary: lockdown takes hold

Our co-founder Dr Ishani Patel is a GP based in north-west London and the eHub lead for four primary care networks. In this series of weekly posts, she explains how she and her colleagues are managing in the face of the coronavirus pandemic.

Before the lockdown began, our local hospital, Northwick Park, was forced to declare a ‘critical incident’ after running out of critical care beds for patients with coronavirus infections. For me, this was sharply juxtaposed with the fact that as I went into work, there were still people walking down the road as if it was a normal day.

This week, it feels very different. Finally, it seems that people are beginning to understand the gravity of the situation. I feel that both where I live and where I work, people are observing the rules. And that’s been really reassuring.

The biggest challenges this week

I’ve had to have some very difficult conversations with patients this week. It’s been hard both professionally and personally. 

More and more we’re needing to work with our community teams and sadly our palliative care teams to reach COVID-19 patients who, due to multiple co-morbidities, have expressed that they don’t want to go to hospital, they want to be at home in a familiar place and they don’t want to die alone. We want to respect people's wishes and support them and their family members. This is about ensuring they have everything they need to have a peaceful passing with dignity and control. 

Friday was a very tearful day for me personally because I had to have three of these conversations with patients in a very short timeframe. One of the biggest challenges is that this isn’t normally something that you rush. Normally you get to have a series of conversations with patients – for example, when they have cancer or heart failure. It's not a one-time conversation. We all want to have time to help psychologically prepare patients and their families. 

But with COVID-19, people can get into respiratory distress so quickly. We don't have the time that we normally have to have these sensitive conversations.

I also feel I really have to emphasise the challenge we’re facing with personal protective equipment. There are still practices who don’t have PPE deliveries, who are phoning and emailing every day trying to understand when the next cohort is coming. It's incredibly difficult to see suspected COVID-19 patients in person in practice or run a ‘hot hub’ (a site specially set up for face-to-face consultations with COVID-19 patients) if you don't have the right equipment. 

PPE is also really important for essential home visits. Our community rapid response teams and evolving home visiting teamlets want to be able see a patient at home and know that we have the essentials so we do not become ‘spreaders’. I want to spend time with my patients and am battling my conscience having these very sensitive consultations remotely. I want to be human about it. 

On a practical level, we’re also facing workforce shortages. Some practices have as much as 70% of their workforce down and this is spanning from clinical to administration and management. There’s an absolute pressing need for primary care networks and federations to set up ‘cold hub’ sites. These are non-COVID-19 face-to-face operations that can manage everything from call handling and prescriptions to virtual online consultations. Having these in place helps to further shield staff from exposure and sustain care for our communities.

Positive moments

It’s been an incredibly tough week. So it was truly heartening, and really moving, to experience the ‘clap for carers’ last Thursday. I went to my front door and the whole of Fulham was just set alight – in a good way. It felt vibrant. The Lantum team were all WhatsApping each other and sharing videos. One of the team suggested it should be every week and it looks like they weren't alone in thinking that. It's a real boost to know that we'll have that experience again every week.

It’s also been fantastic to see the number of people who have volunteered to help the NHS at this time. Not to mention all the practice staff members who are going out of their way to support vulnerable patients.

I’ve marvelled at the speed at which the ExCel conference centre has been transformed into NHS Nightingale – and I’ve put my name down to volunteer to work there.

On a practical note, I feel like we’re getting on top of the remote working situation. All the technical glitches are being ironed out. This is so important for making sure that staff are shielded as much as possible, particularly those at risk. We've got a 72-year-old GP who's working from home for the first time in his life. It's completely alien to him, but he's doing it, he's cracking on. 

It’s easy to be weighed down by this crisis. But what I've seen from the clinical directors, project managers and executive team, from the 20 practices within our ‘mini federation’, is a great sense of togetherness. The teams have adapted, they've come together, they've worked so swiftly. In the space of a day, team members managed to relocate an entire practice to another site, and on a weekend at that. I feel that shows exceptional dedication.

And finally, I’ve felt so supported by the team at Lantum, who are really keen to learn all they can about what we’re facing so that they can provide the right support to the NHS. I and my colleague KJ, who is a hospital doctor, delivered a remote ‘lunch and learn’ session, to educate the team about what’s currently happening and what might be to come.

What’s to come?

The challenges we’ve faced this week, particularly around palliative care, are raising questions about our future approach. We’re now asking – what if we have a community response team where GPs are bolted onto existing services? What can we do to support our patients more at home? Can we start providing home oxygen swiftly? Will a COVID-19 clinic now be a home visiting shift? There’s so much to consider.

There are some signs – as I write this – that the rate of infections may be slowing in the UK. But the next few days will tell us more. For now, I know that things are likely to get worse before they get better.