COVID-19 GP diary: Shielding our most vulnerable patients

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.

It’s been a very unusual Easter for all of us. As I had mentioned last week, our practice remained open over the Easter weekend, along with our community pharmacies. While it was hard work, I felt really good about doing this. I think we all did. No one had a problem with being in over a bank holiday, because we knew it was the right thing to do.

As one of the hotspots for COVID-19 from near the start of the outbreak in the UK, we’re now 5-6 weeks into the crisis. And we’re finding that constantly adapting to the changing situation is now becoming the norm and that the rate of change has slowed. I wouldn’t say we’re ‘used to it’ – I’m not sure anyone can be ‘used to’ such a difficult, strange situation. But we feel less like we’re on the back foot and more like we’re getting out in front of the problems and properly able to support all of our patients.

On a personal level, something I’ve thought about a lot this week is other key workers who aren’t getting as much recognition or support for their work – police officers, dentists running emergency services, staff in care homes, residential nursing homes and also people that deliver food and work in supermarkets. I've had calls with patients in these groups who’ve not been treated well by members of the public. While I’m grateful for the support we’re receiving, I hope it will be extended to them also.

Biggest challenges this week

The biggest challenge on a practical front this week has been identifying and contacting our patients who need ‘shielding’ – in other words, those who are at the highest risk from COVID-19 and who need to protect themselves as much as possible. 

NHS Digital and NHS England have created the clinical criteria for patients who should be shielded and we think it's roughly 1.5 million people across the country. So what we’ve needed to do is ‘code’ these patients – identifying them in our systems – and then speak to them and explain what they need to do during the 12 weeks of shielding and how to access medical and other types of support from the NHS volunteers scheme . 

For our practice, the official list of these patients is around 200 people. However, we’ve decided to augment this. We’re also looking at all of our housebound patients, anyone with learning disabilities, anyone with poorly controlled diabetes, those admitted to hospital in the last year for various things, cancer patients, and people that have high ‘frailty scores’. All in all, our final list is around 600 people.

Because many of these patients have ongoing illnesses which require regular checkups and treatments, we’ve also had to think very carefully about the care we will deliver for them – for example, through home visits, setting up special shielding rooms at the practice, creating separate ‘zones’, and online monitoring with technology companies. We’re looking at all the options.

In terms of treating those with COVID-19 , we’re now starting to find that a lot of our patients are fellow health and social care workers – which is, of course, concerning. 

In addition, we’re starting to find that patients with other conditions who need to be seen by a doctor, for example for ongoing cancer treatment, are incredibly reluctant to come in. Over the weekend, I had a very long conversation with a daughter of a patient who's lost one parent to COVID-19 already and was concerned about the other parent coming in for treatment. I wanted to reassure her that we’ve really thought through how to reduce the risk – because ultimately the risk of not doing the treatment was far greater.

We’ve reviewed an anonymised list of children across all of London that have had delays in treatment for a whole multitude of reasons. It prompted us to specifically remind parents and patients that we are here. Unfortunately, we think the central government messaging has actually deterred parents from calling in because they're scared of taking their kids out of the home. So we've been sending out messages to all of our parents, reemphasising that we’re very much still here for them and their children.

I’ve heard from dentistry colleagues that they’re very concerned about ‘life after covid’. Dentists are an essential partner in our healthcare ecosystem when it comes to oral health and cancer detection – I have concerns that their ability to revert to ‘business as usual’ will be impacted due to current cash-flow challenges. 

Finally, I’ve also seen a surge this week in mental health problems associated with coronavirus and the lockdown. It’s causing new mental health issues to arise, as well as exacerbating symptoms for those with existing conditions – for patients with acute anxiety and depression, for example. It’s also been worrying to see a rise in suicidal tendencies – something we’ll have to watch closely in coming weeks.

Positive moments

Pulling together our list of shielded patients this week has been a huge challenge but it’s also made me incredibly proud of my colleagues. It’s brilliant to see how well they all know their patients – we’ve even had former practice clinicians weigh in. The whole team has collaborated and shared their knowledge of patients to help ensure we get the list spot on.

Another positive for me was working over this Easter weekend and the sense of camaraderie between team members. Staff members have lost relatives and there have been some tearful days this week, as in previous weeks. But it feels like we’re all here for each other. We did a timeout in the garden and it was such a beautiful day. We took a bit of time to sit (more than 2 metres apart of course) and just chat. It felt like a really positive, bonding moment.

A totally unexpected bright spot was having food delivered to us twice this week. One day – completely unannounced – we had lunch bags left for us. And then another day a restaurant sent us free snacks. It was such a lovely surprise and a nice little boost for us.

Imperial College London have developed a medical student volunteers scheme – and we were delighted to meet our lovely student this week, who will certainly be able to support our proactive community outreach and the ‘check-ins’ we’re doing daily 

Finally, the feedback from patients has really kept us going. We’re receiving messages saying thank you for everything we’re doing. And it means so much to us when we get these. Today a local resident delivered face protection visors for us, made by her theatre props company – and we’re helping to ‘pass it forward’ by supporting in disseminating these to the local police and care forces.

What’s to come?

We’re going to be looking at how to implement our plans for the home visiting service this week, supporting our vulnerable patients, as well as those who need at-home treatment for coronavirus and other conditions. There’s a lot to consider – mobilising staff, thinking about who goes where, ensuring we have separate cars to carry out visits to coronavirus patients versus those who are shielding.

Now that the pace of change has slowed, we’re really trying to focus on how to do our ‘regular’ jobs under these strange new circumstances – particularly how we can support patients with long-term conditions. 

We mustn't forget that even in a time of crisis, our patients need help with ongoing issues –  for example, a diabetic still needs care, they still need monitoring, they still need to have reviews. We want to focus on making sure checkups and ongoing support are still available for our patients but can be done with appropriate safety.

My work with Lantum is, of course, also an important part of the coming weeks. The team has worked extremely hard to adapt and develop our product to support primary care COVID-19 response efforts. Together, we’re supporting hundreds of PCNs and federations with COVID-19 response hot and cold hubs, home visiting services and more. 

I would love to hear from you if you feel Lantum could help you too – you can reach me on ishani@lantum.com.