The impact of COVID-19 on United Kingdom (UK) family practice / primary care

Rodger Charlton

HK Pract 2022;44:33-35

Two years have brought significant changes to our clinical practice, our personal continual professional development and how we teach trainees.

Clinical Practice

In 2019, I wrote about new models of primary care and discussed the possibility of digital consulting.¹ Little did we know that the COVID-19 pandemic was going to fast track digital consulting in all its formats including; email, SMS messages, telephone and video calls, meaning that virtual consulting largely replaced our traditional face-to-face method of general practice.

In the UK, the majority of consultations prior to the pandemic were held face-to-face. However, many continue to be conducted virtually even now and interestingly there are many patients who prefer the convenience of the new format despite media pressure for a return to the ‘good old days’.

Public health measures such as lateral flow tests and the wearing of masks have now been removed in the UK, except in healthcare settings. Even this may also change shortly as COVID-19 is now endemic in the population. There has been a high uptake of vaccination and severe sequelae from infection are much less likely than at the start of the pandemic.²

The UK government's approach is not necessarily supported by the medical profession and doctors are being cautious both to avoid contracting the infection themselves and to avoid passing it on to their patients. This makes meeting health targets in relation to chronic disease management and hospital procedures very difficult, as the majority of time and effort until recently has gone into preventing and treating COVID-19 infections.

Waiting rooms in family practice and hospital settings are now completely different. Chairs are arranged in a socially distanced manner, the number of people waiting is limited and appointment times are staggered to avoid waiting room congestion. Patients are very carefully screened to ascertain if they have any COVID-19 symptoms and many GPs will only undertake a face-to-face consultation if it is clinically indicated and cannot be managed virtually. This has huge ramifications for the doctor-patient relationship and the consultation as it once was.

Waiting times in family practice, emergency rooms and other hospital settings have increased considerably and are increasing further due to staff sickness caused by an active Covid infection, long Covid or mental health problems that have resulted from the considerable traumas of looking after very sick patients, some of whom have died.³ An added difficulty for GPs has been developing new skills in virtual consulting, which is always likely to be suboptimal compared to face-to-face consulting. In addition, the workforce is diminishing as GPs decide to leave or retire as their role changed and job satisfaction is reduced. It should also be said that the general public, who were once very supportive of healthcare workers, are now becoming frustrated by a changing and overstretched service. Sadly, there are now regular reports of abuse towards healthcare workers.⁴

The devolved nations of England, Scotland Wales and Northern Ireland have each interpreted COVID-19 data differently and had their own public health responses. An important but often absent public health message is that COVID-19 is more than just an upper respiratory tract infection. A large number of the population have gone back to mixing in confined spaces without adequate ventilation and infections continue to be high at 1 in 55 people.⁵ As the availability of free testing kits has ended, the true rates of infection are largely unknown.

The public are often unaware that COVID-19 seems to be associated with higher rates of cardiovascular and cerebrovascular complications. Further research is needed into the true number of patients with long Covid, what constitutes long Covid, how it can be treated and what its impact on the workforce both within and outside the NHS. Self-isolation for those with an infection is no longer mandatory and so the need to protect vulnerable patients, such as the immunocompromised, is no longer being recognised.

With the many emerging variants of Covid and the well-documented issue of recurrent infection, there remain many questions about how to achieve long-term immunity. The implications of this for primary care and our patients are still unknown. A further challenge for UK General Practice is the surge in other childhood viral infections as children start to mix again and return to schools and nurseries after nearly two years. COVID-19 then spreads from children to parents teachers and the wider community.⁶ Despite this, the current Government strategy is “Living with COVID-19”.⁷

Continuing Professional Development

Day-to-day learning used to come from meeting clinical colleagues and talking to other members of the team in the corridor or knocking on their doors to seek advice. With many doctors working offsite and consulting virtually, these opportunities disappeared, along with the ability to quickly ask for a second opinion and the learning that can arise from this. Many GPs are working in isolation and managing a completely new form of workload, with most of their time spent sat at a desk staring at a computer screen of results and keeping a pace with telephone calls that need to be made and hugely difficult judgements necessitated by more often not consulting with patients face-to-face.

Attending clinical meetings or academic conferences still happens, but they are usually virtual in order to be “Covid secure”. Most learning is done through the completion of online electronic modules. Opportunities for networking, once recognised as so important, have been curtailed. Continuing professional development is something that now happens in isolation and needs to be evaluated.

Teaching Trainees

During the pandemic, teaching moved to virtual teaching for undergraduate trainees, rather than face-to- face. Students have only recently started to attend lectures in-person again, but still have the option of learning from recordings of lectures. Similarly, small group work has been virtual and only recently has returned to face-to-face with the practical measures of social distancing and wearing masks. Students must also undertake regular lateral flow tests and not attend teaching if feeling unwell.

Furthermore, as clinicians in primary care are mainly consulting with patients virtually, the student experience as an apprentice is diminished as the opportunity for face-to-face consultations is considerably reduced.

There is an opportunity for postgraduate meetings to be held virtually and there are the advantages of not having to book a venue or the need to travel. For the trainee there is the important issue of isolation and not easily being able to interact with one’s peers. There has been the rapid development of a hybrid model where trainees can choose whether to meet face-to-face for teaching or where video is being used for teaching can be watched remotely. It may be that they cannot attend teaching as they have an active Covid infection but remote teaching allows training to continue. Anecdotally there is some reluctance to return to face-to-face teaching even though holding educational meetings virtually has difficulties of engagement as cameras are often turned off. Care should be taken to craft virtual learning events to increase and maintain learner engagement.⁸

Conclusion

In conclusion the impact of Covid-19 on primary care consulting has seen the development of a new model with certain advantages and benefits. Similarly, there has been considerable development in digital teaching and technology for trainees, again with advantages and benefits. However, it is unlikely that we will return to pre-pandemic consulting and teaching and we should embrace the benefits of what is new, but be conscious of any disadvantages.

References