Dr NICK SUMMERTON reveals the crisis has tested our GPs as never before

How is the pandemic affecting general practice, the mainstay of NHS care? Across the UK, thousands of GPs are having to find new ways of looking after patients — potentially changing how all of us are treated in future, as this fascinating weekly diary, written by a GP in Yorkshire, reveals. 

The author, Dr Nick Summerton, has been a GP for 32 years, running several rural practices for nearly two decades, as well as writing medical books. 

THE ‘PHONEY WAR’ — AND GOING TO THE HAIRDRESSER

March 16-22

‘I reckon we can train you to use a ventilator in a day or so,’ he said. These were the parting words from John, an old medical school friend with whom we’d been staying in London for the weekend.

Both John and I are now 60. He is a surgeon in a large teaching hospital, while I’ve spent the past 32 years working as GP across Yorkshire. I fully retired from my own practice a couple of years ago but I have continued to help as a locum — mainly in one small rural practice.

It is always fantastic to catch up with old friends, but this time things felt very different. We limited ourselves to walking in local parks and John talked about how he and his wife Julia would self-isolate at home if either developed Covid-19 symptoms.

He spoke of the changes that had already been made within hospitals across London, including cancellations of routine operations and outpatient appointments.

They were clearly taking coronavirus very seriously and I began to feel quite anxious about what lay ahead.

Back at home in East Yorkshire on Monday morning, the builders arrive to replace the roof on our home. We’d been planning this for several months and they seem quite unconcerned by coronavirus. ‘Sounds just like getting a bad cold,’ one of them remarks as I set off for work.

Somewhat shaken by my experience in London, I half expected the practice to be in lockdown. It wasn’t. As well as two full days of appointments, I had several home visits booked in.

One individual — a regular customer with chronic bronchitis — comes to see me mid-morning. He is recovering from a chest infection and I chat about coronavirus and what could be done to protect him.

In addition to suggesting — again — that it is time to stop smoking, I give him more antibiotics and steroids to keep ‘just in case’. Like many people with chronic chest problems, he has a oximeter — a device that clips on the middle finger and measures the amount of oxygen in the blood. 

He’d bought it from the local chemist a couple of years previously on the advice of a specialist nurse.

Readings under 95 per cent can be a sign that the lungs aren’t coping — even before worrying symptoms such as severe breathlessness occur. A drop of 2 per cent is also a warning sign.

I ask my patient to make sure the device is working and doesn’t need any new batteries. He listens carefully, smiles and says: ‘Don’t worry doc, I’ll be fine.’ He taps his breast pocket, leans forward and adds: ‘I always carry a small bottle of hand gel with me, so I’ll be quite safe.’

The rest of that week I struggle to keep up with the ever-growing mountain of guidance from the Department of Health. It is also becoming quite challenging to apply the guidance to my day-to-day clinical practice. 

What exactly is a ‘new onset continuous cough’? Is recommending self-isolation at home for everyone with a temperature — at any age — sensible or safe? For a young child who is unwell with a high fever I worry more about meningitis than coronavirus.

I am asked by one patient if her 89-year-old mother with heart problems and diabetes could go to the hairdresser. Her age and her health problems mean that she will certainly get very sick if she catches coronavirus.

On the other hand, I know that for many older ladies, having their hair done is a very important social activity and, for some, may be the only time they have a decent chat in a whole week.

The recommendations are unclear so I suggest she makes a final trip to the hairdresser now as they might not be open much longer.

At the end of the week we receive our first supply of face masks and plastic aprons for use by clinicians for treating suspected Covid-19 cases only. I think we have enough.

The main doors are adorned with posters about coronavirus and some red tape is stuck on the floor in the entrance two metres from the reception desk. All visitors are asked to remain behind this thin red line.

RUSH OF PATIENTS WITH SKIN ISSUES

March 23-29

‘It seems a bit like Christmas,’ I say to staff when I arrive on Monday. They appear somewhat bewildered by my comment, but I am simply thinking about the annual rush every December, two weeks before Christmas.

Then the demand for appointments spikes, with many people flocking to surgeries with relatively minor problems they’d been storing up and want sorting now — or who simply need a double supply of their regular medicines before the holidays start. With a national lockdown widely anticipated, we’re experiencing a pre-Covid-19 rush.

That morning I see lots of spots, back pain, foot problems and verrucas. But for the receptionists, it does not feel very festive. Several people are quite aggressive over the phone. A local pharmacist goes home in tears after being shouted at by customers for running out of paracetamol.

When I explain to a patient that I can’t do anything to speed up the appointment for an ingrowing toenail, she storms out, slamming the door behind her.

Some people are not keeping two metres away from the reception despite both the red line and — now — a table, so we install a plastic barrier and bollards we got from a builder working nearby.

I also notice that the posters on the main doors supplied by NHS England the previous week are now out of date, referring to coronavirus in travellers from certain countries. I handwrite new ones with the latest official advice: ‘If you have a cough or a temperature/fever — don’t come in. Go home. Call 111 or practice if concerned.’

There are still some big clinical challenges. I help one of my younger colleagues to work out the best way to care for a young child at home with a temperature and a cough — without putting either the child or the practice at any risk.

Another GP becomes very upset after a patient manages to gain access by denying they have any symptoms — then within a metre of the doctor, begins coughing profusely. 

The patient is sent home to self-isolate and the room is out of action for the rest of the day while it is dealt with by the practice cleaner.

We have no access to testing in the practice, but this is probably our first case of Covid-19. Meanwhile, I am faced with a somewhat aggressive individual wanting me to write a letter for her employer stating that, as she is seriously overweight, she needs to be shielded at home from coronavirus. 

She also demands additional support to get more food and medicines.

Although I am tempted to suggest that being forced to reduce her calorie intake would not do her much harm, I bottle it — and try to explain the differences between the people asked to shield and those expected to be more stringent about social distancing.

On Friday it is clear that large numbers of patients are being dealt with efficiently over the phone. But as an experienced GP, I know I could be helping much more, so I approach my local health managers and sign up to the national recruitment programme to provide clinical support to the 111 service.

iPADS FOR CARE HOME CHECKS

March 30-April 5

It IS announced that 12 people across my local area have died from the coronavirus. By the middle of the week the number has doubled.

Perhaps the pandemic has reached us and the phoney war is over? But as there are problems with the hospital testing at the local laboratory because of a shortage of chemicals and swabs, we have no idea how many cases — or deaths — there really are in the community. 

It’s like fighting a war without knowing the strength or locations of the enemy troops.

I speak to John in London. He tells me they have just discharged their 100th patient with coronavirus. He is clearly stressed but coping. 

Another friend working in a hospital midway between John and myself says half of their intensive care unit is now taken up by coronavirus patients and he’d been surprised how many younger people are requiring ventilation.

Our builders had disappeared the previous week after Boris Johnson’s announcement to stay at home, leaving us with half a roof. They cautiously return to ensure everything is watertight. 

The conversation is much less jovial than before, and only two — who share a flat — are working on the roof. If they want to ask me anything, we speak by mobile phone.

But there are some patients who still don’t understand the meaning of ‘staying at home’ and limiting social contact. 

One elderly lady clearly thinks it is just like the Blitz, sending her husband out every day to get ‘rations’ from the corner shop. A farmer tells me that he is now only travelling into town to see his girlfriend for a meal twice a week.

Old friends and colleagues who have retired are returning to practice and, for all of us, the heavy yoke of over-regulation by the CQC (the Care Quality Commission, which tells us how to run a general practice), the GMC (General Medical Council, which tells us how to practise as a doctor) and the CCG (the Clinical Commissioning Group, which tells us how to do everything else) is finally being lifted from our shoulders.

We’ve been released from having pointless — and time-consuming — annual appraisals and CQC inspections. These had led to many excellent doctors of my generation retiring in droves over the past decade. But now we can become real doctors again — at least while coronavirus lasts!

There has also been a dawning realisation among many of us in general practice that we’re now all in this together. Rather than simply grumbling about administrators or other aspects of NHS organisation, doctors are coming up with solutions.

One GP sets up a WhatsApp group to share information and to help with questions or concerns. Another starts exploring how we might get local firms to supply us with personal protective equipment (PPE), even asking 3D printing companies to make eye protectors as we are unclear about supplies from NHS England.

Soon, we are all getting used to wearing our ‘glamorous’ PPE — masks, aprons and eye protection (we have enough for our needs). A local practice tells me that their usual 700 weekly face-to-face appointment load has now been slashed to just 200, using telephone triage.

Visits to local nursing and care homes are being done virtually — I just wave from an iPad as I’m ‘carried’ around the home by one of the staff, who holds the device up close to patients so I can ‘examine’ them. I stop only once to look more carefully at a lady’s red swollen hand and prescribe a course of antibiotics.

THE STORM IS ABOUT TO HIT

April 6-12

The week begins with blue skies, warm sunshine and a pink moon. But we all know that the Covid-19 storm is on its way. The chief executive of a local hospital pops up on the regional TV news to say they’ve freed up as many beds as possible in anticipation of the surge in the next few days.

Over the weekend the total deaths from coronavirus in just one local hospital double to 70.

It’s Tuesday and I now am self-isolated at home with a cough, despite feeling fine. I have no idea how to get tested locally but, thankfully, my application to support 111 nationally has galloped along and I’m signed up to do my first remote session chatting to patients over the phone on Thursday evening.

My colleagues in general practice have also identified locations — referred to as ‘hot hubs’ — where individuals with coronavirus can be seen face-to-face if they require more than just a phone call or a video consultation. 

One CCG manager announces that — for reasons of confidentiality — they are keeping the location of their ‘hot hub’ secret. I wonder if they’ve received a supply of blindfolds for the people invited to attend their secret ‘hot hub’.

But there are some lighter moments, too. Visits to one local chemist now involve ringing a bell, shouting your name through the glass door and then any medication is thrown out of a small hatch on to the pavement.

I’m also keeping extremely busy with messages from friends, family and neighbours asking for medical advice. One tragic conversation concerns a gentleman who had died alone — and in pain — at home while his wife was downstairs on the phone struggling to contact their local practice to get a visit. 

In contrast, a local GP emails to say: ‘It’s not all bad. My colleagues and I have time ‘to meet’ for 30-45 minutes every morning for a chat and an update. Lunch breaks have come back.’

Four weeks ago, I was a part-time locum GP easing myself into retirement. Now, so much around me in general practice has changed, in ways that I think will become permanent, that a different future presents itself.

I do wonder if we can learn something important about over-regulation from this crisis so that we can keep the many medics who’ve flocked back in droves to help the NHS. I think of my former senior partner — an expert in palliative care — who loathed every annual appraisal he was forced to endure, but has now come back to help those in pain and distress at the end of their life.

In the past, I have been a sceptic of the 111 service, but my views have altered dramatically — it has really stepped up to the mark, shielding general practices from a massive influx of coronavirus patients. I now feel very proud to be working for them myself.

Only seeing patients by video or Skype does mean that I can’t hold a patient’s hand, listen to their heart or pass them a tissue any more. Also, I cannot ‘smell out’ a smoker or the odour of stale urine in a failing care home.

But we do know that doctors get the most important and reliable information to spot cancer from simply talking to patients.

And while I continue to cough, I can still work as a Skype GP or chat to patients on the phone. And getting coronavirus myself is an opportunity to re-learn the tremendous importance of looking at and listening to patients. Training on how to use a ventilator can wait!