Mword Issue 63 - Dr Michelle Drage's latest update for GPs and practice teams

MWord 63 update: an earlier version of this message stated that we were not aware of antibody testing being available in any area of London, this has been corrected to say it is available in South West London.

4 June 2020

Dear Colleague

As we officially enter summer, I do hope you and your practice team members are holding up under the circumstances. We know that workload and demand are on the rise again and we are doing all we can to be your "voice" and communicate to the NHS system the many incredible changes and adaptations you have implemented in short order over recent weeks. Underpinned by our well-received document, General Practice During The Pandemic: The Role of the General Practitioner and Practice Team, with everyone's growing experience we are also exploring with fresh eyes what can be stopped and what should continue, and which of the changes at practice, PCN and system level will offer the most clinical value to patients during the next phase of the pandemic. But today I bring you these 5 items:

BAME health disparities.
Our latest Londonwide Covid-19 Living Guide version 10.
Antibody testing.
Controversies and contradictions: The shielding SOP; The PCN DES; CQC subject to inspection; Re referrals.
Homeless person health.

1. BAME health disparities.

Earlier this week the Government released the long awaited PHE London "Fenton Review" considering the relationship between ethnicity and risks/outcomes of Covid-19. The report concluded that the death rate from Covid-19 was highest among BAME groups and identified, unsurprisingly, that London is significantly more impacted than other parts of the country on most of the metrics used/ reported on.

Patients over 80 years old diagnosed with coronavirus are 70 times more likely to die than those aged under 40. And men are more likely to die from the virus than women - accounting for 46% of diagnosed cases, but nearly 60% of deaths from Covid-19 and 70% of admissions to intensive care. Despite the fact that the majority of trusts in London do not consistently report coronavirus hospitalisations, death rates in London from Covid-19 were more than three times higher than in the region with the lowest rates, the South West. The excess mortality model suggests there have been 9,035 excess deaths in London between 20 March and 7 May, compared with 2,900 in the South West. The report also cites Office for National Statistics analysis which shows that between 1 March and 17 April 2020, local authorities in London had the highest mortality rates from Covid-19 in England when the age structure of the population was taken into account.

Also worth noting that the report suggest that occupational exposure accounts for some infections, which means that healthcare workers (HCW) are particularly at risk of infection, but also individuals working in other people-facing occupations such as retail, hospitality, transport and security.

Compared to previous years, all cause mortality was almost 4 times higher than expected among black males for this period, almost 3 times higher in Asian males and almost double in white males. Among females, deaths were almost 3 times higher in this period in black, mixed and other females, and 2.4 times higher in Asian females compared with 1.6 times in white females. The excess mortality model suggests there have been 43,941 excess deaths among the white group, 2,301 black, 3,083 Asian, 385 mixed and 1,038 in the other ethnic group. Deaths in black males were 3.9 times higher than expected in this period, compared with 2.9 times higher in Asian males and 1.7 times higher in white males. For females, deaths were between 2.7-2.8 times higher in black, mixed and other ethnic groups in this period, compared with 2.4 in Asian and 1.6 in white females. The percentage of these excess deaths for which Covid-19 is mentioned is highest in males in the other ethnic group (94.0%) and Asian males (80.9%), and lowest in mixed females (58.2%) and females in the other ethnic group (62.8%).

So those are the facts we have been told. What we haven’t been told is the analysis of the socioeconomic factors that are likely to underly these figures. I will leave it there for now.

For practices seeking to assess the risk to BAME staff, and to take appropriate action, in the absence of any firm detailed guidance from NHSEI or PHE, we are sharing three tools which may be of help. The ALAMA tool offers an occupational health evidence-based risk-assessment tool, and the SAAD and BAPIO tools provide some advice on what to do in practical terms. The Risk Reduction Framework circulated by NHSE&I is of more limited practical use. Please note that whilst I am sharing these tools today, do bear in mind that nobody has the answers to the primary care BAME risk assessment practicalities at this time. Please see also our Londonwide LMCs Covid-19 Living Guide which contains up to date guidance on wider HR issues.

2. Our latest Londonwide Covid-19 Living Guide version 10.

Please also see the latest Londonwide LMCs Covid-19 Living Guide, version 10 which updates practices with the latest guidance from RCGP and NHS England on safe remote consulting, and was informed by Londonwide LMCs’ Medical Director Dr Richard Stacey and our Director of Workforce, Training and Innovation Kathryn Yates. We also have a new guide on staff safety to help practices consider workplace and workforce risk assessment and management, and some small updates to our HR guidance covering furloughing.

3. Antibody testing.

The government announced the start of a major new national antibody testing programme, with plans to provide antibody tests to NHS and care staff in England. This was due to commence from the end of May but we are only aware of it being available in South West London, with other areas having discussion on how it will be delivered. Further details can be found here.

4. Controversies and contradictions.

The shielding SOP – The third revision of the general practice standard operating procedure was released on Friday. Not markedly different from the previous version, it still identifies three key patient groups (patients with Covid-19 and/or symptoms, shielded patients, and patients at increased risk of severe illness from Covid-19 who are not part of the shielded group). The key question is less "what is in the SOP" and more "what does it mean… and how can it be implemented?". With questions of consistency re shielding, visits and face to face in light of the further Government guidance put out at the weekend, we'll come back to you as and when we can. In the meantime, the GPC have produced a summary.

The PCN DES - The 31 May deadline has passed and practices have decided whether to participate in the PCN DES for the remainder of 2020/21. I hope that our Londonwide LMCs PCN DES decision-making tool helped you to make the right pragmatic choice for your practice. And whilst the next scheduled opportunity to "decide" is next year, Londonwide LMCs GP Support team is here, along with your local LMC team to help you with any issues or concerns that arise in the meantime.

And if you are a PCN CD, I am particularly eager to build our support for you as the role begins to become more complex. Whether it is supporting you to see the NHS wood for the trees, or with more practical issues, we are hear for you too. Please do make contact with me with your thoughts and considerations at mword@lmc.org.uk.

CQC subject to inspection – I totally understand the discontent and outrage created by the proposed CQC Support Framework's telephone inspection. Throughout the pandemic we at Londonwide LMCs, and you in your networks and practices, have supported each other to provide safe and effective care for patients whilst looking after ourselves and our staff. We have shared best practice and collaborated as critical friends. I will be raising these concerns with Dr Rosie Benneyworth, Chief Inspector of Primary Medical Services and Integrated Care for CQC and previously the organisation’s London lead inspector.

Re referrals – As we are urged to return to normal and "reset" I hear more and more that the message doesn’t appear to be reaching our consultant and hospital colleagues. We are actively pursuing as a priority issues raised with us regarding rejected referrals, mass pass-backs of referrals submitted prior to the pandemic, and to related issues of workload generation at the interface between general practice and secondary care. Cases and evidence of this happening on the ground are invaluable. Please drop me a line with your own experiences: mword@lmc.org.uk.

5. Homeless person health.

News of free to attend webinars from Healthy London Partnership covering practical information and learning on primary care homeless health for GPs and practice staff. Part one is on Monday 8 June from 6-7 and part two is on Thursday 11 June from 12.30-1.30.

As ever I welcome your feedback at mword@lmc.org.uk, and know that my team of experts and leaders here at Londonwide LMCs will always be by your side.

Keep well. Stay safe.

With best wishes