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Dear colleagues

You will all be aware that, on Monday, the Prime Minister issued a statement introducing even  tougher measures on social distancing and said that people “must stay at home” in order to protect the NHS and save lives, by reducing the spread of the infection.  As both the Prime Minister and the Secretary of State for Health and Social Care have now both tested positive, and with England’s CMO Prof Chris Whitty also showing symptoms, the spread of infection is clear.  It’s all the more important to use remote methods for consultations to the maximum, to limit face to face contact with patients to the absolute minimum and when only absolutely clinically necessary, and then to use PPE at all times.

Vulnerable patients and social distancing
Following the announcement last week introducing new measures on social distancing , advising those at increased risk of severe illness to be particularly stringent, the CMO has published a letter defining those at high risk which are:

  • aged 70 or older (regardless of medical conditions)
  • under 70 with an underlying health condition and with particular chronic diseases- i.e. anyone eligible to get a flu immunisation as an adult each year on medical grounds

We have published joint guidance with the Royal College of GPs on Vulnerable Patients – Role of General Practice during COVID19, which can be accessed on the RCGP COVID-19 hubpage . This document may be updated over time and we will let you know should that happen.

There are two specific groups of very high risk patients - those in category B (Groups 1-3) will automatically be sent a letter by NHSBS. The CMO letter communicated a need for General Practice to identify and write to group 4 patients. We are awaiting further formal guidance in terms of next steps for identification of group 4 patients. You will have received a similar message through your system suppliers. 

We know there has been some confusion about the definition of the very high risk groups. These groups were categorised by the NHS England Clinical Reference Group and other specialist clinicians, into the very high risk patients that could be identified by extracting relevant groups from national datasets using HES data as this was readily available. Those doing this acknowledge the potential flaws in this process but it was the best that could be done in a short space of time. NHS Digital are currently working with system suppliers to try and reconcile any inaccurate codes applied.

These patients will have received different texts to the ones going to the general public, and they should receive letters directly. Practices should have received lists of their patients in this group and codes will be added to patients’ electronic record. 

PPE update
We have been very concerned about the lack of appropriate PPE for primary care providers and the problems practices are having in obtaining additional supplies. We are working to resolve this with NHSE and the DHSC as urgently as possible and I spoke to the Health Minister, Jo Churchill MP, about this again today. The BMA wrote to the PM last week calling for this to be urgently resolved, as well as demanding that testing be made available for HCWs. This week BMA demanded answers about PPE from the Government, and Chaand Nagpaul, BMA chair of council, made this statement 

It is imperative that practices and other primary and community care organisations get regular supplies of PPE and that practitioners are given confidence that the PPE they receive and use is appropriate. Practices should not need to purchase this themselves.

As a result of our pressure we have finally secured some action in delivering PPE to practices. The messaging on the helpline has now changed. The National Supply Disruption Response was designed to deal with supply disruption in the event of no-deal Brexit and is now focussed around the distribution of PPE. Additional stock, following the initial delivery a few weeks ago, has been placed with distributors and wholesalers (such as Phoenix/ DCC Vital/ Williams) to enable GP practices to order through their BAU routes.

NHSEI and DHSC are working with the military to enable swift movement from pandemic stockpiles into distribution centres to fulfil demand.

For more immediate short term issues NSDR are able to issue ‘pre-packed kits’ with a minimum of (100 Type IIR facemasks; 100 aprons and 100 pairs of gloves) within 72 hours. Primary care providers who raise requests for kits through NSDR must to be able to make arrangements to receive emergency delivery of these ‘pre-packed kits’ outside of business hours. They are focussed on providing swift responses to meet gaps until scheduled deliveries arrive; and until orders with wholesalers through BAU are back up and running. The National Supply Disruption Response 24/7 telephone helpline is 0800 915 9964.

We are also expecting an NHS-wide statement on PPE from the CMO to be published imminently.

I was quoted in the Yorkshire Post on Monday, highlighting concerns about PPE and the pressure of NHS staff being in self-isolation and reiterated these points on LBC on Sunday evening and later in the week to TalkRadio, and again today, to talk about the importance of testing. The BMA letter to the PM was reported on by The Telegraph , Channel 4 News, and Daily Mirror. The BMA call for better PPE led the new bulletins and was reported by The TimesBBC news online, BBC News at Six , GuardianMail, ITV online, Metro , Buzzfeed , Sun , Evening StandardAsian Image, Pulse , GP online, BBC Radio 4 and a large number of regional publications . Chaand Nagpaul, was interviewed on BBC Radio 5Live (1hr10mins in) for an immediate reaction following a press conference featuring the Health Secretary.  Phil White, GPC Wales chair, spoke to  BBC Radio Wales as part of a Covid-19 phone-in.

Workload prioritisation
We have published joint guidance with the RCGP on workload prioritisation for clinicians in general practice during COVID-19. This should be read alongside our own guidance on prioritisation published last week, where we advise practices to prioritise the urgent needs of their patients and do so in a safe way that protects the workforce. As this is a rapidly developing situation it is possible that this guidance will need to be updated and we will inform you if that is necessary. Read the guidance on the RCGP COVID-19 hubpage
Retired doctors and returning on performers list
Last week, the GMC wrote to the doctors who have retired in the last three years to ask if they would be willing to return to practice to provide support during the pandemic. This week we have written a joint letter with NHSE/I and the Royal College of GPs, to GPs specifically to let them know how they can help if they would like to, including letting people know how they can ask to be temporarily registered on the Performers List. 

The MDOs have waived their fees for retired doctors returning to work – read more on their websites:
Medical Protection
Medical Defence Union

Remote consultations and homeworking
The BMA has published guidance to support doctors in any healthcare setting to conduct remote consultations during the pandemic pport doctors in any healthcare setting to conduct remote consultations during the pandemic

A new BMJ article on remote consultations provides a very helpful summary on how to do these as effectively as possible and also underlines the importance of reducing face-to-face physical consultations to an absolute minimum.

Digital isolation note
A digital isolation note created by the NHS and DWP is now available to provide patients with evidence for their employers that they have been advised to self-isolate due to coronavirus, either because they have symptoms or they live with someone who has symptoms, and so cannot work. The notes can be accessed through the NHS website and NHS 111 online. After answering a few questions, an isolation note will be emailed to the user.

Emergency access to GP Connect capabilities
Arrangements have now been made for practices to request emergency access to GP Connect capabilities, that can be used if a practice has to close due to the Coronavirus outbreak and patients are being treated at another practice which uses a different IT system. Read the NHSD guidance here 

NHS regulations – amendments relating to primary care during a pandemic (England)
The NHS Regulations amendments relating to the provision of Primary Care Services during a Pandemic 2020 NHS Regulations amendments relating to the provision of Primary Care Services during a Pandemic 2020 have now been published.  The amendments include:
 -             provision to allow for opening on bank holidays and Easter weekend
-              provision to prevent remedial action in the event of a breach
-              provision to allow an increased number of bookings from NHS111
-              provision for dispensing doctors and pharmacies to delivery medicines to patients
Emergency COVID-19 bill and Easter opening hours
The Emergency COVID-19 Act has now become law. In addition emergency changes to GMS contract regulations published yesterday, require practices to be open on Good Friday and Easter Monday, as it is expected that this bank holiday period will coincide with a peak in activity. We are working with NHSE/I about the details of this and will provide more information as soon as possible.
Death certification and cremation- UK
We are liaising with the DHSC to clarify as quickly as possible what the new procedures will be following yesterday’s passing of the Coronavirus Act 2020 for certifying death and cremations. NHS England and MOJ guidance is imminent and will be linked to on our website. As soon as this is available we will circulate to members and LMCs. In lieu of this the General Register Officer has issued a letter with guidance on the measures which is attached.
Scottish guidance on death certification
The Scottish Government has published the attached letter with guidance on death certification, which includes nomenclature for the disease/infection; procedures  to speed up certification in anticipation of significant increases of deaths; and removal of requirement to notify Crown Office and Procurator Fiscal Service (as a notifiable disease).
COVID-19 community hub arrangements – Scotland
Plans by the Scottish Government (co-signed by SGPC and RCGP Scotland) on COVID-19 community hub arrangements are outlined in the attached letter, which describes changes in the triage and assessment of COVID-19 in Scotland.  From Monday, NHS24/111 will be the single point of contact for people (previously GP practices were involved during day time). More detailed information is available here
RCOG advice pregnant women working in the NHS
The Royal College of Obstetricians and Gynaecologist has published updated advice for pregnant women who are working in the NHS during the coronavirus outbreak . The updated guidance emphasises that pregnant women of any gestation should be offered the choice of whether to work in direct patient-facing roles during the pandemic.

Engagement of locum GPs
As general practice continues to adapt and prioritise the delivery of services in relation to coronavirus, we are aware that many practices with existing engagements with locum GPs are continuing as best as possible to honour these commitments and to find equitable arrangements for the division of work. During this stressful time it is important that the workforce continues to pull together and support each other. Where there is uncertainty over the ability to honour existing commitments, please continue to engage at the earliest possibility to find collaborative solutions.

Guidance for employers on COVID-19 Job Retention Scheme
Guidance for employers on the Coronavirus Job Retention Scheme has now been published. It is designed to support employers whose operations have been severely affected by COVID-19, however it states that public sector and publicly-funded will generally not be eligible for the scheme.

QOF calculations in England 2019/20 and 2020/21
NHSE/I has published a letter confirming that calculations for QOF 2019/20 will be made as usual, and will be analysed to understand the impact of Covid-19. This letter also committed that NHSE/I will ensure that all GP practices in 2020/21 continue to be paid at the same rates.

Social Prescribing Link Workers COVID-19 guidance
The National Association of Link Workers about Social Prescribers and General Practice, has published guidance regarding what social prescribing link workers should be doing at this time and the support that could be available from them. Read more here 

Preparedness letter for pharmacy
The NHSE/I preparedness letter for community pharmacists , was published last week. This has references to general practice within it, particularly relating to prescription length.  We would again encourage practices to limit prescription length and where possible use repeat dispensing to help support our pharmacy colleagues.  
Medication and specialist advice during the COVID-19 pandemic
UCL Hospital’s Medicines Information Service have put together a list of useful links that outline the significant number of guidelines produced to support medication advice for patients. The document is attached.
BMA ethical guidance on COVID-19
The BMA has now published ethical guidance on COVID-19 – access it here. The RCGP will be bringing out further, primary care specific guidance shortly and the BMA will be bringing out more detailed guidance once the CMO has issued its guidance on prioritisation and triage.
BMA COVID-19 webpage and guidance
The BMA COVID-19 webpage is updated daily with guidance and links to official information:

The BMA has published FAQs on your contract terms and conditions which will be updated regularly. See also the COVID-19 ‘update page ’ with links to BMA priorities, guidance and news.

If BMA members have any specific concerns or issues related to COVID-19 please contact the BMA’s advisers on 0300 123 1233 and support@bma.org.uk .

At times of crisis it is also vital that we all look after our emotional as well as physical health and the BMA has a range of wellbeing services including 24/7 counselling, available to ALL doctors and medical students (not just BMA members).

The BMA has set up a ‘wall of thanks’ webpage where the public can send message of gratitude or donate funds to doctors working tirelessly in response to COVID-19

Letter of thanks for supermarkets
The BMA is rolling out care pages and have also written a letter of thanks to the supermarkets care pages and have also written a letter of thanks to the supermarkets across the country for taking steps to ensure NHS staff remain able to access essential goods.

ARM 2020 has been adjourned until September 2020 
As the NHS works to contain the spread of coronavirus, BMA Council has adjourned this year’s Annual Representative Meeting, due to be held in June 2020, until at least September 2020. More information here 

NHSE/I daily primary care bulletin
NHSE/I will publish daily primary care bulletins on COVID-19 – sign up here ere

See this week’s GP bulletin here 

Read the latest Sessional GPs newsletter here 

I normally wish you a good weekend, and I still do so, but I've no doubt that for many of you the pressures you've faced over recent days will continue over the weekend. I want to thank you to all those that took part and applauded NHS staff in #ClapForOurCarers last night. I know it has been appreciated by very many working in general practice. It is though equally important that we look after our own wellbeing and that of our family and friends.  Colleagues in Leeds have produced resources that may be helpful.  If you have children here’s some ways to keep them entertained and if you don’t here’s some other ideas to help you focus on something different.

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