General practice is sometimes described as the spine of the healthcare service. It is not always visible but vital for underpinning and anchoring everything else. In a pandemic this anchoring role acquires additional importance. General practice must both respond to the challenges of the new disease (85 per cent of patients with Covid-19 infection are diagnosed and managed in the community setting) and it must continue to see and prioritise non-Covid healthcare. This is a challenge general practitioners have risen to, in among the understandable hype and drama of a new and challenging virus.
In March, by the time the first lockdown was announced, general practitioners had already responded by innovating in order to stay open; undertaking to manage illness while easing closed the front door. Overnight, GPs minimised practice footfall by moving to telephone and video consultations; implemented rigorous infection-control procedures; and checked in to daily educational briefings on all things Covid. Practice reception staff answered the phone to volumes of anxious and stressed patients and shouldered an enormous task keeping GPs in contact with their patients, administering prescription requests and adapting to being frontline workers in ways they may never have imagined.
Patients were exceptionally supportive and sympathetic to the changes. Our phone lines were jammed and on occasion went down due to overload, but individuals were largely patient and pleasant about it. We adapted and opened up again, seeing patients after assessment on the phone, prioritising those who were vulnerable, those who couldn’t communicate well by phone, and those where ‘the laying on of hands’ was intrinsic to an informed diagnosis. We fretted about missing meningitis when every temperature was a presumed diagnosis of Covid, and we worried about our unworried unwell who had always needed to be cajoled in to seeking healthcare and had disappeared from our radars. Practice nurses prioritised infant immunisations and phoned sometimes reluctant parents to reassure them that it was safe to attend the GP practice.
Innovations came that we had long requested. Within weeks an electronic prescribing system was agreed, allowing prescriptions to be sent securely to a patient-nominated pharmacy. We vow we will never go back to the much-loathed clack-clack of the dot-matrix printer. We established good working relationships with the Health Service Executive; years of a certain mutual suspicion overcome by ‘needs must’. Working together we could innovate and ensure our responses to challenges were agile and mutually supportive.
Testing algorithms changed, sometimes on a daily basis, GPs adapted and got on with it, while our public-health colleagues supported us with expertise and information. The HSE set up respiratory assessments hubs so that GPs could safely see the sickest Covid patients and ensure they were treated and could stay out of hospital if at all possible.
Lessons were learned and as all healthcare now works through a second lockdown it is imperative that we are aware of the challenges it brings. What quickly became apparent in March and April is that many well-intended patients deferred contacting their GP, feeling they didn’t want to bother her or him when they were so busy. They put off or completely avoided asking for health advice for which they might previously have made an appointment.
Patients made light of symptoms and said sure there’s others worse than me. The lump that they thought they shouldn’t fuss about, the mole that they reassured themselves was really not anything, the loose stools that might just be the effect of the pandemic stress, or the persistent cough that didn’t seem so important when everyone was talking about Covid coughs.
Referrals by GPs to rapid-access cancer assessment clinics halved over the course of one week as patients delayed presenting with symptoms. Referrals are largely back to normal levels but there is a lost three months that may yet impact on some patients’ health outcomes.
Care of chronic conditions such as diabetes and heart failure – core general practice – continues as part of a newly-resourced and structured programme. Lives will be saved by coaxing patients not to smoke and lowering blood pressure, thus reducing the risk of stroke. Not sexy but effective and rewarding. Childhood flu vaccination by GPs has begun and is an effective measure as children get much sicker from influenza than they do from Covid infection.
Mental-health problems, both those pre-existing and persisting during the restrictions, and those resulting from the societal and economic challenges, have been a legacy every GP comments on. We know it is hard to initiate a telephone consultation to say, “I am not coping”, to say “I am feeling low and I think I need help.” Many mental-health issues are more often presented to GPs by patients as ‘by the ways’ or a GP picks up the non-verbal cues and asks an open-ended question such as “How have things been?” We must all remain aware that ‘lockdown version two’ is likely to hit harder and have more longer lasting effects than the first one. The winter doesn’t help.
GPs have been mindful of the rise in intimate partner violence and the importance of patients knowing they can contact and attend their GP to report the issue and seek help – something that can be done if necessary under the guise of presenting a different medical problem.
Women, always more vulnerable to putting the needs of others first, deferred cervical smears in the midst of the challenges of home schooling and working from home, and there is now a renewed focus on asking women to prioritise their health during the lockdown, before the Christmas busyness inevitably arrives. To all patients GPs would say: get those fiddly bits checked and make an appointment. General practice is open and keeping an eye to non-Covid healthcare. Each year there are more than 23 million consultations in Irish general practice. That level of activity exists for a reason. It is the backbone that keeps the health service straight. Use it.
Dr Mary Favier is past president and Covid-19 adviser of the Irish College of General Practitioners