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‘GPs and pharmacists must manage patient expectations during COVID-19’

“Patients often talk to their pharmacists about their symptoms before seeing the GP”

GPs and pharmacists should work together to manage patient expectations and explain why healthcare has been disrupted during the pandemic, says Dr Toni Hazell

“May you live in interesting times” is said to be an ancient Chinese curse – and we are certainly living in interesting times at the moment. Last December, a cluster of unusual pneumonia cases was identified over 5,000 miles away. Who would have thought that a few months later most people aged over 70 in the UK would be staying indoors all the time, supermarket shelves would be bare and parents would be facing the alarming prospect of having their little darlings off school for months?

At the time of writing, primary care is in limbo. The official advice for people who have COVID-19 symptoms is to not visit their GP or pharmacy, so some practices are eerily quiet. One morning a few weeks ago I saw only three patients, but signed what felt like hundreds of electronic prescription service (EPS) scripts, which I suspect was a result of patients ordering their medicines early in anticipation of drug shorages.

But it doesn’t seem possible for this state of affairs to continue – NHS 111 and hospitals are overwhelmed. I have heard talk of practices having “dirty rooms” and “clean rooms”, where certain members of staff see patients with possible cases of COVID-19, protected only by the out-of-date and inadequate personal protective equipment we’ve been given. We will also have to manage all those patients whose routine referrals or surgery can’t go ahead, meaning they will get sicker from conditions other than COVID-19.

It seems likely that the morbidity and mortality from other conditions not being treated as a result of the pandemic will be significant. So, what can pharmacy do to help and what can GPs do to help pharmacists? We are all going to be short-staffed, so managing expectations will be useful. Patients who are unhappy that much of normal healthcare service has been put on hold may well complain to their pharmacist about the GP, and vice versa. Trying to help people understand the severity of this crisis and that we are all doing the best we can would be a good start. 

Patients often talk to their pharmacy team about their symptoms before seeing the GP. Clearly pharmacists can’t be expected to take full responsibility for triaging them, but if patients mention medical issues that are non-urgent, you could suggest self-care and holding off seeing the GP until things have calmed down a bit. Now isn’t the time for anyone to be worrying about a bunion that has been a bit sore for the last few years.

Similarly, encouraging patients not to panic order their medicines and rationing sales of things like paracetamol and the elusive hand sanitiser should mean there is enough for everyone.

Pharmacists are our eyes and ears in the community. Our elderly patients in particular may have symptoms of other conditions that are urgent – things that merit a referral with a two-week wait, for example. If they tell you they are avoiding bringing these issues to a doctor, please encourage them to do so, or call the patient’s GP.

Pharmacists are also the experts in helping people self-care. As most of those with COVID-19 symptoms are advised to self-isolate at home, they will need your help with how to manage symptoms and which over-the-counter medicines to use. Pregnant women and those on long-term medication will value your guidance on what they can and can’t take.

The next few months and years will be tough for us all – I don’t mind admitting to being a bit scared about the future. I find it somewhat surreal to be living through a pandemic that my grandchildren will learn about in history lessons. Pharmacists and GPs need to support each other as well as we can, and hope that we all come out the other side.

Toni Hazell is a GP based in London

22 Comments

Jenny Etches, Community pharmacist

I've been working on CovidCAS 111 as a pharmacist clinician and the story we hear is - my GP is closed or they're not answering the phone or they told me to phone 111 or the online thing on the GP website told me to phone 111.  And often I end up referring to GP at the end of a consultation If they have a professional phone line on DOS I can use that but there's still GP practices that don't appear to have one. 
A lot of this is about the perception of both the public and community pharmacists alike. And the perception is that GPs are closed. May not be true but that's what it feels like to many patients. 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

It would be nice to collaborate with a GP over coronavirus - however, it's IMPOSSIBLE to get anywhere near a GP because of coronavirus.

Toni Hazell, GP

we're open and have had free call slots every day so far

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Then, if your phone message is the same as every other one I've heard from the number of surgeries I have rung, CHANGE IT to reflect this. The messages I hear are effectively a veiled 'Bugger off, we don't want to see you'. That's why you have free call slots - no-one knows they exist and people are coming to us, standing out in the open among all of the germs of the world, instead. I have been telling people who need to see a doctor to INSIST on speaking to their doctor because that is their JOB. The impression that the public have of general practice at the moment is that it is closed and many many people will die or be seriously ill unneccessarily if this perception is not changed and only General Practice is in the position to change it. 

Kevin Western, Community pharmacist

Toni
I have no idea what sort of patients you are seeing and what you aren't - my surgeries have certainly not seen fit to let me know. How many are video? How many and what get face to face?
If you have already told your Pharmacists that's great but it would help

Richard Binns, Primary care pharmacist

 

all patients are still entitled to be seen as they previously where under the GMS contract, the only difference is that face to face consultations need to go through a triage process first. if a patient is displaying covid symptoms they are seen at designated red zone/hot hub. if a video/telephone consultation is viable to provide suitable care then it is done, as it provides far less risk to the patient than unecessarily attending a surgery. The big changes that are resulting from than pandemic are from the suspension of routine services in secondary care, the patient can see/speak to a GP but they cant necessarily get a referal for a routine procedure/non-urgent investigation as the hospitals have suspended these services.

My advice to you as a community pharmacist is that if you need to refer/signpost a patient to a surgery then nothing has fundamentally changed, the phone lines/online access are still operating as before and appointments with a GP can still be made (from my experiences, patient access to appointments actually seems to have improved over the past couple of months)

 

 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

My local surgery has more or less put the shutters up. You cannot attend unless you have a timed appointment, there are barriers to access everywhere, no waiting room access, nothing. Everyone has to queue outside which wasn't too bad when the weather was nice but now....?. Just one closed window you have to shout through. By contrast, their own pharmacy is like an ants nest that's had a stick poked in it. If people can be sensible enough to follow pandemic rules for pharmacy access it should be the same for GP access. After all, it's supposed to take 15 minutes of close contact to catch the thing. Appointments are 10 minutes, therefore GPs are at no higher risk of getting Covid than the rest of us. Or has someone lied about the time it takes to get infected.....?

Richard Binns, Primary care pharmacist

also not to forget the patient facing work done in amber & red zones/hot hubs, that GPs are currently performing.

There seems to a common misconception that because GP patient access has been forced to fundamentally change as a result of the crisis, that it has been  withdrawn altogether.

I personally believe that the changes to general practice have been both necessary and sensible, I also detect a level of frustration from the community pharmacists that the GPs have been supported in these changes and they feel they havent.

what  I would ask the community pharmacists is if they felt empowered and supported to adapt their way of working in response to the crisis, what would they change with regards to how they manage their workload?

 

 

 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Not have every Tom, Dick and Covid encrusted Harry free to come in whenever they please, demand to speak to the pharmacist IMMEDIATELY then proceed to stand far too close for far too long with me unable to get away.

Free access to pharmacists and pharmacy is too great a risk to all the members of staff but because we are not financed directly by the NHS as are GP surgeries (I should imagine the budgetary savings during this have been pretty significant for surgeries), we have no choice - it's either take the risks or starve.

Fair remuneration for what we do would also be helpful, i.e. put the money back into dispensing so that pharmacies can become viable operations again without having to spend ridiculous amounts of time doing spurious 'services' that no-one wants.

Oh, and the reason we feel we haven't been supported and you've managed to detect a level of frustration is because we haven't been and we are!!

 

N O, Pharmaceutical Adviser

"""The official advice for people who have COVID-19 symptoms is to not visit their GP or pharmacy""

Hmmmmmm. Correction. Which official advice was this? that mentioned not visit Pharmacy??

Richard Binns, Primary care pharmacist

 

 

for clarity, copied from ;
https://www.gov.uk/government/publications/covid-19-stay-at-home-guidance/stay-at-home-guidance-for-households-with-possible-coronavirus-covid-19-infection   

If you have symptoms of coronavirus (COVID-19), however mild, OR you have received a positive coronavirus (COVID-19) test result, the clear medical advice is to immediately self-isolate at home for at least 7 days from when your symptoms started. Do not go to a GP surgery, pharmacy or hospital. You should arrange to have a test to see if you have COVID-19 – go to testing to arrange.

 

 

 

A.S. Singh, Community pharmacist

Good article Toni, however...

As a pharmacist and contractor in a surgery pharmacy I truely feel that GPs have got away with it during covid. Shutting doors and on full pay, in no other walk in life can you still command that.

The surgery(more like a health centre) have refused patient's repeat bit of paper and instead have asked us to email everything over which is time consuming, sometimes hours in the day. Who's going to pay for that staff time? 

If only pharmacy bodies were as strong as the BMA, the GPs would be opening their doors so fast it would make our heads spin

Toni Hazell, GP

well we haven't done that. Yes, we have asked people to ring rather than coming down - that is common sense, you can't have 40 people in a waiting room in the current time. But we have spoken to everyone, seen those on video who needed to be seen on video, seen in person those for whom it was necessary, liaised with health visitors, district nurses, palliative care - yes, and pharmacists. Don't tar all GPs with the same brush just because some local to you may have taken the mickey. 

 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

From my experience Toni, you are the exception rather than the rule. I admire your bravery for sticking your head above the parapet btw but I suspect you don't know what the situation is like with regards to an awful lot of surgeries which is why you are getting so many negative comments.

Joan Richardson, Locum pharmacist

Ordering early in anticipation of drug shortages!  That says it all!  This increased pressure on the drup supply chain and consequently caused the very shortages that they wished to avoid! 

Exactly the same as in the supermarkets - if everyone had purchased as normal then there would have been stock on the shelves!

cardiff pharmacist, Superintendent Pharmacist

managing expectations!- yes when you have signed the hundreds of prescriptions dont tell the patient they will be in the pharamcy and ready to collect tommorrow.

If Gp's had managed the prescriptions then pharmacy would not have been inundated with patients wanted their prescriptions early and expecting them all to be done.

The simple solution-is for pharmacy to manage the repeat prescriptions- no Mrs Jones you dont need your meds for 2 weeks so come back a bit closer to the time...rather than  having to explain that although the surgery said it was ready today..what they meant was we recieved it today..along with that foot high pile of other prescriptions, and when we have finished yesterdays foot high pile we will start on this one!

V K P, Community pharmacist

will the collaboration mean that the GP remains closed come flu jab time and will sign post the patients to their local community pharmacy for the vaccines? 

Adam Hall, Community pharmacist

The only collaboration I have seen is GPs saying to patients "We are too important to the country to be exposed to you pestilent-ridden masses. Go and see your Pharmacist" and the Pharmacist saying "I'm not waving, only drowning"

Kevin Western, Community pharmacist

"One morning a few weeks ago I saw only three patients, but signed what felt like hundreds of electronic prescription service (EPS) scripts, which I suspect was a result of patients ordering their medicines early in anticipation of drug shorages."

 

In the past, this has always resulted in a "no" or more frequently, the request being simply ignored. Why were they all suddenly put through? did no one have any thought to the effect? did this "working together" involve any contact by the GPs to warn or preferably discuss with Pharmacists?

you are asking us for help, and saying we should work together, perhaps a reasonable explanation would help start rebuilding any bridges that existed before. Certainly its past time for GPs to actually make the effort to talk to Pharmacists - the reverse is generally impossible, as, like for patients, you are all very well guarded by your staff.

I salute your bravery in writing here but this should be a two way street and uptil now, generally, the only ones on it have been pharmacists.

 

 

Toni Hazell, GP

oh and I always take calls from pharmacists and so do all GPs here. might ask them to hold on if I'm in the middle of a difficult consultation but will always take the call 

 

Kevin Western, Community pharmacist

Toni

I have always assumed that you, personally at least, do so, but unfortunately, the vast majority of GPs point blank refuse to do so. The damage caused by the flushing of a months worth of scripts in little over a week with no obvious checking on need is going to resonate for quite a long time. It caused real mental harm in Pharmacy teams up and down the country. If there was true dialogue (or even any!) this could have been avoided. 

We are still having to fend off patients who believe that their surgery is closed  and we can sort their problems - i will if i can but some are jusy outside our scope - I know they are taking calls but getting in is a major trial.

PCNs are supposed to involve Pharmacy but how many PCN clinical directors actually do? 

Do you have a dedicated phone line for Pharmacists or do they queue up with the patients to listen to the canned music? Great if you do, but again, 30 minute waits just to get through to surgeries arent uncommon.

I had the phone handed to me the other day and was told it was  A GP!!! my automatic assumption was that i had made a very serious error. - its that rare.

generalisations are always dangerous and I am sure there are pockets of good practice out there but mainly, the picture is apalling. In many ways I admire GPs for their hard headed attitude to the NHS, and wish we had similar leadership but if they truly want us to be their "eyes and ears" there has to be a way for the signal to get through, and it cant be via chinese whispers through receptionists, however nice they are.

 

 

Toni Hazell, GP

you have a point there and it was maybe poorly written. I also turned down loads that were clearly very early. I meant those that seemed to be ordering a week or so early. 

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