Modifications to the delivery of NHS face-to-face general practice consultations during the COVID-19 pandemic in England

Introduction

In March 2020 it was estimated that more than 80% of patients with COVID-19 would not require hospitalisation,¹ and it was likely that many would seek treatment in general practice. In order to minimise transmission of the causative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during general practice (GP) consultations, NHS England’s Standard Operating Procedure was revised in March 2020 to a remote triage and consultation default, with adapted models for face-to-face contact used only when clinically necessary.² The use of telephone, video and online consultations in English general practice has been studied elsewhere.³ In this paper we report on the delivery of face-to-face general practice consultations across England during the first wave of the pandemic, in spring/summer 2020.

The need to separate patients with diagnosed or suspected COVID-19 [‘COVID-19’ patients] from others to minimise cross-infection during clinically necessary face-to-face consultations was evident. NHS guidance suggested three possible ways to manage patients, premises and workforce for optimal Infection Prevention and Control (IPC):²

NHS guidance indicated decisions regarding model use were to be determined locally, and that these could require flexibility as patient demand and workforce capacity fluctuated throughout the pandemic. All decisions were to be made in agreement with the relevant Clinical Commissioning Group (CCG),⁴ the organisation responsible for planning and commissioning NHS health care services in the area. In June 2020, 135 CCGs and 6761 GP practices were in operation across England, with each practice forming part of their local CCG.⁵

This study aimed to identify the ways in which local delivery of NHS face-to-face general practice was re-organised across England during the first wave of the pandemic.

Methods

A cross-sectional survey of the 135 CCGs in England was conducted to identify how face-to-face general practice consultations were delivered nationwide in spring/summer 2020.

Survey design

Survey questions were devised by the study team. They concerned models of face-to-face consultations used and the patient populations each were available to; prior use of the hub model; and planned evaluations. Questions were pre-tested with a researcher experienced in survey design, two CCGs and one provider of primary healthcare. Minor changes to wording were made for clarity. The final questionnaire is available as Extended data.⁶

Data collection

Questions were sent by email to all CCGs in June 2020 under the Freedom of Information (FOI) Act 2000. This legislation enables public access to recorded information held by public authorities in England. Responsibility for cleansing data lies with the authorities responding to FOI requests⁷ and research ethics approval was not required.

Individual CCGs were identified on the NHS England website and their FOI procedures followed. FOI regulations mandate a response timeframe of 20 working days. Where, rarely, replies were not received within 25 working days, follow-up emails were sent, and telephone calls made if necessary.

Data analysis

Full responses were collated in an Excel spreadsheet for analysis. Additional columns were created to summarise the use of hot hubs, cold hubs, zoned practices and home visits within each CCG. Queries regarding response interpretation were discussed during regular online meetings (June-October 2020) and in on-going email contact between the authors. Internet searches and occasional email / telephone communication with CCGs were also used for clarification (to establish whether specified ‘hot sites’ were hubs or zoned practices for example) or updates.

Emerging themes were discussed by the authors and further columns added to the spreadsheet indicating flexibility in operational hub numbers and co-location of hot hubs with cold services. Data was analysed individually and jointly in an iterative process as further responses were received.

Common patterns of delivery across the 135 CCGs were then identified using the summary columns indicating services for COVID-19 patients (hot hubs, zoned practices and home visits). Initially, data for each CCG reporting the use of hot hubs was examined to check whether zoned practices and/or hot home visits were also being used in any of their GP practices. Consideration was then made of how other services (cold hubs, cold practices and/or cold home visits) were operating across these CCGs. A similar process was repeated for the remaining CCGs, in which zoned practices and/or hot home visits, but no hot hubs, had been reported.

In this way, a total of 12 different forms of model use were identified, each describing overall delivery of general practice for COVID-19 and non-COVID-19 patients across a CCG. Due to the varied reporting of home visiting services however (e.g., as hot and/or cold home visits, or with no COVID-19 specification provided, or with an indication that they were organised outside of general practice), it was considered that categorisation of CCGs on this basis could be misrepresentative. Those models which varied only in the reported use or otherwise of home visits were therefore merged, resulting in the amalgamation of 10 of the 12 models into 5. Together with the two remaining original models, in which hot home visits were specified as the only or major form of provision for COVID-19 patients, this yielded a final set of 7 models to which each CCG was assigned for comparison. Data on population density⁸ and GP practice numbers⁵ were also obtained and added to the summary spreadsheet to aid analysis.

Results

Responses

Replies were received from all CCGs, 99% by 31^st July 2020, with the final response received on 2^nd October 2020.

Response interpretation

Terminology used in responses varied – ‘hot sites’, and ‘resilience hubs’ could refer to the same or different services for example, as could ‘green’ and ‘amber’ colour coding. Provision for non-COVID-19 patients was also sometimes unclear. Complete response sets (including any documentation provided on model pathways and usage data), were therefore used, together with internet searches and further CCG contacts, to interpret and categorise all face-to-face consultation types according to the models in this report.

The following interpretation of the data is the authors’ own and has not been approved or otherwise by the CCGs. It relates to the period between March 2020 and CCG response dates (largely June/July 2020), and reflects all models in use by GP practices within each CCG's boundaries. A summary spreadsheet supporting these findings, is available as Underlying data.⁹

Adapted delivery models

General practice face-to-face delivery was modified within each CCG using combinations of the three indicated models:

Figure 1. Models used to separate COVID-19 and other patients during face-to-face NHS GP consultations in England.

Authors’ interpretations of CCG responses according to the following definitions:

• • Zoned practice: co-location of hot and cold services on a single site, serving own practice list

• • Hot or cold hub: site of multi-practice working for COVID-19 or other patients respectively

COVID-19 services shown as 'hot' or 'red'; non-COVID-19 services shown as 'cold' or 'green'.

Models 1-4 are named according to their COVID-19 adaptation.

Each CCG (n = 135) was assigned to one of the seven model combinations according to overall use by GP practices within its boundaries. Individual practices may have used one or more of the models indicated within combination models. Home visiting service use varied within models and is indicated separately in the top, pale blue box.

The different means of delivering face-to-face services were compared for each CCG. Some reported a consistent approach to hot and cold service delivery by each GP practice. In other CCGs however, distinct local patterns of delivery were used. The combined approaches taken by all GP practices operating within each CCG were therefore assessed and all CCGs were found to fit one of seven forms of overall service delivery, albeit with some distinctions, notably the different use of home visits and of co-located hubs.

The seven model combinations and their use by CCGs are shown in Figure 1, and in the summary analysis table.⁹ Their distribution across England is illustrated in Figure 2.

Figure 2. Local models used to separate COVID-19 and other patients during face-to-face GP consultations across England.

Model combinations:*

1: zoned practices (+/- home visits)

2: hot hubs + cold practices (+/- home visits)

3: hot hubs, cold hubs + cold practices (+/- home visits)

4: hot home visits + cold practices

5: hot hubs, cold hubs + zoned practices (+/- home visits)

6: hot hubs, cold hubs, zoned practices + cold practices (+/- home visits)

7: zoned practices, cold practices + hot home visits.

*Authors’ interpretations of CCG responses according to the following definitions:

• • Zoned practice: co-location of hot and cold services on a single site, serving own practice list

• • Hot or cold hub: site of multi-practice working for COVID-19 or other patients respectively

N.B. 16 CCGs did not describe face-to-face consultations for ‘cold’ patients. 15 of these were assigned to model combination 2 as hot hubs were described which were not co-located with cold services; and 1 was assigned to model combination 5.

The face-to-face delivery data presented was correct between March 2020 and the date of response [by 30^th July (n = 134) and October (n = 1) 2020].

More than half of CCGs reported the use of a common model for COVID-19 patients by each of their GP practices (model numbers 1-4). Indeed, the ‘hot hubs + cold practices’ model combination (#2) was the most frequently used nationwide, employed by 40% of CCGs. Only 9% of CCGs used zoned practices alone, and 1% used home visiting services as their main or only form of provision for COVID-19 patients.

As Figure 2 illustrates however, geographically larger CCGs tended to report the use of ‘mixed’ models of delivery (numbers 5-7), giving model combination #5 (‘hot hubs + cold practices + zoned practices’) the greatest coverage across England. However, the physical size of a CCG did not necessarily reflect its population size with both remote rural areas and large conurbations contributing to the English landscape. Indeed, wide ranges in population density – from 63.8 to 16,427 people/km² – were seen in the different CCGs, and this range was similar for those assigned to the single (1-4) and mixed (5-7) COVID-19 models.^8,9 Similarly, the numbers of GP practices in each CCG ranged from 7 to 214 in June 2020 and these too showed a broad spread among both single and mixed models.^5,9

Evaluations and flexible models

87% of CCGs reported on-going, complete or intended reviews, generally of hub and/or telephone triage use, although one CCG was considering the potential of its drive-through model for influenza vaccinations, and others were focusing on staff or patient perspectives. 25 CCGs reported reviewing usage to facilitate dynamic models, with hubs either available but as yet unused (n = 3), or numbers being flexed up and/or down (n = 22). [Assignment to model combinations 1-7 was based on provision at time of reporting.] Indeed, four of the twelve CCGs assigned to the ‘zoned practice’ model #1 reported having hot hubs available if needed. In mid-October 2020, with COVID-19 incidence rising in the second wave of the pandemic, contact with three of these, each in areas with markedly higher case numbers than the national average and in mandated local lockdowns,^10,11 revealed that, while their hubs remained available, escalation plans had not yet been necessary. Some other CCGs also indicated that only some of their potential hubs had been required.

17 CCGs provided data on face-to-face contact across 21 hot hubs. While representing only a small proportion of total hubs, wide variations in usage were seen, with average weekly consultation numbers ranging from 2 to 79 per hot hub (March to July 2020).

Discussion

Conclusions

This study has provided an overview of adaptations to face-to-face GP consultations during the first four months of the COVID-19 pandemic in England. Varied and dynamic models were implemented to suit different and changing local conditions around the country. Evaluation of the delivery modifications described, including analysis of the management of both COVID-19 and other conditions, as well as other impacts on staff and patients, may also be used to identify beneficial elements of the rapidly enforced adaptations to inform practice both during the COVID-19 pandemic and beyond.