# Ethical Guidance on COVID-19 and Primary Care

During the COVID-19 Pandemic, primary care staff will be working under considerable pressure, will be required to work differently and will be making challenging decisions. We will all need to consider our responsibilities to our patients, our practices, ourselves, our family and friends and the public. This guidance is intended to support with such decisions. It does not seek to replicate or replace national guidance. It seeks to answer frequently asked questions (FAQs) by members using an ethical prism.

These FAQs will be updated as new guidance is added, events emerge, and new questions arise.

## An Ethical Framework

Prior to the 2009 flu pandemic, the Government issued an ethical framework in 2007 – revised in 20171 – designed to help people think through strategic aspects of decision making during a pandemic, as well as providing an ethical compass for clinicians. The following is a summary of the frameworks guiding principles and is also consistent with the relevant BMA COVID-19 ethics guidance2.

Equal concern and respect: everyone matters equally, but this does not mean that everyone will be treated the same. The interests of each person are the concern of all of us, and of society.

Respect: people should be kept as informed as possible, have the chance to express their views on matters that affect them, have their personal choices about care and treatment respected and where they cannot decide, have decisions made in their best interests.

Minimising the harm of the pandemic: we should try to reduce the spread (of the pandemic), minimise the risk of complications, learn from experience (home and abroad), and minimise disruption to society.

Fairness: everyone matters equally. People with an equal chance of benefiting from resources should have an equal chance of receiving them – although it will not be unfair to ask people who could get the same benefit at a later date, to wait.

Working together: we need to work together to respond to the pandemic, helping one another, taking responsibility for our own behaviour and being prepared to share information that will help others.

Reciprocity: based on the concept of mutual exchange, if people take increased risks or face increased burden, they should be supported in doing so and risks and burdens should be minimised as far as possible.

Keeping things in proportion: information should neither exaggerate nor minimise the situation and should be as accurate as possible. Decisions taken to protect the public from harm should be proportionate to risks and benefits.

Flexibility: plans should be adapted to new information and changing circumstances.

Good decision-making: good decisions will be open and transparent, inclusive, accountable and reasonable.

Sometimes, there will be tension within and between these principles and a judgement may have to be made on the priority to be given to each principle in the context of particular circumstances.

Dr Victoria Tzortziou Brown (RCGP Joint Honorary Secretary) and
Professor Simon Gregory (Chair RCGP Ethics Committee)

### Acknowledgement:

We would like to thank the following colleagues, including GPs, ethicists, and lay members for their thoughtful contributions, constructive comments and generous effort to put this guidance together in a short timeframe.

Frances Cranfield, Grainne Doran, Kamila Hawthorne, Martyn Hewett, Richard Huxtable, Jonathan Ives, Richard Knox, Carey Lunan, James Matheson, Margaret McCartney, Catherine Millington-Sanders, Andrew Papanikitas, Owen Richards, John Spicer, Simon Stockley and Jonathan White.

## FAQs

### COVID-19 related treatment decisions

When should I refer, or not refer, a patient with COVID-19 to the hospital?

As GPs, when we make clinical decisions, we often have to balance the needs of the individual patient and the needs of the population that we serve. The COVID-19 pandemic is likely to make such decisions more challenging because need for in-patient treatment and support may exceed the resources available.

When considering a referral, the following factors are usually taken into account:
• What treatment or other support the patient needs and is willing to accept (this question focuses on the individual patients clinical need and preferences); and
• What treatment or other support is available (this question refers to the public interest and therefore includes considerations of distributive justice and resource allocation).

GPs will need to assess whether the individual patient is likely to benefit from a referral to the hospital, taking into account relevant national and local guidance (e.g. NICE: https://www.nice.org.uk/guidance/ng159) incorporating the latest evidence on the effectiveness of clinical interventions (evidential approach to decision making). Decision-making should not be disease specific (see advice at https://www.rcplondon.ac.uk/news/ethical-guidance-published-frontline-staff-dealing-pandemic)

Information on the potential benefits and risks of a hospital admission needs to be communicated to the patients and their family/carers to facilitate a shared decision-making approach which incorporates the patients preferences and best interests. Having proactive conversations and anticipatory care planning with the most at-risk patients, can improve the quality of such decision making.

Regular updates on hospital capacity can assist primary care decisions and good communication and close working with ambulance and secondary care colleagues are important in order to ensure the maximum benefit from existing resources.

Increasingly such decisions may need to be made by remote consulting and primary care professionals will also be learning how to assess COVID-19 symptoms and patients’ conditions remotely. Relevant advice on remote working can be found at: COVID-19: a remote assessment in primary care, by Greenhalgh, Koh and Car, BMJ 2020: https://doi.org/10.1136/bmj.m1182. However, working together and consulting colleagues, as much as possible, can assist with making difficult decisions and provide mutual support.

Whilst referral for hospital treatment may not be always clinically appropriate or acceptable to the patient, all patients should receive compassionate medical care, including appropriate symptom management and, where patients are dying, the best available end-of-life care.

### Non-COVID-19 management decisions

Access to elective procedures: delays are expected for what is considered “elective”, for example, hip operations. However, such procedures are important for improving quality of life. Is quantity of life being prioritised above quality?

Elective procedures concern issues which improve quality rather than quantity of life. In view of the COVID-19 pandemic, there will be increased waiting times for elective procedures. https://www.england.nhs.uk/coronavirus/secondary-care/

Whilst the suspension of elective procedures may result in reduced quality of life for some patients due to symptoms such as pain and reduced function, it should be balanced with concerns about safety at a time of a pandemic in view of a) risk of cross-infection with coronavirus b) risk from potentially reduced access to intensive care if there are post-operative complications.

It is important that patients have access to resources on self-care and appropriate symptom management in the community as much as possible.

There needs to be a system for appropriate escalation of care where delayed access to elective procedures may lead to complications in the intervening time (e.g. strangulation of a hernia) and there should be a system of prioritisation when elective care resumes, taking into account the level of clinical need and waiting times.

I am worried that we will end up focusing resources on a condition where there is only supportive treatment available versus conditions with definite treatment such as stroke or ischemic heart disease. The reduced access to specialist care may result in deterioration of many long-term conditions.

There is guidance on the provision of hospital care for different specialities during the pandemic: https://www.england.nhs.uk/coronavirus/secondary-care/other-resources/specialty-guides/#medicine.

Medical and surgical emergencies should continue to be treated. Treatment should be expedited to avoid delays and access to rehab should be prioritised to minimise length of stay as much as possible.

Diagnostic procedures and admissions for elective procedures should be risk-assessed and deferred or delayed, if possible.

Access to outpatient services is likely to be reduced due to safety reasons and redeployment of staff and resources, though, similarly to general practice, some may be delivered remotely. With anticipated reduced access to specialist follow-up and proactive management, long-term conditions may deteriorate whilst the workload and clinical risk within general practice can increase. With higher chronic disease prevalence and poorer anticipated outcomes, people from deprived areas are likely to be more disadvantaged by loss of elective services.

Good communication with secondary care colleagues and use of remote consultation methods can assist to ensure we maintain and optimise the health of individuals with long-term conditions over the course of the pandemic. Continuous risk assessment and flexibility are important as the risk-benefit analysis of everything we do will change and evolve.

Ethics around how long preventative medicine can be deferred for (e.g. smear tests, immunisations).

As the health service prepares for and is impacted by the direct effect of COVID-19, indirect effects also need consideration. Preventative medicine is a significant and important part of the role of primary care. When considering the withdrawal of preventative measures, appropriate risk-benefit analysis should occur. Certain aspects of preventative medicine may be deliverable via remote consulting, but even this may be scaled-back due to staff shortages.

From a global perspective, UNICEF is concerned about the impact of a pause to childhood immunisations, which will inevitably disproportionately affect resource-poor countries (https://news.un.org/en/story/2020/03/1060402). If there is a significant pause in routine immunisations, the resultant emergence of vaccine-preventable infections could place a further burden on health systems already severely impacted by the direct effects of COVID-19. The current guidance in the UK (as of 20th March) is ‘Keep calm and carry on vaccinating’ (Public Health England Vaccine Update issue 306, March 2020 ). Where children and their care givers are symptom-free (and not engaging in self-isolation), routine immunisations should continue as far as possible. Practices may need to restructure clinic schedules and procedures to augment social distancing and preventative measures (for further guidance see WHO Europe briefing [pdf] )

There may come a point where an individual practice’s staffing levels do not permit a ‘carry on vaccinating’ approach. The immediate and acute need may take precedence over preventative measures. This decision may also be taken at a regional or national level. Where vaccines are missed, prioritisation should be given to appropriate catch-up programmes as soon as is possible.

In response to front-line demand, there may be pausing of some screening programmes on a local or national level (e.g. 20th March – NHS Wales paused cervical screening). Even where screening is not formally paused, individuals may not be able to attend appointments due to self-isolation or care-giving responsibilities. Local staff availability may also be a factor – practices will understandably need to prioritise urgent activity and will need to work closely with public health services to execute catch-up provision at a later stage where possible.

Irrespective of whether screening is paused, it is important to ensure that patients are encouraged to report symptoms that could be suggestive of cancer. There is the risk that patients confound screening and investigation of early symptoms and may therefore delay presentation unnecessarily.

### Personal versus professional

How can I manage my professional obligations and my obligations to my family?

This is incredibly hard and represents a genuine dilemma. As a healthcare professional you have obligations to patients and your employer, but also have obligations to your family. What can you do if those obligations clash? There is no straightforward answer, and much may depend on the exact nature of your concern. Are your concerns about leaving your family whilst you are working, or are they about exposing your family to risk of infection?

How you resolve this will be very personal and will depend on your unique situation. Are you a single parent? Are you struggling with childcare? Do you live with people who have care needs or who are particularly vulnerable? Are you at increased health risk from COVID-19 infection? Are there ways that you can amend your working hours or duties according to your circumstances and needs?

The GMC requires doctors to ‘make the care of the patient your first concern’ (Good Medical Practice). At first glance, this would seem to negate all personal and family-related responsibilities. Sokol argues in his BMJ critique of this edict that ‘in extreme circumstances – such as epidemics, where treating patients involves a high risk of infection and modest benefit to patients – doctors’ obligations to their children, parents, siblings and loved ones may take priority over the care of patients.’ His suggested amendment to the original edict is ‘Make the care of your patient your first concern, bearing in mind your other patients and their particular needs, as well as any protective obligations to the broader community and obligations you may have towards others for whom you are responsible.’ (BMJ 2011;342: d646)

Overall, a 'greater good' approach might suggest that you should do whatever you can to mitigate the possible harms to your family and continue to work. But it is not that simple if you are unable to mitigate those risks and harms (see qualitative study on Healthcare workers' attitudes to working during pandemic).

According to the principle of reciprocity, if people are asked to take increased risks, or face increased burdens, during a pandemic, they should be supported in doing so. Employers and organisations need to minimise these risks and burdens as far as possible.

In summary, you may have a clash of obligations that cannot be easily and simply reconciled. You need to think about the risks and harms of working versus not working, reflect on which are more serious and consider with your practice/employer how either can be mitigated. Ultimately, if you can find ways to mitigate the risks for your family, then you do have a professional responsibility to do that and continue to work. If you haven’t already done so, you may wish to discuss your particular situation with appropriate colleagues and your employer.

I am self-isolating and feeling guilty about leaving the work to the rest of my colleagues

We often feel guilty if we feel we are letting others down, but, feeling guilty does not always mean you have done/are doing something wrong.

If you are self-isolating because you may pose an infection risk to others, you are doing the right thing by staying away. You must observe the current social distancing and self-isolation measures in order to protect your colleagues and patients. If you are feeling well enough, there may also be remote work that you can be engaging with to help your practice or health care organisation.

Where testing for COVID-19 is offered, this should be taken up, and the results appropriately acted upon. It should of course be noted that you may be unwell for reasons other than COVID-19. A negative test does not negate you from legitimately being unable to work because of symptoms you are experiencing from a different illness.

Am I obliged to put myself at risk in order to continue caring for patients?

You do have an obligation to care for your patients - which applies to any patient to whom you have formal 'duty of care'. For primary health care professionals, that is almost always the registered patient.

However, that duty is limited by the risk that you might be exposed to in discharging it. For example, it would not be an obligation to enter a burning building to care for a patient. The GMC recognises this limitation. You are not required to sacrifice your own health and/or wellbeing. At the same time, there are some situations when one may be morally required to accept some risks in order to care for others. It is important to keep in mind that any risk you choose to expose yourself to, should be proportionate to the good you can bring about.

All clinicians must consider their obligations to patients as well as to themselves, their families, and their future ability to contribute. The risks of caring for COVID-19 patients can be mitigated to some degree by the provision of appropriate PPE (gloves, masks etc.) where there is face to face interaction, or the use of remote consultation methods as a first choice (or where PPE is not available).

According to the BMA guidance3: “All employers have both a legal and ethical responsibility to protect their staff and must ensure that appropriate and adequate personal protective equipment is available, and that staff are trained in the use of it”. Also, “doctors would not be under a binding obligation to provide high-risk services where employers have failed to fulfil at least minimal obligations to provide appropriate safety and protection and to protect doctors and other health professionals from avoidable risks of serious harm”.

You will have to use your own discretion about what risks are acceptable for you to take – and this may change on a daily basis, depending on the patients you are seeing, the availability of PPE, as well as your own personal health risk factors.

I'm feeling so anxious/worried/stressed, I am not sure I am making good decisions. Should I carry on or stop?

This is an absolutely healthy and normal response at times of threat. Anxiety tells us that there is a threat (COVID-19) which needs to be responded to (social distancing, isolation, handwashing, PPE).

It is experienced as physical symptoms (restlessness, tension, palpitations, butterflies) and mental ones (worry, rumination, preoccupation and intrusive thoughts and imagery). There are also anxious behaviours such as excessive checking of news items and social media feeds, avoidance of everyday mundane tasks and repetitive reassurance seeking from colleagues and loved ones.

Symptoms tend to subside for most of us as the situation evolves, as we gain more control over our environment, learn more about the threat and its consequences and use task-orientated activities to distract our bodies and our minds.

If symptoms do not subside or if they begin to interfere with daily living or sleep then this might be the time to take action, even to pause what you are doing, including work, and seek help. Continuing regardless may put patients, and yourself at risk through, for example, being unable to concentrate, easily distracted and overly cautious.

If you are feeling anxious, overwhelmed and uncertain: plant both feet on the ground, take a few deep breaths and think about what you do know and what you can do today.

It may be useful to talk to colleagues, and it is important to cultivate, as much as you can, a supportive working environment, where people who are struggling, feel safe to be open about the difficulties they are facing. The Intensive Care Society have issued some helpful guidance on sustaining staff wellbeing: Intensive Care Society: Wellbeing Resource Library. Also, the NHS Practitioners Health website has advice on wellbeing and the Academy of Royal Medical Colleges has relevant resources.

I feel like I can't do anything right in this situation. Whatever I decide, someone will go without.

As a primary health care professional, you will be called upon to make decisions about who is referred to hospital and about how to prioritise care amongst your usual patient populations. There will be other less dramatic, but equally important decisions such as who should be given rescue medicines or medicines ‘just in case’, who to see on a home visit, who to allow to come for a face to face appointment. We are used to treating the patient in front of us and moving to a virtual and triage mindset can be difficult and uncomfortable.

The clinical decisions you may have to make during a pandemic are decisions that few have ever had to make outside wartime or emergency situations. Clinicians will not be able to ‘do everything they can for their patients’, rather ‘do the best they can, given the current situation’.

Moral distress or injury is a negative emotional response to being unable to act in the way you feel you should, or simply unable to determine the right course of action. It is important to remember that these kinds of decisions will often be moral dilemmas, where you have an obligation to do two or more mutually incompatible courses of action and are forced to choose between them. In making a choice – even if that choice is justified and correct - you unavoidably fail to meet the other obligation. See also:

It is important to remember that feeling that you have done something wrong is not always a sign that you have done something wrong. It may simply be a sign that you have been in a moral dilemma, in which there are no good alternatives. The left-over feeling, like you have still done something wrong, is termed 'moral residue', and it is likely to be unavoidable in a situation like this pandemic.

The importance of appropriate debriefing cannot be overemphasised. Although incredibly difficult to maintain, the continued cultivation of mutually supportive working environment should be prioritised.

### EoL

Who should be doing Anticipatory Care Planning (ACP) and how? Should it be done by clinicians who know the patient and are remote conversations ok?

Anticipatory Care Planning (ACP) is about having conversations with patients and their family/carers before they become ill, and less capable of making treatment or care decisions. This is not new. It is about respecting patient autonomy and choice as expressed before a situation arises. It is considered that many patients who are vulnerable to the serious complications of COVID-19 should have such conversations with their GPs, or any trained member of the Primary Care team. Ideally it should be a clinician known to the patient, but this may not be possible. Good clinical communication skills are important.

Flexibility will be required when choosing the method and place for ACP conversations given the social and workload constraints of the COVID-19 pandemic. Such conversations take time to do well. Primary care teams should exercise their judgement as to how and where such time is utilised, bearing in mind other clinical commitments and the availability of remote (telephone or video) ways of consulting.

The principle underlying these conversations is to establish and respect the autonomous preferences of patients, who are often vulnerable, on the types of care they would like to receive in the event of getting infected with COVID-19, or any other serious or life-threatening illness. The place where they would ideally like to receive that care, is also important to discuss. A personalised, shared decision between patient and clinician is the goal.

The high-level communication skills and sensitivity needed for these conversations may be compromised by factors such as deafness, lack of understanding or language barrier. Efforts to address these factors should be made and such challenges should not alter the ethical mandate to have such conversations.

Should Anticipatory Care Planning (ACP) include specific questions on care for COVID-19 (e.g. intubation) versus admission for other conditions? For example, can a patient say “yes” to an admission for a heart attack or stroke but “no” to an admission due to suspected COVID-19 considering the effectiveness of treatments is different?

In principle, COVID-19 is like any other potentially serious illness. However, the effectiveness of different interventions can be different depending on the diagnosis. In general, patients can, as part of an ACP, determine what type of treatments or interventions they would accept and which they wouldn’t.

The detail of the ACP conversation should be tailored to the scope of the patient’s wishes. Is, for example, admission, intravenous treatment, CPR, or ventilation acceptable to the patient?

It is not possible for an ACP to cover all the possible interventions that might be considered after admission for COVID-19 but the clinician conducting the conversation will get a sense of the overall preferences of the patient and should record these accordingly.

Relevant information to assist such conversations can be found at https://www.criticalcarenice.org.uk/ which also includes patient information on the different treatments and outcomes in hospital and critical care.

There is a lot of confusion around verification of death during the COVID-19 pandemic and whether GPs can do this remotely.

During the COVID-19 pandemic the processes in relation to death registration and management across the UK have been changing to ensure the deceased are treated with the utmost respect, to help minimise delays and distress for bereaved families and to protect public health. In these extraordinary times, there is a need for various groups of workers to work differently and together as one system.

This is why, we have worked with our ethics committee, our EoL clinical leads and with the BMA, to produce guidance for the verification of expected death with the remote assistance of other workers so that the verification process can be completed by a clinician safely, ensuring that bereaved families do not experience needless delays, reducing the risk of unnecessary exposure to the virus and allowing clinicians to continue on the front line. You can find this guidance here: https://www.rcgp.org.uk/-/media/Files/Policy/A-Z-policy/2020/covid19/RCGP-guidance/BMA-RCGP-Guidelines-For-Remote210420.ashx?la=en

### PPE

Should I undertake my clinical work when there is inadequate Personal Protective Equipment (PPE) available?

All doctors must comply with PPE advice and must follow other important protective measures such as handwashing and sanitization to protect themselves and others from infection.

Early data suggest that healthcare workers are at an increased risk of COVID-19 infection, due to pathogen exposure. Data from previous similar epidemics suggest that appropriate use of PPE is strongly protective against infection. (Seto et al, Effectiveness of precautions against droplets and contact in prevention of nosocomial transmission of severe acute respiratory syndrome (SARS). Lancet, 2003 May 3;361(9368):1519-20.) New PPE guidance is now available at: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control.

Healthcare professionals concerns regarding PPE can be because of poor access to PPE (because PPE is unavailable or inadequate) or compromised ability to comply with PPE advice due to time or space limitations (e.g. if the time allocated between patient contacts is insufficient to allow clinicians to change PPE). The inadequacy of PPE for clinicians in primary care settings has been a major concern during the COVID-19 outbreak. The RCGP has been very active in advocating for provision of PPE.

The degree of risk due to inadequate PPE will vary depending on the patients condition and the interaction or procedure as well as the vulnerability of the clinician to a) catching COVID-19 and b) suffering major ill health or dying. A clinician who sees a patient with a respiratory illness may be at greater risk than a clinician who sees someone with depression. CPR is a higher risk procedure than immunisation. A clinician who is on long-term steroids or who has a long-standing severe respiratory illness is more vulnerable to COVID-19.

Clinicians in at-risk groups may need to consider not participating in frontline face-to-face interactions with patients. Instead, they can provide care through remote consultation and triage services. It should not be considered unethical if those who are at higher risk, reduce or abstain from frontline face-to-face contact with patients, especially if there is inadequate PPE available. Indeed, it should be considered unethical for a health system to expect a clinician at high-risk to be exposed to that risk without considering how this can be mitigated.

All employers have a duty to ensure there is sufficient time to safely deploy PPE. This means not overbooking sessions and ensuring that there is enough time to safely change PPE between patients.

Lack of access to PPE or compromised ability to comply with PPE advice need to be raised with the management of a healthcare organisation and a risk assessment will need to be undertaken. All clinicians must consider their obligations to patients as well as to themselves, their families, and their future ability to contribute. Clinicians should not be expected to treat patients without adequate PPE, even when under moral pressure to do so, due to the potential personal, patient and public health risk. Any pressure to do so should be reported under public interest disclosure (Freedom to Speak Up) duty, if clinicians have unsuccessfully raised their concerns through the usual formal channels within their healthcare organisation.

Other resources:

### Health Inequalities Q&A

The following are some suggestions by the RCGPs Health Inequalities Group on actions we can take as GPs in order to promote health equity and reduce some of the impact of health inequalities during the COVID-19 pandemic.

With thanks to the contributors: Gemma Ashwell, Lucy Chiddick, Gilles De Wildt, Katy Hetherington, Patrick Hutt, Catriona Morton, Anne Mullin, Rachel Steen, Andrea Williamson.

Editorial team: Simon Gregory, Carey Lunan, James Matheson, Victoria Tzortziou Brown.

What should we do about "vulnerable" groups whom we aren't being asked to contact and marginalised and excluded groups?

Everyone matters equally, this is fairness. Population groups at very high risk of COVID-19 are being identified and advised to self-isolate. Primary care has been asked to identify and contact vulnerable people in their practice populations to check on them and provide COVID-19 related advice. Primary care teams may be aware of people who will be vulnerable for social reasons including marginalised and excluded groups who may not be within already defined high-risk groups but may still need extra support. It is important to consider the needs of these groups and to avoid excluding them.

Writing about healthcare for homeless people, the King's Fund encouraged services to find and engage vulnerable people and go above and beyond existing service limitations. (https://www.kingsfund.org.uk/publications/delivering-health-care-people-sleep-rough). This accords with the principle of flexibility.

Clinicians should consider creating a list of those deemed most socially vulnerable - people with severe mental health issues, the increasing homeless population, people living in poverty or driven into it by COVID-19's economic effects, those with substance dependence, those at risk of abuse and with safeguarding needs- and contacting them to give them advice and let them know how to access care and support as services narrow their focus.

How do we best care people who are experiencing homelessness during this pandemic?

Guidance on services for people experiencing rough sleeping is now available on the gov.uk website, recommending reduction measures for transmission of the virus within temporary/emergency accommodation venues. Prior to this, this group of people who developed a cough were being denied access to some night shelters and other facilities.

People who are experiencing homelessness have the lowest life expectancy, which also means the greatest potential gain from interventions. Housing and appropriate support are probably the most effective interventions. This group of people have no ability to stockpile. Their day to day survival depends upon being mobile and sociable to obtain money, food and shelter. They have little ability to self-isolate. As such, they have been identified as significant vectors for disease spread. Some areas have helped large numbers of people experiencing homelessness into hotel accommodation. The government has made available funding to support this. It would be important that such efforts continue after this specific public health crisis passes.

People become homeless for many reasons but there are common themes of multi-morbidity, social vulnerability and often addiction. People still have these problems in a hotel room. For many, now in accommodation, the move has been a major dislocation geographically, socially and from services. Needs should be assessed urgently, and services assembled around people to meet these needs. Services cannot rely on people with chaotic lives to come to them. Practices and those who commission services with people who are newly accommodated (previously homeless) should rapidly identify what the needs are and how these will be met.

From a GP perspective, it is important to be reminded that people do not need proof of address to register with a GP. Relevant information for practices and the Safe Surgeries Toolkit can be found at: https://www.doctorsoftheworld.org.uk/what-we-stand-for/supporting-medics/safe-surgeries-initiative/safe-surgeries-toolkit/#

Resources

https://www.gov.uk/government/publications/covid-19-guidance-on-services-for-people-experiencing-rough-sleeping

Dr. Al Story, Clinical Lead and Manager for Find&Treat and Professor Andrew Hayward, Professor of Infectious Disease Epidemiology and Inclusion Health Research, University College Hospitals NHS Foundation Trust give a briefing on the implications of Coronavirus for homeless populations at Pathways from Homelessness 2020.

https://vimeopro.com/narrowcastmedia/coronavirus-homeless

How can I support my patients with pre-existing mental health conditions during the pandemic?

A large proportion of GP consultations are about mental health issues. People with severe mental health conditions are known to have poorer physical health outcomes. They are also at higher risk of loneliness and social isolation. In deprived areas, mental health problems are more prevalent.

Many practices have replaced their routine appointments with on-the-day urgent access slots. There is therefore a risk that people with mental health issues are only assessed at times of crisis. The pandemic and its consequences may result in a marked worsening of mental health conditions. There are several resources on the management of mental health and well-being during social isolation measures, but these mostly focus on the effects on the previously well population and not on those with pre-existing mental health conditions.

Whilst prioritisation of urgent cases is important, space must be made for reviewing the mental health of those at risk of deterioration, before any crisis presentation. Some practices are creating a greater number of shorter counselling slots, delivered by phone or video, to cater for the predicted increased demand for advice. Other practices are making short videos with anxiety management techniques that patients can watch on the practices website.

Where, previously, the offer of online CBT or the use of an App might have seemed like we weren’t taking the problem seriously, with other options reduced, this now has more credibility and a better chance of acceptance. Try it. Not everyone has the internet or can use it but our patients remain resourceful – ask them what they are doing to keep their mind healthy and encourage and support it. Gather support around them – consider how their family and friends may be able to help. Plan for both crisis aversion and for the crisis.

Caution will be needed when prescribing medication for anxiety, panic attacks and insomnia during the pandemic. It may be tempting to think of lockdown as a short interval of identifiable stress that will pass and this may result in overprescribing of dependency-forming medications. We need to be mindful of the harmful consequences of these down the line and consider alternative ways of supporting people.

The following link provides some guidance on mental health and wellbeing during the pandemic: https://www.gov.uk/government/publications/covid-19-guidance-for-the-public-on-mental-health-and-wellbeing

Will I be seeing more or less of my patients with addictions?

COVID-19 is already affecting the availability of illicit drugs because of border and travel restrictions which are limiting the import of supplies and because of the inability of distributors to travel and dealers to dispense drugs. This means that the availability of drugs to substance users will be increasingly limited.

Past drug famines give us some clues as to what to expect. When drugs are in short supply, quality tends to reduce with increased cutting, sometimes with other dangerous psychoactive substances. This can markedly increase harm and emergency presentations. When the amount of substance in a quantity reduces people may increase the amount they take to compensate, and this can increase the risk of overdose. We may also see increasing numbers of people presenting to GPs and specialist services for support coming off drugs or looking for opioid substitution therapy (OST).

Substance-users are at high risk from respiratory infections (although we do not have specific data on COVID-19 yet). The risk is higher for those who smoke cigarettes and/or smoke drugs.

Due to a driving necessity to secure drugs and the means to pay for them substance users are also identified as high risk for spreading the virus. Third sector drug and alcohol services may lack capacity to respond to increases in demand during the COVID-19 crisis. Shortfalls in services, including wider services like needle exchange programmes, will present a risk to individuals and to society.

As part of working together, GPs are encouraged to communicate and coordinate with their local substance use services to meet the needs of this highly vulnerable population. You could also consider about getting skilled up in substance misuse so that you can prescribe under the guidance of community drug services.

Useful resources:

Scottish Drugs Forum Guidance on contingency planning for people who use drugs and COVID-19 http://www.sdf.org.uk/covid-19-guidance/

Why am I hearing that abuse is likely to rise?

As social-distancing and isolation measures become more stringent, the number of reports of domestic violence and calls to Childline can rise.

The by-product of social-distancing outdoors is social proximity indoors, which can increase pressure on all relationships but especially those which are already compromised or fragile. Increased anxiety, outright fear and, for many, inadequate and unhealthy housing can create a high-risk environment for anger and violence to break out. For some children, school is the safe place away from what happens at home and this safety netting has been withdrawn for most children now (apart from those already identified as vulnerable who receive support from social care). For victims of domestic abuse, the loss of social contact can mean the loss of support and the safety of witnesses.

In primary care, we remain a first point of contact for many of our patients. When talking about other issues, we need to be aware of the above. It may be worth enquiring about the situation at home under the pressures of isolation measures and exploring the reasons for anxiety, depression, injuries or unusual behaviour in people of all ages, in order to minimise the indirect harms of the pandemic.

We need to work closely with social services and for those households that don’t meet the criteria for referral or intervention but are still generating concern, we could consider creating a watchlist and remain in supportive contact with patients until the concern has passed.

Useful resources:

Family Lives – coping practically and emotionally during the COVID outbreak (managing conflict, working from home, structuring the day, advice for people with SEN or disability, bereavement): https://www.familylives.org.uk/advice/your-family/family-life/coping-practically-and-emotionally-during-the-covid-19-outbreak/

As part of working together, GPs are encouraged to communicate and coordinate with their local substance use services to meet the needs of this highly vulnerable population.

What about the Gypsies and Travellers we sometimes see passing through – who is thinking about them?

Gypsies and Travellers, as a group, have the worst health outcomes in the nation after street homeless people. They also shoulder a huge burden of stigma and prejudice associated with their lifestyle. Research has unveiled that this prejudice is widespread in many settings and primary care is not excluded as barriers to GP registration have been reported.

This is another group of people who frequently have a high burden of (often undiagnosed) chronic health conditions, at high risk of COVID-19, with limited ability to self-isolate due to the proximity and social support structure of their families and communities.

For CCGs with traveller sites in their areas, COVID-19 response planning must include engagement with Gypsies and Travellers in order to minimise the harm of the pandemic. Good, shared decision-making rather than imposition, will be vital to the success of such planning. For GP practices, allowing and, indeed, encouraging Gypsies and Travellers to register, even if only as temporary patients can also be very helpful.

Useful resources:

Travelling to Better Health – Welsh government guidance on working effectively with Travellers: https://gov.wales/sites/default/files/publications/2019-04/travelling-to-better-health.pdf

Coronavirus: framework to support gypsy/traveller communities – Scottish government guidance https://www.gov.scot/publications/coronavirus-covid-19-supporting-gypsy-traveller-communities/

How may COVID-19 affect health care provision for children?

The health and wellbeing of children during the COVID-19 crisis has received much less attention than other areas. This is probably because the experience of other countries tells us that children, if symptomatic, are likely to have mild disease, are less likely to be hospitalised and highly unlikely to die from Corona virus.

Children, however, can be vulnerable to the indirect and social consequences of COVID-19 and the pandemic response. Calls to Childline are increasing, as are reports of abuse. Social distancing and isolation measures can reduce access to protective safeguards whilst restricting children in often pressured home environments. As child poverty is growing, with an estimated 1.1 million more children expected to be living in poverty by 2022, many children are reliant on free school meals to eat. Some schools are working hard to replace this service, but others haven’t been able to do so. Food insecurity is a problem that can be worsened by COVID-19 if donations to foodbanks plummet and a coordinated effort to address the problem is needed

Primary care teams should be particularly mindful of children, who will become a less visible part of the population during social distancing and isolation. Childhood immunisations are key services for the prevention of multiple communicable disease outbreaks in the future or concurrently with COVID-19. Safeguarding is probably more important than ever, and practices could consider creating supportive watchlists of families where there are concerns if those concerns do not meet the threshold for social services referral or intervention. Coordination with local social prescribing schemes and local authority interventions and working together with community group and foodbanks can help to ensure that patients have access to food and, in particular, children are not victims to the pandemic’s socioeconomic sequelae.

Useful resources:

Young Minds’ guidance to looking after your mental health whilst isolating: https://youngminds.org.uk/blog/looking-after-your-mental-health-while-self-isolating/

Parent Club – everything you need to know about Corona virus – tailored to age groups: https://www.parentclub.scot/

What about the care of refugees and asylum seekers?

Refugees and asylum seekers are another group who are at risk from getting infected and spreading COVID-19. This population is likely to be in social situations which increase its vulnerability and exposure to the disease and may have chronic, often undiagnosed, health conditions which increase the risks from the disease.

Because of the barriers in accessing care, either because of the difficulties understanding and navigating a new system or because of fear of financial penalties, refugees and asylum seekers may not get the healthcare advice and treatments they need.

The work done by Doctors of the World, both through the Safe Surgeries Toolkit and by translating relevant COVID-19 information for patients in 34 languages, can help GP practices improve access to care for this population.

Useful resources:

NRPF Network’s advice on supporting people with no recourse to public funds during COVID: http://www.nrpfnetwork.org.uk/Documents/coronavirus-factsheet.pdf

Is now the time to be encouraging people to cut down or stop drinking alcohol?

Many people turn to substances such as alcohol at a time of stress. Off-licences were added to the Government's list of UK retailers allowed to stay open during the coronavirus pandemic and there are reports that alcohol sales have increased recently.

But alcohol will not help to manage the stress of self-isolation and it can be an unhelpful coping strategy. It is important that people are aware of the risks and how to calculate alcohol units https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/. We need to signpost people to healthy coping strategies during the pandemic including eating healthily, exercise, and ensuring they get enough sleep and social support. https://www.mind.org.uk/information-support/coronavirus/coronavirus-and-your-wellbeing/#collapsedc006 Also, to combat feelings of anxiety, it may be helpful to stay off social media sites or limit the amount of time spent watching the news each day. Being proactive about maintaining mental health can help reduce triggers.

We should also be supporting people with pre-existing alcohol addiction as they may find the pandemic period even more challenging. Anxiety and loneliness can exacerbate problematic drinking while restricted access to alcohol, may lead to symptoms of alcohol withdrawal. Unplanned detoxes can be deadly. However, we could assist people to cut down on alcohol consumption through the local addictions services and by signposting them to online help where people can find helpful resources, access peer support and attend meetings online.

Useful resources:

Online resources for alcohol addiction recovery during the coronavirus https://ahauk.org/recovery-during-coronavirus/

South London and Maudsley NHS Trust’s advice on harm reduction for alcohol dependence: https://mcusercontent.com/c4876cb152fa1983ef265ad1b/files/b9b3f977-7403-4042-8cb7-d04c51b01404/Alcohol_harmminimisation_18032020.pdf?mc_cid=71866880b8&mc_eid=137e254eb9

How can I support those smoking? Is now the right time?

Emerging evidence from China shows smokers with COVID-19 are 14 times more likely to develop severe respiratory disease. Smokers are more vulnerable to infectious diseases and studies have shown that smokers are twice more likely than non-smokers to contract influenza and have more severe symptoms, while smokers were also noted to have higher mortality in the previous MERS-CoV outbreak. Therefore, the current pandemic offers a good opportunity for initiating conversations on smoking cessation.

Have that conversation, use local support services if available, issue scripts and encourage people to quit. There are also many online resources and the Smokefree app which can help patients stop smoking by providing daily support and motivation. If people stay smoke free for the 4-week programme they are up to 5 times more likely to quit for good.

Resources:

https://www.gov.uk/government/news/smokers-at-greater-risk-of-severe-respiratory-disease-from-covid-19

https://www.todayistheday.co.uk/support/

https://www.nhs.uk/oneyou/apps#nhs-smokefree

What do we do to help people that are genuinely socially isolated and lonely?

Loneliness was already prevalent before the social distancing rules were applied but can be made worse during the period of lockdown.

A 2017 systematic review of 40 studies from 1950 to 2016 published in the journal Public Health (https://www.researchgate.net/publication/319687009_An_overview_of_systematic_reviews_on_the_public_health_consequences_of_social_isolation_and_loneliness ) found a significant association between social isolation and loneliness and poorer mental health outcomes as well as all-cause mortality.

This is an important time to consider those that may be lonely. There are strategies that people can employ to ensure their well-being and good mental health. Most of these involve either finding ways to distract themselves (keep busy) or finding ways to connect with others (despite the circumstances). Keeping to a regular schedule as much as possible, being physically active and connecting with family and friends via online means can help.

There are useful online resources you could direct people to:

https://www.campaigntoendloneliness.org/blog/coronavirus-and-social-isolation/

https://www.verywellmind.com/how-to-cope-with-loneliness-during-coronavirus-4799661#citation-1

How can I support my autistic patients and those with learning disabilities?

Autistic adults and people with learning disabilities are likely to find the coronavirus outbreak, the restrictions placed on daily living, and the changes to how their support is delivered, particularly confusing, worrying and in some situations distressing.

Good communication is important. GPs may need to use diﬀerent communication methods depending on patients` preferences such as emails, visual aids, and assistive and digital technologies. Communication should cover one matter at a time to avoid confusion and should be devoid of jargon.

Be aware of the increased prevalence of safeguarding issues and the increased risk of exploitation and abuse, grooming, being drawn into ‘gangs’, and neglect.

One of the ethical principles mentioned above is that everyone matters equally. The provision of care should be based on clinical need and the ability to benefit and any clinical decisions should not discriminate. GPs have an important role in communicating with and advocating for autistic people and people with learning disability during the coronavirus outbreak.

Resources:

https://www.england.nhs.uk/coronavirus/publication/letter-responding-to-covid-19-mental-health-learning-disabilities-and-autism/

https://www.learningdisabilityengland.org.uk/news/information-on-the-coronavirus/

Learning Knows No Bounds is a Facebook page for families with special education needs: https://www.facebook.com/learningfromhomeuk/

Doesn’t this all sound like a lot of extra work to be taking on in the middle of a crisis?

Perhaps but, of course, it shouldn’t be. Whilst providing a service for everyone, we should always allocate the most resources towards the greatest need. The Strategic Review of Health Inequalities in England introduced the concept of ‘proportionate universalism’ (https://www.parliament.uk/documents/fair-society-healthy-lives-full-report.pdf) , suggesting that health actions must be universal, not targeted, but with a scale and intensity that is proportionate to the level of disadvantage.

General practice has a very important role to play during the COVID-19 pandemic, saving many lives by providing high quality, compassionate primary care to those who need it.

Things will get better, won’t they?

COVID-19 has already caused much suffering and hardship for our practice populations and the communities we serve, and we will be dealing with the sequelae including the consequences of the disease, trauma, bereavement and healthcare service interruption long into the future.

However, good has also come of this crisis. We are seeing governments support people in an unprecedented manner. We have seen rapid and momentous change in how vulnerable groups of people are treated. Society has recognised “key worker” roles – often the lowest paid and most insecure of jobs - as the ones which keep society going and demonstrates this publicly.

We have seen the rebirth of community. People have volunteered in staggering numbers and, throughout society, people have started looking out for and helping others. We need to encourage more to do so:

https://www.hscworkforceappeal.co.uk/ (Northern Ireland)

https://www.goodsamapp.org/NHS (England)

Important change has happened already and now we have an opportunity to ensure that this positive change endures.

### Other questions on ethical issues

How can we practise in an evidence-based way at a time of uncertainty and evolving evidence?

Dr Margaret McCartney advises on the importance of recognising the lack of robust evidence at times such as these, thinking critically and supporting the generation of new evidence through research.

How can I maintain compassion during remote consulting on challenging issues?

Dr Roger Neighbour advises on the importance of choosing the right medium, maintaining continuity as much as possible, avoiding platitudes and on the importance of listening.

Is there any advice on having, potentially challenging, COVID-19 related conversations with patients?

You can find advice on having such conversations with patients here. Further resources are available in the 'End of life care' section of the COVID-19 resource hub. There is also a helpful video presented by Professor Alf Collins, Professor Neil Maskrey, Dr Liz Moulton, Professor Richard Lehman, Dr Libby Maskrey, Dr Sam Finnikin and Dr Nick Price below.