Swiss Cottage Surgery, GP Practice

Swiss Cottage Surgery is a GP practice in north-central London that employs five physician associates. Lead PA and partner at the practice, Raj Gill, fills us in on how he and the team are dealing with COVID-19.

How has your service changed its working practices since the start of the COVID-19 outbreak?

As part of my partnership responsibilities at the practice, I am responsibly for HR and staffing. I recognised before a formal lockdown was introduced, that this was a distinct possibility and that we needed to be prepared for a different way of working. I developed a shielding rota, which introduced significantly reduced face to face contact with patients and lessened the amount of time spent with colleagues. All clinical staff are now working long days and grouped in the team, so if one staff member becomes unwell and is likely to have infected other staff or staff need to isolate, we have back up teams you have not been exposed. Each team does not work each day at the practice, the CCG have arranged for a number of EMIS enabled laptops to be available for clinical staff to use, so staff can still be contributing to essential practice work, when not at the surgery. The CCG have also introduced a system of “Hot and Cold Hubs” each practice acts as a cold hub, seeing patients for essential face to face consultations e.g. childhood immunisations and the single centralised Hot hub sees patients with potential COVID symptoms and offers a home visiting service for patients with COVID and non COVID symptoms.

How has the role of the PA, and the duties you perform, changed?

We have had to introduce new ways of working and adapt to the ever-evolving situation. The PA is now the first point of contact for all patients and visitors to the surgery. All patients are screened and have their temperature taken at the door. If they need to enter the building, we provide patients with PPE to wear. This PA also sees all patients who need observations and an examination in our designated “Pod” that can be easily decontaminated after use.

Picture 1: Physician Associate Kaisa Vainio screening patients at front door

PAs wear the appropriate PPE available when seeing patients face to face. Generally patients are accepting of this, but sometimes it can require significant negotiation to ensure patients observe these rules and keep their PPE on.

Picture 2: Chanceeth Chandrakanthan Physician Associate conducting anticoagulation clinic

Where possible, face-to-face appointments are avoided. Most consultations are conducted over the telephone or using video consultation facilities. Younger patients have adapted very easily to using the new technologies. It has proved more challenging for our older patients and sometimes the most difficult part of the consultation is getting the patient to position the camera on their phone so we can see them.

Our most vulnerable patients are our care home patients. Our care homes are usually managed by our PAs with oversight from a lead GP and geriatrician. Ordinarily our PAs would conduct a weekly face to face ward round and a monthly MDT ward round with our community geriatrician. This has been adapted to limit the amount of face to face contact with residents. The PAs have given training and equipment to the care home staff, so these ward rounds can be conducted by video link. The care home has a laptop that can be taken to residents and staff have been trained to take basic observations such as oxygen saturations and blood pressure. The PAs will only visit a limited number of patients who need an examination or a procedure to establish a management plan. The care home staff ensure that residents wear PPE and the PAs will also attend wearing the available PPE.

Picture 3: Raj Gill Physician Associate Partner conducting video consultation with patient

Picture 4: Ernesa Sfarca Care Home Lead Physician Associate and Nasra Yusuf, on care home visit

The Physician associates at the practice have also been participating in delivering the centralised “Hot Hub” service for the CCG. Referrals are made directly to the service from the GP practice. These referrals are then triaged by GPs who decide whether patients should be seen face to face at the Hub or need to be visited at home. The patients are usually suspected to be COVID-19 positive with symptoms that need to be managed to prevent admission or non-COVID-19 symptoms in high risk patients that again need to be assessed to avoid unnecessary emergency admission. PAs are involved in seeing patients at the Hub and conducting the home visits.

Picture 5: Raj Gill Physician Associate and Dr Daniel Beck GP donning PPE before undertaking home visit

What have you and the other PAs found most difficult during the COVID-19 outbreak?

The nature of the PA role allows lots of flexibility, with members of the team working in secondary care, community care and PA education alongside their roles in general practice, so we have adapted easily to new ways of working.

Whilst training as a PA the importance of good and thorough history taking was stressed over and over, this has never been so apparent as it is now, where most of our management plans are based solely on history taking or directed examinations via video. This new way of consulting initially felt a bit alien, but both the PAs and patients adjusted to it very quickly.

Ongoing issues surrounding the lack of statutory regulation and prescribing rights has affected our ability to dispense treatments at home visits, and additional work arounds have had to be established.

The lack of clear guidance on shielding for patients caused people significant confusion and distress and involved lengthy note examinations and conversations with patients and employers to rectify.

What are your hopes for PAs post COVID-19 outbreak?

I hope that there will be an acknowledgement of the contribution that PAs working in primary, secondary and community care have made during the COVID-19 pandemic. I also hope there is accelerated progression towards statutory regulation alongside a parallel consultation on prescribing rights so that we can work to our full potential during this and future health crises.