In our 118th edition, Louise has summarised Nice's Long Covid guidelines, Leila has been dealing with difficult patients, Kirsty has been looking at the McCloud consultation on NHS pensions, Liz has advice on its tax implications, and Judith has her eye on the nation's health. Plus much more.
The Sessional GP
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April 2021
NASGP community
How GP locums handle difficult consultations
"Whatever you decide to say does not matter, the point is, you want this patient to explain how they feel, so that they feel valued and for us as GP locums to gain a better understanding of the patient in front of us. "
A lack of familiarity can put us in the firing line.
By GP locum Dr Leila Saeed As I sit here as a GP locum in this new GP surgery on a sunny Monday morning, I find myself staring in bewilderment at my computer screen. It is around 8:50am and I am still reeling after the last patient, who has just stormed out of my room. The patient was evidently not happy with the consultation today and did not hesitate in letting me know both through body language and words to the effect of: “This is nonsense, you do not care about me.” Despite being rare, these consultations can leave us as GP locums feeling disappointed, shocked and quite frankly contemplating why we chose this career path, even if this thought is only temporary. Furthermore, it can make us feel guilty about how we came across: Did I provoke the patient? How could I have done things differently? Will this result in a complaint? Self-reflection has been encouraged throughout all of our medical training but in particular, in GP training. In these tense scenarios, reflection has the most impact, as we finally use this almost redundant skill to guide us through our lives as a GP locum. Difficult consultations It is fair to say that if you have not encountered a ‘difficult’ consultation yet, that you are either lucky, have it yet to come or are great at avoiding such scenarios. For me a difficult consultation is one that leaves me feeling deflated or the patient feeling dissatisfied with their care; worse still, both parties feeling a little rough around the edges. The reason for choosing this topic was because I was aware (from personal and friends’ experience) the need to analyse ‘difficult consultations’ so that we can best increase awareness and also not allow it to have an impact on our enjoyment of day-to-day life. GP locums are more at risk of these types of consultations for a multitude of reasons including ‘difficult patients’ being placed with the GP locum; not having the ability to build a rapport or follow up due to session patterns; and other pressures at play during a GP locum session including lack of understanding of the systems etc. In order to preserve the longevity in this career path we must look back at difficult consultations and learn from them. Moving forward and after having numerous discussions with colleagues and friends, I have put together a list of ways of bringing the consultation back from the depths of negativity. My aim is to encourage thought, discussion, and to help my fellow colleagues avoid burnout. Before proceeding, we have to take into consideration that we are all different as humans and doctors, and therefore have a different outlook on what makes a consultation difficult. We also will have different approaches to how to combat these situations. By referring to a case study, I will frame my suggestions. In practice One example: you arrive at a new GP surgery that you have never locumed at, which took a stressful 30 minutes of incorrect directions from Google Maps. You are running fifteen minutes late due to the fact you could not sign into EMIS and the passwords provided were not working. Once signed in, you glance over the appointment book and notice that despite stating to the practice manager a week ago that you did not want to do home visits, that they have allocated two slots at the end of the morning clinic to this. To add to your anguish, you cannot see any ‘admin time’ allocated. As you are running late, you decide that rather than having a back-and-forth discussion with the practice manager regarding these issues highlighted, you will start your session and discuss it later. You feel slightly on edge but take a deep breath as you start your morning clinic. Booking notes for 8:30am appointment (10 minutes): “John Clarke. Patient would like to discuss the delay in referral to gastroenterology- very angry”. EMIS indicates last seen by the GP Partner Dr Smith for stomach pains. Referral sent one week after consultation. Non urgent. How can GP locums handle difficult consultations? A good introduction goes a long way This sounds like a cliche but cannot be any truer than in this situation, where we may be faced with confrontation from a patient who does not recognise us. If we can best diffuse the situation from the start, with gestures to show that you are a. willing to listen b. not looking for a fight, it may just help the situation. This could be getting up out of your seat to welcome the patient or collecting them from the waiting room. During Covid-19 times, it may simply be a polite introduction over the phone. This simple task could help alleviate any animosity between you and the patient and get you some GP locum brownie points. Another suggestion (IT dependent) could be to turn this into a video consultation to avoid the barrier to empathetic body language. Listen to the patient in front of you Despite our best efforts of a warm introduction, the patient is still angry and starts to raise their voice before he has even sat down/we have finished introducing ourselves. He is understandably upset about the referral delay and wants answers. With not being the original doctor involved or even being familiar with the systems, it puts us in a vulnerable position as a locum. My suggestion would be to stop, literally stop searching on EMIS, stop apologising and stop talking. Let the patient say what has to be said. When they have finished, we can then follow it up with “You seem understandably upset, tell me more about how you are feeling?”. This can now go either of two ways: further anguish as the patient wants answers or maybe, just maybe, if the patient sees a calm, empathetic and open GP with a slow pace of talking who is non-confrontational, they may feel calmer. Whatever you decide to say does not matter, the point is, you want this patient to explain how they feel, so that they feel valued and for us as GP locums to gain a better understanding of the patient in front of us. Apologise The delay in referral may have been the right or wrong thing to do, and this very much depends on the clinical scenario, but that is not the case right now. Apologising for how the patient feels is paramount to building that trust with the patient. If there was an error made in referral timing, we can amend this by explaining to the patient that we are sending out an urgent referral, but we are definitely trying our best to avoid getting into the ‘blame game’. Respecting our colleagues is crucial and so letting Dr Smith know what changes have been made by sending a note/message is both respectful and thoughtful. There are many options to be considered at this point, but the important learning lesson here is that we can apologise to the patient without incriminating anyone. End on (some sort of) good terms Even if the consultation goes to tatters despite our best efforts, and we are not getting anywhere, it may be best to surrender. Rather than having both parties going round in circles, with no outcome, we can suggest at this point that it is best to book another appointment. This may give the patient time to think about what has happened and also preserve some patient-doctor relationship. There is only so much that can be done in one 10-minute consultation, and having an open-ended consultation is not the worst thing. It is best to avoid wasting ours and the patients time and instead resort to plan B. Take a break This sounds counterintuitive, why would we decide to take a break when we are already running behind? Well, most likely after such a heated consultation, we may be feeling somewhat subdued or worked up. So, lock that computer screen and walk out of the room, even for five minutes. It is therapeutic to reflect on how we feel and deconstruct it in our brain. During a mid-morning surgery, it could be walking outside, chatting to a friend or just grabbing a coffee. Continuing to work when feeling heightened emotions could lead to the rest of the clinic being a negative drag. So best to stop and take five minutes out. I hope that you found this article useful and it gave you some ideas to help you manage your day-to-day life as a GP locum. Being a locum has been a great career choice and have given me the flexibility to explore other career choices and also allowed me to consult with patients from all backgrounds. It is best that we preserve our mental health and look after each other. Dr Leila Saeed lsaeed@nhs.net Leila completed GP training at the Buckinghamshire Deanery in 2017. Since finishing GP training, she has been a GP locum and a salaried GP in different parts of the UK. Alongside working as a GP, she spends three days a week as a clinical educator in a UK medical school. Special interests include medical education and consultation/communication skills.
Do you know which NHS pension section you are a member of? In the times we live in you can hardly be blamed for glazing over when you attempt to make head or tail of the plethora of information and recent changes relating to the NHS Pension scheme and pension legislation. Recent research has shown that 75% of GPs are unaware of the annual and lifetime allowance limits on their pension savings (Wesleyan, 2020). Possibly more alarmingly, the same research showed that 31% didn’t know which section of the NHS Pensions scheme they were members of. This is not limited to your colleagues in general practice. Knowing which pension section you are a member of determines the rate at which you accrue benefits, your normal retirement age and, in light of the ‘McCloud Remedy’, could give you some important choices in the future. Your annual allowance In the 2020 spring budget, the government increased the earnings limit when you start to experience tapering of your annual allowance from £110,000 to £200,000. This was in response to the issue of so many pension members hitting and exceeding the annual allowance limit, often due to their allowance being tapered due to ‘high earnings’. Unfortunately, this didn’t fully get to the root of the problem as it is still possible to exceed the full, untapered £40,000 annual allowance and land yourself with an additional tax bill in return for taking on extra duties, getting a pay increase, award or other previously sought-after career markers. The Annual Allowance Charge Compensation scheme The Government has now introduced the Annual Allowance Charge Compensation Scheme, where the scheme pays any additional charge, and your pension benefits will not be reduced to repay this at retirement. But once again, the onus is on the individual to realise there’s an annual allowance problem, get it calculated, and then complete the necessary paperwork to secure the compensation by the set deadline. Not exactly worry-free or easy. Believe me, it’s complex and not to be tackled unless you’re very confident in the process – but Legal & Medical can help with that. The deadlines set were: 31 December 2020* SPE form target – paid to HMRC by 14 Feb 2021 31 Jul 2021* Formal hard scheme pays deadline 31 March 2022* AA charge compensation scheme form 2020/23 McCloud remedy likely 31 July 2024 Amend speculative SPE form *relates to the 2019/20 tax year The McCloud remedy ‘This is already complicated enough,’ I hear you cry! But then along came the age-discrimination legal challenge – the McCloud judgment. Although the ramifications of the age-discrimination legal challenge are not fully settled, it could mean that some NHS pension members will see their annual allowance input and associated tax charges change retrospectively. It could also mean that some members choose to move back into the old heritage sections of the NHS Pensions scheme. This will be especially meaningful for members working less than full time, as the new 2015 scheme uses a career average earnings method of setting income used for the basis of pension calculations, while some of the heritage schemes use best of the last three years, and accrual rates differ in all three schemes. If you are working on a less than full-time basis, you could benefit from a greater pension in retirement under the old schemes. But nothing is certain as yet. This is yet another complex issue and it will take some time to fully understand the fall out for members. The same research I mentioned earlier found under 7% of GPs surveyed do not understand the McCloud judgment’s impact on their own personal situation. I’m not surprised! With ‘Covid work-life’ as it is, family life, home-schooling and your own ‘normal’ life to keep on top of – I’m amazed any of you are even trying. At Legal & Medical, we work every day advising members of the NHS pension scheme and are carrying out in-depth analysis as information is rolled out. Thankfully the BMA are lobbying hard for the age discrimination remedy to be tailored to all doctors, full-time or part-time. But the ‘remedy’ itself is far from clear at this time. So I’m afraid I’m saying it’s another case of ‘watch this space’, and don’t hesitate to speak with us if you aren’t sure if any of this applies to you. Personally, I would like to see a full overhaul of the pension regulations but I have been specialising in this area for too many years to believe that’s something we can really expect any time soon! So, in the absence of a magic wand to simplify it all, keep informed and keep taking the best advice you can from specialists like ourselves. Kirsty McGaun kirsty@legalandmedical.co.uk 07769 677505 e would always advise you to seek specialist financial advice to ensure cover is appropriate to your needs Kirsty McGaun is an Independent Financial Advisor (IFA) at Legal & Medical with over 20 years’ experience in financial services.
largely dependent upon which scheme - or schemes - you're in.
"Thankfully the BMA are lobbying hard for the age discrimination remedy to be tailored to all doctors, full-time or part-time. But the ‘remedy’ itself is far from clear at this time."
Three ways NHS pensions changes could affect GPs
Financial planning
"It doesn’t often work the other way round, but there are things a GP locum can do to stand out. It’s good to get out and talk to the team."
It always helps to keep in touch
How to approach a practice manager about salaried work
Gary Hughes is a practice manager and partner with 12 years’ experience. He explains how practices like his are coping with the pandemic, how Covid-19 has affected their outlook for using locums, and his advice on how to get a salaried post at a GP practice you like. Tell us about the profile of the practice that you manage. I manage a training practice of 14,000 patients with six partners. Our patient list has grown about 23% in five years and we have a full multi-disciplinary team. And we use GP locums regularly. We have two currently working in the practice on a fairly long term basis. We work hard at fostering good relations with our locums, and we have a big list of locums we work with. When the pandemic hit, how did that affect your locum bookings? Initially, the workload in the practice crashed. The first two or three months, it really dived. We didn’t need locums at all, and probably there was also the fact that we didn’t want to bring them into the practice from a safety aspect as well. But in August we started to think, ‘Okay, capacity is ramping up’ and GPs hadn’t taken holidays. Then we started to use some ad hoc locums again. By October or November we needed a bit of regular capacity because we lost our paramedic and we weren’t going to try and recruit a paramedic at that time. So we took on one six-session locum and one four- on a longer-term basis – probably through until the beginning of March. As things stand at the moment, in the summer we will go back to how we were using locums before Covid-19 for ad hoc sessions. What advice would you give a locum who is looking for a salaried post? GP locums looking for salaried posts want to adopt the attitude that they’re employed in the practice and part of the team, not just somebody coming in for three hours to do whatever bit of work that they’ve been asked to do. They need a different mentality. If you’re looking for a permanent post, you’ve got to demonstrate that you are the right person for the team. When we’ve needed a partner or a salaried GP, rather than advertise, we always contact the locums that we like and that we think would make a good salaried GP and offer it to them first. One of our partners of a number of years was a GP locum at first. When she started locuming about 10 years ago she always kept in touch. We contacted her for a salaried role with a view to a partner. And it’s the same with one of our salaried doctors. It doesn’t often work the other way round, but there are things a GP locum can do to stand out. It’s good to get out and talk to the team. That’s difficult at the moment because everyone’s stuck in their rooms and trying not to mix and to distance from one another. I’d be looking for a willingness to deal with all the paperwork, including results, and bringing patients in – particularly at the moment. IT is another big challenge. It sounds obvious but if something goes wrong with the system and GP locums try to fix it themselves before asking for help, it says a lot about their mentality. If the GP locum approaching the practice has embraced being in the practice – not only doing the work that they’re given but asking if there’s anything else to do, and really solved problems so patients don’t cycle back into the system a week later – then they’d be a good candidate for salaried work, long-term locuming, or even just repeat bookings. Gary has published over 130 short blogs on all things leadership, business and management, a book ‘Leadership in Practice’ and hosts a podcast of the same name. leadershipinpractice.co.uk
Health and career
What does the McCloud consultation mean for my pension?
There will be practical implications for most of us
"Reversion back to the legacy schemes will mean that annualisation (which quite frankly is the enemy of any Locum GP) will not apply to membership with the remedy period."
Accountancy and tax advice
Much has been written about this since the results of the McCloud consultation have been published and this article does not seek to duplicate the technical aspects. But what are the practical implications and what do you need to do now (or not, as the case may be)? Deferred Choice Underpin (DCU) The decision has been made to implement DCU – this means that you won’t actually need to make the decision about which scheme you want your pension benefits to accrue in until you come to retire and draw your benefits i.e. the choice is deferred to a later date. When the time comes, you will have the option to choose whether or not pension benefits accrue in the legacy scheme (1995/2008 schemes) or the reform scheme (2015 scheme) for the ‘remedy period’ (this spans 1 April 2015 to 31 March 2022). From 1 April 2022 all active scheme members will be transferred to the new reform scheme. This is beneficial in some ways as you will be able to work with real data to compare the effects of these choices. In the first instance eligible scheme members (more about this below) will simply be put back into the legacy schemes for the ‘remedy period’ as a matter of course. This should be automatic with no application required, and should be implemented no later than October 2023. This means that in most cases you don’t need to do anything immediately at all aside from waiting for finer details on how exactly all of the changes will be executed. Who will be affected? Individuals who joined the NHS Pension scheme on or before 31 March 2012 and were still in service on 1 April 2015 (or who had a break in service of less than five years). To whom does this not apply? Anyone joining the NHS scheme on or after 1 April 2012 is not affected by these changes – they will remain in the 2015 scheme. If you have already taken your pension since 1 April 2015 You will be offered the choice in respect of the remedy period (for you this will be from 1 April 2015 to the date that you started to draw your retirement benefits) and this could affect the level of pension to which you may be entitled. The choice will be offered as soon as practicable, so when the appropriate legislation has been passed, you may wish to find yourself a good pensions adviser (with specialist knowledge in the NHS Pension scheme) to help you make the decision when the time comes. If you are planning on retiring shortly Again, proper advice is key, start talking to a financial adviser now – they may not be able to tell you much at the moment but having that relationship in place will be extremely important when the time comes and you may well find that this could affect your planned retirement date. How will this affect my taxes? Reversion back to the legacy schemes will mean that annualisation (which quite frankly is the enemy of any Locum GP) will not apply to membership with the remedy period. This means that certain doctors will be entitled to pay at a lower tier rate. That said, the mechanism for refunding contributions has not yet been decided, nor how to deal with the tax effects of a refund. Once the reversion has happened, the calculation of annual pension growth will also be affected – this could affect your annual allowance position. The changes could reduce or eliminate charges for some, while they could increase or create charge for others. The situation will need to be evaluated on an individual basis as there is no hard and fast rule about how pension growth will be affected, so it’s important to consider the changes thoroughly. Where there is extra tax to pay, HMRC have suggested (at present) that they will only look to go back four years from the implementation of the changes. Where a refund is due (perhaps where an annual allowance charge has been reduced, for example) it has been suggested that you will, unusually, be permitted to make a claim for the whole of the remedy period. What will change in the long run? The consultation results will not affect the completion of the 19-20 pension certificates – they should be completed based on current rules and any adjustments which subsequently arise will be dealt with at a later date. This means that annualisation rules still apply for those currently in the 2015 scheme, even where you will be reverted to the 1995 scheme in due course (this may mean that you pay a higher level of contributions now which will subsequently be refunded to you). Annual allowance calculations and reporting are also still based on current scheme membership and rules as they stand. This may mean that you have to pay a charge now that will change later. Some will think that this is ludicrous (perhaps it is) but tax is law. The changes are coming but they’re not in effect yet. Tax effects at retirement Although membership for the remedy period will revert back to the legacy schemes initially, at retirement a decision will be needed to be taken as to whether the 1995/2008 scheme or the 2015 scheme would provide the best benefits for you. In some cases a member may want to switch back again to the 2015 scheme. This, again, has an array of potential tax implications – and, as yet, the practical details of how this will work have not yet been decided. We await further guidance (just keep the thought in mind). What are the benefits of employing a specialist medical accountant? This consultation has opened up a minefield, but you’re not alone. Your accountant should be able to estimate the effect of the change back to the 1995/2008 scheme so far as annual allowance charge, and pension contributions are concerned. (NHS figures will follow, but they are unlikely to be able to provide definitive figures for some time). Your accountant will be able to work with your Pensions Adviser to comment on the tax effects of the options available to you. When the time comes, your accountant will be able to help you reconcile the greater tax implications of the changes to your pension (notifying HMRC and helping with scheme pays, for example). Whilst this change successfully removes age discrimination in the pension scheme, is it likely to cause additional costs and administrative burden for the members involved to ensure that they are able to account correctly for the tax effects, and are able to make an informed choice at retirement. This is just the beginning, there will be much more to come on this topic, so watch out for developments and keep in touch with your IFAs and accountants. The information contained in this article is for guidance only, and does not constitute advice given by Liz Densley or Honey Barrett. No responsibility can or will be accepted for loss occasioned to any person or entity as a result of action taken or refrained from in consequence of the contents of this article. Professional advice should be obtained before acting on any information contained herein, from your own accountant, or by contacting Liz at liz.densley@honeybarrett.co.uk for a free initial consultation.
Judith Harvey
'Is there any other way of putting pressure on Westminster to move away from short-term thinking based on cost to and substitute social benefit as the yardstick?"
The health of the nation: who’s keeping score?
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What if there was an index that incorporated all the factors relating to the nation's health?
What if we had a single measurement for the nation’s health? Judith Harvey outline’s the need for the new Health Index, currently being compiled by the ONS. How many New Year Resolutions have you kept? If I don’t get around to clearing out the box room, no-one is going to hold me to account and it isn’t the end of the world. How many countries fulfil their undertakings to cut carbon emissions? If the nations of the world fail to cut carbon emissions, the world may indeed end. If it ends, who would hold them to account? Government policy shapes our chances of a healthy life. The pandemic has highlighted starkly that deprivation kills. Eighty percent of our health is dependent on our luck in the tombola of social determinants of health: education, housing, transport, employment opportunities, our exposure to all sorts of pollution. Slapping a pre-election Elastoplast on our National Illness Service won’t improve these. If the government fails in its duty to the society it governs, it’s the health of every one of us which may suffer. But how can we ensure that governments accept responsibility for their actions – or inactions? We can vote the scoundrels out of office, but elections are a blunt instrument, and very rarely issue-based. In any case, governments have time to lie their way out of a predicament and to announce generous-sounding bungs to the NHS. Judicial Review is a powerful way of challenging the way decisions have been taken by public bodies. The government didn’t like Judicial Review rapping its knuckles over Covid-related contracts, and is working out how to make it a less effective weapon. The NHS does not equal health. But it takes years to demonstrate that improved air quality has improved the health of the population, and governments want to see results they can boast of in the next election campaign. Health is seen as a cost – an overhead – rather than an investment. Yet the pandemic has demonstrated that economic performance depends on health, not vice versa. Investing in health is a national insurance policy. With all the Departments clamouring for funds, it is flashier to commission an aircraft carrier or launch Eat Out to Help Out than to tackle intractable long-term problems like housing or social care. Or to invest in horizon-scanning committees, spare capacity and stockpiles. Over the past year the country has had to count the cost of inadequate insurance. You can’t improve conditions without measuring them. So we need a mechanism for assessing our long-term progress in health improvement, something which keeps the government’s eye focused on its responsibilities. We have a few bodies which look beyond the next Parliament. There is a National Risk Register, which evaluates possible catastrophes, including pandemics, and discusses mitigation strategies. (It has now withdrawn its 2020 pre-pandemic report.) The Climate Change Committee advises the government on tackling climate change. There is an all-party Committee for Future Generations, middle-aged MPs mulling over plans for generations unborn. David Cameron abolished the Sustainable Development Commission, a watchdog which monitored government targets, and the government has just announced that it is putting the axe to the Industrial Strategy Council. But, though these organisations have a value, none directly holds the government to account for the nation’s health. Nor does a yellowing White Paper, however laudable its proposals for future legislation. Do other nations do better at getting their governments to think beyond the next election? Countries all over the world have Future Committees but few have enough power to make a government uncomfortable. Scotland’s Future Forum is strong on worthy aims and its website is extensive, but I could find no practical suggestions and no list of achievements. In Wales, however, the obligation to protect future generations is enshrined in law, and a dynamic Future Generations Commissioner has secured changes in plans for transport, housing and land use to take into account the lives of future generations. Is there any other way of putting pressure on Westminster to move away from short-term thinking based on cost to and substitute social benefit as the yardstick? “Whose Health it is, Anyway?” ask former CMO Dame Sally Davies and her colleague, public health doctor Jonathan Pearson-Stuttard. It’s our health, but so much that influences it is beyond our control. So in 2018 they proposed a composite Health Index, a highly visible measure incorporating not just healthcare data but, crucially, also data on all the social factors. The index would track progress in improving what is arguably the country’s most valuable asset – the health of its people. Year on year, we, and those in power, could see how we were faring and how they were doing. It would shine a light on successes and illuminate the dark corners of failure. Governments rely on an index, the Gross Domestic Product, to measure how the economy is performing Every three months the government, economists and business scrutinise the GDP data: two falls in succession and they declare we are in recession. But what national assets are included? As Bobby Kennedy said in 1968, “The production of napalm and nuclear warheads counted towards GDP but the health of American children and the joy of their play did not.” A Health Index would not oblige a government to take specific decisions, any more than GDP does, but if it had the same visibility it could be a powerful stimulus to action. If it showed that respiratory illness and air pollution had been increasing for several years, it would provide strong pressure to tackle air pollution, albeit at the cost of measures unpopular with organisations which fear decreased profits. Similarly governments would be less reluctant to tackle alcohol and keener to promote public transport and protect green spaces if they were being judged on the adverse health consequences. The Office for National Statistics (ONS) has taken on the challenge. It is developing the toolkit for a Health Index, working out how to incorporate information about all the topics that influence health, and how to keep the Index updated. It has to ensure that it is useful not just for keeping Westminster’s attention on what is affecting the whole nation’s future health, but also providing information local authorities and others can use in their planning. The ONS then has to incorporate all this into a practical guide. It’s a huge undertaking, but one that future generations should thank us for. Whose Health is it. Anyway? Sally C Davies & Jonathan Pearson-Stuttard, OUP 2021 Judith Harvey judithharvey12@gmail.com
This is a new guideline from NICE on managing the long term effects of COVID-19, published in December 2020. What does this eagerly awaited guideline tell us that is new? In summary, not a lot. The most useful bit for me was on the investigations that are advised. Basically, listen to people, be holistic, manage any urgent symptoms, do a few tests if you need to and then signpost them to self-help material, or refer them on as appropriate. It is worth bearing in mind that this is a ‘Live’ guideline. There is just very little evidence at present to guide what we should be doing. As more research is done and as time goes by, the guideline will evolve. I will summarise some of the key points. I am assuming that we all know to be inclusive and to treat patients as individuals and to be holistic and will therefore leave these bits of the guideline out. Definitions Acute COVID-19 – up to four weeks after initial infection. Ongoing symptomatic COVID-19 – four to 12w after initial infection. Post COVID-19 syndrome – 12w or more after initial infection. Long Covid – this refers to both ongoing symptomatic COVID-19 and post COVID-19 syndrome (ie more than 4w after initial infection). We should not exclude a patient from further assessment, management or referral based on the absence of a positive swab result. What advice should we give people with acute COVID-19? Among the normal kinds of information we give people, we should advise the following: The most common ongoing symptoms. How to manage their symptoms. Symptoms which should prompt the seeking of further advice. Who to contact if they are worried about new, ongoing or worsening symptoms, especially if they have them more than 4w after the start of infection. What can long Covid patients expect from their recovery? Recovery time varies, but most people are better by 12w. Initial symptom severity doesn’t predict the likelihood of developing long Covid. If there are new, or ongoing symptoms, these can vary over time. How should we assess symptoms in people with long Covid? We can consider using a screening questionnaire to assess symptoms. None have yet been validated, but there are 2 recommended by NHS England: The Yorkshire Rehab Questionnaire. Newcastle Screening Tool (Appendix B). Some people (especially kids and older people) may not have the most commonly reported new or ongoing symptoms. Older people may experience a gradual decline, deconditioning, worsening frailty or dementia, or loss of interest in eating and drinking. Be aware that symptoms can change and fluctuate over time. If there are new cognitive symptoms, use a validated tool to assess them. They don’t advise on a specific one. People who have been discharged from hospital with COVID-19 should be followed up by a hospital physician after 6w. What investigations should we do in people with long Covid? If you are concerned about a condition that needs urgent management, then obviously deal with that (eg chest pain, severe hypoxia, signs of severe lung disease, or multisystem inflammatory disease in children). NICE advises that “no one set of investigations and tests would be suitable for everyone because of the wide range of symptoms and severity”. We can therefore use our clinical judgment in organising investigations. They give the following for us to ‘consider’ as investigations: Bloods ( FBC, UE, LFT, CRP, ferritin, BNP, TFT). CXR (if they haven’t already had one since being unwell). Exercise tolerance test. Three- or 10-minute active stand test. Exercise tolerance test NICE advises that there is no evidence over which tests are better. They have suggested the 1-minute sit to stand test. We should record their level of breathlessness, their heart rate and O2 sats. This will not be suitable for everyone (eg patients with chest pain or severe fatigue). NICE links to the following 1-minute sit-to-stand test which describes the test under the ‘methods’, then ‘1STST’ active stand tests. If the patient has postural symptoms (eg palpitations or dizziness) then do a 3-minute active stand test. This is basically doing a lying/standing BP and heart rate. The patient may have symptoms of postural tachycardia syndrome (POTS) or other autonomic symptoms. If you suspect, then do a 10-minute active stand test. This article from Clinical Medicine (see page 3, identifying autonomic dysfunction following COVID-19 infection) explains how to do a 3-minute active stand test. There is also information on doing a 10-minute active stand test on the POTS website. Who should we refer on? Obviously, refer on anyone with suspected severe illness. Patients with mental health problems should be referred on as you otherwise would do. Consider referring patients to a specific multidisciplinary assessment service for COVID-19 if there is one available in your area. This can be from 4w after the initial infection. NICE don’t give any specific advice as to who should be referred on for this service. What advice can we give to patients to help them self-manage their long Covid? The specific advice in this guideline is fairly sparse. Most of the information that patients will need is on the Your COVID Recovery website. This also has a section on when to seek further support. They suggest that when advising patients, we outline the following: Ways to self-manage, like setting realistic goals. Who to contact if they are worried or need support. Sources of advice and support (eg Your COVID Recovery social prescribers, support groups and online forums). No specific support groups or forums are advised. How to access support from other services (eg housing, financial etc) as appropriate. What should we expect a multidisciplinary assessment service to do? They should develop a personalised rehabilitation and management plan with the patient. This should include their goals and ways to manage their presenting symptoms. They should encourage patients to track their goals, their recovery and any changes in symptoms. This may involve using a tracking app (though no specific apps have been advised). How should we follow patients up? Among our normal follow up, consider supported self-monitoring at home (eg heart rate, BP and O2 sats). What symptoms may be part of long Covid? Well clearly this is a very long list, but NICE have outlined the following: Respiratory symptoms Breathlessness. Cough. Cardiovascular symptoms Chest tightness. Chest pain. Palpitations. Generalised symptoms Fatigue. Fever. Pain. Neurological symptoms Cognitive impairment (‘brain fog’, loss of concentration or memory issues). Headache. Sleep disturbance. Peripheral neuropathy symptoms (pins and needles and numbness). Dizziness. Delirium (in older populations). Gastrointestinal symptoms Abdominal pain. Nausea. Diarrhoea. Louise Hudman louisehudman@gmail.com
Online learning
A pragmatic approach to an illness we still know Very littLe about
Managing Long Covid in general practice
"Older people may experience a gradual decline, deconditioning, worsening frailty or dementia, or loss of interest in eating and drinking."
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Promises, promises
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