By Dr Jeannie Knapp, GP and Primary Health Care Improvement GP Adviser, North Western Melbourne Primary Health Network.
Patient numbers are down
The pandemic has created significant disruption and stress in our individual working environments and to the general practice sector as a whole.
Managers are overwhelmed by the need to implement rapid changes and source equipment. Clinicians are needing to quickly adapt to new technology and to manage a very different demand on our services. Support staff are swamped while they manage new processes and documentation.
Many clinics are reporting a significant financial downturn, which may suggest that patients who need routine medical care are not receiving it. Many patients are not attending because they fear that they may not be safe in a general practice environment. Staff and practitioners also feel anxious about the risks we might be exposing ourselves to.
Attending a medical appointment is one of only four allowable reasons to be out of your home during lockdown at present. The Victorian Department of Health and Human Services’ advice is that we should “encourage patients to continue to proactively manage chronic illnesses, take routine tests and attend health services”.
The rate of community transmission is currently quite low. Therefore, the risk to personal safety for a patient who chooses to leave their house and attend a medical appointment is also very low. In theory, this should mean the risk to ourselves and our staff is also very low.
While these are difficult and challenging times, the change will not be permanent. As the lockdown progresses, more people will decide their medical needs cannot be delayed. Eventually the pandemic will end and things will return to something like before – but with increased telehealth capacity!
Why it is important to provide face-to-face options for patients
It is important that patients continue to present to general practice for both routine and emergency care of their physical and mental health. While telehealth is a welcome addition to our toolkit, it is debatable whether it is as effective for providing clinical care as a face-to-face consultation.
The Federal Government has acknowledged the importance of continuing to provide face-to-face consultations by doubling the Practice Incentive Program Quality Improvement incentive payments to support face-to-face consultations. To be eligible to receive the double payment you must be open for face-to-face consultations for at least four hours per business day.
Mental health issues are almost certain to be a significant outcome of the lockdown. Anecdotal evidence from GPs who are performing face-to-face consultations suggests that patients are grateful for the opportunity and that the human contact is beneficial for their mental health. We’re human and seeing each other in the real world allows us to build trust and relationships with each other that you just can’t get down a phone line or through a screen.
Rates of family violence are unfortunately predicted to rise due to the enforced prolonged cohabitation many people face. A face-to-face consultation might be the only safe way for a victim to disclose the abuse and seek help.
There are some things that have to be done face-to-face and cannot wait until the lockdown ends. Examples include procedures to insert long-acting contraceptives, removal of suspicious lesions, some physical examinations and immunisations.
It is also important to remember our clinicians’ wellbeing when changing our approach to clinical care. Using new technology and developing new skills in such a short period of time can be very difficult for some clinicians. Many GPs enjoy seeing and spending time with their patients and some have reported finding it difficult to not see as many patients face-to-face.
It can be very lonely for GPs becoming disconnected from their patients, especially if they are working from home. Being able to retain a “business as usual” approach – or close to it – can have a positive effect on the mental health of clinicians.
Of course, I understand that for health reasons some clinicians will be unable to continue to provide the number of face-to-face consultations that they usually would.
When NOT to provide telehealth
The RACGP recommends that video or telephone consultations should generally not be used and arrangements made for an in-practice face-to-face consultation:
- For assessing patients with potentially serious, high-risk conditions requiring a physical examination, particularly for patients with chronic disease who are unable to self-monitor appropriately and patient groups deemed high risk for poor outcomes from COVID-19.
- When a physical/internal examination is required/cannot be deferred to support clinical decision making.
- Where a patient’s ability to communicate by telephone or video consultation is compromised and they do not have a support person to assist them during the consultation, impacting clinical quality and patient safety.
- In situations where there is any doubt about the clinical appropriateness of a telephone or video consultation (in these instances, attending the practice in person for a face-to-face consultation is preferable).
Providing safe face-to-face consultations for patients, ourselves and staff
Here are some suggestions to help you continue to provide safe face-to-face consultations. We welcome any comments and further suggestions: please email firstname.lastname@example.org with your tips.
- Advertise how you are making your clinic safe for patients to attend. You could use your website, social media, online booking platform or send an SMS or email.
- If you have doctors providing face-to-face consultations, let your patients know.
- Allow doctors and clinicians to have input into the level of face-to-face contact they feel comfortable with.
- Consider adopting a policy of not seeing anyone face-to-face who has any cold, flu or potential COVID-19 symptoms. This will be easier to manage for inner-city practices with easy access to testing facilities.
- Think of ways to screen patients if you do not wish to see any patients with potential cold, flu or COVID-19 symptoms. For example: post a notice on your online booking site or ask reception to screen patients when they book.
- If you are seeing patients who are unwell, consider having a fixed time of day to see these people when non-infected clients are on site. Ensure you have sufficient personal protective equipment (PPE).
- Post a notice on your front door asking patients not to enter if they have any cold, flu or potential COVID-19 symptoms.
- Some practices have chosen to screen all requests for appointments with telehealth as a first port of call. Please be mindful if doing this that the MBS items are explicitly described as not to be used for triage.
- Some practices with capacity are screening patients by telephone while they wait in the car park. It is not considered safe to treat patients in a car, especially when providing vaccinations.
- If you have them available, consider providing masks to all patients who present for a face-to-face consultation, as this may help your patients feel safe and confident to attend.
- Implement the 1.5 metre physical distancing requirements in waiting rooms, reception areas and consultation rooms. Do you have another space that you can use to expand your waiting area? Some practices are using carports and even tents.
- Consider arranging a sneeze screen for reception.
- Have hand sanitiser readily available and visible for patients to use.
- Telehealth during COVID-19
- RACGP – telehealth
- Financial assistance for general practice
- Victorian immunisation services factsheet (Word)
Please note: We updated this article on 7 May 2020 to make it clear that the advice to consider providing masks to all patients is not a clinical recommendation. It is something to consider if your practice has a surplus of masks only.