Adaptation in a crisis: will this change the face of General Practice forever?

Dr Benn Gooch, Health Education England Primary Care Fellow and GP Partner


March 11, 2020: I spent the morning seeing patients and making telephone calls, I had just finished a home visit and was heading off for my afternoon surgery when a BBC news notification appeared on my phone. The news flashed up that the World Health Organisation had officially classified the Covid-19 outbreak as a pandemic. What I didn’t know at the time was that this was the start of a period of unprecedented change for the NHS. My working day as a GP in Oxford would never look quite the same again.


In just a few short weeks, almost every aspect of how we deliver care in General Practice has changed. We’ve reinvented our patient pathways, with the introduction of “total triage”. This means that all triage is now done by telephone. We’ve also needed to drastically increase our use of video consultations and now only offer face-to-face consultation where clinically essential.


For some teams, implementing these necessary changes has been a steep mountain to climb. Luckily for me, my team at the Manor Surgery in Oxford were in a fortunate position as early adopters of a video consulting tool called Nye. This meant that when the new guidance was published in response to the COVID-19 outbreak, it was very easy for us to dramatically increase video consulting and continue to offer our patients the high-quality care, minimising the impact of these changes.





Besides video, Nye can also be used like a normal telephone, without a need for the patient to download anything. When using Nye for phone calls, I can use my computer “hands-free” and don’t have to manually dial patient numbers.


When we first started remote consulting, some of my patients were nervous about using video and some colleagues feared that it could exclude patients who did not have the technology it required. The fact that Nye offers secure telephone, as well as video, means that risk of exclusion is minimised as the minimum a patient requires is a landline or mobile telephone. As patients have become more familiar with remote calling though, I have found that they are also more comfortable with video calling and we have been able to offer it more regularly because the advantages are obvious to our patients.


Generally, I tend to initially contact patients using Nye’s telephone function. Making the calls is free and it can be done from anywhere, regardless of whether I’m at home or in the practice, so I find this suits me and my patients' needs best. If during the telephone assessment, I decide there is a need for a visual assessment, I simply end the call, and from the same web page, click the video icon. In the same way as the telephone call, the patient's phone rings, except that when the answer this time, Nye launches a video call rather than a telephone call.


One of the key skills in clinical medicine is the physical examination, which includes careful assessment for visual signs of illness or disease. Clearly, this is impossible over the phone but seeing a patient on-screen offers a wealth of clues about their current health status. Nye has given us a new way of assessing patients - in their own home. Seeing patients in this way gives a window into not just their personal health status but also their environment. Particularly with frail elderly patients, seeing the environment in their own homes is a very powerful tool for assessing functional status and without video it would be impossible to directly assess mobility, gait, neurological function etc.


I’ve also found Nye’s video function helpful for the assessment of skin problems. Unlike some other video calling systems I’ve tried, the Nye video feed has excellent resolution, allowing me to make those crucial visual assessments or see high-quality images. This also makes it useful for taking vital signs. Respiratory rate, capillary refill time and use of accessory muscle of respiration, can all be assessed via video, which couldn't be done over the phone. Video can be a helpful tool to support relatives as well. Under normal circumstances, discussions with relatives and loved ones around end-of-life care would be done in person. Now we can offer more personal and emotional support by video where appropriate.


Right across General Practice, there has been a sea change in our ways of working. Along with the introduction of total triage and video, a whole host of changes that we’ve talked about for years, have now been implemented at scale in a very short period of time - necessity is truly the mother of invention! Personally, I have been deeply affected by the ingenuity, resilience and professionalism which has been demonstrated by my colleagues in the past few weeks.


Using new tools under difficult circumstances has been a challenge for us all. Like with any innovation there are some eager early adopters. There are other clinicians though, who are anxious about the ramifications of so much innovation in such a short time. I strongly believe it is important to listen carefully to voices from both sides, particularly those who feel uneasy about the scale and rapidity of change. We must be mindful that we have had to adapt to a crisis, the likes of which has not been seen for 100 years. We will need to reflect and learn from our experience; no doubt profound lessons are yet to be learned. What is clear however, is that new tools have been powerful enablers for change. Personally, I am committed to using every available resource to care for my patients.


I’m thankful that tools like Nye exist as they have ensured that I have been able to continue to provide my patients with care during this difficult time. However, I do also look forward to the day when we can once again open our practice doors. This pandemic will end eventually and when it does, the NHS will look very different. The NHS is a resourceful and resilient organisation but we must recognize that these innovations have come from necessity in a time of crisis. I only hope that we can retain our willingness to adapt and innovate when we emerge from this pandemic.



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