Primary care updates (COVID-19)

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Update 32 - shielding changes, repurposing of medicines in care homes, updated SIGN guidance

National Update
Shielding Changes– Additional information attached on Shielding Patients and an FAQ 

Local Update
Repurposing of Medicines in Care Homes - please find attached guidance from our Pharmacy team.

National Update

SIGN Guidelines – link below to updated SIGN guidance.

https://www.sign.ac.uk/assets/covid19_assessment_of_covid19_in_primary_care.pdf

This is a review of available evidence, Key Findings are:

Symptoms, characteristics, comorbidities and clinical signs in adults which may indicate a higher risk of progression to severe disease:

  • The only symptom identified which may distinguish severe disease is shortness of breath/dyspnoea.
  • Characteristics which have been associated with severe disease are older age, male sex and Asian ethnicity. Older age is the strongest predictor.
  • Comorbidities/risk factors most associated with severe disease are hypertension, cardiovascular disease, diabetes, obesity, stroke, chronic pulmonary disease, chronic kidney disease and cancer.
  • No significant associations were found for chronic liver disease. Most studies have found no association between smoking and severe disease. There was no evidence of any association between steroids and immunosuppressant medication or angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor (AT1) antagonists but very few studies have investigated this.
  • No studies investigated the impact of socioeconomic status or frailty.
  • Clinical signs which have been found to be associated with severe disease are low oxygen saturation levels, low blood pressure and high respiratory rate. Of these, the strongest evidence relates to oxygen saturation levels.
  • The evidence base is too weak and emergent to make definitive recommendations.
Update 31 - Shielding Update, Social Support Information, Mobile Testing Facility, Distress Brief Intervention Service

National Update

Public Health Guidance
Please see a link to the most up to date guidance for primary care from Public Health Scotland, there are a number of updates and links in it which are new (noted on the version control cover page). Further health protection advice can be accessed via the coronavirus mailbox also noted below.

https://hpspubsrepo.blob.core.windows.net/hps-website/nss/2930/documents/1_covid-19-guidance-for-primary-care.pdf

HPSCORONAVIRUS (NHS NATIONAL SERVICES SCOTLAND) nss.hpscoronavirus@nhs.net

National Update

Shielding Update
Please find communication attached from the Chief Medical Officer updating on shielding arrangements for vulnerable patients.

Local Update

Social Support Information
Please find attached an information leaflet on support services available.  Further hard copies will be distributed to practices shortly.

Local Update

Mobile Testing Facility
Please find below details of the mobile testing locations for the next week. 

National Update

Early Access to Medicines Scheme for remdesivir in the treatment of COVID-19.
Please see attached details on implementation of the scheme and management of supply.

National Update

Distress Brief Intervention Service
On 14th April the First Minister announced that expansion across Scotland of the Distress Brief Intervention service (DBI) - www.dbi.scot.
This gives people over the age of 16 who are in emotional distress the opportunity to speak to a member of trained staff from a voluntary organisation background about their problems. Supervised contact is offered within 24 hours of referral for up to 2 weeks. The DBI worker provides compassionate listening and problem solving with the person in distress, involving family as appropriate. They can introduce the person to any additional necessary service and assist the person in making contact with those services. At the end of the contact the person creates a distress management plan to be shared with their GP, and any other service or person appropriate.
The DBI programme has already been operating since 2017 in 4 pilot areas - Inverness, Aberdeen, Lanarkshire, Borders and the Associate Programme area of Moray, with over 7,000 people receiving DBI support and has had a positive interim evaluation. It is not a substitute for existing services but is an addition. It provides rapid, sustained but brief support for anyone in distress who does not need an alternative emergency service thereby reducing demand on primary care and other front line services. In the 5 current areas referrals to DBI come direct from primary care, emergency departments, police and ambulance services and this will continue. For the first time the National extension takes referrals through NHS24 Mental Health Hub direct to DBI in the 5 current sites since 13th May and from across the whole of Scotland from 8th June.
The DBI programme is keen for your members to know about it, given that GPs will be notified by NHS24 when a referral is made to DBI and will receive notification from the DBI service about the outcome of referral.
If you would like more information www.dbi.scot contains good information and the national programme manager is Kevin O'Neill at NHS Lanarkshire, who can be contacted via the DBI Central Team: DBIcentral@lanarkshire.scot.nhs.uk.

National Update

Covid Update to Primary Care
June update from Scottish Government attached for information.

Update 30 - PPE gloves, Near Me, Single use visors, Coaching for Wellbeing

Local Update (North Highland only)
PPE (Gloves) – Stores have a small supply of LARGE and SMALL gloves. If any practice requires a supply of these gloves, please contact Aileen, on aileen.cuthbert@nhs.net

National Update
NEAR Me in the “new normal” health and care service – please find attached information from Clare Morrison (National Near Me Lead, TEC Programme)

National Update
HPS Guidance – PPE statement regarding use of visors - single/sessional use – see attached information from Charlotte Leggat.

National Update
SIGN publication
Assessment of COVID-19 in primary care: the identification of symptoms, characteristics, co-morbidities and clinical signs in adults which may indicate a higher risk of progression to severe disease

Published 7 May 2020
Since the outbreak of coronavirus, there has been an abundance of rapid and systematic reviews published on the diagnosis and management of people with symptoms of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), known as COVID-19, mostly from a secondary care (hospital) perspective. The challenge for primary care practitioners is to identify and triage patients presenting with potential COVID-19, a disease in which the pattern and duration of symptoms is heterogeneous.

SIGN and researchers in primary care at the University of Glasgow have produced a rapid review of evidence of prognostic indicators, risk factors and clinical measures to identify people self-managing symptoms of COVID-19 in the community whose symptoms may change or worsen, and therefore may require monitoring or clinical intervention after their initial presentation to primary care.

This advice complements the Scottish Government’s COVID-19 Scottish Primary Care Hub Triage Guide, and aims to provide further information on prognosis of patients with COVID-19 who present in primary care with mild-to-moderate disease.

While the evidence base is not yet robust enough to support evidence-based recommendations, key findings are presented. Evidence in this area will be monitored every two months and the review will be updated when new, more definitive evidence is available.

The review is available on the SIGN website

National Update
Coaching for Wellbeing – a digital coaching service for all health and social care staff (OFFICIAL) Health and Social Care Scotland – see attached

From Monday 11 May, a free online service offers two options for online coaching for wellbeing. Both are designed to support staff with issues they may be facing during these challenging times. Experienced coaches will support them in building resilience and improving wellbeing and if they lead others there will be space to explore how they support their staff too.

The service is for all staff and whichever option they choose, coaching will help bring new ways of understanding themselves and their situation, clarity as to how they can play to their strengths and further strategies for staying on track.

https://www.knowyoumore.com/wellbeingcoaching/
Please share across your networks to enable workers in health and social care services to access this newly created resource.

National Update
COVID-19 Therapeutic Alert – Early Access to Medicines Scheme (EAMS) for Remdesivir in the treatment of COVID-19. Implementation of the scheme and management of supply – see attached

National Update
CMO Letter – COVID-19 Therapeutic Alert – Implementation of Early Access to Medicines Scheme for Remdesivir in the Treatment of COVID-19 – see attached

Update 29 - MOD Mobile Testing Facility, GP Practice Additional Funding, Death Certification

Attached is a letter which details the next stage of the NHS response to COVID 19. I encourage you to read it as it sets the scene well but, as expected, primary care features strongly here, recognising the essential role you have in our health system. Before making any decisions we wanted to both understand your status, and also take in your views and ideas as we move into this next stage. Perhaps now more than ever we have an opportunity to rethink some of our perennial conundrums and make leaps that have been too disruptive in the past.

Below is a link to a short survey, which is closely tied to the clinical priorities for primary care, as outlined in the letter. We have asked you to indicate, via a RAG status, your readiness to move forward on these priorities, and also given space for you to describe how some of these services might be provided differently. In addition to those areas outlined in the letter, we have asked about your readiness with regard to some of the specific operational practices outlined by Dr Davidson in his update of 20th May. We have also asked you to give a view on what the board’s clinical priorities should be in the next phase, or if those listed in the letter should be different for Highland.

I have also attached a checklist that may be helpful in your thinking about how to operationally prepare for the coming months. It is for your own internal use. We are learning together on what these months look like, and further feedback on what support would be most useful would be welcomed.

Your insight and ideas are gratefully received.

https://forms.office.com/Pages/ResponsePage.aspx?id=veDvEDCgykuAnLXmdF5Jmmo0qPmfcJJBkI_HtWmzApxUMkIxOTNGUUFUSUxTRjU1T1c3QzYySldZVS4u

Local Update

MOD Mobile Testing Facility – for information, please see below for the locations where the mobile testing unit will be deployed during the next week.

National Update

GP Practice Additional Funding – please find attached letter from SG around the additional funding allocated to General Practice to support Covid-19.

National Update

Updated Guidance to Medical Practitioners for Death Certification during the COVID-19 Pandemic – updated guidance attached from the Chief Medical Officer attached.

Update 28 - Change in Case Definition, Multi-professional Oversight, Disposal of Recalled Eye Goggles Care Homes

National Update

Change in Case Definition Covid-19 – updated guidance attached from Scottish Government regarding case definition for Covid-19.

National Update

Multi-professional Oversight Care Homesattached communication from Cabinet Secretary on updated guidance.

Local Update

Public Health/HPS Update – updated below from Dr Jenny Wares

‘Contact tracing, in conjunction with other measures, will form an integral part of the outbreak response going forwards as the identification and management of COVID-19 contacts enables the rapid identification of secondary cases which provides an opportunity to intervene promptly to interrupt further onward transmission and minimise the risk of further cases. Contact tracing also enables a better understanding of disease transmission and provides supporting evidence for the decision making around the use of control measures.

Although contact tracing is a core function of health protection teams across Scotland, the demands of the COVID-19 outbreak will exceed this capacity. As such, NHS Boards have been tasked with developing interim solutions for growing and strengthening the local contact tracing function to build capacity at a local level over the next two to three months whilst a national contact tracing service is being developed. Support for this will be needed on a temporary basis from other departments and services within NHS Highland but also out with the NHS. Support in principle has been offered from a number of departments and formalising this is in motion. Modelling the potential case numbers is very challenging given the uncertainties around the impact of any easing of the lockdown and the implications of expanded testing strategies. However, we would plan to build the service iteratively to best meet the current demand.

A digital tool has been developed which will enable local teams to have an oversight of the cases and contacts and associated work activity in order to support the contact tracing work. However, this tool is not a surveillance app (proximity tracker) nor a symptom tracker and thus differs to other apps being used to support contact tracing.  

With respect to timeframes, contact tracing will be implemented across Scotland from the week commencing Monday 25th May. However NHS Highland, in conjunction with two other boards, is supporting the piloting of the contact tracing process, the associated training and guidance materials plus the digital tool over the course of this week. The materials and process will then be refined based on the feedback gathered during the pilot phase.

As detailed, a national contact tracing function will be implemented in due course and the plans for this are also being progressed.’

National Update

Disposal of Recalled Eye Goggles – please see attached update on the local disposal of  recalled eye goggles.

Update 27 - Local Updates: Admission & Testing Flowchart for the over 70's, ECHO, PPE, CPAP, BiPAP, National Updates: EAVE-2 extracts, Staff death notificiation

Local Update

Admission & Testing Flowchart for Covid Testing in over 70’s in NHS Highland hospitals – In line with Scottish Government Policy we will be testing all admissions over 70 for SARS CoV-2, the attached flow chart should help with patient placement whilst the test result is awaited. If your patient has no Covid-19 symptoms we are screening and the patient should be treated as a “green“ pathway patient until the result is available. If the patient has new respiratory symptoms, fever, or worsening of the a pre-existing respiratory condition; a frailty score over 5 and delirium; or frailty score over 5 and no obvious non Covid diagnosis; or is from a nursing home, test the patient and place on the red pathway until the test result is known.  Current guidance is to also screen every 4 days during an admission.  

Local Update

ECHO Training Sessions – Please note the link for Echo training which is arranged via the Highland Hospice https://highlandhospice.org/what-we-do/education-learning-development/project-echo/echo-form

There are frequent sessions for Remote & Rural GPs and a regular GP session each week.  For anyone wishing to upskill for end of life care, there are regular sessions on difficult conversations.

People wishing to join the sessions need to register using this link and complete the form and select OOH Echo for a Friday 3.30pm invitation.  This needs to be done in advance and the invite with a link will be sent to them on the day by email.  The meeting links should not be shared as participants are required to register individually.

Local Update

PPE Visorsattached is information on sessional use of PPE and cleaning of reusable PPE.

Local Update

CPAP/BiPAP – The Primary Care Guidance provides advice on home visiting for GPs https://hpspubsrepo.blob.core.windows.net/hps-website/nss/2930/documents/1_covid-19-guidance-for-primary-care.pdf

Primary care staff should avoid visiting patients who are on CPAP or BiPAP at home.  GPs should consider phone consultations in the first instance to assess whether the patient requires a home visit.  If it is safe to postpone the visit until symptoms have resolved, then do so.

If a home visit cannot be avoided:

  • Find out what time the patient is on CPAP/BiPAP and plan visit for at least an hour or more after the CPAP or BiPAP has been switched off.
  • Ask the patient to move to another room in the property and close the door to the room where the CPAP or BiPAP is undertaken.
  • If the visit must take place when the patient is on the CPAP/BiPAP or if the above measures cannot be followed, the practitioner must wear AGP PPE in line with table 2: performing an AGP.
  • If the practitioner is not fit tested for an FFP mask, the patient will require admission to hospital for assessment. Alert the ambulance that the patient is a suspected/confirmed COVID-19 requiring CPAP/BiPAP.

National Update

GP Extracts During Covid-19 – an update attached on data extraction from General Practice to support the EAVE-2 research project.

National Update

Notification of Suspected Covid-19 Related Staff Deathsattached is revised reporting arrangements from Scottish Government for notifying any suspected Coronavirus (COVID-19) related staff deaths.

Update 26 - Resilience webex, PPE recall (Tiger eye protectors), Scottish Government updates: Shielding, Community care, Nursing home and residential care, Novel clinical trials

General Practice Resilience Webex – details of a Webex to take place on 13 May 2020 (1.30pm-2.30pm) of relevance to practice managers. See attached flyer

PPE Recall (Tiger Eye Protectors) – attached is national recall of Tiger Eye Protectors with the relevant batch numbers.  Additional PPE deliveries will be distributed to practices later this week which will include a supply of visors.

Scottish Government Update – Shielding Information for GPs

Please find attached an update to general practice from the Chief Medical Officer on shielding of the clinically highest risk patients updating GPs on:

  • People receiving renal dialysis treatment
  • People who have had their spleens removed
  • Identification of additional patients for shielding
  • People incorrectly identified for shielding
  • Coding
  • Audits in Vision
  • ESCRO Shielding reports
  • Updates to GP records systems

Scottish Government Update – Shielding Information to Secondary Care

Please see attached two documents:

  • An update on new categories of patients for inclusion for shielding (aimed at hospital clinicians but of relevance to GPs for information)
  • New version of the CMO’s letter which GP practices or secondary care departments can use if they wish to write to patients before a letter is issued centrally.   The new version refers to shielding until at least 18 June (instead of at least 12 weeks) and the annex has been updated to reflect the current conditions and diseases which the CMO advises for shielding.

Scottish Government Update - Guidance for Community Covid-19 Related Care

Scottish Government Update - Guidance for Nursing Home and Residential Care Residents

Scottish Government Update - Novel Clinical Trials Covid-19

Update 25 - Samples, HPS guidance: paediatric multisystem inflammatory syndrome, HPS guidance: Care Home and testing

Updated Local Guidance

Advice for Collecting Samples in Primary Care during the COVID-19 Pandemic – attached is important advice from NHS Highland Blood Sciences about blood samples in primary care.  Please note that there is a shortage of UN3373 compliant containers which we are urgently addressing.  At present there is a limited supply that will be distributed to practices until our additional supplies become available.  We will update on distribution in the next few days.  In the meantime, please note Practices should only be sending urgent samples only and priority still needs to sit with Covid testing of respiratory specimens.

Updated HPS Guidance

Paediatric multisystem inflammatory syndrome temporally associated with COVID-19attached briefing note from HPS providing information on important developments around paediatric multisystem inflammatory syndrome.

Updated HPS guidance

Care Homes & Testing - please see link to updated HPS guidance on care homes which was updated on 1 May to take account of new testing requirements.

COVID-19 - Information and guidance for care home settings

https://hpspubsrepo.blob.core.windows.net/hps-website/nss/2980/documents/1_covid-19-information-and-guidance-for-care-homes.pdf

https://hpspubsrepo.blob.core.windows.net/hps-website/nss/3046/documents/1_COVID-19-guidance-domiciliary-care.pdf

https://hpspubsrepo.blob.core.windows.net/hps-website/nss/3045/documents/1_COVID-19-Guidance-Social-Community-Residential-Care.pdf

COVID-19 - guidance for Health Protection Teams (HPTs)

Update 24 - Haematology patient shielding, Transport Service, Police Scotland

Shielding Patients with Haematology Conditions – please see attached local update from the Haematology Department.

Transport Service North Highland (8 May 2020) – please note that there will be the usual transport service operational on 8 May 202 which will include delivery of PPE supplies to practices.

Police Scotland Firearms Licensing temporary measures for COVID-19 - Police Scotland have reviewed their COVID-19 interim processes with regard to the grant and renewal of firearms applications.  They continue to accept a minimal amount of new grant applications for Firearms and Shotguns and are processing only those for essential employment purposes.  They are progressing all renewal enquiries and would seek to contact local GP practices where necessary.  Where practices have capacity to complete the GP response form, Police Scotland would appreciate if they could continue to do so.  This will enable Police Scotland to manage this process without retrospective enquiry with GPs and support GP practices post COVID-19 by reducing the backlog that will develop.  Individual participation is at the practice’s discretion.  If you are unable to complete the requested GP response form at this time, arrangements will be made to follow up in the future.

GPs should continue to contact Firearms Licensing where they identify any concerns in respect of their patients.  Firearms Licensing continues to be a critical function for Police Scotland at this time.

Update 23 - Financial entitlement statement, Practice additional Funding payments, Childhood immunisation DES directions 2020. Patient registration

Statement of Financial Entitlement 2020/21 – please find attached details of the update to the SFE.

Practice Additional Funding Payments – attached are details of the claim process for the additional funding passed to practices in relation to Covid additional expenses. 

Please note the deadline for submission of claim forms which should be returned to your Primary Care Manager before the deadline expires. 
General Practice Additional Costs related to COVID19 Reimbursement form
General Practice Additional Costs related to COVID19 Reimbursement total costs form

Childhood Immunisation Scheme DES Directions 2020 -  update attached from Scottish Government in relation to the childhood immunisation DES.

Patient Registration   We are aware that over the last few weeks, Primary Care Support has had a number of queries from GP practices and patients about patient registration, and it may be useful therefore just to clarify the current position during the Covid-19 pandemic as we understand it.

The contractual obligation to accept new registrations still stands;  should a patient wish to register with you, and you do not have a closed list, you must accept them unless you have reasonable grounds to refuse which do not relate to the patient’s race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition. The regulations state that it would be reasonable to refuse a patient who lives out with your practice catchment area and Scottish Government recently stated that during the Covid-19 pandemic, it would be reasonable to refuse to register a patient who is already currently registered with a local GP practice within your catchment area.

It is important that you continue to register new babies and families of registered patients, noting that you must accept immediate family members of a registered patient even if your list is closed. Patients who move into nursing or care homes in your catchment area should also continue to be registered as before.

In the current situation where practices are taking steps to reduce footfall in the surgery, Practitioner Services, through Primary Care Support, have confirmed that registration forms can be submitted by post or email to surgeries or details can be taken over the phone. This allows patients to access registration with a practice with arrangements being made to sign registration forms later. There is no need to physically see a patient before accepting application to register and the new patient appointment required does not need to take place before 6 months from date of registration.

It is hoped that by taking these steps practices can continue to take steps to reduce footfall whilst ensuring that patients have access to registering with a GP.  Please remember that if you do have reasonable grounds to refuse to accept a patient, you must write to them within 14 days of receiving their application explaining the reason why.

Please do not hesitate to contact your Primary Care Managers if you have any queries.

Update 22 - May PH, Registration of babies

May Public Holidaysattached is a letter confirming the position that GP Practices will be remaining open during the May public holidays.

Registration of Babies – a few queries have been received about registration of babies.  We have confirmed with PSD that there is no system or process issue with GPs registering patients even though the birth has not been registered by GRO/NRS.  Often there are timing issues where the NHS number and the GRO/NRS birth registration are not linked immediately, but this will be picked up through the registration QA process and will eventually resolve itself. 

Update 21 – Immunisation Toolkit

Basics Responders & PPE - all Basics responders were sent a questionnaire a few weeks ago from Basics Scotland about responding and PPE.  This informed a piece of work with SAS to compile a list of those who:

  • Had full FFP3 PPE and who were prepared to respond to cardiac arrest/AGP
  • Had droplet PPE and were happy to respond to calls other than cardiac arrest
  • Didn’t want to respond during Covid 19 (tracking devices have been temporarily disabled to minimise costs while they can’t respond)

Basics Scotland are still working with SAS to firm up the way of tasking for these two groups as the usual algorithm has to be changed. The Sandpiper Trust (and SAS) are working to procure PPE and to face fit individuals.

Lorna Duff, Basics Scotland (lduff@basics-scotland.org.uk) is more than happy for individuals to contact her direct if they are concerned that they didn’t answer the questionnaire, or if, as a Basics responder, they have any other questions about responding just now.  Lorna is also happy to discuss PPE provision with any individual.

NHS Highland will also assist with provision of higher level PPE for this group.

Immunisation Toolkit – details of updated toolkit promoting immunisations during the Covid pandemic are found here.

Accessing Psychological Support – please note that a new resource has been set up to support staff experiencing psychological distress during the Covid pandemic.  This service is available to all GP Practice staff.  The phone helpline is available between 9.00am and 5.00 pm but people can leave messages out of these hours and they will be called back the next day between 9.00 am and 5.00pm. The email is available 24/7 but again will only be responded to between 9.00am and 5.00pm.  The email helpline is - high-uhb.covid19staffsupport@nhs.net and the telephone helpline is 01463 704683.

Update 20 – Shielding, Person-centred Care, Housebound patients in Community COVID Assessment Pathway

Shielding - a video resource has been produced by HIS to help the public understand why their GP practice may be phoning them to discuss aspects of anticipatory care planning.   The 3 minute video explains what anticipatory care planning is, and why it is important.  This may be useful for GP practices to use on their website or to share with their practice population. http://www.healthcareimprovementscotland.org/our_work/coronavirus_covid-19/care_planning_conversations.aspx

See also shielding advice on TAM

Person-centred Care – Healthcare Improvement Scotland has developed a single source of information to share inspiring examples of person-centred care during the pandemic: https://ihub.scot/person-centred-communication-covid19

Practices are encouraged to share examples by email to: hcis.personcentredscot@nhs.net, and tag us on twitter @online_his using #C19carescot.

Message from GP Sub and NHS Highland - Housebound patients in Community Covid Assessment Pathway - All patients or carers must call 111 if they wish to discuss symptoms they are concerned about in a suspected Covid illness. NHS24 will triage this call and, if it cannot be resolved on that call, it will be passed to the Highland Covid Advice GP for a telephone consultation. If this doctor feels that the patient warrants further assessment and deems that they are housebound by virtue of their clinical circumstance, they will not be asked to travel.

Where this situation arises in normal working hours the doctor will liaise with the patient’s registered practice, or a practice serving the area where the patient is located. A clinical handover will occur, and the practice may decide to retriage based on their knowledge of the patient.

If contact occurs during the out of hours period, the patient will be referred to the local PCEC. These patients would not be transported to the Covid Assessment Centres.

It is likely that the majority of care home patients will be considered housebound. However, if they are able to go out and do indeed go out of the care home then it may be reasonable for them to attend the Covid Assessment Centre. 

Media Message ‘The NHS is Open’attached is details of a media campaign which will be running promoting the NHS to be open.  Practices are asked to update their websites with this information to share with patients.

NHS Highland Epidemiology Report – attached updated from Public Health.

Update 19 – Resus Guidance TAM, Covid 19 Communication for People with sensory loss, Consolidated Guidance on Shielding

Resus Guidance - update on TAM on resus guidance available on the following link.

Covid-19 Communication for People with Sensory Loss – updated guidance from NHS Inform: https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/coronavirus-covid-19

Community Optometry – during the Covid-19 pandemic, community optometry practices will continue to provide a telephone triage and consultation service for essential and emergency eye care.

Emergency Eyecare Treatment Centres (EETCs) have been established across Scotland to provide face-to-face emergency eye care services to patients who have had a prior telephone triage or consultation with an optometrist, and who have been assessed as not experiencing Covid-19 symptoms. The EETCs may be Community Optometry Practices or Hospital Eye Service Departments (Hospital Eye Clinics).

Optometrists referring a patient to an EETC must do so following the relevant local EETC pathway and protocol. This is particularly important as the nearest EETC to the patient’s location may be in a different NHS Board to the referring community optometry practice.

Patients experiencing an emergency eye problem, are worried about their vision or have problems with their glasses or contact lenses must phone a local community optometry practice (optician) and discuss their situation with them. A list of community optometry practices and contact details can be found on the NHS Inform Website.

Furlough of Practice Staff – we have received a few queries recently around practices furloughing staff and have sought advice from Scottish Government.  The advice is that there is no need for practices to furlough staff.   Practices not only continue to have their income protected they have now received, and will continue to receive, additional funding for Covid-19 related additional expenditure.  It is therefore not appropriate that any practice furloughs any member of their staff due to Covid-19.  Furloughing is only available to those businesses/organisations that meet the UK government criteria, General Practice is not one of the businesses that meets this criteria.

For any member of practice staff who has received a shielding letter, this member of staff’s original terms and conditions should be maintained and not reduced, this is in line with the Scottish Government funding protection for General Practice and the new agreement to cover additional costs linked to Covid-19.  If you have any queries please do not hesitate to contact your Primary Care Manager.

Update 18 – Conservation of End of Life Care Medicines, Care Home Flow Chart, DVLA D4 Medicals, Medical Certificate of Cause of Death (MCCD), Shielding

Advice Note to Primary Care: Conservation of End of Life Care Medicinesattached advice note from pharmacy colleagues.

Care Home Flow Chart – See TAM

DVLA D4 Medicals – please see link below to latest advice from UK Government advising:

  • Temporary removal of the routine D4 medical for bus and lorry drivers to renew their driving licence.
  • As long as they are fit to drive, applicants will be able to apply for a 1-year licence without the need to provide further medical evidence.

https://www.gov.uk/government/news/government-takes-further-action-to-support-bus-and-lorry-drivers-who-are-keeping-the-country-moving?utm_source=35d75bc9-0288-4d4c-9a75-df0f0669d9e2&utm_medium=email&utm_campaign=govuk-notifications&utm_content=immediate

Medical Certificate of Cause of Death (MCCD)attached is letter from Chief Medical Officer around timely notification of deaths during Covid-19.

Shielding Advice: see TAM

Update 17 – End of Life Care, Modified DMARD monitoring requirement during Covid 19 pandemic, Gp Support for Care Homes

Practice Red Room Work-around Update (Dr Stewart MacPherson) - You will have received notification to your practices (Monday 13th April 2020 @12.49) that an upgrade to Docman collection of Covid Assement Hub reports has been successful therefore practices will now receive information on an hourly basis through Docman asking to review one of your patients that has been triaged through the Covid Hub. These patients will have presented with symptoms that on balance the GP triage assessor believes are more likely to be of a non-Covid origin (although the possibility of Covid 19 still exists). The patient will be expecting a phone call from the practice to discuss their case and arrange for the patient to be seen in the red room if the practice believes this is necessary.

End of Life Care – please find details here of a short life working group that has been formed, please feedback comments on this important piece of work to Lorien.cameron-ross@nhs.net

Important New Information
Modified DMARD monitoring requirement during COVID 19 pandemic - patients on DMARDs are often high risk for infection and reducing contact for their safety is vital. Additionally DMARD monitoring takes resources which may be needed elsewhere. The Highland TAM app/portal now has very clear updated guidance on monitoring of patients on DMARDs during this pandemic. The direct link is - https://tam.nhsh.scot/home/covid-19-coronavirus/dmard-monitoring-during-covid-19/. There is a section on the TAM called 'COVID-19 (coronavirus)'. There are several important and useful updates in this from various specialties, including this one. It is well worth looking at.

GP Support for Care Homes – attached is guidance issued from Scottish Government around support for care homes and Care Home support Q & A

Scottish Government Update to Primary Careattached is a revised version of the update from the Scottish Government Primary Care Policy Division (Primary Care)

 “Please note this attached revised version of the Primary Care Update issued on 10 April 2020. This corrects two errors in the Personal Protective Equipment section:

 A phone number included and described as being for GPs and Social Care to escalate PPE issues has been removed as it is only for Social Care workers.

  • The email address for helping escalate PPE issues directly to NSS was missing a hyphen and this has been corrected.

We have also revised the section on Cardiac Arrest Guidance. The previous version contained specific reference to PPE equipment referred to in the HPS guidance. HPS continually review the latest evidence for all of its guidance and so our referring to specific equipment in this update risks causing confusion should HPS release updated guidance at a later date. We have therefore removed any reference to specific PPE equipment. Please refer to Health Protection Scotland for the latest clinical guidance.

 We apologise for any confusion or inconvenience these errors may have caused.”

Update 16 - Epidemiology Report, Information if you are a patient or carer, Mental Health Pharmacy Clinical Advice Service

NHS Highland Epidemiology Report 14 April 2020attached is latest epidemiology report from Public Health.

Covid-19 (Coronavirus) and Carer: Information if you are a patient or carer - please find attached an updated communication from Scottish Government for people living with cancer or caring for someone with cancer.

Mental Health Pharmacy Clinical Advice Service – Please note that the New Craigs Pharmacy Clinical Advice Service remains unchanged and can be accessed through by email High-UHB.pharmacydepartmentnewcraigshospital@nhs.net. This is reviewed during normal working hours with a response time standard of 1 working day and can sometimes prevent or divert referrals which may otherwise have gone to generic teams. Alternatively, the telephone contact number is 01463 704663.

Update 15 – Shielding, Anticipatory Care Planning

Further guidance and letter regarding Shielding from Interim CMO and Deputy First Minister – addition to previous guidance.
Patient letter: Update on Keeping safe from coronavirus
Patient letter: Important advice to keep you safe from coronavirus
Clinician FAQs on shielding
Local Authority contacts on shielding

Update from Scottish Governmentattached is a weekly update from the SG Primary Care Team.

Anticipatory Care Planningattached is template from SG Primary Care Team to support anticipatory care planning for patients under Shielding arrangements.

Supplies of PPE to Care Homes – some practices have been contacting Public Health direct in relation to supplies of PPE in care homes.  Colleagues from our Adult Social Services Division undertake a daily telephone call to all providers daily which allows them the opportunity to raise any concerns.  There is also a 7-day helpline available for providers which is a dedicated number for in-house or independent sector care home managers/seniors to contact with any COVID-19 related issues or concerns relating to provision of care home services for older people. 

PETAL Support – attached are details and a  leaflet of a bereavement counselling and support service.

Remote Consulting Red Whale guide, helpful tips if not already seen.

Update 14 – Immunisations

Immunisation Programmesattached is guidance from Scottish Government around the Scottish immunisation programme during Covid-19.

GPs 4 GPs - colleagues are reminded at this time of increased stress, that a confidential GP service is available for GPs and their families where discussion with the routine GP is not appropriate or desired.  This is a longstanding service and Dr Jane Munro is very experienced in supporting GPs through times of difficulty.  Jane can be contacted in confidence by email: jmunro5@nhs.net

GP Registration Cards - Access to Healthcare cards were developed last year by SG colleagues and Scottish Public Health Network.  They were designed to help the more vulnerable groups such as Gypsy/Travellers, people experiencing homelessness and New Scots when registering with a new GP practice.  They are also of help to GP practice reception staff as they set out an individual’s rights to healthcare in Scotland.  They also provide contact information for NHS Inform and the Patient Advice and Support Service.  These cards which can be downloaded from the Health Literacy Place.

NHS24 Response Times - NHS 24 have modified their staffing and working processes to support the 111 COVID19 clinical advice line. The volume of calls to 111 has been over 5000 daily. Over the course of 10 days NHS 24 staff have reduced call back times from 90 minutes to 38 seconds yesterday and now have over 100 staff dedicated to this task.

 

Update 13 – Covid-19 Ethical Advice and Support Framerwork, Covid-19 Clinical Advice, Gypsy Travellers

Covid-19 Ethical Advice and Support Framework attached is guidance from Scottish Government on ethics and support.

Covid-19 Clinical Adviceattached is latest guidance on clinical advice from Scottish Government.

Guidance for Stakeholders - please see link below to the new Guidance for Stakeholders which was published on the Scottish Government website: https://www.gov.scot/publications/coronavirus-covid-19-guidance-for-stakeholders-on-the-coronavirus-scotland-act-2020/

Clinical Negligence Cover – please see attached from the Cabinet Secretary in relation to provision of indemnity for all Covid-19 related work.

Gypsy/Travellers – please find link to the framework to support Gypsy/Travellers in relation to COVID-19: https://www.gov.scot/publications/coronavirus-covid-19-supporting-gypsy-traveller-communities/

Primary Care Dental Services Update (during the COVID outbreak) - all General Dental Practices and NHS Highland Public Dental Service (PDS) clinics are now closed for patient treatment. However, General Dental Practices will provide triage of urgent cases by telephone during office hours. Patients should contact their registered GDP. The NHSH Dental Helpline continues to provide triage of PDS patients and unregistered dental patients during office hours. Urgent Dental Care Centres (UDCC) have been set up at the Centre for Health Science (Inverness), Fort William (M&S Dental Practice), Portree Dental Clinic and Lochshell Dental Clinic (Wick) to treat asymptomatic patients. A further dental centre, for the treatment of symptomatic patients and patients requiring Aerosol Generating Procedures has been set up at the Abban Street Clinic (Inverness). Clinics open 7 days a week during office hours. These clinics are now staffed and operational. NHS 24 continue to triage urgent dental cases out of hours.
Medical colleagues requiring dental advice:
In-hours(weekdays) - contact the NHSH dental helpline on 0845 6442271
In-hours (weekends) - contact the NHSH OOH Dental Team on 01463 255230
Current arrangements may change at short notice and any change will be communicated.

Update 12 – Prudent Prescribing of End of Life Care Medication, Shielding, Electronic Transfer of Medical Certificates of Cause of Death, Referrals to Gastroenterology

Update from Public Health

Dear colleagues,

Hope this finds you well and thank you so much for everything you are doing at the current time. I appreciate that you are already getting a significant number of updates but please find an update from the HPT on the situation across Highland, national developments and some information related to care homes.

Health Protection Update:

  • To date across Highland, we have had a total of 102 confirmed COVID-19 cases. Approximately 42% of the cases have been residents of Argyll & Bute which likely reflects the fact that transmission in A&B more closely reflects that of the central belt (A&B population = 86,260; 27% NHS Highland board area) . The incidence rate for NHS Highland is around half that of the Scottish incidence.
  • We have a number of clusters identified as detailed within the attached mapping document that has kindly been pulled together by the health intelligence team. We will aim to get this circulated more regularly now although we are not planning to put this in the public domain as the whole population is at risk and we have concerns that identifying ‘hotspots’ provides false reassurance around the risk of COVID-19 for communities not designated as hotspots. The population as a whole needs to be following the national advice with respect to household isolation and social distancing regardless of where they live. As you will be aware, the lockdown began on Monday 23rd March and so today is the 14th day since the lockdown was introduced and, as such, the coming week will be key to better understanding any early impacts of the measure in light of the incubation period and the time prior to presentation.
  • We are really keen to get your local intelligence with respect to the situation locally and so please do get in touch if you have any concerns.
  • There is increasing recognition of the wider health and wellbeing impacts of the COVID-19 outbreak and a social mitigation cell has been convened within the public health department to mitigate impacts on mental health, alcohol and drug misuse for example.

Care Homes:

  • As detailed in the attached letter, we are now receiving an increasing number of COVID-19 confirmed and suspected cases in closed community settings such as care homes and hostels as the virus is now circulating widely in the community. To date, we have had one confirmed COVID-19 outbreak in a care home and sampling from four others has been negative. To date, we have had 19 care homes under surveillance although only 6 are currently under active surveillance.  
  • The letter provides more information with respect to the management of care homes. As per the attached, we would be grateful if you could kindly contact us in the event of concerns of illness in a closed community setting please. In keeping with other infections such as influenza, frail older people may not have the typical COVID-19 symptoms of cough or fever. As detailed within the good practice guide from the British Geriatrics Society, COVID-19 can present with non-respiratory presentations such as new onset/worsening confusion, diarrhoea or falls and care home staff are well placed to recognise subtle signs of deterioration in their residents. If you are asked to clinically assess a suspected case or cluster of respiratory illness/illness in a closed community setting such as a care home we would be grateful if you could kindly notify the health protection team on 01463 704886 please. We will then follow up with the care home to provide Infection Prevention and Control advice, monitor the progress of the outbreak and offer advice regarding any other control measures that may be required.
  • Although the majority of Care Homes in NHS Highland are linked with the Health Protection Team for advice in relation to communicable diseases, there are also 12 care homes directly managed by NHS Highland and advice for these care homes is obtained from the Community Infection Prevention and Control nurses. More information re this is available in the letter.

National Update:

  • There are now 3,706 confirmed cases across Scotland and 220 deaths.
  • The issue of the need for modelling data to be available nationally to enable better preparedness has been emphasised to SG colleagues. We have been advised that the forecasting depends on the compliance with the social distancing measures and that there is considerable uncertainty in the estimates which is why there is reluctance to release information around this but we believe that this is forthcoming.
  • The death reporting process is changing and going forwards the data will be taken directly from NRS. There will be a significant increase in the number of deaths reported going forwards as a result given the death reporting will include deaths in suspected COVID-19 cases in addition to deaths in laboratory confirmed cases.  
  • The JCVI will be releasing a statement regarding the deprioritisation of some current vaccination programmes including a postponement of many of the adult and teenage programmes. Childhood immunisation programmes, in addition to pertussis vaccination for pregnant women, will continue as normal though and further communication is awaited re this.

From: Consultant in Public Health Medicine (Health Protection)

Prudent Prescribing of End of Life Care Medication – please find attached update from Jackie Agnew, Head of Community Pharmacy Services & CD Governance around stock of end

Shielding attached is information on local assessment centres to support people shielding for a 12-week period at home across North Highland and Argyll & Bute.

Electronic Transfer of Medical Certificates of Cause of Death (MCCD) from Health Services to Registrars and Next of Kin - please find attached guidance to assist doctors with the electronic transfer of Medical Certificates of Cause of Death (MCCD) from Health Services to registrars and next of kin. This guidance is intended to supplement the CMO letter which was issued on 24 March 2020.  The guidance will be available on the main Coronavirus section of the Scottish Government’s website.

Referrals to Gatroenterologyguidance about making referrals to gastroenterology during Covid pandemic.

Update 11 – Denosumab, HPS Guidance, Infection Prevention & Control, Scottish Cervical Screening Programme, Shielding, Death Certification

Denosumab – please find attached advice from our pharmacy colleagues in relation to Denosumab injections.

HPS Guidance – Version 10.5 available for General Practices: https://hpspubsrepo.blob.core.windows.net/hps-website/nss/2930/documents/1_covid-19-guidance-for-primary-care.pdf

Infection Prevention & Control – updated UK guidance available: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control

Scottish Cervical Screening Programme - due to COVID-19, its impact on clinical services and the requirement for social distancing, the screening programmes listed below have been temporarily paused until further notice & invitations to take part  in them have been suspended:

  • Abdominal Aortic Aneurysm (AAA) screening
  • Bowel screening
  • Breast screening
  • Cervical screening
  • Diabetic retinopathy screening

With respect to cervical screening:

  • During the pause in the screening programme, women on routine & non-routine screening intervals will not receive invitations to take part in screening.
  • During the pause in the screening programme, NHS Scotland’s National Services Division, which oversees the screening programme across the country, has asked that clinicians do not carry out any cervical screening tests.
  • However, if a clinician elects to perform a cervical screening test, it should be submitted in the usual / regular way. Tests received by cervical screening laboratories will be analysed as capacity allows.
  • Women whose screening tests are analysed & whose results indicate that further assessment is required, will be referred to the Colposcopy Service.
  • If the appearance of the cervix is suspicious of malignancy, clinicians are responsible for referring women to the Colposcopy Service for further assessment regardless of the screening test result & before the screening test result is known.
  • Colposcopy Services will assess women as capacity allows, with priority being given to women referred by the screening programme with high grade changes & women referred by clinicians on account of the appearance of their cervix being suspicious of malignancy.
  • During the pause in the screening programme, women with gynaecological symptoms are advised to contact their GP Practice – please see https://www.nhsinform. Women should be assessed & referred for further investigation as clinically appropriate.

Please contact Rob Henderson, Consultant in Public Health Medicine, if you require further information – r.henderson@nhs.net

Shieldingcommunication from the Chief Medical Officer in relation to the Shielding methodology and process, and details of the new 7th vulnerable group that has been identified.

Death Certification – a few practices have asked about death certification and the letter from the Chief Medical Officer is re-attached for information.

Prescription Deliveries - attached details of a new standard operating procedure for pick-up and deliveries to community pharmacy.

Prescriptions and Supply of Medicines COVID Hub and Assessment Centres – attached is information around prescription and supply of medicines from Covid Assessment Hub and local Centres.

Daily Hospital Status Report – attached for information is the daily hospital status report.

Dental Services - all General Dental Practices and NHS Highland Public Dental Service (PDS) clinics are now closed for routine patient treatment.  Each GDP practice and PDS Clinic are continuing to triage patients.  Patients are being offered Advice, Analgesia, and Antibiotics initially.   Those with acute dental problems will be appointed to one of the four Urgent Dental Care Centres in North Highland (Green) – Wick, Portree, Fort William and Inverness.

If the patient is COVID confirmed/suspected or a patient that requires an Aerosol Generating Procedure they will be seen in a designated clinic (Red) in Inverness.

The NHSH Dental Helpline continues to provide triage of PDS patients and unregistered dental patients in hours.  NHS24  provides Dental triage OOH and this feeds in to the 4 Urgent Dental Care Centres which also operate OOH.

Any patient with an acute dental problem should contact their own GDP first or Dental Helpline on 08456 442271 if they are not registered with a Dentist. The message will advise patients of how to contact their Dentist or access OOHs.

Current arrangements may change at short notice and any change will be communicated.

Update 10 - Easter, Scottish Government website: staff governance, Shielding update

Easter public holidays -  Attached is a letter confirming the nationally agreed decision for practices to remain open over the Easter public holidays. Thank you.

Scottish Government Website -  just launched for employees during the Covid-19 outbreak.  This will be regularly updated so please don’t print this out – you can access on any device.

https://www.staffgovernance.scot.nhs.uk/coronavirus-covid-19/guidance/

This covers a number of issues including:

  • The virus and information about transmission
  • Advice on appropriate use of PPE
  • Advice on Underlying conditions / Pregnancy / Over 70s
  • Leave and Childcare arrangements
  • Colleague Testing

We will issue a further communication specific to Highland drawing out key points of note and advising on how we will manage any changes , however, we want to make this available to all colleagues as soon as it was published.

Shielding Update – Highland clinicians have already been in touch providing details of patients falling within the 6 medical high risk categories and these have been forwarded to ISD.  A 7th category of patients has been created:

“A 7th group of patients has been included in letters issued from 31 March onwards. This group will include all patients that GP or Hospital Specialists think will benefit from following shielding advice who are not covered by the original 6 groups defined by CMO’s”

An updated version of the patient letter has been created for these Category 7 patients – attached which can be used by GPs or hospital clinicians. 

Further guidance has been provided for updates to Vision with associated timescales.

Rachel Hill (rachel.hill1@nhs.net)

Update 8 (2) – Palliative Care Guidelines

Palliative Care Guidelines – this document contains helpful advice for end of life clinical support and easing distress in COVID19 patients. This difficult topic will be further supplemented by guidance being prepared by Jeremy Keen of the Highland Hospice in the next few days.

Personal Protective Equipmentattached is a reminder of the current guidance for all healthcare settings. Embedded are links to Health Protection Scotland sources which emphasise the evidence base behind the guidance. There is considerable concern expressed at all levels of the healthcare community about both the quality and type of PPE to be used, however this advice is the best available to us in Scotland and I am grateful to you for taking the time to review it once more.

Update 7 - Retired GPS, Primary Mental Health Worker Service, Primary care PPE, Waste management, SAS

Returning Retired GPs – there will be a formal process established for retired GPs who wish to return at this time.  The details of the process will follow, however if you are aware of people who are interested please ask them to email us direct nhsh.primarycareteam@nhs.net

Primary Mental Health Worker Service attached contact details and working arrangements for the PMHW team. 

PPE Message from SG Primary Care Division - please see the IPC’s comments with regard to home-made PPE:

The Infection prevention and control guidance for pandemic coronavirus is available from the following: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control           

Within this guidance, section 5.4 addresses Personal Protective Equipment. Specifically this states that:

“All PPE should be compliant with the relevant BS/EN standards (European technical standards as adopted in the UK)”

As well as detailing other specific measures.

To that end, all PPE should be tested and compliant with these standards prior to use.

Donations of PPE Equipment - we really appreciate that companies and businesses are volunteering donations. To ensure appropriate protection of all staff the use of donated equipment needs to come through a validated process which is being coordinated by the procurement department.  Any offers of donated PPE should be directed to High-UHB.areastoresraigmore@nhs.net

Management of Waste – please see attached letter from NSS about management of Covid-19 clinical waste.

Message from Scottish Ambulance Service:

“We are seeing an increase in 999 calls from GP practices across the patch. Once crews are arriving for often trivial medical problems the patients are advising that they did not want an ambulance however the advice being given was to dial 999.

The consequence here is twofold, firstly it’s not the correct advice, secondly as we use more bank staff there is the potential for an increase in admissions. Can I ask if possible a message is relayed to GP practices around the usage of the 999 system.”

Jim Quate Area Service Manager (Clinical)

Just Ask - please see poster attached

Resources for young people

Update 8 – Pausing of Adult Screening Programmes

Communication for Health Professionals – Pausing of Adult Screening Programmes - Due to the rapidly changing situation with Coronavirus (COVID-19), the Scottish Government, on the advice of the Scottish Screening Committee, has taken the decision to temporarily pause the following screening programmes until further notice: 

  • Breast Screening (Mammograms)  
  • Cervical Screening (smear tests)
  • Bowel Screening (home test kits)
  • Abdominal Aortic Aneurysm (AAA) Screening
  • Diabetic Retinopathy (Eye) Screening
  • Pregnancy and Newborn Screening Programmes will continue where logistically practical.

There are a number of factors behind this decision, primarily to minimise the impact on essential NHS services as we respond to COVID-19, to facilitate social distancing and to potentially allow the re-allocation of screening programme staff to support these essential services within NHS Boards.  This means we will pause invitations and cancel all issued screening appointments within a maximum of 48 hours of the decision to pause. Results for those participants who have recently been screened will continue to be processed.  Laboratory activity and testing capacity will be reviewed as the situation progresses.

For cervical screening, we will pause prompts and reminders and ask primary care and other clinics to cease taking samples with immediate effect.

For bowel screening, we will cease issuing kits for the foreseeable future. Kits that are returned will continue to be tested however we are asking participants to keep kits which have yet to be completed until we re-start the programme. Please note that for kits already issued and in participant’s homes, the expiry time is approximately 18-24 months. Individuals who have had a positive screening result but are still awaiting colonoscopy will receive a letter explaining that there will be a delay in this taking place. They will be offered reassurance that the risk of cancer is low and told that colonoscopies will resume as soon as it is safe to do so.

The programmes will be in touch in due course to invite those who have missed invitations, reminders and appointments.

Please reassure your patients that if they have concerns, they should contact NHS Inform or Screening Centres. In between screening appointments or as they wait for rescheduled screening appointments, they should continue to be aware of and act on any symptoms associated with the conditions being screened for.

Please signpost www.nhsinform.scot/screening for more information on screening as well as symptoms.

Individuals should contact their GP practice if they are concerned about  symptoms.

We will re-start screening programmes as soon as it is agreed safe to do so following the evidence received on Coronavirus which will be reviewed on a regular basis by the Programme Boards for each screening programme.

Repeat Prescription Requests - due to the coronavirus pandemic, and in order to reduce footfall, some Practices are only accepting repeat prescription requests online. However there are some patients who cannot access the internet or do not have anyone to do this on their behalf. Many of these have been going to their Community Pharmacy asking for help to order their repeat prescription. Some patients in this category are understandably becoming distressed, upset or angry as they are fearful of running out of medication.

Whilst appreciating the need to reduce footfall and manage workload, we would ask that Practices consider alternatives for those patients who cannot order online. This may be a temporary acceptance of postal requests from patients by letter or by submitting the right hand side of the prescription form to the Practice.  It is also anticipated there may be many in this group who may be self-isolating due to being deemed to be ‘at risk’.  We are grateful to you for considering how best to support this group to access their medication in a timely fashion.     

COVID-19 and Asthma/COPD Rescue Kits - NHS Highland is aware of social media posts advising patients with asthma to contact their GP to request prescriptions for “rescue packs” of oral antibiotics and steroids. This is creating unnecessary work. Patients with respiratory conditions and, at this time, experiencing a worsening of symptoms will need to seek clinical opinion and should be advised to call 111 for their symptoms to be triaged.  Anticipatory prescribing of oral antibiotics and steroids may be appropriate for the management of exacerbations in COPD as part of a personalised action plan but is NOT generally recommended for most asthmatics, who must be assessed before treatment with oral antibiotics and steroids can be considered.

Update 6 – Chronic Pain Management Service, Out-patient referrals

Shielding – the Chief Medical Officer requests your help in identifying and protecting the most vulnerable patients, a number of actions are set out and guidance provided.

ID Badges for Independent Contractor Staff – please find attached details for independent practitioner staff to access an NHS Highland name badge.   As enforcement come into place around social distancing, NHS staff may be asked to produce ID for a variety of reasons.  Each Practice Manager is asked to co-ordinate the submission for their practice on the attached pro-forma.

 Local Assessment Hub (Highland Hub) attached are a set of FAQs that have been developed to support the new service.

Community Assessment Centres – the Mackenzie Centre continues to see patients for Covid assessment.  All other sites will be mobilised within the next few days.  Work is on-going to establish an online clinical rota tool (similar to that of the OOH GP service) which will make it easier for clinical staff to put themselves forward for a shift.  Further details will follow.

Social Distancing – practices re reminded to review workforce arrangements within their practices around social distancing, and also within their public areas (e.g. waiting rooms). https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/coronavirus-covid-19/coronavirus-covid-19-social-distancing

Chronic Pain Management Service – notification of temporary changes to the pain management service attached.

Out-patient Referrals – please find advice on out-patient services.

OOH Palliative Care Advice Line - since 2016, Highland has provided a direct access line for patients at the end of life requiring urgent OOH care, in order to expedite access to OOH care.  Given the rapidly developing situation around Covid-19, we are taking the decision to step down this service.  It is increasingly likely that patients at the end of life may also have Covid-19 and it will not be possible to triage/separate such calls coming direct into Highland Hub. As Highland Hub is also the 24/7 Covid Hub handling calls, it's evident that there is not the capacity to deliver this service effectively under current demands.  Of course, we will support patients and their families who are already using this service, but we would ask that, with immediate effect, the number and information leaflet be withdrawn from circulation.  It's crucial that patients at the end of life still have access to urgent palliative care without delay. We're aware that NHS 24 are experiencing  unprecedented call volumes since the launch of Covid Hubs and Centres so we cannot risk patients at the end of life having to attempt this route.  Before the Highland Palliative Care Line was set up, many practices and Community Nursing Teams had excellent, responsive local arrangements in place for patients. These were often the patient's own GP or nurse giving their work mobile number to the family and setting up ad hoc on call within the community team.  I would urge that local teams move now to reinstate these arrangements on a patient centred basis. (Clare Rumgay, OOH Clinical Services Manager).

Extended Hours – with immediate effect we are proposing to stand down Extended Hours for the next 4 months without financial detriment to practices. 

Palliative Care Medicines – There is clearly concern about the availability of palliative care medicines as it is likely that there will be an increased requirement for medicines for end of life care. Local stock holding pharmacies, in particular, and other pharmacies will hold increased stocks. GPs and Dispensing Practices who carry their own stocks may also wish to increase stockholding, but this must be realistic so that stocks aren’t depleted unnecessarily. Our advice is, if you have 1 box, then increase to 2 boxes.  The more complete advice on Primary Care Palliative Care Stock Medicines that was previously circulated is attached.

Continuation of Vaccination Programmesguidance from Chief Medical Officer.

Update 5 – Letter from the Chief Pharmaceutical Officer

Scottish Government COVID Update to Primary Careattached is a summary briefing from SG around the recent developments in primary care. 

Covid Assessment Hubs – the Mackenzie Centre, Inverness went live on Thursday, 25 March 2020.  We appreciate your support over the last few days in getting us to this point.  Practices are asked not to stand down their existing red room facilities in the event they may be needed.  We appreciate all the offers of support to provide staff for all the assessment centres.  By the end of the week, there will be a live rota system in operation whereby staff will be able to indicate the shifts they are willing to work across the region.  In the meantime, staff who have confirmed their availability will be contacted individually for cover over the next week.  Your support and cooperation has been much appreciated. 

Staff Testing  - the Health Minister has announced that testing will be made available for health care workers. To enable this NHS Highland has created a new process for accessing testing, please see the attached information and referral form.

If you are a healthcare worker who provides face to face patient care AND you have COVID-19 symptoms, are seeking advice on your fitness for work and would like to be considered for staff testing then please discuss this with your line manager and your manager can email your details to Occupational Health on  High-UHB.OHCOVID@nhs.net  using the appended referral form for EACH member of staff as attached.

Letter from the Chief Pharmaceutical Officer – please take account of advice in relation to access to regular medicines and Access Emergency Care Summary.

Guidance to Medical Practitioners for Death Certification during the COVID-19 Pandemic guidance from the Chief Medical Officer around death certification.

PPE – Dr Jenny Wares has highlighted the attached link which will be of interest - https://hpspubsrepo.blob.core.windows.net/hps-website/nss/2985/documents/1_2020-3-19-Rapid-Review-IPC-for-COVID-19-V1.0.pdf

Equipment/Donations – Practices have advised that local companies have been offering donations of PPE to some of our practices.  There are concerns around the quality of such donations in complying with NHS standards.  Practices are asked to notify us of such donations so a register can be compiled in the event that they may be needed at a later time and ratified as safe before use.

NHS Near Me – 62 practices have set up a waiting room with about half of practices regularly using Near Me as a means of consulting. 

Update 4 – Vaccinations

Covid-19 Community Hubs

Attached is a joint letter from Scottish Government, BMA and RCGP around the establishment of the Community Assessment Hubs.

Also attached an email communication which was sent to all GP practices this morning from Stewart MacPherson around the setting up of the Community Assessment Hubs across Highland. 

Vaccinations

Please see attached a letter from the Chief Medical Officer in relation to the vaccination programme and the importance of it to be continued at this time.

Letter from Secondary Care Colleagues

Attached is a letter from Ken McDonald around the reconfiguration of acute services.

Isolation Notes

The link below to guidance on the issue of isolation notes. https://111.nhs.uk/isolation-note

 Message from GP Sub Colleagues

Dear Highland GPs,

 As you may be aware from an earlier internal announcement, NHS Highland has a Gold, Silver and Bronze COVID-19 Command Structure.

Your GP Sub sits on Bronze COVID, daily between 1300 and 1400. 

Thank you for your Practice’s hard work at this very challenging time.  General Practice in Highland is responding as we invariably do, with great spirit and teamwork.

Today, we have been asked to take forward two actions, and we would appreciate your assistance with both: 

  1. Please can your practice send one email to jill.mitchell@nhs.net should your Practice wish to start video consulting with NHS Near Me.
  2. Please can your Practice stop directing patients to community pharmacies to order their repeat prescriptions if that is not the process the patient previously followed. The community pharmacies are unable to cope with the surge in demand, and this is impeding delivery of their core functions.

Kind regards,
Jonathan & Iain
Dr Jonathan Ball, GP Sub Chair
Dr Iain Kennedy, GP Sub Professional Secretary

Update 3 - Hub, Assessment Centre, Community Pharmacies, Prescription requests, MATS helpline, Staff testing, Urgent outpatient referrals, ECHO

Highland Covid Hub

The Highland Covid Hub went live on Monday taking calls from NHS24.  The Hub provides a service across Highland, Western Isles, Orkney and Shetland.  Most calls were managed by phone with only two patients referred to a Local Assessment Centre.

Of interest, NHS24 received almost 15,000 Covid calls in the first day of operation through the 111 number. 11,000 were managed by advice only, 4000 were called back by nurse advisors, only 300 needed passed to Covid hubs for assessment.

Local Assessment Centres

We are progressing with the establishment of the local assessment centres.  There has been a delay with the building work at the MacKenzie Centre in Inverness which will now come online from Wednesday, 25 March 2020.  The arrangement for suspected Covid positive patients of being referred to practice ‘red’ rooms will remain in place during Tuesday.

Community Pharmacies

Our community pharmacies are under great pressure at the moment and we would be grateful if practices could assist by sharing the proposed messages to patients:

  • We have experienced an unprecedented demand for prescriptions which will take the local pharmacies 3 days to process. Please do not attend the pharmacies unless it is of critical urgency.

Repeat prescription requests are increasing - all Practices are advised not to authorise repeat prescriptions which are ordered early or for amounts greater than 2 months - we are aiming to optimize medicines supply for everyone.  Your co-operation at this time is appreciated.

Temporary Residents/Requests for Prescriptions

We are aware of the pressure on services that may be caused by people who have travelled into the area, some of whom may seek to become classed as temporary residents with practices. One of the common reason why people may seek temporary resident status is likely to be having forgotten to bring prescription medications.  Please note:

  • Replacing a prescription for a repeat medication (which would be non-urgent care) is not a reason for seeking temporary registration with a practice.
  • There are established processes whereby community pharmacies can supply an emergency supply.
  • If a patient is registered as a patient in Scotland, then this supply can be made free of charge under Community Pharmacy Urgent Supply.
  • Patients from outwith Scotland would have to pay the cost of medicines supplied, but an emergency supply can be made.
  • Clearly, not everything would be supplied, e.g. medicines liable to misuse.
  • However, whilst community pharmacies would not turn anyone away, they are under just as much strain as other parts of the NHS at this time, especially with the unprecedented increased demand for prescriptions.
  • The safest and quickest way for patients to get access to their necessary prescribed medicines will almost always be through their own home GP and community pharmacy.

Clearly, a certain amount of pragmatism will be required, e.g. for an essential worker who has moved into the area.

MATS Helpline

NHS Inform have advised us that they have closed the Musculoskeletal Assessment and Triage telephone service due to the pandemic and the need to use resources for essential activities. Within Highland we had a generally low uptake of this service, and with the introduction of Physiotherapy FCPs we were expecting a further reduction as people will likely choose to access these in the first instance, therefore we are not anticipating a major impact due to this decision.  

Staff Testing

NHS Highland has tested 34 health care workers for COVID19 over the last few days. 2 have tested positive and are taking appropriate measures. This testing has been evaluated and has not significantly improved the return to work time for colleagues and is thus paused. We are awaiting guidance on testing symptomatic family members which if allowed may have a greater influence on our workforce challenges.

Urgent Out-patient Referrals

Practices have asked about making out-patient referrals.  Secondary care colleagues paused out-patient activity last week to reconfigure acute services within Raigmore.  Out-patient activity has now recommenced and practices can make urgent referrals to secondary care as before.

Highland Hospice – ECHO Programme

Please find attached details of the ECHO programme events which are taking place on a regular basis.

Update 2 - GP escalation plan, Buddy practice arrangements, Hub and Assessment centres, PPE, Practice flow zone, National COVID-19 guidance

General Practice Escalation Plan

I attach a document that summarises our NHS Highland GP escalation plan which has been agreed by our colleagues on GP Sub Committee.  We will be updating this document as our plans develop over the coming weeks.  The Scottish Government has now implemented daily reporting of escalation levels for General Practice.  All NHS Highland practices have been reported as Level 1 as we are aware that all practices have made changes to their access systems in line with demand.  Practices escalating to Level 2 or 3 should complete the notification form and submit this as requested.  These notifications will be discussed at our daily meeting and feedback will be made to the practices within 24 hours. 

Local Enhanced Services – Buddy Practice Arrangements

We have held back on sending out the LES for any cross-practice cover arrangements that are put in place.  We have been advised by Scottish Government that further advice will be issued to us over the next day or so.  When this arrives, we will share it with you all.  Our Primary Care Managers have asked practices to share the details of their buddy arrangements and if you have not done this, please do so.

Local Community Hub & Local Assessment Sites

We are progressing with setting up a central hub for NHS Highland GP Practices.  We are fortunate that the Highland Hub at Raigmore has the infrastructure in place to allow us to develop the triage advice service on a 24/7 basis.  In addition we will be setting up local assessment sites where patients can be referred to for clinical assessment after triage.  We will be bringing multiple sites online from Monday, 23 March on a phased basis.  The focus initially will be on the following areas – Caithness, East Sutherland, Mid Ross, Inverness, Aviemore and Fort William with others coming operational thereafter.  We will keep you updated as these plans progress.

PPE

All GP PPE supplies have arrived at stores and are in the process of being packaged and dispatched.  Practices should be in receipt of equipment by the end of this week.

Practice Flow Zone

Attached is some posters for practice zoning that have been designed by Dr Ross Jaffrey, Croyard Road Practice.  Please feel free to adapt and use these as required.

National Covid-19 Supporting Guidance for Scottish General Practice

Attached is a document which Scottish Government have issued to support practices.

Update 1 - PPE, Remote working, Screening Key Healthcare Staff, Local Community Hubs

HPS website NHS inform Scottish Government

This is the first of our regular brief updates. Simply for information and to provide guidance or helpful resources. Please find attached 2 posters and also guidance on PPE for different healthcare environments.
Transmission based precautions poster
Droplets poster
General public information

PPE

North Highland supplies have been received at the stores in Raigmore and A&B supplies have been delivered to Oban.  Supplies will be packaged and distributed to all practices within the next 48 hours.  Practices should be in receipt of supplies by the end of the week.  If this is not the case, practices are advised to contact their respective Primary Care Managers to update them accordingly.   

eHealth Solutions for Remote Working

We have been working closely with eHealth colleagues over the last few days to define the solutions available to all GP Practices to support remote working for staff who are self-isolating.  The options available for each practice will be shared with you by the end of the week.

Screening of Key Healthcare Staff

NHS Highland have agreed a local policy to screen key healthcare staff who are currently self-isolating.  Arrangements for such testing can be arranged through contacting the Health Protection Team. (In hours: 01463 704886)

Local Community Hubs

Scottish Government have instructed all Health Boards to establish Local Community Hubs that will operate 24/7. These are intended to improve the resilience of primary care by diverting some of the Covid-19 patients away from General Practice. The plan is to extend the role of the Highland Hub in Inverness to operate 24/7 providing clinical assessment and advice over the phone. We are also required to set up local Covid-19 assessment centres where patients can be signposted to.  These will be designated community locations which will require to be staffed and we will be discussing with practices the options available.  I am aware that some locality plans are already well advanced in buddy arrangements and these local assessment centres will fit with such plans.  Launch date for this new service is 23rd March.