Redrawing Primary Care to Support our Communities

Swansea Bay University Health Board’s Primary Care Services have been mobilising in order to continue to operate under new and unprecedented pressures related to the COVID-19 pandemic.

Primary care covers around 90 per cent of health care which goes on outside of hospitals and is a huge undertaking, involving around 1,500 health board employees based in numerous locations working alongside many other NHS services, including 49 GP surgeries grouped into eight clusters, across the Swansea Bay area.

With the risk of the virus spreading necessitating a virtual lockdown, the manner in which we access often vital services such as seeing a GP, or having an infected tooth removed, has had to be redesigned in order to keep everyone safe.

As a result, most routine appointments have been cancelled and all non-essential services scaled back, ensuring there are enough staff to maintain new and vital roles, some of which involve helping to combat COVID-19 itself.

Giving some context to the scale of the task ahead, and what has been achieved, so far, Hilary Dover, Swansea Bay’s Primary and Community Services Unit Director, said: “As with our hospitals, the changes in primary care have been fairly dramatic.

“I am impressed at the scale and pace that the whole range of community health services and local authorities have been working together to ensure so that we have robust and safe community service provision in place to reduce the need for hospital services and to support patients to be discharged as soon as possible where hospital admissions are unavoidable.”

Those responsible for the reorganisation, faced the delicate task of balancing what was vital and what could be temporarily set aside.

Andrew Griffiths, Swansea Bay’s Interim Head of Primary and Community Service Development said: “There’s been a lot of work undertaken, with the heads of each department coming together to create and implement a coordinated plan so we understand what services are continuing to operate and which ones are stepped back to enable staff to be redeployed to the areas of greatest need.

“For example,  our school health nurses are running the community testing unit seven days a week to support frontline workforce testing.”

Mr Griffiths has nothing but praise for the manner in which Swansea Bay staff have stepped up to the plate in these testing times.

He said: "The response from members of staff has been absolutely superb.

“Where we have asked people to step up and into new roles, and to do things differently to how they have been done before, they have responded brilliantly – they set up a home testing model in days.

“They have just got on with it and dealt with it professionally, with an enthusiasm to get the job done and to get it done right.”

As for the weeks and possibly months ahead he said: “From a primary community services perspective, we will continue to provide care for people and we will do our best to make sure we are communicating those changes as we go along.

“We have excellent, superb staff and they have really shown their caring natures and adaptable spirit to be able to provide care to patients, with or without Covid-19, and respond to the challenges that this pandemic has placed upon us to make sure people are still being seen and kept safe knowing they are still valued by our health service.”

Dr Iestyn Davies, lead GP at Cwmtawe Medical Group, typified the response to the call to arms of his fellow GPs and health care professionals.

He said: “This is a difficult time for all, so we must all pull in one direction, clinicians and patients, in order to achieve the best outcomes during this pandemic.

“We have encountered obstacles never previously experienced, and have had to adapt quickly.

“We have been fortunate in that we have, over the years, kept pace with technology and embraced change. A good example of this is the online platform, askmyGP which, has enabled us to deal with large volumes of requests daily.

“This system is now being rolled out to the wider Swansea Bay practices so that they can also benefit from this system.”

So how has our primary care cover been reorganised to meet the challenges which lay ahead?

GP Surgeries

All 49 GP practices within Swansea Bay University Health Board remain open but now operate behind what can be termed closed doors with no walk-in appointments permitted. Only those patients that are assessed by the  in the practice to manage their care are being given a face to face appointment.

Dr Anjula Mehta, Interim Unit Medical Director of Primary Care,  said: “GP services have changed significantly. In a period of weeks they have moved to now provide all of their services via an initial telephone call, email or video consultation, as patients can no longer self-present.

“They are still invited into the surgery for necessary face to face consultations but they have to make first contact over the phone or email.”

To ensure that the Primary Care clusters can continue to provide care to certain patient groups they have developed a streamlined and centralised approach to phlebotomy, childhood and maternal immunisations, family planning services and are developing a similar approach to wound care services.

Attend Anywhere and askmyGP

Like the rest of the health board, the GP surgeries have shown a real “can do” attitude in taking on board new ways of working in preparation for the times ahead.

One of the most significant and noticeable changes, for many patients, will be the introduction of digital consultations with around 60 per cent of surgeries signing up to a new system called askmyGP.

Patients are asked to enter some basic details which will then be read by a GP who will determine the correct course of action.

The existing method of contacting the surgery by telephone will remain in place offering patients a choice.

Those surgeries not signed up to askmyGP will use a video conference system called Attend Anywhere.

Dr Mehta said: “We are supporting the GP practices to adopt digital platforms, askmyGP and Attend Anywhere.  Both of these will allow patients an additional way of accessing GP services. 

“They will allow GPs to see patients without the need of a visit to the surgery, which at this time will really support the ‘social distancing’ requirements and minimise infection rates.”

GP Recruitment

Recently retired GPs are being contacted with a view to inviting them back to work on a temporary basis to provide extra medical cover.

Primary Care COVID only Cluster Assessment Hubs

Cluster Assessment Hubs are being established across Swansea and Neath Port Talbot to provide robust assessment, review and management of patients who are self-isolated and require medical attention that cannot be managed by their own GP practice. 

The Cluster Assessment Hub includes a group of GP practices working together within a cluster from a central location. This means that practices are supporting each other to deliver care for patients with COVID-19, from a controlled environment to prevent the spread of the virus and ensuring they can keep patients away from those patients and staff that may be vulnerable to catching COVID-19.

The clinicians working in the Cluster Assessment Hub will be using Personal Protective Equipment (PPE) and will be seeing patients in a separate area away from well patients, following infection control procedures to reduce the spread and keep other patients safe. 

Dr Mehta said: “In cases of a confirmed or suspected COVID-19, where the patient still requires primary care services, the GP may refer the patient to the Cluster Assessment Hub, which will provide support for patients, either through visits to their homes where necessary or on an appointment basis.

“GP Practices have come together to put this in place so that there is a safe environment for their staff to work in and to minimalise any potential transmission as well as reducing the need for people to go into hospital.”

COVID-19 Testing Unit

The Community Testing Unit has been up and running for a few weeks. Testing is prioritised for NHS staff and other partners, including the Welsh Ambulance Service, prison staff and other frontline staff who need to be tested to enable them to return to work.

Mrs Dover said: “In order to successfully release staff back into the workforce who are self-isolating due to household symptoms, we are also testing family members of critical frontline staff.”

District Nurses

District Nurses are frontline line staff who provide home-based care for patients with complex health needs, along with the frail elderly population within our communities.

They are playing a vital role in skilled and compassionate care to keep people at home, and keeping hospital admissions and readmissions to a minimum by delivering a 24 hour service seven days per week

Mrs Tanya Spriggs, Interim Unit Nurse Director of Primary and Community Services, said: “Our district nurses are continuing to visit patients to provide people, with the health care that they need. Like any other service, they are prioritising the work that they do.

“They are continuing to provide palliative care in the community, making sure people have the right care and support in their end stages of life in their own homes. Palliative care has always been a priority of district nursing.”

Acute Care Teams (ACT)

ACTs are currently working with the acutely ill patients in their own homes to prevent hospital admissions.

The function is to provide diagnostic and appropriate interventions based on the results. This is a consultant-led service with the Advanced Nurse Practitioners, and a wraparound service which includes nurses, therapists and care workers to optimise patient outcomes and maintain patients’ independence as far as possible.

Mrs Spriggs said: “We have had a lot of support from the community, local businesses, previous patients and staff with some of the kind gestures including donations of flowers, cakes, chocolate, tea and coffee while a member of the public anonymously paid for one of our nurses’ petrol.”

Pharmacies

Swansea Bay UHB has been working closely with pharmacies throughout the area to ensure they get the help and support to continue to provide their vital service during a time when they are under never before seen pressure.

In order to obey the rules of social distancing and to be able to keep up with an unprecedented demand, whilst often having to overcome staff shortages, pharmacies are also operating under a closed doors policy with a change in normal opening hours in some cases.

The manner in which prescriptions and repeat prescriptions are issued from GP surgeries may also have changed – patients are advised to check with their individual surgery and pharmacy for the exact arrangements.

Urgent Care Dental Centre

All dental treatment that can be is being delayed at present. However, local General Dental Practices are available but are triaging patients, known to them or not, providing advice and reassuring patients who have a dental problem by telephone.

This avoids patients travelling and presenting at the dental practice to minimise contact with people. If a face to face consulation is necessary, dentists can provide this and limited treatment otherwise people will be directed to an Urgent Care Dental Centre.

Mr Karl Bishop Primary and Community Services Dental Director said: “The UCDC is for patients identified through telephone consultation, who have an urgent or emergency need that cannot be delayed. This includes severe pain that does not responded to painkillers used for 48hrs, some cases of swelling, bleeding or recent trauma.

“The UCDC will accept patients, following triage by a local dentist, who are COVID - or are suspected to be - positive and are in self-isolation, as well as those COVID negative patients that require specific urgent care. This will be in a controlled environment to prevent the spread of the virus.  

“The clinicians working in the UCDC will be using full Personal Protective Equipment and will be seeing patients in a separate area away from well patients attending for urgent care.”

Urgent Primary Care

Swansea Bay’s Urgent Primary Care treatment centre, which operates out of hours, has a new temporary home in the Beacons Centre for Health in SA1.

The move, from Morriston Hospital, has been orchestrated to free up valuable bed space as preparations to tackle the COVID-19 outbreak gather pace.

Open from 6.30pm to 8am on weekdays, and all day on weekends and bank holidays, if you need to see a GP urgently during these times, and cannot wait until your own surgery opens, call 111.

Patients will be answered by a trained call handler who will take some details and then, if appropriate a GP will call back to assess their needs. They may be offered self-help advice, or a face-to-face appointment depending on their needs.

Optometry Practice Services

SBUHB has been working with local optometry practices to develop community optometry practice ‘clusters’ to reduce the number of practices required to remain open but providing sufficient geographical cover and enabling links to wider primary care services.

Optometrists will now be using a telephone triage system to determine whether patients need to be seen. This will be by appointment only, and only for those who have urgent eye or sight-related symptoms which cannot wait.

An emergency centre where suspected or confirmed COVID patients can be directed for assessment of urgent eye care needs is also being set up.

Returning home from hospital and keeping people safe at home

Working in partnership with Swansea and Neath Port Talbot local authorities and the community, Swansea Bay UHB is trying to ease the strain on our hospital through making sure all patients who are able can return home as quickly as possible.

Mrs Dover said: “We are supporting as many people as possible to be able to come home from hospital now. People who don’t have COVID-19, we don’t want them to get it, we want them to be able to go home as soon as possible.

“Families and the public are being asked to manage on a different level of care and support than they may historically have had, otherwise we won’t be able to support the number of people to come out of our hospitals and we risk seeing people remain in hospitals and potentially catching the disease.”