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How did England’s National Health Service (NHS) change at the start of the COVID-19 pandemic? In two companion Brief Reports on F1000Research, Lorna Duncan and Kelly Cheng explore how the NHS modified general practice (GP) consultations to minimize the spread of COVID-19 and what the public thought about these changes. We spoke to Dr. Duncan about what they discovered and the potential implications for primary care.

How did NHS GPs first respond to the pandemic?

In March 2020, NHS England modified its Standard Operating Procedure for general practice to mitigate the spread of COVID-19. Local GP practices adopted a remote, triage-first model for all patients accessing healthcare. Similarly, if patients then needed a consultation, the default model would also be remote, using telephone, video, or online appointments.

However, if a face-to-face appointment were clinically necessary, patients with diagnosed or suspected COVID-19 would be isolated from others to control transmission. Practices could do this by using a ‘hot hub’—a site shared by locally collaborating practices to see COVID-19 patients only. All other patients would be seen at ‘cold’ practices.

Alternatively, patients could visit their usual practice if it could be separated into two zones: a hot zone for COVID-19 patients and a cold zone for everyone else.

What did you investigate as part of your first study?

Our first study analyzed the different ways GPs in England adapted their face-to-face consultations at the beginning of the pandemic. NHS guidance indicated that they should agree on all decisions related to modified services with their local Clinical Commissioning Group (CCG). CCGs are groups of GP practices that come together in each area to plan and commission the best services for their patients and population.

As such, we sent questions by email to all 135 CCGs in England, asking about adaptations used in their area. We did this under the Freedom of Information (FOI) Act 2000, which enables public access to recorded information held by public authorities in England.

Which adaptions were the most common?

All but one CCG reported that GP practices used hubs and/or zoned practices in their area. Many also offered home visits for patients who could not travel. Practices in the remaining CCG used hot and cold home visits for all their face-to-face consultations.

Hot hubs were the most common model reported, used in 90% of CCGs, with zoned practices used in 47%. Additionally, some CCGs reported the use of cold hubs, where non-COVID-19 patients from collaborating practices could receive care.

Over half of CCGs reported that all practices in the area used the same model. However, in other CCGs, a mix of hubs and zoned surgeries were set up to suit local circumstances.

What influenced whether GPs opted for one modification over another?

CCGs indicated that the pre-existence of local collaborative GP networks could promote hub use, with demand for appointments influencing the number of hubs available. The adaptability of surgery premises and concerns around continuity of care influenced zoning.

What are the practical applications of these findings?

Our findings can help assess how GP adaptations influenced the management of COVID-19 and other conditions, as well as the additional impacts on staff and patients. Understanding who the different options are useful for and why can inform practice both during the pandemic and beyond.

Furthermore, the results of our study led us to question the apparent anomaly between our findings and contrasting reports in the news media. NHS Digital data reported around 16 million GP appointments were taking place each month at the time of our study. Yet, press and other reports indicated that patients could not access appointments. Some claimed that practices were ‘closed.’

As a result, we decided to ask the public about their experiences and understanding of general practice at that time as part of a second study.

How did people experience access to health care?

All respondents who had in-person consultations were left satisfied with these. Some people preferred the increased accessibility that the remote healthcare options provided. For some, it was easier to fit a phone or video consultation around their schedule.

However, more than one-fifth of respondents who tried using general practice were either unable to access it successfully or were unhappy with the outcome of their contact, typically due to the availability or mode of consultations. Participants reported that phone lines were very busy, perhaps unsurprisingly with the switch to telephone consultations and triage.

Plus, a further 11% did not try to access general practice for various reasons, including their fear of COVID-19. 

How informed were patients about NHS general practice changes?

Some patients were happy with their communication and were aware of the general practice changes locally. However, others were confused by unclear, out-of-date, or insufficient messaging. Plus, the lack of access to digital technology was a critical issue for some.

Significantly, 7 in 10 of our respondents did not know that COVID-19 patients were isolated from others during face-to-face consultations. Furthermore, some participants said they would have felt reassured to contact their GP if they had known this. In addition, a quarter of those who sought help thought face-to-face GP appointments could not happen at all.

How can your research findings be used to improve the patient experience?

Our survey has highlighted some of the different needs and preferences of patients and shown how this has impacted their access to general practice. Some patients have benefitted from the adapted delivery models during the pandemic, while others have experienced reduced access. The importance of effective communication in managing change is also clear.

Evaluation of all the impacts of these models, incorporating both staff and patient perspectives, may be used to inform best practice. In addition, the study of how communication can be made effective for each patient can be used to ensure everyone can access healthcare when they need it. I am currently working on these themes with Bristol, North Somerset, and South Gloucestershire CCG.

What role do you see open research having in primary health care research?

Open data can promote time- and cost-effective research. In addition, it can also provide a more level playing field for all researchers. For example, we used freely available online data from NHS Digital, NHS England, Public Health England, and others to facilitate our analysis. FOI legislation also provided a level of open access, enabling data collection in our first study within a relatively short, one-month timeframe.

Publishing research on an open-access platform accelerates its availability for researchers and the public alike. F1000Research performs quality checks before acceptance, and peer review begins immediately following publication, with the article’s peer review status visible. This is particularly beneficial in fast-changing situations such as the pandemic.

Read the full Brief Reports today on F1000Research:

• Modifications to the delivery of NHS face-to-face general practice consultations during the COVID-19 pandemic in England
• Public perception of NHS general practice during the first six months of the COVID-19 pandemic in England