GP on the frontline: ’The past six weeks have been unlike anything I’ve known’

Edinburgh GP Gavin Francis reports on how he and his practice have dealt with the escalating crisis since lockdown

This is an edited version of an article that originally appeared on The Guardian 

By the time the schools closed in late March my GP consulting room in Edinburgh had been emptied of clutter, its surfaces rendered easy to wipe down with disinfectant. It felt as if the decks had been cleared. 

There are almost 4,000 patients at my practice on the south side of the city, close to the university. As the lockdown began my colleagues and I were spending our time ‘phoning two or three hundred of the frailest, as well as the 30 or so who had been advised by the government to ‘shield’ from the virus until July at least. 

On the ‘phone we made sure they understood the advice to stay in and that they had arranged food deliveries for the coming weeks. We checked they had a ‘key information summary’ – an electronic précis of their principal medical issues – available for paramedics, A&E and hospital staff to access should they become unwell.

In the first few weeks of the year the pandemic had been a dreaded, but distant, anxiety. I had little sense of how severely it would hit us, and how much planning would be enough. The speed of its arrival was startling, and the past six or seven weeks have been unlike anything I’ve known in general practice.

A complete transformation

Everything about the way we work has been transformed. The number of face-to-face encounters with patients has dropped by 90%. Home visiting is both more time-consuming (because of the requirement for PPE) and perfunctory (to cut contact time). Dread has given way to fatigue, but not to complacency. I’m worried that too few people are being tested, that the test itself is often inaccurate, and that our PPE provision is inadequate. The health gap between rich and poor, already wide from a decade of cuts to councils and benefits, is being stretched wider.

Now that restrictive lockdown measures are starting to be eased cases will surely climb. My GP colleagues and I have all seen some patients with COVID-19 but, because of the effectiveness of the lockdown, fewer than forecast in those dark days of March. Two of our patients have died of it – about the same proportion, one-in-2,000, as have so far died of the virus nationwide.

The agility of the NHS in response to the crisis has been impressive. Our practice has four GPs and two nurses; all still travel to and from the clinic every day, and the four receptionists are still fielding and triaging calls; the appointments’ book is filled as usual, but now with names for the clinicians to ‘phone back, rather than with appointment times for patients to come in.

The NHS is notorious for its slow uptake of technology – I still use fax machines and pagers daily – but we can now text patients’ phones with a link to open a video call to our aged desktop PCs. There are still clinical problems for which a physical examination is imperative; those I do at the practice if the patient is fit enough to come in, or at their home if they’re not.

Either way, I wear a mask, apron and visor, and two pairs of gloves. As aspiring GPs we were taught to value the subtleties of human communication – to carefully attend to body language, to silences, to the way a patient holds or evades eye contact. In a mask and visor I feel less like a GP than an old-school surgeon, oblivious and insensitive.

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The Scottish perspective 

On 7 May, the first minister of Scotland, Nicola Sturgeon, had extended our lockdown, shortly after recommending the use of’“cloth face coverings’ on public transport, in shops and in places where physical distancing isn’t possible. On 10 May, she announced that she had “asked the UK government not to deploy their ‘stay alert’ advertising campaign in Scotland”. The message in Scotland, Sturgeon said, was not “Stay at home if you can”, but “Stay at home full stop”.

The lockdown has already had profound social and economic consequences. It’s likely that unemployment is going to soar this summer and, unless robust housing legislation is put in place, so will evictions. On my occasional work at the Access Practice, a GP clinic providing health services for Edinburgh’s homeless population, I’ve seen how they’re preparing for a surge in need.

In late March the Scottish government, public health officials, charities and local authorities came together to mitigate the worst of the pandemic’s effects on homeless people with an initiative brokered by the charities Streetwork and the Bethany Trust. By the evening of 24 March 80 of the city’s rough sleepers had moved into rooms in one of the city’s empty hotels. With homeless shelters closing to minimise the spread of COVID-19, another hotel was opened as a temporary night shelter. Mobile outreach clinics were set up in each hotel, and rapid detox and methadone programmes initiated for those who needed them.

I was due at the outreach clinic in one of the hotels last week but, just before attending, I came down with a viral headache. I felt weak, nauseated and feverish, so instead of going to the clinic I went to a test centre, where a knitting needle of a swab was plunged into the depths of my nose.

Vital work must not be lost

While waiting for the result I ‘phoned Rankin Barr, the service manager of Streetwork, to arrange a visit to the outreach clinic, and asked him about the effects of the lockdown. “The people presenting for emergency shelter are not your traditional rough sleepers,” he said. “Many are coming from domestic problems, relationship breakdowns – with lockdown they can’t stay with family, can’t go to B&Bs.” 

We spoke of how much had been done so far – of the rapid setting up of clinics, of food provision, immigration advice and vaccination programmes, and how the city council was, even now, procuring more emergency accommodation for the emerging social crisis. The calamity of the pandemic has triggered a new attitude and approach to the city’s chronic housing shortage. “This virus has changed everything, but there’s an opportunity from now to do things differently,” Barr told me. “The city and public health authorities are completely on board. We just can’t lose all the vital work that’s been done.”

My result came through: negative. I felt better, and will be able to visit the outreach clinic later this week. On the ‘phone recently I asked one of the doctors organising treatment for the homeless, John Budd, how many cases he’d had to deal with. “We’ve been lucky so far – unbelievably, there has only been one confirmed case. That’s, perhaps, symbolic of just how marginalised the homeless are from society – but when it enters this relatively closed community, it will spread like wildfire,” he said.

“But this virus is like Voldemort,” he laughed. “We know it’s out there, we just don’t know when it’s coming back.

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