A GP's view of the pandemic

Submitted by AWL on 26 January, 2021 - 6:06

A GP talked to Zack from Solidarity about the pandemic. An extract of this was printed in Solidarity, the full interview is below.

Zack: What do you think should have been done differently in the vaccine rollout?

GP: The Joint Committee on Vaccination should have planned from the start when they were going to give the second dose, so that they didn't change their mind.

They shouldn't have asked private companies, like Pinnacle, to do things like the computing side. They should have used our existing providers.

Vaccination isn't the only answer. You need to have track, trace, support, and isolate.

People thinking that the vaccines are the only thing that's going to stop the pandemic is quite worrying. When they brought in compulsory seatbelts in cars, the number of pedestrians and cyclists killed went up. That's called risk compensation. Are people who've been vaccinated now going to behave more dangerously and isolate less? I haven't seen that myself yet, but it's being discussed.

Zack: Can you say a bit more about the wider public health measures?

GP: I think face masks should be mandatory everywhere, and I mean actually mandatory. The government should never have said that some people can not wear them for health reasons.

There might be a very, very few people: obviously small children who can't understand might not be able to wear them. I think people with learning disabilities who can't understand might not be able to. And some people with mental health issues.

The number of people with asthma and chronic bronchitis that can't wear them is actually very, very low. It sends a very bad message to those people, as well as to the general public, that if people just say they don't want to wear one, that they don't need to wear it.

Track and trace absolutely needs to be in the hands of public health. The research work to prevent pandemics and to limit them, which is massively underfunded, needs to be brought back, and then public health needs proper funding. It has been underfunded for 30 years.

If we had people who understood epidemiology and public health and they were phoning people and they were trying to sort out where a cluster of cases was coming from, by now we would have much better understanding of when people are catching it. Are people catching it from people who are positive with no symptoms? Or is it that actually people are infectious much longer than we've assumed? And so then they're infecting people after 15 days, instead of the 10 days?

In fact it's being done in a very broken up system. You would have thought with Serco's reputation they shouldn't have been given any contract, but they were given two thirds of the track and trace money, and they've done an absolutely appalling job at track and tracing.

Apparently what Serco do is talk to one case, get the telephone numbers of all the contacts who that person seen — and then have someone else phone those contacts. So then there's no overarching connection of who saw whom.

At our practice, we're phoning every person that gets the positive test: we don't always get through, but we do try. This is to check up on them medically, but it also gives us much more of a sense of where the outbreak has come from.

People who work in councils, in public health, they are used to dealing with outbreaks of salmonella, or whooping cough, or various other infectious diseases like that. So they understand that you need to find who the person was that started it, or what was the piece of chicken, and where was it bought from, and all those things. And then they they get an understanding of how it worked. But because that system isn't there, even when we had the Covid outbreak in our local working men's club, no one really got a hold on how the outbreak had happened.

Everybody knew everybody, so it would have been really easy to contact everyone and get some understanding of who was there, when, who caught it from whom, and where were they sitting. And that would have been really, really educational then for the rest of the country. If people had known that if you sit on the same table, or you go up to the bar and get a beer, you're going to catch Covid from the person at the bar, there might not have been this nonsense, that opening the pubs and then getting a second wave.

Zack: The Health and Social Care Act, the longer term privatisation of the NHS, underfunding of the NHS and overworking of NHS workers, what impact has that had?

GP: Health and social care is particularly important because nearly all care homes are private, and a lot of the staff are either agency staff or very low wage, and often on zero hour contracts. So it's actually quite common that they might feel like they should go to work when they've got Covid symptoms. We've had lots of people ringing us up for sick notes, because they feel under pressure to to go to work, though they're not even feeling well enough to do the work.

The UK has the lowest number of hospital beds per head of population in Europe, and the lowest number of ICU for comparable healthcare systems. That will have had an impact on death rates.

They didn't manage to get enough PPE for staff in the hospitals. It was only relatively recently that they rolled out free PPE for people in care homes. We certainly had patients who caught Covid before they got PPE provided, working looking after elderly people in care homes.

The last two or three years there haven't really been enough beds even in the summer, and there never have been in the winter. Last winter people were nursed in the corridors and in A&E and in ambulances. And it's not really possible to do that now. So you imagine how crowded the hospitals are.

We've also had six months at least of everything except the most urgent work in NHS hospitals has been shelved. People who've needed to have symptoms investigated or operations done, have had them cancelled or postponed.

That's not going to get caught up for a long time and some people's cancers are going to be significantly worse by the time they are treated, because of the delays. That's all been impacted by the fragmentation, the partial privatisation of bits of the NHS, the cherry-picking. Lots of money is going to the easy bits of the service.

That means there's less money for the bits that are complicated. Mental health is a major issue. There was already a massive backlog of people were waiting for mental health treatment. Because the pandemic is really impacting people's mental health, that's got worse.

Zack: Can you explain what you mean by cherry-picking?

GP: There have been "Waiting List Initiatives" money, so private hospitals have done knee replacements and hip replacements and things. But the contracts weren't properly organised so that it was like for like. A patient may have a knee replacement done in a private hospital and they may really like it because in terms of hotel facilities, it's a bit better. But if you have a heart attack in that private hospital due to the anaesthetic, then you usually get transferred into an NHS hospital.

You often don't get physiotherapy included after a private operation. But most knee replacement patients need quite a lot of physio. And the NHS has spent a huge amount revising some of these operations that have been done in the private sector, because they haven't gone well.

Zack: As I understand it, in England, vaccination rollout has been organised by a GP practices and groups of GP practices (the PCNs, Primary Care Networks). Individual practices and sets of practices can opt in to providing this service, which isn't formally known an essential service. The opt in by agreeing to the contact that NHS England has negotiated nationwide with the BMA. According the contract, it seems to say that by signing up to the vaccination programme and administering the vaccines, it doesn't change the responsibilities and obligations of GP parties to deliver more essential services. But, in practice, does it impact the ability of GP practices to deliver them?

GP: I think in recognition of the fact that it is a lot of work, they have actually abandoned various bits of work that we're supposed to do. They are reducing the work that's normally imposed on us. From this Monday 18 Jan, they suspended the Primary Care Network extra work. So that's a whole load of stuff: looking at learning disability annual health checks, cancer audits. But the acute day to day work isn't going away.

For GPs anyway, that acute work is most of work. Nurses do quite a lot of routine checks. Checking on people's asthma, or chronic bronchitis, or blood pressure problems, and so on.

So in theory, we could reduce the amount we did of that in order to send staff to the vaccination centres.

It's much easier for big practices to do that because they have much more ability to spread themselves more thinly, because of economies of scale.

Zack: So the kind of things which are being dropped, according to their advice, is not the very urgent important stuff, but routine check-ups. In practice, is the acute stuff being impacted in many practices?

GP: It's difficult to know, but practices are working quite hard. Normally for the five cities in our PCN, there is a Walk-In Centre, which is run on a rotation of GPs who provide extra appointments. That has been suspended since March. So the workload of practices who had a lot of patients going to that will have gone up a lot. And obviously people's workloads have gone up a lot because of more illness.

We are doing fewer house visits. But we're having to deal with quite complicated things. We're trying to stop people go to the hospital, so they don't risk catching Covid. We are also aware that the hospitals are running at 110%, so we don't want to burden them with unnecessary patients.

Quite a lot of people with Covid get ill, but not ill enough to just call 119 and go into hospital, so we're having to deal with them. We're trying to assess them without seeing them in person.

One method is using these machines for taking people's oxygen by just inserting a finger. The council's got a scheme where they'll send a volunteer with one of these oxygen machines and drop it off at a patient's house. Then we videocall them and we look at them doing their oxygen. That helps us make a decision about whether they need to go to hospital. That's a very different way of working from normally.

We are a little bit behind on routine checkups, but I've just got the list today of the people who didn't get their checks in November, when we would generally write to them, and it's not really very different from normal for this time of year. For example, although we did have hardly any cervical smears in the first few months, we've been trying to catch up with that.

If we don't do them, that's potentially going to miss some women with cancer. Plus if we stop all of those things, I don't know how we're ever going to catch up.

Zack: So has your practice now signed up to the vaccination programme?

GP: No. The other doctors in the practice are saying that if at some point we are allowed to have the vaccine at the surgery, then we will consider signing up.

We only have a couple of thousand patients and we only have two full time equivalent GPs, probably one and a half full time equivalent nurses and a part time health care assistant. The vaccination programme were asking for us to contribute so many hours of staff health care. We just didn't feel that we could afford that degree of people not being in the building.

If were were to try and commit to that, then essential stuff would end up not getting done. We are already working very long hours to start with.

Zack: A lot of people, when they imagine this vaccination programme, envision a long queue of people with someone going from one arm to the next injecting people. Can you paint a picture of what it actually involves?

GP: A few dozen patients of our practice got vaccinated, who were all over 80. We had to, first of all, ring them and invite them and book them in for their appointments.

Then someone had to look at the notes to check whether or not they had ever had an anaphylactic reaction in the past. That's one where you can't breathe and you need an adrenaline injection. That took at least five minutes per person. I think it is streamlined now and you can do a search automatically on the notes.

Then each patient needed a patient specific directive. That's a piece of paper which then has to be scanned back in and sent to the vaccination centre, saying that a doctor looked at the notes and that everything was fine for this person to have it.

The patient has to get to the vaccination centre five or ten minutes before their appointment.

The day I went to get vaccinated it was really cold. When I got there, there were already probably 10 people in the queue, two metres apart, wearing their masks outside the building. Then we had to go in and they checked each of us in, and we were sent to a waiting room.

There was a desk for someone to go through the information. They asked you who you were, did you know what you were doing, did you consent, and had you ever had an anaphylactic reaction. Then you get sent to another place to sit. There were five or six vaccinators and little cubicles with Perspex in between.

The vaccinator then triple checks these details, vaccinates you, and gives you your vaccination card saying you've had your first dose. They give you a yellow Post-it on your coat saying the time, and we had to sit and wait 15 minutes — in case we got an anaphylactic shock or some other reaction. If someone gets a bad reaction, they have to have their second dose at the hospital.

If the Covid vaccination centre had had access to patient notes, if they had had access to the software and system that we use in practices, a lot of this stuff wouldn't have been necessary.

Now they've sorted out the system so that your vaccine coding is going directly in and we're not having to code almost a hundred vaccines into the notes every week. It's just happening automatically.

We're doing the searches, we're doing the calling, and inviting. I don't think our patients are getting a worse service, they probably aren't aware that we're not signed up. What we're not doing is we're not send sending three staff every week down to the centre to do the vaccinations.

Getting local practices to send staff is not a model that's being used everywhere in England. In some places they're getting volunteers, including paying recently retired doctors. It's possible that they're paying for agency staff in some places too.

Zack: As I understand it, the contract makes GP practices and PCNs responsible, perhaps entirely responsible, for the vaccines themselves rather than manufacturers and suppliers. This is despite the generic guidelines which apply to vaccines in general making it quite clear that any negligence or wastage would be the responsibility of the doctor. And the contract can be can be changed at any point, unilaterally — but GP practices will remain locked in until August 2021.

GP: Yes. I contacted the BMA. They didn't actually answer my question properly, but that they said that the only reason a GP themselves would be negligent is if they vaccinated the wrong patient or vaccinated them in the wrong way. Which isn't what the contract said. The BMA also added that the government has agreed to underwrite any risk.

It seems, from the medical press, that lots of other doctors have been complaining, so they've changed those aspects of the contract. But there are parts they never should have had in the first place.

The contract has already changed quite a few times already. So, for example the Joint Committee on Vaccination announcing that they wanted more people to have the first dose, and not worry too much about the second dose being at three weeks. The BMA and the GPC didn't renegotiate that because they had no choice. They have renegotiated other aspects. JVC have recognised that this caused a lot of extra work.

It was probably two afternoons' work for one person phoning those few dozen people. Some people over 80 do have mobile phones, but not that many.

So we were having to ring them, and ring them again, until they picked up. Two of them were very, very rude about it, saying, "Why are you doing this?" We have to explain it was a government decision, it wasn't our decision. They said resentful things like "I bet you're having yours in three weeks!", which isn't true.

Zack: In terms of the numbers alone, the UK vaccination programme, compared to a lot of the world, seems to be doing quite well. It's the highest per capita rate in Europe, and the fourth highest in the world. That said, compared to the government targets, it's doing quite badly. These numbers don't tell you about how the rollout ensures the safety of people getting vaccinated, how well vaccines are being targeted, what wider health care is being dropped, and how much vaccine is being wasted. From your perspective as a GP, how does the programme look?

GP: Health and social care workers should be very, very high priority.

If that was done, that would deal with a very large number of the black and ethnic minority people who are at high risk. It wouldn't deal with all of them.

I'd be very happy to have my vaccine later if I knew the hospital doctors and nurses and staff were getting the second dose at three weeks, because they're the people that need it. One hundred thousand people are off work from the NHS (of slightly over one million), either because of having Covid, or because they are self-isolating or shielding. That is having a huge impact on their ability to care for people with Covid.

Another relevant thing is the studies have been disproportionately on younger, healthier people. In frailer older people the immune response isn't so good. You hear claims about how effective vaccinating the oldest sections of the population first is for saving lives, but they are often slightly nonsensical and using back-of-the-envelope maths. Firstly, the vaccine probably isn't as effective when vaccinating over-80s. Claims are often based on the "94% effective after two doses" statistic. Well, is not 94% after one dose, and probably it won't be 94% in an 80-year-old anyway — because their immune response will be less good.

Secondly, the death rates used to make many of these rough estimations are often based on the care home population in the first wave and first lockdown. Those people are extremely unhealthy in comparison to the 80-year-olds now being vaccinated, because by definition, the latter people are living in their own homes and they're well enough to go to a vaccine centre. The people who are over 80 and too ill to visit a vaccination centre are the group that were dying in the first wave, along with the people in care homes, who are also much less healthy than those being vaccinated.

So many of these broad brush claims are nonsense. You have to bear that in mind when considering the vaccine priority of over-80s as against NHS hospital workers, for example.

Zack: How do you think the BMA has been this last year?

GP: They should have been more assertive and direct with the government about lack of PPE.

They keep saying that they are a trade union. Of course people are not going to walk away from looking after sick patients due to lack of PPE. But I think they should have been really putting pressure on the government.

I accept that negotiating the contract was done in a hurry, but they've known that there was going to be a vaccine by the end of this year, they could have been thinking about negotiating a contract and sorting it out earlier on.

Zack: Has there being much rank-and-file pressure by members of the BMA over these things?

GP: I don't know about the PPE, but with the vaccine contract definitely.

Zack: Anything else you want to add?

GP: This is a very serious situation, and society needs to decide what its priorities are. Obviously, lots of people who are getting Covid are suffering terribly. And it's terrible for people who've lost people from Covid. And the implications of what that means for families is absolutely terrible.

But there are also all the other people who are not able to work and are living on extremely little money. The amount of domestic violence that's going on has increased, and child abuse as well. This is a very, very big issue and we need to take it extremely seriously. The worry as well is that maybe another novel disease will mutate because of globalisation, and all the issues to do with that.

So whilst we should be optimistic about the vaccine, we need to absolutely agitate for more track, trace, support, and isolate. This government has really not been very good at the support. They promised lots of money to councils which didn't come.

But we need support so that people can isolate: financial support for people on zero hours contracts, taking medication to self-isolating people, and all that sort of thing.

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