Covid19 Daily Briefing 23 March

**Email sent on behalf of the LMC, Clinical Directors and NHS Calderdale CCG**
Hi everyone
General Update
Key Contact for Primary Care queries in Calderdale is via the CCGs Transformation email: please direct queries here, rather than to individual staff, so that we can collate and then share a response through the daily bulletins to keep everyone informed.
Over the weekend, a number of new communications have been received which require urgent action, dissemination and provide support for primary care.
CAS ALERT 2020/011 -
Much of this is about the focus on the six urgent priorities which were set out in Nikita Kanani’s letter to GP practices of 19 March 2020.
As a reminder, the six priorities for primary care are:
1.   Move to a total triage system
2.   Agree locally with your CCG which practice premises and teams should be used to manage essential face-to-face services.
3.   Undertake all care that can be done remotely via appropriate channels
4.   Prepare for the significant increase in home visiting
5.   Prioritise support for particular groups of patients at high risk
6.   Help staff to say safe and at work, building cross practice resilience
We have a meeting with LMC, Clinical Directors and CCG today to work things up further and I know there have been discussions on Friday in PCNs. It is likely that we will have to move to this way of working by the 30th March 2020 at the latest.
1.    Identifying and shielding the HIGHEST risk patients of Covid-19
1.1 National letters
Over the weekend, three letters were cascaded to GP practices and Trusts to address priority 5 – prioritise support for particular groups of patients at high risk.
The letters for GP practices are attached as follows:
a)    Letter from CMO and National Medical Director (includes Annex 1)

b)    Method for clinical groups – Annex 2

c)    Final patient letter for GPs to use for additional patients – Annex 3


1.2  In summary, this information explains that:
·         Adults that meet the criteria of being eligible for an annual flu vaccine have been given public advice. These patients will not be proactively contacted but have instead been asked to take steps to reduce their social interactions in order to reduce the transmission of coronavirus.

·         There is a subset of this group who have clinical conditions which are likely to put people at the highest risk of mortality and severe morbidity from COVID-19.

·         Emerging clinical data about COVID-19 indicated that the death rate would be high for groups of people with particular chronic diseases.

·         GP practices are likely to know of specific additional patients in your practice who you think are particularly high risk. This is going to require some clinical judgements by clinicians about your patients.

1.3  Of the most at risk patients:


a)    Some will be contacted centrally by NHS England

b)    Acute Trusts (in specific medical subspecialties) will be asked to identify and contact additional patients in their caseload

c)    The Academy of Medical Royal Colleges to cascade general guidance for hospital specialties to help them identify and contact further high risk patients from their caseload;

d)    Guidance will be issued to GPs to help them identify and contact high risk patients from their own caseload (for example those with severe multi-morbidity)

e)    A letter will be sent to these patients asking them to stay at home at all times and avoid any face-to-face contact for at least twelve weeks.


1.4  What happens next?
·         The patients of your practice that have been contacted directly can be identified through an “at high risk” indicator code that has been applied to each patient record by your clinical system supplier. Your supplier will inform you of the code they have used, which should be treated as temporary until a definitive list of COVID-19 ‘at risk’ SNOMED codes is released

·         A copy of the letter sent to patients can be found in Annex 3.

·         The RCGP will shortly publish guidance to support GPs identifying additional high risk patients. The guidance will also support GPs to have shared decision-making conversations with all high risk patients as needed, and help GPs to understand what health needs these groups may have.

·         GPs will be asked to contact these groups directly to recommend they are considered for inclusion in the shielding group.

·         If you choose to identify additional individuals you consider being at highest risk of severe outcomes, you will be required to proactively contact this group of patients to discuss your recommendation with them. Many patients who fulfil the criteria may, after discussion with you, prefer not to be placed under such strict isolation for what will be a prolonged period. We also suggest that anybody with a terminal diagnosis who is thought to be in their last 6 months of life should be excluded from this group.

·         It will be important to link closely with our social care colleagues, Community Pharmacists, Social Prescribing Link Workers and the Voluntary sector to offer a great deal of support to these individuals.

As a CCG in Calderdale we are seeking to provide support through assisting with some of this work and would like some thoughts over where we would be most useful in this.
2.    Guidance On Supply And Use Of PPE
We are aware some guidance around PPE was shared by NHS England but we are clarifying the exact process for Primary Care supplies and will update asap.  We are also escalating the requirements and stock issues raised by practices around PPE.
Key points to note are:
·         Expiration date queries: It has been a common query about why do the FFP3 masks have a different expiry date? The response provided is as follows : Some products may appear to have out-of-date ‘use by/expiration’ dates or have relabelled ‘use by/expiration’ dates. Please be assured products we are issuing have passed stringent tests that demonstrate they are safe. The PPE is exposed to extreme conditions for prolonged periods to see how the product deteriorates. Any that are not up to standard are destroyed and are not distributed to trusts

·         Face mask or FFP3 - When to use a Face Mask or FFP3 (acknowledging that there are supply issues):
·         Posters which you may want to print and display in your consultation rooms with advice for putting on and taking off PPE:
a)    Link to Poster –putting on PPE:

b)    Link to Poster – taking off PPE:

·         PHE advice is - surgical masks, apron and gloves are adequate protection when routine examining COVID patients within 1 metre.

·         Single-use only - All PPE that is used when encountering confirmed cases of COVID-19 is single-use only and should be changed immediately after each patient and/or following completion of a procedure or task.

·         Clinical Waste - PPE should be disposed of after use into the correct waste stream i.e. healthcare/clinical waste (this will require disposal via orange or yellow bag waste).

3.    Covid-19 Testing
We know that the availability of testing is a common query and is a specific concern for healthcare professionals, who we know are keen to be able to fully support the response and their colleagues. We are expecting further information on the increase in testing imminently but in the interim, the following updates have been provided locally:
·         Calderdale and Huddersfield Foundation Trust (CHFT) are following national guidance relating to Covid-19 testing and are not testing their own staff.  They will be looking to support primary care as soon as they are able.

·         Mid Yorkshire Hospitals Trust (MYHT) are not currently analysing tests but are preparing for it.

·         Below is the national priority order for analysing the samples:

-       Group 1 (test first): patient requiring critical care for the management of pneumonia, acute respiratory distress syndrome (ARDS) or influenza like illness (ILI)†, or an alternative indication of severe illness has been provided, for example severe pneumonia or ARDS

-       Group 2: all other patients requiring admission to hospital* for management of pneumonia, ARDS or ILI

-       Group 3: clusters of disease in residential or care settings, for example long term care facilities and prisons

Consideration is being given to:
All Kirklees tests have been directed to Leeds microbiology and they are at maximum capacity
CHFT introduced local analysis capability on Friday 20 March 2020. This has the potential to be much faster than Leeds.
Availability of testing kits - this is being prioritised nationally.
As soon as further information and clarification is available relating to the new antibody testing as announced by the Prime Minister last week, we will action and disseminate as soon as possible.
4.    Building Cross Practice Resilience through Triage First and Remote Consultation
·         Following feedback from patients, OOHs providers and acute trusts this week, it is evident that there is sometimes a perception that practices are ‘closed’ or are refusing care and we know that is not the case and not the advice which has been given nationally or locally.
·         In Calderdale, we have issued media releases and social media updates to try to explain to patients how the general practice model has switched to ‘triage first’  and is likely to mean that practices will have to work together.
·         Local Care Direct are adopting the same guidance as practices and ensuring ‘triage first’ but if face to face visits are required, they are continuing to visit taking the appropriate precautions and with PPE.
·         To support triage first and remote consultation of people with potential Covid-19 cases, there is a paper attached relating to assessment of respiratory distress through the use of the Roth Score.
5.    Cancer Alliance Guidance – 19 March 2020
The following advice was issued to the Cancer Alliance on 19 March 20 in relation to Covid-19.
The guidance below should be interpreted as modifying existing Cancer Waiting Times guidance with immediate effect (19 March 2020) until further notice:
·         On receipt of a 2ww referral, providers should ensure that as far as possible telephone triage is available to stream patients directly to a test where appropriate and minimise interactions and appointments with health services.
·         A telephone appointment with an appropriate specialist clinician as detailed in Cancer Waiting Times guidance will be accepted as ‘first appointment’ for the purposes of recording Cancer Waiting Times data until further notice.
·         The policy remains that providers receiving referrals may not downgrade urgent cancer referrals without the consent of the referring primary care professional. Where capacity is particularly constrained providers should ensure processes are in place to prioritise particularly urgent referrals, including greater communication between primary and secondary care to downgrade or avoid referrals where possible.
·         Where referrals are downgraded or avoided outside the usual policies and NICE guidance, providers should seek to ensure appropriate safety-netting so that if patients deteriorate or their risk of a cancer diagnosis increases, they can be appropriately referred for further investigation.
All providers receiving cancer referrals should continue to stay alert to any further changes in this advice following updates from Government and NHS England and NHS Improvement.

6.    Nice Rapid Guidelines and Evidence Reviews

NICE are supporting the NHS and social care to respond quickly to the challenges of the coronavirus pandemic. We've brought together information that may help you.
The first 3 guidelines cover care for people receiving:
·         critical care

·         kidney dialysis

·         systemic anticancer treatments.

They're developed in collaboration with NHS England and NHS Improvement and a cross-speciality clinical group, supported by the specialist societies and royal colleges. We're using a different approach to normal in order to develop these quickly.

7.    Coronavirus infection and pregnancy

See attachment – Maternity Comms with Primary Care
8.    Urgent Update from CHFT

As the system continues to plan for further escalation of Covid-19 demand, CHFT, in line with other acute trusts nationally have identified changes to their current service offers.  This is to ensure that their workforce is mobilised to support current and predicted acute activity.  The following provides an overview of the CHFT changes:
·         Closed to all routine referrals from Monday 23 March 2020
·         Cancer 2WW referrals will continue – the Trust have deployed staff to try to create resilience in each tumour site pathway
·         Closed to routine diagnostics; MRI, Echo, Neurophysiology and ultrasound
·         Will continue to offer capacity for Urgent diagnostic referrals but please ensure you provide sufficient details to explain rationale for urgency
·         To establish some locality phlebotomy hubs -  PCN Clinical Directors will be asked to consider optimum sites
·         No out-patient clinics at Todmorden Health Centre
·         Implementing national guidance on rapid discharge pathways
CHFT will continue to keep you updated as things progress.
Thanks very much and apologies for the late circulation.
Dr Caroline Taylor CCG, Dr Seema Nagpaul LMC, Dr Fawad Azam CD, Emma Bownas

Attachmens are here