When baseline workload is high it is difficult to proactively take steps to move forwards—something that no doubt many healthcare professionals are familiar with. But certain situations can act as catalysts, increasing the rate at which change takes place. Coronavirus means that we are doing things differently through necessity; to reduce the spread of infection face-to-face contact has almost disappeared and there has been a seismic shift to online meetings.

In primary care, more consultations than ever before are happening remotely. Our recent survey about the impact of COVID-19 on primary care highlighted that: 

  • 74% of respondents reported no face-to-face consultations with patients with COVID-19 symptoms
  • 72% of respondents reported that more than half of their consultations with patients without COVID-19 were by telephone.

Around half of respondents reported that they are less busy than normal, and only 20% of respondents feel they will not have time for learning and continuing professional development. If you are interested to learn more about the results from our survey, read the report at: GinP.co.uk/covid-survey-results

COVID-related changes in primary care are not just limited to the format of consultations. Dr Toni Hazell highlights some important adaptations to death certification procedures that have come into force following the Coronavirus Act 2020. These changes are aimed at simplifying the process of registering a death and completing the necessary paperwork for cremation, to reduce unnecessary infection risk and workload for medical practitioners. Read the article to learn about who can verify deaths in care homes and in the community during the COVID-19 pandemic, criteria that must be met for any doctor to sign a medical certificate of cause of death, circumstances that merit referral of a death to a coroner, how to apply for cremation, and where to access the relevant guidance. Dr Hazell has also condensed the key messages in a 5-minute video—watch it online at: GinP.co.uk/video-deathcert

That’s not to say that change only happens in the event of a global pandemic. In the context of clinical guidance, change is important; recommendations should always be underpinned by the most up-to-date and robust evidence. As new evidence is published, guidance is updated and so best practice changes over time. For busy healthcare professionals, keeping abreast of these continuous changes can be challenging. Guidelines in Practice aims to support you with keeping up to date with new guidance, and this issue includes three articles that focus on recently updated guidelines.

NICE first published a guideline on venous thromboembolic diseases in 2012. Since then, new evidence has emerged and practice has changed relating to diagnostic tests, prognostic tools, investigations, and treatments for venous thromboembolism (VTE). In March 2020, NICE published a new guideline which includes updated recommendations to reflect the new evidence and changes to practice. Dr Frances Akor and Professor Terry McCormack outline the important changes to the guideline recommendations with a focus on those that are of particular relevance to primary care, including new recommendations on D-dimer testing, outpatient management of low-risk pulmonary embolism, and anticoagulation treatment. The updated guideline represents an opportunity for primary care to be more involved in certain aspects of the management of VTE, and moving these services out of secondary care into primary care is expected to improve patient experience and deliver cost savings. However, this is likely to require significant change; in some localities pathway redesign and investment in point-of-care testing will be required.

SEM image of a blood clot

Venous thromboembolism in adults: NICE updates

Dr Frances Akor and Professor Terry McCormack

Guidelines may also be changed or updated if there are concerns about the safety of medicines recommended within a treatment pathway. An example of this is the Primary Care Dermatology Society (PCDS) has recently updated its Actinic keratosis primary care treatment pathway, removing topical ingenol mebutate as a treatment option while the European Medicines Agency conducts a review of the medicine’s safety. Dr Kash Bhatti summarises the updated recommendations made in the PCDS actinic keratosis pathway, provides a reminder for how to diagnose and manage the condition, including practical tips for managing patient expectations about treatment outcomes to improve adherence.

Malnutrition is an important consideration in people with chronic obstructive pulmonary disease (COPD) and guidance is available to support the nutritional care of patients at risk of or experiencing disease-related malnutrition in primary care. The first Malnutrition Pathway best-practice guide to managing malnutrition in (COPD) was published in 2016. In January 2020, an updated version was released, which incorporates recent guidance from NICE and the Global Initiative for Chronic Obstructive Lung Disease, and updated evidence around nutritional requirements and interventions for people with COPD. Dr Anita Nathan highlights key learning points from the updated guide, covering routine screening for malnutrition, managing malnutrition according to risk, ensuring nutritional support is acceptable and effective, and when to refer for dietetic input. People with COPD are at increased risk from COVID-19 infection, and malnutrition impairs the immune system making people more vulnerable to infection—read the article for important COVID-19 considerations for this patient group.

Lastly, in their View from the groundDr Emily Tyer and Dr Safian Younas describe how they moved a careers event for ST3 trainees online so that it could still go ahead when weekly VTS training days and time for in-house education were cancelled to manage an expected increase in COVID-19 workload. The authors highlight the importance of keeping learning going: ‘To lose medical education would be a tragic casualty of this pandemic … the crisis will come and go and trainees still need to be prepared to ensure they are ready to deal with the workload that will undoubtedly come in its wake.’

Major events engender change and there is no doubt that the coronavirus pandemic has done just that. The question is, which changes are here to stay, and which will fade away when all this becomes a distant memory?