“For the college, the biggest challenge has been constantly adapting to the changing landscape, ensuring we are getting important information out to GPs and to the general public and adapting how we work to cope with the rapidly developing crisis. I really think that the College and GPs have stepped up to the plate at an unprecedented  and extremely challenging time for the country.”

College medical director Tony Cox and his colleagues have been under no illusions about the size of the task facing them as the Covid-19 crisis continues to develop. Even as we went to press, the testing criteria had been changed with the College and the IMO liaising with GPs on the case definition and new algorithms.

“I think we quickly realised from the start that this crisis was going to be more serious than anything we had dealt with in the past and that we had to act quickly and effectively. Early on, CEO Fintan Foy convened a College GP Advisory & Communications group, which he has chaired and which has been acting as the ‘war cabinet’ throughout this national emergency. 

The other members of this group includes ICGP representatives Dr Tony Cox, and Drs Mary Favier; Nuala O’Connor; Rukshan Goonewardena; Mel Bates; Brian Osborne, John O’Brien, who is national HSE-ICGP Covid-19 lead; Mr Dermot Folan; and from the IMO Drs Ray Walley, Denis McAuley and Padraig McGarry. Another member is HSE primary care GP lead Dr David Hanlon.

The ICGP clinical leads for CVD, asthma, COPD, diabetes and therapeutics: Drs Joe Gallagher, Dermot Nolan, Mark O’Kelly, Diarmuid Quinlan and Paul Ryan have also been on hand to provide guidance in their clinical areas, and, says Tony, all College staff have been working hard to support general practice in adapting to this unprecedented crisis.

“The Covid-19 Advisory & Communications Committee has been meeting regularly each week either face-to-face, before the situation escalated, or more recently by tele-conference every evening. The group also holds regular meetings (now three times weekly) with key personnel in the HSE and the Department of Health for updates – these meetings are also now held by teleconference. 

“Through this process we can act as a conduit for all the questions and concerns of general practice and then clarify and act upon those, and in return the HSE-DOH give us up-to-date information for us to communicate to GPs on the evolving pandemic situation. 

“Everybody on our committee, as well as liaising with the HSE/DOH, is also available for media interviews. Our president, Mary Favier and infection control lead, Nuala O’Connor have perhaps been the most frequent public faces of the ICGP and general practice during this crisis and I think they have been outstanding communicators. 

“Our colleagues in the IMO, and most notably Padraig McGarry, Denis McCauley and Ray Walley have also participated in all media outlets. The messaging across all of general practice needs to be consistent and accurate and I think we have achieved that,” said Dr Cox.  

Ongoing concerns

Tony says there have been a number of concerns raised by GPs with the College. “I think an ongoing concern has  been the availability of personal protective equipment (PPE). Following our liaison process with the HSE/DOH, the supply situation hopefully will improve. Testing delays too, have been a frequent concern. 

“Other issues raised have included ensuring that GPs are up-to-date with the HPSC algorithm for dealing with patients with symptoms, which has changed as the situation has developed. We advise GPs to check this twice a day on our Clinical Hub at www.icgp.ie/COVID19 and also to check on our regular email notifications.”

Tony Cox says GPs have also raised concerns about specific situations; for example, what to do if a staff member has symptoms, implications for other staff if that staff member tests positive, etc. Another frequent query has been what information to give to patients about self-isolation.

“Then there are queries about specific therapeutic issues, for example there were some concerns and confusion about ibuprofen use and hypertension medication. It’s a question of getting out accurate information to GPs, and to the public in answer to these queries. But a key message we are always emphasising for GPs and the public is the basic requirements – hand hygiene, cough etiquette, physical distancing, etc.”

College resources

“Our Clinical Hub (www.icgp.ie/COVID19) has played a key role in getting important information out. The Clinical Hub is updated daily and includes HPSC guidance, algorithms, information on infection control, PPE, notifications, resources and links, GP self-care and patient information. GPs should keep checking the College website twice daily and open all email notifications. Dr Nuala O’Connor has organised very informative webinar updates on Covid-19. 

“We are very mindful that we don’t want to overload people with information so we ensure that any information we provide is relevant and as concise as possible. We are organising  regular webinars and teleconferences for GPs.”

Tony says another issue that the College has liaised on is with the health authorities on the changing Covid-19 testing arrangements. “Since mid-March access to testing has centred on GPs, who could refer patients who contacted them for testing, and the criteria for testing at the time widened greatly to any patient with potential Covid-19 symptoms. We are acting as a conduit for possible new cases that contact us and we can if necessary refer them for testing so that public health can identify, contact trace and isolate. A key priority for us here has been to stress it would not be possible to test for and manage Covid-19 referrals through out-of-hours services, as the patient would not be dealing with their regular GP and out of hours is already extremely busy.“

The change towards a GP-centred testing system, says Tony, really hit home on Monday, March 16. “This was one of the busiest days I have ever known in general practice and I think it’s a date that will remain in the memory of most GPs. The phones rang all day long, with patients contacting their GP needing to be referred for Covid-19 testing.

“The Healthlink system through which we were making the Covid-19 referrals at the time slowed down due to the volume of traffic going through it. Thankfully, Healthlink put in place a temporary Healthmail option through which we could also send referrals. This entailed Healthlink staff having to manually input all the Healthmail referrals later; however we were very grateful at the time for this additional e-referral facility. The pressure on the e-referral system has started to reduce and at the time of speaking it seems to be coping with the volume of traffic.”

Support and advice

Some GPs with specific questions contact College asking for support and advice; for example they might have a particularly challenging case and they are unsure how to act. “Myself and assistant medical director Brian Osborne, Dr Nuala O’Connor and other members of our GP Covid-19 Advisory & Communications Committee deal with these queries. We understand that this is a very stressful situation for everybody. Another query we often get is whether there is a fast-track mechanism for GPs and practice staff to get tested for Covid-19 (this has been initiated) and there are frequent queries over availability of PPE and on what the plans are for the next phases of the pandemic.”

Tony says one of the positives to emerge from the crisis has been the vital role IT, video-conferencing and telemedicine has played. “This would include GPs dealing with consultations by phone or video consultation, teleconferencing each other, and setting up WhatsApp groups for mutual discussions, sharing of information and support.” 

He further emphasised, however, it is really important that information is accessed from reliable sources, which is the primary aim of the College website. 

The increased use of IT also extends to the College’s educational activities. Obviously, the Covid-19 crisis and the need for social distancing has affected how training, CME and PCS are performed. “For example, the CME tutors have already started to run CME meetings via Zoom video conferencing. The training programmes around the country are being provided with expanded video conferencing technology so that training can continue on a ‘virtual’ basis. Dr Finola Minihan, CME director, and Karena Hanley, Training director, and colleagues have led out on this and it is a wonderful safety net for all GPs as we work in an increasing stressful environment.”

As regards PCS, GPs have been concerned in the current situation about meeting their PCS requirements by the end of this month. These concerns have been raised with the Medical Council, which has indicated that it will adopt a supportive approach in the current circumstances.

The ICGP annual conference, due to take place in the Convention Centre in May, has been postponed and will now take place (subject to Covid-19 restrictions being lifted) in November. However, around the time the Conference should be taking place in May, Tony Cox says a ‘virtual’ conference is being planned, which would cover Covid-19 and many of the topics from the original programme in a half-day online session on Saturday, May 9. 

As to what will happen when inevitably a number of GPs start to test positive for Covid-19, Dr Cox said that GPs around the country are putting contingency plans in place to deal with this. “This is where local CME tutors and CME groups, and faculties aided by video-conferencing, teleconferencing, WhatsApp, etc are going to play an important role. We are organising ourselves into local groups that can support each other. So, for example, if a local practice had to close due to a positive test on a member of staff, then a neighbouring practice would provide support.”

Tony is struck by how completely Irish general practice has reorganised itself and changed in a matter of weeks. “My day as a GP in Ennis is now spent triaging nearly every patient on the phone or using Facetime or a video-consultation tool. The small number of patients who are given an appointment are asked to wait outside in their car and are called in for a consultation when we are ready. There is no waiting room any more. The ‘waiting room’ now tends to be the patient’s car in the car park. “Because we’ve been forced to work differently we have had to embrace many new solutions, some of which we may have been a bit reticent about in the past, such as telemedicine and video consultations.

“When the Covid-19 pandemic has passed I suspect that GPs will have much more confidence around making greater use of new technology, and will be more willing to consider offering this to patients. I think GPs will be more amenable to using telemedicine in the future in the correct circumstances and with the appropriate safeguards in place.”

Another change Tony has noted is that ‘walk-in’ clinics no longer exist and are unlikely to return to any great extent. “I’ve operated a walk-in clinic in the mornings for over 20 years, but that’s gone now. I doubt that they will come back, and nearly all GPs will very likely operate their practices by appointment only. Even when the crisis ends, we will all be more aware of the need for infection control, particularly as Covid-19 could in future become a seasonal occurrence. 

“I certainly think in the future, in terms of infection control, we will no longer look on a full waiting room as a sustainable feature of general practice. I think GPs will look at having more efficient appointment systems and utilising better time management with consultations.”

Tony says the College is aware of the danger of GPs suffering from stress and possible burn-out in this unprecedented scenario. 

“Everybody is working very hard. The new way of working; doing the bulk of your work by phone or video-consultation, is in itself stressful. You still feel exhausted at the end of the day. Certainly, we need to support each other. WhatsApp groups that have been sprouting up around the country are very helpful. I’m a member of five different Covid-19 WhatsApp groups at the moment. They’re a great source of information and support.” 

Tony believes the Covid-19 crisis has shown the ICGP, and general practice at its best. “I think it’s very encouraging and inspiring to see all the hard work, advice, cooperation and mutual support that is happening in the College, in general practice and in the health service nationally. Everybody is working together to help the whole country get through this difficult period.” 

GPs are advised to check the Clinical Hub for updates twice a day at www.icgp.ie/COVID19