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25 March 2020

Dr Phil Whitaker: Even at our provincial surgery, the reality of the coronavirus crisis is affecting us deeply

 In less than a week, we converted the practice to a “triage” model.

By Phil Whitaker

The tipping point for our GP practice was Monday 9 March. We’d been monitoring the Covid-19 situation carefully; there was an increase in the numbers of patients getting it with no travel history or contact with a known case. The virus was out there and spreading.

There was no guidance from NHS England at that stage. In less than a week, we converted the practice to a “triage” model: no one can book an appointment without speaking to a GP first. We’re dealing with everything we can by phone to reduce the numbers coming in. People without respiratory symptoms who need to be seen get booked into “cold” slots. We’ve created a two-metre perimeter in front of the reception desk and appointments are timed to keep the waiting room as empty as possible.

The presence of a fire exit in one of the consulting rooms means we have a “hot” room with its own entrance. This has been stripped of all but essential furniture and equipment. Any patient with fever, cough, or breathing difficulty whom we judge needs face-to-face assessment is seen in there by a doctor clad in the personal protective equipment NHS England has since supplied – which is sub-standard, according to the World Health Organisation, but better than nothing. We’ve created a quarantine zone in the car park outside the fire escape. Patients wait in their vehicle until fetched by the GP, entering and exiting by this door.

On 12 March, the UK government announced it was ceasing attempts to contain the virus and was seeking to delay its spread through tightened self-isolation. I am writing this just ten days later, which feels bizarre: so much has happened, it is as though time has telescoped. We had a huge surge of calls from patients with viral symptoms, some frightened, some disbelieving what the media was telling them. Angie, in her forties and with a chronic hypomania, was one of them. “Have you been on gov.uk?” I said. “All the information is there.”

“I can’t touch the computer,” she told me. “It’s crawling with viruses.” This could have been a realistic assessment of her malware problems, or it may have been a Covid-inspired delusion. I had so many other people to ring, I didn’t have time to find out.

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Prescription requests went through the roof, people attempting to stockpile medication like loo roll. The work involved in safely managing this spike in demand added significantly to the strain we were under. In spite of our efforts, the nearby pharmacy ran out of the commonest asthma inhaler within days. By the end of last week, though, we were eerily becalmed. Colleagues in different parts of the country have reported the same. It is as though a wave of panic had engulfed us then receded from the shore.

It feels unsettling, like the swell and fall of the ocean that precedes a tsunami. Our local hospital now has several confirmed Covid-19 cases in its intensive care unit (ICU). As a provincial area, we’re lagging behind London; the news that Northwick Park hospital in Harrow recently ran out of ventilatory capacity, and that several others in the capital are struggling, felt like a harbinger. 

Patients who would have stayed in hospital while their discharges were planned are now being dumped back home to create extra bed capacity. We are scooping them up as best we can, not helped by the fact that overlapping periods of self-isolation left us with no district nurses for several days.

Meanwhile, the usual stuff keeps occurring. We had an 84-year-old suffer a cardiac arrest in surgery, from which she mercifully came back. It took an hour and a quarter for the ambulance to arrive. Another patient in her mid-fifties with a bowel tumour has had her urgent outpatient appointment postponed twice; we still can’t get an answer as to when she will be seen. These are the “standard” patients who will also suffer as a result of Covid-19.

I am following international developments closely. The truth is, no one knows how best to manage a pandemic with these particular characteristics. China and Singapore have gained control through stringent population-based restrictions. South Korea has done so through a vigorous campaign of testing and quarantine, avoiding limiting the majority of its citizens’ freedoms. The UK policy is based on modelling that suggests that suppressing the pandemic now simply postpones the crisis until next winter. The aim of our self-isolation and social distancing policies is to keep case numbers within the limits of NHS capacity. 

We are following the same trajectory that Italy was on 14 days ago, and the behavioural theories that are informing policy seem, to me at least, to have misjudged people’s willingness to take action on a voluntary basis. If we are to avoid our health service collapsing as Italy’s has, something has to change. I increasingly think we should be buying time with a Chinese-style lock-down: time to understand the biology of the virus; to upscale our ICU facilities; to increase our testing and isolation capabilities; to seek a vaccine and understand potential treatment options.

I saw my first Covid-19 case out-of-hours, unwittingly referred by 111 with a “chest infection” not responding to antibiotics. When you’ve seen innumerable patients like this, the atypical leaps out. He still had a high fever five days in, and his examination findings didn’t fit. He was wearing a face mask and I took all due precautions as soon as I realised. He didn’t qualify for testing and contact tracing; all I could do was to stress the importance of self-isolation.

It was a chilling sensation, meeting our adversary for the first time. And it was a great relief for me to have passed the incubation period and remained well. We had the sobering news this weekend of the first two UK medics needing intensive care with Covid-19; one of them did not survive.

Dr Phil Whitaker’s column is now weekly

This article appears in the 25 Mar 2020 issue of the New Statesman, The crisis chancellor