Executive summary for Series 5: 21to 27 August 2020
This is the fifth of the national surveys of New Zealand general practice experience with COVID-19 and its aftermath. This survey was launched when NZ was in alert level 3, and the rest of New Zealand at alert level 2, due to a cluster outbreak from an unknown source.
Policy recommendations based on responses
It is concerning that some patients with respiratory symptoms are bypassing the triage system to consult directly with their GPs, who are therefore not protected. Messaging to the public around the importance of letting medical staff know about respiratory symptoms when asked should occur. COVID-19 policies and restrictions are also disproportionately effecting the vulnerable: Māori, Pacific, the elderly, the poor, those mentally ill and unemployed. Greater support for vulnerable communities is advised. Some practice staff are under intolerable stress and may require additional support.
Effects of COVID-19 on practices
The strain on practices from COVID-19 has increased with the cluster outbreak, with 90% reporting significant to severe impact, and only 1% reports no ongoing effect. 18% report ongoing effects of COVID-19 leading to staff layoff or affecting leave arrangements, similar to the 20% in S4.
Testing
All but 8% are conducting practice-based testing, with 46% doing over 40 tests per week. There is a range of approaches when patients require testing: 29% conduct these themselves within their practice; 28% refer them to a colleague in-house; 5% refer a nearby designated COVID-19-testing GP or urgent care clinic; and 25% to a community-based testing centre. 88% could test for any reason, with 12% having no testing capacity. 25% of respondents reported there was still lack of financial recompense for testing. Of concern, 41% reported that patients sometimes or frequently presented with respiratory symptoms to them without previously reporting these to reception. A large number of different reasons were proffered for this.
Patients may decide that the rules do not apply to them:
“Don’t think THEY could possibly have COVID” [GP]“Don’t take the time to read STOP signs at the door… think general messages do not apply to them” [PM]“Sense of entitlement or plain stupidity” [GP]“They lie. At least once every day a patient denies symptoms and then admits them in my office” [GP]“Have already made their own minds up that it is not COVID. eg ‘My husband/kids/work colleagues had it last week so it’s just the same thing’!!!!!!!!!” [GP]
They may not want to have the inconvenience of being triaged and tested:
“Didn’t want to be sent elsewhere; didn’t want discuss twice; wanted to discuss symptoms with Dr not staff” [PM]“If they mention it on the phone they think we won’t see them face to face” [GP]“Worried about having to have swabs” [PN]“Don’t want to wait for resp clinic, they think it is not a issue, they lie” [PN]“Worried they maybe directed to a COVID testing station and have to queue” [PN]“If they have symptoms they will see another dedicated doctor not the one they were booked with” [PN]
Their consultation may be for something else, so they do not admit to respiratory symptoms:
“Coming for another issue they see as more important… happened to have a cough or sore throat at the same time…. interpreted the reception staff’s question as what they were coming in for” [GP]“Usually children whose parents add them onto their own consult as an aside” [GP]“Turn up for something else, and after 15 mins indicate they’ve had fever and cough for a week” [GP]
Effects on patient care
Decrease in patient volumes is again an issue, reported by 44% (10% in S4), with 54% reporting that well and chronic care visits are still limited for COVID-19-related reasons (20% in S4). One comments that there are “much less other infectious illness consultations this year”
A number of different issues arising for vulnerable patients are identified, both regarding medical issues “fear reducing presentation”; “missed other diagnoses”; “hospital appointments being deferred”; “mental health issues prevalent”, and also social ones “Need food packs”; “elderly are very fearful”; :”job insecurity”; “increasing anxiety”; “inability to physically get to a CBAC or testing site. no car, can’t take public transport, can’t afford a taxi”; “swamped with patients wanting to be seen now! it makes it hard for the vulnerable to be seen”; “our patients are generally living in poverty and may have no sick leave from seasonal or casual jobs” and “overcrowding, social stigma and fear of COVID”.
Telehealth consultations
55% report they have patients who struggle with telehealth, use of which has again increased under higher Alert levels. 58% of practices are conducting video consultations (up from 31% in S4). Almost all are conducting telephone consultations, and for 55% this is for more than 20% of consultations (up from 21% in S4). 46% are also conducting other types of e-consultations such as via email or patient portal (compare 37% in S4). Reimbursement is an issue for some: “working just as hard but as a lot of our work is on the phone our income is significantly reduced”.
Morale
There are positives. Some practices highlight “understanding patients willing to fit in any change of usual system”. Teams again feature frequently “our practice team has really come together”. One in Auckland under Alert 3 says “easier 2nd time around – all systems in place, e-scripts – staff up to speed and not so anxious about risk”. Another reports “asked to set up a testing clinic starting 9 the next morning. We tested 800 people that day and the next – all the staff in the practice stepped up and were amazing. Excellent team work!!”
However huge workloads, exhaustion and burnout are common themes: “nurses continue to have huge workloads”; “burnout amongst the staff & partners and the constant level of stress”; “overwhelmed by the extra workload.. stressed with the risk”; “constant demand from patients”; “staff are battle weary, patients are ‘COVID complacent’ and everyone is irritable”; “so much change, difficult to keep up with it” and “notable increase of phone verbal abuse from patients”.
One GP writes of being “under severe financial pressure” having earnt only 20% of income while working full-time in lockdown. Now recuperating at home after severe illness requiring hospitalisation but unable to take sick or holiday leave. “Working 10 to 12 hours on my half days and 12-13 hours on my full days. I can go 3 days in a row without seeing my kids.” Worried about personal safety: “Last week a patient kicked me and threatened to kill me and shoot me because I asked them to wear a mask (turns out they had had viral symptoms too!). It is grim out there” and professional safety: “seeing multiple mental health patients, complex elderly, plus “behavioural issues” in children, on a daily basis.. all generating hours of extra work per day, meaning it is dangerous and unsustainable” and “a month or more behind in non urgent paperwork and reading clinic letters…terrified that I will miss something”.
Financial considerations
Most had no issues around personal protective equipment (PPE), but 9% reported reusing or relying on homemade options, and 6% had financial barriers to accessing PPE.
Many report that “income taken a hit”. “Financial viability is in question: ”unsure if we will survive given the huge drop in consultations and non urgent services which help to keep practice afloat”. One GP reported “non-clinical manager is unaware of what she doesn’t know and is making financial based decisions rather than best practice. Won’t listen to the clinicians. It’s scary”.
Method
On Friday 21 August, the fifth of the fortnightly Quick COVID-19 NZ Primary Care Survey was launched. An invitation to participate was distributed to general practice GPs, nurses and managers across the country, disseminated by the RNZCGP, RNZCUC,GPNZ, PMAANZ, RGPN, and NZMA. The survey closed on 27 August.
Sample
There were 231 respondents: 177 doctors (GPs or urgent care doctors), 21 practice nurses [PN], 3 nurse practitioners (NP], and 30 practice managers [PM]. 76% of practices were GP-owned; 75% had more than 3 GPs; 28% independent and part of a larger group, 1% was DHB-owned, 10% owned by a community trust, and 17% as urgent care / after hours. 17% identified as rural.