Caring for COVID-19 in the community: devil in the details

FEDERAL Health Minister Greg Hunt’s “really simple proposition” to have GPs and other primary care practitioners treat patients with COVID-19 in the community rather than in hospital is proving to be anything but simple, as GPs, Colleges and medico-legal experts grapple with the scant details on offer.

Dr Karen Price, President of the Royal Australian College of General Practitioners, told InSight+ that the all-important details of how community care of COVID-19 will look would come down to a hyperlocal approach.

“Each GP and practice manager is going to have to work out how this is going to work for their particular practice,” Dr Price said.

“It depends on the particular conditions – does the practice have the ability to see patients who might be COVID-19-positive in a separate environment, like an isolation room, or a set-up in the car park? Does the GP have their own health vulnerabilities that puts them more at risk? What are the social circumstances of the practice’s patients?

“Those are just some of the questions each practice needs to work through before deciding whether to care for patients with COVID-19.”

Georgie Haysom, Head of Research, Education and Advocacy at medical defence organisation Avant Mutual, told InSight+ the plan for GPs to care for patients with COVID-19 in the community raised “quite a few concerns” from a medico-legal point of view.

“There will be a steep learning curve for GPs who choose to be involved with this, because they haven’t previously been involved in treating people with COVID in the community,” Ms Haysom said. “There’s a lack of familiarity that they may have with COVID-19 that may lead to an increase in medico-legal risk.

“Also, the current GP model of care isn’t really well suited to providing regular monitoring of patients.

“Another risk is the nature of the infection itself, which can have a sudden deterioration.

“Another issue that we have that increases medical legal risk is around the lack of consistency and lack of consistent approach across jurisdictions,” Ms Haysom said.

“In some states, that inconsistency is also within jurisdictions. We found that there are different approaches that have been taken in different states. So, for example, South Australia, I understand is going to be taking a statewide approach, whereas New South Wales is taking a very much localised approach, involving the Local Health Districts and the Primary Health Networks.

“That lack of consistency is problematic.”

Ms Haysom said the biggest risk was the effect the pandemic has already had on GPs.

“The final concern we have, which gives rise to medico-legal risk, is the poor GPs who are stressed and exhausted from having to deal with COVID-19 over the last 2 years,” she said.

A risk assessment process was vital, Ms Haysom said.

“There are a couple of conflicting duties at play here,” she said.

“There’s the Workplace Health and Safety obligations to keep your staff safe, and the people visiting your premises are safe. And then you’ve got your duty to the patients.

“They could potentially be in conflict.

“Therefore, it’s really important that doctors do a risk assessment. They need to consider what control measures can they implement to reduce the medico-legal risks to themselves and their staff.

“That might mean thinking about where to see patients who may have COVID or are suspected of having COVID; what [personal protective equipment] to use. Does it mean seeing COVID patients at different times of the day, perhaps.

“Ultimately, we are really concerned about the stress that this places on the workforce, so we’re particularly keen on making sure that [GPs] are properly supported.

“Having good clinical guidance would be really helpful, as would a consistent approach across the jurisdictions.”

Dr Price said the College’s COVID-19 Working Group was putting together a document of “overarching principles which will need to be adapted for local environments”.

“That will include guidance for diagnosis, risk factors, monitoring, as well as decision tools.” A timeline has not yet been finalised for that document, although Dr Price assured that it was “a high priority, given this is a living situation”.

As was the case with the COVID-19 vaccination rollout, GPs on the frontline feel like they have been left out of the communication loop when it comes to details of how “care in the community” will look and work.

Dr Angela Rassi, a GP in Sydney’s inner west, told InSight+ there had been “very little official communication” about the plan, other than the announcement of a $25 Medicare Benefits Schedule (MBS) rebate for face-to-face consultations with people with confirmed or suspected SARS-COV-2 infections.

“At the moment, most COVID-positive patients in the community are being treated by remote hospital teams who call them every day,” Dr Rassi said. “GPs have had very little to do with it.”

In her clinic, Dr Rassi said, patients with suspected COVID-19 symptoms rarely made it through the front door, as they were sent to government respiratory clinics for testing, before they entered the GP clinic itself.

“The $25 MBS rebate is supposed to cover the extra costs of setting up separate facilities, extra staff, and the extra personal protective equipment,” she said. “If we are visiting people in their homes, it also has to cover travel time, petrol costs, and the time spent away from our regular clinic.

“It’s pretty disappointing and it feels disrespectful of the work we do.”

Dr Rassi said GPs were already working to their limits administering the vaccination rollout on top of their usual patient load.

“We worked out how to make the vaccination rollout work – you figured out a way to make it viable,” she said.

“This [care in the community program] is not so easy to navigate.”

Dr Price pointed out that GP clinics were free to add an “infrastructure fee” on to the basic consultation cost if they felt the rebate was not sufficient to cover the extra costs of being a doctor seeing patients with COVID-19.

But Dr Rassi said it wasn’t as simple as that.

“They’re expecting GPs to either absorb the extra costs, or pass it on to the patient by charging them more. Many of us are in bulk-billing clinics. Our patients can’t afford to pay more.

“As GPs, we are contractors. We don’t get sick leave. If we contract COVID-19 from a patient and have to take time off, we don’t get paid.

“Ultimately, I believe there should be more government respiratory clinics, rather than relying on GPs in their local clinics.”