COVID-19 Response Lewisham and Greenwich Trust – GP Communications

10 November 2020

1. Changes to referrals at Lewisham and Greenwich Trust

Referral type

Non-Covid services – We understand that patients may be nervous about coming into our hospitals and patient safety measures community sites for treatment, but please be reassured that we are doing everything we can to protect you from Covid-19.

The risks of not having treatment can be higher than the risks of Covid-19.

Our safety measures include: • Ensuring that our staff have the right PPE to keep you safe • Seeing patients coming in for planned care in dedicated part of our hospitals – well away from those receiving treatment for Covid-19 • Asking everyone who enters our buildings to wear a face covering or surgical mask (unless exempt) – we will provide them with a mask if you don’t have one • Installing clear signage within our hospitals to remind people to socially distance.

You can find more information on our website. Referrals – Please refer as normal and attach the referral letter at the point of referral / within Suspected Cancer 24 hrs. Please let patients know about the safety measures that we have taken to (Two Week Wait) keep them safe.

While we understand patients' reluctance to attend hospitals we need your help to explain to patients that a delay in a cancer diagnosis could make it much harder to treat successfully. Urgent referrals Please make referrals via the usual routes. The Trust will triage the referral and either book into a virtual appointment or arrange a face-to-face appointment if necessary. Please see above for the steps we are taking to keep patients safe if they are coming to the hospital for planned care. Routine referrals Please continue to make routine referrals through the NHS electronic referral service e-RS.

If you would find advice from a consultant helpful, please use Consultant Connect or Advice & Guidance where appropriate

Patients booked for an To reduce the need for patients to attend our hospitals for appointments, we are outpatient appointment managing appointments via phone or video consultations where this is clinically appropriate. More information about our video consultations for patients and a troubleshooting guide is available on our website.

Where a face-to-face appointment is necessary, we are asking patients to attend alone if possible unless mobility or communication difficulties make this impossible. We are asking that patients arriving by car are dropped off and collected when their appointment and any on the day tests are complete.

All urgent and 2WW patient follow ups will be managed in the usual way. Some may be converted to a telephone appointment if suitable.

Services with a Referral The RAS service is open on eRS for referrals for our services. Assessment Service (RAS) (Blue button) Services with a Clinical Please refer as normal ensuring the referral letter is attached ASAP. No review can Assessment Service (CAS) take place until the referral letter is available. (Blue button) Please book a dummy appointment for the patient as normal but advise them that there may be a delay in hearing from the Trust. Please make sure the patient is aware that it is a dummy appointment and that they should not attend the hospital on this date and time. Radiology General update We are endeavouring to provide a normal radiology service currently, and still have a couple of imaging modalities (Non Obstetric Ultrasound, and Dexa) to fully recover post Covid-19 outbreak wave 1. This recovery work is ongoing and hoped to be concluded shortly.

In general, we would ask that referrers consider carefully whether the imaging will genuinely have an immediate or significant clinical management impact on the patient’s management before generating a request. This is really important as we prepare for the imminent next Covid 19 outbreak.

We have observed a significant increase in urgent and two week referrals from General Practitioners : • Going forward, please be aware that we will be applying a more rigorous clinical vetting procedure and challenging / refusing any vague clinical requests in line with Royal College of Radiologists (RCR) and British Medical Ultrasound Society (BMUS) guidance.

• For urgent requests, please tell us what other supporting abnormal clinical information you are aware of eg abnormal LFTs which justifies these referrals being expedited.

• Please write on the radiology request, the clinical question you want answering.

• Please refrain from requesting multipart imaging examinations unless clinically indictated so greater focus can be given to the presenting complaint.

• Please provide a summary of the patient history , in support of the imaging request. We do not need a full copy of the most recent GP consultation.

Therapies Including We request that you do not refer any non-urgent referrals for outpatient therapy Physiotherapy, intervention. Occupational Therapy, Speech and Language Dietetics Therapy, Dietetics, All patients will be offered a virtual appointment. In some cases we are able to see Podiatry & Orthotics vulnerable or clinically suitable patients face-to-face. This will be decided on a case by case scenario.

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Physiotherapy and Speech and Language Therapy Please make referrals via the usual routes. NB for the current time we are not providing our usual physiotherapy walk-in clinic for acute injuries at Lewisham hospital but please refer and we will see urgently.

To reduce the need for patients to attend our hospitals for appointments, we are managing appointments via phone or video consultations where this is clinically appropriate. Patients that do require face-to-face appointments will be offered this in the department, where strict IPC and social distancing is being followed.

Podiatry Service remains open. Clinic appointments can only be booked via telephone and all new referrals to be emailed to [email protected] for triage.

Orthotics Service remains open. All referrals via eRS

Prescribing Medicines that would usually be prescribed via GP should continue. When the patient is seen by a non-face to face means and the prescription is issued by the hospital the medication can be collected by the patient or their representative from the Hospital Pharmacy. Alternatively it may be posted to the patient with the exceptions of: urgent medicines, fridge items, schedule 2 & 3 controlled drugs, cytotoxic medication, liquid medication, clinical trial medications or high cost drugs; these will be sent by courier.

2. Service delivery changes

Service Covid recovery clinic Lewisham and Greenwich Our respiratory teams have set up post Covid-19 clinics for patients who are still experiencing symptoms after being discharged from Queen Elizabeth Hospital or University Hospital Lewisham. Some of these patients may still have symptoms such as breathlessness and fatigue and could benefit from further treatment or rehabilitation.

If a previous Covid-19 patient is already known to the hospital, they should receive a call from us to assess their ongoing symptoms. However, if they did not attend hospital at the time of their illness, they should be referred as a ‘Post COVID’ case via RAS which is being re-opened on eRS. For more urgent queries, please contact the respiratory team via ‘Advice and Guidance’ or Consultant Connect.

Phlebotomy services Over summer 2020, Phlebotomy were required to move from walk-in to a booked service to meet infection control guidelines and maintain patient safety. To support this, the Trust introduced a central booking line - 020 8333 3217. In response to issues with the booking system, the the Trust has increased the number of call handlers and lines from six to 20 and has introduced the latest helpline technology (to ensure that callers are not cut off). The Trust website also now has an online form which can be completed so that we can call the patient to agree their appointment. https://www.lewishamandgreenwich.nhs.uk/book-a-blood-test

Some appointments in October 2020 recently had to be cancelled due to an NHS supply issue. Where this was the case, the Trust has been contacting patients directly to reschedule their appointments.

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Cardiology Diagnostic Bexley, Greenwich and Lewisham Services ECG Service The Electrocardiogram (ECG) walk in service is now an appointment only service. Patient who require a GP ECG should be asked to contact us directly on the numbers below to arrange the timing of their ECG. Queen Elizabeth Hospital – 020 8836 4443 Lewisham Hospital – 020 8 333 300 ext 6147

GP Echocardiography and 24Hr Holter Service Please continue to refer all patients via the Diagnostic eRS system and the service will continue to book appropriate patients while holding shielding patients on a wait list.

GP Ambulatory Blood Pressure Service – Bexley and Greenwich only Remains suspended. Please continue to refer all patients via the Diagnostic eRS system and the service will continue to hold referrals on a wait list.

If you would find advice from a consultant helpful, please use Consultant Connect. Early Pregnancy Unit Patients presenting to GP surgeries with early pregnancy complications who meet the criteria for referral to the early pregnancy unit should still have a written referral as usual. However please could the patients be asked to contact us directly on the numbers below

EPAU Lewisham telephone triage: 0774 833 3103

EPAU Queen Elizabeth telephone triage: 0774 833 3105 to arrange the timing of their assessment by the early pregnancy unit.

Midwifery Antenatal and Some early appointments such as the initial risk assessment (booking) are now being Postnatal Pathway carried out over the phone.

From 24 weeks “in-person” appointments are arranged in the midwifery hubs across the three boroughs of Lewisham, Greenwich and Bexley.

Fetal/ Maternity Day Units and Antenatal Appointments At present, the policy remains as women to attend unaccompanied. This includes antenatal appointments in the hospital and the community hubs. Women are welcomed to FaceTime/ video call their support person to have a discussion with the clinical staff during their appointment as the service understands how difficult it is to always remember the plans/discussion. There are plans to enable that this video call be facilitated by maternity via media such as Zoom or Microsoft Teams in situations where the woman is unable to facilitate this herself.

Maternity Ultrasound Scans

When a partner/companion is accompanying a woman to a scan or in labour they are requested to complete the document embedded

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The maternity service understands the importance of scans being a shared experience between the woman, partner, and/ or family. One partner/ named person is welcome to attend the 12 and 20 week ultrasound scan.

Maternity Ward This is applicable to antenatal and postnatal women: A partner or one named visitor can visit the ward between the hours of 14.00- 19.00hrs. This has been in place since 20 July 2020.

A partner or named visitor is advised to bring in a face covering, and adhere to infection prevention practices, and physical distancing wherever possible. These practices include washing hands with soap and water upon arriving on the ward, and not sitting or lying on the woman’s bed.

The named visitor has to be the same person during one visiting episode i.e. no swapping between 14.00 to 19.00hrs. Ideally, the visitor on the day of discharge should be the person taking the mother and baby home.

Community postnatal care The service will see most women on their first day following discharge in their home.

Midwives are working in hubs across the three boroughs of Lewisham, Greenwich and Bexley and inviting women in for the Day 5 visit (when the blood spot is performed).

Information about any changes to our maternity services is posted on our Edie the midwife facebook page and communicated via our Maternity Voices Partnership. Please encourage any pregnant women experiencing reduced fetal movements to contact their midwife. If any further information is required about changes to maternity services please do not hesitate to contact our Director of Midwifery [email protected] or speak to one of our midwives on our maternity helpline: 020 8836 4491.

See embedded document

Home birth service The homebirth service is fully operational

Pregnant women are advised to contact the Maternity Helpline on 020 8836 4491 for any further advice. Birth partners At present a named birthing partner is welcome to accompany women in labour as long as they are well and have no symptoms of COVID-19. Birth partners are asked to leave once their partner is transferred to the maternity ward unless this is between the hours of 2pm-7pm when they are welcome to remain on the maternity ward. 5 | Page

Birth Centres The Birth Centres at Queen Elizabeth Hospital and University Hospital Lewisham remain open to ensure that women continue to have a choice of place of birth. Breast Cancer Services The following outpatient clinics have been temporarily suspended • Family History • Genetics • Plastics Follow up appointments are being rescheduled to 3 months if possible or done by telephone.

Please only refer patients under the 2ww rule if they have a high index of suspicion. Mr Thakar advises that the following conditions should be monitored in primary care for 2-3 months while keeping a diary of their symptoms; • Breast Pain • Gynaecomastia • Non-blood stained nipple discharge Definite lumps of more than 4 weeks duration should definitely be referred.

Gynaecological oncology Please only refer patients for review under gynaecological 2WW pathway if there is a strong suspicion of malignancy. Attached below is a joint guidance from RCOG, BSGE and BGCS on management pathway for abnormal uterine bleeding in the evolving Coronavirus (COVID-19) pandemic. Please note many of these patients should have their basic examination in primary care settings before hospital appointments in order to limit risk of exposure to COVID-19.

3. Visiting our hospitals and discharge arrangements

ADVICE AND GUIDANCE Visiting our hospitals To protect patients, staff and visitors from the risk of infection, we have introduced new visiting restrictions to both University Hospital Lewisham and Queen Elizabeth Hospital.

Inpatients Visitors are no longer allowed onto any of our adult inpatient wards and family members will be asked to instead keep in touch with patients via telephone and video calls where possible. We are working to enable additional video calls to keep patients in touch with their loved ones.

For infection control reasons, we had to make the difficult decision to allow just one visitor (with the agreement of the ward manager) for patients who are critically ill or near the end of their life.

We have received smartphones and tablets to help keep our patients connected to loved ones during the coronavirus outbreak. Any iPhone, iOS or Android device will be accepted. Devices are disinfected, wiped of any data and have communication apps installed. We have also launched an e-card service to enable loved ones to send a message to inpatients to let them know they are thinking of them during their stay.

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Visiting our hospitals To protect patients, staff and visitors from the risk of infection, we have introduced new visiting restrictions to both University Hospital Lewisham and Queen Elizabeth Hospital.

Maternity and children Women attending for pregnancy scans are asked to come alone. However, women in labour in our maternity unit will still be able to bring a birthing partner with them and children under 16 on our inpatient wards will still be allowed one parent or adult visitor.

These have been incredibly difficult decisions to make, but as a Trust we feel these measures are necessary to keep our patients and staff safe. Discharge arrangements We are collaborating with local councils and clinical commissioning groups (CCGs) to speed up the discharge process for patients. The Trust has condensed the paperwork required for patients who need to be discharged home with a care package or to a rehabilitation centre, enabling social service teams to put packages in place much more quickly. We are calling this a discharge passport. This means that much-needed beds can be freed up for more seriously ill patients.

Both University Hospital Lewisham and Queen Elizabeth Hospital are running a 7-day a week discharge service. We are tracking all discharges along with the COVID status to support ongoing care.

During COVID-19 we are following the HM Government COVID-19 hospital discharge service requirements.

When an inpatient is medically fit for discharge from the ward, our discharge team determines which of the 4 discharge pathways they are on.

Acute hospitals are responsible for leading on the discharge of all patients on pathway 0, ensuring that the 50% of patients who can leave the hospital only needing minimal support, do so on time.

Providers of community health services lead on pathways 1-3, playing a lead role in assessing and providing care for patients once they are home.

A discharge passport is completed for pathway 1,2 and 3 and submitted to the respective SPA (single point of access). The SPA will work with the providers to highlight the needs of the patients to support discharge. Therapy and on-going 7 | Page rehabilitation is now being moved to the community.

Contact our hospital discharge teams QEH: 020 8836 4096 UHL: [email protected]

4. Advice and guidance

ADVICE AND GUIDANCE RESOURCE AVAILABLE Consultant Connect Consultant Connect lines are now available for all GPs in South East London for the following specialities: (Local Trust and National Consultant Network • Cardiology Lines) • Dermatology • Diabetes & Endocrinology • Elderly Care • ENT • Gastroenterology • General Medicine • Gynaecology • Haematology • Neurology • Paediatrics • Renal Medicine • Respiratory Medicine (now available at all 3 Trusts) • Rheumatology • Urology

Where available, calls will first go through to your local trust’s specialist team. If the call is not answered, it will pass to the National Consultant Network which now supports all lines throughout South East London. This will ensure as many calls as possible are picked up. e-RS Advice and Trusts are asking that GP teams use e-RS Advice and Guidance as much as possible to Guidance ensure avoidable referrals are prevented. Please monitor worklists daily for advice responses. PhotoSAF share PhotoSAF share: For Lambeth, Southwark and Lewisham GP’s please use Consultant Connect PhotoSAF to send images for Dermatology consultant review, prior to making a Dermatology referral. If you are unable to do this, you can also send images via e-RS. Paediatric advice We recognise that assessment of children over the phone can be challenging during the COVID-19 pandemic.

Our paediatric consultants are still available via Consultant Connect 9am—5pm Monday-Friday for any cases you wish to discuss.

We will also be happy to speak directly to any parents if you think that will help.

Please use Consultant Connect for paediatric advice during this time.

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