The new long Covid enhanced service – what practices need to know

GP partner and trainer Dr Pipin Singh explains what practices need to know about the new long Covid enhanced service requirements

Covid-19 not only causes significant acute symptoms but we now recognise it can lead to a syndrome known as long Covid in a significant proportion of patients.

In December 2020, NICE released a set of rapid guidelines on the long-term effects of Covid-19, summarising what we understand so far and providing suggestions for management of the condition.

NHS England has now detailed an enhanced service for practices to manage to long Covid. The total funding available to general practice to deliver the service is £30 million.

The enhanced service specification explains that the additional funding is for GP practices to enhance their training and infrastructure to enable them to better support patients with the condition. [1]

More specifically it requires practices to demonstrate through self-assessment that they have established the following:

• Education and training on identifying, assessing and managing the condition for all team members involved – for example, doctors, nurses, pharmacists, social prescribers and care navigators
• Knowledge of local referral pathways
• Accurate coding (using SNOMED CT)
• Equity of access.

Ensuring we have good education and coding should help to improve management of the condition and also develop our understanding of the nature and scale of the problem.

Background

To understand the enhanced service set out by NHS England, it is important to understand what is meant by long Covid and the expectations on general practice in identifying and managing it.

NHS England’s specification says long Covid encompasses both ongoing symptomatic Covid-19 and post-Covid-19 syndrome, in line with these NICE definitions:

• Acute Covid-19: signs and symptoms of Covid-19 for up to 4 weeks
• Ongoing symptomatic Covid-19: signs and symptoms of Covid-19 from 4 to 12 weeks
• Post-Covid-19 syndrome: signs and symptoms that develop during or after an infection consistent with Covid-19, continue for more than 12 weeks and are not explained by an alternative diagnosis. [2]

The NICE guidance details a range of symptoms that should prompt consideration of long Covid (see box at the bottom of this article). These symptoms are highly variable and also extremely common in general practice – the challenge moving forward will be to establish if any of these common presentations are linked to long Covid.

History and examination findings will guide further investigations, or acute admission if suspecting VTE, ischaemic, cardiac or significant neurological complication.

In April 2021, NHS England released a document on development of post-Covid assessment clinics based on emerging evidence about the complexity of acute Covid-19 and those with symptoms lasting longer than 4 weeks after covid. They quoted the following based on a variety of studies: ‘COVID-19 may be associated with post-acute organ impairment. A study by the Office of National Statistics found that hospitalised COVID-19 patients have elevated rates of diabetes, major cardiovascular events and respiratory disease post-discharge, and risk was greater for younger age groups and ethnic minority groups.’ [3]

In addition, research internationally shows that COVID-19 patients may have persistent impaired lung function, or ongoing myocardial inflammation after acute infection. [4,5]

Investigations may include:

• Plain chest film
• ECG
• Echocardiogram
• Blood work, not limited to FBC, UEs, HbA1c, BNP, D-Dimer.

You may also wish to consider a sit to stand test.

Where a mental health condition is identified as the main symptom, support and/or treatment should be considered in line with existing local mental health pathways.

If ongoing symptomatic Covid-19 is diagnosed (from 4 weeks after infection) patients can be offered:

• Signposting to self-management support including the online platform Your COVID Recovery
• Supported self-management; this may include input from social prescribers, health and wellbeing coaches and care coordinators, linking into community groups or other existing community services as appropriate
• Referral into a post Covid assessment clinic if self-management alone is not appropriate and if further investigations or support are required.

Education

The specification states the requirement is for practices to demonstrate they have ‘workforce education and training in place on how to identify, assess and manage Long COVID; this learning may differ depending on the role and learning need of each professional.’ [1]

It does not specify how training should be undertaken and practices/PCNs will need to come up with what they feel reflects an appropriate level – for example, an online module, CCG education event.

Training modules on the Health Education England e-Learning for Healthcare portal and this RCGP online course can be used. The BMJ also has a useful resource on long Covid.

Staff can do this in their own time, although you could appoint a lead clinician to put on a learning event.

The difficulty will be in providing tailored, appropriate education for non-clinical staff. Care navigators will need to know about what services to signpost people diagnosed with long Covid to, so more about their knowledge of local services. There will be a lot of overlap with services such as Age UK, mental health services and exercise groups. I expect practices will need to allow staff around 1-3 hours training time.

Promoting knowledge of local referral pathways

It is important that practices signing up have access to long Covid clinics within their area and are familiar with the NHS England document on setting up post-Covid assessment clinics from April 2021.

Ensure all GPs have read the specification, had the training and understand how to refer into clinics. Secretarial teams will need to know the administrative process of referring into the clinic. GPs will need to try and work with the clinics to help facilitate tests if able – although current primary care workload may make this difficult – and ensure coding is accurate from letters.

The specification emphasises that long Covid management requires a multidisciplinary approach involving doctors, nurses, physios, occupational therapists and also access to psychological input. It’s likely that cardiologists or respiratory physicians will be required if major systems involved, but neurologists or infectious diseases teams may also be needed.  

Ensuring accurate coding

This requires comprehensive use of the correct SNOMED CT codes (see box) for:

• Diagnosis 
• Signposting 
• Resolution.

Practices must also demonstrate they are using appropriate coding for key clinical information in letters from clinic or specialist services.

This will be both a clinical and an administrative task, with the clinical team ensuring that the diagnostic codes and signposting codes are completed, while administrative staff may be required to complete referral codes and resolution codes with appropriate guidance from the clinical team.

Ensuring staff are aware of the codes is very important. This will come with the education within the practice, but it may be worth having a clinical lead for the enhanced service who ensures staff on the coding team are trained adequately and coding is done accurately.

Long Covid SNOMED CT codes

SNOMED CT diagnosis codes are:

– Ongoing symptomatic COVID-19 (4-12 weeks after infection) – 1325181000000106

– Post-COVID-19 syndrome (12 weeks plus) – 1325161000000102

CT Signposting and referral codes are

– Signposting to Your COVID Recovery – 1325021000000106

– Referral to post-COVID assessment clinic – 1325031000000108

SNOMED CT resolution code is:

– Post-COVID-19 syndrome resolved – 1326351000000108

A list of other relevant codes is detailed in Appendix B of the national commissioning guidance.

Payment

The specification states: ‘Practices will be entitled to £0.371 per registered patient (75% of payment) upon sign up to this Enhanced Service.

‘This will be paid via monthly instalments, with the remaining £0.124 per registered patient (25%) being  paid upon commissioner confirmation that the self-assessment set out above has been completed by 31 March 2022.’

For a practice list of 10,000 patients this will equate roughly to £4,900.

The enhanced service emphasizes that the funding is in addition to that ‘already available to practices through global sum which reflects their core contractual responsibility for the provision of essential services to this cohort of patients’. The work may feature within the GMS contract within the next couple of years as Covid continues to circulate and the prevalence of long Covid increases, so it makes sense for practices to use the funding available now to embed the training and infrastructure.

Summary of key points for practices to consider:

• Standardised training within the PCN will need to be achieved
• The wider team must also be educated, for example, social prescribers, care navigators
• The appropriate SNOMED codes need to be known by all team members
• You will need access to a long Covid clinic to refer into
• This is work your practice is likely to be expected to undertake in future so it probably makes sense to participate and make use of the funding available.

Symptoms that should prompt consideration of long Covid

Respiratory symptoms

Breathlessness

Cough

Cardiovascular symptoms

Chest tightness

Chest pain

Palpitations

Generalised symptoms

Fatigue

Fever

Pain

Neurological symptoms

Cognitive impairment (‘brain fog’, loss of concentration or memory issues)

Headache

Sleep disturbance

Peripheral neuropathy symptoms (pins and needles and numbness)

Dizziness

Delirium (in older populations)

Gastrointestinal symptoms

Abdominal pain

Nausea

Diarrhoea

Anorexia and reduced appetite (in older populations)

Musculoskeletal symptoms

Joint pain

Muscle pain

Psychological/psychiatric symptoms

Symptoms of depression

Symptoms of anxiety

Ear, nose and throat symptoms

Tinnitus

Earache

Sore throat

Dizziness

Loss of taste and/or smell

Dermatological

Skin rashes

References

1. NHS England. Enhanced service specification – Long Covid 2021/22  Published 21 June 2021

2. NICE. COVID-19 rapid guideline: managing the long-term effects of COVID-19 Published 18 December 2020

3. NHS England. National guidance for post-COVID syndrome assessment clinics Published 26 April 2021

4. Huang C, Huang L, Wang Y et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet 2021; 397: 220-232

5. Puntmann V, Carerj M, Wieters I et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA 2020; 5: 1265-1273