Update from Dr Nicola Jones,
Chair of the South West London Primary Care Cell

15th April 2020

Dear Colleagues

Thank you for the fantastic work that you did over Easter to open on Friday and Monday, caring for our patients and supporting the rest of the system to cope. Many practices received messages of thanks from patients expressing their gratitude to the practice and the NHS.

I know that many practices also worked over the long weekend on identifying their patients at highest risk of complications of COVID19. This has been a difficult piece of work to manage, with a lack of clarity about the ask, changing instructions and a lag in the production of searches and lists. There is some further advice about this as part of this bulletin. I recognise that practices know their patients well and are doing their best to make sure the most vulnerable people have the advice and support they need.

Best Wishes
Dr Nicola Jones
Clinical Lead, SWL Primary Care

Highest risk patients

This national letter was sent to practices at the end of last week requesting specific action from practices to complete the process of identifying patients at the highest clinical risk of mortality and severe morbidity from COVID-19.

We are aware that the deadlines outlined in the letter were extremely tight and you understandably may not have been able to meet them. However please read the “what do GPs need to do” section of the letter and carry out the work as quickly as resources allow to ensure that patients who are at the highest risk are aware of the precautions they should take and can get the support they need.

The action you need to take should be prioritised as follows (please read the “what GPs need to do” part of the letter for detailed actions):


  • Review individuals identified nationally through the clinical algorithm – you will have a search on your clinical system.
  • Add flags/code for individuals who you know to be vulnerable, who have not been identified through the clinical algorithm or provided by secondary care clinicians

Then (after 17th April):

  • Review individuals who have self-identified as vulnerable (this list will be sent to you within your GP IT system on or around 17th April)


  • Review individuals identified by secondary care providers – practices are being sent letters from specialists about individual patients

Please contact your borough lead if you have having problems in carrying out this work.

Marie Curie support for ACP/CMC records for care home residents

Key messages in the attached supporting documents are:

  • Marie Curie have a team of nurses commissioned to support GPs with priority completion of ACP/CMC records for all care home residents (nursing, residential and LD)
  • This is an additional resource to supplement the ACP/CMC work already being prioritised by GP practices
  • The pathway has been developed and signed off with input from Dr Catherine Millington-Sanders and the SWL Palliative Care Task and Finish Group chaired by Lucie Waters
  • In completing the template and sending to the Marie Curie Team (at you are advising on the patients/relatives you wish to be contacted and confirming their capacity status (GDPR compliant under recent temporary Covid-19 legislation)
  • GPs should contact the homes they look after advising that they will be using this service (Marie Curie Team will also confirm with the home)
  • GPs wishing to complete these records themselves are free to do so and should advise the Marie Curie Team so they can tick off the list
  • GPs who have completed records for all their care home residents need only advise the Marie Curie Team that their practice is complete
  • The Marie Curie nurses will liaise with the home and patient/relative, complete the record and inform the GP once completed who will then need to review and publish so the record is visible

GP Team Net

You will have received an e-mail from this address about the launch of a SWL GP Team Net portal where you can find, in one place, the latest COVID-19 guidance and information as well as these updates – please look out for the e-mail. Existing GP Team Net users will be able to access the portal using their existing logins. If your practice has never used GP Team Net then your practice manager will receive a separate email with details of how to get set up and how to access staff training.

Information governance advice for health and care professionals

NHSX, the Department of Health and Social Care, NHS England and NHS Improvement Digital Transformation Unit, has published advice on information governance which:

  • States that in the current circumstances it could be more harmful not to share health and care information than to share it
  • Includes advice from the information commissioner, who has said that she cannot envisage a situation where she would take actions against a health and care professional clearly trying to deliver care
  • Includes advice on mobile messaging, video conferencing home working, using your own device and communication between colleagues.

Pan-London acute and GP data sharing

In order to support the London-wide response to COVID-19, SWL are fast-tracking a series of data sharing initiatives via the OneLondon (Cerner) hub, to ensure that front-line clinicians have access to the broadest patient dataset. The changes that will be implemented in the immediate/short term in SWL are described in the attached document, along with a further attachment describing the project across London.

NHS Diabetes Prevention Programme- Healthier You

Healthier You sessions are being delivered as a fully remote (via telephone) service. ICS Health & Wellbeing is communicating with all participants ahead of their next sessions.  Service users who missed sessions due to COVID-19 will be sent e-learning modules and an offer of catch-up sessions.  Referrals are welcomed so please continue to refer into the programme in the usual way via DXS, EMIS or Vision.

Diabetes Book & Learn – the diabetes education booking service for people in south London with diabetes

Please continue to refer in to Diabetes Book & Learn.  Patients are now being offered a range of remote or digital diabetes courses as an alternative to the face to face programmes.  Patients can also access information and support for self-management during self- isolation.  Diabetes Book & Learn provides a single point of access for patients and referrers to book free diabetes education across south London. Click here to see the types of courses available.  If you have any queries, please call 020 3474 5501 and the relevant team will be happy to help you.

Guidance on symptom control using non-oral, non-parental routes of medication administration

Changes in delivery of care pose particular challenges to the administration of medication for symptom control for those with advanced life-threatening illness, including in the last days of life, and to those with COVID-19. This attached guidance from the London EOLC Clinical Network supports prescribing for these situations, including alternative routes of medication administration e.g. non-subcutaneous, non-oral routes of administration.


  1. Pathway Marie Curie ACP
  2. ACP CMC template for completion
  3. Pan-London Acute and GP data sharing response to COVID19 pandemic – Staff Briefing
  4. OneLondon
  5. Guidance on symptom control using non-oral routes of medication administration during COVID19

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