Long Covid: A GP’s Perspective

Article | Dr Toni Hazell GP, freelance medical writer, blogger and editor.

For most of 2020, the acute management of patients with COVID-19 was the top priority for the NHS. Over time, it became clear that at least 20% of patients would have symptoms that persisted for 5 weeks and 10% of patients would have symptoms for more than 12 weeks. The term long COVID is acknowledged by the National Institute for Health and Care Excellence (NICE) as commonly being used to describe signs and symptoms that persist for more than 4 weeks after the initial illness.

Healthcare professionals with long COVID have described a range of experiences, including difficulty in accessing healthcare, varying patterns of symptoms and dismissive behaviour from health professionals. A particular issue has been when patients are told that because they never had a positive COVID-19 test, or they do not have antibodies to the virus, their current symptoms cannot be due to long COVID. For much of 2020 only those admitted to hospital were tested, so clearly it is possible that some patients with COVID-19 never acquired a positive test. We also know that levels of COVID-19 antibodies decrease over time and NICE now clearly states that their guidance applies irrespective of previous COVID-19 test status or admission.

The aetiology of long COVID is unclear, but it may have an autoimmune element. [7] It is understandable that healthcare professionals may feel nervous or uncertain about encountering a patient with possible long COVID.

This is a new disease, and it presents with a wide variety of symptoms (some of which are listed below).

Cardiac/Respiratory

shortness of breath, reduced exercise tolerance, chest pain, palpitations

Neurological

dizziness, memory loss, difficulty in concentrating, headache, sensory symptoms (pins and needles / numbness), delirium (more common in older patients)

General

fatigue, insomnia, ongoing fever

Psychiatric

anxiety, depression, symptoms of post-traumatic stress disorder

Gastrointestinal

diarrhoea, nausea, abdominal pain, reduced appetite and weight

Skin

rashes and chilblains on the toes (so-called ‘COVID toes’)

Metabolic

worsening of diabetes control

Musculoskeletal

joint and muscle pain and weakness

Ears, Nose and Throat (ENT)

tinnitus, sore throat, ear pain, hoarse voice, prolonged loss of taste and smell

Autonomic

thermal dysregulation, postural palpitations or dizziness due to tachycardia/hypotension

A return to first principles is therefore important – take a good history, starting with open questions to ensure that the patient feels heard and has an opportunity to tell you everything that is going on. Then consider a more closed style of consultation in which you aim to rule out red flags for serious acute disease, such as venous thromboembolism, stroke and acute coronary syndrome.

Your local hospital may be full to the brim and discouraging new admissions, but if the patient in front of you is acutely ill then they still need to go in. At a practice level, consider having information on your website that encourages patients who think they have long COVID to present, and ensure that all healthcare professionals feel comfortable assessing patients with possible long COVID. A teaching session during a practice meeting may help to achieve this goal.

The full assessment of a patient with possible long COVID is beyond the scope of an article of this length, but NICE suggests that it may include basic blood tests, a chest X-ray and a measure of exercise tolerance, such as the 1-minute sit-to-stand test.

The referral pathway for this group of patients varies from area to area, but it usually involves a long COVID clinic. These vary in their scope, and some have been criticised by healthcare professionals with long COVID for having an excessive focus on the psychological aspects of the disease. It is, therefore, important that any long COVID clinic has access to the expertise and investigations needed to diagnose the 66% of patients with long COVID who have organ damage and the 25% who have damage to multiple organs.

Once organ damage has been excluded or identified, individual rehabilitation plans should be made which give attention to both the physical and the psychological aspects of the disease.

Signposting to the NHS website ‘Your COVID Recovery’ may also be helpful.

Those who employ healthcare professionals with long COVID should be aware of the rules for sickness absence. Agenda for Change staff should be paid as if they were working, rather than as if they were on sick pay, which is usually based on their basic salary only. Sickness absence due to COVID should be recorded separately and should not be counted for the purposes of any absence triggers or management policies. For staff who are only entitled to statutory sick pay (SSP), this should be paid from day 1, not day 4 as is usual, and employers are encouraged to offer more generous terms than SSP. Pay should not drop to half as it would usually, and mechanisms are in place to allow continued full pay after 1 year of absence.

COVID-19 is not going away; we are going to have to learn to live with it and that will include living with long COVID. It is important that those who commission services make sure there are good pathways for these patients and that all healthcare professionals are aware of the issues they face

Dr Toni Hazell

GP, freelance medical writer, blogger and editor

Toni is a GP in North London and works for the Royal College of General Practitioners (RCGP) as an eLearning fellow, writing and editing eLearning.

She also does similar work for a variety of other organisations and is a regular presenter and chair at GP educational events. She is a GP appraiser and sits on her local individual funding review panel.

Her blog can be found online at www.tonihazell.co.uk

Blue Stream Academy’s Long COVID eLearning module

Blue Stream Academy’s Long COVID eLearning module is available on our GP eLearning suite. The module provides a summary of the most commonly reported symptoms of long COVID, information on caring for people with long COVID, and an overview of the NHS enhanced service specification for long COVID.

For more information on this module, please phone us on 01773 822549 or visit our website’s LiveChat feature (www.bluestreamacademy.com).

You can also email info@bluestreamacademy.com