key: cord-1053730-3x7dzc1i authors: Veremu, Munashe; Sohail, Ali; McMaster, David title: COVID-19: exploring out-of-hospital solutions to increased service demand date: 2021-04-27 journal: Fam Pract DOI: 10.1093/fampra/cmab032 sha: 8c3d413ab4630fb50c257a20f0da6b73674dfa5c doc_id: 1053730 cord_uid: 3x7dzc1i nan Dear Editor, In 2020, COVID-19 caused widespread disruption to all aspects of medical care, including cancer screening procedures, elective surgeries and outpatient face-to-face appointments. As we emerge from this pandemic, we must plan for the inevitable increased service demand of non-COVID-19 conditions that have been neglected. One potential solution is to select appropriate services for delivery by qualified primary care physicians and increase their involvement in telemedicine services. Disruption to surgical procedures has caused a reduction in the detection rates of colorectal cancers (1,2), primarily screened through elective gastroscopies. Delayed screening procedures combined with the neoplastic nature of tumours results in diagnosis at more advanced stages, with a less favourable prognosis and the potential to cause severe problems for health care systems. An increase in emergency presentations of cancer at advanced stages requiring surgical intervention (e.g. colostomy), the long-term additional management this creates, and the strain on screening services are just some of the consequences (1). Moving appropriate elective procedures (e.g. gastroscopy, minor skin surgery) to primary care and equipping GPs with necessary training is a potential solution to help reduce the demands on the health care system. Guidelines for the requirements of primary care centres to perform minor surgeries have been published, indicating adequate infrastructure (3) . Moreover, there is already established evidence that shows the safety and competency of GPs performing colonoscopy screening and minor skin surgery in primary care (4) (5) (6) . The Lancet Commission on Global Surgery's call-to-action in 2015 recommended for greater collaboration between specialists and generalists, with 'task-sharing' in order to stretch the surgical workforce (7) . Although the report was aimed at low-and-middle-income countries, COVID-19 has caused immeasurable obstacles to service delivery, calling for innovative ways to help reorganize existing resources. The UK already utilizes GPs with Extended Roles (GPwER), and more collaboration between GPs and surgeons would bring the Lancet's recommendation closer to reality, allowing for greater tasksharing of the increased workload, and allowing GPs to provide a more comprehensive model of service delivery, closer to patients. This is a growing area of research interest, and longitudinal studies would be required to compare the competency of GPs with specialist surgeons. Telemedicine is a rapidly evolving field, with some specialties (e.g. dermatology and ophthalmology) having adapted well, incorporating services into their response to the pandemic. Annually, there are 1.1 million GP dermatology referrals and 7.8 million ophthalmology outpatient appointments in England (8, 9) . The use of telemedicine within dermatology and ophthalmology has been extensively reported (10) (11) (12) (13) , with a recent publication of a 14-year review of a hospital-based UK teledermatology service finding a 50% reduction in secondary care referrals, when using a 'store-andforward' model of service delivery (12) . Similarly, in ophthalmology, this method of service delivery was found to have no significant difference in patient outcomes when compared with in-person consultations (13) . Incorporating GPs within these teleophthalmology and teledermatology services could help alleviate the burden on health care services, enabling GPs to directly refer suitable cases to remote specialists, without increasing face-to-face secondary care consultations. GPs are already intrinsically involved within the referral process, and due to their existing relationships with relevant stakeholders and allied health care professionals, they are in a position to preside over the appropriate referral channels. Further research would include: (i) regular quality improvement projects that investigate the effectiveness of incorporating GPs into telemedicine at reducing face-to-face secondary care consultations; (ii) observational studies comparing generalists (e.g. GPs) with specialists (e.g. Dermatologists/Ophthalmologists), particularly investigating the evaluation and management of selected virtual cases (on a secure online repository). These investigations would be beneficial to assess the efficacy of this intervention and to identify knowledge gaps to inform the future training of GPs. Addressing the burden of missed care that has accumulated during this pandemic, including cancer screening procedures, elective surgeries and face-to-face outpatient appointments is one of the greatest challenges health care systems have ever faced. Now is the time to explore, research and invest in telemedicine and the training of GPwER to perform elective procedures in the primary care to manage the increased service demand. Impact of the COVID-19 pandemic on the detection and management of colorectal cancer in England: a populationbased study Italian Colorectal Anastomotic Leakage (iCral) study group. Colorectal surgery in Italy during the Covid19 outbreak: a survey from the iCral study group Guidelines on the facilities required for minor surgical procedures and minimal access interventions Guidance and Competences for GPs with Extended Roles in Dermatology and Skin Surgery Safety of communitybased minor surgery performed by GPs: an audit in different settings Screening colonoscopies by primary care physicians: a meta-analysis Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development Transforming Elective Care Services Dermatology An assessment of the cost-effectiveness, safety of referral and patient satisfaction of a general practice teledermatology service Teledermatology-the Cardiff experience A 14-year review of a UK teledermatology service: experience of over 40 000 teleconsultations Accuracy of periocular lesion assessment using telemedicine Funding: none. Ethical approval: none. Conflict of interest: none.