Chaplaincy has been provided in primary care (General Practice surgeries) for over 20 years. There are various iterations across the United Kingdom, but their unifying purpose is person-centered holistic care delivered through listening and guidance.
The Pandemic – and lockdown – have presented both Primary Health Care and Chaplaincy in general practice with challenges, particularly with protection of primary care givers and health professionals, and General Practice Chaplains.
The most significant change for chaplains has been that all patient contact is now done by telephone, with visual cues and immediacy being lost. A small number of patients, however, appear to prefer telephone appointments, and some have accessed spiritual care who would otherwise not have been referred. One GP provided this quote from a patient who would not have been referred to, or attended, a face to face appointment, “I feel like a huge burden has been lifted off me. I didn’t realize how heavy the burden was until it was removed.”
Here, we offer excerpts from a Report for the Association of Chaplaincy in General Practice on Spiritual Care During the COVID-19 Pandemic.
Introduction
Chaplaincy in general practice (CGP), also known as primary care chaplaincy (PCC), offers prompt access and thoughtful listening for patients who wish to explore issues that impact their health and well-being. Patients are referred by their GP, or can self-refer, for a range of issues and complex needs, and they are seen promptly at their own GP surgery for an appointment of 50 to 60 minutes.
Amidst modern medicine, Chaplaincy in general practice seeks to maintain and develop the commitment of primary care to person-centered and holistic patient care. As a “talking therapy,” it has been shown to improve wellbeing scores and reduce repeat referrals to GPs for related issues. Chaplaincy has been provided in general practice for more than 20 years, and has been found to be effective, particularly for patients experiencing loss or change in their lives.
The Association of Chaplaincy in General Practice has affiliated groups in England and Scotland and works with the NHS, the UK Board of Healthcare Chaplaincy (UKBHC), and the College of Healthcare Chaplains (CHCC) to provide training standards and accreditation for the delivery of chaplaincy in general practice. With over 90% of healthcare in Scotland being carried out in the community (NHS Scotland, 2016), and comparable rates in England, it is prudent to offer chaplaincy care in this setting, as well as in the traditional setting of hospital and hospices.
This report is based on the responses to a questionnaire, which was circulated to four CGP/PCC hubs where spiritual care is available to over 400,000 patients through chaplaincy services in 52 surgeries (see table 1, above). Chaplains, both paid and volunteer, offer generous listening, usually in a non-clinical room at the GP site. These hubs all have associations with the Association of Chaplaincy in General Practice. For evaluation purposes, the Association of Chaplaincy in General Practice chaplaincy services use the Warwick and Edinburgh Mental Well-being Scale (WEMWBS). The report details the effect of, and response to, the coronavirus pandemic in primary care chaplaincy during the spring of 2020. The questionnaires were completed in mid-May, when lockdown across all of the United Kingdom was still complete; details were representative of the chaplaincy in general practice response at that time.
Within weeks of the outbreak of COVID-19, general practice in the United Kingdom changed radically and at unparalleled speed. Normal methods and patterns of consulting were replaced with “virtual” consultations by phone or video calls. Clinicians and allied services now triage every contact, in order to reduce the risk of COVID-19 transmission. Home visit rates have been substantially reduced. Concern has been raised regarding service delivery and equitable access for the more vulnerable patients – those with existing physical and mental health issues.
Just as much of the longstanding, seemingly secure infrastructure and delivery of general practice was dismantled at remarkable speed, so too was primary care chaplaincy. The result of the COVID-19 pandemic and resulting lockdown on primary care chaplaincy services has been, in the words of one chaplain, “dramatic”. All appointments are now carried out by telephone. In each service, there has been a reduction in referral rates.
Anecdotal evidence suggests that more patients are now struggling with anxiety and a broad range of losses. These losses include the loss of normality, purpose, socialization, income or employment, and loved ones. There may also be observed differences in demographics – perhaps a greater proportion of younger people? Issues precipitating appointments are increasingly to do with the ramifications of lockdown and people’s experiences, either caring for those who have had COVID or having been ill themselves. Those who have been ill speak of the wide-ranging and long-lasting effects of the illness.
One GP reflected that, as “with all events of extreme proportion some dig deep and survive, and some are broken even more than they were before”. Predictably, many patients are struggling with the ongoing pandemic and its ramifications. A wide range of intra- and interpersonal issues are reported. Many issues are similar to those often seen in primary care chaplaincy – loss of many kinds, relationship difficulties, and matters relating to faith and wider spirituality. One new issue seems to be that grief from past loss is more challenging to deal with, and current bereavements are difficult to navigate in lockdown. Parents describe the challenge of the competing priorities of home schooling and employers’ deadlines. Obsessive-compulsive disorder type conditions may have been exacerbated.
While contact with those directly affected by COVID-19 is not (yet?) the main focus, those who have been bereaved in the pandemic speak of the agony of not being able to visit or say goodbye in person, and the pain of isolation while grieving.
Chaplains anticipate that new concerns will emerge as lockdown is eased and the safe space of home is no longer the only venue that is expected to be inhabited. These challenges may lead to a lowering of general resilience and self-esteem. An increase in discussions about “spiritual” issues was reported by chaplains. Conversations about the purpose of life, sources of hope, and wondering “where God is” were reported. Requests for prayer or for scriptures to be read have also been more common.
Organizational Response to Delivery of Spiritual Care
In most surgeries, the cessation of face to face spiritual care appointments occurred in the weeks immediately before lockdown was announced on March 23, 2020. Remote access to surgery facilities has been or is being organized for chaplains, and a variety of proactive responses in chaplaincy provision arose. Reminders to referrers were issued, and some medical centers ensured that spiritual care services were visible on websites. An offer of staff care to local GP clusters was made. In some surgeries, chaplains contacted those on the “shielding” lists. Elsewhere, patients seen by the chaplain in recent months were re-contacted.
One chaplaincy service not only maintained but aimed to double its listening and guidance capacity. This involved increasing some hours for existing staff and recruiting three additional new staff. However, by mid-May only one of the six primary care networks were fully utilizing the increased hours. Another surgery texted their patients, making them aware that chaplaincy services were still available, but uptake was limited. Some chaplains have facilitated a debriefing service for staff via Zoom meetings. At present, there is a disparity between the generally perceived need for talking therapies and mental health support and actual referral rates for chaplaincy.
The most significant change for chaplains has been that all patient contact is now done by telephone, with visual cues and immediacy being lost. A small number of patients, however, appear to prefer telephone appointments, and some have accessed spiritual care who would otherwise not have been referred. One GP provided this quote from a patient who would not have been referred to, or attended, a face to face appointment, “I feel like a huge burden has been lifted off me. I didn’t realize how heavy the burden was until it was removed” (D1).
Reflections on Organizational Change and Response
As 80–90% of chaplaincy appointments arise from a GP referral, the reduced footfall in GP surgeries unsurprisingly has led to a reduction in chaplaincy referrals. Some patients have assumed that chaplaincy services were suspended, or indeed a few seem to have believed that the GP surgeries were closed. Others are not able or willing to interact by telephone, due perhaps to lack of privacy at home. Others do not feel they justify this type of care at the moment.
A few patients have not needed as much support as before, reporting that “lockdown life” is beneficial for them. These people appreciate increased support at home or a slower pace of life. Others find the reduction of social stresses and the reprieve from constantly “putting a face on” helpful in managing long-term challenges.
The unanimous response from chaplains is that working by telephone is hard work and not ideal for delivering the type of service that spiritual care in primary care aims to achieve. Loss of the usual cues leaves interactions less informed and not as rich. Primary care chaplaincy services may offer prayer either during or after the appointment, but the appropriateness of this is more difficult to judge when done via telephone. More detailed reflections reveal that chaplains find the pacing of conversations more difficult, especially when patients are upset, and some find the establishment of roles and boundaries more difficult to define.
(It has been suggested) that working by phone (for GP’s) is exhausting because it is new, and the narrowing of available information causes the listener to focus on sound and silence in new ways. Practically, there are also administrative hassles when patients do not answer a phone call or are interrupted by situations in their homes.
Chaplains, however, have noted the quick engagement and development of trust that has frequently been established during many telephone appointments, seen, for example, in the raising of spiritual issues. Both GPs and patients report that “help” is being received, and repeat appointments are being requested, suggesting that telephone chaplaincy is, at least in part, delivering the type of care and support that it aims to do. Unsurprisingly, those for whom this is a first engagement with chaplaincy seem more satisfied than those who previously had face to face appointments. Similarly, chaplains who began this work without prior experience of offering face to face appointments are less frustrated by this way of working than those who have worked with patients in person. Staff care is anticipated to increase over the coming months, as the busy peak of the pandemic passes and healthcare staff have time to reflect and seek help.
Issues Going Forward
In the longer term, there are questions which are currently difficult to answer, as the implications of COVID-19 are not yet known, and the shape of GP provision is not yet clear. The challenge for chaplaincy is the same as for other parts of general practice, where “primary healthcare systems need to be deliberate and have clear plans to ensure that this devastating pandemic leaves a positive legacy”. This could be an opportunity to listen to patients, reflect on established patterns, and innovate, based on current presenting issues, equitable access, and proactive care for the most vulnerable.
The interruptions occurred at a time when many patients had experienced the dismantling of external structural supports, with the consequent exposure of their potentially unmet internal or spiritual needs. We know anecdotally and through early research that footfall through primary care has fallen dramatically. It is emerging that those with mental health conditions are describing greater levels of anxiety, perhaps heightened by reduced access to their usual networks. It seems, then, that chaplaincy must be more aware of and responsive to the increased vulnerability and needs of our patients during this COVID-19 pandemic. This presents both opportunities and challenges.
1. Sarah Giffen is Principal Chaplain at the Regent Gardens Medical Practice, north of Glasgow, and an Advisor to the Association of Chaplains in General Practice (ACGP).
2. Gordon Macdonald is a General Practitioner and trainer of over 20 years with research interests in primary care chaplaincy and care of the elderly.
