I have been a doctor for 22 years and an NHS GP partner for most of those. Never have I known such frustration with the service we provide to our patients coupled with collective disillusionment in my profession.
This week alone I have had conversations with GP colleagues across the land who report more resignations from their practices. What exactly is going on?
In simple terms the equation is [less GPs] + [more patient contacts] = failure demand but it is far more nuanced than that. There is not enough space here to go into detailed arguments about underfunding, stealth privatisation, poor retention and staff burnout. All of these are critically important but there is already enough useful rhetoric out there about these issues. It is probably more useful to look at what has happened on the ground in terms of accessing GP services.
Firstly because of the pandemic, general practice had to adapt quickly. It brought our working practices into sharp focus and allowed us to work in a way that was finally not locked in the 1990s. Asking patients to text us pictures of rashes or pictures of medication packets, a heavier focus on phone and video consultations, more triage (filtering the reasons for patients wanting to access us) have all become the norm whilst respecting social distancing.
The problems associated with this are numerous. Firstly, many people did not access, or as many folk say, “bother” us, during the first lockdown, so there is a world of unmet need backed up which we are now dealing with. Most consultations now consist of several problems to solve and that takes more time. Also there was an uptick in the 300 million consultations a year we provide at the start of 2021.
Once NHS diktats added in the use of online consultations, it meant that patients could potentially send messages 24-7 to the surgery, however minor (a colleague recently got one asking if someone should become vegan). This has totally tipped the balance in terms of demand. It’s a great thing in theory and means that as a patient we do not have to hang on for a call via switchboard but it makes the daily workload almost insurmountable. Over 200 online consultations a week not only take 10 minute minimum as appointments, someone has to read them all and filter them for urgency. That equates to almost two full time GPs a week in terms of time commitment.
What’s the solution? We desperately need patients and practices to work together. As primary care teams, we need to understand the needs and patterns of access of our populations better than ever and somehow fit that into the model that we are currently working with. Every GP I know is racking their brains. That’s what we do by nature as generalists - we are problem solvers but truth be told we are running out of steam.
Firstly no two patients needs are the same. Online consultations, for instance, digitally exclude those without internet access. This needs thinking through without creating hour long waits to get through on the phone. There is good news in terms of ARRS roles which primary care networks (usually groups of GP surgeries) are reimbursed for. This allows other team members including social prescribers, pharmacists, mental health professionals, paramedics and physiotherapists among others to work in practices. We need to work hard to promote these roles and makes sure that they see the right case mix. By that I mean there is a lot of hidden quality work that goes on practices which may not seem obvious or important.
Also for many years, patients have been able to see ‘their doctor’. This is a rapidly vanishing luxury despite a named accountable GP being mandatory. It’s not hard to see why, if you look at my equation above. But continuity is essential for some patients. Many patients health needs are so complex that carving their care up into other disciplines can create more work. People with complex health needs require someone to manage them as a whole. This often means more than one person providing that continuity and health coaches can be invaluable in this role.
There is also a push towards digital health solutions which I think can be amazing including remote monitoring, text messaging en masse, but I fear that no AI-driven primary care solution will work for some users of our services. Ultimately it is about people and we are unique and complex.
There is also a PR issue around not seeing people face to face as frequently. We never stopped seeing people face to face but it is now based on need rather than being a default. Any mode of consultation uses up the limited number of hours a clinician can realistically work in the day so the myth that phone calls save us time is totally false. I much prefer seeing people face to face although many patients do not want to come in and prefer the phone. Again it needs practices to understand the population they serve.
Let the public and GPs engage with each other, perhaps through their patient participation groups and primary care networks, to come up with actionable solutions at local level. It comes down to whether general practice is deemed useful by the public and then whether it is viable or sustainable. At the moment it looks like it may not be. If it's not the case then we need a once in generation total rethink. If it is, then please get behind your surgery, get your MP involved, get the press involved - local and national.
Let's do this.
My random musings