General Practice has been a tale of disruption and change over the last year - and we need a solution says Dr Joe McManners.
The last year in General Practice has been a tale of disruption and change, for patients and healthcare staff. What is the story? Why did this happen and what is the argument about now?
It’s Monday morning, one day in 2019. 8.30am comes around and the phones have just switched from the out of hours GP service. A phalanx of hardened receptionists struggle to answer the flood of calls requesting appointments.
By 9.30 am the last urgent ‘slot’ as been allocated. The next patient who asks to see their GP is told the choice is either a long wait for a ‘routine’ appointment, or to ‘ring back at 8.30 tomorrow morning’ and participate in another game of telephone roulette.
This was General Practice pre-Covid. Patients didn’t especially like it, GPs weren’t a fan, and it was inefficient- patients would often book appointments weeks ahead to be sure, and then try to get an ‘on the day’ one as well.
Some GP surgeries were beginning to fix this broken model before the pandemic, but two weeks or longer to see a GP, and then not ‘your own’ GP was typical. Then in March 2020, almost literally overnight, it all changed. The week the world shut down almost every GP surgery switched to ‘phone first’.
Partly because we didn’t know which GPs we would have available on the day with Covid running free, but mainly to make sure that those coming in didn’t have Covid-19. Physical contact was a rationed commodity – we all appreciated the tragic purpose of the national mission to distance one human being from another.
This change was established, in the true sense of the word, some days later with the national NHS body, NHS England, instructing GPs to change our practice to practice ‘total triage’, a screening assessment to establish the type of appointment needed should be universal.
Matt Hancock went even further, not letting his lack of medical degree or real-world experience get in his way, suggesting that unless there were good exceptions, GP appointments should be digital or virtual rather than physical.
Most GPs and health care professionals like seeing patients, we like the face-to-face contact. Patients also like it, although many (if not more) appreciate the convenience and speed of on-line or telephone.
The problem is that there is only so much clinician time, so the most excluded, and potentially the sickest people, may be squeezed out by the sharp fingered digital natives. There has been a concerning spike in demand for primary care recently, and hospital waiting times are frightening which displaces this need onto primary care. With teams stretched, out of control digital demand might mean that other work is pushed out.
The crisis comes when you combine this tricky mixture of problems onto a GP workforce that has been stretched for some time; then stir in a lot of burnout; add a dash of fiery tabloid rage, 90% of a mass vaccination campaign, and we can see the recipe for disaster. Or at least for frustration.
It was into this hostile environment that the officials of NHSE stumbled. A letter instructing GPs to offer face to face appointments on demand (contradicting previous instructions), provoked an outpouring of rage from social media and WhatsApp that was almost audible.
Insult was again added to injury with the letter nestling nicely into media campaigns to see patients ‘again’ – we never stopped. Colleagues across the country reported abuse, fed directly by the toxic blend of the offending letter and the front-page headlines.
Whilst GPs are not always known for holding back complaints, the messages even from those who don’t normally moan was powerful. The Royal College of GPs swiftly distanced themselves, the BMA described it as ‘tone deaf’, and their GP Committee has now passed a no-confidence motion in the NHSE leadership. The situation is not healthy, but it has opened up a really important discussion.
What is important now is for us all to decide what we want: 90% of NHS patient contacts are in Primary Care. Good access is a matter of life and death, health inequalities can be improved or worsened by how we handle access to primary care. And if primary care fails the NHS fails – hospitals are swamped, and people die earlier, especially the poor.
With limited resources we need to ensure that those who are not able to use digital means get fair access, but we cannot go back to two week (plus) waits for appointments and the daily rush.
Patients who need face to face appointments should get them, obviously, but going back to non-filtered face to face appointments (or even telephones) would inevitably increase the waiting times and exclude a different group. The system before was far from perfect, and there are major problems at the moment.
We should be able to find the answer to this problem, but under resourcing and burnout needs sorting, and we need support, not blame. There is not a magic computer answer, there was not a golden age to go back, and this is not black and white.
We need a 2020s answer and whatever it is, it will be found by local clinicians and their patients figuring it out together.
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