Is it the same but different?

I saw an interesting exchange on twitter that perked my interest, hence this blog post. Prof Partha Kar is absolutely right in his replies to this recent tweet.

“I think the narrative of “it’s all the same” is starting to sting. We need to say more loudly it can’t be. There has to be less face to face – that doesn’t mean the work is less”

“That’s the thing- no where do I hear the “different” bit. It’s not the same as usual- it can’t be- and in fact, shouldn’t be either”

My last blog post ran through a fairly typical day, I excluded some bits because I didn’t want to over complicate things. At some point I’ll explain the other roles I have as a GP partner, but for now I want to change the narrative. General practice is not the same as pre-Covid, and I doubt it ever will be. Why have we had to change our systems in general practice?

Pre-Covid

• You could walk in to your surgery reception, queue up and ask for an appointment, maybe even have a little chat with the receptionists

• You could use your online account or NHSapp to book straight in to see a GP/advanced nurse practitioner if there was availability

• You could book 2+ weeks ahead

• There was minimal triage of appointment requests

• Waiting rooms were busy with people waiting for appointments with various clinicians

• No-one thought about PPE or the need for social distancing

• High demand for appointments

In the year of 2019 when social distancing didn’t exist and our practice took part in #parkrunpractice

Change to access

In March 2020 the UK was in the depths of a pandemic so we had to adapt our model of care to protect both patients and staff. This doesn’t mean general practice closed, but it simply had to adapt like the rest of the NHS and remains very different.

We moved to a phone first first model, this means that every patient request for appointment is assessed before we see that patient face to face. Calls can be triaged to prioritise. Some practices perform this triage using an online system but many do this over the phone. Many practices have web enquiry forms (called Econsultations) where you can submit a query online 24/7.

Telephone consulting. My headset is so important!

There are two reasons this is important: firstly, we need to clarify what the patient’s symptoms are and if we can manage them remotely over the phone or they need to be brought down to a face to face appointment. Secondly, we need to check that the patient has no symptoms of Covid-19. This is important for all face to face clinical contacts from blood tests to cervical screening.

We are avoiding booking too far ahead, for us 48 hours at most for GP appointments, due to the unpredictability of the rota. Clinical staff often need to self-isolate due to personal or household Covid-19 symptoms. We want to avoid having to cancel a whole week’s worth of clinics when this happens. Limited ability to book ahead gives us flexibility in ours rotas.

In practice

I find this model of care more challenging. It has reduced our capacity to help as many patients. If you can imagine, we have 10 minute telephone slots to telephone consult with patients. Many of these clinical queries can be managed remotely, over the phone but many need further assessment. For my practice, this means a patient is then booked in to a 15 minute face to face (f2f) slot, usually later the same day, but sometimes 2-3 days away depending on capacity and patient availability.

What was previously 1 x 15 minute slot per patient, is now at least 1x 10 minute phone call (or several) and 1 x 15 minute f2f slot.

During my face to face clinics I need to wear PPE (mask, apron, gloves) and between patients I need to clean my room down. This takes time so we need small gaps between my face to face contacts.

The only thing missing in this photo is my safety specs.

Previously our waiting rooms could be busy if 4-5 clinics running at the same time. Now we need to ensure the waiting rooms allow for social distancing. This means we try and stagger clinic appointment times to reduce number of patients in the waiting room at any one time.

Standard GP practice seating of old. Getting new chairs very soon!

Phone lines are busier as we are encouraging patients to contact us by phone rather than walking in to reception areas. I know it is frustrating being on hold for a long time, or worse the phone line cutting you off by saying we are too busy. Many practices have an online option for sending an appointment request so I would encourage patients to check out their practice website for details.

Many GPs find this way of working much harder with less job satisfaction. Telephone consulting is a skill and can be risky in comparison to face to face contacts. We have to be confident what the patient is telling us is accurate, some patients find it very difficult to verbalise their symptoms and seeing a patient in the flesh gives us a complete idea of how well/unwell that patient is. Video consulting can give us more information, but there is some reticence to use this method of consulting, both from clinical staff and patients.

My trusty phone.

Being a GP, in normal times, is quite isolating compared to working in a busy hospital. We work from our individual rooms and often don’t leave our rooms for 2-3 hours at a time when telephone consulting. Not being able to meet up for coffee and a chat during a break due to worries about social distancing has impacted on the enjoyment of the role. Add in the general assumption that GPs haven’t been doing “their bit” during this pandemic, and morale across primary care is low.

The changes have been tough on us all

I get asked a lot, “when is the practice getting back to normal’ – in all honesty I don’t think it ever will. As the pandemic has progressed, it feels as if negativity towards the NHS, particularly general practice, has increased. Maybe this is due to patients finding it difficult accessing us or an assumption that we have been closed. There is a proportion of the population that feel the pandemic has inappropriately taken over normal life.

Covid-19 has impacted on people in many ways; the pandemic has seen job loses, a surge in mental health illness and a rise in reports of domestic violence. Maybe there are people that feel the other domains of healthcare haven’t been a priority; clinics, surgery or treatment cancelled, so there is rightly some resentment.

We are all tired, whether you work in healthcare or not. I think we are all feeling the frustration that Covid-19 has wrecked so many facets of our life. For some Covid-19 still feels very hypothetical, they might not have experienced first hand the devastating impact of the disease. If you haven’t seen it, it is very hard to imagine how sick some patients can get.

We are trying to balance chronic vs acute illness. As I alluded to in my previous post The doors are closed… general practice has a responsibility to manage chronic (long term) disease. We had to change how we offered annual reviews, prioritising the higher risk patients initially. We didn’t want to put these patients at risk of Covid-19 by bringing them down to our waiting rooms and didn’t want to completely stop this vital service. The nursing team had to be innovative, using texting/phone calls and video consulting as a way to review these patients.

A trusty sphygmomanometer (manual blood pressure device)

There are some things that has stayed the same…

It is still difficult to get a GP appointment.

We can say we are open and here to help over and over, but if a patient is on hold for 30 minutes and still can’t access us, I can understand it may feel like we aren’t open or available.

Demand locally for GP appointments is high and this only dipped at the very beginning of the pandemic. Since April/May the number of patients contacting us normalised, and if anything, demand feels like it is increasing compared to Autumn 2019.

It can feel very scary coming to the practice, some patients are put off. We have done everything we can to keep you safe.

We need to have an honest conversation about this. Why cannot everyone that wants an appointment get one? The answer to this is complex and isn’t just “employ more staff”… it deserves a whole blog post of it’s own. GP appointments are a precious and highly sought after resource. I think we can all forget that sometimes.

Staff working in general practice continue to work hard, that hasn’t changed and never will. Systems may change but the ethos of general practice remains the same. We are here for you.

Change can be good…

I posted recently about the positives of the pandemic, What have I learnt? We have to see there have been some changes that are here to stay.

Firstly, remote working. Telephone consulting can be good; many patients are feeding back they much prefer this option, it gives them flexibility and means they might not need to take time off work or arrange childcare to come and see us. There are lots of conditions I assess over the phone that can be managed really well that way.

Video consulting can be really valuable. We have used it for our weekly care home ward rounds and it works really well. I can see the staff and patients, have a discussion and make a plan without putting the residents at extra risk. We are still doing come home visits in person when needed but quite often it isn’t required. Some of my patients with mental health illness really value seeing my face, and me theirs. We can keep that important human interaction and rapport, without the patient needing to leave their home.

There was always a strange assumption that GP staff couldn’t do clinical work from home. Oh how this has been proven wrong this year. We now have a great number of secure laptops accessible to all roles to use from home if needed. General practice has struggled to recruit GPs in the past, in part, due to lack of flex in working hours. The ability to work from home has been a huge positive for so many people I know, not just in healthcare.

The familiar accuRx bar

Managing skin conditions in general practice will never be the same. Clinicians working in primary care will know the value that accuRx has been during the pandemic. Sharing images via text has been revolutionary. I can send sick (fit) notes via text message! I can have full blown clinical conversations via text. It is brilliant.

Remembering that feeling at the beginning of the pandemic, of all being in it together, we need to bottle that.

I will finish with the words of Chuck Noland…

“Now I know what I have to do now. I gotta keep breathing because tomorrow the sun will rise. Who knows what the tide could bring?”

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