There has been a lot of negativity around general practice over the last two years and it has left me pondering, why do I carry on being a GP? Mostly, because I still love the job and I couldn’t imagine doing any thing else. GPs are an integral part of a successful NHS. I could have chosen to be a psychiatrist, a gastroenterologist, an anaesthetist or a surgeon, but I chose general practice, or maybe it chose me?
GPs are leaving and I understand why. Its really hard, long 10-12+ hour days as standard drowning in admin long after the clinical work is done, while relentless demand continues to increase. In order to encourage more doctors in to general practice (and to reduce the numbers leaving/retiring), we need to make the job attractive, worthwhile and fulfilling.
I saw a recent tweet from a hospital colleague highlighting the great bits of their job and it got me thinking…
…Why do I keep going?
• Variety: I like the different people, interesting symptoms and consultation types we see in general practice. Today, for example, I saw patients with abdominal pain, skin lumps, depression, went on home visits, spoke to patients over the phone and communicated with some via text. I liaised with hospital teams, community nurses, supported end of life care and supervised new baby checks. My clinics are never boring!
• Patients: The relationships that are built over time are a privilege. We get an insight in to peoples lives, the good times and the bad.
• Colleagues: They are just brilliant; HCAs, practice nurses, allied health professionals, fellow GPs, receptionists and many many more. General practice is built on a foundation of good people wanting to do their best for others (a sometimes thankless task, especially for our reception team).
• Partnership: I truly think the partnership model is an asset to general practice and I am worried that some feel it is not worth continuing, it is very good value for money given the extra non-clinical non-visible hours of work done by hard working partners across the country. I value the leadership opportunities partnership has offered me and I get to work with some incredible people.
• Innovation: as a GP partner, my two passions are working to both improve patient access and the communication from practice to patient. I love that we can develop our service to the needs of the local community and as an independent partnership we can be dynamic and try new things. The pandemic has also allowed us to learn, change and develop in ways that we had never imagined. Using digital platforms to assist us; to manage our demand, ensure safe and timely care for our patients so that they can be assessed by the right clinician in the right timeframe. I have really relished the partnership/non-clinical aspect of my job in the last couple of years – dealing with external and internal communications and leading on all things Covid (just maybe don’t mention the searches for shielding or cohort 6 of the vaccination roll out). For far too long general practice has offered the same stagnant model of care and I am not sure it works in a modern world.
• Give general practice a mission and we get it done – see covid vaccination roll out!
• Expanding multi-disciplinary team: The newer roles in general practice will continue to develop, it is so fantastic that you can see a first contact musculoskeletal practitioner if you have a painful knee, or a first contact mental health practitioner if you have anxiety symptoms.
• Teaching/training: One of my favourite roles is being a GP trainer. Mentoring GP trainees can be hugely rewarding and adds variety to my week. Nurturing someone who is less confident about independently managing patients in general practice and demonstrating the worth of general practice – there is nothing better.
• So much more than what you see: general practice is chronic disease management, contraception advice, end of life care, postnatal checks, supporting patients with learning disabilities and people in care homes and much much more. I am proud to be part of all that.
• And the cheesy bit: some days you just feel like you have made a difference. It might be taking the time to chat to a carer about their concerns, or spotting a sign of a serious condition or being the first person someone has spoken to about their OCD symptoms. I do a lot of listening and there is so much power in that.
Well that all sounds great, why are GPs struggling?
I want general practice to flourish, to be able to give all my patients the high quality care they deserve. I love my job but am worried that in the months or years to come it will become difficult to do a good job.
What am I worried about?
• Staff absence: This is impacting all sectors across the country at the moment: flights are cancelled, cafes are closing and schools struggling – all because many staff are currently off with Covid related symptoms. This is a real issue across the NHS. Patient facing staff working in the NHS have to follow stricter covid guidance compared to that of the general public. We continue to test regularly and must isolate from work if we test positive. Some of us can work remotely from home if we are covid positive and well enough to work (eg GPs, pharmacists, MSK practitioners), but some clinical staff are unable to – eg phlebotomists (take blood).
• High demand for GP appointments: Winter is classically a busy month in the health care sector, but it now longer feels like there is a peak over winter, more of a steady high demand all year. We are permanently on a hamster wheel desperately trying to catch up; working harder, working faster. This is not safe or sustainable. We need more clinical staff, more GPs especially. Energy needs to also be spent in improving the working conditions for GPs – too many are leaving or retiring early as the job satisfaction is reducing and the stress increasing.
• Drowning in minor illness: A lot of cases I see in general practice don’t need to have a GP appointment; fungal toe nails, request for a letter to complete a marathon, mild eczema or tooth ache. There are national TV campaigns to encourage self care, but are they specific or direct enough? Could we offer more education to younger people (in schools?) to highlight mild symptoms and sign post to local community pharmacies, dentists, opticians or NHS111 for appropriate advice?
• If everything is urgent, does urgent even mean anything?: One of the frustrations I see daily is that our patients want something managed urgently, although the clinical condition isn’t urgent. So what does “urgent” actually mean? Clinicians have a very different definition to patients I expect. We have an online triage system that allocates urgency based on some question answered e.g. how bad is the pain, are you passing blood, any red flag symptoms etc etc. Is it urgent because the patient is going on holiday tomorrow and wants it sorting. Is it urgent because the patient is not able to work due to pain? All entirely reasonable reasons for wanting something sorting quickly. From a clinical perspective, urgency is based upon the likelihood of the problem getting worse and making you very unwell. We have to prioritise the most unwell, and sometimes this means patients have to wait longer than they would like. This is leading to more formal complaints which in turn leads to more bad feeling.
• Expectations: What can general practice can actually achieve day to day in the current climate? We need some honesty and clear messaging from the government, media and local trusts/practices about the current challenges. We simply cannot offer all patients an appointment the same day, and it is often OK to wait a month for an appointment for a routine issue. We are already working as hard as we can, there are only so many clinicians and appointments. Demand is simply outstripping supply.
• Feeling the weight of blame: Is the reason you cannot get a timely GP appointment the fault of your practice? Not in general. GP practices in England receive around £155 per patient per year to provide a variety of services. That might sound like a lot if you haven’t had an appointment for a few years but some patients need our services on a weekly or monthly basis. We need more clinical staff and better purpose built premises to work from and this requires investment. The mainstream media haven’t been kind to general practice since lockdown and that has weighed heavy on many of us.
• Saturated NHS: Our local hospital is full – partly because of current covid rates and partly because there are lots of sick people needing their inpatient care for other reasons. It is challenging when I need to admit a patient to hospital as I know I may potentially face barriers to admission as there are no beds. Community nursing teams are struggling with staff shortages meaning patients are waiting longer for blood tests, dressing changes or continence assessments. Ambulances are taking longer to reach patients, both 999 and those that we arrange to take our patients to hospital.
• Backlog: There continues to be a backlog in routine hospital care too – eg locally here is a 6 month wait for physiotherapy and neurology is a year + wait for a clinic appointment. Waiting lists for everything are insanely long which in turn has an impact on our demand. A Patient will understandably contact us to chase up their referral or because the wait for their knee replacement has been 18 months they might want stronger pain relief or maybe they haven’t heard about the MRI scan the hospital organised. It is the GP practice that is generally accessible and the first port of call for all these sorts of queries.
• I am not a dentist.
Before we can start to rebuild general practice, we need to define what we are. We then need to communicate this effectively to our patients so that they understand what we do, and how we can help. We simply cannot do it all. Something has to give, and that’s where being open about the current challenges is key.
Selfishly, what do I want for myself?
I want to feel hopeful. I want my trainees to feel positive about the career they chose. I want general practice to be here for years to come so if/when my loved ones need community care it will be there for them. I want to run clinics where I can give each patient the time they need; not feeling rushed, knowing I can refer on for further tests/specialist clinics that will be completed in a timely manner. I want to offer continuity of care alongside appropriate urgent/same day care. I want the job to be interesting; less tick boxes would be nice. I want a good work life balance for myself and my staff. Time for lunch every day asking too much?
I want all GPs to feel that they are doing a good and safe job. I want us all to feel valued. I want patients to trust in their GP, to know they are doing the very best for them.
And what do I want for my patients?
I want patients to feel listened to, to be able to access care from the right services, from those with the right expertise. I could do a whole post about the inequalities in healthcare that have only widened in the pandemic. Dentistry is a perfect example: I can totally understand why patients seek antibiotics from us for their wisdom tooth infection because they can’t afford to travel to the emergency dentist NHS111 sent them to 40 miles away. Invest in school health, social care, public health, dentistry and this will have a knock on effect to the job we’re doing in general practice. We can concentrate on the stuff we are trained for and good at… and have time and space to do it well.
Is there hope for a better future for general practice?
I really think so.
This isn’t blind optimism.
Will it take fight and resolve?
Yes I think it will.
I cannot stand back and watch the NHS be dismantled.
It’s sometimes grim out there but there is still magic happening. The same NHS doing marvellous things.
The first step?
Ultimately, I want general practice to be funded properly, invest in us now, be open about the challenges and we can ensure a safe future for the backbone of the NHS.
“Its always something, to know you’ve done the most you could. But, don’t leave off hoping, or it’s of no use doing anything. Hope, hope to the last” C Dickens
3 thoughts on “Hope?”
Beautifully written and an insight into the work of General Practice, Dr Abbie. As a non-medic but trained scientist, I wonder if after the customary 10 minute single appointment (or 20 minute double slot if needed) whether the GP could dictate the diagnosis and treatment and the audio transferred to text, would this cut down the time for patient notes? Admittedly there would be form filling to do routinely but online where possible might increase throughput. Just some thoughts from an almost 75 year old Northerner who was born at home via midwife just before the NHS. My mother once told me as a child that you had to pay to have a baby which I then thought was like buying a commodity, not realising that the midwife had to be paid. Thank God for the NHS for the past 74 years and long may it be the first port of call. We have the best service in the world but need more government help, GPS, and more medics in government. Robert.
Thanks for your insightful comment Robert. Audio dictation is an option, lots of ways to be more efficient with tech I think. We must keep the NHS going, a US style health system would only serve to stretch the already present health inequalities in society.
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You’re most welcome and the NHS is our heritage and must never be privatised.