The Downland Practice – News from the frontline
Written by Dr James Cave OBE FRCGP
It can be so frustrating. Sitting on the phone for hours, then finding all the appointments are gone and being told to ring back later or tomorrow.
Let’s see if I can explain and, if not remove this frustration, at least give you a glimpse into what is going on behind the scenes as we try to serve you as best we can at the Downland Practice.
But first, let’s look at the bigger picture:
International Picture of General Practice
General practice does much more than seeing you when you feel ill. It organises vaccination programs and health promotion. It treats patients with risk factors (such as hypertension) and diseases such as diabetes and maintain your unique medical record- ensuring it stays up to date and accurate. When the breast screening program wants to check details of a patient, they come to us. If the police want to issue a shot-gun license, they come to us. Every time you are seen by any other health professional in any other part of the NHS, in any part of the UK we are informed and manually add the details to your notes. Studies (see the commonwealthfund.org) have shown time and time again that good general practice is the most important part of a health system when it comes to a healthy nation- it explains why a Cuban’s life expectancy is better than an Americans despite the huge discrepancy in money spent on health systems in each country. There are some unique features of general practice that it is important to maintain such as continuity of care because research has shown that these features have a direct impact on death rates and hospital admissions. Just this month another study in the British Journal of General Practice confirmed this. (see https://bjgp.org/content/early/2021/10/04/BJGP.2021.0340).
Unfortunately funding to other parts of the NHS over the last 30yrs has risen much faster than in general practice. Whilst we have 70%+ more consultants (53,000) working in hospitals than we did 16 yrs ago – with many working part-time (see Nuffield Trust) there has been no increase in GP numbers over this time. Indeed there has been a decline- with a further drop of 1600 since the pandemic started. England now has the lowest level of GP staffing of any of the four home nations and internationally only 4 countries in the OECD have fewer doctors per capita of population. Since 2009 District nursing numbers have fallen 40%- that’s the equivalent of losing two district nurses for every five previously.
Health visitor numbers have also declined such that they no longer play any routine role in the care of the newborn or the family.
At the same time the population of the UK has risen by 15% and life expectancy stands at 81yrs. In this practice alone our population, over the 120 square miles that we serve has risen from 8500 to 11,000.
The 10 minute consultation
Typically, in the UK GPs have seen patients in 10-minute timed appointments and perhaps had a “sit and wait” system for urgent appointments. Whilst this worked in the 1960s and 1970s when GPs were seeing patients with short term illnesses this system does not provide adequate time to deal with the problems GPs are seeing in 2021.
Rise in workload
In my 30 years as a GP we have become responsible for diagnosing and treating most long-term diseases such as diabetes and hypertension- conditions previously treated by hospital consultants. Taking diabetes as an example, the diagnosis of diabetes has doubled in the last 15yrs. 90% of these patients are now managed in general practice. With 68% of men and 60% of women living with an unhealthy weight the number of diabetics is likely to grow. Diabetes is the commonest reason somebody becomes blind or requires kidney dialysis. It is also responsible for increased heart disease and strokes. To prevent this we need to look at and control 8 separate factors such as weight, blood sugar level, kidney function, blood pressure etc— measuring them by examination or blood tests and then treating them with lifestyle and medication. The government quite rightly sets standards and expects us to meet them. A ten-minute appointment does not get close to the time we need to spend with our diabetic patients to ensure they remain healthy. Now add in hypertension, asthma, COPD, heart disease, mental health conditions, disability and you begin to see the complexity that we are juggling.
This increase in treatment of conditions has led to an explosion in the number of drugs a patient might need to take. Treatment is now often controlled by national guidance based on evidence that a GP is expected to follow. This has led to the average 60yr old person now taking 4 or more different medications a day. Whilst this is usually beneficial for their health, these drugs can have side effects and interact with each other, so it is important that patients on regular “repeat” medication have a regular review each year. As the number of patients taking medication increases, the number and complexity of these medication reviews increases.
With the increase in conditions being managed in general practice there has been an inevitable rise in blood tests. Many of the drugs we now use need regular blood tests to assess how well they are working or check they are doing no harm. These tests need to be organised and taken- and then the result reviewed and acted upon. It has been estimated that there has been a 300% increase in blood tests undertaken in general practice over the past decade. The time taken each day to review the results now equates to an additional 5000 extra GP’s time each year- 5000 more GPs that we don’t have- on top of the further 5000+ GPs you hear about in the press being needed and promised by the government.
Moving work from hospitals to GPs
Whilst hospitals still manage some diseases such as rheumatoid arthritis and inflammatory bowel disease, there has been a shift to “shared care” with GPs. In this arrangement the GP prescribes the medication the specialist is using and therefore takes responsibility for it. This usually requires the GP to carry out tests and monitor the patient regularly. In the last decade the number of shared care agreements has blossomed – there are now 38 in place in Berkshire. Despite it being clear that this additional work needs additional clinical time practices have not received any.
In 2015 NICE produced its first guidance on diagnosing suspected cancer. This vital guideline has improved the survival for many patients whose diagnosis has been found more quickly as a result, but this guideline has significantly increased GP work and the pace at which that work must be completed.
I hope I have painted a picture that goes some way in explaining why general practice was struggling even before the pandemic.
Let’s now look at the practice and the impact the pandemic has had on us since March 2020.
The Pandemic- the first shut-down.
Keeping patients safe, ensuring vital supplies of medication to shielding patients and seeing patients with COVID were our immediate priorities, on top of our regular work. Just the task of seeing a patient was complicated by “Donning” and “Doffing” PPE and cleaning the room after each patient. Initially we could not use our waiting room so had to arrange to call patients in from their car. We had to re-arrange working to cope with staff absence due to shielding, or isolation, or illness. Software systems were introduced to improve our ability to text patients.
With volunteers we set up a daily delivery service of medication to those isolating in our community. During the first lockdown over 8000 items were delivered this way.
In Spring 2020 we set up a “Hot Hub” for sick patients to be seen and triaged at the Racecourse. This required all the bureaucratic hoops to be jumped as you would expect in a 21st century health system- CQC, Health and Safety, infection control etc., at the same time as we were running our practices. Many patients were very wary of coming down to the surgery and we introduced a system of phone calls first, with the doctor and patient organising a face to face that afternoon if it was needed. This of course meant some duplication of work compared with keeping to just face to face appointments but is allowed us to ensure we only saw patients who needed to see us and others could remain safe at home.
The Racecourse Vaccination program
During the winter of 2021, the practice worked with its neighbours to set up the vaccination centre at the racecourse. We were lucky to receive fantastic support for an army of volunteers but the practices’ staff made up the majority of clinicians work at the site- doing this work in addition to their normal work.
Some practices moved to a system of “total triage” especially in areas that were overcome with workload. In this system all requests to see a GP are made online with receptionists helping those without access to the internet to complete the form. These are then reviewed each day by GPs who then determine who needs what in the way of an appointment- be it advice to see a pharmacist, a phone call, face to face or other. This system works for some – the tech savvy and young, and not for others- particularly the old and frail. It can also mean a GP has over 60 requests to triage each day even before s/he arranges to see those that need it.
Downland Practice approach
As a practice we did not opt for total triage. We are concerned that it does not improve access, but creates a barrier and can damage continuity of care. Instead we have done the following:
- Increased the number of appointments the practice offers overall.
- Ensured that people who feel their problem is urgent on the day get a face to face appointment on that day.
- Offer a range of appointments – face to face, telephone and web.
- Opened up our website options to contact us through it for non-urgent issues.
- Set up a texting service allowing us to text you personally and receive responses to those texts, if required.
National consultation figures. The practice never closed and never stopped offering face to face appointments. In June 2020 NHS digital started using our consultation pages on our IT systems to record GP appointment numbers. Because of this they asked us to change how appointments were recorded so numbers could be compared across England. This has had an impact on how you compare consultations before and after this time. In 2020 GPs alone in the Downland Practice provided 20,000 appointments with just under half (9,300) being face to face.
The coming Winter 2021
This promises to be the hardest period I have experienced in 30 years as a GP. Our teams are tired – it’s been a long 18 months and work has increased, not decreased. In addition we are sorry to say goodbye to two excellent GPs: Dr Waise Haider and Dr Daveeta Dhesi. Neither are retiring, but rather choosing other career options that offer them a better life/work balance. Despite our best efforts we have been unable to recruit replacements so will run into the winter with over 100 appointments a week short of our usual numbers. We are making efforts to make up the numbers; our current team will work longer hours and we will employ locums where available.
Without replacements we will allocate the patients of Dr Haider and Dr Dhesi across our remaining GPs on a temporary basis so there will be a nominated GPs overlooking your care. Our receptionists will know who this doctor is if you ask and we will try and ensure you see the same doctor each time to ensure continuity.
We ask you to be patient, consider other services such as a Pharmacist, NHS 111 (either by phone or online). It is likely we will have to restrict some services to remain safe and ensure we can offer a core service.
We ask for your patience, especially with our reception staff who have possibly the hardest job of all.
Thank you. Please ensure you get vaccinated and have a healthy and happy 2022.
Dr James Cave OBE FRCGP