Things are changing so quickly now, and I thought it was important to hear from a GP in this crisis. I have seen mixed comments about what is happening around the country. I want to thank Dr Simon Hodes (@DrSimonHodes) for taking the time to write this very thought provoking piece. Simon has worked as a GP partner in the same Watford practice since 2001 and is also a GP trainer, appraiser and LMC rep.
“2020 has been a memorable year, for many reasons.“
“We have seen the importance of good responsible leadership and the ultimate importance of mutual respect, kindness and societal responsibility. Coronavirus has touched all of us, left many people with long term health issues and tragically taken many lives. Lives often ended prematurely, and possibly many preventable.
Working as a front line GP throughout the Pandemic, in a large group Practice serving 30,000 patients, has been remarkable. Like the rest of the NHS, GP Teams have been forced to completely change everything and adopt new ways of working.
The NHS can be thought of as Primary Care (everything out of hospital), and Secondary Care (everything in hospital). Primary Care deals with 90% of all NHS contacts (on just 7% of the total budget). To put it in perspective Primary Care has 300 Million contacts a year – compared to 23 Million A&E visits. So clearly any problems with access to GPs are widely noted by patients. And even a small shift of patients away from primary care, due to reduced access, can have an amplified ripple effect on walk in centres, 111 and Emergency Departments. Matt Hancock has repeatedly referred to General Practice as ‘The bedrock of the NHS’, and many would agree. We are often called the ‘Gatekeepers of the NHS’.
GP staff usually stay in post for many years, tend to be dedicated to their communities and generally think in a very patient centred way, always trying to consider our patients’ needs. Having to close our doors, close our appointment books, see empty waiting rooms and move to a phone assessment first approach has been very difficult. My ‘normal’ day BC (before covid) would be arrive c 8am, see around 15-20 patients face to face each morning, a quick bite to eat with my colleagues, a home visit or nursing home ward round, often a meeting, paperwork (prescriptions, hospital letters, blood results, phone calls, emails), then another 15-20 patients in the afternoons. Home for around 8pm. Dinner. Then often log in from home to mop up all the ‘urgent’ stuff that will not wait, could not be done in the day, or simply to get ahead for the next day – as the work constantly piles in. It’s a long day, but hugely varied and rewarding – so time flies by. Like many GPs I usually get a day ‘off’ during the week (usually filled with admin), often work at weekends to catch up, and have various extra roles outside of the practice – in addition to my personal and family commitments.
Like most GPs nationally, our practice has tried to remain as accessible as possible. Our practice is keen on providing ‘Continuity of Care’ as it confers so many benefits for patients, clinicians and the wider NHS. Enquiries are now by a web form (eConsultation) available from our website, or via phone. We discourage walk in patients – although our doors have been open again since September. Our clinics are the same in number, maybe more contacts now, but all phone calls initially, filled by reception or via the web forms. We can then ask patients for more information eg photos by text, or convert to a video call if needed. The majority of problems can be safely dealt with by phone or video. This is safer as it reduces footfall, and many patients find it convenient. For many, access is faster and better than before Covid. However other patients struggle with technology, or miss seeing their doctor in person.
Any patients who wish to be seen in person, or where we deem it safer, we always arrange a ‘face to face’ assessment. We have to wear PPE for this and clean the rooms down in between patients, which as you can imagine takes much longer.
We joke that ‘bedside manner’ has been moved to ‘webside manner’. It’s been a huge change, and one that we know has impacted greatly on patient care.
Many GPs are worried about too much focus being concentrated on Covid. All the non Covid work continues. What concerns many of us the most are the statistics of reduced diagnosis of new cancers and heart disease – as these problems will not have gone away – they are just not being diagnosed. Mental health problems are widely talked about, and there are worrying statistics about domestic violence and suicide rates. This needs addressing on a national level. But on a personal level, GPs would urge all patients to seek help as normal from the NHS, especially for emotional problems, and potentially serious symptoms – such as new chest pains, unexplained weight loss or thirst, unexpected blood in your urine or poo, or a new lump.
In addition, because hospitals were told to cancel all routine care and outpatient clinics to free up capacity, there is a huge backlog of patients with delayed treatment, or now waiting even longer for specialist advice. We try and work as closely as possible with our hospital colleagues to try and minimise referrals or pass advice on to patients, which helps to reduce waiting times.
We arrived at Covid with a known ‘GP crisis’, and with overall around 10% staff vacancies in the NHS. Unfortunately this is often worse in deprived areas for various reasons, further compounding health inequalities, which we know are a risk factor for Covid. There have been falling numbers of GPs over the last few years despite many political promises to increase. In 2015 Jeremy Hunt, then health secretary, promised 5,000 more doctors in general practice by 2020. In real terms 180 practices closed between Feb 2019-2020, averaging 3 per week. Despite this workload is up, with more contacts and less staff . So the ‘system’ is under tremendous strain. Add into this staff illness and self isolation now affecting many GPs, and also tragically the loss of life for some GPs in the line of service.
When Covid struck the UK in March, Primary Care, like the rest of the NHS, was told to go digital first. We had to rapidly plan and implement strategies for continuing patient care whilst limiting the spread of infection. We re-organised overnight, largely using our own common sense and shared ideas on social media. We were told to close the doors to prevent any walk in patients, to triage all enquiries by phone and to switch off online booking (normally heavily encouraged contractually). UKG messages were advising patients to avoid using their GP and to use 111. We have had a ‘tech revolution’ with all GPs having access to secure video platforms and advanced interactive SMS services that allow photo uploads to be saved into the notes. Whilst this works well for most patients there are down sides, and many GPs are concerned about ‘digital exclusion’ which may once again widen health inequalities.
Some newspapers have been running headlines such as “Despite virtual appointments more than doubling between January and August, around a million fewer patients are being seen by doctors every month”. Clearly this is true as we are using phone and video assessment as default and only then see patients face to face where clinically indicated – so this should hardly be newsworthy. We are working differently, not less. However, these headlines, and also the reality of some patients being unable to access their GP have fuelled stories on social media about GPs ‘being closed’ or ‘not seeing patients’. This is hugely insulting and demoralising to the vast majority of GP Teams who are working extra hard to try and ‘keep calm and carry on’.
At the time of writing this blog 29.10.20, Wales is in full lockdown, and many parts of the UK are in Tiered lockdown. There have been 45.955 deaths to date, and my thoughts go out to all their families, friends and loved ones.
If 2020 has taught us anything, it is to appreciate what is important: our wellbeing, the NHS and all our key workers – who often work long, antisocial hours. And Covid has highlighted the need to look after ourselves if possible through healthy diet and exercise to reduce our chances of all disease, to think about health inequalities in society, and that only through mutual care for one another can we beat a major pandemic.”
Thanks to DR Simon Hodges for giving us an insight into the difficulties that NHS staff have faced in turning around their primary care services so quickly to meet patient’s needs. Clearly we do not see what goes on behind the scenes. Many people are all too quick to complain if they cannot get immediate attention and do not think of the wider consequences of how Covid impacts the lives of both patient and health professionals. Having said that, I am still concerned that there are delays in diagnosis and treatment for cancer patients. There is still a long way to go
to reduce delays in order to save lives .
I was delighted to share Simon’s piece because you are so right! People don’t understand what issues primary care is facing too. We are trying to improve that by opening up communication between patients and HCPs.
Like you I am also concerned about treatment delays for people affected by cancer. But unlike the first wave, we are at least discussing those issues now! I will be working to ensure that things don’t get any worse than they are now.
Thanks for sharing your own thoughts and stay safe, Chris
Hi Dianne, thanks for your comment.
We are on the same page. Literally 🙂
The changes within the NHS have been massive and were very quickly necessary. It’s a huge learning curve for all – and while it might suit many patients well, others are clearly struggling to access Primary Care either due to ‘digital exclusion’ or a poorly performing GP practice (let’s be truthful – this is an issue too).
If you look at all causes of death at present (morbid topic – apologies) c96% are not covid related (and even those that do have Covid on the death certificate it may have been within 28 days and incidental = not the actual cause of death)
So while of course we are in a Pandemic, and 96% of the news is all about the pandemic – my own view is that we should not forget the huge ‘shadow pandemic’ of all the non Covid illness.
Cancer, heart disease, strokes etc will remain commonest causes of death and illness and the policy makers should ideally not lose sight of this.
Thank you for your post.
I currently work in a GP surgery & experience the abuse from patients when they cant get an appointment but not for the want of trying. Believe me it is frustrating for staff too when we cannot provide what patients want.
Sometimes I feel we in the GP sector are not included within the “frontline” work but appreciate what comments you have made & the credit you have given.
It is also not easy for our GPs either to work under the current situation but are doing a fantastic job in the limited way they can!
Thanks for your comment
The entire NHS has been under strain and working so hard to deal with Covid – in addition to everything else. Let’s not forget things were far from perfect before Covid arrived….
The media do tend to focus on hospitals and ITU, despite the fact that 95% of all NHS contacts occur in the community.
It is a sad fact that many GP staff have received abuse over the last few months due to some false reports that we are closed – which could not be further from the truth. If you have not already seen this BMJ article from last week it may be of interest and gives further background https://twitter.com/bmj_latest/status/1323961434540298242?s=20
Think we are all (the entire NHS) trying to do our best in very challenging circumstances. Perhaps working with patient groups and the media to promote new ways to access NHS care is key to making access better for all?
Best wishes and keep up the great work
Thank you Dr. Simon Hodes for this very interesting article, and continuing to keep us safe even though you must be exhausted! My daughter-In-Law is a nurse in an A & E department and has expressed concern over patients visiting A & E when they should have seen their GP many months before. Recently I contacted my GP surgery (Luckily I haven’t needed to see a GP for over two years) My GP telephoned me and asked lots of questions, sent me for a blood test and said to phone back if I needed to, and I must say for me this was a better experience than visiting the surgery.
I am a highly qualified and Insured Complementary Therapist registered with the FHT and AOR treating people with cancer (I also founded a CIC to give free treatments to people affected by cancer) stress and anxiety. We can help GPs the NHS and their patients with anxiety, stress, mild pain, loneliness, cancer support and much more if only more GP’s would refer their patients to us. I would love to know your views on this Dr. Simon Hodes. Many thanks
Thanks for the comment. 3 comments back
1) Many patients are finding new ways of contacting their GP faster and more convenient – so that is excellent to hear.
2) We are hearing our hospital colleagues reporting some patients attending as they cannot see their GP – this is definitely a concern and the reason why we are try to get the message out of how to access your own GP practice. This website has excellent resources https://www.rcgp.org.uk/covid-19/general-practice-is-open.aspx
3) Your complementary therapy sounds excellent – would have thought the best way to promote this would be linking in to your local Hospice & GP practices ?
Simon, what a valuable insight into the life of a medical professional during these most testing of times. Like with most vocations, unless you have tried it yourself, it’s nigh on impossible to gauge just what it entails or the trials and tribulations that go with it.
As a cancer patient, I am definitely more aware now of respecting a GP’s time, despite the essential necessity of ongoing treatment, I, without doubt, am certainly more conscious of their workload. This blog certainly hammers this home.
Although you mention the days off (and paperwork) the piece has an overall flavour (and I like flavour) of positivity.
I think having health professionals engage with patients this way is fabulous, a lot of us forget that Doctors get ill too, and family members, and a deeper understanding from us, as those very patients, is a prerequisite for better empathy and change.
Thank you for sharing your warm words
Many thanks for your kind comment
The main reason I wanted to write a blog for Chris, is to break down the patient / doctor barrier.
I believe we all need to interact more via digital platforms to help provide the best shared care we can.
It is really crucial at the moment the NHS / Government helps patients know that GP Teams ARE still open (contrary to some bizarre news headlines) and to try and help patients understand new ways to contact their GP
– Web enquiry forms on our websites
– Via the NHS app
– Or just phone as before !
– (only thing we request in no walk in patients for safety reasons)
Covid has imposed so many changes on all walks of life – and the pace of change is relentless – Covid vaccine discussions since writing this = some light at the end of the tunnel…
Like many of my colleagues I feel so privileged to follow a vocation that I truly love, and although we do have bad days – like any job – and some very difficult times, it is a truly rewarding and humbling profession to be in.
Take care, and thank you again for your warm words