Life As A GP On The ‘Front Line’

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.”