Doctors' Orders: the crisis in our GP service

Telephone first consultations, first introduced as a safeguard due to pandemic, have become the norm.

The pandemic speeded up their introduction. Many saw this as both inevitable and essential.  Unfortunately this is taking place without consultation and before many GPs have been provided with upgrades to their system to allow them to cope with the volumes of calls that are being generated.

The result can be that only those with lightening reflexes for the redial button and who get up at the crack of dawn are likely to speak to a doctor the same day. And when you pause to think about the implications of that you are left concluding that the most vulnerable are also the most likely to fall to the back of the queue.

There are needs for refinements , but let there be no doubt: without it, the system would be in even greater trouble than it faces today.

Readers of some of the tabloids might have been led to believe that seeing fewer patients face to face is the medical equivalent of working from home and the changes are aimed at providing doctors with an easy life.

In fact the GP crisis that underpins it has been coming down the track for a long time. As far back as 2016 the King’s Fund was warning of the increases in workload being imposed on GPs not being matched either by funding levels or the size of the workforce.

Consequently the funding for GPs as a proportion of the overall budget was falling year-by-year.

This is not therefore a matter of hindsight, rather a further example of the mindboggling historical  lack of workforce planning in the system, evidence of which has been mounting for decades.

The fact is that pressures on general practice are compounded by work which is becoming more complex and more intense. This is mainly because of the ageing population, increasing numbers of people with complex conditions, initiatives to move care from hospitals to the community, and rising public expectations.

Additionally surveys show that GPs in the NHS report finding their job more stressful than their counterparts in other countries.

So the pandemic merely heightened what was already a growing trend, which is putting general practice under considerable pressure.

This is set to worsen  with latest projections suggesting a significant shortfall of GPs over the coming decade, despite the increased numbers of GPs in training and the deployment of additional roles.

In Northern Ireland the number of GP trainees  has increased by  70% from 2015 levels. And a working group set up to further examine the issue  is recommending a further increase  of 10  GP training places for the 2022/23 academic year.

This still won’t be enough to meet increased demand, and a health service unable to provide enough GPs to cope is a service on the brink of being completely overwhelmed.

In Northern Ireland increasing GPs is just one part of the response. Others include  the wider roll-out of what are called  “Primary Care Multi-disciplinary Teams”. These include Physiotherapists, Social Workers and Mental Health Practitioners who will often be based at the local health centre. Patients can book appointments directly with them, so they do not have to go through their GP.

Also the introduction of Advanced Nurse Practitioners will also take some of the load off GPs. They are a relatively new type of nurse. The Royal Council of Nurses defines them as graduates who make autonomous decisions for which they are accountable. So they would be able to examine and diagnose patients, order investigations, put people on care plans and provide treatment and care.

This, together with the introduction of new technology is seen as a big part of the solution.

Meanwhile practices are finding it increasingly difficult to recruit and retain GPs. GPs reaching the end of their careers are choosing to retire early in response to workload pressures. They have also been affected by changes to the tax treatment of pensions which create disincentives to work when the lifetime allowance for pensions has been reached.

Compounding the problems is the fact that fewer GPs are choosing to undertake full-time clinical work, with more opting for “portfolio careers” , that is to say having more than one job, or working part-time.

Plans to close the gap won’t work if a career in the NHS is no longer seen as attractive. Therefore the  NHS needs to focus on becoming a better employer, a good place to work and to build a career.

Persuading people to stay in the system is every bit as important as finding new recruits

But that is more difficult than it sounds. Burnout and attrition as a consequence of the Covid-19 pandemic are already having  a heavy impact on the already strained general practice workforce and as staff levels drop as a consequence, workloads intensify. It is a truly vicious circle.

There are other factors too. Rising demand, growing complexity, higher expectations, increased administrative burden and rising thresholds for referral to other parts of the system, all exacerbated by the impact of Covid-19 and the elective backlog which means that general practice is being required to manage more complex needs while unable to unlock access to other services.

As in all other areas of the health service problems are mounting and they are difficult to solve. When an entire system is stretched to the limit excess pressures, even those which in isolation would be easy enough to solve become intertwined.

That’s the scale of the problem we face and it so much easier to define than it is to solve.