Written evidence submitted by Dr Tracy Crickmore (FGP0111)

I have been a GP in a semi-rural practice for 26 years and in that time I have seen many changes. It has always been a demanding job but in the last few years the hours have become much longer. I typically work a 13 hour day, expecting to catch up at least 2-3 hours work per day worked on each day off. I am half time, 4 sessions a week, and work at least 32 hours a week. I, and several of my colleagues have had to seek help for mental health problems and burnout. I have drafted a resignation letter as my health is suffering from the relentless stress levels. I am also lead GP at a Covid vaccination centre which adds another 16 hours a week to workload.

Perception The public only see GP appointments as our work. Many who only attend when they have an acute illness have no idea of the amount of chronic disease management we also do such as diabetes, mental health and COPD reviews. They do not think of referral letters, reading hospital correspondence and summarising the contents. They have probably never heard of audits, or quality improvement plans and have no idea we review all cancers diagnoses, deaths and have numerous safeguarding meetings too. Then we have a business to run with staffing issues, finances, insurance, employment law and meetings on primary care network initiatives. The media has driven a perception we are closed and having an easy time when the opposite is true.

Demand for instant access has really risen in the last year. I call it the ‘Amazon prime effect’. We used to be really pleased with a 10 day delivery, now we expect things the next day and demand for GP appointments seems to be similar. I have appointments available next week but patients insist on being added to the triage list for a same day appointment for chronic problems such as eczema, joint pains, and period problems. This often results in loss of continuity of care and over investigation. Of course an acute illness needs to be triaged and acute illness/children seen promptly. We have increased reception hours and they still cannot keep up with the phone calls coming in. We tried allowing email messages / consultations but staff did not have the time to copy and paste emails into the medical records and some patients thought that a prompt reply could start an exchange of emails. One patient replied 5 times in 24 hours so actually having 5 consultations in 24 hours. We had to turn email off and go to an on-line system from within the medical records but patients have to register for the service first and that disadvantages the elderly. We had to turn e-consults off at weekends as we would phone back / reply on a Monday and some patients had even forgotten they had submitted a consultation request at all yet the document had been imported by reception, passed to triage, read by triage and then actioned. What a waste of time. The very elderly and vulnerable such as learning disabilities still need access by phone so it is important phone lines are available and manned.

The reports in the media that GPs have been slacking and not seeing patients has been totally demoralising! We have seen patients who needed to be examined and are not aware of missing significant disease. Our cancer referral rate did not drop. It has been exhausting assessing by phone, then bringing patients in to be seen and squeezing in time to don and doff PPE and clean the room. Some patients have found telephone follow up for depression or to relay test results very convenient. Most patients would understand the need to limit people in waiting rooms if the media took a few minutes to find out the facts. We have a small waiting room for 8 consulting rooms and an ancient building with little ventilation.

We have tried varying our workforce to include more healthcare assistants and some salaried GPs but ultimately the buck stops with the partners. We are left after 6.30pm with results to sort out, staffing meetings, building problems etc . Salaried GPs rarely want to be leads on safeguarding, diabetes, or mental health etc. General practice does not have the back up of maintenance, human resources, legal and records dept etc. We have a practice manager and assistant trying to do it all! We do not even have secretaries and type all our own referrals as admin staff are frequently swamped with sorting out appointments, and trying to find locums.

Workload ALL our GPs have now reduced sessions in the last few years. We seem to be losing sessions faster than new GPs are coming in. 3 of us are considering retirement before age 60. I love the continuity of general practice but that is rapidly disappearing and even 2 days a week are becoming unmanageable! On the positive side we now have health care assistants taking on roles such as diabetic foot checks, ECGs and half the learning disability review. We also have a part-time pharmacist helping with polypharmacy in the elderly and doing COPD reviews plus discharge summary medicine reconciliation. We have also employed a company to manage our hospital correspondence and summarise it but we are taking a pay cut to do it. We seem to spend increasing periods of time dealing with rejected hospital referrals and work bounced from secondary care. A classic example was we were asked to take most of our diabetics on insulin back from hospital care and we would get a local consultant clinic weekly and a diabetic nurse specialist to help with clinics. The specialist nurse disappeared and the consultant is now about once a month if we are lucky. We now have to initiate and monitor insulin and do hundreds of extra checks for no extra funds so we are out of pocket again. Rationing prescription items like laxatives, creams , painkilling gels etc may be saving the government money but without a huge information campaign it is adding to GP workload as patients complain and argue.

This year GPs have worked exceptionally hard. We have moved to triage, we have continued to see patients, risking Covid infection. We have had 3 months with few blood bottles making chronic disease management virtually impossible. There has been a huge surge in demand for same day appointments too. We have worked over-time delivering the covid-vaccination programme and ultimately due to the blood bottle shortage we are likely to have a significant pay cut unless QOF reviewed as we only have 3 months left to do a years work whilst putting all efforts into covid vaccinations push. Changes in guidelines and the constant media release of information, changes in cohorts, vaccination intervals etc, often before we are told drives unreasonable expectations and blocks our phone lines. This year has been exhausting and next year looks as bad. This is not sustainable! The current extremely long hours become very frustrating when we are then asked to do extended hours as well, e.g evenings and weekends so my 7.45 am – 8.30 pm day becomes 7.20am to 9 pm day

If we are going to be able to deal the complex co-morbidity of elderly frail patients we need 15 – 20 minute appointments and time for MDT meetings with community teams. We also seem to spend increasing amounts of time dealing with families concerned about the lack of available social care for their loved ones. Primary care with an aging population is becoming more complex. I think it would save the NHS a lot of hospital admissions if GPs had smaller lists and more time to provide continuity of care with a named doctor ( or at least a pair of doctors who share a list). To do this we need more investment in primary care and more doctors.

Like other practices we really struggle when anyone is off sick or we have over-lapping leave ( a necessity when multiple partners have school aged children who rarely see their parents!) Finding locums is extremely difficult, especially as we are rural and they cost a fortune. One of the problems for general practice is the hospitals can go to opal or red alert and stop doing things, reduce admissions etc but general practice is just meant to absorb like a sponge and we then become unsafe. Two 4-hour surgeries followed by 20 tasks/phone calls, 2 visits, another 4-hour surgery and then hours of admin is not sustainable. The fear of missing something then leads to insomnia and a downwards spiral. I have not had a proper lunch break in my 13 hour day for over a year.

The continuity of care, and the detailed background knowledge of social factors and family dynamics is invaluable for patient care. A GP is often the only person with a total oversight of a patient who is being investigated by multiple hospital departments, occasionally in different hospitals. We can stop over / repeated investigations too. General practice is the bedrock of the NHS and without us limiting demand for hospital services the NHS will sink. The inappropriate use of casualty is a good example.

I am not convinced working in a primary care network has really helped but then that may be a managerial issue in ours. The covid-vaccination programme did pull us all together under a different manager. We are a rural mix of large and single -handed practices so finding models to help all is difficult. Pharmacists have been a help and social prescribers too but we have to remember how to refer to all these new people! We are not allowed to employ what our rural area needs which is advanced nurse practitioners to help with a visiting service. The additional roles are  too prescriptive.

Solutions.

-          Give primary care networks the freedom to find local solutions. Rural areas distant from hospitals need advanced nurse practitioners for a visiting service.

-          Give general practice the resources it needs for administration and secretaries. Why do consultants get secretaries but GPs do not yet we probably deal with more patients a day.

-          Make patients appreciate appointments and charge for missed appointments. Free if not abused.

-          Stop off-loading secondary care work onto general practice with no resources e.g care for diabetics on insulin, rejecting referrals such as child and adolescent mental health

-          Fund adequate IT systems such as text systems but remember the elderly still need a receptionist at the end of a phone.

-          More investment in general practice could safe substantially more in secondary care costs.

-          A clear mechanism that allows general practice to say we are full / amber alert and to be able to close the doors.

-          Re-think the partnership model. Currently we are self-employed but with very little say in changes to our terms and conditions. We are told about changes, expected to absorb often underfunded work. Contracts are changed mid-year or published late e.g QOF targets or QUIP giving half the time to get the job done. No other industry would accept all these changes. The covid vaccination programme is an extreme example of constantly moving goal posts and very short intervals for primary care networks to meet and really discuss the implications of another phase. We have no sooner agreed than everything is changed piling pressure on practice staff.

-          GP partners should be equivalent to a consultant, possibly salaried GP equivalent to a staff grade doctor and pay should be similar. After all few GPs have the opportunity to earn extra income seeing private patients  but we have similar training, have to have extensive knowledge base of all disease areas and referral processes, work very long hours and treat huge numbers of patients trying to keep them healthy and out of hospital.

 

We need a solution to our workforce crisis and soon. We need to attract new GPs to save primary care. Continuity of care ultimately saves a lot of secondary care costs. We need government to set realistic expectations for patients.

Dec 2021