Written evidence submitted by Medical and Dental Defence Union of Scotland (MDDUS) (FGP0341)

 

The Medical and Dental Defence Union of Scotland (MDDUS) is a medical defence organisation that represents the professional interests of more than 54,000 doctors and dentists across the UK, offering access to indemnity, legal advice, and support.

 

We welcome the opportunity to submit to the House of Commons Health and Social Care select committee’s call for views on the future of general practice. This response addresses the areas of the call for views most relevant to MDDUS, namely the challenges facing general practice over the coming years, and the issue of burnout and low morale amongst staff.

 

Introduction

MDDUS responded rapidly to our members’ urgent need for support and training as the pandemic fundamentally altered their ways of working. We provided expert legal, medical, dental and employment law advice, as well as regular online training, updated constantly to ensure relevancy to the pandemic and emerging issues in care.

 

With doctors on the frontline facing new challenges, and the increased complexity of concerns raised by doctors tackling Covid-19, our in-house medical team saw the time taken to deliver advice increase by nearly a third in 2020 to 1,742 hours.

 

We became aware very early on in the pandemic that doctors were experiencing enhanced stresses, and identified that the key areas of concerns for GPs included:

1.     Managing patient complaints related to accessing medical care and potential delays in treatment;

2.     Maintaining and minimising exposure risk to staff;

3.     The risk of claims for clinical actions and decisions made during the pandemic.

 

We are also aware that a high number of GPs are now considering prematurely leaving the profession. We surveyed almost 2,500 of our members at the peak of the second wave of Covid-19 in 2020, and at that point found that half of all those who responded planned to leave the NHS or take early retirement. Key drivers were spikes in stress and anxiety, which was particularly acute amongst GPs.

 

General practice is the foundation of the NHS - it is often the first point of contact with the health service and has long been highly valued by patients, but it is clear that it is also under immense strain. As we move into Covid recovery and beyond, it is vital that general practice is given the support, resources, and investment needed as they continue to face the challenges and long-term impacts of the pandemic and respond to changing patient and professional needs.

 

 

 

 

Q2. What are the main challenges facing general practice in the next 5 years?

 

Medico-Legal issues:

 

  1. Claims, complaints, and regulatory issues caused by the pandemic

The ongoing impact of the pandemic on GPs and GP staff must not be under-estimated. While the full picture may not be known for months (perhaps years), we do know now that the healthcare professionals we represent have been through a traumatic and challenging experience, unique in its difficulties and of a scale that has no comparison within living memory.

 

Since the start of the Covid-19 pandemic, the NHS has had to redirect much of its resources to care for patients with Covid-19, causing other areas of care to be disrupted and increasing backlogs. This combined with patients avoiding seeking, or being unable to obtain, healthcare referrals during the pandemic led to 5.38 million patients on waiting lists for elective care by September 2021, of whom 1.95 million had been waiting for more than 18 weeks, including 301,000 waiting for more than a year[1].

 

The backlog of cases requiring or awaiting secondary care will distract general practitioners from their core functions as they will inevitably be drawn in to providing a proxy for secondary services; for example, enhanced and more complex disease monitoring than is appropriate for general practitioners to provide. There is an enhanced risk that by working to tackle the backlog of cases whilst providing routine care, GPs could face an increase in complaints and claims.


It is our strong view that the exceptional circumstances of dealing with the pandemic are not forgotten when using hindsight to judge medical decisions or actions taken during this period. Capturing a record of this period will be vital to ensure that all those who worked in healthcare throughout Covid-19 will be treated fairly in the case of a claim, complaint, regulatory process, or criminal allegation in its aftermath.

 

While we are pleased that professional healthcare regulators, including the General Medical
Council, have made commitments about how fitness to practise hearings will be conducted, we firmly believe this is a topic that requires ongoing scrutiny.

 

Throughout the pandemic, we have called for an independent, expert advisory report with recommendations and guidance to ministers, the judiciary, regulators, NHS employers and Ombudsmen on:

 

        The claims, complaints, and regulatory issues likely to be raised by the pandemic, both directly and indirectly

        The processes by which these can be tackled fairly, reflecting the exceptional and unique circumstances in which clinical professionals have been working

        Any specific changes to normal procedures and sanctions necessary to produce expeditious outcomes, and so minimise the stress and uncertainty of investigations relating to actions taken during Covid-19

To that end, we would urge the committee to support the retention of that memory and ensure that retrospective decisions are balanced and properly bench-marked, thereby minimising the mental stress and impact upon health professionals both now and in future years.

 

  1. Remote consulting

At the start of the Covid-19 pandemic, general practice responded swiftly with a complete reorganisation of its delivery model, offering telephone and online appointments as default, whilst ensuring patients were seen face-to-face where clinically necessary - in line with national infection protocol guidance.

 

The ability to consult remotely has been, and will continue to be, invaluable for both GPs and patients in making healthcare more accessible across the UK whilst also ensuring the safety of patients and practice staff. There are, however, increased risks associated with remote consulting that GPs must consider to ensure the needs of patients always come first.

 

Remote consultations can be dependent on the patient’s ability to express themselves clearly, and it is important that GPs consider differences in patient demographics and other characteristics. Of particular concern is the protection of vulnerable or at-risk patients during remote consulting. Some patients may be disadvantaged, for example those who are technically inept, hard of hearing, or living in an unstable domestic environment. In such scenarios, we believe it is important for GPs to use their instincts and carefully consider the need for face-to-face assessment.

 

Video consultation may be potentially safer than telephone consultations, providing better visual cues. However, video consultation will not provide the same level of assurance as a face-to-face consultation given the limited scope for physical examination.

 

Finally, prescribing remotely presents a particular challenge and it is important that GPs allow adequate time to ensure safe compliance and prescribe only when there is full and accurate knowledge of the patient’s health, and they are satisfied that the medicines serve the patient’s needs.

 

Whilst there are many merits to the use of remote consultations, we believe it is vital that general practice is able to offer shared decision-making on the mode of consultation we would encourage the committee to explore this more closely.

 

  1. Relationships and communication

 

It is inevitable that communication between doctors and patients will be different in remote settings when compared to face-to-face consultations. It is likely that some patients will feel more comfortable communicating remotely and vice versa. GPs must be able to balance demand and patient need with the appropriate consultation type for a particular circumstance.

 

  1. Mental health and wellbeing

In addition to the existing workload challenges outlined above, GPs are also dealing with the managing their own mental health and wellbeing. As with the wider NHS workforce, they are now suffering from high levels of burnout, increased stress and anxiety.
 

Our members are facing the dual task of dealing with the patient treatment backlog that developed during the major lockdown periods, as well as being called upon to play an individual and collective role in the recovery of the NHS post-Covid. Both these duties place a highly stressful burden on the health profession and, in our opinion, will continue to put specific demands on their resilience and long-term ability to care for the complex needs of patients.

 

We surveyed almost 2,500 our members at the peak of the second wave of Covid-19 in 2020, and at that point found that half of GP’s were more stressed than during the first wave, and 45% were more anxious. In addition to this 63% of the GPs surveyed expressed worry that their decisions during Covid-19 will lead to a claim or complaint against them.

 

There is a clear and urgent need to tackle the wellbeing crisis in general practice which we hope the committee will prioritise in its recommendations to government.

 

  1. Public inquiries into the handling of the Covid-19 pandemic

As you will be aware, the UK government is planning to launch an independent public inquiry into the handling of the pandemic in Spring 2022, and a public inquiry in Scotland is scheduled to begin before the end of this year. Whilst public inquiries into the handling of Covid-19 are a welcome step, we believe that it is vital these do not increase pressure on the NHS nor on individual healthcare workers.

 

It is our strong view that any public inquiry must be organised tightly and completed swiftly, with a focus on national decision making as opposed to individual clinical decision making. If the timeline of the inquiry is allowed to run into several months or longer, it risks a loss of valuable immediacy and the ability to draw out lessons to be learned and implemented in a timely manner. It is important that these inquiries take a broad view of what happened and address areas of public concern while at the same time assuring health professionals they will be conducted with integrity, honesty, objectivity, and impartiality.

 

Therefore, whilst we fully support governments’ plans to hold inquiries into the handling of the pandemic, and particularly welcome the opportunity for lessons to be learned, we consider that it is of the utmost importance that they do not increase pressure on general practice staff as they play their part in the UK’s Covid recovery over the upcoming years.

 

 

Q5. What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?

 

In addition to the issues addressed in our response to Question 2, the ongoing criticism in the media, and from politicians and the public, surrounding GP access is likely to further damage morale amongst the general practice workforce. It is vital that the government begins to understand the real threat that general practice is under and address the ongoing reasons for this. Creating awareness and educating the public on the pressures facing general practice would be a positive step in increasing public support and appreciation for the workforce and subsequently boosting morale.

 

GPs and their teams have been working hard throughout the pandemic to deliver care to patients presenting with both Covid-19 and non-Covid-19 conditions. As we look to the future, general practice will continue to play a key role managing patients in the community, helping to deliver the Covid vaccination programme, all while dealing with a backlog of cases caused by the pandemic. We hope the committee will take into consideration the recommendations made in our response Question 2 to ensure that GPs and practice staff can continue to deliver high levels of care and play a key role in communities now and in the future.

 

Dec 2021


[1] National Audit Office (Dec 2021) NHS backlogs and waiting times in England.
https://www.nao.org.uk/report/nhs-backlogs-and-waiting-times-in-england/