The full story of how GP workload is jeopardising patient safety
Pulse’s seminal workload survey has revealed that patient safety is being compromised by high GP workload. Anviksha Patel reports
‘There is a point where I feel cognitively drained; after about 20 patients, there is not an iota of empathy left.’
This Hertfordshire GP’s experience is the stark reality of what it means to be a GP in 2019, and is echoed throughout Pulse’s first-ever survey of GP workload.
The results, which saw almost 1,700 members of the profession describe the challenges they face, were staggering and underlined GPs’ widely held belief that they are operating under unsafe conditions.
An average working day comprises 11 hours, including eight hours of clinical care, the findings show. And GPs working full time have an average 41 patient contacts a day – far higher than the 30 contacts that respondents call a safe limit.
GPs currently are making themselves ill in this job, and it isn’t sustainable
Dr Matt Mayer
Dr Matt Mayer, former BMA workload policy lead, says GPs are at their wits’ end, with some ‘making themselves ill’ as they struggle to manage excessive workload.
He says: ‘The results of the survey done by Pulse are concerning, and confirm GPs are working far beyond their capacity.
‘GPs currently are making themselves ill in this job, and it isn’t sustainable. Often they are left with no choice but to cut their sessions, retire early or leave the profession. No job should be at the expense of someone’s mental health, family or life. No job is worth that.’
There is currently no official reporting of GP workload; Pulse’s survey represents the clearest picture of a GP’s typical day. We asked GPs to record their workload pressures as part of a snapshot of a single day – in this case, Monday 11 February.
A total of 1,681 GPs submitted responses, with others taking to social media to post live updates. We heard from GPs from across the UK; some even contacted us with anecdotes on behalf of colleagues too busy to do it themselves.
The message was clear: GPs are indeed working above safe limits. As the Hertfordshire GP put it: ‘It now feels that we are mere processing lines for patient problems – the conveyor belt effect.
In my own practice recently, I had a 12-hour day and 100 patient contacts
Professor Helen Stokes-Lampard
‘You feel stressed out, mentally and physically exhausted, and more likely to give in to patients’ demands, and later regret doing so. This can affect your confidence in patients’ future care. What’s more, it affects your home life too.’
RCGP chair Professor Helen Stokes-Lampard is another feeling the strain. She says: ‘In my own practice recently, I had a 12-hour day and 100 patient contacts – GPs across the UK will tell similar stories.’
The potential effects on patient safety are concerning. Most shockingly, 52% did not feel they were working at a safe level that day. Yet the majority said it was a typical day.
The survey asked GPs to estimate a safe number of patient contacts; on average they had 37% more than they deemed safe. Around one in 10 reported 60 contacts or more in a day – double what respondents consider safe.
And many contacts were far from simple. Although there was a mix of face-to-face, phone and online consultations and home visits, respondents said 29% were ‘very complex’ and 37% ‘fairly complex’.
The average eight hours of clinical care exceeds the scheduled, with partners facing the longest days. This huge workload burden has an effect on patient safety – and GPs’ own wellbeing.
Professor Clare Gerada, former RCGP chair and an expert on GP burnout, says: ‘In general practice, you’re using your brain all the time, constantly, and every patient could be anything from a minor sore throat to lung cancer. You have to concentrate on every single patient.
‘There’s no adrenaline, it’s very mundane, so it’s easier and easier to make a mistake if you get tired.’
She says the high number of patients GPs are seeing is more likely to lead to tiredness – and possible mistakes.
She adds: ‘You could miss a result or misread a letter, or you don’t focus on the right symptom or ask the right question. You might put yourself at risk. You might end up being rude to a patient and then get a complaint, because when you’re tired you become irritable.’
Nottingham GP Dr Jonathan Harte, who took part in Pulse’s survey, says he felt the risks to patient safety grow throughout the day.
He says: ‘By lunchtime I felt on the edge and risked missing urgent tasks and contacts, thus affecting patient safety. I did miss the fact that a patient I had tried to contact earlier in the day had called back, so I didn’t call her back before the surgery closed.’
I miss[ed] the fact that a patient I had tried to contact earlier in the day had called back
Dr Jonathan Harte
The UK is an anomaly in terms of patients contacts. Dr Mary McCarthy, vice-president of the European Union of General Practitioners (UEMO) and a GP in Shropshire, says ‘25 or fewer consultations a day’ is common according to surveys of European doctors.
Dr McCarthy says in European countries, a GP’s workload is balanced out in accordance with list size. ‘In a lot of European countries, GPs are limited to 1,000 patients. In Italy for example, if you go over 1,000 patients, you have to employ another GP.’
In November in Spain, when workload became unmanageable, GPs even took to the streets of Barcelona as the Doctors of Catalonia union demanded a cap of 28 patient consultations per day and minimum 12-minute appointments.
In England, the key driver of increasing workload is well known – a lack of GPs. In February, it was revealed the number of full-time-equivalent GPs had fallen by 2% in a year – just the latest in a long line of worrying figures. A report in March concluded the NHS will have 7,000 fewer FTE GPs than needed within five years.1
Practice closures are also an ever-present threat. A Gloucester GP says staff shortages and retirements mean her practice is at risk of ‘imminent closure’.
They said: ‘The only full-time partner is emigrating later this year taking with him his partner, who is our excellent diabetes nurse. This leaves us massively understaffed in a climate which makes replacing them unlikely. All the doctors who could retire have done so.’
Increasing patient demand has even more impact, yet seems to be actively encouraged by the Government, especially in England.
The only full-time partner [at our practice] is emigrating later this year
GP in Gloucester
It continues to push its routine evening and weekend GP access policy, despite patchy appetite from the public. Health secretary Matt Hancock has been much criticised by GPs for statements encouraging unofficial screening – including gene testing. This follows Public Health England’s ‘heart age test’ campaign, which told people to see their GP if they don’t know their blood pressure.
NHS managers have started to take notice of this cocktail of factors and insist they are working to reduce GP workload. In England, the new contract agreed by the BMA and NHS England includes an annual £891m by 2023/24 for practices in networks to hire 20,000 extra healthcare professionals.
An NHS England spokesperson says: ‘We know general practice is under pressure. Investment in local doctors and community services is increasing by £4.5bn, helping fund an army of 20,000 more staff to support GP practices as part of the NHS long-term plan.’
However, the spokesperson adds ‘we are also aware almost 9 out of 10 salaried GPs currently work part time’ – suggesting the profession is partly to blame.
We know general practice is under pressure. Investment in local doctors... is increasing by £4.5bn
NHS England spokesperson
NHS England has also announced an extension to its ‘Time for Care’ programme, introduced as part of the GP Forward View in 2016 to encourage new timesaving initiatives, such as social prescribing and digital consultations. It claims the programme has saved around £40m worth of GP appointment time and is extending it across the country.
In the devolved nations, Scotland’s new contract has the GP as the lead in a multidisciplinary team; in Wales, the Government says a potential new contract will look at ‘how we can reduce GP workload’. And in Northern Ireland, GP practices last year started to receive some of a multimillion pound investment in practice-based staff, including physiotherapists, mental health specialists and social workers.
Yet GPs are unconvinced by such measures. They warn that, for example, in England the creation of networks under the new GP contract could add to workload in the short-term with time needed to hire extra staff, set up the 30,000-50,000-patient networks and appoint a clinical director.
Meanwhile, initiatives such as Time for Care are a drop in the ocean, given the challenge of tackling workforce numbers and patient demand.
In the short term, practices should be given permission to close for half a day a week
Professor Clare Gerada
GPs say radical measures are needed to curb demand. Walsall LMC chair Dr Uzma Ahmad says: ‘The Government has to change its stance from demand driven to disease driven, to make sure patients who are really unwell and complex get GP advice that we’re trained for.’
Dr Ahmad says the Government can stop fuelling patient demand itself by ditching the promise of routine GP appointments at evenings and weekends: ‘If we can drive those funds towards daytime access, that will immediately relieve pressure on GPs. It’s been shown that extended access is not taken up.’
There are other radical solutions. Professor Gerada says: ‘In the short term, practices should be given permission to close for half a day a week. I think NHS England needs to acknowledge that if they don’t immediately allow partners to have a rest the whole system is going to fall apart. In the longer term, we need a fundamental review.’
It seems practices are ready to take matters into their own hands. Earlier this year, Pulse reported that one in four GP partners surveyed had cut clinical services to deal with their practices’ rising workload. One in seven said they had considered closing their practice.
But GPs will ask why it should be up to them to reduce workload, when there are such major systemic issues in play. Until commissioners provide some tangible measures to reduce workload, the risk to GP health and patient safety will continue to grow.
Additional reporting by Karl Tomusk
References: ¹ The King’s Fund. Closing the gap. March 2019