The pandemic has compounded already high GP workloads while bringing extra challenges, including patient frustration about reduced services. Nicola Merrifield reports on the pressures the profession is facing
Two years ago, Pulse reported that GPs were at their limits, with more than half saying they were working unsafe hours. The report generated national headlines and was even raised at Prime Minister’s Questions.
Of course, since then, the Covid-19 pandemic has turned the world upside down. So much so that some sections of the media – and even health authorities – have been pushing the idea that general practice hasn’t been open for patients.
GPs know this is untrue. And Pulse’s latest workload survey of 1,400 GPs across the UK, a snapshot of workload on the first Monday in March, has proved not only that general practice is open, but that many feel it is unsafe.
GPs are still working an average 11-hour day, including eight hours of clinical care. And the average number of patients GPs dealt with in a day – 37 – far exceeded the 28 patient contacts they felt should be the safe limit for a GP working in the pandemic.
Most shockingly, around half of GPs (49%) said they still believed their workload was not at a safe level on the Monday the survey took place.
In other words, the pandemic has seen one workload crisis replaced by another.
RCGP chair Professor Martin Marshall says: ‘The pandemic has only exacerbated these pressures. GPs and our teams continue to work long days – well above “normal” hours – as they strive to deliver the care patients need, as well as all their other responsibilities.’
When the pandemic started a year ago, it did reduce patient demand. But it added new challenges. Remote consultations became the norm, GPs entirely reorganised their practice buildings and procedures, staff were off with Covid, and a new group of patients with the virus emerged. The list goes on.
A year later, and not only do these factors remain, but NHS England board papers reveal that, including Covid vaccinations, GP appointments rose to around seven million per week by the end of January 2021 – which is around one million more per week than before the pandemic. With no respite, GPs are questioning how long this level of workload can continue.
‘Morale is suffering and many are on the brink of exhaustion,’ says Gateshead and South Tyneside LMC chair Dr Paul Evans. ‘This tempo of work cannot be maintained.’
Remote consulting adds new pressures
The main difference in 2021 compared with two years ago is the format of appointments.
Since the pandemic hit, as is now well known, GPs have been doing fewer in-person consultations. The latest official NHS statistics, from February, show just over half (55%) of appointments in England were conducted face to face, with 41% on the phone. In February 2019, 82% of consultations were face to face.
This has affected the length of consultations – 55% of respondents to Pulse’s survey say they are longer now than before the pandemic.
Remote consulting does take longer, says Dr Albert Pereira, a GP partner in Wirral. ‘There is more multitasking now, reading e-consultation forms first then phoning the patient, waiting an answer.’
All of this leaves GPs feeling exhausted: ‘It is hard to manage more than 40 telephone consultations in a day,’ says another GP responding to Pulse’s survey. They add: ‘Consultations now are much more draining.’
The switch to remote working has also changed patient behaviour. More patients now contact their GP over the weekend via online consultation forms – which creates bottlenecks for practices, says Berkshire GP Dr Chauke Kade.
A worrying development, Dr Kade adds, is that patients are increasingly ‘consulting by email’, rather than using official e-consultation forms, meaning there’s a risk the messages will be missed.
‘They are using the practice’s generic email and asking admin staff to forward their email to their doctor. This is a safety issue. We do not access our emails daily.’
Where GPs are providing face-to-face consultations, these are taking longer too.
As locum GP and Kent LMC medical director Dr Andy Parkin puts it: ‘Face-to-face consultations require cleaning, donning and doffing PPE, and then cleaning again using disinfectant wipes on surfaces, the couch, chairs, handles. They take a lot longer.’
At the same time, around 29% of patient contacts on the day of Pulse’s survey were ‘very complex’, according to respondents.
BMA GP Committee chair Dr Richard Vautrey says: ‘While more and more appointments are now taking place via telephone or online, there is a misconception that remote working is somehow “easier” for GPs and other practice clinicians, or takes less time than face-to-face consultations. This is not the case and the opposite is often true.’
GPs say they are also now being hit with a wave of patients who held off contacting the NHS during the first nine months of the pandemic after being told to stay at home by the Government. Their symptoms have now worsened, making the cases more complex (see below).
GP partner ‘We are dealing with a deluge of chronic problems that have deteriorated’
When we started doing online consultations a couple of years ago I would do 50-55 contacts on a Monday and that wouldn’t be such a bad day. Now I’m doing in the order of 35-40 and am absolutely rinsed.
It’s like a switch has flicked and everything that’s been going on in the background for nine months is now coming forward. It’s a deluge of longstanding chronic problems that have deteriorated beyond the point of self-care.
Patient behaviour changed as the pandemic drew on. We’ve now got a population who are fearful and anxious about everything – quite understandably – so what they’re consulting about is more undifferentiated and complex.
Now we have real presenting illness that is much more serious than it used to be. In my practice alone we’ve had five or six melanomas in the past six weeks, which is an extraordinary amount all at once. Almost invariably people had had symptoms for months.
The story is always, ‘I’ve been putting off coming to see you about this because I knew the health service was busy’.
We had someone with a terrible inflammatory bowel disease flare-up and they were unable to speak to their IBD nurse support because they were redeployed or shielding.
The support service for that person has shifted towards primary care – and it’s not a straightforward management, but someone who is complicated and already on third- or fourth-line drugs. That means I’m doing a medical specialty consultant’s job, as well as being a consultant psychiatrist because we can’t get people into mental health services.
There are not enough people to do what’s needed. We cannot carry on with a vaccine programme, we cannot carry on shouldering a large burden of the workload that would normally take place in secondary care – and also expect to get on top of our own chronic disease management, which has been on pause.
Dr Dave Triska is a GP partner in Surrey
GPs also risk missing crucial information with remote consulting as they are unable to conduct physical examinations.
Bristol-based portfolio GP Dr Harry Minas says: ‘We miss the body language element of the communication, which can be as much as 80% of what both parties see and use to make decisions.’
And while waiting lists increase for secondary care services, GPs are left with the clinical responsibility.
Another survey respondent says: ‘Patients are deteriorating while waiting for secondary care input. We need to manage associated risk, which causes lots of repeat patient contacts – for instance, patients asking “when will I be seen in the long Covid clinic?”.’
Admin piles up
Around 70% of GPs in our survey said in general, daily workload now was ‘significantly’ (35%) or ‘slightly’ (35%) higher than on a typical day before the pandemic.
Admin work is contributing to the problem. Throughout the pandemic, GPs have had their usual admin to do. But on top of that they’ve received reams of operational updates from the NHS about how to adapt services.
One GP in our survey, who asked to remain anonymous, says: ‘It’s impossible to keep up with new guidelines, services, IT, ways of working, meetings. I have given up – I can’t keep up with all the information I am sent.’
On the day of the survey the GP had to use the weekend to get ahead of their paperwork: ‘I started my admin the day before on my day off. I still haven’t finished looking at all my emails for the day… and I have multiple reports hanging over me. I don’t know when I will do them. Probably over a weekend but I am exhausted by then.’
There have also been extra requests from hospitals to carry out tests as their face-to-face clinics are on hold.
Last autumn, a workload analysis by Bedfordshire and Hertfordshire LMC, alongside Cambridgeshire LMC, found additional work transferred from secondary care during the pandemic would require an extra 1,150 full-time GPs across England.
Meanwhile GPs have been left to deal with surges of patient phone calls following government announcements about new criteria for priority vaccination and patients who should be shielding from Covid.
In February, the new QCovid algorithm added an extra 1.7 million people to the shielding list, but mistakenly included patients who previously had gestational diabetes that had now resolved. Patients with asthma were also confused about whether they should be prioritised for vaccination, following ambiguous NHS England guidance.
One GP in our survey said these pressures meant their workload was higher on the day of the survey because they ‘had to deal with fallout from the recent shielding letters’.
The GP noted the ongoing strain of the pandemic: ‘We are constantly planning clinics and admin on top of the day job.’
Kent LMC’s Dr Parkin says GPs’ management of the Covid vaccination programme adds to the pressure.
‘A lot of practices are finding it hard to manage the vaccination workload, the increasing day-to-day work and patient expectations of being able to contact their GP remotely whenever they want.’
The result of sustained high workloads is GPs feeling ‘tired’ and ‘tense’, which can lead to minor mistakes, Dr Pereira says.
‘This includes forgetting to print out prescriptions or sick notes, occasionally recording information in the wrong notes when changing medications from a hospital letter, or selecting wrong medication from a list to print out.’
Practices have been open
Practices have been fighting to stay open despite the challenges. However, patients have been worried by media claims that GPs have been closed – because they are only offering face-to-face appointments where required. This followed a notorious NHS England press release in September, saying GPs were being reminded to offer in-person appointments.
And this seems to have increased dissatisfaction. Pulse’s survey revealed 40% of GPs have had either ‘significantly’ (16%) or ‘slightly’(24%) more complaints in the pandemic.
According to one GP in the survey, patients are feeling ignored: ‘It’s everything from access… to hearing GPs “are not seeing patients because the politicians said so”, even though we have seen people every day face to face.’
Patients are also concerned about wider delays in the NHS, says Dr Evans: ‘They are immensely frustrated with system delays and failings, but they complain about GPs when the underlying issue is waits of more than 12 months for secondary care.’
NHS England itself has in effect acknowledged that GP practices are open – and are working to capacity.
The launch of the vaccination rollout led NHS officials in January to lay out a series of measures designed to cut GP workload while the programme took off.
This included income protection for QOF work and the suspension of locally enhanced services, with funding protected. Last month it also announced a new six-month £120m Covid fund for GP practices – mirroring the £150m fund given earlier on in the outbreak.
However, a BMA survey in February revealed that LES income protection has not been provided for one in 10 practices. Even more worryingly, practices will be expected to restart the QOF in full from April – and GPs had to confirm to NHS England that core contractual work will continue as a condition of taking part in next phase of the vaccination programme.
For GPs, this is only the beginning of a long road ahead, juggling complex patients and remote ways of working, while shouldering the responsibility of a vaccination programme the nation is relying upon.
NHS England insists it continues to help GPs. A spokesperson said: ‘In recognition of challenges that GPs, like all NHS staff, have faced with Covid-19, and to help alleviate some of the pressures in general practice, we have provided a number of financial and practical measures to support practices and staff which includes coaching and mentoring, additional financial support for clinical directors and £150m to expand capacity during the pandemic.’
But Dr Vautrey warns: ‘As we move beyond the crisis stage of this winter wave, GPs will continue to face intense pressures and we must ensure all in the general practice workforce are given time to rest and recharge before autumn.
‘Not only will we have the annual flu programme alongside any further Covid vaccination boosters required, we will also need to address the huge backlog of care while there is the potential for further spikes in coronavirus infections.’
He adds: ‘And while [GPs] have gone the extra mile for their patients throughout the pandemic, there is only so far they can stretch themselves before they reach breaking point.’
Locum GP ‘I had two or three months of no work’
In many cases, locums GPs have experienced a lack of work, as this anonymous locum in England tells Pulse
This month I have done one session as a locum so far. On average before the pandemic, I would do four sessions a week. It’s gone down to about four a month, if that.
I am a portfolio GP. I do a lot of work with out-of-hours and as an appraiser and I teach at a university, so I’m fortunate in having other jobs. But appraisals work also stopped – we were told everything was cancelled. That’s a lot of income gone. I managed to fill up with out-of-hours work – but because that’s booked months ahead I had two or three months of no work.
In the first lockdown, all my locum work was cancelled in a matter of a week. I was told ‘we don’t need you, because no one is taking holidays’.
I have changed my terms to require practices to give me at least a week’s notice, but a locum has no legal standing if a practice cancels.
As an appraiser I see the other side – salaried GPs and partners having burnout – but I think that’s partly their own fault. They decided to keep working and not take breaks. Usually they would have had holidays or taken sick leave – but now if they are slightly poorly they work from home.
The people I appraise haven’t taken any leave at all. They say ‘we can’t go anywhere’ but that’s not the point. As a locum you know to take time off, even if you’re at home twiddling your thumbs to make sure you look after your own health and wellbeing.