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In full: GP practice’s 16-page letter to patients


GP workload


A Derbyshire GP practice, Ivy Grove Surgery, has penned an open letter to patients explaining how demand for services has doubled in recent months as services have been used inappropriately. The full letter is as follows:

April 26, 2021

AN OPEN LETTER TO OUR PATIENTS ABOUT DEMAND

Thank you for bearing with us during these hugely stressful times for everyone. We have been touched by the many kind messages of support whilst we have strived to provide you with the best service we can.

As many of you may know, General Practice has seen absolutely unprecedented demand over the last 6-9 months and this demand continues to increase. ‘Unprecedented’ has probably been one of the most overused words in the last year, but quite genuinely, it has been one of the most challenging times of our entire careers for some of us.

In a previous update, we informed you that even 6 months ago, GPs were already dealing with more patients than they did in the same period the previous year, along with all the constraints of covid cases, PPE and remote working, whilst also accommodating the biggest vaccination campaign the country has ever seen.

Our own demand at Ivy Grove has practically doubled in recent months.

Rather than simply just saying “it’s sooooo busy, please stop bothering us”, we’d thought we’d be a bit more scientific than that and analyse what is actually happening at the moment and what we intend to do about it.

In doing so, we want to provide an open and honest account of the situation that we find ourselves in. And we know for certain that we are definitely not alone in this. GP surgeries all around the country are experiencing the same problems. Even if they don’t tell you about it, we know they are going through it too.

This is an extremely long read, so make yourself a drink and have a sit down, but we do hope that by the end of it, you will come to understand just some of what is happening in General Practice at the moment.

If you aren’t able to read the whole thing, please check our website for the summary version.

Open letter carries on below.

ONLINE CONSULTATION SERVICE AND ITS IMPACT

eConsult is our online consultation service. Use of such a service is part of the GP contract and eConsult is only one such provider. Compulsory digital services in General Practice are part of the government’s Digital First Primary Care agenda for the NHS so there is actually no escaping an increased involvement in IT in accessing GP surgery services.

Unfortunately, due to the open availability of eConsult, and some limitations in how it is being implemented, our experience with it is that it has been like opening up a brand new lane on a full motorway that was already littered with roadworks and having an instant traffic jam as a result.

Many of our issues relate to eConsult, its implementation and our patients’ use of the service.

OUR PHONES ARE BUSIER THAN EVER

We appreciate those of you who have read our regular status updates, read our information on eConsult and all our additions on our eConsult page which are intended to improve the implementation of the service. We appreciate the efforts of those patients who have taken the time and trouble to use eConsult, giving sensible and detailed responses to the questions, thereby enabling us to provide them with the most efficient and effective care possible, often within hours of their submission. We appreciate those who have understood how the service should work and those who have managed their expectations in using the service.

We did worry about how eConsult would be accepted, as we all know change can be quite difficult to cope with, and sometimes it is considered unwelcome, but we saw that the more people who used it, the more satisfied they were with it, from only half of users happy with the service initially, rising up to three-quarters after several months.

The overall aim of eConsult was to encourage almost all patients to use the service in a responsible manner, with the hope that this would reduce the level of phone calls coming into the building, thus freeing up our staff to help other patients in need, and to be able to do other much-needed jobs around the practice.

The aim was also that patients would complete the right eConsult for their health condition or their admin request, and that this would be routed to the correct team and lead to increased efficiency and time savings.

We also knew that the older population might have more difficulties with an IT based service, however, the presumption was that demand on the phones would be sufficiently relieved and that this would free up our staff to help the vulnerable and the elderly or others struggling with IT and to guide them through the system, thereby encouraging them to use it themselves going forward.

Unfortunately, this has not happened at all, and the phones have remained as busy as ever, as anyone attempting to ring into the practice will have discovered. Despite 16 lines in and out of the building, we know you will still have trouble getting through – we are that busy.

The reason for this is that we have had a core of patients who have consistently not engaged with the service, or indicated that they would struggle with using it, despite it being very easy to use and no different from browsing a website or online shopping.

Most patients have already been happily receiving texts from us for many years now, going online and completing forms for flu jab appointments, and going online to external sites to book covid jab appointments, yet there is a significant group that seem unhappy or unable to complete a simple form about their health condition.

In fact, we know that thousands of you visit our website regularly but that not all of you want to fill out an eConsult. And please be aware that this is by no means confined to the older population, in fact, people of all groups have very decidedly not engaged with the service and have continued to ring us instead.

Over the last six months since we started eConsult, we have tried all means to encourage such patients to use the service, with gentle prompting, with texts, with help on the website, actually taking them through eConsults, but with little success in encouraging consistent personal use.

Consequently, we have been hit with a double whammy of increased online demand and increased phone demand.

INCREASED CONTACT AT EARLIEST ONSET ON MINOR SYMPTOMS

We are finding that many patients are contacting us via eConsult in the very earliest stages of their condition, with the expectation that we will immediately cure them, and with no patience in either seeing what their condition could be, how it might develop, how they might recover and perhaps most importantly, without trying any form of self-care whatsoever.

We are finding that people are unable to tolerate any symptoms of ill-health at all and therefore demand instant treatment. So, for instance, we have patients contacting us within a few hours of developing a sore throat, or an earache that developed the night before, or tiredness since waking up that morning or having vomited or having had diarrhoea just the once.

In fact, patients are sometimes reporting their symptoms so early in their condition before anything else has developed or evolved, that consequently it is difficult to know what actually is the matter. Real medicine is nothing like on TV medical dramas where not only a complex diagnosis can be made but also that it is fixed before the closing credits. Real medicine is not like that, and using ‘time as a diagnostic tool’ (and as a therapeutic, i.e., treatment tool too) is well recognised – sometimes waiting to see what else develops can help to determine the best course of action or can aid in expectant recovery.

Please bear in mind that we’re not in any way suggesting that if you are seriously ill, or if you have a red flag symptom, that you need to wait to get worse before getting in touch with us. No, not at all. We’re talking about people who are still very well in themselves, carrying on with all usual activities, going to work, out to the shops and so on but with very short-lived minor illness symptoms and who have not tried anything at all to help themselves, other than get in touch with the GP immediately.

Red flag symptoms are symptoms like chest pain, bleeding, paralysis, difficulty swallowing that could indicate serious disease like cancer, a stroke or heart attack and were covered in the last status update – we actively encourage you to get in touch with the right professional if you have red flag symptoms

Our human bodies are not perfect despite what anybody might say or think. We are constantly subject to all sorts of insults and attacks on our systems on a daily basis either externally, or from our own actions. However, we do have immune systems that are designed to repel attacks from infections like the viruses that cause most sore throats or earaches, and which will lead to resolution of problems within a week or so. And we do have bodies that are also designed to repair themselves after a damage or insult.

With self-care and due attention, most cases of minor illness do resolve without ever needing treatment from the GP.

SELF-CARE SELF-HELP AND SELF-REFERRAL ACTIVELY IGNORED

In line with the above, we have found that most patients actively chose to ignore all forms of self-care and that their first port of call is always the GP.

As part of our own enhanced implementation of eConsult, we set up dozens of new self-help and self-care pages, with the aim to helping our patients navigate the myriad of services out there and so that they can always start to get the help that they need.

The aim of this was that those completing eConsults with more minor and self-limiting illness could be directed to self-care and those completing eConsults for conditions better managed by other healthcare professionals would be directed to self-refer. This would then free up the GP to be able to deal with those with more serious health conditions in a timely manner.

The aim of all of this is that more people can be helped at any one time.

But we have found that people have actively ignored self-care, self-help and self-referral services and simply scrolled past all these and clicked the box to contact the GP, only to be then told, when we have eventually got round to them and have assessed their responses, that, yes, they do indeed need to try self-care, self-help or self-referral first.

The huge amount of our time that we have spent signposting patients to more appropriate services could have been better spent dealing with more of those who really do need the GP.

Active signposting is not something we at Ivy Grove have just made up. It is actually an official and integral part of the NHS’ High Impact Actions plan to help free up time for General Practice, but it does require the full co-operation of patients.

As many of our patients will know, Ivy Grove Surgery has always promoted an attitude of resilience and self-care in their patients.

Self-care has many advantages. It means that you already know what it is that you need to do when you develop something. It means that you can get to the help you need much quicker and more conveniently than waiting for the GP to tell you what to do. It also means that you and your family are empowered to look after yourselves, not just now, but in the future too. Just like extended families used to look after each other in society and passed on important knowledge, gentle wisdom and sensible advice down the generations, now unfortunately, largely sadly lost.

RELIANCE ON GP TO DIRECT AND SIGNPOST FIRST

The last comment about society brings us to this next point about the culture we currently find ourselves in.

You may think that our philosophy on self-care, self-help and self-referral above is just about fobbing patients off and stopping them from contacting us or seeing us. If you are one of those who feels that this is our aim, then our response to you is that if this is the plan, we are doing an extremely poor job of it. Our appointment books and telephone lines tell a very different story and to be honest with you, it is tremendously demoralising for our teams to hear of such views, when everyone is at breaking point, when we are on our feet for 12 hours a day working through huge lists of patients one after another.

Those who already firmly believe that all we do is to stop people from seeing us or contacting us will not be convinced by what we now say, but the evidence is actually already  all around for you to see. Let us explain.

You will have noticed that last year, 2020, the 5,000 extra GPs did not magically arrive, as promised by the former health secretary some 5 years previously. Obviously covid hit, but even in the years before, no additional GP numbers had been achieved throughout the five years, despite increased numbers of GP trainees in the latter few years. In fact at the end of the time period, the actual total number of full-time equivalent GPs went down. It’s because despite more trainees, many left General Practice, never to return, and the others chose to work less than full-time, in an active measure to reduce their exposure to the environment of General Practice. So the actual total number of full-time equivalent GPs went down.

So there are fewer and fewer GPs left seeing to more and more patients.

You may also have noticed that GP surgeries now work in neighbourhood networks, called PCNs, which stands for Primary Care Networks. Ivy Grove is part of ARCH PCN, which is Alfreton, Ripley, Crich and Heanor Primary Care Network. The evening and weekend hub appointments at Church Farm that existed pre-covid were part of a PCN provided service (the appointments and capacity are currently being used for covid vaccination).

The aim of these networks is to share good practice, and do things in a more collaborative fashion, saving each practice from having to reinvent the wheel and with the hope that it will reduce some overheads, some time and save costs.

Costs are important because if a GP surgery cannot make enough profit for the partners that own it (for ‘profits’ actually read ‘wages’), then GPs resign, more work lands on the GPs that are left and eventually, the GPs hand back their contract and the GP surgery will go out of business. When a GP surgery goes out of business, all its patients have to be reallocated elsewhere. This then puts more pressure on the remaining surrounding GP surgeries and before you know it, you have a domino effect going on. This has happened many times all over the country, with more than 1.5 million patients being displaced as a result.

NB: just to assure you, we’re not going out of business and GPs are not resigning, we’re just explaining how GP funding works. In fact, we have been extremely fortunate with our succession of excellent new doctors in recent years, each of whom has then become a partner in the business.

Recognising that there finally is a crisis in GP recruitment and retention, something which we have been telling it for a decade or more, and which it had repeatedly denied, the government has now finally provided additional resources to hire extra staff for these networks of practices.

Remember that the network is composed of all the same GP surgeries with the same numbers of GPs that they already had in them; there are no extra GPs that have been magically generated out of thin air.

So the PCNs have the additional resources, but the extra staff to be hired are therefore not GPs. They will be people like practice pharmacists, community paramedics, mental health workers, first contact physios, physician assistants, dieticians, podiatrists and all sorts of other workers.

If you don’t believe any of this, then just look up any of these example phrases below and you will find loads of information:

Primary Care Networks (PCNs), Additional Roles Reimbursement Scheme (ARRS) – someone was clearly having fun with acronyms that day we think, future primary health care team (PHCT), Integrated Care Systems (ICSs)

Now why would this be the case? It is because they will now be part of an extended primary health care team that previously comprised only GPs and practice nurses (and/or nurse practitioners). And because there are now fewer GPs and for that matter, also fewer nurses, the presence of these new workers will complement and strengthen the existing teams.

So in future, if you have a back or joint problem, you’d get in touch with the first contact physio directly. If you had a medication issue, you’d get in touch with the practice pharmacist directly. If you needed a home visit, you’d speak to a community paramedic directly. If you had a mental health issue, you might contact the mental health worker directly. If your issue was mainly social, you’d contact the social prescriber directly and so on and so on.

You may think with all of this, what will GPs do in the future, they will have no work and just be putting their feet up or going on the golf course? You can be assured that there will always be a huge amount of work left for us, examples such as complex cases, palliative care, care of the elderly, clinical expertise and specialism, leadership, co-ordination, planning and working with others such as the wider community and secondary care colleagues to improve health outcomes. Don’t worry, we don’t think GPs will be short of work, ever.

NB: we don’t know any GP who goes on a golf course during their working day by the way.

Now, the key to all of this, and this is the gamechanger, is that the patients themselves contact the correct worker first, hence the word ‘directly’ in the above examples. It is actually not for the GP to decide that the patient should contact a particular worker. This is because there are no longer enough resources for every patient contact to be channelled through a GP first.

This represents a massive cultural change which most patients are still not aware of (and indeed almost all other NHS staff too), and this change will take a lot of getting used to. It is entirely contrary to the direction of travel which has been happening for most of the natural history of the NHS. The GP is already, and has been for several decades, easily the most accessible highly qualified professional in the entire country. Think about it, and think about how quickly you’d be able to access any other equivalently trained professional. You just can’t.

Over the decades, due to political pressures, promises for votes, loss of close-knit extended families and caring communities and for many other reasons that we won’t go into right now, the GP has become the default ‘go to’ person for literally everything in society, from being a proxy parent, a teacher, a social worker, a counsellor, a priest, a marriage guidance advisor, a pharmacist, a housing and heating advocate, a public health physician, an employment advisor, dangerous sports authoriser, a gambling monitor, cycling promotor and so on. The list is endless.

The examples given above are in no way meant to detract from the importance and value of those actual professions, but merely just to illustrate that the GP has consistently been considered to be ‘ideally placed’ to deal with that field in some way.

To further illustrate this, we bet nearly everyone will have, at some point in their lives, heard the phrase ‘you need to go and see your GP’, whether that be from a friend, a family member, someone in the street or another health professional. It has become such an automatic and ingrained response to almost every situation in our society that patients are often told to do this even when it is blatantly the wrong thing to do. Unfortunately, pressures are so great nowadays that this simply cannot continue otherwise the whole system will collapse and in some areas of the country, it is already starting to.

At Ivy Grove, we have always asked our patients to get in touch with the right person, many years before PCNs ever came into being. We knew and we continue to feel that this is the only way that GP surgeries can remain sustainable, viable and therefore available for you and your family, for your medical needs, now and in the future.

Times are changing, the problem is most people haven’t realised it yet, or don’t want to believe it.

So the point here, is that, no, it is not necessary for you to be told by the GP who it is that you need to see. We have the resources to help you find out who you need to see. So now you should have the confidence to go and easily refer yourself to the right person in the first place.

AVOIDANCE OF RESPONSIBILITY FOR LOOKING AFTER ONESELF

As we say on the new patient registration of our website, we strongly feel that healthcare is actually a two-way process, not a one-way process with care being transferred from the GP to the patient. If this was the case, our work would be extremely easy, but as we know, life is a bit more complicated than that.

The information from our new patient page is reproduced here:

At Ivy Grove Surgery, we have always considered care to be a two-way process. We will always aim to provide you and your family with high-quality and friendly health care. 

In return, we expect all our patients to accept some responsibility for their own health and we encourage them to do all they can to look after themselves and to stay healthy.

Your health is not a commodity that can be treated as a convenience provided at the expense of others, it is actually an innate and priceless privilege that is available to everybody. Your health is nurtured throughout life, from childhood through to old age, by looking after yourself, and when you need it, with appropriate and timely help from the right professionals.

We do not see our job as being here just to fix you. But we will do all we can to help you to fix yourself. Therefore, and fully in line with current NHS philosophy, we actively promote the principles of self-care, helping yourself, and signposting yourself to the right professional.

We welcome new patients who are prepared to work with us on building a long and healthy relationship together.

We actively encourage all patients to do all that they can to keep themselves healthy. We actually all know what we need to do to keep healthy but as humans, and maybe as part of human nature, we do not do it.

We all know that we have to eat healthily, that we have to watch our weight, that we should exercise, get fresh air and sunshine, that we need to go to bed on time and get enough sleep, that we have to avoid excessive alcohol, that we shouldn’t smoke, or take illicit drugs, that we should keep our minds interested and active, that we need to communicate and socialise with others (within covid restrictions currently of course), that we should always take time out for ourselves in the busy stressful environment that we live in. But we do not do these things either at all, or if we do, we don’t do them consistently.

And because we do not do this, what then happens is that we become poorly. We are finding that many patients are contacting us and seeing it as our job to then fix them, when in reality, in the vast majority of patients, there exists within each of us the capacity to make small choices here and there in the right direction, to start taking some responsibility for our own health and to help ourselves and to start getting healthier. We can always inspire confidence and motivation in you but we cannot directly push these things into you – they are something that you will in yourself.

Please bear in mind that the above is not to say that we will never help you. Not at all, but we do feel that each of us must accept some responsibility for looking after ourselves. Passing on responsibility for looking after yourself to someone else might sound like an easy solution, but it is already based on very rocky foundations.

By looking after ourselves, we can all reduce health risk and avoid becoming ill in the first place.

MULTIPLE PROBLEMS PRESENTED WITHIN ONE APPOINTMENT SLOT

Because demand is so high at the moment, and because so many people are desperate to see or speak to the GP, we are finding that many people are presenting shopping lists of multiple problems to us.

So for instance, we see some people submitting two or three eConsults to us each day, or when on the phone to us, they are using the opportunity to present multiple issues to us, often prefacing the request with ‘I know you’re already busy and have other people waiting but…’. Each of these extra contacts takes time to sort out.

Lists can sometimes be useful to doctors as they may present us with more of an overall understanding of what is currently troubling patients, and we are always understanding of people’s wishes. However, in the current climate when we already have dozens of patients on the list waiting to speak to us, it is not fair on any of these patients following, who will also have been waiting an equally long time to discuss their single problem.

We are quite sure that you would not see your solicitor in a single appointment slot (however long might be allocated) and present them, without warning, with an employment contract issue, a divorce issue and a boundary dispute issue, all of which need resolving by the end of the appointment. However, as GPs, we are frequently expected to deal with three or four problems within a 10 minute time slot. That is exactly 150 seconds to deal with each problem. Count them. You will all know that this is not humanly possible with the laws of physics being what they currently are.

The drawback with the presentation of multiple problems to the GP is that there is a risk that the most important issue may not be dealt with. There are many cases in the medicolegal literature of adverse outcomes following situations where GPs have been presented with ‘oh, and another thing’, with the result that important jobs or tasks might be missed, such as a cancer referral, or that an important symptom might be skipped over or ignored or more likely, forgotten about, simply because too many things are happening at the same time.

We would always encourage you to let us know your most troubling concern at the outset when communicating with the GP. This allows us to prioritise and treat you in the most effective and efficient way. This is for your safety and our sanity.

CONTACTS BEING TREATED AS URGENT REQUIRING INSTANT RESOLUTION

Along with low tolerance for any symptom, we are also finding that, quite worryingly, more and more patients are demanding instant solutions to their problems. Perhaps this is a sign of a society where instant movies, instant knowledge, instant food, instant parcels and instant gratification are all now deeply embedded. So perhaps instant health needs to be added to that list. We don’t know all the reasons, but we do think this type of culture has a significant part to play in what we are now seeing as quite a worrying trend in healthcare.

It is back to the ‘treating health as a commodity’ issue that we mentioned previously.

What we do know is that instant culture means that many patients are presenting with routine issues that have been going on many months, or in some cases, many years and demanding that they be dealt with immediately, same day. This happens very frequently. And when, quite correctly but tactfully, we try to address such demanding behaviour with appropriate feedback or information, or a timely appointment at a later date, we are often faced with an aggressive and unwelcome response.

Why do we try to address this? Well, the problem with such behaviour is that it means that our ability to prioritise work is adversely affected, and it means that we cannot therefore devote the time needed to treat actual clinically urgent patients appropriately and in a timely manner, because our time is being taken up with much less serious conditions that could actually wait a little longer to be dealt with in turn.

The word ‘clinically’ is highlighted here because urgency must always be determined on a clinical (medical) basis, and not determined on the basis of convenience, prior engagements, eagerness or any other reason.

If you push in, it means you have pushed someone else out, someone who could be quite vulnerable and in need, and the next time this happens, that person might be you. This is a safety issue that has an impact upon anybody who truly needs to be assessed quickly by a GP.

Because, if everything is urgent, then nothing is urgent.

EXTENSIVE SUPPORT AND HELP FOR MENTAL HEALTH ISSUES BEING LARGELY IGNORED

Mental health has always made up a good proportion of the daily workload of a GP. Sometimes this work can be one of the most rewarding to sort out, but also the most challenging. However during the pandemic, as mentioned in our previous updates, we have seen huge numbers of people whose mental health has been affected during these very difficult times that we are all experiencing at the moment.

On some days, mental health cases and also cases where mental health is a contributory factor, are taking up to 10-15% or more of the total cases. We are also dealing with cases of significant self-harm, where assessment can take anything from 30 minutes up to an hour for that single patient and where subsequent referrals to secondary care or crisis teams can take a good part of the day to arrange.

Whilst dealing with serious cases like this is part of bread and butter general practice and we must stress that we do not have a problem at all with helping people when they are at their most vulnerable, we are also finding that many people, especially those with milder illness, are also actively avoiding contact with many of the other services that are available to help them during this crisis.

Even some who are just needing a bit of advice or reassurance from a mental health professional are actively ignoring the links we have provided to those mental health professionals and choosing to contact us first, again only for us to tell them to get in touch with the correct services directly. This can lead to frustration for both patients and staff alike, and delay access to services.

There have also been services newly set up in the pandemic to support patients’ mental health and wellbeing but which are being ignored by patients, whose preference it is to contact the GP first before doing anything else.

As a practice, we have tried to help our patients by collecting all available mental health resources so that they can be easily accessed by anyone, from children, right through to old age. Many of these services are an appropriate first port of call for patients in this situation and we actively encourage you to explore them in order that you may start to get the help that you need.

Always bear in mind, and this is true not just for mental health services but for most other NHS services in general, if you contact or present yourself to the wrong service, or you have presented yourself to the right service, but subsequent assessment shows that your case needs escalating, you will always be directed to the right service. So for instance, please don’t worry if you have self-referred to counselling, thinking your case might not be appropriate – the service will assess and advise you and can indeed refer you on if needed.

MEDICAL ADVICE BEING IGNORED

Again choosing a solicitor as an example, would you ring your solicitor asking for advice on a complex legal matter, and once they had given that advice, then proceed to berate them saying you completely disagreed with it or just completely ignore it? Or, indeed would you approach any other highly qualified professional, asking them for their opinion on something well within their specialist field and then promptly disagree with them?

Outside of the crucial principle of consent, and just as a side note, it would be interesting to know why medicine seems to be treated differently by everyone, because on the one hand, it is so important that a specialist with their specialist knowledge must be involved, but on the other hand, the opinion of the patient is as equal to or exceeds the importance of that specialist knowledge.

We have many instances where patients have readily contacted us for our specialist professional advice on a health matter, but who will then promptly choose to dismiss or ignore the advice because they are unhappy with the answer or with what we have said.

We always try to involve our patients in any decisions regarding their care, however there are some interactions where there must be a definitive response or outcome, such as you do need 999 if you can’t move your arm and have slurred speech from the stroke you have just developed, and you do not refuse to go in because you don’t want to trouble anyone else and you personally don’t think that the crushing chest pain you have could possibly be a heart attack.

Undue delay resulting from ignoring or dismissing medical advice can give rise to increased risk of complications and harm to patients.

We always make our decisions on the basis of clinical need and urgency and based on what you have told us, either on the telephone, or within an eConsult and not because we want to be awkward, obstructive or dismissive. Remember it is always in our interests to deal with your problem as effectively as possible so that you can get healthy and well and don’t need to keep coming back to us!

INAPPROPRIATE PAIN SCORES RESULTING IN ONLINE SUBMISSION PROBLEMS

In using eConsult, we have found that a significant proportion of patients are kicked out of the system and told to ring 111, attend A&E or contact the GP, as a result of the pain score that they have just entered.

In line with safety protocols, patients with severe pain are informed to contact the appropriate service immediately. This is for your safety.

Outside of eConsult, in order to improve its implementation, we have ourselves provided extensive online material and tried to educate our patients on recognised pain scales and what scores mean, so that any questionnaires asking for pain scores can be completed correctly, hopefully reducing the risk of failure of eConsult submission.

We know pain is highly subjective, but, in line with many clinical studies on the matter, we also find that most patients significantly overestimate the level of pain that they have. Regardless of the reasons why, what this then means is that safety protocols must be triggered to refer that patient to the most appropriate service. But this means that some patients who have put down high pain scores may be inappropriately advised to ring an ambulance or attend A&E when they don’t actually need to.

Conversely, we are also finding that some patients with significant pain are actively diminishing their level of pain so that they don’t get kicked out of the eConsult system and can continue to submit the eConsult so that they get to speak to us. This is not only not ideal, but also unsafe, and we have witnessed situations where patients with significant pain have come through to us on an eConsult when they needed to have gone to hospital already.

This can cause delay in receiving the most appropriate care.

The next point also relates to the provision of information within the eConsult service which has also impacted upon our workloads.

INCORRECT OR INCOMPLETE INFORMATION BEING SUPPLIED IN ONLINE SUBMISSIONS

Related to the above, we have also found that many patients are entering misleading or incorrect information on eConsults in order that their eConsult can be submitted through to us. Some examples include:

Using a different symptom from the actual symptom being experienced, so for example, using ‘headache’ instead of ‘chest pain’ and answering completely irrelevant headache questions (because chest pain would have resulted in a referral to 999 for suspected heart attack)

Using a symptom when they are actually well with no symptoms at all just to get through to us

Giving answers that have no bearing at all on what is actually going on

Giving one word answers to questions that expect more detail, like a description of the problem or some information that will help both doctor and patient to determine what needs to happen

All of these situations make life a bit more difficult for everyone. It means that your eConsult won’t get to the right person. It might mean that your care is delayed.

We always encourage honest and detailed responses to questions as these help the doctor to determine the right course of action and the right timescale in which to help patients.

MULTIPLE SUBMISSIONS FOR MINOR ISSUES RISKING ABILITY TO DETECT SERIOUS ILLNESS

The pandemic has affected all of us. The repeated lockdowns have affected all of us.

But we have, first-hand, experienced the impact of people suddenly having lots of time on their hands.

Consequently, as examples, we have had many eConsults from patients suddenly worried regarding a longstanding (but unchanged) issue. Along the same lines, we have had eConsults from patients whose condition has been made worse simply by thinking about it. We have had many eConsults simply because people have been thinking about their bodies and what has, or could go wrong with them. We have had eConsults submitted at all sorts of random hours, in the dead of night, at times when patients would not have ordinarily called an out of hours doctor or rung 111. Each of these submissions takes time to sort out.

We do appreciate that it is very difficult being isolated from our friends and family and our peers and colleagues – we have all been there. Previously, in company, a quick look or calming chat along with a sense of perspective might have reassured, but obviously in the current situation, one might only have one’s own mind or Dr Google to help with that, and we have therefore seen the effect that the pandemic and lockdown have had on people’s worries and anxieties about their bodies, their minds and their health.

Related to this is the attitude that ‘you can never be too sure’, and also the tendency to keep booked appointments when the problem for which the appointment was booked has completely resolved and the patient is well, ‘just to be sure’.

One of the jobs of a GP is to detect serious disease early so that we can do something about it. This is why we look for things like red flag symptoms or subtle nuances in a collection of symptoms that could mean something really serious is going on. But our jobs are made all the more difficult when we are faced with lots of things that are much less likely to be anything serious. It is genuinely like finding the needle in the giant haystack. Not a problem if you are part of the haystack, but it could be a big problem if you are that needle.

There are several things you can do. You can ask someone you trust. That could be a relative or a friend. We would love a return to reassuring advice from an experienced family figure. Even though we may not be able to socialise together due to the current restrictions, nothing stops a phone call or a video call or even a message chat with people you know and trust. You can use a symptom checker. And if you actually do have a red flag symptom, do get in touch.

GP SURGERY BEING CONTACTED FOR HOSPITAL-RELATED ISSUES

Hospitals have their own processes and systems, and their own staff to manage those. But we are finding that many patients contact us first off with queries regarding their hospital appointments, hospital tests and hospital results, either through the phone, or via eConsult.

We are also finding, quite inexplicably, that patients having contacted the hospital quite correctly, are then told by hospital staff to ring their GPs for information!

Hospitals, under terms of their contract, are required to discuss your tests, results, appointments, and any other query you might have about your hospital care with you and in fact, it is also the duty of the doctor who ordered the test to action the result, not your GP. And while we are here, it is also the duty of the hospital doctor treating you to provide you with a fit note (sick note), regardless of what they might say.

Unfortunately we cannot spare any staff the many hundreds of hours it would take to chase up appointments, tests or results that are actually the responsibility of another organisation.

We do realise many patients are having to wait a long time for appointments, but again, if you do have a query about your hospital appointment, please ring the hospital in the first instance, not your GP surgery.

IF WE ARE FULL FURTHER ASSESSMENT WILL ONLY BE ON BASIS OF CLINICAL URGENCY

It is perhaps primary care, which includes General Practice, uniquely amongst any other service in the NHS, that is the only service which cannot restrict or limit its workload and hand it over to another service. Even hospitals with their extremely busy A+E departments, can call a black alert and essentially close their doors to new service or direct patients elsewhere. This is to make sure that working conditions do not escalate into being dangerously unsafe, both for patients and staff. Other NHS services that work to appointments means that once their clinics or operating lists are full, they are full and you can only be accommodated if there is a cancellation or in the next available clinic.

GP surgeries, quite uniquely, must absorb all extra demand with the same or reduced numbers of staff, so even when a GP or two is off sick, the demand does not let up, the calls do not stop coming in, the eConsults do not stop. One would not expect a pilot, whose co-pilot has gone off sick, to keep flying the plane with double the numbers of passengers within it. It simply isn’t safe. However, GP surgeries all round the country are expected to work like this, day in, day out. Just like that airline pilot, we are dealing with your safety, first and foremost.

The principle we all need to work to, is to say that if all our slots are used up, we are full, and we can then only see to you if your problem is deemed to be medically urgent. Remember, as with other services, this is in order to keep you the patients, and us, our staff, safe.

UNSAFE WORKING RISKS STRESS BURNOUT AND MISTAKES

Studies have shown that doctors start to lose concentration and decision-making starts to deteriorate after just 14-15 consecutive patients. You might consider this to be a particularly low number of patient contacts, but it can represent about 2.5 to 3 hours work. This can lead to mistakes being made and potential harm coming to patients.

If you do not believe this to be an issue, then ask yourself, do you really want to be the patient that sees their doctor after he or she has worked continuously for 12 hours already? We know we wouldn’t. We would want to see a GP who is bright, sharp and ready to go.

All of the issues we have described in detail above have the potential to lead to unsafe working practices, stress, sickness leave and burnout amongst staff. We’re sure you all know someone who has gone off sick with work related stress.

As a practice that always aims to be responsive to our patient population, providing a safe and family friendly high quality service, and as a practice that prides itself on communicating well, working together and looking after our staff, we have had to make the decision to change our appointment system and reduce the emphasis on using eConsult.

Clearly this will be very disappointing to a significant number of patients who have found the service very useful. This should not be considered a failure. In fact, we feel the way we have promoted, managed the service and aimed to resolve patients’ issues through eConsult quickly and efficiently has significantly increased its use, so we are almost a victim of our own success.

We will now be returning to a more traditional service, similar to that which existed before covid, in which appointments will be allocated to those in clinical need.

To match future ways of working and our longstanding philosophy of self-care, self-help and self-referral, we will also signpost you appropriately to other more suitable professionals and services. And when we are full, we will tell you so, and any further assessments that day will only be on the basis of clinical urgency.

We hope that these changes will improve matters for everyone, and set the practice up to be in a good position for when lockdown ends and society starts opening up again, something which we are sure everyone is looking forward to.

Thank you for bearing with us and thank you for taking the time to read this.

Ivy Grove Surgery, April 2021

READERS' COMMENTS [16]

Richard Singleton 30 April, 2021 4:49 pm

Whoever wrote that has my vote for Health Secretary, hell give then the keys to the country it was that good. Shame nobody in positions of power is so eloquent or sensible.

Not Arvind Madan 30 April, 2021 5:00 pm

If i lost interest after 10 pages, what do you think patients will do?

Dont waste your breath. Hunker down. Limit econsults, limit the number of contacts you have and get through.

Patients dont care.

Tina Sumner 30 April, 2021 5:05 pm

Am I the first person to get to the end and hence comment?
some very sensible points made in the first half but later on is sadly diluted by basic ranting. yes we are all in this together but those to whom this letter was penned clearly won’t be the ones to read it sadly

John Graham Munro 30 April, 2021 5:07 pm

DO WHAT YOU CAN IN THE ALLOTED TIME THEN SOD OFF HOME

Katharine Morrison 30 April, 2021 6:07 pm

Thanks for posting this. It could make a useful document for practices to summarise and tailor to their own patients. The situation cannot carry on like this as it puts patients at risk and puts doctors at even more risk of mental and physical harm as they try to evade litigation and do their best for sometimes very ill and very often over demanding patients. There needs to be a demand reduction approach and it would be great if the RCGP had a go at producing a summary document which could be available in paper form and also e mailable so that patients could be given guidance. This could then be given some publicity by morning TV doctors and journalist doctors covering on a regular basis discussing symptoms and what is urgent and needs a doctor, what is not and can be dealt with by other health professionals and what they can do for themselves.

And John Graham Munro, I understand that you are not a doctor and have some axe to grind with GPs. Whatever you may have experienced personally or have read about or seen on the TV about GPs eg Doctors or Dr Foster or whatever, we work our backsides off and have long days in a pressure cooker environment, often missing meals. We neither earn Professional Footballers’ salaries or come anywhere near their fitness levels due to the amount of time sitting at computers that need 8 separate user names/log ins to be fully functional and often break down.

John Graham Munro 30 April, 2021 8:23 pm

KATHARINE MORRISON———–I qualified in 1968 and have been a G.P. partner on three occasions, so I’ve been around the block a bit wouldn’t you say? I’m sympathetic to my colleagues who feel they may be coming off the rails. but if they will work the way they do then what do they expect.?

Mohammad Adnan 30 April, 2021 9:45 pm

Spot on John ! …. I’m perhaps an toddler in comparison having been a partner for 5 years. When I joined my fellow partner went off on stress due to work load and another partner resigned. Same old story long days , uncountable extras etc.

I thought to myself no ! If I’m to survive then we need to learn to say no and can’t simply see anything and everything! Because at the end of the day when you make mistake due to fatigue your on your own!

Isn’t it funny how as partners we hire salaried GPs and try to live up to the model contract with a job plan of defined workload, yet have no boundaries of work ourselves despite our numerous commitments.

It is all well and good using great analogies of not expecting pilots to do the same or a solictor doing multiple legal jobs in one sitting …… but the fact is if you continue to act and work in the same way, then expect your health to suffer and more .

David Mummery 1 May, 2021 8:59 am

Whoever wrote this deserves a medal

John Glasspool 1 May, 2021 9:03 am

I like it! Problem is they will now be swooped on by the CQC as a practice that must be putting patients at risk, after such a cri du coeur, they will be condemned by the RCGP for not being a doormat (patient-centred) and the CCG will do nothing to help. They will probably be referred to the GMC too.

Patrufini Duffy 1 May, 2021 11:13 am

Quite a historic document. Volcanic and real. Like rubbing your head on a cheese grater, and offloading dark, honest truths.
It maybe a rant, to deaf, concrete ears.
BUT, I add my sincere congratulations. For stepping out. Just for having integrity and a belief system. The ability to observe, and be fearless of the machinery.
Like I said, GPs are also the problem, it starts from within the rotten tree. 90% sheep. 10% aware. The sheep only see what they like, and it makes them comfortable, self-important and part of the crowd. They will disregard the 16 pages. That is ok. But they are the complainers, ultimately.
This unnerved them, and your dossier seems like an obstacle to their pre-conditioned, perfect GP world of doing good, and they will default to side with the patient, demand and NHS juggernaut. Most GPs and “leaders” won’t read 16 pages. But, they’ll sign PCN contracts, slave away at an appraisal, practice in fear of lawyers, leave work at 9pm, get complaints and practice this infinite pool of lifestyle “medicine” and then congratulate themselves for being miserable, tired and robotically unfulfilled. Believe in something. Anything. And see if you can act on it like this surgery with guts. Put your hand up at a meeting, and stare your manager in the face and say what you think. You can’t. Because they’ll crush you. You can’t even decline antibiotics or a referral. What have you become? Only when you know individually, will this change.

Smith Joanna 1 May, 2021 11:37 pm

Ivy Grove Surgery you have my admiration and respect for putting down in a document what I expect many GPs like me feel about the current issues in General Practice. I feel your pain and hope you receive a good result from the clear information and helpflu suggestions you have given your patients.

Aparna Katari 2 May, 2021 10:12 am

I feel sorry for the Practice and the patients , no one deserves this. I have felt and expressed many of these sentiments during brief morning coffee breaks with my colleagues. But it shouldn’t be us against them either.
We need to look for solutions that work for all, I do thinkPCNs are a good place to look for some local solutions.
I think the bad press we get constantly from media certainly does not help. I wish the doctors in this surgery the best, Hope they get over this truly tough time and do what they do best , care for patients !

John Graham Munro 3 May, 2021 9:14 pm

My apparently beleaguered colleagues do not have to go the extra mile——do not have to go above and beyond—-do not have to work all hours God sends, to bale out the government—-If they do and make themselves ill in the process then they are of no use to anyone. Still, partners will be taking their long awaited holidays soon and more resilient locums should temporarily take over.

Gerard Bulger 5 May, 2021 10:32 am

Just awful. If you cannot say it on a page of A4 it is not worth saying

James Cuthbertson 6 May, 2021 6:30 pm

I’d be interested to hear if anything positive comes from this beyond catharsis

C Ovid 7 May, 2021 8:58 am

Seminal document for the upcoming Museum of General Practice. Just look at ourselves! Time to stop all this madness… how often have we said to patients with “stress at work Med3s” : “ not being at work for a bit seems to be the only way for your line manager ( insert NHS / public here) to notice what you do” Hypocritic Oath!
Let’s admit we don’t have the self preservation instincts to make a stand.

Oh and by the way, these patients are the ultimate responsibility of the DHSC not their GPs so don’t give me the commitment excuse. As long as you give enough notice, the GMC can’t touch you.

Finite workforce leaves, anxious DHSC rewrites the terms of engagement. If we all saved up enough to last 3months off work, we could sweat it out.

I have already jumped into sessional work after 15y as a senior partner: looking back in, you are all your own worst enemies. Sorry to have to say it but it is true.

I know you won’t make a stand, even though ultimately the patients will benefit, too.