Dr Emma Mi is a Vice President of Conservative Young Women and a GP registrar in Oxford.
Lately, it seems that general practice has been engulfed in storm after storm – whether it’s face-to-face appointments, workforce challenges or the GP ‘postcode lottery’. I’m not a melodramatic person but even I find myself wondering nowadays whether there’s a future for it.
What’s truly alarming is that, in all the discourse, there seems to be few ideas on real solutions to the crises. More money alone isn’t going to solve things. We do need more GPs and other healthcare professionals, but endlessly repeating that, when those people simply aren’t there now (and probably won’t be in the short or medium term), isn’t going to help. We need practical action urgently.
As someone working inside the system, I can tell you that tinkering with the organisation, management, financing arrangements, etc of primary care won’t make a big difference to productivity. We have to focus on the actual day-to-day work processes of healthcare professionals.
There’s been a huge furore over access to face-to-face appointments, with many GPs preferring to maintain new ways of remote consulting ushered in by the pandemic. The question not asked enough is, why?
Broadly, it’s not because GPs are scared of Covid (I’m yet to meet any GPs who are reluctant to see patients and have personally seen a number of confirmed Covid positive people face-to-face). Some of the main reasons are that telephone consultations allow an opportunity for initial triage (where a healthcare professional can quickly evaluate how urgent a patient’s problem is and what the right service for them is).
They also generate small efficiencies in our work. For example, being able to write notes and prescribe while talking to a patient on the phone (which would be difficult face-to-face).
So, we need to solve the root problems. One way is instituting systems of complete single triage by a trained professional; NHS 111 methods are a good template, which could be adopted in GP practices.
Importantly, there has to be clear communication to patients about the nature and goal of any remote consultation, whether triage or full assessment (as the two are not the same). Confusion about this is, I believe, a key reason for dissatisfaction with remote appointments. Greater clarity for patients would go a long way towards tackling this.
We should also extend the use of existing tools like eConsult (a questionnaire that patients fill in about their symptoms/issues) – not instead of, but in addition to (before) a consultation. Patients could then go directly to a face-to-face appointment, during which GPs would be able to assess them in a more focused way and get to the bottom of their problems quicker.
It would also save GPs admin time that’s spent on documentation, as the questionnaire can go automatically into the electronic notes. Patients would benefit too, with no more anxiety about forgetting something or “running out of time” with a GP.
So, for anyone with the capability to fill one in (which takes only five-10 minutes), this should become the norm. With the time saved, GPs could spend longer with people that have communication difficulties or disabilities who need full face-to-face consultations.
GP working would be considerably more productive with easier access to the full range of standard diagnostic tests, including CT and MRI scans, without needing to consult or go through specialists in secondary care. Sometimes, I might have to spend half an hour on the phone to get a scan approved.
At the moment, long waits for specialist referrals are causing much frustration (and are a major cause of repeated attendance), so it’s particularly important that patients are able to be fully investigated by their GP to get a diagnosis, or to rule out anything serious, as uncertainty is often half the problem.
Investing in diagnostic capacity in the NHS and removing barriers to their access must be a top priority. To free up appointment capacity for more new patients to be seen, we also need to reduce unnecessary repeat attendances.
Patients should be able to use remote communication methods (e.g. text) to talk directly to their doctor for follow up, when needed, such as to give updates about their progress on treatment, and to receive updates on test results. I use this in my practice, and it works well.
These are only a few examples of changes in working practices, eminently achievable and not especially costly, that would transform the working lives of GPs and the experiences of patients. They could provide a lifeline for struggling primary care services in the immediate term.
However, in the most under-doctored areas, efficiency alone will not be enough. There’s huge regional inequality in GP-to-patient ratio across the country, which translates directly to real-life experience. In my practice in Oxford, our patients generally have good access to appointments (including face-to-face and same-day), but I know that is vastly different to many others’ experiences, including that of my parents living in an under-doctored area. This is the challenge of a generation and must be part of the ‘levelling up’ agenda.
There’s a whole host of societal reasons why some areas are less attractive than others as a place to live and work for doctors – schools, amenities, etc – which no one in the NHS alone can change. But we ought to act on those things we can.
GP jobs, especially those in under-doctored areas, are tough – they require working under a lot of pressure, for long periods, alone. So we need to attract top talent into general practice and to under-doctored areas.
How? By giving the best trainee doctors an attractive all-round career package. There are already financial incentive schemes but few high flyers would sacrifice career progression for money alone. We also need to offer faster progression or training, opportunities to do top-level academic research and to gain leadership roles. In return, those who have the capability can work more and hold more responsibility.
The key is flexibility in how we design and run medical and GP training. For example, we could pair existing academic posts at top institutions like Oxbridge (which are highly competitive) with clinical jobs in under-doctored areas within training programmes, which is feasible as much primary care and public health research can be done remotely. This would also give patients in under-doctored areas the opportunity to benefit from research, where they have traditionally not been well included.
We could use creative approaches, such as technology-enabled remote supervision and teaching, to break the vicious cycle of short staffing, lack of capacity to provide training and fewer trainees in under-doctored places. None of these would cost more money than what’s currently spent on GP recruitment and retention; it’s about rethinking the ‘business as usual’ processes in the NHS.
Ultimately, all of us who work in and use the health service know how things could be done better. My greatest fear is that, if we remain paralysed by arguments and recriminations, the current conflict between the profession and Government will continue to escalate, and the rampant negative media coverage will put off scores of new trainees from choosing general practice, undoing years of investment in recruitment and retention.
There will be fewer and fewer GPs under more and more pressure, and there will be no way back. It’s vital that all sides, the profession, Government and public, come together, leaving agendas aside, and take constructive action now.