17/06/2024
At certain times we may have to ‘cap’ the number of patients we deal with in a day. Why?
At Willow Tree Family Doctors we have always run a system providing the capacity to deal with the predicted demand. Demand for appointments is more on a Monday, so we build in more appointments, in flu season we have more appointments and so on. In the past this was known as ‘Advanced Access’ but it sounds pretty basic - a ‘no-brainer’ in fact.
You probably expect everyone does it but actually it is not the traditional way the NHS works. Usually a number of appointments are provided dependant on the number of doctors and nurses available and if the patient demand exceeds it, waiting list are built up. We see this is when a doctor goes on holiday – those appointments are simply lost from the system – a surgical list is cancelled, an outpatient clinic or a GP session. Waiting lists are embedded in NHS culture.
At Willow Tree we treat it differently – partners may alter their rota or do additional sessions to keep the supply of appointments up to meet the demand and give good access to our patients. We have been dealing with everyone’s clinical problems and queries incredibly quickly, usually on the same day, often within an hour or two of submission! Providing additional capacity to provide such a service comes at a cost though and we are now struggling.
Locums are often brought in to make up the shortfall and keep the rota filled to meet the demand but these temporary doctors and nurses cannot do the full job of the person they are replacing. And they are very expensive, often coming though pricey agencies. And their cost has rocketed in line with demand and this demand has further increased the cost these doctors can charge for their services: many locum GPs now demand £120 an hour. Hospitals and GP surgeries can only afford so many and then the waiting lists build up again.
We have spent over £600,000 in the last year on locums to enable us to continue providing excellent access and rapid response but this is unsustainable. In effect the partners have been subsiding the NHS from their own pockets.
Where are all the doctors? GPs joining in the boom years of the 1980s and 90s are now retiring and the pandemic greatly speeded up this process. Others are retiring early and are not easily being replaced. In some parts of the country where existing practices cannot attract new blood, the remaining GPs are finding carrying on impossible and are simply handing back their contracts and walking away. From being a very popular option, fewer young doctors now want to become GPs and when we do have applicants we find they will only commit to a small number of sessions which will not provide good continuity of care. Or they choose to become locums when they can name their price, work whatever sessions they want and have none of the responsibility of running a practice or doing any of the admin.
After locums, there are two other main types of GP – a partner and an employed GP. Partners hold the practice contract with the NHS. They may own the building or rent it but in any case are responsible for managing it and providing all the equipment, for employing staff, for adhering to the many contractual requirements (and a GP contract is extremely complex with many add-ons and KPIs to meet), finances, infection control, information governance, health and safety, safeguarding and so on, all to tight deadlines. We also have strict regulators such as CQC and the General Medical Council to please.
The job of a GP partner, is therefore very stressful, especially with the increased patient demand and decreased workforce. They are having to take on more and more work: clinical and administrative. Bureaucracy has mushroomed and much of the job has become administrative and is now seen as pen pushing: not what we chose medicine for as a career. The support systems are unhelpful – hospital waiting lists are often endless, so GPs have to do more difficult clinical work, budgets are squeezed mercilessly, financial arrangements are ever more obscure, administrators and good managers are in short supply, NHS support structures become ever thinner as budgets are tightened and IT systems are becoming more and more complex and creaky. The NHS is undergoing constant change, there is massive fragmentation and loss of autonomy and so planning and running a complex machine like a general practice (in effect a mini hospital but without all the various supporting departments) is increasingly difficult.
We have had massive problems trying to recruit effective team members at all levels- from GPs to managers to reception staff. Our poor practice manager is pretty much on her own since the assistant manager left for a promotion in the NHS a couple of years back and we have failed to replace her. We are missing a patient operations manager and we cannot recruit good reception staff – our pay rates are limited by the fairly fixed amounts we can earn – we cannot simply increase production, take on new work or improve efficiency as could a manufacturing business. Practice nurses are incredibly rare and we have had a considerable deficit in that area, which has had a knock-on effect on GP workload.
We have lost 4 good partners over the last 3 years to relocation, retirement, emigration and one taking up a lucrative post in health-related IT with a couple more retirements planned. We have been fortunate to find two new partners but there is still a shortfall placing a considerable burden on the remaining ones who themselves cannot work at the past rate of 8 ‘full-time’ sessions -it is simply not sustainable, or safe. We have had a shortage of employed GPs and to have had to fall back on locums.
Political parties have long promised more places at medical school to train more doctors but of course that takes years to filter through the system. Other solutions are to speed up training – but with scientific knowledge increasing and medicine becoming more complex all the time, is that safe? Similarly, lots of additional clinical staff roles have been created but none have enough knowledge or autonomy and can only do small bits of a GP job. They require a good deal of hands-on training and supervision, and that means GPs taking time away from patient care, compounding the issue. And these new roles often they move on rapidly.
General practices are small businesses. We are not really part of the NHS; we contract our services to the NHS. We employ staff and provide the building, equipment and resources. The NHS reimburses rates and rent but most of the rest we provide. For instance, though our building is rented (it was built to our requirements and leased to us), we had huge unexpected costs this year as some of the complex climate control and air filtration equipment broke and we had to pay from our own pockets over £70,000 to get it fixed. We have fears for the other parts of the 8 year old system and much more of this sort of thing could bankrupt us.
Against this difficult background most practices limit what they can offer. We all hear about those many practices where you have to start ringing from 8am and are lucky if you get answered before all the appointment slots have been used and then you try the next day and on it goes: a most unsatisfactory system.
We have always planned different systems to avoid this and the current use of the simple online Patchs system (now available through voice on the telephone for those without keyboard skills or access) allows us to get a quick view of the problem in order to prioritise and plan a suitable response. It means we can deal with everyone’s queries on the day of submission or next day if submitted later in the evening. It also means we can bring patients in for face to face appointments whenever needed as we don’t have sessions booked up a week or two ahead as we used to (often people would book for things that just needed a quick phone contact sort out). This is the only way we have been able to meet the demand given the shortage of doctors and nurses but is a very efficient and responsive system.
We can no longer afford to pay the huge locum costs and so will inevitably have to restrict what we can offer at certain times. When all our capacity has been used up we shall stop accepting new Patchs and ask patients to call 111 for advice if unable to wait until the next day. This is what other practices do, though usually much earlier in the day following the morning rush filling all the available slots. If doctors become over-whelmed with demand, they can start becoming unsafe, as anyone would and we must guard against unsafe working.
The BMA (British Medical Association) is mounting a campaign to improve GP working lives and some posters are attached here.
We shall monitor the situation daily and adapt as we go along and as patients feed back. We hope with better recruitment that we can go back to our usual model of responsiveness as we firmly believe patient access should be as easy, consistent yet flexible as possible though it must be provided within an appropriate cost envelope.
