The GP crisis long predated COVID-19. During the pandemic, despite being ideally placed, primary care was bypassed at every stage; triage, test and trace, vaccination boosters. In this essay, Simon Hodes paints a detailed picture of the myriad pressures placed on the GPs service, showing the necessity of greater attention and investment into it.
“How a society treats its most vulnerable is always the measure of its humanity” is a well-known quote often attributed to Mahatma Gandhi. Never has this been more true than during the COVID-19 pandemic, which has highlighted the dramatic effects of health inequalities, and the need to shield and protect our most vulnerable members of society.
The “Levelling Up” agenda is a key priority for the current government, and the effects of pre-existing health inequalities and deprivation have never been exposed more clearly than by the wide-reaching effects of COVID-19 pandemic. We all need to focus more than ever on the health of the most vulnerable in our society.
As the UK moved on from the critical phase of the COVID-19 pandemic, General Practice not surprisingly became centre stage of NHS discussions once again. This is because we all rely on the NHS from before cradle to grave – and for the vast majority of people, most NHS contact will be through their GP Practice. UK primary care is the bedrock of the NHS, providing around 90% of patient contacts for under 10% of the NHS budget. GPs are seen as the gatekeepers to the NHS, making rational use of limited resources and providing well over 300 million patient consultations each year (compared to 23 million emergency department visits).
So where equitable access to high-quality primary care falls – either due to increased demands, or a failing system – vast numbers of patients will be affected. Sadly, this is the position we are in now, due to a combination of unprecedented demands on the NHS on a background of many years of chronic underfunding, and some of the lowest ratios of doctors and hospital beds per population of an OECD nation (the only European countries with fewer doctors per head of population are Poland and Slovenia). Patients who are unwell or worried and who cannot access their GP will naturally turn to other services such as 111, or unscheduled care (e.g. walk-in centres and emergency departments). This puts undue pressures on the hospital system and risks overwhelming secondary care.
GPs are thought of as ‘generalist specialists’ able to deal with everything from minor illness to end of life care on a daily basis and everything in between. Due to the falling number of GPs, government policy has been to push practices into large groups of 30-50,000 (called primary care networks or PCNs) with a view to working at scale. This change was made despite there being little evidence base for it, and with no formal consultation with the profession before the policy was introduced in England in 2019. One of the key PCN policies is to provide additional staff such as paramedics, pharmacists, social prescribers, first contact physios and mental health workers under an ARSS (additional roles reimbursement scheme).
These expanded GP multidisciplinary teams are perfectly placed to offer population-based health care and reach our most vulnerable and at-risk patients. The most celebrated and successful part of the UK response to the COVID-19 to date was NHS-led: the initial vaccine rollout, which was spearheaded by GP teams who organised and administered around 75% of injections. There is well-documented evidence and stories of GP teams calling around their patients in evenings and weekends to physically book appointments, making domiciliary visits to the housebound, arranging pop up clinics in homeless shelters, places of worship and football stadiums and many other initiatives to try and reach our most at risk patients. However, without a cohesive strategy for the ongoing rollout, it seems that numbers are now faltering for boosters, and there has been much confusion over third primary doses.
Although UK Primary Care is world renowned, it was conspicuously sidestepped in the pandemic. Rather than scaling up and strengthening our existing primary care service, along with public and environmental health services – who would normally deal with infectious disease outbreaks – the UK created a new ‘111’ service (the CCAS, or COVID Clinical Assessment Service), and has spent a £37 billion on a much criticised test and trace system. To put this in perspective, the entire annual primary care budget for England is around £12 billion.
Way before the pandemic, Matt Hancock was a huge proponent of digitalisation and health technology. The UK Government actively encouraged GP at Hand – an NHS remote-only service launched in April 2018, which eventually took over 86,000 patients, became very profitable and was criticised for cherry-picking low-challenge patients from local practices, leaving the more complex and frail patients for the traditional GP care. At the start of the pandemic, the NHS was told to go digital first, and then to perform ‘total triage’ to keep patients and staff safe.
Not surprisingly, as a result there has been a huge shift from physical to virtual consultations both in hospital and GP clinics. However, media outlets particularly the Daily Mail and the Telegraph have been openly attacking GP services, calling for all patients to be seen face to face, despite the UK being a world hotspot for COVID-19, and GP waiting rooms being unfit for safe social distancing and full of sick patients. Rather than consulting with GP leaders, Sajid Javid seemed to bow to these media pressures, announcing in October his new plans to try and force GPs to see more patients face to face, and relaxing social distancing rules. These plans looked unworkable, and were rejected by 93% of the GP workforce. The story is evolving at the time of writing this article (21.10.2021).
With increased remote working, many GPs have been concerned about the risks of ‘digital exclusion’ yet again exacerbating health inequalities. Some 7% of UK households remain without any internet access. Internet non-users are disproportionately disabled, women, and those aged over 75. Deprivation and social factors also impact on remote healthcare delivery. Statistics sadly show an increase in domestic abuse during the pandemic, with only 1 in 5 surveyed survivors saying that their online activity was NOT monitored by their partner.
Unfortunately, workload in general practice is rising rapidly – a toxic combination of an ageing growing population, more complex medical treatments, a shift of work into the community – and the well-documented decline in GP numbers. Not surprisingly, GPs nationally are at breaking point. The current crisis in general practice predates COVID-19, but has been intensely magnified by the pandemic. Despite all this, more and more work is being transferred to primary care without the associated funding or resources.
GPs and their teams have played an essential role throughout the pandemic. General Practices have been running community hot COVID clinics, and supporting NHS 111 and the COVID Clinical Assessment Service (CCAS). We are now supporting 5.7 million patients on NHS waiting lists, who are often struggling with severe symptoms and in need of extra support, as well as supporting about 1 million patients with the effects of long COVID, while adapting to new ways of working enforced by a global pandemic. In addition, GP teams have delivered the majority of COVID vaccinations thus far. We are currently being asked to recall our most clinically vulnerable patients for their third primary doses of COVID vaccines, or routine boosters. The resulting increased phone traffic to practices, makes it increasingly difficult for patients to get through. All the increased workload and dependence on General Practice has been achieved despite the proportion of the NHS budget spent on NHS general practice and the number of GPs per person both declining in England in recent years. Urgent political action is required to prevent a collapse of General Practice before it is too late. As it states on the NHS Five Year Forward View: “If general practice fails, the NHS fails”.
- There is strong evidence base that the density of primary care doctors is directly connected to life expectancy.
- The GP crisis long predated COVID-19. Despite promises for 6,000 new GPs by 2024 we are now nearly 1,800 FTE GPs less. So we are facing a deficit of nearly 8,000 FTE GPs.
- Where access drops to Primary Care patients turn to 111, unscheduled care and emergency departments.
- We have a growing population who are living longer and with more complex and medically demanding health conditions.
- Digital health solutions suit many patients, but we risk losing non-verbal clues, and widening health inequalities through ‘digital exclusion’.
- Access to NHS care should be fair and equal to all. However at present there is a postcode lottery, further exacerbating health inequalities.
- GP turnover has increased in the last decade nationally, with regional variability. This may most greatly impact the most deprived areas in particular, where GPs often need to deal with more complex health needs.
- Continuity of care has a strong evidence base for reduced morbidity, increased life expectancy and also brings improved satisfaction for both Patients and care providers. However, continuity of care is being eroded by serial health policy.
- Health inequalities have been a major independent risk factor for COVID-19 deaths and health inequalities are also a huge determinant of poor health and reduced life expectancy.
- The rate of investment in General Practice is far below that seen in secondary care pro rata. Although 90% of all NHS contacts occur in primary care, it is given less than 10% of the NHS budget. This percentage has been falling over the years.
- During the pandemic, despite being ideally placed, primary care was bypassed at every stage; triage, test and trace, vaccination boosters.
- We need to urgently strengthen Primary Care. As it states on the NHS Five Year Forward View: “If general practice fails, the NHS fails”.
Simon Hodes grew up in Manchester, graduated from Birmingham in 1996, and after various hospital rotations qualified as a General Practitioner in 2000. Since April 2001 he has worked as GP Partner within the same NHS GP Practice in Watford, being fortunate to look after generations of many families. For many years he also worked one afternoon a week in A&E as a Hospital Practitioner. Simon has a passion for traditional, holistic, patient centred care, and a firm belief in the importance of continuity of care. He is an approved GP trainer and enjoys mentoring medical students, junior doctors, trainee GPs & other clinical staff. His non clinical roles include GP appraiser and LMC rep.
Simon recently started a part time role as a Private GP at the newly opened Cleveland Clinic London.
Out of work Simon enjoys spending time with his family, and is a keen swimmer, runner and cyclist.