Face-to-Face or Remote Access? Facing up to the Challenges for General Practice in Britain Today
The coronavirus pandemic has changed the way the UK’s National Health Service (NHS) works and, in so doing, has further laid bare the problems of providing healthcare in an equitable and efficient manner at a time of economic crisis. It has also drawn attention to the tensions between primary and secondary care in a service that many in the know recognise to be working at the very limits of its available resources, as shown by repeated crises, not only during winters but now all-year-round.
You can hardly expect members of the general public, the media, and populist politicians to understand the problems of healthcare delivery and to sympathise with GPs unable to see patients in person at a time of crisis, when doctors are themselves up against each other. A particular source of misunderstanding and conflict relates to increased attendances at emergency departments by people unable to access their own GPs (long phone queues, telephone triage systems by receptionists that either redirect callers elsewhere or fail to provide timely appointments, appointments restricted to one complaint at a time and not with one’s own GP). Similarly, GPs are also unhappy about patients being transferred prematurely back to their care by hospital specialists, either after major surgery or for the specialised care of complex long-term conditions, without adequate back-up and funding.
The mismatch of supply and demand for healthcare can be partly addressed by increasing the supply of healthcare providers, along with the simultaneous management of demand for their services. GPs have traditionally functioned as gatekeepers, acting as the first point of contact for those seeking to access healthcare, and then determining who should be referred to a specialist. Triage by GPs can partly help manage demand, by sorting callers’ complaints and prioritising those who present with “red flags”, particular symptoms that suggest potentially serious underlying conditions. But when this is done remotely, there is always a small risk of underestimating a patient’s symptoms and failing to diagnose early potentially fatal, yet eminently treatable, illnesses.
Ever since the pandemic began, phone, video, and email consultations have increasingly replaced face-to-face consultations. These different ways of communication have often worked well but have also placed certain sections of the public at greater risk of inadequate care, such as those with impaired hearing or eyesight, those who do not own computers and smartphones or lack confidence in their use, and those with a limited knowledge of English (loss of information in translation). Equity of access to care has been compromised as a result.
When it comes to the numbers of healthcare providers available, GPs readily agree that some of their work could be done by others, with the BMA recommending increased use of alternative healthcare professionals, including “nurses, pharmacists, physiotherapist, physician assistants, mental health workers, and paramedics”. But even as alternative providers are identified, there still remains a problem with the actual numbers of GPs. Declining numbers mean that only 46.3 fully qualified full-time equivalent GPs were available per 100,000 people registered with a general practice in England in March 2021, down from 51.4 in March 2016. It has also become clear that while the numbers of GP registrars (trainees) and salaried GPs (employed by practices) have increased, the numbers of GP partners, who own practices and are directly involved in their administration, continue to fall. Training, recruitment, retention, and return to practice by those doctors who have left prematurely are all important to ensure adequate GP numbers to cope with existing demands.
The UK Government made a somewhat ambitious pledge, in November 2019, to recruit 6,000 more GPs and 20,000 more additional support staff, both clinical (nurses, pharmacists, physician assistants) and non-clinical (practice managers, receptionists) by 2024-25. But then it was close to a general election, when such promises generally tend to be made. The reality is that the available numbers of medical students and doctors in training, and the supply of international trainees, just do not add up to allow this particular target to be met.
The current model of the NHS isn’t working and hasn’t for some time. Both its workforce (excessive workload, poor work-life balance, lack of funding) and the recipients of its services (limited access to GPs; long waiting times; delayed diagnoses, especially of cancer) are unhappy, and merely propping it up with more resources will only perpetuate its existing inefficiencies, which have now become well-established. Healthcare continues to evolve, with many new innovations and efficient ways of working, as does the population that is served (ageing; long-term survival with previously untreatable chronic diseases and cancers; ethnic diversity). Better integration and collaboration, both between individual general practices (primary care networks) and also between primary and secondary care (integrated care centres), along with a breakdown in the traditional and often unjustifiable barriers to the access of diagnostics (specialised blood tests, x-rays, ultrasound, CT scans) and specialist care, are essential. The coronavirus has dealt us a massive blow, and as we continue to recover we have a chance to improve matters in the longer term by better planning for the changing demands of the future.
Ashis Banerjee