Life of a GP: 'We are crumbling under the pressures of workload'
|
Version 0 of 1. As well as the desk, chairs and examination couch found in any GP’s consulting room, Dr Veena Jha’s also has paintings by patients on the walls, thank-you cards displayed above the hand-towel dispenser and a mug on the window ledge with the words “VOP: Very Overworked Person” on the side. The mug was a jokey gift from one of her colleagues to mark the completion in 2013 of a much-needed extension to the Manor Park surgery where they work. But it accurately conveys the constant busyness that is Jha’s norm. “We are all crumbling under the pressures of workload,” she says with a sigh. Jha starts work just after 8am at the surgery in Glossop, an old Derbyshire mill town in the Peak District that is increasingly home to commuters working 15 miles west in Manchester. Few days last less than 12 hours. Switching on her computer immediately tells her how many “tasks” – pressing matters involving patients’ health that the receptionists or some of the nine other GPs have flagged up – she has to deal with on top of what is an already crowded schedule. There are anything up to 10 tasks that she has to deal with somehow while coping with the rest of her daily workload which involves: seeing up to 20 patients in her morning sessions, which start at 8.30am, speaking to others on the phone, doing home visits at lunchtime and treating another 15-20 people at her afternoon surgery. This must be done while all the time listening carefully, making detailed notes, dispensing her best advice and making important, sometimes difficult decisions, like whether to send someone for a scan or have them admitted to hospital. Time, Jha’s most precious resource, means she has to prioritise her tasks. Not all always get done. Happily, Jha loves her job. “I was a hospital doctor, a gynaecologist, for 14 years. But switching to general practice was the best decision I have ever made in my life because I get tremendous job satisfaction, even though it’s nearly always busy. As a hospital doctor I treated a condition, but as a GP I treat a patient. “As a GP I have a more personal and more intimate relationship with patients, professionally speaking. You get to know about their family and the dynamics in that. For example, if I know that a male patient is an alcoholic and his wife comes in with stress, but won’t say why she’s stressed, I’ll already know what’s happening in the background ... so am more empathetic to them. “A 78-year-old man came to see me who, when I asked him: ‘What can I do for you today?’, said that his kitchen sink was blocked. I thought he was joking, but he did want my help with his kitchen sink. He came to me because he saw me as a helpful person in his life. My girls [the surgery’s receptionists] called the council and got it sorted,” she recalls. There is a downside, though, to constantly hearing so much detail about people’s lives. “As a GP it’s so much of an emotional rollercoaster because you have dealt with so much sadness during the day. At the end of the day you just go home and sit down and do nothing,” Jha says quietly. ‘There’s a lot of people queuing up at reception’ Another negative is the pressure caused by the apparently inexorable rise in the number of patients seeking appointments. Manor House, which cares for 13,000 patients in Glossop and another 3,000 at its smaller sister surgery in nearby Hadfield, is experiencing the same problems as many of the UK’s 9,770 GP practices. The ageing, growing and, in some ways, increasingly unhealthy population means more patients want or need to be seen than the surgery can easily accommodate. It vividly illustrates how overstretched the NHS has become. MPs have recounted in parliament how constituents have desperately sought their help to get a GP appointment, while the revelation in December that patients were having to queue in the dark from 6.30am outside their surgery in Surrey showed the extent of the problem. One of the patients in one of Manor House’s two waiting rooms, Sheila Redford, says: “They are obviously under pressure. You can feel that when you walk in. There’s a lot of people queuing up at reception. There’s almost always a queue there ... that’s not a criticism; it’s just a fact.” Redford, a patient at Manor House for 45 years, says things have changed for the worse. “Many years ago there was a homeliness about being in the doctor’s surgery. ... Social niceties have got lost, like receptionists asking: ‘How are you getting on?’. Even they don’t have time to do that anymore. They’re too busy answering phones, making appointments.” Each family doctor does a certain number of morning or afternoon sessions every week seeing patients. They are expected to see 16 patients and speak to three more on the phone in a three-hour morning session or see 14 and assess two others over the phone in a two-and-a-half-hour afternoon one. Each session is divided into 10-minute slots. None of the doctors think that is nearly long enough, especially with the growing number of older people who have several things seriously wrong at the same time, such as diabetes, heart disease and breathing problems. “The longer you have been in the surgery the more comfortable with you patients become and so they start raising more than one problem. But 10 minutes is barely enough for one problem,” says Jha. “You have to greet them, establish a rapport, find out what the problem is, do an examination and draw up a management plan, for example ordering a blood test, peak flow test or blood-pressure check. If the patient is acutely unwell with abdominal pain you have to decide if it’s serious enough for them to be admitted or if they should just go home. Those are very important decisions.” Jha sees three or four such patients most days. Their health means she cannot afford to make a wrong call. It also takes half an hour at the end of each session to “mop up”: to ensure that the details of every patient’s symptoms have been entered into their electronic medical record. Related: A&E crisis: 'emergency medicine has become the first port of call' On many, if not most days, Jha goes without a break. Lunch? “No lunch. Maybe an apple. Or I’ll maybe grab a sandwich on a quiet day, though work while I’m eating the sandwich.” In 2009, Manor House’s GPs put on 49 sessions a week, during which they typically saw 736 patients face-to-face and did telephone consultations with 121 others. That has risen to 64-and-a-half sessions a week, at which they usually provide 991 appointments and talk to 123 patients on the phone. Across England, the number of consultations has risen from 304m in 2008-09 to 372m in 2014-15. Despite the chronic shortage of GPs across the UK, Manor House has its desired complement of doctors. But it is telling that its staff include doctors from Romania, India, Pakistan and Malaysia. For Jha and her colleagues, there is also an unending number of meetings to attend, both internally and externally, for example with the local NHS clinical commissioning group, which supervises all the health services in Tameside and Glossop. They can be about targets, the financial incentives GPs receive, safeguarding children and vulnerable adults, palliative care, patients’ long-term care plans and analysis of patient safety incidents, as well as many other issues. “Often these meetings and educational activities have to be moved to the weekends as there aren’t actually enough hours during the weekdays to go through them,” Jha says. The surgery has up to five people simultaneously answering phone calls, a large team of receptionists, 10 family doctors, five nurses and three healthcare assistants. Opening hours in Glossop are 8am-6.30pm, with surgery beginning at 7.15am on Mondays and finishing at 8pm on Thursdays. It does not open at weekends, though; a deliberate attempt by the GPs to maintain a work-life balance. ‘Some patients can be aggressive and approach you outside the surgery’ It usually gets busiest about 9.30am. “That’s because by then the appointments have basically all gone,” explains Jo Jenkins, the reception supervisor, who heads a team of 30 at the two surgeries. Those who cannot get a consultation that day are offered one at another time or the opportunity to speak to a doctor at lunchtime – telephone triage – or are added to the shortlist of those whose condition sounds like they need to be assessed promptly and are given one of the few “on-call” slots. “Patients who ring at 9.30am or 10am and are told there are no routine appointments left can get a bit frantic because they want an appointment. You have to be professional and try and calm the situation, but the person may be shouting at you because they want an appointment at 2pm. But sometimes when I say: ‘Sorry, we don’t have one at 2pm, can you come at 5pm?’, they say: ‘No, I’ll be shopping then, or at the hairdresser’s’,” says Jenkins. Another member of staff even describes some patients as aggressive. And another says: “If you go into Tesco in your uniform people will say: ‘Can you get me an appointment? I’ve tried to get an appointment’ or ‘I’ve tried to get through to your surgery, but I couldn’t get through’ or ‘my prescription wasn’t ready’. They complain, even in the pub at night.” However, the practice does act on such informal feedback. They are setting up ways of treating common illnesses such as conjunctivitis and urine infections more quickly, and encourage people to see a nurse practitioner, who can diagnose and prescribe medication, instead of a GP. However, staff also appreciate that illness brings anxiety and fear and thus patients can be very impatient about being seen, whether that’s for a lump they have found, or palliative care they need to organise for a relative, or blood test, or annual review of their diabetes or severe shortness of breath or care for the stroke they had. Ultimately, those who demand to receive prompt attention generally get it, though that may be telephone advice. “You can’t turn people away. You just have to deal with it,” says Jenkins. The fact that 7,500 of the 16,000 patients at the surgeries in Glossop and Hadfield are on repeat prescriptions underlines that, like GPs and hospitals everywhere, Manor House is facing a growing burden of illness which is expected to keep on rising. Dr Nicola Thorley, a GP at Manor House for the last 15 years, echoes what some experienced A&E doctors say when explaining why demand for their services is rising too – that something in society has changed. “Patient expectation has changed an awful lot too”, she says. “Patients aren’t prepared to wait the way they used to ... these days people, especially those under 40, want same day access seven days a week.” Manor House runs various services and specialist clinics, including surgery for patients with skin problems. It also employs its own pharmacist and has hired an extra nurse specifically to look after the over-75s. In doing all this Manor House is already operating in broadly the way that Simon Stevens, the boss of NHS England, says GP surgeries need to if the health service is to cope. His blueprint to safeguard the NHS’s future envisages GP surgeries coming together to form federations and become large enough so that they can provide an alternative to hospital for more and more patients. However, Jha notes that, paradoxically, while offering all these different clinics at Manor House may relieve the pressure on its local hospital, Tameside general, it seems to increase demand on her and her colleagues. Despite family doctors handling 90% of all patient contacts in the NHS, their share of its budget has shrunk to just 8.3%. As pressures have risen the number of GPs has not kept pace and burnout is leading to more and more taking early retirement. Worryingly, that has coincided with the failure of determined efforts to attract enough medical graduates into choosing general practice as a career. No wonder the Royal College of GPs is warning that urgent action is needed, such as the recruitment of 10,000 more GPs by 2020 and much more money by 2017 if patients’ access is not to get even worse. Young medics discouraged from being GPs Like Jha, Dr Guy Wilkinson, another of the GPs, eats lunch at his desk. Over his 17 years as a GP he has watched the family doctor’s role grow ever wider as bureaucracy and medical complexity have also increased. “There used to be hospitals where frail, elderly patients would live long-term. But now more older people, often with multiple illnesses, are being cared for in nursing homes or at home with massive social support. Historically those people had maybe two things wrong with them. Now ageing means it’s five. So more people are on more complex medication and more people need monitoring,” he says. This morning he saw 13 patients, spoke to three others on the phone, and supervised three trainee GPs as they too assessed patients. He then spent an hour writing a five-page care plan for a very ill man who is close to death and co-ordinating the details of that with district nurses, palliative care services and the patient’s nursing home – an important but very complex and time-consuming job. His frustrations include patients who take up an appointment in his view unnecessarily, like parents bringing a small child in at the slightest sign of a problem. “There’s more fear these days that they won’t be able to care for their child through an illness. Historically where people may have gone to their mum or grandma for advice, these days it’s ‘get them to the GP’.” He is very pessimistic about what the future holds for GPs and worries that the stresses and strains involved is discouraging young medics from the profession. Two local GPs recently returned home to India because they had too much paperwork and their working hours were getting longer and longer, he says. “Being a GP is a tough job and it can leave you feeling shot through at the end of the day, because it’s an isolated job, even in a practice with a lot of GPs. You are the last port of call for patients, and we never discharge people,” adds Wilkinson. “I have four children, but I wouldn’t want any of them becoming a GP like I did, because the great bit about being a GP – providing continuity of care, watching kids grow up into adults and living and working as part of a community – is being unbalanced by the high pressure nature of it and the decreasing job satisfaction.” |