UPON THEIR SHOULDERS

GPs are working under greater pressure than ever before, but added to this is a toxic media climate and a rising tide of abuse from a minority of patients. In the fi rst of a two-part study, they tell our writers why change is urgently needed

Surrey

Dave Triska is used to pressure: he is ex-army and came to this quiet corner of Surrey direct from a tour in Afghanistan.

Take that mid-December day, during the Strep A spike…

‘For about 30 seconds, I had the same visceral response as when a daisychain IED went off in the compound in Afghanistan, and all these injured people were streaming towards me,’ he says, without hyperbole. ‘Then you pull your big boy pants up and get on with it.’

On the Tuesday after the New Year bank holiday, they had 459 contacts, more than double their pre-COVID average, and declared a ‘black alert’.

Surge in demand

By noon, they’ve had almost 200 contact requests, to be dealt with today by two nurses and five doctors, including them. Neither of them ever sleeps on a Sunday night: a normal Monday is 11 hours long.

But there are days, many days, when he and his managing partner, Lis Galloway, feel the workload at Witley Surgery is out of control.

It feels like ‘being morphed into an urgent care centre’; the next nearest is 30 minutes’ drive away.

It is a Monday morning in January and Drs Triska and Galloway are huddled over their computers, back-toback in their triage ‘hot room’.

They’re good at flex. The whole team, including reception staff, have had change management training and adopted digital tech enthusiastically: they switched to telemedicine in 2017. In terms of efficiency, access and case management, they’re ‘probably doing the best medicine we ever have’, says Dr Triska. But it’s not enough.

The reasons behind such a surge in demand are complex, and not unique to Witley village.

Their 11,000-strong patient population is among the oldest in the UK, typically still living independently: more than half have longterm care needs. They’re also well-educated and well-read. Dr Galloway winces at a request for ‘a referral today’; a prescription of statins requires a detailed discussion about enzymes.

Increased health anxiety since COVID and ‘uncontrolled transmission’ of winter viruses have played a part. But the fallout of secondary care delays is devastating.

Dr Triska gives a ‘not uncommon’ example: patients with severe rheumatological pain who have lost jobs waiting for a diagnosis and plummeted into depression. Previously, they would have been seen within two weeks and could have expected a resolution within seven months. Today, they have little prospect of help for either condition.

Mental health issues now account for about 40 per cent of Dr Triska’s caseload. He has had one patient seen by a psychologist locally in five years. Last Friday he spent hours trying to find appropriate help for a suicidal patient – and failed. ‘My threshold for “this is bad” is quite high but this is a car crash. If I get this wrong, someone might die.’

Vandalism

The pressures are largely hidden from patients. The waiting room is quiet today, a reflection of effective online triage, remote consulting and the decision to move the dispensary hatch to an external wall.

Despite high patientsatisfaction ratings, ‘negativity’ has increased, says receptionist Sam. A few weeks ago, they called police when a patient became physically aggressive with one of her colleagues. Staff cars have been vandalised, anti-vax propaganda pasted on the door.

The disgruntled come the moral imperative in healthcare: we’re all traumatised because we’re not delivering the care we want to, we’re being trashed and we can’t trust our leaders to look after us. We’re on our own.’

By Seren Boyd

preloaded with mediafed arguments, says Dr Galloway. ‘They assume we’re withholding a service, putting barriers up, and we’re really not.’

The big ‘unseen work of general practice’ is the risk it holds, she says. And, worst of all, there’s no back-up, guidance or leadership.

‘We can say we’re full but if an unwell child comes to us at 4pm, we’re not going to turn them away. You look to local and national leaders and there’s just silence.’

Innovation in the way primary care is delivered is vital, says Dr Triska, but that is impossible without rebuilding trust.

‘We’re rapidly losing

‘It’s a vicious cycle of worry – and that is very stressful.’

York GP Abbie Brooks is scrolling through the list of people requiring urgent, same-day, appointments, and reflecting on failures in publichealth messaging, lessons from the pandemic left unlearned and communities who seem to have forgotten how to self-care for even some of the most minor illnesses.

It’s barely 8am and the list of patients reads: cough, tonsils, cough, cough, ear, tonsils, cough. Among the litany of cold and flu-type symptoms a patient who has much more obviously concerning symptoms –suicidal ideation or possible cancer symptoms – crops up every so often, but the vast majority who need triaging follow a familiar theme.

‘It’s usually not that bad in December,’ Dr Brooks, who has been a partner here for four years, says. But this is Wednesday, 14 December, 2022. Not only is the entire NHS system in absolute crisis, but there has also been an increase in cases of invasive group A Streptococcus –with print and broadcast media, parenting forums and conversations outside the are worried about that too. Those worried parents race for appointments to secure the now even more coveted tablets and fluids. In this maelstrom it is hard to escape the feeling GPs are vulnerable to the effects of whatever is happening in society – so often the ones picking up the pieces when everything else is falling apart. compassion is totally focused and absolutely undivided.

Dr Brooks’s first faceto-face patient of the day, though, has none of those symptoms, and provides a timely reminder about the importance of general practice amid the chaos which threatens to overwhelm services.

He has rung the surgery to raise concerns about a lump in his neck which he says has been there for ‘quite a long time’ but has recently begun to worry him much more significantly. When the patient arrives he is clearly incredibly nervous and, ultimately, reveals he has convinced himself that he has ‘some sort of awful cancer’.

Dr Brooks also finds time to check a skin lesion, to discuss what to be aware of around new and existing moles, and to make it feel much more likely that this patient will call his GP next time he has a worrying symptom, rather than trying to ignore it. It is just one encounter of many during a day which feels like brilliant general practice – where and when it is most needed, but so hampered by strain from elsewhere.

Time and space

Given the pressures on the service and what seem to doctors like attacks from government ministers and the media, not to mention increasing levels of expectation and abuse from the public, it is genuinely quite moving to see the effect of the dedication of doctors working in primary care.

‘I don’t want to put people like that off,’ Dr Brooks says.

school gates ablaze with talk of an outbreak of scarlet fever. Across the country, parents and families are worried –many want reassurance and many want antibiotics.

Patient pressure

The ‘vicious cycle’ Dr Brooks references is in full swing; more people want appointments. Those who get them want solutions – and not just to be told to give themselves time to recover.

As a result, there is a shortage of antibiotics and now parents and families

The lifting of the worry in the room is palpable – so powerful it is almost vicariously relieving – when Dr Brooks is able to diagnose a cyst in the skin of no real concern.

It is an interaction which reveals so much about Dr Brooks and the specialty. On top of the mountain of scarlet fever concern, this was a week in which there have been yet more media stories which feel like barbs for doctors – one of them suggesting GPs might somehow be drafted in to work in ambulances during strikes – and yet Dr Brooks goes about her work as if each patient is the only thing on her mind: that care and

‘We are incredibly busy but I don’t want people like him thinking twice about phoning us. Prior to that consultation I was thinking “this could be leukaemia or lymphoma, what do I need to do to make sure I don’t miss something”. If it had been that I would have had to do a full check of his lymph system.

‘This is the thing, our interactions can be joyous. We’ve taken so much worry away from him. But we do need that time and space to get to know people, to give them a chance to say everything they want to say, to get everything off their chest… And that’s really difficult in the current environment.’

By Peter Blackburn

Health services across NHS

Ayrshire and Arran were on an emergency footing when The Doctor visited Largs Medical Group. On 10 January, the health board had asked GP practices to see urgent and emergency care patients only, and it was not clear when this situation would end.

‘Generally speaking, our days are busy at the moment,’ says Rachel Fraser, one of the 11 GPs at the practice, which serves a population of just over 13,000.

‘We’ve switched to a system where our morning appointments are routine and afternoons are emergency – aligned to the fact that the health board is on an emergency footing at the moment. We had a surge owing to Strep A and the flu, which seems to have reduced a bit this month, so it feels a bit less pressured. But every day our appointments are filled – we really don’t have any spare capacity.’

Travel obstacle

Largs is a charming seaside town in Ayrshire which is perhaps most famous for its association with the Vikings and for its ice cream parlours, notably Nardini’s.

It’s also a sizeable schlep by public transport to the nearest hospitals, Crosshouse in Kilmarnock (two buses or a train and a bus, taking well over an hour) and Inverclyde, which is closer but is actually run by neighbouring NHS Greater Glasgow and Clyde health board. Given that it also has a sizeable older population, and significant new Scottish GP contract, which was agreed in 2018, but still in the process of being implemented.

This involves the presence of a multidisciplinary team, including a mental health practitioner, first-contact physiotherapist, pharmacists and pharmacy technicians, and a community link worker.

As well as its own nursing team, there is also access to district nursing, health visiting, and midwifery on site.

No barriers

These additional roles have largely been welcomed by the local population and demand is high, but not everybody is happy with services offered by the practice, and this takes a toll on GPs and staff.

pockets of deprivation (although not compared with some of its neighbouring settlements), this can be a problem.

The vast majority of healthcare in the town and its surrounds is delivered by Largs Medical Practice, which offers a wide array of services, thanks in part to the

‘There’s an active local Facebook group which has been really quite difficult and challenging, particularly for our staff, who are on the front line,’ says Dr Fraser.

‘There still seems to be this negative media rhetoric that practices are not open, that your GP is “not working” and that’s completely not true. In fact it’s the absolute opposite.

‘We’ve been working throughout and are offering more appointments than ever.’

The balance has changed, she adds, with a higher proportion of telephone consultations to help build more capacity into the system.

‘We’re using every single minute of the whole day to make sure that patients are safe when they come to our practice, but admin staff are on the front line and are dealing with the public on a daily basis.

‘They get the real abuse. I understand that individuals are frustrated at not having the same service from the NHS, but services are in crisis and there’s a finite resource.’

GP partner Colin Jamieson is also feeling the brunt. He has taken the decision to cut his sessions in an attempt to preserve his mental health.

‘I’ve never worked as hard as I have in the last three years – it’s been relentless,’ he says. ‘I do consider myself a resilient person, and I’ve always been able to ignore negative media attention, but it just started to get to me. It’s not just the mainstream media, it’s the local Facebook group – it’s local, and it’s personal.’

Around six months ago he had what he called ‘a proper, bona fide meltdown’. ‘For the first time, I ended up on antidepressants. You know what, I’m tough. I’ve been tough for a long time, but human beings have their limits, and I absolutely reached mine.’

GPs feel obliged to carry on, he says, because they don’t want to let colleagues or patients down. But he has taken the decision to cut his patient-facing hours. ‘It’s to preserve my sanity,’ he says. And he’s not joking.

In a neighbouring room, GP registrar Shivraj Vittalraj is looking forward with enthusiasm to a career in general practice. ‘It’s an amazing field,’ he says.

‘I feel the patient-doctor relationship is great in this specialty because I’m looking at the patient as a whole. It’s the continuity of care –you’re the family doctor.

‘You’re not treating them as a problem [in isolation] – it’s more of a complete package, and I’m very happy with that.’

That’s not to say that challenging.

‘We’re seeing so many patients, and with those numbers, we can’t do justice to everyone. We’re trying to do our best, but we’re humans as well.’

By Jennifer Trueland

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