A HARSH SPOTLIGHT

GPs are prepared for just about anything that comes through their doors – but a politically motivated attempt to undermine the way they work has left them badly shaken. The Doctor continues its study of the pressures facing general practice

London

GP principal Farzana Hussain sometimes feels like she is part of a general practice tribe that is potentially facing extinction.

As the single-handed principal at the Project Surgery in Newham, east London, Dr Hussain has been a fi xture within her local community for almost 20 years.

Nestled within a housing estate and adjacent to the path of the rails of the District and Hammersmith and City tube lines, the practice cares for a patient list of just 5,000, their grandchildren. It’s really family medicine and that’s very satisfying for me.’

False narrative

The Project Surgery was originally founded via an urban regeneration fund new deal for communities.

Since 2013, the surgery has operated on a telephone-triage approach to consultations, something which allowed the practice to meet the challenges of COVID when the pandemic struck three years ago.

With the surgery opening at 8am, Dr Hussain and her colleagues, a locum and a salaried GP, received 65 incoming calls and manage 42 patient consultations between them on the day I visited, while also processing lab links, bloodtest results and electronic prescriptions.

Indeed, just staying on top of and responding to the various emails arriving in the surgery’s inbox takes up at least an hour of Dr Hussain’s daily work schedule.

are just really lazy”.

‘The politicians certainly didn’t support us in countering this narrative. Indeed, at the end of the second wave they started talking about benchmarks for how many face-to-face consultations we should be having.’ something Dr Hussain believes has allowed her to practise the type of family-doctor medicine she feels is becoming increasingly rare.

In the course of a telephone clinic, Dr Hussain speaks to one of her rare, older patients, a man in his 80s set to undergo an MRI, about the medication he is using to manage his pain.

Greeting her like a family friend, he speaks enthusiastically of Dr Hussain’s recent TV appearance and how proud he is of her.

The closeness of the doctor/ patient relationship is evident, yet Dr Hussain fears that part of the toxic narrative of GP surgeries not being accessible to patients is now being used to push a political agenda mandating increased levels of face-to-face appointments.

‘London is a young city and Newham is a young borough. Out of all my patients I’ve only got about 200 over 65 and I can honestly say that with at least 100 of them, I know what their front lounges look like, I know their children and bma.org.uk/thedoctor

It is extremely frustrating therefore when she and her colleagues encounter accusations of GPs not being open and available in the press, among politicians and occasionally the public.

‘I think this whole narrative that the politicians and the papers have said about GP surgeries are closed, I think it’s been intentional,’ Dr Hussain says.

‘I think the public thought “oh, they closed the doors for COVID, but now we don’t have a pandemic, so GPs

‘This government wants to push access but my concern with that is [in doing so] are we actually giving people safety and quality care?’ says Dr Hussain.

‘If one of my patients says, “I’ve got hip pain”, and I know that her husband died recently, I know that that’s going to impact on her pain thresholds. That’s something that you can know instantly, if you’ve got that continuous relationship.

‘You can’t diagnose the cancer within fi ve minutes, you need the time to ask questions and do a really good consultation.’

By Tim Tonkin

Nottingham

Continuity of care is the key principle which runs through everything doctors do at the Elmswood surgery in Sherwood, Nottingham. During the course of one morning in January, Irfan Malik – one of the six partners at the practice – sees patients he has been treating for decades, families whose stories he knows like his own, and even one young adult he first assessed during her baby check 22 years ago.

That continuity is not just a relic of the profession’s past fortunately preserved here – it has been carefully cultivated with partners. The 9,000-patient practice is solely doctored by the six partners and registrars in training, who fight to prioritise a culture led by staff wellbeing and the relationship between patients and doctors.

‘We call it an old school method,’ Dr Malik says. ‘We are probably atypical because we’ve got no vacancies – so many places are under-recruited. We are very lucky and over the years we’ve built up an excellent rapport with the patient population.’

Good relationships

The results of continuity are clear in this residential area, just north of the city centre: rates of admission to hospital are relatively low, even though the population here is ageing and patients are managed in primary care for longer with low referral rates because each partner specialises in interventions which would often be carried out in secondary care.

Beyond that, Dr Malik says doctors here are rarely abused and relationships with patients are excellent, despite concerning trends elsewhere in the country. The mainstream media – and government – narratives about general practice could not feel any further from the truth in Dr Malik’s consultation room.

‘I know we are losing that continuity around the country, but luckily we’ve got it here. And as well as the medical side of things I enjoy the banter and the conversation, too… Talking to them about the football or the cricket is why I’m here as well.’

Dr Malik adds: ‘We hardly get any people kicking off here. The receptionists may have a slightly harder time because they have to put people into appointments but generally the patients are lovely.’

Evidence for the benefits of continuity of care is not difficult to come by, but anecdotally the effect is clear here, too. During the course of 16 patient consultations in one morning Dr Malik is able to deal with incredibly complex patient stories efficiently, but also with great humanity – his understanding of the histories and characters of his patients combined with a genuinely caring and inquisitive disposition, ensures discussion around, and reassurance over, a number of issues to take place in the space of just 10 precious minutes.

By Peter Blackburn

Belfast

We’re sitting in Ursula Brennan’s bright and modern room in Mount Oriel Medical Practice in south Belfast and an email pings. It’s confirmation from the Department of Health that yet another GP practice in Northern Ireland has effectively collapsed.

There had been hopes that a contractor would be found to take on Priory-Springhill surgery, board decides to disperse the patients – essentially sharing them out among other practices – this puts an additional strain on all the GPs in a locality. Sometimes it will be enough to precipitate further practice collapses. ‘An extra 300 patients can make the difference between being viable or not viable,’ she says.

Locum demand

There are several GP-led mechanisms to support practices in trouble, including the Northern Ireland-wide Practice Improvement and Crisis Response Team. But too often the help available is just not enough to stave off collapse. A shortage of GPs means locums are like gold dust, further adding to pressures.

Public perceptions that GPs ‘haven’t been working’ over the course of the pandemic don’t help morale, says Dr Brennan, and sections of the media have consistently fanned the flames. ‘There’s a lot of talk of “part-time GPs” and people think we’ve not been working, and we’ve not been seeing people face-to-face,’ says Dr Brennan. ‘But we’ve never been away – and our workload continues to grow.’ the necessary funding,’ says Dr Brennan. ‘I can see it being five or 10 years until we get an MDT.’

This has an effect on recruitment, she adds. ‘If you were a young GP who wanted to stay in Northern Ireland – which is a diminishing pool – would you want to work in an urban area with a full MDT or would you work in an area without an MDT? If you were smart and savvy you would work where you have as much of the supported primary care team adjacent. It does impact on recruitment – and colleagues who have an MDT say it’s been a game changer.’ but this hasn’t been possible, so instead it was due to be passed over to the South Eastern Health and Social Care Trust.

As with practices across the UK, Mount Oriel has moved to a system where consultations are initially conducted by telephone, with patients being called in to see a member of the team if required. By 9am, Dr Brennan’s morning surgery is already full and the afternoon ‘emergency’ slots are also filling up.

‘We’ve had 11 list hand-backs since April,’ says Dr Brennan, a GP partner and chair of Eastern local medical committee. ‘And so many other practices are one [GP] resignation away from disaster.’

When one practice hands back its contract, it can be a bit like a set of dominos. If the health

Lack of political leadership is adding to the pressure too. The latest collapse of devolution in Northern Ireland means there is no health minister to make vitally needed decisions, and measures that could help – such as a rollout of general practicebased multidisciplinary teams – have stalled.

‘I think our practice is one of the last on the route map to get an MDT [multidisciplinary team], but to be honest it’s a moot point, because we don’t have a health minister, and the civil servants may not be able to divert

Dr Brennan’s voice is invariably cheery when she calls the patients, and most sound pleased to hear from her – even when the news isn’t good. Several consultations in the morning merit a referral to secondary care, but there’s no prospect of anyone being seen any time soon, unless they are prepared to pay privately.

‘We’ve got the worst waiting times in Europe,’ says Dr Brennan, scrolling down a list showing waits for the Belfast Trust. These are truly shocking. An ‘urgent’ neurology appointment will be 157 weeks – and you can forget about ‘routine’ because it’s twice as long. Patients will also take several years to get a first appointment for orthopaedics, then wait a similar time to get the actual procedure. It’s a similar picture across the board.

By Jennifer Trueland