GP appointment restrictions – some background

At certain times we may have to ‘cap’ the number of patients we deal with in a day. Why?

At Willow Tree Family Doctors we have always run a system providing the capacity to deal with the predicted demand which we monitor regularly. Demand for appointments is more on a Monday so we build in more appointments, in flu season we have more appointments and so on. In the past this was known as ‘Advanced Access’ though it sounds pretty basic – a ‘no-brainer’ in fact.

You probably expect everyone does it but actually it is not the traditional way the NHS works. Usually a number of appointments are provided dependant on the number of doctors and nurses available and if the patient demand exceeds it, waiting list are built up. We see this is when a doctor goes on holiday – those appointments are simply lost from the system – a surgical list is cancelled, an outpatient clinic or a GP session. Waiting lists are embedded in NHS culture.

At Willow Tree, we do it differently – partners may alter their rota or do additional sessions to keep the supply of appointments up to meet the demand and give good access to our patients or employed doctors sessions are used to shape the access needs. Providing additional capacity comes at a cost though and we are now struggling.

Locums are often brought in to make up the capacity shortfall but these temporary doctors and nurses cannot do the full job of the person they are replacing. And they are very expensive, often coming though pricey agencies. Their cost has rocketed in line with demand and this demand has further increased the fee these doctors can charge for their services: many locum GPs now demand £120 an hour. Hospitals and GP surgeries can only afford so many and then the waiting lists build up again.

We have spent over £600,000 in the last year on locums to enable us to continue  providing excellent access – every clinical query responded to on the same day. In other words, the partners have been subsiding the NHS from their own pockets.

So, where are all the doctors? GPs joining in the boom years of the 1980s and 90s are now retiring and the pandemic greatly speeded up this process; many are retiring early and GPs are not easily being replaced. In some parts of the country where existing practices cannot attract new blood, the remaining GPs are finding carrying on impossible and are simply handing back their contracts and walking away. From being a very popular option just a few years ago, fewer young doctors now want to become GPs and when we do have applicants, we find they will only commit to a small number of sessions which will not provide good continuity of care.  They look for a ‘portfolio’ career or they choose to become locums when they can name their price, work whatever sessions they want and have none of the responsibility of running a practice or doing any of the administration.

After locums, there are two other main types of GP – a partner and an employed GP. Partners hold the practice contract with the NHS. They may own the building or rent it but in any case are responsible for managing it and providing all the equipment, for employing staff, for adhering to the many contractual requirements (and a GP contract is extremely complex with many different bits, add-ons and KPIs to meet), finances, infection control, information governance, health and safety, safeguarding and so on, all to tight deadlines. We also have strict regulators such as CQC and the General Medical Council breathing down our neck.

The job of a GP partner, is therefore very stressful, especially with the increased patient demand and decreased workforce. They are having to take on more and more work: clinical and administrative. The ageing population and local authority cuts have increased GP workload and the pandemic added additional pressures with continuing after-effects. Bureaucracy has mushroomed and much of the job has become administrative and is now viewed as pen pushing: not what we chose medicine for as a career. Much of this has to be done at weekends and evenings as the day is already overflowing. The support systems are unhelpful – social care is inadequate to support the ageing and often frailer population, many hospital waiting lists seem endless with a large pandemic backlog, so GPs have to do more difficult clinical work, budgets are squeezed mercilessly, financial arrangements are ever more obscure, administrators and good managers are in short supply, NHS support structures become ever thinner as budgets are tightened and IT systems are becoming more and more complex and creaky. The NHS is undergoing constant change, there is increased complexity, fragmentation and loss of autonomy and so planning and running a complex machine like a general practice (in effect a mini hospital but without all the various supporting departments) is increasingly difficult.

We have had massive problems trying to recruit effective team members at all levels- from GPs to managers to reception staff. Our poor practice manager is pretty much on her own since the assistant manager left for a promotion in the NHS a couple of years back and we have failed to replace her. She alone performs the roles of several departments. We are missing a patient operations manager and we cannot easily recruit good reception staff – our pay rates are uncompetitive and limited by the fairly fixed amounts we can earn and the funds we receive through the NHS which do not even meet the pay rises recommended by government. We cannot fund these by simply increasing production, taking on new work, diversifying or improving efficiency in the way other businesses can. Practice nurses have also become scarce and we have had a considerable deficit in that area for a couple of years, again relying on less than satisfactory locums, which has had a knock-on effect on GP workload.

We have lost 5 good partners over the last 3 years to relocation, retirement, emigration and one taking up a lucrative post in health-related IT and a couple more retirements are planned. We have been fortunate to find two new partners but there is still a shortfall placing a considerable burden on the remaining ones who, themselves, cannot work at the past rate of 8 ‘full-time’ sessions -it is simply not sustainable, or safe. We have had a shortage of employed GPs and that is why we have had to fall back on locums.

Political parties have long promised more places at medical school to train more doctors but of course that takes many years to filter through the system. Other solutions proposed are to speed up training – but with scientific knowledge increasing and medicine becoming more complex all the time, is that safe? Similarly, lots of additional clinical staff roles have been created but none have a wide or deep enough knowledge and experience ad are not autonomous and can only do small bits of a GP job. They require a good deal of hands-on training and supervision, and that means GPs taking time away from patient care, compounding the issue. And these new personnel, who are not directly managed by the practices, often move on rapidly.

General practices are small businesses but with many restrictions. We are not really part of the NHS; we contract our services to the NHS. We employ staff and provide the building, equipment and resources. The NHS reimburses rates and rent but most of the rest we provide from the mosaic of NHS income streams. For instance, though our building is rented (it was built to our requirements and leased to us and furnished and equipped by us), we had huge unexpected costs this year as some of the complex environmental climate control and air filtration equipment broke and we had to pay from our own pockets over £70,000 to get it fixed. We have fears for the other parts of the 8 year old system and much more of this sort of thing could bankrupt us.

Against this difficult background most practices limit what they can offer. We all hear about those many practices where you have to start ringing from 8am and are lucky if you get answered before all the appointment slots have been used. You then have to try the next day and on it goes: a most unsatisfactory system. But that is common and what has led to the lurid headlines and general GP bashing in the press. Unfortunately few understand the depth of the problem and the years of underfunding that have fuelled it.

We have always planned different systems to avoid this and the current use of the simple online Patchs system (now available through voice on the telephone for those without keyboard skills or access) allows us to get a quick view of the problem of everyone’s needs that day. We can then prioritise and offer a suitable response. We can therefore deal with everyone’s queries on the day of submission or next day if submitted later in the evening. This is the only way we have been able to meet the demand given the shortage of doctors and nurses. But it has led to an efficient service; better than the old days when everyone had to book their own appointment, often a couple of weeks away and rearrange their schedules to come and wait in the surgery for something that could have been sorted with a brief phone conversation. And we can arrange to see those who need a face to face appointment the same day or at their convenience.

Now we can no longer afford to pay the huge locum costs and so will inevitably have to restrict what we can offer at certain times. When all our capacity has been used up, likely late in the day and hopefully not often, we shall stop accepting new Patchs and ask patients who are unable to wait until the next day to call 111 for advice or redirection to other services. This is what most other practices do, though usually much earlier in the day following the morning rush having filled all the available slots. If doctors become over-whelmed with demand, they can start becoming unsafe, as anyone would and we must guard against unsafe working.

The BMA (British Medical Association) is mounting a campaign to improve GP working lives and some posters are attached here. There is also the Keep Our NHS Public campaign to explain the pressures on general practice, linked below.

We shall monitor the situation daily and adapt as we go along and as patients feed back. We hope with better recruitment that we can go back to our usual model of responsiveness as soon as possible, as we firmly believe patient access should be easy, consistent, transparent yet flexible. But it can only be provided within an appropriate resource envelope – of people, finance and support.