GP’s – WHAT ON EARTH DO THEY DO ALL DAY?
|I wanted to try to explain why the changes made in 1997 and later by successive governments have made life as a GP so much more difficult and have now led to a recruitment and retention crisis in General Practice.
The changes have produced a very unhealthy work/life balance and an increasingly poor quality of life for GP’s. The result has been a rush to leave general practice just as soon as personal circumstances allow. This is very sad as the job and the personal satisfaction from life as a GP used to be wonderful.
I love my clinical work with the patients, but the pressures now are such that I feel I am simply fire-fighting in an attempt to keep my head above water. This is unsafe for patients and leads to a continuous ongoing anxiety that I may have missed a crucial diagnosis or made a mistake simply because I have not had adequate time to focus. There is barely time for a comfort break let alone to reflect on clinical problems.
The changes were introduced in 1997 in response to an ongoing crisis in recruitment and retention because of the quality of life issues for GP’s arising from 24/7 responsibility for patients.
The government agreed to vary the terms of practice in relation to 24/7 responsibility. In addition our income increased a little (not a lot as has usually been reported). The result was a short-lived improvement in our work/life balance and the recruitment of new doctors.
However things deteriorated again after the government’s introduction of 48hr access to your GP for any and every condition, however trivial. It seemed a sensible move at the time, but sadly seems to have produced a situation where some people are unable to deal with their own minor health problems without seeing the GP.
The result is vastly increased demand in relation to sometimes very trivial conditions. This hinders access and the time available for really sick and elderly patients with multiple problems.
In recent years, a lot of patient care has been shifted from secondary hospital care to Primary Care, resulting in increased workload
As the population lives longer, multiple medical problems and increased incidence of chronic diseases, increases the need for patients to be seen.
Apparently, NHS England have decided that any patient who is unable to attend their hospital appointment if they are on holiday will now be directed to see their GP to make a new appointment for them.
Things are made worse by what appears to be a concerted campaign by government and the media to change the perception of GP’s so they are now often seen as lazy, workshy and uncaring about their patients.
This is so far from the truth – and so I set out below a typical day and ask you to consider whether you agree that I am lazy workshy and uncaring:
8am to 8.30am
I have a quick look at incoming pathology result reports -usually about 30-40 reports
Some are normal and just need filing but others show abnormalities that require accessing the patient record to see why they were requested, analysis and action.
8.30am to ??
I start seeing patients at 8.30am.
Twice a week, this is a walk-in service for all problems. This involves 2 doctors who will see between 40 and 80 patients in the following 4hrs or so. Many are minor problems that can be quickly dealt with but the work may also include:
Depressed, distressed, tearful patients
Patients presenting with symptoms quite likely to be cancer
Elderly patients with multiple pathologies
Interruptions with urgent phone calls
Nurses with problems or prescriptions to be signed
The registrar (trainee GP) or student requiring advice and assistance with a patient he or she is seeing.
Some consultations will require the making of appointments for patients using the ‘choose and book’ system. This looks quite efficient to the patient watching but many seconds are spent waiting for the computer to load external websites and choices and multiple computer clicks to make sure all relevant actions are taken to finalise the process and make sure referral letters are dictated and typed.
During each consultation, we are reminded on screen about various reviews required for long term illnesses etc, and these have to take place during the consultation.
1pm to 2pm
We make the 10-15 less urgent telephone calls that have accumulated during the morning – sometimes requesting home visits etc.
Throughout the day we also take calls from District Nurses, Health Visitors and hospital colleagues. This is necessary but interrupts concentration and work flow.
I used to manage 30 minutes to eat a sandwich and reflect on patients I had seen. Now I either have no lunch or grab something whilst doing the prescriptions.
2pm to 3pm
Prescriptions – between 50 and 120 of them each day.
Some can be signed electronically, but many will indicate a medication review. This means accessing the medical records, arranging blood tests, blood pressure checks, long term illness reviews and moving forward review dates tailored to each patient.
This process throws up nagging ‘pop ups’ on the screen for each item indicating those medications that could be prescribed in a cheaper form. These require interventions as we are regularly audited on how we perform as regards medication costs.
During the day, a number of ‘Tasks’ will have appeared in our inbox that need dealing with immediately. These sometimes need a phone call to be made; others will be requests for sick certificates, letters requested by patients and other interventions.
3pm to 4pm
Letters to be dealt with – between 30 and 80 per day.
Some just need filing but others need more work:
Discharge summaries require careful reading, entering of data and medication changes in the patient record, taking enormous care not to make any omissions or mistakes.
Frequently, the letters will require recommendations by other clinicians for onward referral or investigation as it is now not possible for consultants to refer to each other. Every referral has to come via the GP.
We sometimes need to carry out urgent visits. I hope you can see why we are sometimes reluctant to do them. This is not through laziness – it’s just very difficult to find the time to do them.
Other work at this time includes:
Reviewing and filing more pathology reports that have arrived electronically during the day since the morning
Dictation of letters for patient referrals
Meetings with staff and colleagues, meetings within the building and sometimes elsewhere to do with management within General Practice and the health service generally.
It is often impossible to complete all these tasks before evening surgery starts at 4pm
4 pm to 7 pm
The evening surgeries are sometimes the most satisfying for both doctor and patient. This is because they are booked appointments, and often with patients well known to the doctor and who have long term complex health problems. However the slots are only for 10 minutes so it is often very difficult to deal with the problems and complete all the review procedures required for monitoring of long term illnesses etc.
The last booked patient is at 6pm, but often they are not seen until 6.30pm or later.
After this we see any ‘extra’ patients who feel their problem needs to be dealt with that evening.
7 pm onwards
More tasks and phone calls to be done that have come in during the afternoon surgery.
I then start a final session of clearing up more pathology results that have either not been dealt with or have come in during the evening. This is important as I know there will be a new batch that will be coming in overnight.
I hope this gives others some idea of how pressured we are as GP’s.