GPs on the frontline: relentless demand, missing drugs and gaps in specialist services
It’s 11.30am and there is a hushed atmosphere at Hawkhill Medical Centre in Dundee.
The morning is busy, as usual, but in that distinctive way of a GP surgery – not frenetic like A&E, but tense, like a library at exam time.
The large waiting area, in common with GP practices everywhere, is comfortable and self-consciously homely, like a chintzy airport lounge.
Seven patients are dotted around, avoiding eye contact, and a taut silence pervades everything.
Behind one of several identical wooden doors, GP partner Dr Andrew Cowie has been grafting for three and a half hours already.
Prescriptions, hospital letters, blood and colonoscopy results, you name it – each GP at Hawkhill must try and get through between 40 and 100 separate items before surgery starts every single day.
“Sometimes you can get through 40 in an hour – you slam on your Spotify, you focus and get it done – but sometimes it can poleaxe you,” he says.
“On top of that, he must make a list of phone calls, to review patients and sometimes to triage those who haven’t been able to secure an appointment that day.
Then as if that wasn’t enough, there are the endless “annoying emails”.
One of the recurrent ones is about suppliers running out of drugs, something that happens due to their habit of only holding small amounts of any one product in order to keep costs down.
This happens “all the time”.
“It’s really bad at the moment,” he protests.
Cowie, joint deputy chair of the BMA’s Scottish GP committee, is clearly an energetic, good-humoured person but drug shortages are an incessant source of exasperation.
“So, this morning, I was talking about a drug for your stomach which has been around since the 50s.
“Suddenly it’s not there. What do I do? Do I change all my patients over to a more powerful drug? Do I tell them to swig Gaviscon and hope for the best for a few days?”
Sometimes he isn’t even given an idea of when a missing drug will become available.
“Some of the hormone replacement therapies have been out of stock for months. And it’s really frustrating, because sometimes you’ve spent ages finding something that suits the patient and suddenly you can’t get hold of it.”
There are even worse emails than that, though.
“Next you’ll get an email saying, ‘we have closed this ward’. What are you supposed to do about that? Or they’ll say, ‘we are no longer offering this service’.
“So, in Dundee, no psychiatrists. No psychiatrists covering this practice.” He spreads his hands, looking incredulous.
“There are none. None at all. We’ve had locums in and out every so often but at the moment, we haven’t even got a locum. What do you do? Just admit them to hospital?
“Again, endoscopy. They haven’t done any endoscopies [tubes passed down the gullet], except emergency ones, for the last four or five months.”
High-risk patients will get an endoscopy, he adds, but the problem lies with people who are low to moderate risk.
“What happens is that you get patients who are low risk, can’t get the investigations they need to make sure they’re OK and they turn into emergencies.”
The problems with mental health services in Tayside are well known and the subject of a recent investigation by David Strang but the experience of Cowie and his patients underlines how serious they are.
This is a practice with a high proportion of students, being close to two universities, and it is not unusual for Cowie to spend two-thirds of his time on mental health problems.
He recently had a young patient with a suspected schizophrenic-type illness.
The patient should have been referred urgently to psychiatry for assessment, but in the absence of a psychiatrist, Cowie’s choices were to do nothing or admit the patient to hospital.
Unhappy with those options, the only alternative is to try and manage the patient himself by seeing them at the surgery every day to make sure they’re OK, “until somebody [a psychiatrist] turns up”.
GP appointments are already in short supply so this approach exacerbates that problem.
“We are not helping them, we are spending doctor time just monitoring them, so it’s inefficient.”
What becomes clear within a very short time of talking to Cowie is that inefficiency is a chronic problem.
With NHS resources stretched, efficiency becomes more important, but the system can only work efficiently if it is properly resourced, creating a vicious circle from which no one has yet found a way out.
It works like this: GP surgeries are usually patients’ entry point to the NHS and GPs’ basic job is triage.
But for that system to work properly, there need to be, firstly, enough GPs so that all patients who need one can get a timely appointment, and secondly, the right referral pathways available so that doctors can send patients on to the right person elsewhere in the NHS, either for further tests or for treatment.
That’s how it should work. But if there aren’t enough GPs and the referral pathways have broken down, as in psychiatry, the whole system suffers, becoming more inefficient.
If there are too many patients to see in one day, GPs must triage them by phone to make sure they are not in need of immediate attention.
The phone consultation is then often followed up the next day with a face-to-face appointment, meaning the patient is dealt with not once but twice.
As a result, there are fewer appointments available the day after that – and so on.
“If we’ve got 65 appointments free at the start of the day, we’re probably going to be OK; if we have less than 50, we’re probably going to have a disastrous day,” declares Dr Cowie.
“When you haven’t got enough capacity, you start to spend more time trying to put off the capacity; it becomes less efficient.
“Hospitals can deal with this by having waiting lists. They can just say, ‘we can safely see this number of patients and everyone else will have to wait’.
“We really can’t.”
Meanwhile, GPs are trying to do their core job of managing risk.
“You’re always anxious,” says Dr Cowie. “As I always say to medical students, we rarely diagnose.
“Our job is risk management. When we see a patient, it’s pretty rare that I send them out and I know they haven’t got something serious.
“What I can say is, one, you’re high risk – I need to send you up to hospital right now; two, you’re fairly high risk, I probably need an urgent outpatient appointment; three, you’re medium risk, you can probably wait for a routine investigation; or four, you’re low risk, which means I can probably keep an eye on you and see if you change.
“None of them are ‘zero risk’.”
If the system is working, and low or moderate risk patients can be referred on swiftly, then the GP can achieve the best possible outcome for the patient.
But if the system isn’t working, it’s a different story. Cowie gives the example of a patient with a 10 per cent chance of cancer who has to wait more than a month for a scan and spends weeks feeling stressed and anxious; or a patient with a hernia whose pain could be relieved with an operation but must wait eight months for it and in the meantime, visits the GP every two weeks.
With GP time at a premium, triaging can force doctors to make unenviable choices. “Should you see the mental health emergency or should you see the person with stable angina who can wait till tomorrow?
“Problem is, he can always wait until tomorrow because he has nothing acute – until he does.”
What he will not do is start pointing the finger of blame for all this – he’s been inside the system for too long and knows that system breakdown happens by stealth.
When staff at all levels are prioritising urgent and high-risk cases, they are not wrong to do so, but while that might keep the show on the road, the edifice is slowly crumbling behind the scenes.
“It’s like failing to maintain a new car,” he explains.
“It’s not like every day driving your car without an MOT is a disaster, it’s just that every day you’re more likely to get a problem and finally, you get a catastrophic breakdown.
“But you can’t say specifically you made a bad decision at some point.
“The problem with the NHS is that everyone is firefighting and everything you can put off till tomorrow you put off till tomorrow, which means none of the routine stuff gets done, so you get more breakdowns.”
Cowie, who was on the board of NHS Tayside for six years, says he can come up with no simple solutions, but when pressed, says that there needs to be more stress on medium to long-term issues (workforce planning, for instance), while recognising that depends on having the budget and available staff.
He is understanding towards much-maligned NHS Tayside.
“The vast majority of the people I have worked with there have really been trying their best, managers and executives included, but they are constantly confronted with these impossible problems and there is no easy answer.”
GP practice has acquired a reputation for being a tough specialism, fuelled by headlines about working hours and doctor stress, but Cowie insists that, alongside the problems, the job is deeply rewarding.
His consulting room has plain white walls and a wooden desk – regulation furniture in a regulation environment – but it has seen more drama than the set of EastEnders.
This is the place where young students wrestling with anxiety and depression open up, sometimes for the first time; it’s where patients he has known since childhood come in to see him, trailing children of their own; it’s where he offers support to the bereaved.
It’s where, occasionally, he makes “wickedly cool diagnoses”.
Thank you cards totter along the edge of a shelf in front of a stack of medical journals.
There are seven GP partners at the practice, three practice nurses, and a psychologist.
It is not a practice that has GP recruitment problems, but the pressure and frustrations of the system are always there.
The practice has instigated a compulsory coffee break where GPs can “decompress and vent”.
“It makes a big difference, even just 10 minutes just saying, ‘Hi, how was your morning?’ ‘Awful, how was yours?’ ‘Awful.’
“It can be very solitary otherwise.”
The practice is currently plastered with advice posters about coronavirus.
It has students from Wuhan in China among its patients because of a partnership deal between Wuhan and Duncan of Jordanstone College of Art and Design, but so far, there is no sign of coronavirus.
GPs and other primary care professionals are in the forefront of a slowly unfolding revolution in the way healthcare is delivered in Scotland.
With an ageing population putting pressure on the NHS, there is a drive to keep people out of hospital and care for them in the community, in order to improve outcomes for patients and relieve pressure on hospitals.
The new GP contract is part of that, with stage one due to be in place by April 2021.
It places an emphasis on the setting up of multidisciplinary teams on primary care settings, to free up time for GPs to spend with patients.
“It’s not really a GP contract – it’s specifically an everybody else contract,” says Cowie.
“I think it’s a good idea. It’s patchy at the moment and it’s always really difficult to tell, are they doing enough to make it happen by April 2021?”
Audit Scotland said in October that it would be “difficult” to increase the multidisciplinary workforce by 2021-22.
If it works well, however, the biggest benefit for GPs will be the expansion of pharmacy and prescribing, which will reduce GP workload by 10 per cent.
Alongside a Scottish Government commitment to recruit 800 more GPs by 2027, this should make a difference to recruitment and retention of GPs.
Being a GP can be “absolutely brilliant”, says Cowie, and the planned reforms should make working life better.
For now, however, that coffee break is crucial.