UKC

There is some chat in the news at the moment about how bad it is that there are fewer in person appointments than pre-pandemic. Am I the only one who would choose to use phone or video call over an in-person appointment where possible? I get that some things have to be done in person.

The idea of gathering lots of sick people in a waiting room, waiting for ages because appointments are never on time, to just have a discussion which I could have on the phone seems crazy. I have to take more time to cycle to the surgery, faff with trying to lock up my bike as they don't have bike racks (!), wait for ages and then cycle home. A simple appointment takes about an hour all in, whereas a call can easily be 10 mins. So much simpler.

I see the remote appointments as progress. 

I entirely agree - I feel like 95% of the appointments I have have no requirement to be face to face.  No issue screening with calls then saying "actually - can you come in, I'd like a proper look?"

This is pure political idiocy in my view and will have the opposite effect to practicality. GP waiting times for an initial non urgent appointment dropped significantly in the pandemic (from weeks to a couple of days) with a forced massive increase in use of phone and online video consultations. We should continue with this, freeing up more time for those who need face-to-face consultation, so that the system doesn't break.

You can't buy your way out of a GP shortage (formed under successive tory governments) as there is no one to step in and help.

I’d choose a video or telephone call if they gave you an actual appointment rather than “We’ll call sometime by a week next Wednesday”. 

I would like to see a proper system of being able to log an issue, that being triaged, then speaking on the phone/video (with the notes read first) and then a face to face if needed.  And root cause analysis done on those issues to ensure proactive treatment is offered rather than just reactive.  That is, "ITIL for healthcare".

I don't like just phone calls.  The telephone is a poor option for most things other than a quick follow up on something that is already known.  You can't for instance write a set of notes on a condition and pass them over to the GP easily.

Mine does offer timed appointments by phone.  I would agree that open-ended calls are not appropriate.

I agree I won’t miss the snottery waiting rooms, I’m a firm believer in avoiding doctors and hospitals as much as possible though, dangerous places.

I’ve also got enough of a hearing impairment that the phone is an ordeal for me. I’ve found MS Teams a boon over the last 18 months so I think that would be a good option for a lot of consultations.

The GP system is thoroughly broken, though, between fortress surgeries, 100% part time doctors (= lack of continuity of care)and an apparent loss of diagnostic skills. Not helped by silly stuff lumped onto gp’s - I’ve been trying for 2 weeks to get someone to examine me (healthy, active, 69) to complete a D4 form for my drivers licence renewal so that I can still drive minibuses. I’m sure there are lots of other irrelevances they could do without.

You can pay a private GP to do that form.

I agree with you and would prefer a remote appointment myself in the majority of cases. However I think patient choice about this is important. We are just about to book an appointment for our newborn's 6-week GP inspection/checkup. The Dr at the women's hospital where he was born warned us that some local GPs have been trying to pressure people into doing these remotely (and explained we must steadfastly refuse), which is ridiculous.

Like all things, the reality is more complex than what we concoct in our heads - but the push to remote appointments leaves me worried serious conditions are going to be missed.  Even with an in person appointment a GP quite happily waved away stage four cancer in my mum's lung lining as a pulled muscle.  It doesn't seem a stretch to see another layer of triage as yet another step away from GPs having the time and resources to provide quality care.  It may be a necessity given the labor market or economy but I don't have to like it. 

That said, remote appointments booked online would have been a great mercy for my mentally ill younger self, providing a more approachable route to accessing help.  Done well and applied with precision, I think it could offer a lot to patients, but I think the reality will be rather different sadly.

To be fair stuff gets missed in person as well.  It seems my DVT was a number of times...

Starmer was on the news just now, rightly calling out the problems in this new strategy, but in saying the government didn't deliver the extra GPs it promised (we have had a continued decline), it would have been useful to defend the current practical measures to keep things 'ticking-over', despite the GP shortages.

Some here saying the system is broken are in my view dishonest unless they acknowledge the main problems lie in underfunding and in the GP staffing shortage.  PCTs overall seem to me to have done incredibly well in the pandemic, especially in the context of the pre-crisis pressures, and the critics need to explain how we get to a better system for the same cost and staff numbers. It's still true PCTs have failed too many patients and there are many practical changes that could improve things (the irony is that one of those is video conferencing). I'd in theory prefer most primary care to be employed directly by the NHS, alongside better funding and greater training incentives for shortage areas (especially GPs). I recognise getting there would be a massive and slow political task and possibly even impossible in modern UK politics.

It depends. My last two GP surgeries have always offered phone appointments as a choice - and for most things (such as "my physio says I need an MRI - can you book one for me?" or "I want to change my hayfever medication") a phone appointment works well. But sometimes the option for a face to face appointment is good, and a GP might pick up something face to face that they might not on the phone - cancer seems to be the common thread here.

My wife was recently told by her GP (on the phone) that she should book a face to face appointment in two weeks' time - on trying to book this she was told by the receptionist that she had to have a phone call first. She went round in circles for the next two weeks trying to explain to the receptionists that she had already had several phone appointments, and had been told to book a face to face one. I've got some sympathy for the government on this.

Some efficiency could be done by having those who are fairly sure a video call would be sufficient ringing a regional number, only those who need continuity with their doctor actually calling their local surgery. 

Real progress would be Choice   Half the docs in the surgery on any given day doing face to face, the other half of them doing remotes -- and being asked which queue you want to join

My local surgery has been doing same day triage phone calls with a doctor for years. Sometimes that's all you need, and it's a real time saver.

A real benefit would be an open calendar, with 10 min slots, one could book online. With the choice of skype/teams, or phone for remote and in person for non urgent.

The current system is phone up at 08:00 on one of the two phone lines available. Then keep ringing back every 30s until 09:00, only to be told no appointments that day and to try again tomorrow. Phone queuing technology is not new, or anything. A simple you are at place X in the queue, would go a long way. I expect the GP's are saying 'we have 50 walk in slots per day, and they are all taken, so the system works.' What they dont see is the 200 people on the line, that never get to to an appointment. (The lack of a telephone queue platform means they dont have these stats available.)

What I think may be happening is that the tories are deliberately running the health service down, so that people go private. Then they will get some of their US healthcare friends to take over some parts of the NHS. People will initially welcome this as they will be promised a better service.

Still, anything is better than talking the the receptionist. Who needs doctors, when the lady at the desk can triage you issues and grant you a an appointment in 3 weeks, If she thinks your issue is important.

This assumes that the patient is being sensible and knows what they need rather than just wanting something random.

A friend who's a GP says he gets all sorts of crap sent through to him since the practice started to embrace online triage etc. giving each of these people a physical appointment would be a massive waste of time.

I've had a few minorish issues recently which have required numerous conversations with my doctor, all have been sorted quickly and efficiently over the phone. It's worked out very well for me.

My preference would be a face to face appointment. Once I'm sat in that waiting room it's far harder for the surgery to ignore or forget me. Have tried phone appointment at my surgery (booked online) but all you get is someone will phone in next 48 hours so then wait around hoping they don't call at some point when I can't answer. Turns out they didn't call at all, so had to then wait over the weekend to call them on Monday to then wait again for them to call me back. But my gp surgery is useless anyway, I've been on hold for over 3 hours just to get through to them on the phone recently.

I suspect a lot of things will be getting missed on phone consultations that face to face would pick up. In fact I know though experience they are, and with horrific consequences.

The whole problem is a demand one. We know that too many people will, given a choice, choose something that demand can't meet, most that could be dealt with safety and more efficiently from their home. A demand crisis that's been hidden by emergency pandemic changes, which made a really positive difference to reducing demand. Unnecessary physical appointments will overwhelm services in many areas and will needlessly increase covid risks. Still, in those mainly older people getting annoyed having to wait to physically see a doctor for no good reason, the government see a political opportunity. It will backfire on the patients because the certain increased demand for face-to -face as a preference will just lead to queues and less focus for the patients who do need to be there. GP's can't use money for employing extra GP locum staff that just don't exist.

Throughout the pandemic we've been encouraging covid vulnerable old friends to stop going in person to the GP surgery to get repeat prescriptions (setting up to do it automatically and phoning the pharmacy instead) and it's like pulling teeth. Too many old people just don't like change.

As this govenment initiative simply can't work in most places, the question is: what happens next? This thread links to some posts on the friday night covid thread where people reasonably ask are the government setting up parts of the NHS to fail?

I would suggest most GP Drs would vigoursly oppose that. It’s a nice money earner owning a surgery and getting the NHS to pay for it amongst other things.  

Technology means that online appointments are part of the way forward.

I like Hunts idea of stripping away workforce planning to an equivalent of OBR. Good idea. 

Are you sure the financial situation is so rosy?

GP practices are apparently not limited companies and could if they fail bankrupt the partners. Many GP practices in Wales are handing back their NHS contracts, this doesn't sound like they are a guaranteed money maker.

That is always a risk with partnerships, but lets be real the chances of a GP practice going bust are pretty slim compared with other businesses.

I think it depends on the surgery.

My Dad spent three days trying to phone them before I had to go down an see them in person to get him an appointment.

Then when they did call him he couldn't hear them over the phone before being cut off.

I would be quite happy for a telephone appointment for things that didn't need to be seen if it worked more efficiently

Does imply their financial situation is rosy.

We should be giving GPS a thumbs up and letting them use a mix of technology, triage and face to face as they see fit.  The current Tory attack is clearly deflection politics.

I wouldn’t want to be a GP; phone or in face, five minutes to comprehend the communicated symptoms, rule out possibilities, verify your diagnosis and then determine treatment / further investigation.  Then next patient….still on the ball sharp and alert trying to do your best all day long.  Quick fire and high stakes for some patients, knowing that you won’t always get it right with ramifications. For the patient and potentially you.

Handing back the contract means that the GP practice is unviable. The partners are then personally liable for the redundancies of all employed staff and outstanding liabilities if no-one is found to take over the practice. This can involve being made bankrupt and losing your house.

Sorry.  Didn't realise it meant they were closing down.

If the patient is articulate, intelligent and reasonably tech savvy it can work OK. If the patient is elderly, vulnerable, very young, inarticulate or just a bit thick, being unable to arrange a face to face can be disastrous. It can even be disastrous for the intelligent and articulate given the right (wrong) circumstances.... you can't do an abdominal exam over the phone for instance, and a ruptured appendix is no laughing matter, as recently highlighted on UKC.

The best GP practices used the pandemic as a spur to up their game, but the worst used it as an excuse to shirk their responsibilities. One practice in our area now seems to be dividing their patients into three categories, as assessed and triaged by the receptionist: 1- Minor, who are told to ring 111. 2- Middling, who are granted telephone contact with the hallowed GP. 3- Major, who are told to ring 999. I don't know what percentage fall into the middling category but it can't be very high given the nature of the crap they toss over to the ambulance service.

Here's an example of the patients this practice deem unworthy of a GP's time:

4 month old first born with nice professional parents, baby's got a temp and hasn't been taking the bottle very well for the past 24 hours. Parents ring their GP. Receptionist says "yeah, you'd better ring 111". 111 won't risk assessing a 4 month old over the phone so pass it to 999 for a face to face. Ambulance rocks up and assess baby as having a bit of a temp but otherwise looking good and all she needs is a two quid bottle of Calpol and close monitoring for the next 24 hours. But here's the rub, call an ambulance for an under 5 and it's our service policy that they have to go into A&E. Mum and baby are now being exposed to loads of infectious sick people down at the packed local hospital and what could have been sorted out with a 10 minute GP consult and a £2 bottle of Calpol has now cost the NHS upwards of £500 as well as hours of clinical time with multiple telephone triage, one paramedic, one emergency medical technician, one paediatric nurse and an A&E doctor. This is at a time when the ambulance service is so over stretched we've got squaddies and students, without blue light training, driving some of the trucks.

At the height of early days covid, the very worst practices shrugged off all responsibility for any respiratory complaints and just called the ambulance service in to do their assessments for them. As one colleague commented "they seem to regard ambulance crews as covid meat shields".

A&Es are now over run and we're still two months off actual Winter flu season, unfortunately a big part of the reason they're over run is that many patients are unable to access primary care any other way.

Does it? If they were raking it in off their NHS contracs would they be giving them up?

I guess they can always locum to get hold of the extra cash the gov is talking about injecting but that doesn't create any more GPs it just means that there are fewer practices overall.

I think phone or video appointments can work really well if they are done well, at present it appears they are actually done badly in many places.

Unfortunately, I suspect what may happen is that people will lose the opportunity for the "whilst I'm here" question (often the actual reason they made the appointment) that is often slipped in at the end of a consultation about something else seemingly trivial.

Also, as has been said upthread, it relies on people being savvy enough to understand and engage with the system and it's a sad fact that not everybody is.

It can but it’s unlikely I doubt they are that daft. .My gps practise is a ltd  company not a partnership   Provides excellent face to face and online. It’s well run. 

I am guessing here , but I reckon from your professional knowledge you know the good ones and questionable one in your area. Do you think that info should be used to get the poor performing ones to up their game?

I've been to see my doctor twice in the last 3 weeks. She rocks up at 9am so if you're there about 8:45 you're usually first or second in the queue.
I was lucky two weeks ago as I was first in the queue and in and out in less than 15 minutes but I was unlucky last week as I was third and the two old dears in front of me were in with the doc for 20 minutes each so I had to wait over 40 minutes.

My daughter went on Monday with a chesty cough. There were 5 infront of her and it looked like it was going to be well over an hour wait. No probs though because they do appointment only in the afternoons so we spoke to the receptionist and booked a slot at 16:30 that same afternoon.

Can't complain.

E

There is the counter argument that older people need to cope with slight modifications to services, it's 2021 they can't expect services to pretend it's 1971. But, services should change slowly, be well publicised and in a logical manner otherwise no one will have a clue.

Setting up to fail: uk services have been under funded for decades, of course they'll fail. Under any government, in any decade, uk health services have been one of the lowest funded per capita in europe. So yes they'll struggle, occasionally fail, but people are getting what they pay for. 

General medicine is very much a holistic approach type of practice.

An experienced GP can probably intuit quite a lot about your physical and mental health just by looking at you in the first minute they see you in person. The way you walk, talk, move, body language… even how you smell. 
A lot of that is lost when everything is done on the phone.

Developing a relationship with the patient is also important and that’s more difficult to do when they are just a voice on the phone.

Is there nothing you don't know anything about, Rom? You're my hero 🤣🤣🤣

Which is vital for an unknown condition, but if somebody just needs a repeat prescription of some eczema cream, do they really even need to go in, a nurse should be able to do that over the phone, and you collect it at any pharmacy in the county. 

Can't believe I didn't spot it was Rom! 

Difficult one and a lot hinges on the metrics you'll be using to judge what's "poor performing". A GP practice servicing a deprived area could well appear to be performing badly when the reality is that the metrics are just reflecting patient demographics.

 I am a fan of patients voting with their feet. After a final straw type event, our whole family switched practice (choice of two in the village) and it was a very quick and straight forward process.. 

I was under the impression that I was stating the bleeding obvious. If you think that makes me look knowledgeable that’s incredibly kind of you.

Absolutely. I doubt many people are going in person to a GP for this kind of stuff in the first place though. In most cases they won’t let you.

While ltd companies can hold GP contracts, it's pretty unusual and I don't know of any in the region. 

The bankruptcy scenario does happen but it's fortunately uncommon. What has happened to the local practices that have failed and handed back contracts is that the health board facilitates a merger with a larger group practice or they take them over directly and the employees are transferred across. I think they're aware that there'd be a domino effect of closures if they didn't do something.

Primary care is caught between a rock and a hard place.

We already do 300m GP appointments a year for a population of c.70m?

I haven’t been to a GP in 8 years, who’s using them multiple times a year. The elderly and pregnant women….

The issue with video appointments is that the biggest burden on primary care are the least able/ willing to have remote appointments (the elderly).

My solution: more pharmacy prescribing and a European style consultation fee (£10?).

But on a different topic, if you’re elderly and you’re visiting your GP 8+ times a year isn’t their a better healthcare solution that could be put in place?

Definitely.  My surgery now offers a choice (booked online) between in person appointments with GP, phone appointment with GP and phone appointment with Nurse Practitioner - far superior in my opinion as I was able to arrange a timed phone call for a physio referral that took about 5 mins rather than sitting for 30mins in a waiting room, 10 mins of appointment by the time they'd logged into my notes etc plus cycle time to/from surgery.  Freed up loads of time imo for folk that genuinely need a face to face appointment.  I can see the downsides in some cases - friends who are GPs have pointed out the value in assessing someone face to face in picking up other issues, or spotting if the claimed reason for attendance isn't really the reason - esp for mental health issues.  Still, means you can get a phone call with a doctor or nurse practitioner within a few days rather than a few weeks as it was prior to COVID.

Cheers,

Stu

We can try to optimise appointments for sure but at the end of the day you can’t get blood out of a stone, increasing the number of physician per capita to bring it in line with rest of Europe is the only solution.

I feel that the UK health system is too NHS oriented, there are plenty of people who would prefer to use private GPs, but the sector is actually not so well developed, and it’s often an administrative pain in the ass to mix private care with NHS care.

The problem is that the NHS is quasi a religion so as soon as you start talking about private healthcare everybody jumps at your throat.

Don't be silly, the majority of NHS  GP practices are independent private businesses and a!ways have been. There are also plenty of private (non NHS) practitioners covering primary care work, usually through insurance, in the UK. This isn't a public/private problem, nor some kind of NHS cult.

https://www.bupa.co.uk/health/payg/gp-services

The fact that they are run as independent businesses is not relevant to my point though.

Plenty ? What’s the % of people who are using Bupa or other private provider as their first point of contact care ?
I suspect the percentage is very small. So many people get bupa from their employer but end up using nhs anyway.

It’s been 3years since I’ve needed to see a doctor. 

 I had a video call to a local GP using the Livi app to book the appointment and it was excellent for a basic consultation. The prescription was sent to my phone , all easy.

Agree. I also think a lot of people are GP botherers...perhaps at least in part our GPs don't have adequate referral services for mental health. In the same way people phone ambulances for things that don't need ambulances.

GPs ARE doing 75% of the face to face appointments they were doing pre-covid, overall seeing 10% more people (July19 v July21) when you add in the on-line/phone appointments according to figures on the bbc today:

That's at least in part because a lot of PHI has a sizeable(ish) excess payable by the employee

Maybe. I doubt that is the main factor but in any case result is the same, the vast majority of people get their care through the budget constrained NHS, even though a good chunk of the population could very well afford private care

Bit puzzled by this.  "They have to go..." - what happens if the patient (or in this case parents) refuse to go?

And you know this how?  Has there been any studies of this?  Do you have any personal credible insight into this (are you an experienced GP yourself)? Must admit I'd be a bit unhappy to be assessed in this way for something as important as my health.

A few decades of experience as a human being.

And the simple observation that GPs take a holistic approach instead of just cross checking lists of symptoms like an algorithm, and pick up information on softer cues on top on what they’re patient tells them.

It stands to reason that someone who’s area of expertise is the human body will, generally speaking, do a better job of making a holistic assessment of your health if they have physical access to your body than if they don’t.

That’s pretty irrational why wouldn’t you want your GP to make use of all  the information available - including softer cues detectable only in person - to make their diagnosis ?

Every right to refuse treatment (assuming capacity) but nice professional couples, who're first time parents and worried about their baby, never, ever decline.

I have a bit of a cynical view , partnerships have certain tax advantages considering the risk of bankrupcy is low .

Good point on moving. 

personnally I have found the on line appointments to be excellent.  I had a bit of a scare last year with possible lung cancer. .the process done all online was excellent and efficient. X-rays appointments etc all done very smoothly  

I do recognise that not all patients are tech savvy and feel uncomfortable with the process. But in a few years time that will all have changed as the mobile phone generation get older …..

My barrier to accessing GP services and that of some others I know is the array of obtuse booking systems that seem to involve everyone piling on a phone at set times and seeing whose lucky today, and then the assumption that you will be free at the time of the GPs convenience - this isn't critical care, and people have real world requirements from their employment or caring duties etc.  

I'm less concerned about the format of my meeting than the ability to access it in a sane way. I've yet to have a phone appointment that hasn't led to us going in to the GPs in person, but I understand that not all users of the service as so good at pre-filtering their requirements, and I can see the benefit to the GPs (if not the direct benefits to all patients) of doing this.

We have a GP surgery in location X, a child in daycare/school in location Y and a job in location Z, the process goes like this for us....

1. Am I lucky at 08:00 in the phone pile on?  (Assuming I'm not already in to a fully booked schedule of activities by that time, so that would typically rule out 2 days/week in term time...)
   1. No - wait a day and return to step 1
   2. Yes - get an hour long slot where the GP will give me a phone consult - no control over that time
2. Clear my diary in that hour long time slot with professional consequences (begging a colleague to cover some teaching duty for example)
3. Talk to the GP, who then gives me a time slot later in the same day to bring the child in.
4. Clear my diary for the travel times and appointment times with the same consequences

In practice what we end up doing is going to a quiet, local out of hours clinic on an evening where we're in and out within half an hour.   I can see why other people go for A&E (as inappropriate as that is) over deal with some of the Terry Gillingham inspired booking systems out there.

The idea of a non-urgent, online+phone booking system with appointments on future days to allow a modicum of planning doesn't seem unachievable from a technical view point.

Changing topics:  An illustration of remote "tele-dagnostics".  You can decide if they work or if it's easy to jump to totally the wrong conclusion in the absence of face-to-face contact.

ETPhoneHome:

Brand new poster jumping straight in to health and Brexit topcis?  ✓

Calls to common sense in lieu of  actual, rational arguments? ✓

Most posts edited, often within a minute of being made? ✓

Beep Beep [Diagnosis Confirmed] 

You generally need a doctors referral to get to see a BUPA doctor.

BUPA are very good at taking the payment from the employer. Being a business, they want to maximise profit and offset costs. It is in their business model, to take the money and try and avoid doing anything that would cost them. An example is with an existing sports injury. In some cases they will refuse to treat an injury that has been treated by other doctors.

Annual check up, is not included and something you pay extra for on many plans. One might think that a preventative check up would catch issues early, so saving money. The costs of millions(?) of check ups, would be high. It would encourage people to use their service more and so eat into their profit. Much more cost effective for the NHS to do the check ups, and to treat anything found. Only a small percentage of affected people might then opt for BUPA treatment.

This is what, I think, the US health care companies are salivating over. Free money, little work, big profit. And if your private op goes wrong, you get put in an ambulance and bundled off to NHS A&E at no cost to them.

Is he back again on Monday? Oh my heart stands still
Da doo rom-rom-rom, Da doo rom-rom
Somebody tell me that his name will spill
Da doo rom-rom-rom, Da doo rom-rom

Yeah, my heart stood still
Yes, his name will spill
So, from the talk he's home
Da doo rom-rom-rom, Da doo rom-rom

I knew what he was doing when he caught my eye
Da doo rom-rom-rom, Da doo rom-rom
He tried to keep it quiet but my oh my
Da doo rom-rom-rom, Da doo rom-rom
Yeah, he caught my eye
Yes, oh my, oh my
So from the talk he's home
Da doo rom-rom-rom, Da doo rom-rom

He posted here at seven and it looked so fine
Da doo rom-rom-rom, Da doo rom-rom
The indications are that we've seen his sign
Da doo rom-rom-rom, Da doo rom-rom
Yeah, it looked so fine,
Yes, we've seen his sign
So from the talk he's home
Da doo rom-rom-rom, Da doo rom-rom

Yeah-yeah-yeah-yeah...
Da-doo-rom-rom
Da-doo-rom-rom...

It's a really difficult one this.  I could talk a lot on it, but I don't want to.  I do think that mothers in particular and their newborns can get a very negative and counter-productive experience when subject to the interaction of a disjointed set of systems; you gave one example; I have another.  

It's easy to imagine how the additional disjointing between different systems from Covid could escalate to the point of consuming significantly more resources for no gain.

it’s difficult with infants. You may have a low level of clinical concern but the kid can’t tell you how they feel and observations wise, children have a terrifying habit of maintaining, maintaining, maintaining and then suddenly dropping off a cliff.….and then there’s the media aspect. Sick kids make headlines.

In reply

I've been waiting for Roy Lilley's take on this latest foolishness, especially as he is a consistent critic of much of the bad aspects of primary care. He didn't disappoint:

"A failure of leadership...

_____________

According to the front page of yesterday’s Daily Mail, Amanda Pritchard has paid tribute to the newspaper for highlighting the ‘devastating decline in the number of people able to see their GP in person’.

If this is true, it is my view that she should pack her things into a cardboard box and do a slow walk down Whitehall.

If this is not true, she should take a wrecking ball to NHSE comm’s, for allowing this whole campaign to get out of hand.

By the way, Amanda Pritchard is the boss of NHS England… you may not know that.

Let’s look at some factoids.

The NHS Long-Term Plan calls for a ‘digital-first NHS’.

Before Covid the video-consultation pioneers, Babylon, launched and within three months had switched 80,000 patients from their original GP practice, to another, offering their service.

Pandemonium followed. Other companies entered the market. GPs were pushed into offering these services and the reimbursement mechanisms were modified to make the money work.

A huge slug of people, commuters, youngsters, worried-well and ‘up to my eyes in work’, loved the idea.

Along comes Covid.

GPs are told to close their practices to prevent the spread of Covid and were given a telephone system, called Livi, to enable remote consultations. As far as I can see Livi was ‘procured', mysteriously, under the Covid regulations without the usual open-tendering.

Social distancing regulations made it very difficult for smaller practices to operate and has been an impediment for them getting back to biz-as-usual.

As we moved away from the Covid crescendo, a bow-wave of patients, held back through Covid, hit primary care. Somehow or other the Daily Mail decided the problem was; GPs are not doing enough face-2-face consultations. 

They pointed to misdiagnoses on the phone, ignoring the fact that there are misdiagnoses face to face. It happens. They're doctors, not god.

In August, GPs did 25m consults, of which 14m were face2face, 9.2m were ‘tele-med’, the rest were house-calls and allied-professionals. By the way, they also managed 1.5m vaccinations.

The £250m offered by No19 (and claimed by the newspaper as a trophy) to beef-up primary care and get more people into the surgery, is not new money. It comes from existing budgets, is the usual injection of funding GPs get every year, to employ locums and others to meet winter exacerbations and demand.

People cannot get a GP appointment, or even talk on the phone. True. That's because we have fewer GPs now than we did in 2015. Carving out some of the workload, using pharmacists and others, is the obvious route and was well under way before covid.

Locum GPs, if you can find one, may expect to earn, pro-rata, well over £100k a year, without the aggravation of being a partner or the constraints of salaried employment. 

Primary care gives us +90% of first contacts for around 11% of the total NHS budget. 

International comparisons are tricky because definitions of primary care vary. I can tell you we have 3 doctors per 1000, population, of which some will be GPs That puts us behind most EU countries and many across the OECD.

HMG's promise of 6k more GPs, by 2025 is fatuous. More are leaving and retiring. 

Around a third of GPs work ‘part-time’, but at three days a week can still clock-up 40 hrs. Fitting-in family and other commitments, has translated into there being more female GPs than male. 

Free Livi systems are likely to destroy the tele-consult market. We’ll end up with no competition and hostage to one provider. 

The up-sum;

we don’t have enough GPs,

tele-consultations are NHS policy

they are popular with a huge number of people. 

F2F consults are vital...

... GPs aren’t daft and can be left to make that judgement, not the Daily Mail.

Some GP tele-systems are poor but £250m injection = £30k a practice, to fund winter-pressures and staffing. It won’t touch the sides of the cost of decent, universal systems.

The facts, overwhelmingly, point to a neglected system under pressure, being bounced by a cock-eyed newspaper campaign that has ripped the agenda away from Pritchard, NHSE comms, No19 and the No10 press outfit.

They're on the back-foot because this is a failure of planning, policy, communications-strategy and most of all...

... a huge failure of leadership.

Have the best weekend you can."

Bupa is a provident association.

Yep, that is basically the core of the issue, and no amount of remote consultation tech is going to solve it.

Just to get to the same number of physicians per capita as Germany we’d need to increase our numbers by 40%. Not sure how they are going to achieve that when it looks like it’s going in the other direction.

Let the private sector take some of it and let them recruit from abroad at vastly higher salaries than the NHS can offer is pretty much the only short to medium term fix I can think of, but as soon as you say that you become very unpopular.

Not quite so cut and dried as ‘not enough GPs’. According to the BMA, 90% work part time, the average GP works 3.6 days a week (27 hours) and the average retirement age is 59.
Might be more accurate to say ‘not enough GPs prepared to work full time’

3.6 days a week in GP would be full time by any normal definition of the word. It most certainly isn't 27 hours.

The recent reports in the press on the study that GPs were "working a 3 day week" neglected to mention that the average hours worked per week in the study was 40. 

Fair play if them’s the facts. I stand corrected 

There is nothing wrong with phone or video appointments for those who want them but face to face should also be available for those who prefer that option.

I see the doctor very infrequently, when I needed a health declaration completed earlier this year it came to light that it was over 8 years since my last visit. It would probably be unwsie to try and diagnose anything over the phone in a patient that you have not seen for so long.

Is it underfunding or are GPs overpaid?

The average GP earnings on my local surgery are over £80k,  I doubt that any of them would starve if that was 10% less!

But UK has more GP's per capita than Germany......

Are you suggesting that the answer to a shortage of GPs is to cut their salaries?

I have slightly mixed feelings about that. Should it be entirely up to patient preference, or clinical need? All other things being equal, then patient preference wins for sure. But when there are insufficient resources and the doctor is confident that they do not need to see you in person, I think there is a strong case for offering appointments based on who needs them rather than who prefers them.

Interesting thoughts. I haven't managed to read the entire thread (I posted just before heading in for my sleepover shift at work, so only just home now and the thread is now huge!

I agree that phone/ video is not appropriate for everyone, but it also sounds like the huge variety in the ways different GP practices manage appointments means that some would manage the system better than others. 

Our GP is awful for appointments. You can't book in advance, so if I only have one day off in a fortnight (not unheard of in pre-covid summers) and I had something to see them about, I had to take my chances on the phone lottery that morning. If I was unsuccessful, it could be another 2 weeks until I could try again. An online booking system and the option of remote appointments would be way better. The particular ailment which I have bothered the doctors about a few times over the years is a super itchy skin flare up on my feet which is worst in warm, damp conditions. So during the summer guiding season, it's awful. By the time I actually manage to see a doctor, it has usually subsided and I can only try to describe what it looked like! If I could get a remote video appointment, I could even do it from my tent at the end of a guiding day. Then they could actually see something! (After many, many appointments, it has finally been declared probably something like eczema, but still no one has actually seen it!).

I'm almost wondering if you could keep your "family GP" for in-person appointments but there could be some sort of regional/ health board call center where doctors could have access to your records and deal with all the stuff that doesn't need face to face. They could be full doctors, and could prescribe etc, but much easier access. I'm sure someone will tell me why that wouldn't work!

Look at that graph again linked in-thread by barmybaldwin at 00.28. Face to face appointments are roughly at 3/4 of average pre pandemic levels and never dropped below other formats. Are you saying more than 3/4 of appointments need to be face to face, making the throughput situation even worse?

This is a manufactured 'crisis' as a distraction from a genuinely very bad and worsening GP shortage. It's been argued GP numbers due to retire soon exceed planned increases and we simply can't afford significant others retiring early or going elsewhere (where better appreciated) due to low morale from unfair government and public attack. As Lilley (an NHS management expert and ex-tory advisor) says this is very poor leadership and a very bad idea.

When it comes to rants on getting an appointment and maddening booking systems - snap.

I suspect various people in various places are considering how much money it could (a) save for the state and (b) make for the intermediary if provision of that remote GP service was off shored.  

Seems like huge progress to me.  It's less time out and trouble for the patient, more efficient for the GP and less chance of catching something.   Most of the time a video call is probably just as good and it will allow more patients to be dealt with or allow for longer appointments in person when needed.

However, I see the next stage in this as somebody thinking the GP doesn't actually need to be in the UK if it is done over the internet and there are countries with plenty of doctors and far lower pay than the UK.  

Excellent idea, a win for everyone !!!

There would be a lot of hurdles to overcome and it would require a new Medical Act. In order to practise medicine in the UK you need to be registered with the GMC - this includes remotely. In order to be a GP you need to pass exams after 5 years of postgraduate training (MRCGP) and be on the GP register. If you've got a foreign GP qualification you have to go through a series of similar exams as well as a 6 month training placement. 

GPs are in short supply worldwide at the moment - there isn't a pool that could be contracted to work remotely at lower pay unless you lower the bar to any "qualified doctor".

The more likely direction of travel of a system like that they decide it doesn't need doctors at all and becomes like NHS 111. Someone will ask you a load of questions off a list and you'll either get a video call with a nurse or they'll call 999 for the paramedics to look at your fungal toenail as you mentioned you felt a bit short of breath when you ran up the stairs earlier. 

Honestly 80k feels pretty low these days given the qualities required to be a GP, even outside London.

Given the grades required to even start, the years training, the hours, then the years of experience required, the responsibility, being held accountable... they must be driven by some higher morals to work for less than £100k. 

One of the reasons for them retiring early is it’s more advantageous because of disincentives in the  tax / Pension scheme rules to carry in working. Very complicated but for high salary earners these things come into play. Problem is that the gov cannot be seen to favour one group of high earning people over another. The net result is drs retiring early. I am not sure the problem is solvable in that respect. 

They may be in short supply but if you go to say India you could probably double a GPs salary and still be paying half what a UK GP would cost and they're probably pretty good at their job. 

In industries like electronics there is now a lot of skilled labour in India.  At first it wasn't anything like as skilled as what you could get in the US or UK but the gap doesn't last.  There's nothing magic about medicine.  If you can trust people in India to design chips or aircraft you can trust them to do GP work.  Of course, there's more rules about medicine, but rules can be changed.

I'd agree there's nothing particularly special about medicine but being a GP does require social and cultural understanding that only comes from living and working in the country for a while. 

People from the NHS went out to India to try and recruit GPs and despite offering UK incomes and residency they weren't successful, so I doubt that offering double the local salary would cut it. The NHS has an increasingly bad reputation in our "traditional" places to poach doctors from. There is also a shortage of doctors in India (as in most countries).

In any case, if you were an Indian GP and had the relevant skills to work in the UK remotely, you also have the relevant skills to work in Canada or Australia for 2-3 times what a UK GP earns.

I agree the pension problem is serious and foot shootingly unwise as it applies to senior medical staff.  It's not the only problem though: the stick of stress, and working conditions (and even visa issues on families) and the carrot of career breaks and better overall employment packages in other countries all take their toll on numbers..

https://www.bmj.com/content/374/bmj.n1998/rr

The pension problem

https://www.theguardian.com/society/2021/jun/23/number-of-doctors-retiring-...

The exodus abroad

https://www.sundaypost.com/fp/doctors-work-abroad/

The visas problem:

https://inews.co.uk/news/nhs-elderly-visa-adr-doctors-windrush-scandal-9536...

Plus it's not just GPs. In particular the effects on the mental health of front line hospital staff from working on the covid (because our government messed up several times and left hospitals near or over capacity limits, dealing with a horrendous illness) should not be underestimated in leading to near future staff shortages that are worse than the planning anticipates:

https://www.theguardian.com/commentisfree/2021/may/05/stress-covid-pandemic...

It is not an entirely unprecedented way of responding to a budget reduction the woorkplace.

Should any profession be exempt from such necessities?

If there was an absolutely finite budget for total GP salaries plus an endless supply of GPs just chomping at the bit to get a job then I can see how that might work. But given that we can’t replace GPs quicker than they’re leaving I don’t see how making the job even less attractive by reducing their pay is a solution. How do you see it helping?

Btw - do you see reducing HGV driver wages as a solution to that shortage as well?

Didn't work out too well for Pret recently, it took them about a month before they had to back track. Are there any examples of it working, when there is already shortage of trained staff? 

Due to the nature of my work I need to get a medical each year. Last year it was by phone this year I just filled in a form and got a clean bill of health. Next you will be able to write your own prescriptions!

GPs are the latest stooges in a growing list. Classic deflection of responsibility and a signal of moral turpitude 

About 7000 GP surgeries left.

In 2013 about 13 closed,  a typical number.

Since then we have averaged about 100 closures per year…

Successful profitable businesses don’t close.

But yes you are right I guess 1.4% failure per year is probably less than in commercial business. The consequences on the population is greater though if they lose their practice. 
 

 In the private sector if demand outstrips supply then price goes up and the service is restored.
In general practice when demand outstrips supply GP’s are ‘part time lazy overpaid fat cats ‘ The demand and vitriol then pushes them towards an alternative more manageable careers in hospital medicine with lower hours, early retirement/illness or to move abroad. Hence dropping GP numbers and closing practices.

The solution to this problem was in 2013. 
Define an acceptable safe workload like we do for hospital doctors, pilots etc where wrong decisions kill people, then estimate demand and plan how many GP’s you will need to train over a 10 year process to serve the population.

We can start that process anytime….

Or continue the ‘ part time fat cat lazy incompetent should do better ‘ approach of the last 10 years. During that time the NHS has dropped down the international rankings and will continue to do so.

I don’t think that approach has  a great track record or future myself.

I thought it was because they were just consolidating the surgeries into bigger practices with more services,which is what happened round where I live..All sensible stuff.

While it didn't quite make it into the manifesto itself, it was one of the key pledges made by both Jeremy Hunt (then Health Secretary) and David Cameron in the run up to the 2015 election that they would somehow produce 5000 additional GPs in five years.
https://www.theguardian.com/society/2015/jun/24/doubt-lingers-over-jeremy-h...

What they actually delivered was a decline of about a thousand or so.  Or, with a bit more nuance:
https://fullfact.org/health/gp-numbers-or-down/

But they are building 40 new hospitals, as promised ??? 

If 42 is the answer to the ultimate question of the meaning of life, the universe and everything and 40 is the addition of the already counted, a few fractions, future hopes and wishful thinking what does that make 41?