The secret GP
In early March as the country headed towards lockdown, general practice changed, almost overnight. As practices across the country closed their doors to patients for the first time in my memory, GPs had no choice but to adapt to a new way of working.
Gone were our faithful 10 minute appointment slots and in their place, telephone triage, video consultation and econsults. And how they flooded in.
Most noticeably for me, in those early days of confusion and fear was the very apparent lack of guidance and direction from above. NHSE and our local CCGs were disconcertingly quiet.
We survived on our daily updates from Boris and social media hints and tips from other GPs around the country, rapidly putting practice policies and protocols together only for the advice to do a 180 degree turn the next day.
In a blizzard of emails, tweets and whatsapp messages we all quickly became overwhelmed by the huge amount of information circulating about this unknown virus.
GPs around the country shared their experiences, suggesting useful examinations, investigations and treatments, but it really was, and still is to some extent, the blind leading the blind.
The Government issued a centrally sourced list of patients who should be shielding, that is not leaving their homes at all for 12 weeks.
Despite our objections that we really should generate this list of patients ourselves, the list was released and caused mayhem. Some patients felt they had been missed, others felt they had been unnecessarily included.
Cue a barrage of telephone calls, emails and econsults jamming our already busy lines.
As time has gone on, we have adapted. Really quite remarkably so.
Regardless of this, consulting via telephone or video will never feel like the norm. I miss the face to face interaction and rapport with my patients.
At my practice, all of the doctors work from one list of patients, calling them up and assessing how we can best help them. Because we no longer have defined appointments, there is no set end point to this list and so it really is all hands on deck to make sure that each patient is dealt with safely and efficiently.
We typically deal with 60 or 70 phone calls and a similar number of electronic consultations in the average day. That’s not to mention the patients who we ask to come in for a face to face assessment and the home visits to those who cannot come to the surgery.
Suddenly we are very much aware of our outdated computers and clunky software.
Everything is painfully slow, even more so for our poor colleagues working from home.
Screen messages and texts fly back and forth with colleagues apologising that they aren’t making headway with the list because computers have crashed, servers are down or patient’s phones keep going straight to voicemail.
It can feel like wading through treacle just to get through a few names on that ever growing list.
I also worry that I will miss a serious diagnosis.
I find myself lying in bed replaying a telephone or video consultation in my head, fretting that there may have been more to it than I had thought.
Doctors will often speak of their “spidey sense” – an indefinable skill developed over many years of clinical practice that gives you a gut instinct about a patient.
Does my spidey sense still work over a dodgy wifi connection?
Patients seem more apprehensive about accessing medical care now, I worry that this prevents them from seeking help when they need it.
I recently spoke to an elderly gentleman living with his wife who has Alzheimer’s. He called to tell me that he had noticed blood in his urine.
I reassured him as best I could but told him he needed to be seen in hospital within the next 2 weeks.
I made the referral but he called back the next day to say that he wouldn’t be going as “I’d rather take my chances than put my dear wife at risk”.
This is not uncommon. Patients avoid A&E like the plague and steer clear of their outpatient appointments, opting to stay at home instead.
We have had to adapt to this, managing very complex cases in the community which previously would have been managed by a specialist in secondary care. Not only that but our resources are often limited as we can no longer access community services or outpatient investigations like ECG or x ray.
Of course we also worry about our personal safety.
The issues surrounding PPE are well documented and the shortage is certainly something that is felt in general practice.
Last week in our team briefing we were told that we no longer have masks to give to our ‘cold’ patients and that we should tell them to bring their own from home.
Given that the definition of ‘cold’ versus ‘hot’ patient is that we think that they don’t have covid symptoms, this is far from safe practice.
Our local CCG recently removed our covid home visiting service due to lack of funding. This means that the task of visiting housebound patients with coronavirus now falls to us.
Yet conflictingly we are advised not to see both ‘hot’ and ‘cold’ patients on the same shift or even, the same week.
With half of our GPs currently working from home this puts us into a difficult predicament.
But it’s not all doom and gloom.
From the outset of the pandemic we have been supported in prioritising essential clinical work over everything else.
For the first time in my career I have had the power to turn down non-medical work.
Gone are the mountains of requests for letters excusing kids from school trips, permitting charity skydives, cancelling unwanted gym memberships or missed flights.
Our tick-box targets have been temporarily lifted, our appraisals and revalidations postponed.
For this first time in my career as a GP I feel that I have the time to focus on being a doctor. And not just the time but also the freedom.
Guidelines and pathways are now to be applied , according to the powers that be, “with the doctor’s clinical judgement”.
We feel valued and recognised as the experienced physicians that we are.
It’s quite remarkable to see how the general public have changed their approach to general practice too.
From the very beginning it was apparent that patients had become aware of what a precious resource general practice is and were trying their best to protect it.
Like every GP I have examples of inappropriate consultations, from the lady who made an appointment to discuss who she should vote for, to the man who wanted to discuss a parking fine.
These types of consultations have almost totally disappeared. Patients seem to be looking for alternative sources of help before contacting their GP, something that we have been advocating for years but couldn’t quite put into practice.
Before Covid-19, general practice was struggling.
There was a feeling that we had become misused and underappreciated and we were drowning in paperwork.
As the first calling point for all problems, with no gatekeeping or triage systems in place, we were on our knees. I’m not sure how much longer we would have lasted in our previous incarnation, and maybe it has taken a global pandemic to give us the hindsight to see what needed to change.
The use of telephone triage and video consultations are certainly here to stay, they undoubtedly have their pros as well as their cons and the improved access that they allow is undeniable.
Our role in the community will always be as the first port of call for anyone who needs our help. We need to make sure that the path to our door, be that virtual or in real life, is kept clear to allow the most vulnerable members of our community to reach us when they need us.
We all need to look after our NHS, now more than ever. Our new ways of working will help with this but more crucial is the appreciation and support that we are receiving from our patients.
Nowadays patients ask me how I am, they thank me for my help and with palpable concern they tell me to ‘stay safe’.
We are so grateful for everyone’s support at this very difficult time. Now if someone would just get us some new computers…
Related: The NHS was once the envy of the world, we need a new social contract to rebuild it
