Losing Faith in General Practitioners Post Covid
Dr. Mark Burgin BM BCh (oxon) MRCGP explains why Covid has brought General Practice to the tipping point because their patients lose faith.
General Practitioners have enjoyed extraordinary levels of approval from the earliest days of the NHS. This public support has allowed GPs to ration care as gatekeepers to secondary care and maintain low levels of health seeking behaviour. Even before Covid 19 there were cracks appearing such as those in out of hours provision. The minority of patients dissatisfied with their health care attended A and E departments in increasing numbers. It has been estimated that 10% of the population generates most of the demand for A and E.
In the last 18 months changes such as email interactions and virtual (mainly telephone) consultations has led to expanded use by a small minority of patients. They are typically worried well and have health concerns rather than illnesses. These patients are those with excellent communication skills and have led to a change from an average of four 10-minute consultations per year to several hours. GPs have struggled to adapt and are working increasingly long hours to cope. The ordinary patient suffering from symptoms of serious disease has found themselves unable to compete.
Accident and Emergency departments adapted to Covid 19 by spending less time with the walking wounded and more with the seriously ill. This has meant that the quality of care for really ill people has largely been maintained. Unfortunately they have become less vigilant at picking up GP mistakes so a typical clinical negligence case involves repeated GP telephone consultations and physical attendances at A and E. Patients with straightforward problems are being missed and the window of opportunity closes on effective treatment. Primary care type activities already cost as much in secondary care as the spending on primary care. Putting right mistakes in primary care costs secondary care twice as much as the total for primary care.
Increasing clinical negligence.
There has been an uptick in clinical negligence activity with a doubling of stage one screening reports based upon the initial details. The increase in stage two screening reports based upon full medical records has been smaller but still significant. This suggests that the numbers of CPR compliant reports will follow suit over the next 12 months. The main driver of the increase appears to be increasing use of telephone consultations with failure to examine. These cases are generally indefensible because the terms and conditions of service insist upon face-to-face assessment where clinically necessary.
GPs are still trying to assess patients by telephone and often in shorter consultations whereas it typically takes 50% longer to safely assess by telephone as it does face to face. The failure to manage the additional workload from emails and messages by many practices has led to unfavourable headlines. A few GPs have taken on older doctors to assist with the administrative aspects of the workload. These practices are shining beacons which show that it is possible to deliver high quality care whilst improving accessibility. These practices are starting to show lower costs than normal practices and lower levels of toxic stress.
Attempts by the press and clinical negligence organisations to draw these problems to the medical leadership’s attention have given a mixed response. Some medical leaders have argued that General Practice is at a tipping point and will soon collapse without funding. Other leaders have denied that the problem exists by pointing at increasing activity. NHS Resolution has made progress in resolving cases more promptly, but this will be for naught if the likely tsunami of clinical negligence claims hits. The pandemic confirmed that there are tens of thousands of doctors on the GP register who would be happy to help if allowed to.
Move from PI to clinical negligence.
Although there are an estimated 800k clinical negligence events a year only 10K are taken up by lawyers. This is because clinical negligence has been run in a traditional way with high value multiple specialist expert reports. There are several reasons to believe that lower value clinical negligence cases will proceed in the future. The PI changes especially the OIC has led to increased interest in clinical negligence work by many practices previously working in PI. Using the techniques developed in PI such as the low value generalist report and IT innovations these solicitors can make cases even worth as little as £2k turn a profit.
Many MROs who have seen their profits eaten away over the last few years with cost containment in PI have already made the move to clinical negligence. They are on a learning curve as to financial management but have the skills and sophistication to make these cases profitable. Increasing numbers of MROs are actively developing the area and persuading solicitors to look at lower value claims. They are recruiting experts for screening reports and two MROs are even providing training to ensure that the quality standards are maintained. As an expert these changes are impressive and show that legal structures are capable of extraordinary innovation.
Clinical negligence could expand to be greater in numbers than PI was, and this may spell the end of the golden age of General Practice. Doctors are largely unprepared for the changes that are now almost certain and for medicine this could not come at a worse time. Demoralised burned-out GPs looking eagerly to retirement with real terms cuts in primary care funding for a decade and a shrinking workforce. Medical leaders appear incapable of listening to the solutions that everyone is shouting at them and locked into pointless battles with politicians about pensions and pay.
The increase in the numbers of doctors attending mental health services for burn out since the start of Covid is stunning. The sheer numbers combined with the rate of increase suggest that there will soon be a catastrophic failure in the NHS. It is improbable that good clinical care can survive with levels this high and even if toxic stress decreases there will be ongoing deterioration for some time. The first signs are already being seen with negligent failure to manage acute illness and injuries but with time the effects on diagnosis of complex disease will be recognised. It takes up to three years before the long-term effects become clear and General Practice is still not back to normal.
Although it has been said that patients do not care if their GP is burned out, they do care if they cannot get medical attention. Lack of access caused friction before Covid but the public mood has changed. Many people who talked about ‘protecting’ their GP from wasteful attendances are now speaking in terms of the GP denying them treatment. This is having an increasing impact upon the consultations themselves with patients willing to spend part of their precious time engaging the GP on this issue. GPs find that they can either cut back on the time they spend on the medical problems or run over, both cause increased stress to the GP.
Patients knew that their GP wants to do their best but now are beginning to believe that their GP is fobbing them off. The public has always known that there are GPs who fob patients off but until recently did not believe this of their own GP. This change has a dramatic impact on the quality of the consultation so that even good and excellent GPs are struggling to maintain standards. This can be seen in medical records pre and post Covid and appears to be more than just the dumbing down that occurs when using a telephone instead of a face-to-face assessment.
There is a perfect storm happening in General Practice which is causing the public to lose faith in their GP and may well spell the end of the NHS. There were insufficient GPs to manage the workload and the estimated 50% increase in work from email and telephone consultations is killing access for most patients. The GPs themselves are making more mistakes and feeling bad about their performance partly because their patients are increasingly vocal in the consultations. The legal industry which has largely turned a benign blind eye to the high rates of medical accidents in the past are increasingly capable of running low value cases.
GPs are likely to struggle as the numbers of claims increase (predicted to average 4 per doctor per year) and they can no longer afford insurance (already up to £30k per year). Attempts to replace doctors with nurses, paramedics, pharmacists and physios has led to worsening service and increasing error rates. Secondary care is already stretched and costs roughly 4 times as the GP to do the same task. Some patients can get treatment abroad and these cases are already coming through as ‘near miss’ where they seek repayment of their costs.
The medical leadership need to listen to the voices and realise that it is possible to improve morale, improve access, reduce medical accidents, transfer care from secondary to primary care and adjust to an internet enabled world and decrease costs at the same time. Some say that it is already too late and the American model of health care is already too far established, perhaps it is. If patients have lost faith in their GPs then any changes will be sabotaged and be ineffective. If GPs have lost faith in themselves then General Practice will collapse unless a leader can rally them soon.
Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.
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