…But we are open.

I don’t know why but that made me think of “I open at the close”, a quote etched on a golden snitch in Harry Potter. I guess we are at a turning point just like Harry was at this point in the story.

I have seen many news articles and social media posts suggesting that GPs doors are closed, this must mean we have been quiet or refusing to work on the grounds of safety. I mentioned in my last post that I wasn’t going to get down about the inaccurate portrayal of my job in the media, and I’m not. Instead, I am going to write down what my days involve to highlight that GPs have been rather busy.

I will get to a “typical covid day” shortly but first I wanted to go through some of the other responsibilities we have as a practice:

Flu vaccination

Many practices have started their flu jab campaign already and our Saturday clinics roll out this week, and this year they have been more complex to organise as we have to take in to account social distancing AND an extended eligibility.

We order our vaccines months ahead of winter for delivery in September/October, this was well ahead of the pandemic and the change in guidance around 50-64 year olds being eligible.

Normally we run a few Saturday drop-in clinics. They are easy to staff; a couple of receptionists checking people in and several clinicians (HCAs, nurses, GPs etc) giving the jabs. They are busy sessions but work very well and we quickly get through the queues. This year we have had to send people time slots to attend and ensure numbers are at a safe level to allow for social distancing.

Chronic Disease Management

During the peak of the pandemic, in the Spring, GP practices had to prioritise acute illness over chronic disease. This meant that some patients had their blood pressure, diabetes or kidney disease reviews delayed by a few months. This was the safe thing to do at the time. We now have a backlog and want to ensure our patients safety by reviewing their condition, bloods and medication. We are prioritising the higher risk patients first (e.g. patients with a very raised Hba1c – diabetes blood test) and are encouraging patients to get their annual review bloods, where possible.

There are some hurdles in our way: we have to balance the safety of coming for say, a routine blood pressure check vs the risk of an increasing rate of covid infection locally. We are encouraging patients to do home BP readings, if they have a machine but this isn’t an option for everyone. Blood test availability is limited – we are offering appointments across our sites daily but this still isn’t enough. This week comes the news that blood testing may be further impacted by issues within the Roche supply chain.

Our local hospital phlebotomy service is limited to “urgent” bloods only but is hopefully soon to operate a more routine appointment based service. As time goes, on routine bloods soon become urgent. A patient having an annual PSA to monitor their prostate cancer…when does the urgency change? 12 months? 15 months, 18 months? A patient on diabetes tablets that needs his kidney function monitoring yearly, when do we stop delaying it?

Secondary care (hospital) backlog

Many routine hospital clinic appointments or surgeries have been cancelled over the last six months. That has an impact on general practice as, understandably, patients get in touch asking us to try and expedite their appointment as their pain is worsening or their poor mobility is impacting on their day to day life. We are also finding we are dealing with more complex queries, which historically would have been managed at these clinic follow up appointments. There is no blame here, the appointments had to be cancelled but some understanding of the extra work it is bringing back to primary care is important.

Winter

One of my first ever blog posts was about winter in general practice. This year will be like no other. Every new cough or high temperature will have to be treated as possible covid until proven otherwise. Winter brings with it many coughs/colds and chest infections, how are we going to separate the very poorly that need seeing, from the well that can self-care at home?

We have a “hot site” at our practice; two GPs are allocated each day as the team triaging patients with cough/fever on the phone. We have the ability to see necessary patients face to face, if warranted. Many patients are calling with a new persistent cough asking us to see them as “I know it’s not covid, I don’t need a test, just a check over or antibiotics, this happens every winter” for example. In the past we would have seen these patients in our urgent care clinics, taken a history and examined their chest and only prescribed antibiotics if appropriate. But this year is different. We need to encourage all patients with these new symptoms to access Covid-19 swabbing. It could be Covid-19.

It is frustrating, I know, especially if you have young children who often get chesty over winter but it is the situation we are in. My twin sister, for example, has a nearly 1yr old daughter who has just started nursery after maternity leave in lockdown. The little one is understandably picking up new germs given she is coming in to contact with new people. They have had to self isolate as a family twice in the last 2-3 weeks awaiting swab results due to a fever then cough. The cancelling of plans gets more and more tiring but we all have to do our bit to reduce the spread of this potentially fatal virus.

All in a day’s work

So back to the original aim of this post, what do I do with my days in the pandemic world of general practice?

I still arrive for around 8am after dropping the kids off. The main difference on arrival now is that I wear a facemask when walking through our communal reception/staff areas. My clinical room has a box of PPE on the side that is topped up daily and the surfaces are clear of unnecessary items. I change in to scrubs and start the day.

I log in to the patient system, boot up accurx chain (video/text consultation portal) and check my work emails.

There are usually ~30 “tasks” awaiting my input so I try clear some of these first. They could be prescription queries, letter requests, a clinician wanting advice or a note to say my patient’s results are back.

We have separate urgent care and routine care clinics. I will concentrate on routine care for now.

My clinic starts at 8.30am and I have 15×10 minute telephone consultations booked. These are a mixture of new issues and follow up. They have have booked online, using the NHSapp, by phone or via a receptionist if a clinician requested the appointment. It can be such a mixed bunch of problems; some taking 2 minutes (e.g. please can I have a repeat prescription of topical steroids that I get yearly for my eczema) or 20 minutes if a complex problem. I have a couple of blocks in between patient appointments to allow for a break or to catch up.

So what happens late morning?

That’s when the majority of my admin gets sorted. This is the invisible work.

It is a real variation depending on the day; filing clinic letters, reading hospital discharge letters, writing death certificates, processing blood results, signing electronic prescriptions, sending referrals or speaking to hospital colleagues. The admin comes in throughout the day so it is never “finished”.

Around midday we look at the home visits. How many clinicians available and we allocate the visits depending on complexity, location and who the patient knows well.

Home visits take time. We have to take our equipment with us and depending on the location of the practice, it can take time to get there. By their definition, i.e. housebound, they are generally patients with more complex problems so we need to give them appropriate time, care and space to share their problems with us. I hate rushing home visits and there should be no need to. I saw a reply to a facebook post recently saying GPs had a three hour break… I just smiled.

We try to catch up over lunchtime. Working in general practice as a clinician can be quite isolating, staying in one room, especially with telephone appointments dominating the mornings. It is important we take the time to rest, debrief and eat. Lately this is has the part of the day which has been slipping away and it isn’t good for us. Wearing face coverings and trying our best to keep up with the workload and demand has eroded the social aspect of our work. We need to take time out, for the benefit of ourselves and our patients.

Our afternoon surgery starts at 2.15pm. We have mostly face to face appointments in the afternoon; these are patients that had a phone appointment initially and who a clinician felt a face to face contact was appropriate. There can be many reasons a patient needs seeing; abdominal pain needs “a hand on the tummy” or a painful ear needs a look at. Maybe a patient has a genital problem or a mental health issue that is best dealt with in person. There are many reasons that face to face consultations remain important.

Conversely, there are many medical problems that can be dealt with over the phone or online. Since the advent of remote working, patients are able to send photos to us electronically and this has revolutionised how we deal with some problems, especially skin complaints.

We run our afternoon clinics til about 5.15pm and then time for more admin and the on-call GPs to manage any urgent clinical issues. So do we all happily leave the building at 5.30pm? No. As I mentioned above, it is the admin, or invisible work, that takes its toll. Often GPs are working very late to get on top of this.

So are we closed?

No.

Is the door closed?

Maybe.

GPs are available and here for you but how we offer patient care has changed. All practices I know of locally are doing their very best for patients day in, day out. We could not be working any harder.

There is data showing deaths relating to non-Covid related illness have increased this year. Practices have a responsibility to balance the risks of Covid-19 against the risk of harm relating to other disease. Other illness, other symptoms go on and we cannot and should not forget this. We have to continue to wear PPE for patient contacts and triage all patient appointment requests – this is for the safety of both our staff and our patients.

We need to move away from the idea that face to face GP appointments are the gold standard for all. There is now a wide disciplinary team in general practice (musculoskeletal practitioners, pharmacists, mental health workers…) so a GP may not be the best person to speak to. A lot of clinical issues can be dealt with on the phone/video/text but some are best managed in person. Demand for GP appointments has surged over the Summer and we are doing our best to increase capacity where we can.

Ultimately, we need to ensure general practice offers patients flexibility and not a one size fits all approach, taking in to account the limitations Covid-19 brings.