Face-to-face GP appointments should be 'rationed' for good to manage demand, says medic

Other general practice leaders branded new Scottish Government guidance intended to increase the number of patients being seen in practices as "impractical", and said that a reduction in the physical distancing limit from two to one metres in healthcare settings would make "no difference".

It comes after hundreds of "demoralised" family doctors in Scotland signed a letter urging their trade union, the BMA, to liaise with ministers to "help manage patient expectations realistically".

The profession was left infuriated after the Scottish Government's NHS Recovery Plan pledged to "urgently seek to fully restore face to face consultations in GP surgeries", something doctors warned could not be "safely achieved in the near future" given high Covid rates and ageing premises with "poor or non-existent ventilation" and limited waiting room space.

READ MORE: Scotland's NHS recovery plan will fail without serious investment in staffing

The letter, dated September 1, said GPs were also facing a "torrent of abuse on social media" which had been exacerbated by Government announcements "implying that restricted access to GPs is at the heart of the recent pressures in the NHS and A&E attendances in particular".

Although there are no official statistics on exactly what proportion of GP consultations are being carried out face-to-face currently, most practices report that they are seeing roughly 25 to 50 per cent of patients in person.

Dr Iain Kennedy, GP and medical director for Highland LMC, said a return to seeing the vast majority of patients face-to-face was unfeasible given current levels of demand on GP practices

A pivot towards more telephone, email and video appointments during the pandemic has also resulted in many surgeries dealing with far more patients overall, in some cases carrying out nearly twice as many consultations per week.

"If politicians want more face to face appointments, they will need to provide us with the GPs and the multi-disciplinary teams to do that and thus far, they haven't," said Dr Kennedy, whose own group of three practices has lost seven GPs over the past 18 months as one retired, two moved overseas, and four were lured to other surgeries.

A deadline for health boards to provide all GP practices with pharmacists, mental health workers, physiotherapists and advanced nurse practitioners by April 2021 to enable doctors to devote more time to complex patients has been pushed back and now forms part of the Scottish Government's NHS remobilisation plan - though many on the frontline remain pessimistic that it will be delivered within the next five years.

An Audit Scotland report from August 2019 highlighted the scale of recruitment necessary to meet demand for healthcare support staff across the NHS, including to meet the target for creating multi-disciplinary teams in general practice. It noted that there was a "significant risk" that primary care and hospitals would be "in competition for the same limited workforce"

Dr Kennedy does not believe that face-to-face appointments can - or should - be the default again.

"The workload pre-pandemic was already overwhelming and we already had a workforce crisis," he said.

"The pandemic has only made that worse: the demand has gone up, patients are presenting with problems stored up during the pandemic, but the idea that we can see everyone face to face that wants to be seen face to face, is flawed.

"It's clear that as an NHS going forward we need to be focusing our efforts on clinical need and not clinical want. There will be no going back to business as usual.

"Triage is here to stay, as is a blended approach to consultations, whether that be telephone, email, video consulting or face to face.

"The only way we're going to survive as an NHS is if we focus on need, and part of that will be the appropriate rationing of face to face appointments. If patients do need to be seen, they will be seen."

READ MORE: Warning Scotland 'could be left with fewer doctors' than pre-pandemic

Dr John Montgomery, chair of the South Glasgow GP Committee and a partner at the David Elder Medical Practice in Govan - a 'Deep End' surgery handling one of the most deprived populations in Scotland - said it was "inevitable" that remote consulting might miss problems which would be more easily picked up face-to-face, but stressed that "we have to nail this nonsense" that GP surgeries are closed to patients.

He said: "Just this morning a lady phoned me up - 'I've discovered a lump in my breast'. She's down here in an hour and a half, getting examined, and referred appropriately.

"If someone has a problem like that, they're getting seen and seen very quickly."

The proportion of GPs who are partners (dark blue line) in Scotland has been steadily declining since 2014, while an increasing share have opted to be salaried instead - meaning they are employed by a practice or health board. This raises questions about the long-term sustainability of the general practice model, which relies on GP partners owning and investing in their practices

On September 7, the Scottish Government published its updated 'General Practice Recovery Guidance' which outlined how practices could begin rolling back infection control measures as part of a move towards more face-to-face consultations, including a reduction in physical distancing from two to one metre.

Exactly how much practical difference this will make is a matter of some scepticism among GPs, however.

"We've increased the number of chairs in our waiting room from four to six," said Dr Montgomery.

"In a waiting room that before would have had 25 people in it."

READ MORE: Key aims of Scottish GP contract 'will not be met' by April 2021

Besides physical distancing, the document states that all patients should continue to be screened for Covid and anyone with suspected symptoms be treated as a 'high-risk' patient who "should be isolated from others in a separate waiting area".

It suggests allocating all patients with suspected Covid to appointments at the end of the day to coincide with the premises being cleaned, whereas in the case of 'medium risk' patients with no Covid symptoms it is no longer necessary to don full PPE or wipe down the facilities after every consultation.

The guidance, which acknowledges that "each practice will need different solutions", adds that while telephone triage of patients "may be necessary for practices to manage workload" and prioritise care it is "not mandated".

The number of patients over-85 registered with GP practices increased by nearly 25% between 2008 and 2018. Overall the patient mix is now more elderly and more likely to have multiple chronic conditions

It advises one-way systems for entry and exit; opening doors and windows for ventilation; and urges surgeries to 'unlock their doors', saying the measure had wrongly sent a signal to patients that practices were closed and "they could no longer access the treatment they needed".

It adds: "From an infection control and Scottish Government policy perspective, there is now no need to close or lock doors to general practice".

The guidance draws a link between the patients "who are struggling to understand when they can and can’t see a health professional face to face" and "an increase in patient complaints, and aggressive and occasionally violent situations against practice staff".

Although it stresses that this behaviour is "not acceptable", it adds that "we need to consider why this is happening".

READ MORE: Number of GP partners in Scotland slumps to record low

Dr Andrew Buist, chair of the BMA's Scottish GP Committee, said the new guidance "doesn't make a huge amount of difference" and was "really not practical".

"The physical layout of some buildings makes some of this two-metre/one-metre stuff very difficult," he said.

"They're old, passageways are narrow, there's no option to have a red zone and a green zone, so there is a risk of patients with Covid coming into contact with people who are there for other reasons."

However, he added that he "would hope that all practices now have their doors unlocked".

Dr Andrew Buist, chair of the BMA's Scottish GP Comittee

Dr Buist, a GP partner in Blairgowrie, Perthshire, said the profession had been "getting a beating" over erroneous claims that they were not seeing patients, but rejected calls by the Scottish Conservatives that the Government should set a target date for when face-to-face consultations will revert to being the norm.

"It's just a clear nonsense that we could do such a thing," he said.

Even before Covid, general practice was struggling with a recruitment and retention crisis which may not be resolved even if the Scottish Government delivers the extra 800 GPs it has promised by 2026.

The number of GPs in post in Scotland has increased by headcount, but in real terms ('whole time equivalent') been declining at the same time due to an increase in part-time working which is also more common in younger GPs

A third of GPs are over-50 and the stress of the pandemic seems likely to accelerate early retirements, while younger GPs are more likely to work part-time.

As a result, the GP workforce in real terms has declined even as its headcount has grown.

Dr Buist added: "People have rose-tinted spectacles and look back to pre-pandemic as a time of plentiful appointments - it was not the case. Difficulties getting a GP appointment are nothing new, it's just more difficult now than before.

"When will it be normal? Well, when will we get our waiting lists in hospitals down to pre-pandemic levels? I think you're talking two or three years at least.

"In the short term, the best thing we can do is ensure that the capacity we do have goes to those who need us most."

Dr Sandesh Gulhane MSP, the Scottish Conservative's health spokesman who still works as a GP in Glasgow, said family doctors are working "excessively hard" while battling to manage patients whose hospital treatment has been delayed.

He said: "Just myself, I had 80 patient contacts on Monday. That's not safe, that's not sustainable.

"A normal Monday pre-pandemic I'd probably have had about 40 patient contacts - maybe 50 in a bad day.

"Patients are upset, patients are suffering, they are in pain, and it's not their fault that they're calling me - but the reason I've referred them to hospital is because I've reached the end of what I can do for them.

"Someone might need a hip replacement - I can't do that, all I can do is give them more painkillers and maybe that isn't working for them."

A spokeswoman for the Scottish Government said: “GP practices have remained open and are a key part of the community services dealing with non-Covid medical care throughout the pandemic.

“We’ve invested £20 million in GP practices to cover Covid-19 related expenditure and the continuation of GP services and in 2021-22 the Primary Care Fund is increasing from £195 million to £250 million in direct support of general practice – providing support for delivery of the new GP contract and for wider Primary Care reform.

“Specific guidance to general practices was issued on Tuesday 7 September making clear that there is no longer a need to triage every patient, although they should continue to screen patients for Covid before seeing them face-to-face.”