The Doctors Won’t See You Now: What exactly is going on in Britain’s GP surgeries?

At the Trinity Street surgery in Norwich, the doctors have hung a big banner on the wall outside the surgery proclaiming it is open for business.

The practice GPs put the banner up to make sure patients realised the surgery was running as normally as possible despite the pandemic and to encourage them to visit. More importantly, the doctors wanted to reassure patients they can meet them “face to face” for treatments once they have made appointments.

The Trinity Street surgery is not the only UK practice to have felt it necessary to make such a bold statement during this extraordinary post-lockdown period.

As one GP told Reaction: “Patients are getting really confused by the mixed messaging. Many think surgeries are closed. They read reports that doctors are not seeing patients face to face so are put off – or scared – to make appointments.”

The GP, who tries to see as many patients as he can after following the social distancing rules and strict Covid protocols, adds: “Many patients don’t feel comfortable with a video call, so they are not calling. Other patients are not even bothering to call their GPs because they think they are not working. Or they are scared of picking up Covid at the surgery. Some surgeries have put up signs to warn patients from coming in at all.”

“This is a dangerous state of affairs and many illnesses are going undetected. We need to be much clearer about our messaging, both nationally from NHS England and from the government. Illnesses are being missed, and people are getting worried.”

Yet many practices have upped their game to cope with the new protocols, making it as easy as possible for patients to visit. Indeed, some practices – which have been operating a much more open-door policy – are said to have been ticked off by their local commissioning groups for being too open.

The stories are mixed. Many surgeries have been superb at responding to the pandemic, converting their buildings to cope with patients who suspect they have Covid-19. They have done this by creating special “infectious” rooms to which patients can enter through the surgery back door, thus minimising contact with other patients and medical staff.

Yet there are also accounts from all over the country that local GPs are taking days to get back to patients, and that in some cases, patient diagnosis has been delayed for months, mainly because the doctors have relied on online consultations.

As another doctor quipped: “You remember that old saying, that ‘the doctor will see you now.’ Well, I wonder if we have to turn that on its head to say the doctor will not be seeing you now.”

So, what is the state of play? Are Britain’s 6,822 GP surgeries and medical centres open for business and operating as normally as they can? Or are doctors taking the opportunity to take a break, as some suspect? Do they rather enjoy working in a more leisurely manner from home via Zoom and the phone? More critically, have the changes in primary care led to an unsustainable waiting list of patients waiting for hospital appointments? And is remote working here to stay?

State of play

The Royal College of General Practitioners is categoric that general practice is open, and has been throughout the pandemic. The Honorary Secretary, Dr Jonathan Leach, explains: “Following the introduction of lockdown, and in line with official advice, general practice has swiftly and drastically changed the way it works with GPs and our teams delivering the majority of care to patients remotely. This has been to help stop the spread of COVID-19 in the community and keep GPs, our teams and our patients as safe as possible.”

“Despite the increase in remote consulting during the pandemic, face-to-face appointments are sometimes necessary and appropriate – for example, when a physical examination is needed or a child needs to be vaccinated – and these will have been facilitated, based on clinical need, during the pandemic.”

But Dr Leach added the numbers of face to face appointments in general practice are now increasing again.  “However, the pandemic isn’t over, and we need to remain cautious. We’re taking steps to ensure patients who need to come to the surgery are as safe as possible, but it is still sensible to limit footfall in practices where possible, in line with official guidance.”

“We don’t want to see a situation where we rush to change the way we deliver services and have to revert back again – this would be very confusing for patients.”

One of the many reasons why there are such disparate stories being reported about the depth of medical services being offered is the way Covid-19 has spread through the country, in terms of demographics and geography. In East Anglia, for example, where the number of infections has been low – until recently – most surgeries are operating close to normal and meeting as many patients face to face rather than remotely.

In contrast, in high density cities such as Birmingham, Leicester and Leeds, many GP practices appear to be taking a stricter line on taking consultations via video or phone rather than meeting patients physically.

There are other factors to consider: many GPs are themselves over 50 – the age at which the risks of being seriously ill from Covid start to increase rapidly. Many are also of ethnic minority backgrounds: as some studies have shown, a higher proportion of Asian and black Britons appear to be more vulnerable to being seriously ill after contracting the disease.

Research by the Health Foundation, an independent charity promoting better healthcare outcomes, earlier this year showed that at least 8% (3,632) of all GPs are deemed at “high risk” of death from Covid-19, one of the reasons for restricting physical meetings with patients. The research found that age, sex and ethnicity can all contribute to greater risk of death from the disease.

However, all surgeries have been instructed to follow the NHS England guidelines on how to keep patients and staff safe. The first of many NHSE instructions to GPs was sent on March 10, informing them to switch to an “increased use of online consultations and remote triage”. Then, on March 19, the NHSE added: “Move to a total triage system (whether by phone or online)”, and “Undertake all care that can be done remotely via appropriate channels.”

Then, in July, the NHSE sent another letter to GPs outlining the situation to date: “Practices have made great progress over the past few months in delivering remote total triage and online consultations – and we want to encourage this to continue. All practices must now also deliver face-to-face care, where clinically appropriate.”

The NHSE instruction continued: “The best way to successfully manage the combined demands of on-going care for patients with, or at risk, of Covid-19 and non Covid-19 services will be by sustaining many of the transformations in ways of working adopted during the height of the pandemic.”

The UK’s growing number of private practices are also following the NHS guidelines. They too have been swift to adapt their surgeries – and safety measures – to the Covid era so that they can see as many patients face to face as possible. Unsurprisingly, they have seen a rise in new patients during the pandemic.

Dr Chris Clayton-Payne, a partner at the Cambridge Private Doctors, a private practice run from within the Nuffield Hospital in Cambridge, says he and his colleagues have been treating patients “face to face” throughout the lockdown period and continue to do so.

“We have introduced the strictest and highest level of pre-cautionary measures at our practice. When patients arrive, their temperature is taken. They are asked to fill out special Covid questionnaires about symptoms etc. They are asked to wear masks and gloves.”

“We take great care throughout patient visits, washing our desks with sanitiser gel, washing the door handles. The toilets are deep cleaned throughout the day. All these safety measures mean that consultations take longer, and there is a longer gap between seeing patients. But we take patient safety seriously.”

Dr Clayton-Payne, who worked as an NHS GP for more than 30 years and a senior partner at the Gold Street practice in Saffron Walden, adds that they have managed to cut down on patients meeting each other in waiting rooms, or mixing with other staff, by adopting certain precautions. “We follow the Japanese three C philosophy where possible: avoid crowding, confinement and closeness.”

To reduce meeting other people, the Cambridge doctors ask their patients to wait outside or in their cars and phone them when they are ready to be seen to cut down on too many people in the surgery. The Cambridge practice has seen a spike in patients over the last few months from people who would not normally take the private route. “We have had many new patients coming to us because they wanted to know they could see a doctor face to face.”

“They were not able to see their own GPs because they work in surgeries that have decided to cut down the number of  patients they see physically or they have taken a long time to return their calls. Sadly, we are hearing about people with serious symptoms sitting at home and who are even too frightened to go to Accident and Emergency in case they catch Covid.”

This situation could now be complicated by any renewed government attempt to combat a new wave of coronavirus infections. With recent rumours that the government could consider tightening restrictions on social gatherings, in the wake of a reported rise in cases, GPs may soon find this state of play changing once again.

Longer waiting lists 

Fears that patients are being put in danger because of the longer waiting lists are misplaced, according to NHS England.

Giving evidence to the Commons health select committee in June, NHS England’s chief executive Simon Stevens said the health service is now running at more than half of its pre-Covid-19 activity levels. He also said that four fifths of patients on waiting lists are waiting for tests or outpatient appointments rather than operation.

Stevens added that the NHS should be back to around three quarters of normal activity levels by July or August 2020, and that the NHS would be looking at a range of measures to increase capacity over the coming months. This would include extending the deal with the private sector to use its facilities and adapting the Nightingale hospitals for diagnostic testing.

Yet the British Medical Association is cautious about saying when normal primary care services will resume. A BMA spokesman would only say: “When it is safe to do so.”

A recent survey by the BMA of GPs showed that only 54.7% of them had yet agreed on when they should return physically to their surgeries and resume normal service. To some extent, the ultimate decision of the care being offered by surgeries lies with the GPs who are independent contractors to the NHS.

But they obviously follow the NHS guidelines even though they have the freedom to interpret them as they see fit. Indeed, many GPs are reporting that they cannot achieve full capacity so long as social distancing rules are in place.

The doctor will see you now

What will be the new normal? Has Covid-19 changed primary care forever? For example, the BMA believes a strict triage system and mainly remote consultations is the best option to provide healthcare until the pandemic is over.

But who is to say when it is over? What’s more, most in the medical profession are now convinced that remote working is here to stay as part of a healthcare package. So is the day of seeing your doctor face to face over?

Not so, says the Royal College’s Dr Leach. He believes that there is a place in general practice for remote consulting, but isn’t convinced that it will become the norm. “It isn’t in anyone’s best interests for general practice to become a fully, or even predominantly, remote service. Many patients prefer seeing their GP in person, and many GPs prefer this too, particularly for patients with complex health needs who really value the relationship-based care that GPs excel at delivering.”

Dr James Davies, Conservative MP for the Vale of Clwyd and member of the Commons Health and Social Care Select Committee, is concerned that remote consultations should never replace face to face meetings.

Dr Davies, himself a GP, has already raised the issue with the select committee: “I worry that the default use of remote consultations post-pandemic would pose increased risk. It would also result in missed opportunities for clinicians to pick up on non-verbal cues and to carry out physical examinations. Inevitably it is the elderly and vulnerable who have more to lose from such arrangements.”

He adds: “It is important that, as we embrace new technology, all stakeholders are invited to contribute to an evidence-based appraisal of the pros and cons, and that safeguards are put in place to protect patient safety.

However, Dr Davies also said that the replacement of face-to-face consultations with telephone calls, and the ramping up of video conferencing with patients as a new way of working, has allowed GPs to continue to function during the pandemic. “Beyond the pandemic, there is certainly scope for the continued use of remote consultations where safe and convenient to do so. Digital solutions can bring benefits both to patients and to the NHS.”

Dr Clayton-Payne is adamant that physical face-to-face meetings will never disappear. He also thinks the balance is already shifting back to seeing people directly: “The mood among GPs appears to be changing. There is a new recognition that the balance of probability is starting to shift, that doctors are realising that deferring patients or not seeing them face to face because of fears over Covid is a greater risk than catching the disease.”

And making sure doctors catch critical illnesses among their patients will be all the more important over the coming winter months if there is a second Covid spike as well as the usual seasonal flu. Hopefully, that soothing refrain, “the doctor will see you now”, is here for some time to come.

Additional reporting: Alice Crossley and Joseph Rachman.