Will GP practice ever look the same again?

Whilst the immediate public health crisis has abated somewhat and the UK starts to ease lockdown measures, GP practices will be watching with interest.

The Covid-19 outbreak has brought with it a fundamental shift in the ways GPs work. They have, for example gone from having face-to-face consultations with the vast majority of patients, to physically seeing patients for less than 20% of consultations in the space of just a few weeks.

Access to secondary care services and non-emergency or non-covid hospital treatment has been severely restricted which means in practice that GPs have been unable to refer many patients. Those patients have either had to be put on hold, or their conditions managed in the interim by their GP. It would also appear that the number of people seeking consultations from their GP in the first place has also gone down. Presumably this is because they are afraid of exposure to transmission or because they do not wish to burden the NHS during a health crisis.

Since the lockdown started, GP’s day to day workload – and the associated administrative burden – has probably reduced significantly. This is not to say that they are now underworked and have vast excess capacity however; there were wide reports of GPs being overworked and underfunded prior to the outbreak and if anything, workloads have probably come down to a more manageable level.

So as the world slowly starts to return to some semblance of normal, will we see a return to the GP practice of old? Probably not.

Remote appointments are not for everyone and are probably less effective for those presenting with new complaints or suffering from certain conditions, such as mental health. However, reports suggest that remote consultations have, on the whole, been well received, at least by patients who have chosen to engage with them and consequently, it is likely that these will continue at a higher rate post Covid-19 than beforehand.

Technology is also helping GPs to improve communication and interfacing with other health and care services and to empower patients to take a more active role in their own treatment. Patients who would previously attend a GP surgery for routine observations or collect blood test results, for example, are now finding that they are able to do these for themselves at home. More centralised data and telephone triage services, for example, have all proven particularly effective during the Covid-19 response and there is likely to be appetite amongst those working in the sector to maintain a more coordinated, and less bureaucratic approach to the provision of healthcare services.

It is widely accepted that there will be a backlog of deferred treatment needs for those who have put off, or delayed, seeking medical advice because they simply do not want to risk exposure to Covid-19, or those who have been unable or unwilling to engage with remote GP services. This will be in addition to those who have simply had to wait for services to be up and running again. As our management and control of the virus improves and the NHS and other health providers start to reopen access to services which were put on hold, or deemed non-essential during the height of the crisis, it is entirely foreseeable that those deferred treatments will create a significant peak in demand on GP’s and the health sector more widely.

In respect of administrative work, when GPs are able to return to practice predominantly from their surgery, there is going to be a significant backlog of paperwork to catch up. Even if the take up of technology helps to keep face-to-face consultation numbers down, there will probably be an influx of requests for face to face appointments from those who did not engage during the Codi-19 period, and vast numbers of referrals to make and follow up. There will be HR matters to deal with in respect of staff who have been on furlough or those who need to self-isolate or are clinically vulnerable and staffing shortages may continue to be an issue if staff need to self-isolate or shield. CQC routine inspections have been suspended, but are likely to re-commence and GPs will continue to be required to meet their usual regulatory requirements. It is therefore likely that GP’s workloads will return to a pre-Covid-19 state, if not worse, very quickly.

To deal with the backlog of delayed or deferred treatment (or indeed any new peak of demand) GPs, along with everyone else across the whole health and social care sector, are going to have to find a way to prioritise treatments which can or should be offered. Deciding how to best, and ethically, prioritise health needs will require careful thought from scientists, clinicians and probably politicians across the board. However, as a first port of call for many, the GP will be the real front line in this respect and GPs are likely to have to face some tough decisions. We hope that there is sufficient support and guidance put in place for them to be able to do this.

The whole health and social care sector will still have to deal with Covid-19 for the foreseeable future. Unless and until a vaccine is found, or we have a more effective testing and screening programme, GPs are likely to have to assume that every patient who walks into their surgery is a potential carrier of Covid-19. This will have a number of practical and logistical consequences for the foreseeable future surgery space and ways of working will need to be adapted accordingly. It may, for example, become the norm for GPs to wear PPE to seek every patient and patients may be required to wear face masks on arrival. Surgeries may need to split into “green” and “potential covid” areas, or be rearranged to accommodate social distancing.

In practice, this is likely to mean a significant increase in the money and efforts spent on infection control. It is also likely to encourage GPs and patients to persist with remote consultations where appropriate and encourage GPs to offer more routine services out of the surgery (such as mobile vaccination centres). All of this will take time, money and training to implement and coordinate effectively.

Whilst the coronavirus may have reduced the usual GP workload, it is not like GPs have all been sat at home doing nothing with a surplus of free time. They, like many others in the health and social care sectors, have had to adapt their ways of working at incredible pace and have been subject to ever changing Public Health guidance. GPs will probably continue to see significant and frequent changes in the guidelines to which they operate, such as those from PHE, the CQC and NICE, which they will need to remain on top of.

Even before the Covid-19 crisis, there was a severe shortage of GPs in the UK. The Royal College of GPs for example reported in January 2020 that this was causing unreasonable delays for patients, and leading to GP burnout. Recruitment of new GPs was already posing a challenge and this situation looks unlikely to improve in the foreseeable future. Some 50% of newly admitted GPs in 2019 were from overseas and it looks unlikely that foreign travel and immigration will facilitate the easy supply of new GPs from abroad any time soon.

Many GPs will, like their colleagues in the rest of the sector, simply be exhausted once the dust has settled for the rest of us. Mental health conditions are likely to increase amongst GPs. GPs at the end of their careers may be more inclined to take retirement earlier than they may otherwise have done. Those retirees who have already returned to the service to assist with the Covid-19 response will most likely go back into retirement.

Once the public has confidence that the risk of transmission is low and once secondary health services are fully up and running again, GPs’ workloads are likely to increase and get back to the pre-Covid levels, if not exceed them, relatively quickly. Things might get even busier, and tougher, for GPs because they will have to handle a full patient load and prioritise and manage delayed or deferred treatments alongside managing the risk of covid-19 transmission. GPs may find they are again snowed under with work very quickly.

It does not, however, all have to be doom and gloom. GP services, along with and supported by the wider health and social care sector, can capitalise on some of the lessons learned, and success stories, which have arisen out of the coronavirus response. Remote appointments may continue to be the norm, not the exception for many patients. Patients may continue to be able to have more empowered role in their own care and treatment, taking some of the burden away from GPs in management of long term conditions. GPs may find more innovative and effective ways of supporting patients and following up referrals.

Provided GP services are properly supported by the government and the rest of the sector, there is no reason why GP practice cannot end up in a better place than it was pre-Covid in the longer term. However, if that is going to happen, it is critically important that GPs are properly supported and are not overlooked in any government plans for the sector.

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