14 Jan 2015

Increasing pressure on GPs is ‘root cause’ of A&E crisis

Dr Hamed Khan, a south London GP who also works in A&E departments explains how the increasing workload on GPs means their traditional role as “NHS gatekeepers” has been undermined.

Patients now have to wait longer than ever to be seen in A&E. Last December only 83 per cent of patients were seen within four hours, and this year that figure fell to just under 80 per cent – far below the 95 per cent which the NHS aims for.

 Watch: A & E departments 'stretched to the limit' - video

As a doctor in a busy London A&E department, I have seen patients wait for several hours to be seen, despite doctors and nurses working absolutely flat-out and seeing patients non-stop. Patients seem dissatisfied and clinicians disillusioned and burnt out.

What is more disturbing is how government interventions have contributed, perhaps decisively, to the current A&E crisis.

But this state of affairs does not come as a surprise to those of us who predicted that this was bound to happen. A multitude of problems, all intertwined with each other, seem to have set off a vicious circle which poses an existential crisis for the NHS.

The first is our ageing population, with increasing numbers of elderly patients with multiple complex illnesses needing careful long-term monitoring and treatment. Such patients also have extensive social care needs, resulting from problems such as dementia, incontinence and immobility. This group of patients understandably consumes the biggest proportion of NHS resources.

What is more disturbing is how government interventions have contributed, perhaps decisively, to the current A&E crisis.

‘GPs as NHS gatekeepers’

In order to understand this, one must appreciate the vital role of GPs in our health system as the “gatekeepers” to the NHS, treating illnesses in primary care, monitoring chronic diseases and thus preventing people from becoming unwell (e.g. preventing heart attacks in those with heart disease etc.), and liaising with other health professionals to organise care for patients in the community. This system has been hugely efficient – GPs consume only about 8.3 per cent of the NHS’s resources, according to the Royal Gollege of General Practitioners, despite 90 per cent of patient contact taking place in primary care.

 Read: FactCheck: how does A&E in England compare to other countries?  

A few years ago the government passed the health and social care bill, which gave GPs the responsibility to decide how and where to allocate the £60bn NHS budget. The government says that it wanted to give GPs decisive influence over NHS expenditure. But this bill has cost billions of pounds to implement, and some of the most experienced GPs have little choice but to spend more time in boardrooms doing organisational and managerial work, and less time in their consultation rooms seeing patients.

One must appreciate the vital role of GPs in our health system as the ‘gatekeepers’ to the NHS.

Simultaneously the government also ordered the NHS to make “efficiency savings” of £20bn, resulting in several services being reduced precisely when investment was needed most. In addition, the thresholds of the quality and outcomes framework (QOF) system by which practices are paid to achieve clinical targets, have been continually raised, meaning that GPs are having to do more work simply to keep their practices financially afloat.

As a result of all of these factors coalescing simultaneously, the average GP has an impossible daily workload to contend with. Many GPs see 45 to 47 patients per day, and then work late into the night reading through hundreds of hospital letters, blood results, X-ray reports – and finishing off with three or four home visits.

Brain drain

GPs are leaving the profession in droves, with older GPs grabbing the first opportunity to retire, and younger GPs opting to work as freelance “locum” GPs or emigrating to places like Canada and Australia. One senior GP recently joked at a job interview that I would have to surrender my passport on taking up the job.

This has caused an acute shortage of GPs, with practices often unable to provide enough appointments to meet demand, and GPs increasingly unable to give their patients as much time as they would like to.

Read: FactCheck: is the health service in meltdown?

Typically, patients are having to wait one or two weeks to get an appointment, and when they finally see their GP, it is likely that he or she will be overstretched and overloaded and simply won’t have enough time to deal with more than one problem safely. This leaves the GP no option but to ask the patient to book another appointment to discuss other issues – which then means another two week wait for the patient – and thus the cycle continues. Increasingly practices are resorting to telephone appointments rather than seeing patients, in an attempt to increase their capacity.

The GP is simply too overstretched to provide high quality multi-speciality long-term holistic care empathetically.

And that brings me to one of the fundamental reasons for the rise in the number of patients going to A&E – which is because they can’t see their GPs. It either takes too long to get an appointment, or the GP is simply too overstretched to provide high quality multi-speciality long-term holistic care empathetically in the precious 10 minutes he or she has.

The only other frontline service where they can be seen is A&E, often seen as the default alternative. I spend a lot of my time working in paediatric A&E, and have seen swathes of patients who acknowledge that their child’s symptoms are not acute, but either could not get an appointment with their GP, or felt that their GP wasn’t able to spend enough time with them.

‘He preferred to see an A&E doctor rather than a GP’

In one encounter, a father was very grateful to me for treating his son’s tonsillitis in A&E, and said that he preferred to see an A&E doctor rather than a GP. He was rather bemused when I told him that I was actually a GP myself. Considering that his regular GP had had access to the child’s medical records and could follow him up, he would probably have received better care with more continuity by his GP rather than in A&E.

Similarly several patients who know that their problems don’t need A&E treatment, still nevertheless go to A&E. I have worked several shifts in paediatric A&E where over half of the children I saw and treated fell under this category, with illnesses like tonsillitis, respiratory infections, rashes and diarrhoea which could easily have been treated by their GP.

What concerns me most is that long waiting times could deter or delay care being given to those who are seriously unwell, and who actually need acute hospital treatment.

This is why, in my opinion, the root cause of the A&E crisis actually lies in general practice. For decades we have had a system and a tradition whereby family doctors knew their communities and looked after their patients from “cradle to grave”, and worked hard to keep patients out of hospital.

My advice to the government would be to stop treating the NHS like a political football.

But as a result of government interventions, this system is on the verge of collapse. GPs are overloaded and can only “firefight” – and swathes of patients are redirecting themselves to A&E, without any corresponding increase in resources there.

My advice to the government would be to stop treating the NHS like a political football and halt the constant restructuring that comes with every election. Instead they should invest in GP training and the recruitment and retention of GPs, and educate patients about the most appropriate setting for their problem. The rise in A&E attendances can only be reduced by strengthening GPs and giving them the capacity to fulfil their traditional role as gatekeepers of the NHS.

Dr Hamed Khan is a GP and clinical lecturer for St Georges Hospital Medical School (University of London) in south London.