Helen Salisbury: General practice on the brink

No sensible person setting out to build the NHS from scratch would reproduce what we have now. Like an ancient house, which each generation has altered to fit—pulling down a wing here, adding a new storey there—it’s grown into something much loved, which mainly works but sometimes lacks coherence. The quality of workmanship varies, not enough has been invested in maintenance, and large cracks are visible. Right now, the bit most in danger of falling down is general practice.

Things were shaky even before the pandemic, and now we’re buckling under the strain. When I became a GP I signed up to be responsible for the patients on my list, and I’ve been criticised for being unrealistic in trying to cling to my original role. However, I still want to get to know families over years, reassure and treat when I can, and refer to specialists when necessary. With serious illnesses I want to support them through complex treatment and even, occasionally, attend the funeral at the end.

But demand for GP consultations has rocketed,1 making that sort of practice feel like a luxurious relic. For many doctors, work has become an endless series of one-off remote encounters, devoid of context. During the pandemic, hospital staff have been redeployed, clinics and operations cancelled, and GPs left holding the patients with unsolved problems while they wait in pain or uncertainty. When they’re finally “seen” in a telephone outpatient clinic we’re then asked to perform tests, prescribe, and monitor—adding further hours of work to our day.

I suspect (but have no hard evidence to prove) that our own telephone consulting is also less efficient than face-to-face appointments, with fewer problems solved to the satisfaction of patient and doctor in a single call. Follow-up appointments, either to examine or because the original assessment was inaccurate and the treatment unsuccessful, are anecdotally more common.

The workload crisis has many possible solutions,2 but some will take too long to prevent doctors of my generation from taking early retirement. Ideally, patients would be educated to better access information enabling self-care, at least for a few days before contacting GPs (except, of course, when it’s a sign of something serious—so they’d need to learn that too). The root causes of some of our ill health might be removed if people were more active and ate better, but this would take decades to have an impact.

Right now, we need more drastic and immediate action. Hospitals sometimes declare themselves full, diverting patients elsewhere. Most practices don’t do this—at least, not yet. But if the duty doctor has 60 calls to respond to, is it safe to keep adding to the list?

General practice is the foundation of the NHS, and if it fails the entire edifice will crumble. No doubt private contractors will be waiting to build a shiny new structure—but it will be at a much higher price and based on very different values.