DAUK’s GP Team were among the signatories to a letter published in The Observer this weekend, opposing the view that general practice’s problems could be overcome by hiring younger doctors. The letter reads:

Torsten Bell uses US data to claim that when GPs retire, the use of other emergency services rises (“Why baby boomers might end up healthier if their GPs retire early”, Comment). This in itself would be an argument to strengthen primary care in the UK. Bell then claims that new GPs are more likely to pick up a new diagnosis of diseases such as Alzheimer’s, concluding that GPs retiring can be a good thing for patients, while pointing out that it also pushes up the cost of healthcare.

We believe that GP continuity of care not only saves lives and money but also leads to longer life expectancy. The age of your GP is not the problem here. It is the absolute lack of them. The UK is facing a GP crisis that long predates the pandemic. We need to retain our GPs at all stages of their careers – but especially those with many years of experience – who are also best placed to support and mentor junior GPs and the ever-growing number of allied healthcare professionals who are being employed to try to prop up a failing system in the UK.

Better safety and protection

Frontline doctors want the Government and/or the NHS to provide a physically safer working environment, with more air purifiers in hospitals, better ventilation, and FFP3 masks (which provide the highest level of respiratory protection) across all areas while Covid-19 rates are high in the general population.

Improve health and well-being

The grassroots lobbying organisation Doctors’ Association UK said the NHS should ensure staff have access to food and drink at all times. “If too busy for breaks, get a tea-lady (or man) to go round,” Dr Louise Hyde, a GP with the association, said.

“The NHS could provide emotionally safer workplaces by ensuring shifts had realistic arrangements for handovers and time for debriefing;, by tackling any culture of bullying or toxic HR culture; by ensuring all staff have protected holiday time, time off for weddings and funerals, and are not made responsible for making swaps or finding locums to replace them.

“Ultimately, treat health care workers as the valued, skilled professional workforce that they are, with human needs and lives which cannot be sacrificed indefinitely for their job.”

Visas for elderly relatives of overseas-born NHS staff

Over the last 12 months i has highlighted numerous cases of NHS staff – born overseas and now British citizens – forced to choose between their job and returning to their country of birth to look after ailing parents, as tighter immigrations rules reduced the chance of obtaining an adult dependent relative (ADR) visa to almost zero.

It is a ripple effect of th “hostile environment” policy introduced when Theresa May was Home Secretary.

With about 170,000 non-British NHS staff, the restrictive immigration rules are disproportionately affecting healthcare workers. The British Medical Association, along with other organisations such as the BAPIO (the British Association of Physicians of Indian Origin) and APPNE (Association of Pakistani Physicians of Northern Europe), have campaigned for rules on ADR to be relaxed.

Just 70 ADR visas were issued by the Home Office last year – in contrast 2,325 ADR visas granted between April 2010 and March 2011.

Read the full article here

Contrary to widespread reports, GP surgeries have remained open throughout the Covid-19 pandemic. Official NHS data confirms that more GP appointments are being offered than ever before, and GP teams continue to provide over 90 percent of all NHS consultations. 

Practices were already struggling prior to the pandemic and are now facing near-impossible challenges in the face of a “tsunami of demand”.

Attendees at this briefing heard from frontline GPs who described:

• The causes of rising demand on our services
• The increasing cases of burnout amongst GPs
• The damaging effects of unproven bureaucratic interventions
• Consequences of the demoralising, harmful narratives against our profession
• Proposed solutions to our challenges
• How you can help us help our patients

Dear …..,

I am concerned about the airborne spread of Covid in our work environment, especially now it is clear that the new Omicron variant is very easily transmitted through the air.

I would like to make you aware of the new updated guidance from the UK Health Security Agency, released on 21st December 2021. 

My interpretation of the guidance is that employers should make a full assessment of ventilation and air filtration in every clinical area. If adequate air quality cannot be assured, or for those who can’t keep 2m distance for patients, then PPE of a grade appropriate for airborne hazards should be provided. Local prevalence of respiratory pathogens must be taken into account within risk assessments. Currently there is a high risk that any patient or member of the public could be carrying Covid, regardless of their presenting symptoms, so airborne mitigation measures would be appropriate in all indoor spaces where patients or staff mix.

This would be consistent with the evidence that FFP3 masks reduce Covid infection in health care workers.

And with the evidence that air filters in clinical areas reduce airborne viral load.

These interventions are immediately necessary in order to fulfil legal obligations under HSE Health and Safety at Work legislation.

Financially, although some cost may be incurred in order to make these interventions, this would be more than compensated for by the savings in sick pay for staff infected at work and needing to self-isolate.

As we know, Covid is most infective just before, and around the time that symptoms develop. Daily lateral flow testing reduces the risk of someone unknowingly carrying Covid, but has a significant false-negative rate. By protecting our staff from infection, we will also be adding an extra layer of protection for patients, preventing them for getting hospital-acquired Covid.

Although not covered by this guidance, acting to reduce airborne viral load, and offering those patients who are able to wear them the option of more protective masks, would also reduce the risk to patients of hospital-acquired infection.

I would be grateful if you could implement the new guidance and evidence urgently to protect all staff and help us continue to provide excellent patient care in safety.

Yours sincerely

Doctors Association UK representative Dr Louise Hyde, a GP in Tywyn, Wales, says her rural patient group is ‘generally not very demanding or well off’, but despite this she is seeing ‘way, way more’ of them choosing to pay for care.

‘I’ve recently had an elderly lady say she’s too old to wait two years for her cataract op, so she’s going private. An elderly man made the same decision about his hip replacement,’ she says. 

Dr Hyde adds: ‘Urology waiting lists are really bad here and I’ve had one patient with bladder cancer and another with prostate getting tests and outpatient appointments done privately self-paid, although I think both then returned to the NHS for treatment.’ 

Read the full article here

Amid claims that GPs are “hiding” from patients behind telephone triage and e-consultations, I feel compelled to show you a glimpse of “The Other Pandemic”. Falling squarely at our feet overspilling our appointments: mental health.

In March a survey of over 4,000 people in the UK established that “there is a genuine, wide and profound mental health crisis.” The appointment list for my day’s surgery supports the assertion.

GPs have always managed the majority of mental ill-health in the UK. One surprising positive to come from the pandemic, is that talking about mental health is losing its stigma.

At the start of the pandemic, even the worst affected tried to hang on, to give us the time and space we needed to deal with Covid. Those who did come were already in crisis, desperate, having held their breath for too long.

After the first lockdown the floodgates opened, and over a year and a half into a pandemic that seems destined to continue indefinitely, every day brings more new patients.

Mental health services were already creaking pre-pandemic. Community mental health teams provide good, if slightly slower, access to talking therapies for those too ill to access the voluntary sector service, and a crisis team that can react to offer support in a timely way to patients at risk of suicide. 

But what they can’t offer, is medication. That needs a psychiatrist; the adult psychiatrist for my particular area has been unfilled for months. If I think patients need more than an anti-depressant, or an adjustment of anti-psychotics, then we must wait until the situation becomes urgent enough to warrant a review by the psychiatrist from a neighbouring area.

With clear evidence that severe mental illness is best nipped in the bud, preventing both long term illness and recurrence, that can’t possibly be an adequate service for our patients.

Child mental health services fare no better. Child and Adolescent Mental Health Services (CAMHS) have a reputation for being impossible to access at the best of times. They are the only service GPs refer to who routinely “bounce” referrals back, without even seeing or assessing the patient. With disruption to schooling, uncertainty about exam formats, isolation from friends, fear of illness and loss of loved ones, the mental health of our children is suffering, and the service has been overwhelmed.

Even those children who clearly meet the referral criteria are waiting months to be seen. As a GP there is little I can offer here, except monitoring and general support. 

I find myself seeing a child and her clinically vulnerable parent monthly, tracking her increasing anxiety, her flattening mood, the total insomnia worsening to the point of hallucinations. A change that means I can write a letter to expedite the appointment, and six weeks or so later, an assessment happens. I continue to check in with her while she waits again, this time for therapy.

I know just enough about this highly specialised area to be aware that my inexpert input could cause more harm than good; regularly opening a box of unhappiness she may have naturally put a lid on, without being able to help her make sense of the contents, balanced against the risk of not knowing whether she is deteriorating, or how deep that deterioration has gone.

Other regulars include a small cohort of new mums, mostly presenting too late after the birth for the narrow referral window of our perinatal mental health service. Isolation and lack of support has hit hard at a time when sleep deprivation, hormones, traumatic experiences, pain and disillusionment coincide to create a perfect psychological storm. I do my best, but notice that those who can afford private therapy seem to recover faster and more fully.

Another, larger cohort, are the patients with health anxiety. Something that has affected almost all of us to some extent, during the biggest health crisis of our time.

Amongst the onslaught of unmet need, we must sift through those whose anxieties about their health are irrational, and identity those who may have been sitting on a serious physical problem for too long. Both need addressing and often both can occur within the same patient. With delays in secondary care diagnostics, and now a national shortage of blood test tubes, we are working in a minefield.

Working at this intensity, among so much distress and without an end in sight, is starting to take its toll on our profession. In April mental health service NHS Practitioner Health announced they were taking 22 per cent more self-referrals from GPs than pre-Covid – myself included.

Mental health care and general practice are in deeper crisis than ever before, and this needs a political solution. There is an opportunity here to open a conversation and with investment, to create something outstanding. We just need to demand it – please write to your MP to do this.

In the meantime, keep trying if you need to see us, and remember that GPs are human too, so please be kind.

Dr Louise Hyde is a GP and member of the Doctors’ Association U.K.

Covid-19 has caused chaos for me over the past month, and I’m sure I’m not the only one. I’ve got children in primary school, work as a GP – and yes, I do see most of my patients face-to-face – and I’ve had to leave my safe little corner of rural Wales a lot recently, for a party, a course and a wedding.

One striking thing, especially going across the border into England, is how people’s habits around mask wearing vary so dramatically in different settings.

We know that Covid is an airborne virus, so it seems completely sensible that wearing masks when we’re indoors with other people should be normalised. It certainly has become so in most other parts of the world, but somehow, in the UK, nothing is so straightforward.

Travelling through England last weekend on a packed train, windows closed and steamy, I noticed that only a handful of passengers wore masks. We loosely clustered together at one end of the carriage.

For all the debate about mask mandates and hype about ‘freedom day’, the UK population is still quite uninformed about some of the most important basic facts about masks.

There’s a growing body of evidence that says mask quality is important. An FFP3 mask, which seals on the wearer’s face, is better than an FFP2, which is fitted but not sealed. Below them come surgical masks, and then cloth masks.

I rarely see anyone wearing an FFP2 or FFP3 in any setting, and yet, if you or your immediate contacts are clinically vulnerable, that would be one of the best interventions within your power, after vaccination, to reduce your risk. I’ve yet to find a brick-and-mortar pharmacy or shop selling them, although you can order them easily online. And at this stage in the pandemic, there shouldn’t be any supply problems. You won’t be depriving a health worker or carer. Only the UK’s inadequate PPE guidance does that.

Counterintuitively, when something is worth doing, it’s also worth doing badly. In the same way that brushing your teeth for 20 seconds is better than not brushing them at all, a person wearing some sort of mask some of the time is better than none at all.

And the more you do it, the more benefit you get. In the context of a pandemic, if we want to get our rates down, it’s probably better for lots of people to do a half-hearted job of it, than only a handful of people to do it really well. That’s why we need to work hard to normalise mask wearing across as many indoor settings as possible.

At my cousin’s wedding, I was the only person wearing a mask. I went for a black cloth one which didn’t detract from my outfit. In the lovely, spacious, high-ceilinged hotel it felt like a safe compromise. Several people told me they’d planned to wear one themselves, but didn’t feel brave enough or want to stand out. Removing the mask mandate from social settings appears to have actually made those people feel less free to protect themselves and their loved ones.

In parliament, Jacob Rees-Mogg expressed a health belief which would be quite quaint if it wasn’t so dangerous to the general population: that the ‘convivial, fraternal spirit’ between him and his fellow Conservatives would somehow protect them from giving each other coronavirus.

The message that masks aren’t necessary between friends makes it harder for those who want to take the logical step of wearing one when they meet indoors to socialise. Care Minister Gillian Keegan’s reference to masks as a ‘sign of virtue’ adds yet another psychological barrier. Who wants to be seen as a neurotic, unfriendly virtue-signaler?

If public health departments and Government are serious in wanting to control the pandemic and avoid further lockdown, it shouldn’t be beyond them to create a marketing campaign that makes mask wearing more attractive. To give wearing a mask a different meaning than the one it has currently. We need to normalise mask wearing across as many different settings where people share air as possible, like most of the rest of the world.

The strongest argument I can think of is: Mask Up! Everyone’s doing it.

The Doctors’ Association U.K. encourage you to share your #maskup photos on social media – follow us on Twitter @theDA_UK and Instagram @thedoctorsassociationuk

Read the original piece in Mail Plus here

NHS England caused fury after it issued a letter blanket demand that all patients should be offered face-to-face consultations if they choose. Dr Louise Hyde, a GP with the Doctors’ Association UK, sets out the letter NHS England should have written.

Read the full article here.

Lockdown is easing, but as everyone lets out a cautious sigh of relief that normality may be around the corner, GPs are dealing with a tidal wave of work which shows no signs of abating.

When the pandemic descended last March, NHS England mandated the move to ‘total triage’ in primary care to protect patients and staff from COVID-19. We transformed our services overnight, moving our 1m consultations a day to remote telephone, video and online consultations, while localities shared staff and resources to set up hot hubs to see anyone with a clinical need.

Busier than ever

Data from NHS Digital showed, contrary to the reports of being ‘closed’, general practice was busier than ever. Not only busier, but dealing with more complexity and carrying the increased risks of remote consulting.

Every part of the health service has felt the strain of the pandemic. Secondary care deployed staff and cancelled routine work to funnel the majority of their resources into critical COVID patients. General practice held the fort for everything else (before even mentioning the millions of people we vaccinated). Waiting lists have spiraled and we in general practice are feeling the impact.

Patients waiting longer for operations need more GP appointments to manage their unresolved symptoms. We titrate up pain medications in one consultation, only to then treat the side-effects of those medicines the next. Those waiting for investigations have longer to worry about what might be wrong, or to re-present with deteriorating symptoms.

Meanwhile, patients who have stayed away throughout the second wave are starting to reappear. Many have been sitting on worrying symptoms for far longer than usual. People are sicker, there is more pathology, and even when the problem itself is straightforward, health anxiety is rife.

The mental health fall-out from the pandemic is only just beginning. Bereavements, job losses, financial strain, families imploding under the pressure of lockdown, people daunted at the prospect of rebuilding everything from scratch in a world where everything is more difficult than it used to be.

The impact of remote access

Remote access has made us paradoxically both more and less accessible. Online consultation systems allow busy people, who would never take time out of their day to come to the surgery, to contact us more often, about problems they previously would have ignored or dealt with themselves.

E-consults submitted when anxiety strikes at 3am about a self-limiting symptom, seem essential at the time, but more often than not, have resolved when the GP makes contact within the 48-hour timescale. The time spent reading the notes, excluding red flags, and then often dealing with a list of ‘while I’ve got you doctor…’ means GPs are working harder than ever ‘not seeing’ people, leaving the hard of hearing and less technologically able struggling to access care.

Healthwatch’s recent report confirmed that patients do feel they are unable to access a GP, with 75% of respondents reporting negative experiences. Over a year into this crisis, there remains a widespread belief, perpetuated by some parts of the media that GPs are closed. Changing this mindset may prove impossible.

Colleagues report conversations with patients they are in the process of seeing face to face, in their surgery who ask mid examination ‘When are you going to re-open doctor?’. People who have had multiple remote contacts with resolution of their problem also remain dissatisfied – clearly there is a therapeutic value of looking their doctor in the eye.

What is the solution?

The Doctors’ Association UK has asked NHS leaders to take note and urgently review this crisis in primary care – which is a reflection of the state of the NHS as a whole. But what is the solution?

Throwing more money at primary care is only going to work if we have the right people in place to enable it to function. The NHS continues to haemorrhage experienced staff – due to burnout, retirement, alternate careers and more accommodating health systems overseas.

Ivy Grove Surgery in Derbyshire spoke out last week, with a 16-page open letter to patients outlining why demand is so high right now. Many found their honesty unpalatable and patient-blaming but their words undeniably resonated with frontline GPs, and the points they raised need to be brought to the table when discussing how we improve this situation.

Perhaps the answer lies in our individuality as GPs. Access arrangements to general practice have never been more uniform, nor more uniformly unsatisfactory to both patients and staff. What works for one patient population is completely unworkable for another.

Give us back the freedom to limit the e-access and decide what will work for our own unique mix of patients. The risk-benefit balance of a walk in and wait surgery will look very different in a rural community to how it would look in the centre of London. We need to be able to make those choices based on our expert knowledge of our communities, and it is time for us to start putting that expertise back into action.

Read the Opinion piece in GP Online here