The reputation of general practice, once seen as the ‘jewel in the crown’ of the NHS, is under threat. This has not been a sudden change but a slow deterioration over the last few years, further exacerbated by COVID-19.
The NHS has changed out of all recognition since its inception in 1948. The public has found these changes hard to accept in general practice and appears to be nostalgic of a bygone era when the GP was A Fortunate Man,1 a solo warrior against disease and injury available at all times of the day and night.
PUBLIC PERCEPTION
Public satisfaction with general practice has historically always been higher than other areas of the NHS. This started to change in 2017 when satisfaction dropped to 65%,2 the lowest level since the British Attitudes Survey began in 1983. In 2019, the same survey showed that 51% find it hard to get a GP appointment, suggesting access is an issue for many.
The recent COVID-19 crisis has made matters worse. The rapid closure of the doors of general practices, the initial shift of all COVID-19 care to 111, and the widespread adoption of telephone triage has angered patients. There has been a significant fall in face-to-face appointments since the start of the pandemic, with numbers dropping in England from 19 230 573 in February 2020 to 10 381 550 in August, a fall of 47%, with total number of appointments falling by a smaller but still significant 16.5%.3
The new reliance on telephone consultations and triage bring with them issues with continuity and communication. We know that there is something objectively different in a face-to-face consultation, which improves patient satisfaction4 by allowing crucial non-verbal communication including the therapeutic benefit of touch. Similarly, a loss of continuity of care not only reduces patient satisfaction but also seems to increase mortality.5
Public perceptions of the situation are not helped by the media portrayal of GPs, which was shown in a recent study to be overwhelmingly negative.6 It only takes a brief read of the message boards underneath articles about the recent letter to GPs from NHS England to see that the response is a significant feeling that GPs are either too lazy or scared to see patients.
Image: National Cancer Institute on Unsplash.
Issues with public perception must be placed alongside the problems with morale in general practice. There is a reason A Fortunate Man does not have a happy ending and GPs have higher rates of mental illness then the general population. Low staffing numbers and increased bureaucracy have led to inevitable increased work levels, with a recent BMA survey showing that ‘... 79% of GPs are often or very often working beyond their regular hours — the highest of any branch of practice.’7
MANAGING CHANGE
The Royal College of General Practitioners has seen the COVID-19 pandemic and the changed ways of working as an opportunity to break this cycle, with a recent paper suggesting a post-COVID plan for a happy median of telephone and face-to-face appointments along with reduced administration tasks.8
Alongside this there was already movement towards increased use of allied healthcare professionals as part of the General Practice Forward View.9
With all of this in mind it is important that the necessary and inevitable changes in general practice are not seen by the public as a defensive measure, a way of keeping patients out and protecting GPs both physically (from COVID-19) and emotionally (from the stress of the job). While there may be a degree of the latter in our strategy, it must be ensured that the key tenants of easy access, continuity, and good communication are involved in our planning, with a view to both good care but also to improve patient satisfaction.
If we do not manage the current changes well and reverse the flow of public opinion we are in danger of destabilising general practice and, by extension, the NHS itself.
- © British Journal of General Practice 2020
