Today I’m ‘on call’. That means I see urgent cases rather than booked problems and reviews, so it usually means a more unpredictable day at work.
I arrive at the surgery at 8.30am and check in with the reception staff and managers. The phone lines are red hot this morning; as they have been every day since late April. COVID-19 has seen demand for appointments rise significantly and it’s been a challenge to keep up with the demand. Receptionists often receive bad press but I’ve sat with them recently doing training and they are caring, patient and helpful each time.
Like most workplaces, we’ve had to manage with reduced staff levels, with staff self-isolating and shielding, but throughout the pandemic, our fabulous staff have kept working with humour, despite the risks to themselves. Happily, there are no new issues today, so we have a quick chat and I get to my room to power up the computer.
General practice looks and feels very different now and we’ve had to dramatically change how we see patients. We now telephone all patients to discuss their concerns first and, in many cases, we have found it relatively simple and convenient to solve many of those issues remotely over the telephone.
We sometimes conduct an assessment over video and it’s useful for patients to send images by text or email when they have lesions or rashes to assess. Around a quarter to a third of patients still need an assessment ‘face-to-face’ and a good old-fashioned examination. We often call patients directly to our rooms from the car park, as physical distancing in the waiting room is difficult.
By 11am, I’ve telephoned 11 patients and seen three at the separate self-contained unit where we see our emergency patients. The on-call doctor sees those with urgent problems, as well as anyone who has respiratory symptoms or a fever. We’ve continued doing this since February to segregate those patients in a separate part of the surgery, so they’re not having to mix with people having blood tests, vaccinations, dressings and attending with other more routine issues; as many of those who attend our surgeries are also by definition the most vulnerable to COVID-19 infection. This process worked well during the height of the first wave and we’re continuing it, so we’re well prepared for the next spike, if it comes. Happily, no-one we’ve seen so far today is too sick and they only require a prescription and some reassurance.
I see a lady who appears to have had COVID-19 back in April, despite testing negative. She’s still getting episodes of tiredness and shortness of breath four months later and it’s really affecting her. I reassure her there are no new findings and give her some advice on how she can gradually get back to normal, but it shows the effect this virus has had on many people’s lives; even those with relatively mild infections who weren’t hospitalised. We book her for some more tests to ensure it isn’t anything else and arrange a review in a couple of weeks.
Every time we see a patient in person, we wear PPE (personal protective equipment) and have to clean down the room afterwards. It’s much more time consuming but ‘needs must’. The PPE consists of a plastic apron, visor, paper mask and gloves. It’s unpleasant and hot to wear, even on the cold days. How my fantastic colleagues in the hospital ITU and Covid-19 wards manage with wearing the even more stringent PPE and more fitted masks astounds me – they have my admiration! Wearing them on home visits can be rather trying, especially when it’s raining or windy as you try to ‘don and doff’ PPE under the shelter of your car boot! After each patient, we have to clean and wipe down surfaces, so appointments often take twice as long as they used to.
By mid-afternoon, I’ve seen another seven patients at the surgery with abdominal pain, water infections, nosebleed, headache and breathing difficulties and dealt with another 15 or so phone calls.
We’ve seen the population suffer more mental distress since lockdown and the effects on mental health continue to be pronounced. The elderly and the young have been most affected, and I speak to several patients who are really struggling to cope.
People have been more isolated from friends, family and support and at our surgery, we’ve consulted with many more people with anxiety than we usually would. We’ve also seen increases in people contacting us with alcohol and substance use issues. As well as prescribing them medication to help, we’ve been encouraging more exercise and self-help measures like support websites, meditation and mindfulness apps. Mental health services locally have been very effective at adapting to delivering more phone and on-line interventions too.
Lunch is usually a hastily munched sandwich at the desk and today is no exception!
When things finally seem to slow down a little around 4pm, there’s a chance to visit a regular patient of mine who is receiving palliative care as his cancer has returned and is now incurable. I spend a very worthwhile 30 minutes with him discussing his care, alleviating symptoms and am able to liaise with his specialist team. Helping people at the end of life remains a privilege and is as rewarding as it can be draining emotionally.
I get back to the surgery to find five phone calls have stacked up since I’ve been out. There are more sick children, some patients with chest pains that aren’t serious and a couple of people with hospital treatments delayed and issues arising that can’t wait. We’re seeing more of these cases, as inevitably the hospitals have had to transform almost overnight, as we did, to deal with COVID-19 and suspend their planned work. They’re understandably struggling to resume managing all the things they did before. They’re in an impossible position, like much of the health service, which has been expected to deal with a dangerous pandemic and continue ‘normal business.’
At 6pm, I see a frail older lady with an infected leg and after that, examine a young lad with abdominal pain.
6.30pm comes and the phones transfer to the Out of Hours Service. It’s then a chance to catch up on the two referrals, the 30 blood results and the 23 letters sitting in my inbox and needing action before tomorrow. That’s about half the daily number of patient clinic letters than it used to be, but that probably reflects the struggles the NHS is having with resuming ‘normal service’ with reduced capacity.
The pandemic has brought some welcome innovations and, if anything, has made us more accessible in some ways, with same-day phone consults the norm. Video consults are here to stay and we’re even accessible by website and e-mail! But all these changes will take time to be bed in and be accepted by patients, as well as those working in the NHS. No changes can paper over the fact that we still need more GPs and allied staff to service a population who are getting older and sicker.
Today hasn’t been a busy day by pandemic standards, but between two duty doctors, we’ve still telephoned 59 urgent cases, seen 19 of these in person and been out on home visits. Consulting since the pandemic generally takes longer and the increased burden of phone consulting in particular is having an effect on some of my colleagues. It can be gruelling at times but in reality, it’s become a necessity to work this way; with COVID-19 the days of packed waiting rooms are over, as they would be a risky place. We’re all hoping that a second wave doesn’t materialise and that there isn’t a significant flu season putting strain on services either. There’s never been a more important year to get your flu jab!
Finally, it’s time to change back out of ‘scrubs’ into ‘civvies’ again, chat briefly to the cleaners as they do their nightly deep clean of the surgery and head back home to see the family before we do it all again tomorrow. General practice has always been a team effort and that’s never been more clearly demonstrated than in 2020.
Ian Harris is a GP partner working in Oak Tree Surgery in Brackla, Bridgend and a member of the BMA GPs committee