We have all been affected in different ways by the increasing workload and pressures faced each day in practices.
I know that at the end of a day in surgery I feel exhausted and drained. I go home worrying about my workload and the decisions I have had to make, often rushed. I wish I had longer with each patient.
I know that my wellbeing is suffering, and I also know the wellbeing of colleagues across the country must be affected too.
We cannot care for our patients as well as we would like, if we are in need of care ourselves. We have to start prioritising our wellbeing so that we can continue to provide the care to patients that they need.
Reflect, plan and discuss on 9 September
Ahead of World Suicide Prevention Day on 10 September, the BMA GPs committee is encouraging all GP practices to take some time on 9 September – perhaps an hour or two – for staff to reflect on their wellbeing, and what they can do to protect it.
We suggest that practices use this time to reflect on the loss of colleagues, and identify how you can support the health and wellbeing of your practice team, and how you manage your workload.
Reflecting on the loss of colleagues
Sadly, the recent death of Gail Milligan was not the first in general practice, and this is unacceptable. We have a duty to remember Gail, and to prevent the loss of more colleagues.
These resources on suicide prevention might be helpful:
- Zero Suicide Alliance resource library
- World Suicide Prevention Day 2022 – Take time to reach out
- Society of Occupational Medicine – Responding to the death of a colleague in primary care
Your team’s health and wellbeing
You can use our poster with 10 tips to support your and your colleagues’ wellbeing as a guide:
- Check in with each other – let someone know if you are struggling, and look out for signs that colleagues might need help
- Senior staff, stay visible and available, and stress that it’s OK to not be OK
- Rotate staff between high- and low-stress activities
- Pair less experienced staff with more experienced colleagues
- Arrange small support groups and safe spaces for staff to speak openly
- Make food and drink easily available, and encourage taking a break
- Encourage colleagues to connect with support networks
- Call on healthy coping strategies, like exercise
- Be kind to yourself and your colleagues
- Ensure colleagues are aware of where they can access support.
Support services for doctors and GP practice staff include the BMA’s 24/7 confidential counselling and peer support, networking groups and wellbeing hubs with peers, the NHS practitioner health service, and non-medical services such as Samaritans.
Workload and safe working in general practice
There are some things practices can do to control workload and mitigate the worst impact of unsustainable demand and overworking.
To ensure clinicians are providing safe care and advice, we recommend limiting the number of direct patient contacts (face-to-face or remote) to 25–35 per day. This enables clinicians to provide longer and more holistic contacts for their patients, while preserving their own wellbeing. Where the patient’s need is urgent, alternative sources of support should be used.
PPGs (patient participation groups)
Practice PPGs are a crucial ally and resource. We encourage practices to engage their PPGs, and to discuss openly the challenges you face.
Take account of patient contacts in your appointment books as a way of measuring workload. Work undertaken on repeat prescriptions and documents can be counted separately, but it is not currently collected by NHS England.
External un-resourced workload
Practices have no contractual obligation to undertake un-resourced, non-contractual work coming from other agencies and from secondary care, and should pass requests back. The BMA has a pack of template letters for this.
Practice list closure
Practices may consider closing their list if they can provide safe care only to their present number of patients, given their existing workforce. Practices should initially consult with their PPG and then their ICS (integrated care system).
Providing patient care outside the core GMS contract, such as DESs, LCS, QOF and IIF arrangements, is voluntary, and attracts payment separate to the core GMS. Practices may prioritise the areas of non-core work that provide safest and most effective patient care.
PCN DES (primary care network directed enhanced service)
Practices need to consider if the PCN DES enables them to offer safe and effective patient care within the context of their practice, and its workforce. There is a process for practices to say they no longer choose to continue in the DES between 1 April and 30 April 2023, or when there is a change to the PCN DES.
On leaving the DES, the payments associated with it would cease to practices, ARRS staff would no longer be able to provide services to patients on its list, and the PCN may be at risk.
What can GPs say ‘no’ to?
The general medical services contract requires the practice to deliver ‘essential services’, defined as: services required for the management of a contractor’s registered patients and temporary residents who are, or believe themselves to be:
(a) ill, with conditions from which recovery is generally expected
(b) terminally ill; or
(c) suffering from chronic disease
which are delivered in the manner determined by the contractor’s practice in discussion with the patient.
Beyond this are many examples of inappropriate work that practices are often asked to carry out – wasting much-needed GP appointments and causing delays for patients. These are examples, but it’s by no means a definitive list:
- automatic re-referrals resulting from patients not attending hospital appointments
- routine follow-up of hospital procedures where the GP is not best placed to follow this up
- re-referral to a related specialty (eg physiotherapy referral by a rheumatologist), creating unnecessary bureaucracy
- hospitals referring patients for fit note certificates that could have been done there, at the time of discharge
- hospitals referring patients solely to prescribe medication which is the clinical responsibility of the requesting clinician (eg specialist prescriptions outside a GP’s competence, acute prescriptions that should have been issued on the day)
- following up test results ordered in hospitals, which are the responsibility of the requesting clinician
- arranging hospital transport which could be done directly between the hospital transport service and patients
- arranging other tests and investigations that should be part of the commissioned secondary care service.
Some of this work will need to be commissioned appropriately to avoid patients experiencing any difficulty.
On 9 September, practices across England met to reflect and focus on their wellbeing. We have heard from practices that their teams found this time beneficial. Practices have identified changes they can make and actions they can take which will support their teams' wellbeing and improve resilience.
We encourage practices who could not participate in September to identify a time when they could meet as a practice to focus on wellbeing and how to reduce workload.
We are planning further work to support practices with this and will communicate this shortly.
Kieran Sharrock is deputy chair of the BMA GPs committee, England