Unsafe and unsustainable

by Ben Ireland

GPs in Wales share their stories of stress and fears for the future as the BMA launches its Save Our Surgeries campaign

Location: Wales
Published: Tuesday 11 July 2023
burnt out GP

‘The future of general practice hangs on a precipice,’ says Gareth Oelmann, chair of the BMA Cymru Wales GPs committee.

‘Unless urgent action is taken to address workload, workforce and wellbeing, the service is at risk. This crisis should be a concern to us all.’

Warnings about the worsening state of general practice have been stark for some time, but a new campaign by BMA Cymru Wales, Save Our Surgeries, lays bare the situation with hard data and personal testimony from GPs – while offering a practical rescue package for doctors and patients.

Gareth Oelmann OELMANN: Service at risk
suhair alwan ALWAN: Anxiety led to illness

The pressure on Suhair Alwan as a GP partner in Wrexham was so much that she ended up in hospital for 10 days with sepsis, after her 14-year-old daughter called her an ambulance.

‘The lack of sleep, the stress and anxiety and not looking after myself made me become very unwell,’ she says of the effect of an unmanageable workload, continuous interruptions, and the toll of taking sole responsibility for the surgery’s patients.

On her return to work, ‘nothing changed’ and the burden of undertaking 34 consultations a day – as well as making clinical decisions for those who had been seen by non-GP colleagues – was ‘completely exhausting’ and ‘unsustainable’.

‘I would go home and could not speak because I was so tired,’ she recalls. ‘I’d feel constantly tortured by my thoughts… had I made the right call in such a brief period? Did I have all the available information? This level of stress took a terrible toll on my mental health, I didn’t have any energy to see friends and family, and this left me feeling more anxious and lonelier. It’s no way to live.’

Dr Alwan now works as a locum GP. The anxiety returns if she works long hours – and she acknowledges the effect on her family: ‘It upsets me to think [my daughter] also carries the burden of worry caused by my job.’

The lack of sleep, the stress and anxiety and not looking after myself made me become very unwell
Dr Alwan

BMA Cymru Wales’ latest survey asked GPs to rate their average weekly workload on a scale of 0-100, with zero representing ‘manageable’ and 100 ‘constantly excessive’.

The average response was 76/100. Dr Alwan notes the constant interruptions she faced as a partner in a multidisciplinary team which, despite additional staff, ‘ironically ends up causing more work for GPs who are often the only ones qualified to make clinical decisions’.

Natasha Collins also moved to being a locum after nearly five years as a GP partner in South Wales. Persistent recruitment challenges amid growing demand meant: ‘We found ourselves working above our contracted hours to ensure administration work was completed so we could focus on urgent and routine patient requests.’


Patient demand

In March 2022, the departure of a salaried colleague left Dr Collins looking after 6,700 patients alongside one six-session GP, a nurse practitioner, prescribing pharmacist and the nursing team.

The salaried GP leaving ‘tipped us over the threshold’, she says. ‘There was no contingency left for leave or illness. I was missing events such as my five-year-old’s first school sports day.

‘While I felt experienced in managing a high workload, the days were incredibly long. I’d leave my practice at the end of the day, get my three children to bed then work again right up until midnight and beyond each night.

‘To live with that level of pressure day-in, day-out takes a toll, and you worry about patient safety; we know tired doctors are more likely to make mistakes. It was unsafe and unsustainable.’

sue fish FISH: Intense pressure

More than 80 per cent of GPs surveyed by BMA Cymru Wales fear they are unable to provide quality and safe care to patients owing to excessive workloads, a diminishing workforce, and rising demands.

Sue Fish, the only partner at a 2,700-patient practice in Ceredigion in rural west Wales, says: ‘I get in at 9am every day and work until 7pm, and on weekends to keep up with paperwork. We can’t provide high-quality care like this.’

Her former partner retired in May, and while she has recruited two salaried GPs to start soon, Dr Fish says she will hand her contract back by August next year, ahead of her 60th birthday, if conditions in general practice are not addressed by then.

‘GP staff worked right the way through the pandemic. We faced all the different challenges thrown at us, and we’ve gone straight from that to being excessively busy every day,’ she says.

‘Over the last 12 months I’ve had one day where I’m not committed to the surgery. I’m tired and worn out and while not completely burnt out I’m heading in that direction. Hopefully by October I’ll feel different, but there’s no long-term solution.’

To live with that level of pressure day-in, day-out takes a toll, and you worry about patient safety
Dr Collins

Dr Fish is fearful of retaining her recruits long-term because of the practice’s rural location and a lack of appetite among GPs for becoming partners. If no new partner comes forward, the practice is likely to dissolve, forcing its patients to travel to nearby towns to see a doctor.

The knock-on effect would mean: ‘Those practices wouldn’t be able to cope. There wouldn’t be enough GPs to supervise all the staff. And there wouldn’t be the space.’

The BMA report shows a deficit of 664 GPs in Wales compared with the average among OECD countries, following 84 surgery closures in the last decade.

It has left patients in Wales with 18 per cent fewer practices available, a drop from 470 to 386, as GPs take on 32 per cent more patients each (an average of 2,210 patients per full-time equivalent GP, up from 1,675) resulting in an average list size in Wales of 8,378 patients, up 23.5 per cent from 6,780.

Of the 2,324 GPs working in Wales, only 1,445 are working full-time – many have chosen to reduce their hours because of the excessive demands of the role and its effect on doctors’ wellbeing.

Between them, in 2022-23, GPs in Wales have taken 27 million telephone contacts, offered 19 million appointments, issued 56 million prescription items, made 1.3 million referrals to secondary care and issued more than 500,000 fit notes.


Retention crisis

More than a quarter (26.6 per cent) of GPs plan to leave the profession in the near future, according to the survey, while only half of partners see themselves remaining in their positions in three years’ time.

Dr Collins says closing her practice has been ‘destabilising’ for patients who now miss out on continuity of care. ‘My plan was to stay at the practice until I retired,’ she adds. ‘I was sad to leave.’

As chair of her local medical committee, she reports witnessing the pressure piling on GPs across the practices she now works at, partly driven by long waits at hospitals.

Natasha collins COLLINS: Patient safety concerns

Dr Collins says at least 10 per cent of interactions are patients returning to GPs with deteriorating conditions while they wait for hospital treatment, with some of her colleagues saying this can account for up to 25 per cent per session.

Dr Fish adds: ‘Patients are just sitting on waiting lists. Quite often we can’t do anything, for example if somebody’s got a deteriorating joint that needs replacing, or we end up managing conditions we’re not qualified to manage, like deteriorating neurological conditions, because waiting lists are so long.’

The survey found an overspend of almost £11m on managed practices by health boards, some of which overspent by 80 per cent.

Listen to our grave concerns and step in and save the service from collapse
Dr Oelmann

Dr Fish says one of the recruitment challenges for partners has been competing with the salaries offered by managed practices. ‘We haven’t necessarily got the money to pay for all these people,’ she says. ‘And none of them want to be a partner.’

Between 2018/19 and 2022/23, 38 GP practices in Wales have handed back their general medical services contracts. Dr Collins believes the partnership model ‘can thrive again’ if given ‘the right resources and more investment’. That would include doing more to incentivise doctors to stay in Wales and to take up partnerships.


Better funding

The Save Our Surgeries campaign, launched on 28 June, offers a plan to save general practice in Wales. There are four key recommendations.

First is a commitment to funding general practice properly by restoring the proportion of the NHS Wales budget spent in general practice to the historic level of 8.7 per cent within three years, with an aspiration to increase to nearer 11 per cent in the next five years.

Next is investing in the general practice workforce to allow the implementation of a national standard for a maximum number of patients that GPs can deal with to maintain a safe and high-quality service.

save our surgeries BMA Cymru Wales presents its campaign

It urges the Welsh Government to produce a workforce strategy to ensure Wales trains, recruits, and retains enough GPs to move toward the OECD average, tackling the problems driving them away.

Finally, the campaign calls for staff wellbeing to be addressed by producing a long-term strategy to improve the physical, mental, and emotional wellbeing of the workforce.

Dr Oelmann says the campaign’s launch was ‘a defining moment for general practice in Wales’ and that the campaign offers ‘a final plea to those in power to listen to our grave concerns and to step in and save the service from collapse’.

It is the last chance for revival, he says, but: ‘With the correct level of support, general practice can thrive again, ensuring the family doctor’s role in the care of future generations.’

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