David Oliver: Don’t let covid-19 drive a wedge between acute and primary care

When health services are under pressure, unhelpful tension and blame can arise between doctors from different disciplines. I’ve recently seen this play out between GPs and acute hospital doctors, especially in emergency medicine. Changes to services fuelled by covid-19 have amplified it.

It’s a worrying precedent, because clinical professions need solidarity and a concerted voice to avoid further fragmentation and undermining of the NHS. I see many similarities between primary care and emergency medicine, which should serve as points of empathy. Both involve “expert generalists” dealing with every age group and every condition that comes through the door, at high volume and pace. Both manage risk and uncertainty. Both have seen steadily rising demand, workforce gaps, and burnout. Both feel misunderstood by the rest of the NHS.

Emergency department staff can sometimes feel that their overcrowding, long waits, and pressures stem from others in the system not playing their full part in reducing those risks (hospital wards, community services, primary care, NHS 111).1 Meanwhile, even before covid-19, GPs’ representatives had often expressed wider concern that traditional secondary care work was being pushed their way,2 as hospitals focused on patient flow and same day or rapid discharge from what is a comparatively small per capita and very full bed base, yet with increasing bed numbers taken up by relatively stable people waiting for community services.3

Meanwhile, such has been the scale of pressures in emergency departments that the national four hour target has not been met for a single quarter since 2015,3 and attendances at all department types were rising yearly before the pandemic.4 The lights are on 24/7 in emergency departments, with staff, including senior medics, working gruelling shifts at all hours.

We’ve seen a huge transformation in primary care during the pandemic, with GPs still working very hard but moving many of their consultations to phone or online models and limiting face-to-face appointments.5 GPs are keen to shift the balance back partly,67 but the fear of infection on their premises is valid. It’s upsetting to read comments in mainstream or social media suggesting that, just because face-to-face appointments are less common, general practices are “closed” or “lazy.” I’ve also seen emergency medicine doctors expressing frustration at seeing lots of patients who would normally have gone to their GP but couldn’t. This in turn triggers reactions from GPs.89

Now, in the face of models suggesting that many of our acute hospitals could be at 110% of their capacity this winter, NHS England proposes a model whereby patients phoning NHS 111 will have an appointment slot booked for them in the emergency department—or a GP appointment if hospital attendance is deemed inappropriate.10 Some GPs fear an under-resourced, unmanageable mass transfer of patients to primary care. GPs and emergency medicine doctors alike worry that NHS 111 will be overwhelmed or won’t have the right clinical skills—and that worried patients will present to emergency departments regardless, where in reality no one will refuse to see and triage them.11

There seems to have been little time for any consultation, professional buy-in, or risk assessment or for data from pilot schemes or modelling to be released for scrutiny. NHS central bosses are keen to try something quickly, before winter hits with a second covid-19 wave on top of the usual demands. Perhaps the best we can hope for is some good, real time data evaluation that factors in the impact on patients, primary and urgent care, trade-offs, and opportunity costs and doesn’t simply define success by looking at what happens in emergency departments.

In any event, we must stop reflexive antagonism between doctors in different parts of the system. NHS doctors need to present a united front and seek to influence national policy as allies, with one shared voice.