Patients have struggled to access general practice during the pandemic, Healthwatch reportsBMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n798 (Published 22 March 2021) Cite this as: BMJ 2021;372:n798
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We write in response to your articles in last week’s bmi by Abi Rimmer (BMJ 2021;372:n798) and Helen Salisbury (BMJ 2021;372:n786) highlighting the difficulty patients have had in accessing general practice during the pandemic. We, like the rest of the country, moved to total telephone triage in March 2020. We needed to quickly organise the practice into hot and cold zones, risk-assess our staff, work out how to socially distance waiting room chairs, purchase perspex screens, source PPE, work out safe donning and doffing protocols, review infection control and cleaning systems, organise the greater home visiting workload of very sick people, and keep up with the torrent of daily email traffic with dictats from every corner of the complicated NHS bureaucracy. The list is endless! And all this whilst learning about and managing a new and deadly illness our patients were contracting in their hundreds. However, as we began to feel we had the measure of things, we knew that total telephone triage was not for us. Since mid-June, our patients have been able to book face-to-face appointments without speaking to a clinician, with the caveat that they shouldn't book or attend if they have acute covid symptoms.
We are a practice in a deprived part of inner east London with high levels of illiteracy, non-English speakers, poor mental health and digital poverty. It seemed abundantly clear that asking these patients to access us through e-consults and only offering telephone and video consultations was effectively denying them access. What is interesting however is we also serve a group of younger wealthier and highly tec-savvy millennials, who might like the convenience of the “new normal”. We have found that these patients, despite having the option of telephone, video and e-consultations, are also booking face-to-face appointments. The reason is surely obvious to any honest GP who knows about the doctor-patient relationship: nothing can substitute for “seeing” a doctor. We learn about the “hidden agenda” when studying the art of the consultation. How do you explore this on the telephone or zoom? Patients may not always know what their hidden agenda is but innately understand that the transactional nature of a non-face-to-face consultation won't meet their need. Telephone triage is by its nature doctor-centred. Asking questions to steer to a neat conclusion and put the phone down doesn’t allow for the nuances picked up in body language. The system is well named “doctor first” rather than “patient first”. A quick survey of local colleagues reveals most practices are still using this model.
We are a training practice and believe in the apprenticeship model: doing a job we love and passing on the joy of it to our trainees. We feel deeply the loss of joy that our colleagues are experiencing as they wade through transactional telephone calls all day, losing the social and emotional connections and continuity of care with patients. Will the next generation want to work in this joyless environment? We are also concerned about risk. Although we are not aware of any research that looks specifically at health outcomes in general practice with less routine face-to-face care, anecdotally we can cite instances where what sounded trivial and easily reassurable on consecutive telephone calls with different doctors turned out to be cancer and would almost certainly have been picked up sooner in person. There is much talk of the tsunami of mental health problems from the pandemic. How do you properly observe a flat affect and psychomotor retardation over the phone? Or a psychotic patient responding to external stimuli?
We hear a lot about the new normal and those championing digital innovation. We would like to raise a big red flag over the uncritical embracing of this way of working for the future. Not only will we be systematically discriminating against those for whom accessing us is already difficult, but we will also be losing our fundamental role as witness to our patients’ lives, a role that constitutes one of the foundations of our NHS. The relationship engendered by a patient booking to see their doctor in person is essential for them and for us. We fear our trainees will walk away from a profession facing a crisis in morale unless someone shouts this from the barricades and defends what is, after all, the best thing about being a GP.
Dr Lucy O’Rourke
Dr Jim Boddington
Dr Aarany Santhakumar
Dr Paul Kelland
Shoreditch Park Surgery, 10 Rushton St, London N1 5DT
Competing interests: No competing interests