A GP on the Frontline of the NHS’ ‘Perfect Storm’
With A&E in crisis and emergency care in a state of emergency, Sian Norris speaks to a GP about the knock-on effect to primary care
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“There have been triple issues these last six weeks of Strep A, this nasty flu and Coronavirus cases,” says Dr Lisa Nayler, a GP working in the south-west of England. “But this crisis has been coming for six years, if not 12 years.”
It’s the first week back after the Christmas holidays and already Dr Nayler’s surgery is feeling the strain. She’s been working 12 hour shifts “and each day I probably saw 50 patients – that’s not including the hidden work a GP does, such as writing up prescriptions and letters”.
Like many NHS staff who worked through the pandemic and are facing this new winter crisis, the stress is taking its toll on her, her colleagues and her patients.
News bulletins have been filling up with stories about long waits and sick patients in Accident and Emergency, with reports of up to 500 people dying every week because they can’t access emergency care, while elderly patients lie in trolleys on corridors, and families wait, afraid and anxious, for ambulances.
On 23 December in London alone, 216 patients faced a wait of more than an hour to be transferred from an ambulance into A&E – a jump of 24.8% on the figure reported five weeks earlier.
“If someone is seriously ill in the surgery, I will usually suggest a family member or friend drive them to the hospital rather than waiting for an ambulance,” says Dr Nayler. She had heard from one GP surgery where a sick patient needed oxygen, but the surgery’s emergency oxygen canister ran out while waiting for an ambulance to arrive.
“I have been really fortunate in that we haven’t had any issues in getting patients to hospital,” she says. “They are stretched to capacity but they are not refusing to see patients. That’s what happens in every aspect of the NHS – we don’t say no, we just carry on”.
The NHS crisis goes beyond the emergency ward.
Waiting lists are at a record high, with more than 7.2 million people waiting for hospital care and an estimated 410,983 people in England waiting more than 52 weeks to start hospital treatment, according to figures from October 2022. This has an impact on primary care, as GPs take the weight of long delays.
“You get the knock-on stuff from this,” says Dr Nayler. “You’ve got patients who have been waiting over a year for routine surgery like a hip replacement. These people aren’t static – they can’t just sit there for that time. They might have poor pain management, they get depressed, they have to keep taking painkillers and if they are taking opiates, they can be addictive. These patients then present to primary care.”
It has not always been this way. “I used to refer a patient for a hip replacement, put them on a little bit of pain relief, and they would have had their operation within six months,” she says. “Now these patients come back to me over and over again as they wait.”
According to data from NHS England, waiting lists reached a low in 2009, having hit a previous high in the mid-1990s, before rocketing under successive Conservative Governments. In 2000, there were just over four beds per 1,000 people – now that number is just over two per 1,000.
If getting people into hospital is one side of the crisis, the other is in supporting people well enough to leave the ward but in need of social care. One in seven hospital beds are now occupied by someone who is healthy enough to be discharged but cannot look after themselves – however the number of care homes and nursing homes beds have decreased since 2012.
“The longer a patient remains in hospital, the less able they are to come out and look after themselves,” says Dr Nayler, who sees the impact of the lack of social care in her surgery.
To ease the pressure on beds, she adds, “we are seeing more patients being discharged earlier than they used to be”. These patients then return to the GP.
“Another issue is that people are aware of what is going on in hospitals and so hospitals are seeing patients sicker, because they are presenting later,” she adds. “The best kind of healthcare is preventative, and that’s where primary care comes in. But we are in a perfect storm.”
Dr Nayler is categorical about what needs to be done to end this crisis: investment in the NHS. Capital spending on healthcare reached 0.5% of GDP in the mid-00s, now it is 0.3%, dipping as low as 0.2% in the austerity era. UK spend is lower than countries such as Denmark, Germany, Finland and France – as is its per capita spending on healthcare.
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Between 2010-19, the annual increases to Government spending on health fell to less than 1% under the Coalition Government, before creeping up to just under 2% before 2019 – compared to 6% annual increases under Labour.
The campaigning group EveryDoctor has been calling for greater investment in the NHS. Its chief executive Dr Julia Patterson says the organisation is inviting MPs to pledge to five commitments to end the NHS crisis: mental health support, ending the Home Office backlog so foreign employees can start work, reform pension tax regulations, and remove locum caps.
The fifth commitment is to cap energy costs across the NHS estate, as rising gas and electricity bills eat into increases in the health budget.
“The worry is that we’ll get into the springtime, and the current initiative to absorb energy costs is going to come to an end,” Dr Patterson says. “We will see hospitals and GP surgeries hit with enormous bills after budgets have been squeezed so much anyway.”
Back in the surgery, Dr Nayler is bracing for the crisis to continue. “We need to get hospitals working properly, we need to get primary care working properly,” she says. “I’m not a politician or an economist. But the health of our nation is the most important thing – if we don’t have a mentally and physically healthy population then we can’t work, we can’t be productive.”