14.10.2021

A market opportunity

What’s behind the campaign for face-to-face consultations? James Linney gives a GP’s view

There have been growing calls for general practitioners in the national health service to return to pre-pandemic ‘business as usual’; it is being led unsurprisingly by the more rightwing, reactionary media corporations and most loudly of all by the Daily Mail, with the launch of its campaign to “make GPs see patients face to face again”.

Several articles since have claimed that GPs have abandoned patients by not opening their doors to see them face to face and that remote consultations increase the risk of missing important diagnoses. The Mail recently declared a victory when Boris Johnson and current health secretary Sajid Javid supposedly voiced support for the campaign. We were told:

By slashing bureaucracy, [Javid] hopes far fewer patients will have to make do with telephone or online consultations, reducing the risk that serious health conditions could be missed. But the health secretary will warn doctors that those who continue to provide an unacceptably low level of face-to-face access will be held to account.¹

We are given no details as to how Javid will go about reducing the bureaucratic burden on GPs, but I expect that this next logical question is irrelevant to a Mail journalist looking for nothing more than a striking headline.

The Daily Mail is not alone in giving voice to the growing backlash against primary care. For example, a recent Spectator article, titled ‘Why are doctors still hiding behind Zoom screens?’,² asks:

What possible justification can GPs give for not resuming in-person appointments? … GPs seem to be dragging their feet. Sure, I get it, working from home has been a breath of fresh air for many people. It’s shown them a different way of working. But medicine isn’t like a job in marketing. It’s serious.

Worse still is a vile article by Allison Pearson of The Daily Telegraph, titled ‘GPs are improving their work-life balance while worsening the life-death balance of everyone else’, which spewed forth the following: “As long as social distancing is maintained in surgery waiting rooms, there will be no return to normal face-to-face service. I’m sorry to say, that seems to suit a lot of GPs just fine.”³

I could go on, but I already feel soiled for having quoted from these articles. Besides we get the picture: it is apparently good times for those cowardly, lazy GPs, who get to work from home in their pyjamas, while people suffer because their illnesses go undiagnosed. And anyway the pandemic is over, now that we all have been vaccinated. Clearly, gone are the days of the rightwing media and Tories having to pretend to value the NHS by being pictured mimicking the very real and moving demonstrations of working class solidarity that have been and continue to be shown up and down the UK.

It is easy enough to dispel the clear untruths voiced by these stories. For example, Martin Marshall, Chair of the Royal College of General Practitioners, said: “Huge numbers of GP appointments are being made every day, almost half on the same day they are booked. It’s a misconception that GPs and other members of our team aren’t seeing patients face to face.”⁴

NHS Digital’s most recent data reveals that 58% of GP appointments were carried out face to face in August, the first full month since most legal restrictions were lifted in England,⁵ compared to 80% before the pandemic. Early in the pandemic NHS England issued guidance for all GP surgeries to switch to a ‘total triage’ model of consultations; meaning that all consultations were by default initially a telephone assessment, but, if it was deemed necessary, the patient would, following this consultation, be asked to attend surgery for a face-to-face examination. This would be done in a way to maximise patient safety: namely by keeping the waiting rooms as empty as possible and allowing the consultation rooms and equipment to be cleaned in between appointments.

For those patients confirmed to have Covid and needing assessing - or with symptoms suggestive of Covid, but not yet confirmed - special GP ‘hot sites’ were set up. Here the patients could be kept separate from other, non-Covid patients, whilst the clinicians could take extra precautions to prevent the virus spreading. While they continue to operate in most NHS clinical commissioning groups (CCGs) across the country, the speed and efficiency by which these hot sites were set up was truly impressive and they have undoubtedly played an important role in preventing any Covid spread within surgeries. They were/are run by primary care staff, providing admin, nursing and GP cover.

In May this year NHS England updated its total triage advice, now stating that patients should be offered face-to-face appointments if this is their preference, unless there is a good clinical reason not to do that (ie, if they have or are suspected of having Covid). So why, you might ask, are so many primary care appointments still being carried out remotely?

Utter failure

The first and obvious answer (obvious, that is, unless you are a member of the UK government or its compliant army of journalists) is that the Covid pandemic has not gone away and all current data confirms what has been true throughout the pandemic: that the UK government’s response to it has been an utter failure.

Since July there have been on average about 35,000 new cases recorded every day. These numbers are comparable to December 2020-February 2021, when the UK was in full lockdown and the virus was at its most deadly. The incidence of daily new confirmed cases (per million of the population) in the UK remains way above that of USA, India, Italy, Spain, France, Germany and pretty much most of the world. For the past two months the daily deaths from Covid have been hovering around 140 - still significant and tragic, but much less than during the period compared above, where the daily deaths were pushing 1,000 each day and peaked at 1,824 (January 20).

The reason for the difference is obviously the impact the vaccination programme has had. It is a programme with huge logistical implications, which was set up and run by already dangerously understaffed GP surgeries. The amazing success of this vaccination programme was down to the hard work of primary care staff and the volunteers who came to help - not the Tory government, which has since tried to hijack its success in an attempt to distract from the inconvenient truth that its own negligence has led to so much suffering.

Currently 78% of people over the age of 12 have received two vaccination doses and the booster programme to give everyone a third jab is now well underway. Thankfully this has meant that the Delta variant, which continues to account for most cases in the UK, whilst being more transmissible (and more likely to result in a severe illness in the unvaccinated), is currently resulting in significantly fewer hospitalisations and deaths.

However, as long as the number of cases in the population remains high, the situation remains unpredictable. High prevalence means more opportunities for the virus to mutate, either domestically or internationally, into a more deadly and/or resistant version. Of course, this risk is not something that keeps the ruling class up at night: the pandemic has confirmed once again that unnecessary deaths of the working class on a mass scale are nothing more than an inconvenience when you are trying to protect the needs of capital and maintain the rate of profit.

For everyone else though, Covid is still a very real, deadly and potentially catastrophic reality. Vaccines have been crucial in reducing the number of deaths, but even being vaccinated is no guarantee against contracting a very debilitating illness that has the potential to result in chronic mental-health problems and physical disability. Given all this, hands up all those who, this winter, wants to go sit for an hour in a poorly ventilated, packed GP surgery, squeezed into a room full of people (vaccinated and not), many of whom will be expressing the upper respiratory symptoms typical of the Delta variant of Covid? For anyone stupid enough to have their arm raised, I bet you a million pounds you won’t bump into the likes of Boris Johnson, Sajid Javid or Allison Pearson while you are there!

Our health

Primary care staff are not trying to control the flow of patients so they can chill out at home. They are doing it so they can prevent GP surgeries once again becoming major sites for Covid spread. Nurses, receptionists, GPs, cleaners and healthcare assistants have all continued to work throughout the pandemic under conditions of risk and stress. The same Tory politicians now accusing GPs of cowardice have spent the last 18 months allowing tens of thousands of people to die - either through gross, incompetent mismanagement of the pandemic or, worse, by preferencing profit over people’s lives.

Meanwhile NHS staff, along with millions of other workers, have been turning up to work - initially with no personal protective equipment, and ever since with the absolute minimum. The vast majority of surgeries only actually ‘closed their doors’ for the few months after Covid arrived and started spreading in the UK, but even then patients were coming to surgeries by appointment. The pandemic has meant that the already unsafe demand for GP appointments has now reached disastrous levels. Although fewer patients have been seen face to face, the overall number of appointments has continued to increase. GPs delivered 31% more in June this year than in June 2019.⁶ They were already an unsafe number of patient contacts, averaging 41 per day in 2019,⁷ but this number must now be pushing 50. Another factor at play is that despite the government promise of 6,000 more GPs by 2024, the trend is in the opposite direction: there are now 600 fewer GPs compared to before Covid. What is more, a recent survey found that 51% of GPs said they are currently suffering from depression, anxiety, stress, burnout, emotional distress or another mental-health condition.⁸

The point here is not just that GPs should have a less stressful job: that would be for the benefit of every patient - who, after all, wants to be the 48th person speaking to or seeing a stressed doctor or nurse, who has not had time to have a break and who is in the 10th hour of their working day?

The one part of the Daily Mail campaign I do agree with is that patients should be able to have the possible option of a face-to-face appointment with their GP. This will not always be necessary, and many patients will opt for a telephone consultation (for example, people with mental-health conditions may prefer a telephone consultation, with perhaps a follow-up to simply discuss investigation results or treatment response). But, of course, a person with new physical symptoms should ideally always be seen in person - a physical examination is crucial in these circumstances, as things get missed otherwise.

Speaking personally, the other bonus of seeing patients in person is one of the reasons to choose to become a GP in the first place: being able to build a meaningful relationship with your patients. A day full of telephone consultations is far more stressful and ultimately much less satisfying. But such face-to-face appointments must be delivered in a safe environment, allowing for sufficient time between patients for the cleaning of the rooms and social distancing. This will inevitably result in fewer patients being dealt with each day, and longer waiting times to see your GP … well, at least this will give the Daily Mail something else to campaign about.

Of course, there are more sinister things at play in the campaign for more face-to-face appointments than allowing Tory politicians the opportunity to deflect blame or give the rightwing press an opportunity to vent some of the poisonous bile that passes for journalism. It is simply another part of the continuing partnership between the government, private health industry and media corporations; their real campaign has been to undermine the very existence of the NHS. Hence its chronic underfunding and the ongoing privatisation - a process which has been vastly expanded during the pandemic and threatens the NHS on all fronts.

The Tories, whilst happy to pretend to hold the NHS dear when it gives them some political credence, actually see it as a still largely untapped market opportunity. Further, ideologically the idea of the equal provision of free healthcare for all at the point of need has at its centre a socialist kernel, which, of course, they find an abomination.