A GP in Milford Haven exposes the Inverse Care Law as applied by successive Governments, perversely and neglectfully..

The irony of the lack of doctors, and insufficient access to Primary Care is that it is government who is responsible, and it is successive governments who have ignored the advice of the profession. The Inverse Care Law as defined by Julian Tudor Hart, used to apply to citizens in poorer and deprived areas who got less resources when they needed most. Now it is government who are responsible for the inverse care law as applied to health. As private practice becomes more evident, it will be most available in those areas where people can afford it, and the people living in deprived areas will have to put up with a second class service. Doctors, knowing they are rare commodities, can choose where to live, and will mostly choose where infrastructure and education and housing are best. Most of them come from suburban and inner city schools and these doctors when qualified would rather work part time in their home city than full time in a challenging area.

Daniel Weaver, a GP in Milford Haven, has sent this out on facebook, and has been interviewed for the Milford Mercury. Dr Weaver is an experienced and altruistic GP. His cry for help comes too late in many ways. NHSreality has been highlighting the demise of the “Goose that laid the Golden Eggs” of efficiency and avoidance of overtreatment for 6 years. NHS reality has also pointed out the problems with GP recruitment on many occasions, and asked for more graduate entrants to medicine. NHSreality has also reported on the rejection of 9 out of every 11 applicants when they were all recommended to apply because they were good enough. Rationing of places to medical schools, uninformed manpower planning, and an over dependence on females as doctors (because they are better at undergraduate entry) have all conspired to get us to arrive at this point. The short termism of the First past the post electoral system means there is no incentive to plan capacity over 20 years. Obviously we need to address recruitment, but the  shape of the job also has to change. Golden Hellos are not enough…  The heartfelt letter below is a cry for help on one level, and a daming indictment of government at another. NHSreality only disagrees in that there is no “N”HS any longer. Here is Dr Weavers Post: “If anyone is in the Milford Haven area feel free to share this post”:

I wouldn’t normally do this but I feel compelled to put a message out in response to the increasing levels of aggression and abuse towards staff over recent months. Hopefully this will work as something of a FAQ about recent issues relating to the surgery. This may be a long post, stick with it though and hopefully it will give some clarity.

Currently Robert Street is effectively short of 2 doctors (which is 40% of our manpower) & this is less then ideal. This is in part because of maternity leave, and in part because despite spending thousands of pounds on advertising we haven’t had any success in recruiting since a doctor left a couple of years ago. Why haven’t you had success? Multiple factors including a national shortage of GPs in UK and especially in Wales. Wales is seen as less appealing to work in compared with rest of UK and Canada, Australia as earnings tend to be lower and due to harsher social service cuts problems with social care, social problems end up reaching general practice, and longer out patient waiting lists mean that people are seeing GPs more frequently so there is a harder workload. We are further west than most people want to work, and our practice area is one of relative deprivation, so any GP applying knows they will be busier then those working in more affluent areas.

I came to back to work in Milford because I enjoyed working in the town during my time training in Barlow house surgery and I have a family connection to the town, but unless someone has a connection to the area it’s not easy to get people to relocate from other areas. Many international Doctors in the NHS have families overseas and want to settle in a location with good access to airports etc. or to live in larger cities with people of similar faith or culture. We have up to 3 weeks less annual leave then several other local practices which has been cited as a factor when I’ve chatted to doctors who’ve moved elsewhere, especially doctors with children. We have specifically resisted increasing amount of annual leave we allow ourselves because it would pressurise appointments further.

There are higher paid practices in the region. (practice income is complex depends on multiple factors, like if practice is a dispensing practice or has branch surgeries etc) I have medical friends with whom I have discussed about working in Pembrokeshire. Feedback from them often revolves around issues like the above but more locally uncertainty about local hospital services making doctors nervous about possible knock in increased general practice workload in the region.

The loss of maternity services in the county and loss of 24 hour paediatrics is deterring younger doctors who either have children or are planning to have children. Also the state of the secondary schools in Pembrokeshire at the moment puts some off. Locum rates being paid within our health board and elsewhere mean that potentially a GP could earn more money in a week of locum work then if they were in a stable salaried or partnership role for a month. Locum doctors don’t have to follow up patients or results and usually will cap themselves to a limited number of consultations eg 12 in morning or afternoon and 1 home visit. Existing locums have low incentive to get permanent jobs with a practice. There is ironically also a shortage of locum doctors. We are continuously looking for locums, and getting them when we have a chance. We cannot compete with health board for locums as their rates far exceed what a normal general practice can pay.

Another factor is we are not a training practice, I will come back to this later. Would it be financially beneficial and better for work life balance for doctors to leave and do locum work? Yes in short, but if another doctor left it would cause the practice to collapse entirely and we feel a duty to each other, staff and the local area. This is the danger about locum work being so lucrative in the current climate, it actually risks destabilising things further. Why aren’t we a training practice? We’ve been desperate to get training status since I joined the practice, it’s something I’ve always wanted to do, I’m passionate about training and this is something I’ve always been involved in in different forms from my time in medical school. Aside from wanting to train there is also evidence that the surgeries that cannot recruit and have to close are much more likely to be non training practice. Why is that? GP training practices have a registrar or registrars who effectively work as a doctors while completing their GP training, this increases number of doctors available to see patients in training practices. It also allows doctors to test working in a practice. Many trainees will end up in taking a job in a practice they trained at if they had a good experience. The good news is that we have had the first indication that can start the process of becoming a training practice which gives possibility of progress in the next year towards this goal.

Why is it so hard to get routine appointments? Unfortunately at the moment we are often down to 2 doctors a day, as we are frequently seeing 40-60 emergency appointments daily there is limited capacity for routine appointments. This is entirely manpower related. We are working harder then ever. We have effectively close to 3000 patients per full time equivalent GP currently. To put this into perspective a Nuffield Health study in 2011 showed national averages for Scotland was 1400 per GP, England was 1500 and Wales a little over 1600. We are short staffed at the busiest time of the year without locums. If there are 3 doctors in, the routine slots are put on in addition to emergency but these obviously go quickly especially if people are trying to see a particular doctor.

Why don’t you see more patients? During the average day which is usually 10+hours, often the only break is to go out and get food to eat at desk while going through results or letters or for toilet. Although I was not on call today I didn’t get a chance to have lunch so when I got home at 6:45 I ate for the first time since breakfast. This isn’t unusual. I am on call on average 3 or 4x per week either in the AM & PM during an on call there is a continuous stream of messages, script requests queries etc. In addition to usual duties emergency surgeries and home visits and things are often very frenetic and pressurised. Apart from seeing patients in the surgery GPs have do go through letters from hospital, amending medication and arranging tests and referrals. We will often have many letters daily, for example I went through a little over 70 letters this morning. GPs have to write letters for referral or to other agencies, appeals, DWP forms, forms relating to end of life, death certificates, cremation forms. GPs have to also go through Emails from NHS/health board/and check safety updates on medications which get posted through. Review results, bloods results get reviewed and often require further action, same with scans, we will often get results for around 30 patients each daily to go through more if someone is away and we are covering them.

Home visits: these are the least time efficient part of the day. Often if spread out a GP can spend over an hour driving between houses and nursing homes which takes time away from doing other jobs. Phone calls: I can have up to an hour of phone call requests or more in a day. Prescriptions and sick notes. In a typical week each GP is signing several hundred repeat medication prescriptions, along with sick notes. OK, I get that you are busy, what else have you tried? We have tried employing a physiotherapist to see patients presenting with muscular/joint problems to take pressure of the on call, allowing GPs to see other patients. Did it work? No most patients refused to see a physiotherapist and they insisted on seeing a GP.

GP Triage: this is a service which exists due to pressurised situations. A lot of issues can be managed over the phone and potentially saves an unnecessary appointment being used on the on call which can be used for someone else. The GP can access the notes and takes a history/arranges investigations or a face to face appointment if required. We pay for this out of practice budgets. It’s not ideal but it is better then nothing and there is no alternative option at this moment in time.

What about health board? in June we applied with Barlow House and Neyland surgeries for some existing Welsh assembly sustainability money to go towards employing a paramedic practitioner who could take some pressure off the home visits situation. Nothing has been forthcoming. We, on a temporary basis, have attempted to close our practice list although the health board have resisted this. This is given current intense pressure a logical step to try to preserve our resources and time for existing patients as we are aware of the access issues. They are not offering help. What else are you doing? We have been training a practice nurse to become a nurse practitioner, meaning she will be able to see some of the simpler emergency appointments.

Why can’t I get through on the phones? It’s not ideal but we have a finite number of reception staff. At peak times we have up 100 people trying to get through and without a call centre there are likely to be delays. Being on hold is common for doctors too and I often have to wait 20 minutes+ when contacting the hospital to refer a patient in for other reasons.

Image result for overwork cartoonThe NHS in general is struggling to deal with the amount of people who use the service, it’s far from ideal but there is no obvious solution, and no additional funding to help with this. Why do routines only come out on a Thursday? If everyone who wanted a routine appointment phoned up every day it is going to increase phone traffic and difficulties getting through, in other words it would make the problem worse. It’s the same reason why people are encouraged to put in repeat medication requests through via their pharmacy or by dropping a slip in. There is the option of signing up to request repeats online which is super useful, but not many people do this. Thursday is traditionally the quietest day of the week so that time in the PM is least worst time of the week. Why don’t you just abandon all routine appointments and just do book on the day system? This gets discussed periodically but when it has been trialled before people complain about it. Why do reception staff ask me about my symptoms if I want an emergency appointment? They are not being nosy, sometimes people phone to get an appointment with a GP when actually it would be unwise & they should call 999 or go to A&E, for example if having a stroke or suspected fracture. Sometimes the issue is something that can be better dealt with by a pharmacist, a dentist or is completely non medical. Additionally if I am doing an on call, I need to be aware who the likely most ill people are, eg if someone is doubled over in agony with a possible appendicitis or acutely suicidal, I will need to see them before I see someone with mild earache or trapped wind. Will shouting at staff or being abusive help? No, please try and be patient and don’t take frustration out on staff. Everyone is working hard and it’s not an easy time for anyone. Taking it out on staff increases the likelihood of people walking away which makes the problem worse. I still want to complain! Feel free although hopefully this will help put your concerns into perspective. We are very stretched and this entirely relates to staffing issues beyond our control along with a difficult local healthcare environment. I am a doctor, I am not a politician and I have no influence on the larger, complex problems facing our county or country. There are multiple practices in difficulty in the county and elsewhere in Wales, and increasing numbers of doctors handing practices back to health boards due to being unsustainable and impossibly challenging working environments. In summary we are working hard and have been trying things. Why aren’t Barlow House having the same issues? It is harder to get an appointment with us then Barlow House Surgery but this is resource linked. They are fully staffed with permanent GPs and usually have between 2-3 GP trainees giving them roughly double our capacity, despite this they are still busy and working hard as well, as demand continues to rise in part because of problems in social care and secondary care being moved onto general practice. We get continuous complaints about difficulty getting appointments and problems with the phones but hopefully this gives extra insight into reality on the ground. Positive aspects for future are: more trainees coming from local scheme in next few years increases chances of us recruiting in a year or two. Dr Skitt won’t be on maternity leave for ever. We may be able to have trainees in the next 12 months which will help. We and another practice in Pembrokeshire will hopefully soon have a CPN attached to the surgery who may be able to help out with mental health related issues. This is a Welsh assembly funded pilot and hopefully will be positive. Age wise there are no doctors coming up to retirement soon unlike some other practices around the region. My colleagues are grafters and work as hard as any clinicians I’ve ever worked with in my entire career. If we do recruit and become a training practice Milford Haven is will be in an advantageous position compared with most of the rest of Wales with full compliment of relatively young doctors. I appreciate in the short term this isn’t much consolidation but at moment priority is survival. I apologise in advance but I’m not planning to respond to comments on this post as I made a decision some months ago to try and avoid social media and to try to prioritise spending any free time I have with family and friends rather then online. This was a decision ironically I took because of how late I tend to get home from work and the impact my job has on the people around me. Feel free to share this though.

Image result for overwork cartoon

Deprivation differences…. especially across the UK – revisited

Early deaths: Regional variations ‘shocking’ – Hunt

Poverty in Wales

How to kill the goose and create a shortage of 10,000 GPs – Patients kept waiting as new doctors shun GP jobs

Hands up – who want’s to be a GP today?

Recruitment is at an all time low despite rejecting 9 out of 11 applicants for the last few decades..

The Horse has bolted but “play it again Sam”…

“GPs to receive ‘golden hellos’ in hiring drive”….

This entry was posted in A Personal View, General Practitioners, Medical Education, Patient representatives, Perverse Incentives, Post Code Lottery, Rationing, Stories in the Media on by .

About Roger Burns - retired GP

I am a retired GP and medical educator. I have supported patient participation throughout my career, and my practice, St Thomas; Surgery, has had a longstanding and active Patient Participation Group (PPG). I support the idea of Community Health Councils, although I feel they should be funded at arms length from government. I have taught GP trainees for 30 years, and been a Programme Director for GP training in Pembrokeshire 20 years. I served on the Pembrokeshire LHG and LHB for a total of 10 years. I completed an MBA in 1996, and I along with most others, never had an exit interview from any job in the NHS! I completed an MBA in 1996, and was a runner up for the Adam Smith prize for economy and efficiency in government in that year. This was owing to a suggestion (St Thomas' Mutual) that practices had incentives for saving by being allowed to buy rationed out services in the following year.

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