Turnover of reception staff, in particular, has increased at surgeries across Preston, Chorley and South Ribble, a recent meeting of the Lancashire and South Cumbria Integrated Care System (ICS) board heard.
However, the problem of growing public hostility extends across the wider region - and is leading to concerns about the wellbeing of workers charged with helping to look after the health of others.
Flashpoints are usually the result of patients having difficulty in getting appointments - and getting through to practices on the phone.
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However, figures presented to the meeting reveal that the overall number of appointments being provided has risen by 20 percent compared to pre-pandemic levels - with just over 884,000 slots offered across Lancashire and South Cumbria during September this year, up from 734,000 in the same month in 2019.
The increased tally incorporates both face-to-face and telephone or online consultations - and the Local Democracy Reporting Service can reveal that in-person appointments accounted for 62 percent of the total across the ICS area. That is an increase from 55 percent back in March, when it emerged that face-to-face appointments in Lancashire and South Cumbria had fallen by a fifth in the year since the onset of the pandemic.
Of the almost 320,000 remote assessments carried out in September, the overwhelming majority - 99 percent - were telephone consultations, with just under 2,500 done via video. There were also 10,000 home visits made by practitioners that month.
Dr. Lindsey Dickinson, chair of Chorley and South Ribble Clinical Commissioning Group (CCG), warned board members that demands on practice staff were only likely to grow during the depths of winter - against the existing backdrop of “ongoing abuse” that many of them are experiencing.
“[Given] the amount of capacity we have, it's just not physically possible to offer an appointment to every single patient that rings up on every single day - because we just don't have enough clinicians to provide that.
“I think the mental health and wellbeing of our staff is a significant concern at the moment. We are seeing more and more staff turnover across practices - certainly that has been a feature in Central Lancashire over the last few weeks. The number of reception staff...that are leaving [is notable].
“We know things are going to get worse and harder - and people are going to ask more of [staff] - and I think when people are already feeling under significant pressure and stress, that is a real concern,” Dr. Dickinson said.
The meeting heard that patient surveys show that 83 percent of respondents are happy with the service provided by their GP practice in Lancashire and South Cumbria - rating their experience as either “good” or “very good”.
However, Dr. Peter Gregory, chair of West Lancashire CCG, acknowledged that there was “some variation in what is provided - and that must be incredibly frustrating for our patients”. He added that if primary care is regarded as “the front door of the healthcare system”, then it “isn't big enough for the number of people knocking” - and said he worried about the impact on staff of delivering more care with the same number of people.
David Blacklock, chief executive officer of Healthwatch Lancashire - an organisation set up to promote the views of patients in the county - said that although a good service was being provided by practices more often than not, he had heard “stories of patients that aren’t met with the kind of kindness and compassion that perhaps they need...when they're not feeling very well”.
“We’ve got very tired staff that have been met with very tired and frayed patients - and that’s pretty much a recipe for disaster, if you ask me.
“That compassion that patients need to feel and hear when they've been on the phone...for a long time to try and get through [is important]. You need to feel like the person at the other end of the phone is absolutely on your side, said Mr. Blacklock.
He was one of several board members to call for a public engagement campaign in order to help patients understand the system that they will encounter when contacting their GP surgery.
The NHS in Lancashire and South Cumbria has earmarked £331,000 from its £7.6m share of the government’s Winter Access Fund - designed to help provide same-day appointments to those with urgent care needs - for communication initiatives and the “signposting” of patients to the most appropriate care services.
Each of the area’s five NHS sub-regions will also receive an allocation from the winter cash pot. Subject to NHS England approval, Central Lancashire is set to spend £1.5m of its £1.8m tranche on same-day access hubs; the Fylde coast £522,000 out of £1.2m on a pop-up walk-in clinic in the south of the area to provide on-the-day urgent access; Morecambe Bay £526,000 out of £957,000 on a winter package of appointments; West Lancashire £200,000 out of £360,000 on same-day access services; and Pennine Lancashire £1m out of an allocated £2.5m on enhanced primary and community care hubs.
Meanwhile, following a reported - but now abandoned - government plan to place surgeries in league tables according to the number of patients seen face-to-face, Dr. Stephen Hardwick, chair of the Lancashire Coastal Local Medical Committee, said that judging the quality of care being provided by a practice on the basis of whether consultations were conducted in-person or done remotely was a "blunt tool".
“There are plenty of practices who actually provide superb services by providing mainly triage and only seeing those patients who need seeing, but for longer periods of time,” he said.
However, Greater Preston and Chorley and South Ribble CCGs’ chief officer Denis Gizzi questioned the value of public information campaigns - calling instead for better use of technology to improve the patient experience.
“I don't think we have got anywhere near using the right type of technology to assist patients to make the right decisions. [Our] telephony systems are really geared up for 20th century work, not 21st century work.
He also warned that moves to increase capacity could have unintended consequences.
“Opening new swim lanes will only mean we get more swimmers. It doesn't necessarily mean we get more effective at managing demand,” Mr. Gizzi said.
However, Morecambe Bay CCG chair Dr. Geoff Jolliffe said that examples from elsewhere in the world showed that improving public understanding about the impact of demand can help to reduce it. He added that his biggest concern at the moment is “patient expectations”.
“That’s not to criticise patients - it’s just a fact, because patients [have found] life very difficult through lockdown. They've had enormous traumas - physical, psychological, financial - so we understand why patients are in a difficult place.
“But that...expectation does create probably one of the biggest pressures, I think, on general practice - and causes quite a lot of friction at the interface [between patients and staff].”
He added that the public could help the NHS - which he said was having to deal with "pent-up suffering" - by not believing that the pandemic was nearly over.
“I think there is a degree of complacency that we don’t need to wear masks any more, we don't need to keep our distance from people [now] that we’ve had our vaccines.
“[I have seen] lots of patients with respiratory symptoms, so the first question I asked them [was]: ‘When was your Covid test negative’ - and virtually none of them have had a Covid test.
“So there’s a degree of reluctance to accept that the symptoms [they] have got as a patient could actually be Covid,” explained Dr. Jolliffe, who revealed that he had come down with the virus - even after having had three jabs.
“So we need to remember that this is very real.”
‘I WOULDN’T GO ON RECEPTION FOR £1,000 AN HOUR'
A staff member at a GP practice in Preston has told the Local Democracy Reporting Service that her surgery is receiving a constant flow of complaints from patients who have been unable to get an appointment as quickly as they wanted.
Sandra - not her real name, as she did not want to be identified - also said that a “nasty” attitude towards staff was compounding the pressure caused by the current spike in demand, leading to a “massive turnover” of those working in reception roles.
She is so fed up of hearing harsh critiques of her colleagues and others in the same jobs that she no longer admits to people where she works.
“If I meet friends of friends, I just say I work in a florist. If you say you work in a surgery, the first thing they say is: ‘Well, I don't know what it’s like where you work, but at my surgery…’ and then reel off a list of complaints. It makes you feel like it’s [a job] to be ashamed of.
“Even a receptionist at a hospital recently told me how she couldn't get in to see her GP when she found out where I worked.
“But people don’t see what GP receptionists have to do behind the scenes. As soon as the phone switches over in the morning, it's ‘boom’- and full-on until 6pm.
“I wouldn't do what they do for £1,000 per hour,” said Sandra, who works in an administrative capacity at the surgery.
She added: “We’re getting complaint after complaint [from patients] about not being able to get an appointment. [Our complaint-handler] writes back and then spends time on the phone to people.
“She clears one batch of complaints and then another load come in - and it’s the appointments that are everybody's bugbear.
“People are just really nasty. Some [of the reception staff] are young girls and they have got a job in the big wide world and they’re being spoken to like this.
“A lot of people who clapped for the NHS are moaning [about it] now. I do get it if your child is poorly or your elderly mum or dad.
“But people say things like: ‘I could have died’ - and you think to yourself, ‘I don’t think you could have done’.”
Sandra said that morale at her surgery had been hit by negative comments made on social media. She added that the stream of criticism is particularly difficult to swallow when staff have been going above and beyond during the pandemic - including volunteering at vaccination centres, something which she says has put individual practices under even greater pressure.
Primary care facilities across Lancashire and South Cumbria have also directly delivered the majority of Covid jabs - administering almost 1.4 million vaccines, which is 54 percent of the total.
Sandra said that she and her colleagues are often unable to switch off from work even when the working day is officially over.
“A lot of us have laptops at home and are logging on out-of-hours. The other night, after 8pm, four of us were logged on.
“We are trying our best to give a really good service, but people don’t see that side of things - and it’s really rare for someone to thank you.
“We had a really busy flu jabs session recently and then one of my colleagues came in and said: ‘Oh, I see we’re being slagged off on Facebook again’ - and I was like, ‘You what!’
“The girls on reception, in particular, feel really undervalued,” Sandra added.
'THE CAVALRY ISN’T COMING'
The Lancashire and South Cumbria region has the lowest ratio of GPs to its population of any part of the North West - and a leading medic is warning that the situation could be set to get even worse.
The area currently boasts 65.25 full-time equivalent GPs per 100,000 people - in comparison to 79.18 in Cheshire and Merseyside and 77.22 across Greater Manchester.
Papers presented to a recent meeting of the Lancashire and South Cumbria Integrated Care System also noted that those parts of the patch with higher levels of deprivation have a lower doctor-patient ratio - despite bearing “a greater burden of chronic disease”.
Meanwhile, it emerged earlier this month that early retirements amongst GPs meant that a government target to increase the number of general practitioners by 6,000 by 2025 is likely to be missed. The latest figures show that the equivalent of more than 1,800 full-time GPs have finished work since 2015.
“That gap will grow at the end of this pandemic, because [doctors] are hanging on...but at some point people will crack and say...the lid’s off the pressure cooker now, [so] I can honourably retire or slow down because I’ve done my bit and seen [people] through the pandemic,” said Morecambe Bay CCG chair Dr. Geoff Jolliffe, who added that he did not believe "the cavalry" was coming to turn the situation around.
Calling for a wholesale shake-up of primary care - specifically, for some acute care to be provided by other practitioners under GP supervision - he suggested that doctors should focus on “what we’re good at, which is complex care, complex diagnosis, managing frailty, palliative care, [and] chronic disease”.
“I would suggest that, very soon, if we don’t change and have a different model of care, we will drown - and then general practice will be in a very sorry state.”
West Lancashire CCG chair Dr. Peter Gregory said that the NHS had shifted from being a “needs-based system” to a “consumer-based model, where we are providing services that perhaps we don't feel we need to”.
“I think that adds to the challenge,” Dr. Gregory said.
THE DOCTOR WILL SEE YOU NOW - BUT HOW?
884,382 - total number of appointments provided in Lancashire and South Cumbria during September 2021 (up 20.4 percent on September 2019), of which:
552,632 (62.5 percent) were face-to-face
319,777 (36.2 percent) were over the phone
10,001 (1.1 percent) were home visits
2,242 (0.3 percent) were via video
Source: Lancashire and South Cumbria Integrated Care System