Testing times: Why making a GP appointment is unlikely to get any easier

Everybody’s got a story about trying to see a GP in the past couple of years and, whether it’s the embarrassment of having to relay symptoms to a receptionist or the frustration of waiting weeks for the briefest of telephone consultations, it seems that pretty much all of those stories are negative.

The evidence is not purely anecdotal, though. Figures published by the Patient Advice and Support Service, which is facilitated by Citizens Advice Scotland and acts as a conduit between the health service and patients who feel they have been let down by it, show that the number of enquiries it handles has skyrocketed since before the pandemic, with the proportion related to accessing GP services tripling over that period.

“Going back to 2017, we’ve seen enquiries go from 110,000 to 190,000 and the number of individuals supported from 3,500 to about 5,000,” says Jonathan Watt, head of programmes for Citizens Advice Scotland.

“We have a helpline that in 2017 had 1,910 calls – in the year to the end of April this year it was 4,208. That increase has been less about level-one advice [general enquiries that can be answered through signposting] and more about a significant increase in level two, where individuals come to us with concerns or if they are unhappy about a situation. 

“Before the pandemic, in 2019, only about six per cent of those queries were about access to GPs and that was people who were moving [and needed help registering with a new GP]. In April 2022 that rose to 18 per cent. Part of that is linked to Covid and practices’ inability to take people on but it’s also about getting to see a GP or being unable to make contact with them.

“For us, the challenge we’re seeing, and that’s reflected within the NHS, is that we have more complex cases coming through. People have concerns that haven’t been addressed for three years and we have an increase in safeguarding, for example people who are in crisis or suicidal. We’re handling more difficult clients and that puts a lot of pressure on our teams and the advisers who are handling that.”

There's a lack of GPs – as a country we just don't have enough

It is a situation that Dr Chris Williams recognises well. A Highlands-based GP who is also co-chair of the Scottish branch of the Royal College of General Practitioners (RCGP), Williams is well aware of the frustration patients right across the country are feeling. He says some of the problems are being created because patients are not yet used to a system that has been redesigned with the view that other health professionals can be used to both free up GP time and ensure people are seen faster, hence receptionists asking for symptoms and attempting to direct people to physiotherapists or pharmacists, as the case may be.

He stresses, though, that the number-one issue currently creating a problem in the smooth running of the system is a shortage of general practitioner staff.

“There’s a lack of GPs – as a country we just don’t have enough,” he says. “That’s partly due to a worldwide shortage of medical professionals but also, in terms of workforce planning, lots of things need to line up properly for it to be successful and decisions taken now will impact in 10 to 15 years’ time. With medicine that’s particularly the case because it takes such a length of time to take someone from entry to medical school to general practice. There have been times when there haven’t been decisions made to increase medical school places. Sometimes those decisions are taken around how many clinical placements we’ve got. It’s not an easy thing to do well.”

Nor is quantifying just how short-staffed the service is. Williams notes that a recent report from Public Health Scotland found that in 2019 there were around 4,400 GPs working in Scotland, with the number equating to just over 3,600 on a full-time equivalent basis. He says there were problems with collecting the data, though, and that RCGP has identified instances where a single GP has been counted more than once.

While that is problematic in and of itself, a bigger issue is that the numbers do not attempt to connect supply with demand, meaning it is difficult to determine where the gaps are or how urgently they need to be filled. The solution – sharing the load among a wider team of professionals – is adding to the problem.

“Currently it is difficult to map out or calculate how many GPs will give an adequate capacity to meet patient need [and] demand is not always aligned to what is available via the NHS,” Williams says.

“For the current GP numbers to be able to keep some level of service provision, it is obvious that they need to be connected to a far larger team. As we strive to do this, one difficulty that we are seeing relates to trying to deploy lots of professionals who are new to general practice settings and working alongside GP trainees and students from different backgrounds – GPs then find themselves undertaking more supervision and training, which then also becomes a time pressure against seeing patients themselves.”

It’s quite difficult to be giving your all, all day every day, and to still hear the message through multiple channels that patients can’t get to see you

The numbers may be difficult to make sense of, but the impact is not. A survey carried out by RCGP Scotland earlier this year found that well over half of general practitioners (65 per cent) were working at over 110 per cent capacity while only just over a quarter (28 per cent) were working in line with their contracted hours. Around two-thirds (64 per cent) did not have time to take a break of 10 minutes or more every day. For Williams, working at that level but still being unable to meet patient expectations can be demoralising for many GPs.

“It’s quite difficult to be giving your all, all day every day, and to still hear the message through multiple channels that patients can’t get to see you,” he says. “There are several things going on in terms of different ways of working, different pressures in the system, and the sheer numbers of people who are seeking assistance. We’ve done a huge amount in general practice in terms of finding efficiencies, finding new ways of working and trying to reduce inconvenience, but we can’t just simply work harder.”

And it’s not just GPs that are feeling the strain in the post-pandemic world. The problems facing the NHS are well documented – the worst A&E waiting times on record, soaring numbers of patients in the queue to be seen at chronic-pain clinics, a trebling in the number of people paying to go private in order to have their hips or knees replaced – and while that is taking a toll on the general public, it is taking a toll on those staffing the service too.

Dr Lailah Peel, chair of the BMA’s Scottish junior doctor committee, says that a year after a Scottish Government expert working group recommended that junior doctors work a maximum of 48 hours a week, changes have yet to be made and many at the early stages of their career report feeling stressed and burnt out.

“Make no mistake, junior doctors in Scotland are angry,” she says. “We are balancing on a knife-edge right now. Morale is rock bottom, we are exhausted, depleted, and struggling to see the light at the end of the tunnel.

"The workforce is buckling under the current workload pressures and I’m increasingly having conversations with colleagues about their concerns over unsafe working environments. Add in this year’s real-terms pay cut and you are looking at a workforce that feels extremely under-valued and I have serious concerns for the wellbeing of my colleagues.”

The chair of the union’s Scottish consultants committee, Dr Alan Robertson, warns that similar problems are being experienced at the senior end of the profession, with seven per cent of roles going unfilled and spending on agency staff increasing by 16 per cent this year. Like Peel, he says the doctors he represents are “depleted, exhausted and facing burnout”.

“The consultant workforce has been stretched to its limit over the past two years and staff shortages are affecting the ability of doctors to deliver the high-quality patient care they strive for,” he says.

“Not only that, but it is also affecting the high-quality training of junior doctors we want to deliver. The workforce is running on empty: there were reports of widespread burnout and an array of workforce and workplace pressures long before the pandemic hit.

"This, in conjunction with poor pay rises and a punitive pension tax regime, has led to many consultants considering their future – which will clearly only make things worse for patients and lengthen already spiralling waiting times even further.”

As a result, and after rejecting a 4.5 per cent pay offer made in August, the BMA is balloting its members on industrial action, with strikes on the table as a last resort.

Nurses, too, are gearing up to strike, with the Royal College of Nursing (RCN) and the Royal College of Midwives (RCM) currently balloting their members over industrial action. For both, the proposed strikes come after members overwhelmingly rejected a five per cent pay offer that was also made in August, but – as is the case with doctors – the issues at stake are about far more than just pay.

NHS Scotland workforce statistics published earlier this month showed that the number of nursing and midwifery vacancies across the service had increased by over 24 per cent in a year to top 6,000, with the RCN warning that staffing levels are such that both patients and staff are being exposed to “unacceptable risk”. A recent survey from the RCM, meanwhile, found that seven out of 10 midwives are considering leaving the NHS due in part to being put in a situation where they feel there are not enough staff to provide safe care for women.

Both organisations are clear that in order to retain staff and prevent further shortages a pay deal well in excess of inflation – which currently stands at just under 10 per cent – must be offered.

“Our members are telling us that enough is enough.  Every day they are seeing patient care compromised because there simply aren’t enough nursing staff to go round. Patients and staff are suffering,” says RCN Scotland interim director Colin Poolman.

“They are having to cope with the burden of knowing they haven’t been able to do their best while worrying about how they can heat their homes, feed their families and find the money to travel to work. Many simply can’t afford to be a nurse any longer. There remain over 6,000 unfilled jobs across NHS Scotland and spending on agency staff continues to rocket. Paying nursing staff fairly for the safety-critical work that they do would be a simple step to retain and recruit nursing staff.”

At the RCM, Scotland director Jaki Lambert says that midwives and maternity care assistants felt they had “no other option than to consider industrial action” after the Scottish Government “failed to address the crucial issues we laid out in our pay claim earlier this year”.

“We warned them that our members were at breaking point and that failing to deliver a pay increase that would match the rate of inflation could be detrimental to recruitment and retention of midwives and maternity support workers,” she adds.

“Many of our members feel undervalued and have had enough. They are already struggling with the rising cost of living and feel they’ve had no other choice but to make a stand in order for the government to wake up and listen.”

For health secretary Humza Yousaf it is a lot to listen to and take in and, if all the pay demands are to be met, it will require an immense amount of funding – funding that the Scottish Government has repeatedly stated it simply does not have.

When the pay offer to doctors was made Yousaf said it was the largest since devolution, adding that Scotland’s “senior medical staff will continue to be the best-paid in the UK and this will help ensure that NHS Scotland remains an attractive employment option for all medical staff”. Writing in Holyrood’s 2021-22 Annual Review he focused on more changes to the system that are to come, with an ‘early diagnosis vision’ to form part of a 10-year cancer strategy that will be published next year and a new mental health and wellbeing strategy in the pipeline for later this year.

Many of our members feel undervalued and have had enough. They are already struggling with the rising cost of living and feel they’ve had no other choice but to make a stand in order for the government to wake up and listen

Whatever Yousaf is able to put in place is not going to go far enough to meet the various unions’ demands on pay – no offer will come close to matching the prevailing rate of inflation – while plugging staffing gaps without a viable pipeline will prove impossible to do. A series of negotiated pay deals may help stave off problems with retention in the immediate term, but for Williams at the RCGP the longer-term health of the service requires proper workforce planning which, for GPs in particular, begins with taking an accurate picture of staffing levels.

Even if all that happens – and in the current climate it could well remain a big if – the frustration everyone feels about trying to access a GP is unlikely to go away.

“Lots of people want to arrange a convenient time with a GP of their choice so they can have an unhurried discussion about all manner of things, and we’d love to be able to do that, but the capacity we have nationwide doesn’t allow us to do it,” Williams says.

“Those are not times that we’re going to see; it was a different era that that describes.”