Workrate puts pressure on GPs

John Stones had been woken at 2am feeling as if his heart was “jumping out of his chest”.

After calling his local surgery soon after it opened, he was told by his GP Dean Eggitt to take four aspirin as a precaution against blood clots and to see him as soon as possible.

Two hours later he is sitting opposite the doctor.

Concerned about symptoms which left his patient with pain, tightness in his chest and palpitations, Dr Eggitt carries out some basic checks before asking one of the practice nurses to perform an electrocardiogram (ECG) to measure his heart’s electrical activity.

Less than 15 minutes later, he is back in the consulting room where Dr Eggitt tells him there are no signs of heart damage – but to be sure he needs to be admitted immediately to the medical assessment unit at Doncaster Royal Infirmary.

For Mr Stones, 66, still in discomfort with his alarming symptoms, it is a worrying experience. But it is a demonstration of the kind of swift and efficient care the NHS should aspire to – as well as an insight into the growing pressures facing health services.

Mr Stones would have been entirely within his rights to have dialled 999 when he fell ill to be taken to A&E at the infirmary for tests and checks, adding to the severe pressures already facing emergency services this winter.

Three decades ago, when he initially called Dr Eggitt, his GP would have advised doing exactly that.

Now, thanks to advances in medicine and technology, GPs can diagnose, treat and manage conditions which previously would have been the preserve of a hospital specialists.

But the symptoms still left Dr Eggitt with a dilemma. Chest pain is a common complaint but among the potential causes are a life-threatening heart attack, anxiety or a pulled muscle triggered by a coughing fit.

“It could involve simple reassurance or the patient could be on the brink of death,” he said.

The case is typical of the demands now being placed on general practice from an older and sicker population, on top of reduced resources and severe difficulties recruiting new GPs – all problems echoed by Dr Eggitt.

He and his partners at the Oakwood surgery serve 5,300 patients in Cantley and Bessacarr in Doncaster.

The practice has three GP partners and three doctors in training, as well as three nurses, dealing with in excess of 200 patients a day. It runs a telephone triage system for the sick. Patients can telephone after 8.30am and will get a call back from a GP sometimes immediately to assess their problem or, on a busy day, within an hour. Around 70 per cent can be successfully dealt with this way, saving the time of both the surgery and patients, while others can book appointments usually for that day or another if they need to be seen.

“We know patients’ histories, know their problems and don’t have to do an examination again if we’ve already seen them,” he said. “If you’ve built up trust, you don’t need to have face-to-face contact.”

The easy-access approach contrasts with recent criticisms from Ministers who claim difficulties securing appointments with GPs are driving many patients straight to A&E.

But it is also very hard work. On his busiest ever day, Dr Eggitt dealt with 70 patients, but even on a routine day he finds his time being eaten up by growing paperwork, as well as the additional demands from patients.

Days earlier, following an urgent appeal by NHS officials in Doncaster to GPs to reduce hospital pressures, he worked an extra 10-hour day. Another GP in the town kept his surgery open over the weekend.

The workload and pressures are impacting on the number of new doctors opting for a career in general practice. One in eight GP training places were unfilled in 2014 in England.

But the problems are particularly acute in Yorkshire where one in four were vacant. The difficulties meant one GP in Doncaster was recently forced to offer a £20,000 golden hello to attract a new colleague.

“Doctors choose to enter the profession as a sustainable career, to help people, to progress and to be good at what we do,” he said.

“Why would anybody choose it as a job where we simply can’t do that?

“We’re shackled because we don’t have the time to be with more patients and we’re shackled because we have to see them within 10 minutes to fit them all in. Why go into a job where you are under extreme pressure which is insurmountable?

“What we need is someone to reduce the shackles to allow us to do our job.”

Another patient arrives. The 24-year-old is worried about a number of moles and there is a family history of the skin cancer melanoma. Dr Eggitt carries out an examination and is concerned about one mole on her leg, referring her for an appointment within two weeks with a specialist at the hospital.

“If I get it wrong, melanomas are a big problem,” he said. “It may be unnecessary but it has to be the safest way.”

Faced with growing demand from patients, Dr Eggitt said he would need to expand the premises to do more work. But even then, growing burdens from additional paperwork ranging from new checks on doctors’ capabilities, to inspections by the Care Quality Commission – the surgery had its first in the previous week – are taking doctors away from patients.

“Of the 12 hours in my day four of them are paperwork which leaves me eight left to see patients – and I want to give them 10 hours,” he said. “In order for us to support all of this and support patient care either give me more doctors or reduce what I do each day.”

Later in the day, Mr Stones is admitted into the infirmary. He is given a series of blood tests, a chest X-ray and another ECG. A further ECG reveals abnormalities and he is admitted onto the cardiac ward overnight.

The following day the consultant prescribes him statins to lower his cholesterol and he is being given a monitor to measure his heart rate throughout the day. He will also be given a heart scan. He has suffered no more symptoms but is relieved he sought help.

“The consultant says she doesn’t think I have had a heart attack or got a heart problems,” he said. “I’m grateful I was sent to hospital. I must say the care I had in hospital was first class.”

Qualifying from Sheffield University in 2005, Dr Eggitt, 34, became a GP partner in 2010. But every year since he has felt the pressure ratchet up.

“It’s incredibly harder – like putting a weight on your back every year,” he said. “We see more patients, we see them more frequently, they are more ill and older and we can do more for them. I want to get on and see more patients but I need the barriers to me doing that to be taken away.

“I want to be a brilliant doctor but I can’t if I’m taken away from patients or if I work within existing resources. I need a bigger building, I need more staff and need more people to be trained.”