The impact of COVID-19 on primary care and patient safety
Since the start of the pandemic the impact of COVID-19 on the provision of primary care, and those working within it, has been significant. Staff have been under considerable pressure to maintain services despite social distancing measures, adjusting to telephone appointments, virtual consultations, and the huge challenge of helping to roll out the COVID-19 vaccine. They have also had to deal with staff shortages caused by illness and self-isolation, compounding the staff shortages that were already in place prior to the pandemic.
As a result of all of these factors the care available to patients, and services offered, have been severely impacted.
The initial response to the pandemic
From mid-March 2020, the way that general practice worked profoundly changed.
In accordance with Health Commission guidance, all practices moved to remote triage. As you may have experienced yourself, patients are now assessed by phone or online before they can access a GP or other health professional. The ease with which this move happened varied across the country, and the Royal College of General Practitioners reported that many practices struggled with basic IT hardware and software adding further stress for GP’s staff and patients.
To free up capacity, GP practices were given the option to defer some routine activities, including health checks for people aged 75 and older, and routine medication reviews. Other activities, such as child immunisations continued. At the same time, the public were given instructions to access NHS 111 rather than their GP if they had COVID-19 symptoms in an attempt to reduce the vastly increased number of calls going through to GP practices.
Where we are now
Despite the restrictions being lifted, challenges have remained and the majority of appointments are still via telephone. March 2021 saw the highest ever number of telephone appointments in general practice; 11.4 million compared to 6.6 million in March 2020 and 3.5 million in March 2019. Between April 2020 and March 2021, 54% of appointments were face-to-face, compared with 79% in the previous year.
GPs and their teams are reportedly experiencing an ever-increasing workload, contributed to by the backlog of patients that were not seen during the pandemic, their involvement with the vaccine rollout, and the treatment of patients with long-COVID, has been delayed. They have also had to manage the patients whose planned surgery, such as joint replacements, has been postponed.
Although the NHS prioritised urgent and emergency procedures, this delay in primary care still meant that a significant proportion of people at higher risk needed to be supported by primary and community care when these services are already stretched.
This increased patient demand is making it much harder for GP’s to give the care that patients need. Recent BMA research found that doctors are suffering ‘moral distress’ and ‘moral injury’ because they cannot give their patients the care and support they want to.
What impact has all of this had on patient safety?
Patients not seeking advice
At the beginning of the first lockdown (April and May 2020) the number of appointments booked in general practice decreased significantly which led to concerns about unmet need, particularly for people with long-term health conditions, and the potential for delayed diagnoses.
Patients were urged not to avoid seeking help for serious non-COVID-19 symptoms and there were real worries that early detection of cancers had reduced, either because patients had not gone to their GP, or GPs being unable to refer to hospitals for tests.
A study carried out by the NHS showed that four in 10 people were too concerned about being a burden on the NHS to seek help from their GP. People were also concerned about the risk of catching coronavirus if they attended their GP surgery. In response to this, in April 2020 a major new drive was launched, to persuade the public to seek the urgent care and attention they need - it was advertised that the NHS was “open for business”. As a result, there has been an increase in patients seeking medical advice again.
Patients not being able to get appointments or the advice they need
It has been heavily reported that patients have not been able to easily make appointments to see their GP with phone lines being continually engaged and in some practices, no appointments available other than for emergencies.
This is not surprising when you consider how much GP workloads have increased due to the pandemic, but undoubtedly has an impact on patient safety.
In an open letter to patients a local GP commented “…I have never known things as they are right now. As patients you may have experienced increased waiting times on the phone and for appointments. For the staff it is the relentless (& in the vast majority, entirely appropriate) demand together with having to cope with staff absence due to sickness, holiday or isolating. Quite simply our demand is outstripping our capacity to meet it...”
The adequacy of telephone appointments and e-consultations
Telephone appointments and e-consultations were an absolute necessity during the height of the pandemic and enabled patients to obtain medical advice without risking catching and spreading COVID-19. Many practices who had not offered these services before stepped up in order to do so.
A GP local to me kindly gave me her opinion on the effectiveness of telephone and online appointments and how this system can be hugely beneficial if used appropriately. She stated:
“The advent of telephone triage and online consults has met with mixed reviews; however if used appropriately these tools allow us to consult with more patients each day increasing efficiency and improving patient safety. Patients no longer need to wait for a face to face appointment to discuss problems that can be assessed on the phone or via video call. For many who work or have caring commitments this allows them easier access to a health professional. Effective triage via the telephone also means those patients requiring face to face assessment are seen promptly, usually on the same day, ensuring those who are acutely unwell receive the care they need.”
Whilst telephone/online appointments suit a lot of people due to convenience and the ability to fit in with work/childcare, lots of patients prefer face to face appointments with GPs, especially for more serious matters. Even though a telephone triage system may result in a follow up face to face appointment (depending on capacity), a lot of people including a proportion of elderly patients, have reported that they find telephone and online consultations problematic and stressful and so may avoid them altogether.
In addition, there is a real risk that doctors may not be able to properly diagnose certain conditions over the telephone or online and that they will not always be able to assess the seriousness of a patient’s symptoms or whether it warrants a face to face appointment.
A recent tragic case reported in the news shows how a 27 year old woman died from liver cancer after her GP’s failed to spot her tumour during various online consultations. It has been reported that her GP would not offer her an in person consultation and she was diagnosed with a kidney infection in the absence of any diagnostic testing or any physical examination. She was only diagnosed with cancer five months later, at which point it was too late to treat. However, it must be remembered that some cancers are very hard to diagnose and even with face-to-face appointments, things can be missed.
The Health Secretary has recently commented that “more GPs should be offering face-to face access” and “we intend to do a lot more about it.” However, it has been reported that some NHS Trusts continue to incentivise the practice of telephone and online appointments with GPs being offered bonuses to keep in person attendances low.
Whilst the above practices continue, and GPs continue to be under extreme pressure, it seems inevitable that the safety of patients will continue to be put at risk. And, sadly, the consequences can be of the utmost severity.