After a decade as a GP partner in urban England, Dr Anne Noble spent 14 months as a GP in rural Scotland. Here, she discusses how safety must be restored to English general practice for it to survive
I believe everyone needs a family doctor: we all get unwell and have to trust professionals with our health, so an effective health service is in everyone’s interest. And as I recently spent 14 months working in an NHS practice on Skye delivering a well-functioning general practice system, I know that it is possible.
When my consultation with a man who had a rare and serious health condition came to an end, he sighed. His shoulders dropped with relief as he relayed the relative ease of gaining a face-to-face appointment with me, a GP. He thanked me for the well-coordinated care between his specialist and our practice team. This gratitude was a recurring story from English patients who moved to rural Scotland.
The sense of safety these patients seemed to regain from having access to a regular GP has struck me as a hugely important factor in the failings of the NHS in England and other areas of the UK. Safety represents the second need in Maslow’s hierarchy after basic physiological needs are met. English patients speak fearfully of ambulances queueing outside A&E with reduced access to safe emergency care. The less conspicuous lack of safety in general practice is difficult to measure but equally as concerning.
Until 2022, I was working in a busy practice in a deprived area of England. One patient came to see me with severe psoriasis, and another with months-long chest pains. The same old, ‘I know how busy it is for you doctors’, explained their delayed presentation. These patients did not need to be better at self-care or see a pharmacist, they needed to see an appropriate healthcare professional in their primary care team. All over the country, GP teams are acutely aware that they are not meeting their patients’ needs and lack a sense of safety too. Safety must be restored to general practice for it to survive.
In my practice on Skye, there were more GP appointments available for patients, and fifteen-minute appointments were standard. When a patient attended frequently with a minor illness, I was able to explore this drive for medical reassurance over time and discover an eating disorder. On-call days allowed me time to make thorough visits to our most vulnerable patients. It was deeply satisfying to care for two patients from the presentation of their cancer symptoms to their death. I had more time to support the deluge of patients who presented with various lifestyle-related illnesses. And I had closer working relationships with organisations who make the most difference to patients, such as those with mental health disorders, housing issues and care needs.
Recent studies have demonstrated that patients who receive continuity of care live longer and have fewer out-of-hours contacts and hospital admissions. It is also widely accepted that health systems with strong primary care provide the most cost-effective healthcare. Resourcing and strengthening our primary care system should be the Government’s priority at this time of unprecedented declining health. The HSCC’s 2022 report into the future of general practice concluded that relationship-based care and continuity are crucial for patients. Yet the new GP recovery plan makes no attempt to strengthen continuity.
What does it feel like to work in a well-functioning general practice system? Well, it feels like English general practice before it became overwhelmed, and it reminded me that being a GP is wonderful. Even on Skye, though, general practice remains demanding and resources are stretched. Rural practices also have their own unique set of challenges, such as distance to secondary care, lack of coverage of psychiatry and other services, and treating increasing numbers of tourists.
Despite these, I found working on Skye hugely rewarding and compatible with having a normal life. The service is doctor heavy with eight GPs (6.125 FTE) but also has an ANP, three nurses, two HCAs, a physio and a pharmacy team for its approximate 5,500 patients. On a full surgery day, I would see 22 patients along with a few phone calls, and the usual paperwork included results, letters and reports. The intensity, even on a busy on-call day, was much less. My day off was actually a day off, rather than spending it in recovery or catching up on more paperwork.
There is give in their system, which creates space for audit, quality improvement and even appraisal – activities that in England were moved to unpaid hours years ago. It is heartening to read clear recommendations including recognising the administrative workload in the BJGP article, ‘Note for a profession in difficulty’. If the Government delivered these proposals, general practice would be a happier place to work. My role in Scotland was salaried, but as a previous partner I know the burden of work for them is significantly higher. Partner workload is hidden, even from employees, and could be ringfenced.
In both rural Scotland and urban England general practice, I have seen increasing numbers of patients living out the consequences of the social determinants of health. We simply cannot care for a population suffering mass poor health. In a recent blog, the vice president of the association of directors of public health Greg Fell highlighted the role of all organisations and the Government in enabling healthy lives.
Massive change addressing the social determinants of health, as championed in The Marmot Review, could promote safety in our society – and return it to the consulting room.
Dr Anne Noble is a GP in Sheffield
Urban GP in Scotland is in every way in same parlous state as England sadly, gladly without Qof and CQC.
I worked in rural Cornwall for several years before returning to Scotland and like you found rural medicine more fulfilling, I think a lot of the issues come down to poverty and disadvantage.