“Pills, bills and bellyaches: a peek behind the scenes at a GP surgery”
Stephen Moss The Guardian, Sunday 3 November 2013
GPs are under more pressure than ever – to work evenings and weekends, to see more patients and
to run their surgeries with less money. What's day-to-day life like in a hectic practice? We spent four
days in one to check its pulse
If you want to get a real feel for life in a doctor's surgery, sit with the receptionists. This is the real
NHS frontline. At this busy surgery in south London, all that day's appointments have gone by
8.11am – lines opened at eight – and the rest of the day is going to be tricky. "The patients get
frustrated; they take it out on us," says a woman who has worked at the surgery for 20 years. "They
scream and shout at us, but when they go in to see the doctor they're like little sweetie-pies. I've
been called an effing bitch, and then they've gone into the doctor and they're as humble as
anything."
It's a damp autumn morning and the first of four days I am being allowed to spend at the surgery. I
have remarkable access, including being allowed to sit in on patient consultations if they agree. The
only condition is anonymity – of staff as well as patients. The surgery has six doctors (five partners
and a salaried doctor who is covering for a partner on maternity leave); two registrars (GPs about to
qualify who are allowed to see patients on their own but have a mentoring doctor they can consult if
they want a second opinion); three nurses, one full- and two part-time; eight receptionists each
working a few hours a day; and four stressed-out admin staff. After four days, it's surprising how
well I feel I know them.
Health secretary Jeremy Hunt has been accused of waging war on GPs recently, accusing them of
being more interested in making money than treating patients, demanding they take back out-ofhours and weekend services from the contractors currently supplying them, and arguing in favour of
a return to "family doctors", by which he seems to mean the Dr Finlay-style physicians of beloved
memory. All the negative publicity is having an effect: complaints about GPs are rising and their
stock has never been lower.
The surgery I am visiting is collectively rather depressed: cuts in funding – caused in part by the
"cleansing" of their patient list to strike off people deemed to be no longer using their services –
meant they lost more than £300,000 in 2011/12 and had to make two doctors, a nurse and an admin
person redundant. None of the staff have had a pay rise for five years; the doctors themselves insist
their incomes are falling. They are feeling unloved, overstretched, got at: caught between the ever
increasing demands of patients and what they believe to be unreasonable demands from
government.
Two long-serving doctors – men who had set up the practice and run it for many years – retired four
years ago in their early 60s. "In their last two or three years, they often said the work life of the GP
was unsustainable," says the 40-year-old woman who is now the surgery's longest-serving partner –
she started here in 2002. None of the six partners is older than 45; most work part time, though in
practice that still means a 40-hour week. Most days they will work 11 or 12 hours, more or less
evenly split between consultations with patients and admin, where they write up notes, write
prescriptions and fill in forms on behalf of patients who are seeking benefits or time off work.
The senior partner says the list cleansing, which reduced the practice's patient roster from 11,600 to
10,200, was painful. Before it was wound up, the local primary care trust wrote to every patient who
had not contacted the surgery for 15 months. If they didn't respond, they were struck from the
records and the £86.40 paid to the practice for each of them was withdrawn. Some occasionally
pitch up in the surgery to be told they no longer exist. There will be further list cleansing this year.
The partners say that in the past people who rarely used the surgery in effect balanced those with
chronic conditions who came all the time. Now, with the former being removed, its finances will
become desperately stretched: "£86.40 is not very much, and if you're visiting someone at home
four times a year, it doesn't really go very far," says one of the partners. "A lot of the patients had
moved and were genuine ghosts, and of course the practice shouldn't be paid for patients who don't
exist, but a lot of the patients do exist and the patients who don't use the service subsidise those
who do."
Back at reception, the calls are becoming increasingly agitated. "You'll need to call back on the day,"
says the receptionist. The woman on the end of the line is a little deaf. YOU'LL NEED TO CALL BACK
ON THE DAY. The next available one is on Friday. You'll need to call on that morning. Call on Friday at
8 o'clock. The doctor has got a few available, but she won't release them until Friday. Oh, you can't
do Friday. Call on Monday then. She only works Monday, Wednesday and Friday, so those are her
only days, and one of those days she could be on call. So if you want an appointment you'll need to
ring on Monday. You can't do Monday. OK, you'll need to ring on Wednesday. No, you can't see her
today. It's quarter to eleven. You need to ring earlier." "After being on here from 8 o'clock till 12
o'clock I literally come off and I can't talk," says the receptionist. "My voice goes."
No one, except the doctor who devised it, understands the appointments system, where slots are
released late at night for certain days in the next fortnight and patients then have to ring at 8am to
book them, or try to book them online or use a clunky automated booking system. "It's tortuous,"
one 40-year-old woman at the surgery with a young child complains to me. "It used to be easier. You
could book further ahead." She says that one day she phoned at 9am and there were no
appointments available; then she phoned back at 12 and they managed to find her one because
she'd bothered to phone again. "Were there any or not?" she asks. "The fact I'd phoned earlier
shouldn't make any difference. If there were appointments, I should have been given one. It's deeply
untransparent and annoying."
"We know the system has to change," says the senior partner. "It's demoralising for patients. It's a
lottery. You're just bidding against all those other people, and there's no certainty that the people
who need appointments will get them. It's first come, first served." "No appointment system is
perfect," says the recently qualified, 29-year-old salaried doctor. "If you know how to work the
system, you'll get in. The ones that come and see us regularly are the ones who know the system.
They always get appointments. And then there are the infrequent attenders who may actually need
that appointment but really struggle because they don't access the system very often."
If people are truly ill, they can turn up and fill in a form detailing their symptoms, which the duty
doctor – who spends the day sweeping up everyone the doctors giving 10-minute consultations can't
see – will assess. Some of those patients will be seen immediately (buzz words like "chest pains" will
trigger a quick consultation); others given appointments later in the week. If all else fails, they will be
advised there is a walk-in clinic a few miles away where they can sit and wait to be seen. The
receptionists freely mention the possibility of the walk-in centre, but one of the doctors argues it is
bad practice for the surgery not to be able to deal with their own patients and says this should only
be used sparingly.
Often the patients who come just want a shoulder to cry on or advice on some psychological
problem. They will present with physical symptoms, but with probing what will emerge is anxiety or
some sort of life crisis. "There's a lot of depression in this area and a lot of people with mentalhealth issues," says the young salaried doctor. It's a mix of young professionals, working hard and
playing hard, and an older, deprived working-class population. Both groups suffer high levels of
stress. "The doctor is often acting as a counsellor," says one of the receptionists.
There are also many who come with minor complaints and expect to have them dealt with
straightaway. "Things have changed over the past 10 or 20 years," says the senior partner. "People's
perceptions have changed. They don't have ways of coping any more with quite minor things. They
no longer have the extended family or granny, and they think they have the right to pop down to the
doctor's if their scalp is a bit scaly and itchy and they don't like it. A lot of things are self-limiting.
They are going to go away if they're given enough time. But people have a lot of fear and worry, and
they don't feel they can take time off work, so they have to come and get it treated. "
Out in the waiting area, an elderly man is asking whether his blood pressure can be checked, and can
he get the flu jab, and can he have some more of the tablets he was given last time. He is confused
and a little dishevelled. One of the receptionists explains that a couple of weeks previously, a car
reversed into him. He is OK physically and has been checked over, but he wants constant
reassurance. He has also forgotten what medication he is on.
The person behind him, who is also trying to book an appointment, speaks very poor English. This is
a hugely diverse area with a rapid turnover of patients – more than 30% of the list changes annually.
Sometimes the local authority have to send in translators to accompany non-English speaking
patients, and when I am sitting in reception later in the week I see a French-speaking mother come
in to make an appointment with her daughter acting as translator. Logjams occur; frustrations
develop; a young woman starts spraying round four-letter words when she can't get to see a doctor.
The rest of the patients in the waiting area sit heads down, looking at their mobile phones (the
ancient magazines on offer no longer seem to be read); they on no account want to get involved.
Eventually she gets in – she says her child is ill – and, as the receptionist predicts, she comes out
smiling as if the earlier incident had never occurred.
As my week goes on, I grow to like the doctors – young, enthusiastic, committed to working in a
fairly challenging bit of south London. One tells me he did a trial run as a partner in leafy Hampshire,
but found it too sedate and quickly headed back to the city. They enjoy serving a varied community:
"everyone from politicians and the heads of big media companies to Somalian women with 12
children", as one puts it. "If you're not interested in people, you shouldn't be doing it," says another,
who became a partner a couple of months ago.
She is interesting because she has chosen to join the partnership at a time of great uncertainty:
income is falling; the government is trying to claw back money from what it says was an
overgenerous settlement under the last government; the entire partnership model – where the
doctors run their practice as a small business – is under threat, with many seeing the future in big
consortia. I ask her why she chose to join at such a volatile moment, especially as becoming a
partner here costs £100,000 – the amount you have to pay to buy out an existing partner's interest
in the property that houses the surgery.
"It's a shocking time to become a GP partner," she says. "My timing is terrible. But I wanted to come
here. I was attracted to this place because of the quality of the relationships between the partners.
It felt like a really functioning relationship, unlike a lot of GP models." She is a strong supporter of
the partnership model at a time when many other GPs, who have no desire to have the hassle of
running a business, are losing faith in it. The latter see the future as one with larger practices or
consortia staffed by salaried GPs. "There've been lots of changes in general practice," she explains.
"You've seen a big rise in salaried GPs, and it's created tensions between partners and salaried GPs.
Salaried GPs feel like they're the workhorses who have to see all the patients. There are practices in
London where there are a few GPs running several surgeries and employing lots of salaried doctors,
but there isn't the sense of ownership that you have in a partnership. I've only been here a short
time but I already feel much more motivated. I feel they are my patients and feel much more
involved with them."
One of the registrars – a 27-year-old who is about to qualify as a GP – says he fears what will happen
if the consortium model wins out. "I did part of my training at a practice run by a consortium that
owned eight practices across London," he says, "and I didn't like the atmosphere very much. There
were regular visits throughout the year where the top management would come in to assess targets.
When your practice is owned by a mega-group, it does just feel like they're not people you work
with on a regular basis. They're strangers who wander in every few months to give everyone a telling
off and say: 'You're not meeting the targets.' Everyone here is lovely and I've never come across any
tension. I'm not sure what would happen if I started leaking money every day by prescribing
everyone ridiculously expensive drugs. I don't know if one of the partners would come and have a
chat with me and say: 'I own this practice, what are you doing?'" He doesn't know, but you sense he
believes clinical need would outweigh the bottom line.
"Some practices are very financially orientated," says one of the nurses, "and will run clinics because
they pay. You have to reach certain targets to trigger payments. Some managers are unrealistic
about what you can and can't do. They just want to drive through patients. They are thinking solely
in financial terms, and in health you can't do that. The NHS isn't a business. We are not so financially
orientated here. They are running a business, but they're not obsessed by the numbers. Some
practices are run by accountants and their agenda is different. Yes, we need to function, but it
doesn't drive what we do."
The doctors claim the patients like to have a named doctor with whom they can build a personal
relationship – and that is no doubt true for chronically ill patients who come a lot – but many just
want to see a doctor, any doctor. The partnership model, a throwback to the original creation of the
NHS and doctors' demand for independence, has advantages – the motivational stake in the
business – but I wonder about the economies of scale that could be achieved by having a bigger
practice. There would surely be advantages in combining the surgery with the walk-in centre a few
miles away to which they refer patients in extremis and which they use for blood tests and other
services. "I'm a big supporter of polyclinics," one patient tells me. But the polyclinic idea is dead, says
one of the doctors. There was no money to build the infrastructure. Another idea whose time has
gone in the stop-start world of the NHS.
The failures in strategic thinking are extraordinary. Primary care trusts were scrapped in April, to be
replaced by clinical commissioning groups supposed to give local GPs more power. But none of the
partners at this practice sit on the board of their CCG, and all that seems to have happened is that
the management support the surgery used to receive from the PCT has disappeared. "We no longer
know where to go for support," says the practice manager. "At the moment you have to email NHS
England and they say they'll get back to you in two days." They used to have a named person at the
PCT they could deal with. Now the next level of management feels far more remote. One doctor
does say he resented the micromanagement by the PCT and believes the CCG will in time make
health provision more responsive to local needs, but my sympathies are with the practice manager
who is drowning under a sea of paper, never leaves her office and has little or no managerial
support.
Technology, as always with the NHS, is a disaster. Different practices use different IT systems and
often they are not compatible. When a patient goes to another practice, it is frequently impossible
to forward their records electronically, so the whole file has to be printed out and posted. "The
system of having to print things off and then send it by paper is Dark Ages, isn't it," says one of the
doctors. "When will the whole NHS have one system?" I ask. "I'd hazard a guess at never," he says.
Underlying everything of course is the fact that increasing life expectancy means the practice has to
deal with more and more elderly patients with chronic conditions. One of the admin staff tells me
they used to provide about 20 dosett boxes, where tablets are organised into compartments for
patients who need to take a lot of pills and delivered to them on a weekly basis. Now they are
supplying 112. I accompany one of the doctors on a home visit to an elderly patient who is just out
of hospital after a five-week stay. All her tablets are lined up on a chest of drawers in her bedroom,
but her son says there are too many for her, she can't cope with the large ones, and she is eating so
little they are making her sick. As the doctor talks to her, it becomes clear she has more or less given
up. "If I could go to sleep and not wake up, I'd be relieved in some respects," she says tearfully. "At
least then it would be over. In hospital I used to think, 'Why can't it just be over?'"
I look at her hospital discharge form. She has diabetes, hypertension, peripheral vascular disease,
chronic kidney disease, severe systolic dysfunction and a range of other conditions expressed in
acronyms I can't interpret. "I didn't want to come home, but I didn't want to stay in hospital either,"
she says. "I thought, 'I've gone this far with all this pain in my legs'; four years is a long time to be in
pain." She is also in the early stages of dementia, and all she really cares about is replacing the bed in
which she is propped up, which she associates with her late husband. The bed has become the
symbol of all her problems. The doctor is powerless to help her. He offers some tablets to lift her
mood, but the last thing she wants is more drugs.
The home visit takes place at lunchtime, after the doctor has spent four hours seeing patients at the
surgery or talking to them on the phone. He will do 15 face-to-face consultations in the morning and
another 15 or so in the afternoon. I sit it on six, and am impressed by his ability to listen and the eye
contact he maintains. He is not one of those GPs who taps away at his computer as you talk. Rather
than handing down judgments from on high, he tries to involve his patients in the decision-making.
These days most of them have googled their symptoms and reckon they know exactly what's wrong
with them, so there needs to be a conversation, if only to dispel the misconceptions they have
picked up from the internet.
A pregnant woman comes in with her coughing toddler. They discuss whether the child should have
antibiotics – undesirable in someone so young. A woman in her 40s comes in with a foot problem,
but it transpires the real problem is she is alcohol dependent. She has had half a bottle of white wine
already that morning, is consuming a couple of bottles a day, and has just lost her job because of her
drinking. It is a complicated story that has to be teased out, and the consultation takes more than 20
minutes – so much for the 10-minute slots which all the doctors agree are ridiculous.
The toughest, though, is still to come: a 54-year-old woman who has been diagnosed with ovarian
cancer. She is shocked but resolutely upbeat. She asks if she will be able to go back to work in four
weeks as she is hoping to start a new job. No, he advises, this is a major operation, she will need at
least three months to recuperate, focus on that. I find it all draining, yet I have only sat through onefifth of his day's consultations. How will he feel by 7pm?
I am left full of admiration for the work the GPs do. It's a tough calling. OK, they earn close to
£100,000 on average if they are willing to do a 50-odd hour week, but the demands are huge. My
sense is they are in it primarily to make a difference. The doctor who is about to qualify tells me he
chose to become a GP because it gives you a chance to get to the heart of a patient's problems; in
hospital he just felt like he was on a "conveyor belt", offering routine treatment without ever seeing
the person behind the patient.
Doctors, especially if they live locally, are never quite off-duty. If they spot them in the street, some
patients want an instant consultation. "The worst time was when I was down at my local Sainsbury's
not far from here," recalls the senior partner. "A couple of women patients were chatting to me, and
one of them suddenly asked for her vaginal swab results while standing in the queue. They thought
that I might know their results. I couldn't understand how they could ask that, let alone think I might
remember the results."
This government wants GPs to do much more – to open on weekends, take back out-of-hours work,
conduct consultations by Skype, be available to patients by email. The GPs think it is pie in the sky.
"We'd be too spread out and there'd still never be enough appointments, so unless huge amounts of
money come in or there's a massive increase in the number of GPs it's just not going to be feasible,"
says the salaried doctor. Some see conspiracy in the government's propaganda war. "The feeling
among trainees is that the government is putting a lot of power in GPs' hands, so that if the NHS
shake-up does fail, there is a quite obvious scapegoat," says the soon-to-qualify young doctor. "The
government will be able to say patients wanted GPs to have the power to commission, and now that
it's failed it's obviously the GPs' fault."
The deputy practice manager says there is a creeping privatisation. "The government is privatising
from within," she argues. "People with hearing problems are now sent to Specsavers [which now
offers hearing tests and sells hearing aids]. They're gradually sneaking the companies in. That
worries me because I've lived in the States and I know what private medicine can do." A recent (far
from scientific) survey of GPs in Pulse magazine suggested a majority would favour making patients
pay for a consultation, not least to discourage no shows (about 10% of those who have booked
appointments at this surgery do not attend). Most of the doctors and staff in this practice dismiss
the idea as the thin end of the privatising wedge. "It would sort out the demand issue at a stroke,"
says one of the partners, "but unless it was brought in incredibly carefully it would also widen health
inequalities because almost by definition the people who need to be seen are the ones who
wouldn't be able to afford to pay." "It would kill the NHS," says one of the nurses firmly. NHS
dentistry has already been wrecked and a two-tier system created. Paying for consultations would
mean general practice going the same way.
For all the good intentions and hard slog, I have a sense the GP model is broken. The appointments
system is a mess. The IT system is an even bigger mess. If you are seen by an out-of-hours doctor, he
or she will not have easy access to your records. The ending of PCT looks to me to have been
ludicrous, since no effective replacement has been put in its place. "We've got no idea what is
happening," says the deputy practice manager. "They've given us one telephone number for NHS
England. It's basically like a pack of cards someone has flung up in the air to see where they land."
CCGs have not replaced the management function discharged by the PCTs, and Health England feels
too distant. Practices are being left to sink or swim.
Politicians have chopped and changed over what is desirable in the face of ever increasing pressure
on the service. The ageing population is placing impossible demands on surgeries and on the NHS
generally. Hospitals are full of old people who need care rather than treatment, and the shortage of
beds means other patients are being discharged earlier, putting more stress on surgeries.
Immigration has also imposed pressures: more people from abroad using the NHS; more patients
with little or no English. If they fall in their catchment area, the surgery tries to help whoever wants
to register – there is no requirement to prove you are here legally – but it is one more demand on an
already creaking system.
Ultimately, the questions are political, philosophical even. How much money are we willing to
spend? Should you even begin to try to cater for demand that is pretty well infinite? What is the
point of keeping people alive when their quality of life is so low? Should we accept that ultimately
people who can afford it will have to pay? How should time-wasters and persistent no-shows be
treated – should they just be summarily excluded from accessing services? Is the wonderfully
democratic, limitlessly beneficent, communitarian model of the NHS dead? Or, if not dead, in urgent
need of the sort of dispassionate treatment governments seem incapable of providing.
Pity the poor young doctors setting out on their careers. "Years ago I think GPs were well respected
and well liked," says the recently qualified salaried doctor. "But as funding's cut and time's cut and
pressures mount and people become more demanding, there's less of a perception of us as being in
an authoritative position. People come and they say, 'I'm not leaving unless I get this,' even if it's
completely unrealistic. Our respect levels have gone down and we've been made scapegoats by the
government. I did 11 years of training to get to this position and I only want to help people, but
you'll come in and have people shouting at you and swearing at you and being aggressive because
you can't quite deal with their demands. I feel we've been crucified in the press. I can understand
where they're coming from with saying we should open seven days a week and try and do it eight till
eight, but it would be impossible." Doctors, though, are expected to do the impossible. Surely there
is a pill that will solve everything.