Hospitals and GP surgeries have always had a symbiotic relationship and the hospital crisis this winter has had a significant impact on the way that we are able to offer care to patients in the community.
In our practice, demand has not changed significantly as far as minor illnesses are concerned. We had an expectation of winter pressures and planned for more urgent appointments across all days of the week (including a Saturday shared rota with a hub of other local practices). But what we have seen is a significant rise in the complexity of cases – even when compared with a year ago.
Patients often turn up for their 10- to 15-minute appointment with several complex problems or secondary care related queries. Some practices advise patients to discuss one problem per appointment, and this has come under criticism from the Patients Association for potentially preventing people from raising health worries.
With many practices struggling to recruit GPs and nurses, and running on skeleton staff in the face of escalating demand and threats of closure, it is unhelpful for patients to see us repeatedly for a few minor complaints when a single appointment could sort all the issues.
At our surgery, we offer 15-minute appointments for routine problems that are booked in advance and 10 minutes for the on the day urgent problems. It is unusual to finish consultations within these times. Most days I will admit one or two sick patients into hospital – sometimes the decision to admit is clear cut, on other occasions it’s more complicated. Ultimately, it comes down to the patient’s best interests and their wishes, and the hospital being able to offer assessments and treatments that we cannot in the community. But increasingly, I am having to factor in long waits at hospital and the scarcity of beds in my decision. This week it took over 24 hours for my patient to be admitted from a care home to the hospital. Another patient, Dorothy, is in her 80s and usually well and independent in her warden-controlled flat. Then she became acutely confused, unable to walk and began hallucinating – there was also the possibility of a head injury from a fall but we were not able to corroborate this. I discussed her case with a hospital specialist and an assessment and a CT scan of the head was recommended via A&E. I called for an urgent ambulance. They too were inundated with emergencies and unable to hand over patients promptly through bottlenecks in A&E, medical admissions units and the wards. It was nine hours before Dorothy arrived in A&E. Her head scan was normal but it was another 12 hours before she was moved to a surgical ward as an “outlying” medical patient. Both she and her daughter who accompanied her were exhausted and upset.
Faced with worryingly high occupancy rates, many hospitals are admitting patients to non-specialty wards. In our area there are more than 100 patients on non-medical wards. This poses its own risks, with overstretched staff caring for more patients than safe thresholds allow.
Dorothy was discharged three days later, still confused, frail and unable to manage in her own home. There were no step-down or intermediate care beds to speak of and her daughter struggled to care for her. I had few options – she needed more help but I did not feel that she would be any better in hospital given current pressures. But a social care assessment would take days to arrange. I asked the rapid response team to support her until things improved. They too were working well above their capacity but agreed to take her on their caseload for a few days.
There are daily pressures to discharge patients like Dorothy to make way for new admissions. It is not surprising that with an ageing, frail population there are often no quick fixes. I am now seeing more failed discharges, with patients ending up in a crisis at home and unable to cope. Some hospital discharge summaries have clear instructions to offer supportive or end-of-life care, and not to readmit. For some patients this is appropriate – for others less soso as there are no new avenues being offered as an alternatives to admission. With overstretched GPs and community nursing as well as social care in disarray, the government is abandoning the most vulnerable in our society.
Last week, Theresa May blamed GPs for this “non-crisis”, claiming that NHS funding has been more than adequate – an assertion vehemently disputed by the head of NHS England, Sir Simon Stevens.
Despite the government’s misinformation on so many fronts, it is clear that today’s NHS is no longer resourced properly to adequately care for our sick population. And there is also another crisis unfolding – one of poor morale and retention of NHS staff, who are forced by chronic underfunding to either work in an environment where patient care is compromised within primary and secondary care, or to leave the profession. But it would seem that like the other “human crisis”, the government is in denial about this. too.
