Winter pressures in practice Why fewer doomsday headlines don’t equate to a comfortable winter on the NHS front lines

‘NHS just about managing’ isn’t a headline you’ll have seen recently.

January’s official statistics suggest that pressures on the NHS this winter are similar to last winter, but with the British media seemingly set to either ‘crisis’ or silence (or perhaps simply distracted by Brexit), seasonal pressures have slipped from the front pages. 

In my job as a Policy Fellow here at the Health Foundation, that’s a picture I recognise. Our ongoing analysis of NHS England’s performance data shows the NHS is busy – there are more A&E attendances than last winter, more admissions and high bed occupancy – but the system seems to be just about managing. Ambulance waits and breaches of the 4-hour A&E target are high, but there are fewer delayed discharges. And unlike last year, hospitals haven’t been asked to cancel planned operations to try to free up capacity for patients admitted through emergency departments. 

But in my other job as a GP, it doesn’t feel that way. There’s never really a spare moment in general practice, but in the past few weeks my colleagues and I have noticed the pressure ramp up. Phrases like ‘busiest ever’ are uttered depressingly often, as one Monday after another trumps the previous record for volume of calls. And it’s not just doctors feeling the strain – it’s a load being shared by our entire practice team. 

In general practice we have finite resources for potentially infinite problems. At my practice, if you phone and ask to speak to a doctor then we will always call you back that day, and arrange to see you if we need to. That’s the right thing to do, and the safest too, but we can’t control how many people ring us. The number of clinicians is the same whether it’s 30 telephone triage calls or 100, whether it’s 10 patients needing urgent face-to-face appointments or 40.

Seasonal illness affects staff as well as patients, and if clinicians are off sick, the same thing that drives increased demand on our appointments paradoxically means that we have fewer of them available. We can’t close the floodgates though, and so the load is simply shared between however many of us are left standing. 

So winter pressures are partly about volume – more patients, more illness. But any GP will tell you that some consultations are more challenging than others, and the balance of those contributes to how you perceive your workload. In the past few weeks I’ve felt like even more of my patients than usual are having a very hard time. Anecdotal n=1 stuff this may be, but even more of my consultations than usual are with people struggling with low mood, anxiety, social and relationship challenges.

With these patients, 10 minutes often doesn’t feel like enough time to ensure that someone feels heard and cared for, and for each there’s a different reason. The holiday season may be a reminder of loss or absence and can be particularly hard for people struggling with substance misuse. Poor quality housing and cold weather are a brutal mix – I note the number of layers my patients are wearing and ask them whether they have heating. Affording gas and electric is hard for some, and the meter runs down faster in this kind of weather. 

Benefit changes ricochet in to general practice

This year there’s also a new problem on our block – universal credit. It’s being rolled out in my patch at the moment, and as patients are switched onto the different benefits system, I’ve lost count of the number of people in tears in my consulting room worried about what will happen to their income. Or people simply without income, nor food in the fridge. Teething problems with universal credit – including delayed payments – have been much reported, and the local council have made an emergency fund available for people awaiting first payments.

As ever though, the reasons that people are most in need are often the same reasons that make them least able to access help where it is available, so the people in my consulting room often haven’t heard of or accessed any temporary funds. Why are they seeing me – the GP? Perhaps because with other public services stripped back, general practice is one of the few doors left open. Our social circumstances and our health are intrinsically linked, and, above all, people need help and to feel that someone cares. 

For all these reasons and more, this winter is feeling like a tough one in general practice. The new NHS Digital General Practice activity data represents significant progress in the reporting and availability of activity data from GP-land, but falls well short of recording the realities of this type of pressure. 

With all the above in mind, it’s no surprise that doctors aren’t shouting from the rooftops about how wonderful it feels to be working in an NHS apparently not in ‘winter crisis’. Of course I’m grateful that it isn’t worse, but saying that a system is ‘just about managing’ isn’t the same as saying that it’s ‘good, ‘better’ or ‘best’.

It’s important to recognise progress (and arguably it’s improved hospital discharges that have kept the system moving better this year), but 95% bed occupancy is well over any limit considered to be safe. And there are large parts of the system – general practice included – where the NHS is simply not capturing data that adequately reflects the pressures faced. The NHS may just about have its head above water this winter, but there are an awful lot of people swimming very hard to keep it there. 

Dr Rebecca Fisher (@BecksFisher) is a GP in Oxford and a Policy Fellow at the Health Foundation.