General practice and the multiple conditions challenge

Tomorrow, I’ll be seeing Winnie. According to her notes she’s 57, but you’d be forgiven for thinking that the frail figure hunched over her three-wheeled stroller is 20 years older. We didn’t have any appointments left, so I’m seeing her as an extra, slotted on to the end of morning surgery.  It’s not ideal, but we’re battling to keep her out of hospital and need to keep things under regular review.

At the moment, it’s a fight on two fronts: her legs and her lungs. The former is Winnie’s priority. Heart failure has made her legs swell, and so far, the drugs we’ve tried aren’t shifting the fluid. It’s painful, her skin itches, and she feels less steady on her feet. The last thing we need right now is a fall.

Winnie gave up cigarettes years ago, but she’s still feeling their effect. Her smoking-related lung disease is flaring up in the cold weather, and the fluid on her lungs from the heart failure isn’t helping matters. She’s coughing and feels out of breath. We may need to add to her eight medications to get things under control. 

Time in short supply

I’m a GP in a part of Oxford far from the dreaming spires, and my patients often experience significant socioeconomic hardship. Getting to look after Winnie and others like her is a privilege. It’d be easy to characterise the management of people with multiple conditions as a burden on GPs, but often it’s the opposite. Knowing a patient over time, understanding what matters most to them and using medical expertise to tread criss-crossing tightropes of polypharmacy and complex physical and psychological conditions is part of the joy of the job.  What diminishes that joy is the sheer pressure of it; we’d be able to do so much more if time allowed, but time is a commodity in perilously short supply.  

Seeing Winnie isn’t, in itself, stressful for me. In fact, in between the hacking coughs, she’s all smiles. What is stressful is that 10 minutes is simply not enough time, and while those 10 minutes become 12, 15 or 20, the waiting room is stacking up with patients, many of whom will also need more than their allotted time. No one said that appointments in general practice have to be 10 minutes long, but the volume of people who want to see us is simply so great that we can’t routinely offer longer appointments.

A hand unfairly dealt

Although managing these patients and these consultations can sometimes feel stressful for doctors, ultimately, it’s always the patient – and their lived experience of illness – getting the short end of the stick. For some of my patients the logistics of managing their multiple conditions is a challenge. Many are too frail to drive, and not everyone has someone who can take them to appointments. Cuts to bus services to our estate matter here, especially in a population where taxis are a luxury most can’t afford. Seemingly small things like appointment times can make a big difference. Cancelling a hospital appointment might mean waiting months for another one, but getting to an early morning consultation can be impossible when you can’t control what time your carers come to get you dressed.

The data in the Health Foundation briefing on multiple conditions may be new, but the points it proves support what many GPs already experience. We see the human cost of multiple conditions, and we feel it in our workloads. We bear witness to the effects of structural inequality and deprivation; the vicious cycles through which poverty drives ill health and ill health drives poverty. Walk five miles through the dreaming spires of Oxford to the other side of town and life expectancy rises by 7 years.  Many of my patients live with a hand unfairly dealt, stacked against them from the start.

Reconceptualising our approach

It doesn’t seem hyperbolic to relate the sustainability of general practice to our ability to adapt to the challenge of multiple conditions. Answers can seem simple – longer appointments, more continuity of care – but delivering them is difficult.

We’re already working smarter, and can work smarter still, but we can’t work much harder. It’s a truth well-acknowledged that we need more GPs, and more practice nurses, health visitors and district nurses too. The Health Foundation’s work on continuity of care, and the role of patient activation in the management of long-term conditions, asks questions we’d do well to try and answer. It would be an error, though, to view the challenge of multiple conditions as a problem to which general practice alone has the solution.

The NHS long-term plan offers an opportunity to re-conceptualise the way we approach multiple conditions right across the NHS in England. No one expects this to be easy. Tackling multiple conditions means action on health inequality, but ducking the challenge is no longer a viable option.

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