Dr Becks Fisher is a Senior Policy Fellow at the Health Foundation. She’s also a practising doctor and works two days a week as a GP in Oxford. Here she talks about how her role as a general practitioner has had to adapt significantly as a result of COVID-19, and shares some of the Health Foundation’s current research into how general practice is being impacted across the country.
How has COVID-19 impacted on your work as a GP?
COVID-19 has meant huge changes in my professional life. For a start, I spent April–June working full time in clinical medicine. I continued to do my usual two days in general practice, but spent the other three working in a COVID 'hot-hub'.
Now I’m back to my usual split between clinical and policy work, but the clinical part has changed hugely. Instead of most of my appointments being face-to-face and about one-fifth by phone, the ratio has almost exactly switched and I now have only a few face-to-face appointments each clinic.
We’ve also been using digital tools more – texting and getting photos from patients, and using e-consultations. As you’d expect, those changes haven’t been without teething problems, and there have been difficult days. But we’re getting there, and the scale and pace of what we’ve done has been impressive.
Relatively early in the pandemic we set up a Health Foundation research partnership with Professors Judith Smith (University of Birmingham) and Louise Locock (University of Aberdeen), qualitatively tracking the experience of GPs, practice nurses and practice managers as we respond to COVID-19. That work is still ongoing, so in time we’ll have answers to this that go beyond the experience of the individual.
What were the main challenges your practice faced and how has it responded?
It’s amazing reflecting back to March, realising how far we’ve come and how many problems we’ve solved. Literally everyone in the practice has been involved – and no one is doing the same job now as they were in February. Managing this much change as a team has been interesting – and all while trying to stay 2 metres apart in a practice building that wasn’t built with social distancing in mind.
I feel very grateful to our patients – their understanding has allowed us to innovate. In doing so we’ve solved some problems that have plagued us for a long time (like long waits to see a GP).
Keeping everyone safe – staff and patients – has been a constant worry though. We’ve just published Health Foundation analysis identifying that a significant proportion of GPs – particularly in deprived areas – are themselves at high risk from COVID-19, and discussing the implications of this for face-to-face consulting. Unusually for a practice in a deprived area, most of our clinicians are low risk, so most of us have continued to see patients face-to-face where needed. But judging risk, and sharing decisions with patients around when to come in, has become another obstacle to navigate.
GP practices across the UK have had to introduce virtual consultations at speed, how has this affected your work as a GP?
I’m trying not to have an existential crisis about what it is to be a GP now… COVID-19 has certainly changed and challenged professional identities, and has stripped all of us (not just clinicians) of parts of the job that we loved.
I do see benefits to remote consulting. I certainly have more control over my clinics than I used to. Each call takes as long as it takes, and I do the next one when I’m ready. That’s less stressful than knowing I’m over-running and have a waiting room full of patients. But my colleagues and I certainly aren’t finding telephone consulting more efficient, and I worry much more about what I might be missing. That’s both in a clinical sense, and from a more holistic perspective too.
I worry that we have inadvertently created new barriers to care – some of my patients don’t have access to a phone, let alone a smart phone, and data and wifi costs money. Access to confidential, secure space isn’t universal, and being able to come to the surgery was at least a bit of a leveller. Without the 'safe space' of a consulting room, it’s hard to truly know whether my patients are somewhere they can talk safely and confidentially. And I worry that we are sacrificing continuity of care for access; that in itself may negatively impact on health outcomes.
I don’t want to assume that my consulting skills naturally transfer to being a good telephone clinician, so I’ve been working hard to try and make myself better. But there are lots of things I miss about the old ways of working. There is science and art in medicine, but also craft – and I miss working with my hands, examining people often, using a full range of clinical skills.
How has COVID-19 impacted on patients with other health problems, and what’s likely to be the long-term impact?
This is a massive concern and a big unknown. There are parts that we can guess at – and to a certain extent having to remove aspects of 'care as usual' during COVID has been an interesting natural experiment (though not one we’d necessarily have thought it wise to do). For example, we’ve had to suspend some long-term condition reviews. We don’t know what the impact of that will be (it’ll be particularly interesting if it doesn’t affect outcomes – it’s always helpful to find things that we don’t need to be doing!).
Like many, I’m particularly worried about cancer. National data suggests massive drop offs in the number of urgent cancer referrals, and that echoes my clinical experience. You have to remember that a significant proportion of cancers are detected on non-urgent pathways. So presumably the huge waiting times we’re going to see on those will also impact cancer diagnosis and survival.
We weren’t able to refer anything other than emergencies or possible cancer to the hospital for several months. Even now many hospital specialities aren’t running at anywhere near normal capacity, and some are still closed. The impact of massive waiting lists and delayed access to care is very worrying. People are really suffering; that’s also reflected in the large number of people we’re seeing with new or worsening mental health difficulties.
What chance is there of GP practices going back 'to normal' in the future, or are some of the changes made due to COVID-19 likely to be here to stay?
I think we’ll look back on March 2020 and the start of the pandemic as a watershed moment in general practice. Some of the ways we’re working now are positive, but some won’t be – and there may be some consequences that we won’t know about for some time (for example the impact on GP recruitment and retention). As a system we have to ensure we’re capturing data on a wide range of outcomes so that we understand what is working well, and what needs to change again.
General practice pre-pandemic was struggling with a decade of under-investment, with high workload and workforce problems. We’ve worked exceptionally hard throughout the COVID-19 outbreak and – if we had a moment to take stock – would rightly feel proud of what we’ve achieved. We’re in this for the long haul though, and just as the acute sector needs ongoing funding and support to manage the pandemic, so too does general practice.
This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.