What are GPs worried about?
Many practices already feel they are working at or beyond maximum capacity, often with staff shortages - so taking on more work through winter is unthinkable.
'Already lacking in clinical staff due to retirements and unable to recruit permanent staff, having to rely on locums who will not deal with visits and all the clerical and paperwork that is necessary to continue safe practice!'
'One flu epidemic and my out-of-hours service will be in meltdown. It literally will be survival of the fittest. The ambulance service cannot cope (40min+ wait for teen stab victim last year), there are no beds available in the hospitals and overnight I singlehandedly cover half a county (approx 500.000 people). The public will have to sleep, take paracetamol and pray. There is no way we will cope. We were working at capacity during August never mind January.'
'One full-time vacancy unfilled for two years. No way of increasing capacity without working more hours or employing even more locums and becoming even more financially vulnerable. No tangible winter pressure plans from our CCG. Keep calm and carry on.'
'We are already struggling. Have restricted GP leave in December. Trying to cover our chronic shortfall in sessions with more locum cover, but there is also a shortage of locums available. We tried making more appointments book on the day, but this led to unacceptable increase in time waiting for routine prebookable appointments so have had to release a portion of these again. It is likely that duty doctor days will be increasingly pressured.'
How is the crisis spreading through the NHS?
Last winter, scores of hospitals were forced to sound the alarm as pressure rose to the point where they could no longer maintain a full range of routine services. Targets have continued to slip throughout the year, leaving the acute sector ill prepared to absorb more work through winter, despite the £335m bailout fund announced in the government's 2017 budget last month.
'The pressure on hospital beds is such that the purpose of an admission is not to diagnose and treat patients but get them out as fast as possible ultimately resulting in inadequate investigation or treatment, multiple readmissions and escalating patient distress. The consequence to primary care is these patients keep coming back to primary care upset and ill with very little or no information and huge amounts of time is wasted trying to sort them out.'
'The pressure comes from increased consultations, more unwell patients due to winter, in conjunction with failing secondary care and higher turnover of bed occupancy resulting in sicker patients being discharged earlier.'
'We are unable to recruit to vacant salaried GP posts. Locum GPs have been used but they do not fully contribute to workload as much as salaried GP or GP partner. We have a community matron to try to help reduce hospital admissions. We have a clinical pharmacist who does minor illness clinics. Both these people are prescribers. Practice phoned 999 twice yesterday to admit poorly patients. Took two hours for ambulance to collect these patients. Email received from CCG yesterday 22/11/17 saying A&E cannot cope with workload so GPs must try to reduce admissions. All our emergency admissions have to be sent to A&E despite prior discussion with on-call speciality staff.'
How is workload pressure affecting GPs?
GPs are suffering the effects of heavy workload and stress in a very personal way. Four times as many GPs as expected signed up for support from the NHS GP Health Service in its first weeks earlier this year - a scheme set up to help doctors facing burnout, depression, addiction and other mental health issues.
'Personally, I am working as few clinical sessions as possible in general practice as I have had general practice-induced mental health problems in the past and I now want to protect myself and my family from the detrimental effects of general practice. I am trying to support my colleagues informally. At CCG level I am persistently raising the issue of workload and stress.'
'Too much demand, people contacting us about irrelevant things. Sickness in doctors, already we have one off sick. Last year we had two and it was a real struggle. The rest of us just have to pick up the workload, or we get complaints which increases the workload further and then we make mistakes.'
'We are struggling to offer urgent appointments and are constantly having to send people to the walk-in centre. We have had two members of staff off sick due to work stress.'
What are GP practices doing to address winter pressure?
'We are overhauling our appointment system to have a majority of on-the-day appointments to try and reduce the workload of the duty GP (triaging regularly over 40 calls per session with potential visits) and trying to reduce our four-week routine appointment wait.'
'The practice has put a lot of effort into making this winter better as last winter was awful. We have extra staff doing clinical sessions and are planning the rota and appointments very carefully.'
'The usual steps of aggressive flu vaccination and freeing of more emergency appointments at the expense of routine care.'
'We have an urgent access clinic every morning so any patient needing to be seen will be seen that day however the number of patients in the last week has doubled . This means that we are pulling doctors off routine surgeries to help but this means we are short of routine appointments.'