This winter is my worst yet in the NHS, says GPC chair

The BMA's top GP has said this is the worst winter for the NHS he has seen in 30 years in general practice, warning that an emerging flu crisis threatens to put 'unprecedented pressure' on primary care.

Speaking exclusively to GPonline, GPC chair Dr Richard Vautrey said this winter was the worst he had experienced in the NHS 'because of a decade of underfunding, which is year after year after year making the situation worse'.

The GPC has this week called for the suspension of QOF targets in England - a measure NHS leaders have refused to implement in previous years - to ease pressure on practices. NHS England has not ruled out the move, but it may take the emergence of an even deeper crisis to force its hand.

Calls to suspend the QOF come after the government announced the cancellation of elective care until the end of January, as acute trusts struggle to cope with extreme pressure on hospital beds and ambulance services. Even if the move reduces strain on hospitals in the short term, the GPC chair has warned, it will drive up pressure on GP practices as thousands of patients struggle with frustration and anxiety over delayed care.

Signs are growing too that the UK could face a major flu outbreak - prompting a warning from Dr Vautrey that general practice is already operating at maximum capacity and has 'simply no headroom' to cope with the impact on workload that a flu crisis would bring.

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In recent weeks, growing strain on GPs has been brought into focus as winter drives up pressure across the health service. Dr Vautrey said: 'We have heard lots of reports from individual GPs working in their practices and out-of-hours about how steep the workload increase has been in recent days and weeks.

GPs have already 'gone the extra mile and done significantly more than would be expected of them to keep the show on the road', the GPC chair said. 'You can only do that for a certain time before it starts to have an impact on your own personal health and wellbeing, but GPs will do the best for their patients.'

But a major concern is that this pressure is already in evidence when flu has not moved beyond low levels. Flu cases are on the rise, and hospitalisations for flu are at 2.5 times the level they were this time last year, but overall statistics at the end of last week showed that presentations in primary care remained in the 'low' category.

If an epidemic were to develop - as it has across the Channel in France - Dr Vautrey is deeply concerned about the capacity of general practice in England to cope.

Flu outbreak

He told GPonline: 'That’s one of the big fears - while we have seen an increase in workload pressures, it’s not primarily down to flu at the moment. Yes, there is an increasing number of flu cases as you’d expect at this time of the year but we haven’t seen the anticipated rapid increase in flu cases yet.

'That could happen, but it’s not flu that is causing this current sharp increase in workload - it’s a mixture of other seasonal illnesses conflated with a much more vulnerable population that needs more care - so the real worry is if we were to get a flu outbreak, there simply isn’t any headroom in the system to rise to that challenge.

'That will put unprecedented pressure on every bit of the system if we were to get a real rise in the number of cases of influenza. That is why we have been very vigorous in trying to increase numbers immunised this year. But ultimately even with that protection there is a risk that it could have a real serious impact on all bits of the system over the coming weeks.'

Underfunding

Alongside an ageing, more complex patient population, underfunding is the key factor driving pressure on general practice, he says. 'We know that [funding is] not keeping pace with the rising number of patients that we have to deal with and the rising number of elderly patients who are frail and vulnerable living with multiple conditions.

'That disparity between the funding and workload inevitably means that every year is worse than the last. There aren’t enough people on the ground to provide care to the growing numbers of patients we have.'

The BMA has predicted that even with additional funding promised for general practice through the GP Forward View - which pledged a £2.4bn annual increase by 2020/21 - GP services will remain underfunded by around £3.4bn by the end of this decade.

Adding the cancellation of a month - so far - of elective care across the NHS into the mix will compound the problem.

'It’s going to leave a lot of patients very frustrated and anxious. They may well have made arrangements with their families and carers for periods when they are going to be in hospital and all that has to be changed.

Winter pressure

'For practices it often means that patients will make appointments with their GP for care while they are waiting for these procedures to be done - it means that more patients will be living with, potentially, pain or discomfort or disfigurement that was going to be corrected by the operative procedure; it means that some patients will be asking their GP to try and expedite appointments as they wait for a reschedule, so there will be more work shifted onto practices. And it just creates more unnecessary anxiety for large numbers of people, which ultimately ends up impacting on GPs and GP surgeries.'

Analysis by GPonline shows that average rates of hospital bed occupancy across England in December have been similar in each of the past five winters. So why is the NHS feeling the strain more than ever?

'It is primarily down to demographic changes in society,' says Dr Vautrey. 'There are increasing numbers of elderly patients - in their 80s, 90s, even over 100. It doesn’t take a lot for those individuals to tip over into a situation where they need specialist care.

'We are hearing reports of real pressures in A&E - it’s often not down to minor illness, seasonal illnesses and people falling over and needing bones fixing, it’s down to very frail men and women who need extra care. While numbers of people in that cohort increase, we will need to increase the capacity of the system to be able to manage them.

'The reality is that numbers of GPs have gone down not up - practices have been struggling to manage a recruitment crisis for a number of years now. There are many practices where they haven’t been able to recruit, they are carrying vacancies, they are not able to secure locums. They are just trying to manage the work as well as they can.

'We need to see an expansion of the workforce, not just of GPs, but nurses and pharmacists and physios and therapists working alongside practices so that we genuinely have an expanded workforce that can meet the expanded needs of our population. Cuts to social care and community nursing too - it’s all inter-related.'

Asked whether part of the £335m emergency winter fund should be diverted to primary care to ease pressure on struggling practices - and whether the fund should be increased - Dr Vautrey said: 'As [NHS England chief executive] Simon Stevens made clear prior to the budget - the funding the Treasury has provided is well below what he predicted was needed and compared with other European countries is still well below what they are funding their health systems with.

'We do need to recognise that that is the root of the problem. General practice does need that extra investment - there has been £20m made available for CCGs at the end of December to try and give them some resource to provide additional appointments and other activities that might support practices in the community between now and Easter. Some areas are using it for home visiting with paramedics and so on - the key is to provide extra capacity and support practices in that way.'

But in the absence of the kind of long-term investment the BMA has demanded, this seasonal support will bring only limited relief to practices struggling with rising workload. Flu data due later this week could begin to reveal just how bad this winter could become for the NHS.

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