‘Data not dates’ has been the mantra for government in recent months, as it monitors the impact of Covid’s third UK wave - or in this part of the country, its fourth - on the health system.
Only ten days ago, health secretary Matt Hancock was extolling at select committee the virtues of improved data collection during the pandemic, claiming it had moved on since the fraught period a year ago when public health directors weren’t even being told who in their areas had Covid.
But concern is growing that ministers are still only looking closely at intelligence from one part of the NHS, for while hospital admissions get plenty of attention, the growing crisis in primary care gets less emphasis. Yet that is the part responsible not only for keeping many patients out of hospital, but also, to a very great extent, for delivering the vaccine roll-out.
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As the Manchester Evening News revealed last week, some general practitioners are now walking out on the job, warning the system is on the brink of collapse. Staff told of extreme burn-out, of patients unable to get appointments, of exodus from the profession.
“Primary care is a system now hit by far more than a triple whammy,” says Wigan’s director of public health, Prof Kate Ardern, who is becoming increasingly worried about the implications of that pressure.
“It has backlogs to clear; patients finally coming forward with ailments after avoiding the NHS last year; a rising tide of mental health cases, for obvious reasons; a current surge in milder Covid cases that need treatment outside of hospital; long Covid; and the vaccination programme, three quarters of which is being provided by GP networks.”
Capacity is constrained, too, just as it is in hospitals, due to infection control measures. Face to face appointments are taking twice as long due to cleaning and the time taken to put on and take off PPE. Phone consultations also take longer, because GPs haven't got the visual cues they would pick up on in person. So the primary care bottleneck becomes even narrower.
This combination of pressures is particularly acute in a part of the country that has consistently seen higher Covid rates over the past 12 months, was first into the second wave and this Spring was the first to be hit by the latest one.
Yet the only NHS data widely discussed in the public arena is the other side of the coin - hospital capacity and admissions.
Part of that is due to the way the system is set up and funded, say many spoken to by the M.E.N. That complexity, they say, is key to understanding why we hear little about it from ministers, despite patients on the ground palpably finding it harder and harder to get an appointment, while GPs warn of system collapse.
Unlike hospitals, accurately assessing pressures on primary care is tricky, explains Dr Vish Mehra, chair of Manchester’s GP Board.
It isn’t always clear what exact data should be collected. Meanwhile GP budgets are provided per head of population, whereas in other parts of the NHS, funding is linked to the amount of activity they carry out. That means the level of demand in primary care is more likely to fly under the radar, while in hospitals it equals hard cash.
“I don’t think they have a clear view,” he says of the government, “because of some of the complications around the data and also the way that GP funding works, based on a budget per patient.
“So the amount of actual demand is not relevant from a financial perspective for government, whereas in other places, the more activity is generated, the more cost is generated. And that’s a disincentive to try and capture data around general practice demand and also to do very much about it.”
His point is arguably borne out by the government’s response to this article, in which it said that nationally, GP appointments in March were in fact one per cent down on pre-pandemic levels. Yet Manchester’s own data shows general practice currently facing almost a third more demand than before Covid hit.
“The data - which is an underreporting, actually - shows substantial increases in activity,” insists Dr Mehra.
“There’s approximately a 30pc increase in demand on pre-Covid levels.
“So it’s actually substantially higher than pre-Covid - and pre-Covid we were already in a bit of a crisis then.”
The real figure will be even higher, he says, because the data does not factor in those patients being seen online.
For a number of practices, activity is showing up on official records as close to ‘zero’, because the data on online presentations isn’t included.
“All that work is happening - but it’s not being recorded.”
GPs are also growing increasingly frustrated at the suggestion that primary care is ‘closed’, when they say that in reality, practices are being pulled in all directions.
“At the peak of Covid, people were trying very hard to stay in and not go out and do anything and a lot of routine things were deferred - routine reviews, like blood pressure and diabetes,” he says.
“You can only do that for so long before it becomes a safety issue, so we’ve been trying to catch up and get through, in priority order, some of that demand.
“Because Covid has been the main thing in the national conversation for some time, and because people’s lives have been substantially affected, there’s been a lot of general health anxiety coming out and there’s been a big surge in mental health pressures. So that type of consultation is increasing.
“A lot of people put things off during wave one and wave two and some of those presentations are beginning to come in. And then just the general effects of Covid itself - we’ve taken some of our capacity into ‘hot’ clinics in order to assess and ensure only those who need to go into hospital go into hospital. Obviously, that’s a new source of work.
“And with patients who have had Covid, you're seeing quite a variety of long Covid and post-Covid complications.”
At the same time, ‘around 75pc of all Covid vaccination has been delivered by general practice’.
Inevitably, he says, the upshot is causing difficulties for patients, who are ‘frustrated they’re struggling to get access to GPs’. Is the current situation unsustainable?
“It certainly feels like it’s getting there.”
Another senior Manchester doctor also highlights a string of new pressures that have arisen thanks to the pandemic.
“The things that are really taking practices to the edge are that there’s a heck of a lot of work and time that’s been generated by dealing with hospital waiting list issues,” he says.
“If you’re at home in agony and can’t get out of bed and on a waiting list, you’re interacting with primary care, chasing up appointments, pain relief, not the hospital.”
Then there is the rapid increase in mental health problems, particularly among kids.
“There are a hell of a lot of child and adolescent mental health issues after a year where the only interaction has been with social media and a lot of general mental health issues as a result of financial strain, uncertainty, families cooped up together.
“And I think the issue is that normal mental health services are saturated, so there's a lot of spill over from the secondary care mental health services into primary care, so they’re under big strain in terms of mental health.
“On top of that they’re dealing with Covid vaccination issues and long Covid issues.”
There is - as there was before Covid - a considerable variability across the system, he says. Where GP practices had already clubbed together to form networks prior to the pandemic, there is more ability to cope.
But there may be ‘very little resilience’ in a single handed practice ‘that can’t cope if you layer on lots of sick kids, lots of mental health issues, lots of complex Covid care’.
He agrees data is key.
“The thing about secondary care is it’s really easy to provide a ‘sit rep’ of people in ICU and it’s all very easy to measure.
“You've got a situation in primary care where you’re layering on more and more and more - and in areas where there’s not that flex to deal with it, it risks breaking certain areas of primary care.
“But without data, you’re just another person with an opinion.”
This concern isn’t limited to Greater Manchester, where the latest wave of Covid cases has been building for some time. In Sheffield, the city's public health director, Greg Fell, is also becoming increasingly alarmed about the noises he is hearing from GPs.
He too points to gaps in data and says this is ‘always an issue’ where primary care is concerned. It is both ‘hard to source’ and ‘largely doesn’t exist in a coherent format’.
“Data on GP access is notoriously difficult to get. Compare this to hospitals, where a lot of the funding is linked to activity - thus there is indeed excellent data.
“Also, what data do you collect in primary care? In other words, what is a ‘contact’?
“Is ‘contact’ a phone call, a face to face appointment, medicine review, long term condition review, a blood review? It could be any of the above and all are valuable and all are routine bread and butter stuff for general practice.”
Yet the experience of GPs and patients bears out what the data doesn’t show, he insists.
“Just because there isn’t data, doesn’t mean that it isn’t a true story.”
Neither does it mean GPs are sitting on their hands, he adds.
“I hear from lots of people who are telling me they can't get to see a GP, thus the GPs must be on the golf course.
“We are seeing an increased trend of members of the public raising issues around doctors surgeries – they can't get in and are understandably frustrated at this.”
Dr Mehra agrees.
“The vast majority of GPs will want to do the most they can to look after their patients as best they can and that’s why they are working very, very long hours and they are stressed and burned out.”
But there is only so much the system can take, he stresses. If primary care can’t cope, it will be the hospitals that start to feel the effects.
“It’s logical that if patients are struggling and can’t access primary care, then one of the other places they end up going into is secondary care - patients that could have been dealt with elsewhere.”
In Lancashire, where, like Greater Manchester, the fourth wave of Covid has been heating up for weeks, there are similar concerns.
There is also the fear that well-documented existing health inequalities, already borne out and exacerbated by the pandemic, will now only grow further as a result.
Blackburn’s director of public health, Professor Dominic Harrison, points to new research by Lancashire and Cumbria’s public health collaborative, as yet unpublished, finding that the North West is likely to be disproportionately hit by long Covid and mental health problems as a result of its high infection rates, hospital admissions and deaths over the past year. All of that will require the primary care sector to hold up, even if the national political focus is all on hospital beds.
Based on current rough estimates that one in ten Covid patients still have some kind of symptom after three months, in Greater Manchester alone that could translate into more than 50,000 people, the paper finds.
While that will require all parts of the NHS - and public health - to come up with a long-term response, at the moment GPs are bearing much of the brunt.
“The reality of the impact on the hospital system means much of the necessary care is being displaced into primary care, who are already overwhelmed with unseen or untreated long term conditions that have exacerbated during various lockdowns,” adds Prof Harrison.
“They are also now dealing with people increasingly poorly with Covid in the community again as rates rise.”
So there are growing concerns that ministers need to look more closely at what is happening in primary care. Not only does the scale of the pressure here risk widening existing health inequalities further down the line, but it also has a bearing on the roadmap.
“At the moment nationally they’re not joining the dots,” says one senior Greater Manchester official of both ministers and their advisers.
“I suspect they think that GPs just hand out prescriptions, refer to hospitals and play golf, a bit like the Whitehall view of local government - they just do bins, don’t they?
“You best protect secondary care and intensive care by investing resource into prevention and primary care.
“Plus if primary care falls over, that’s the vaccination programme scuppered. To be blunt.”
In Sheffield, Greg Fell agrees. He points to primary care as the hidden fragility in the government’s roadmap out of the pandemic.
“It is clear the government is focused on four tests for risk assessing a response to Covid,” he says.
“‘Overwhelming the NHS’ is rightly and understandably one of them. However, in this we neglect pressure in primary care at our peril.”
While the ‘public consciousness and the focus on data analysis’ is on hospital capacity, he points out, the health system is ‘interconnected’.
“It wouldn’t take a huge shift in GP gatekeeping decisions to put significant strain on the hospital sector that would have a bearing on intensive care.
“Thus pressure in primary care probably also needs to be part of the critical considerations of government in the four tests.”
Oldham GP Dr Zahid Chauhan, also the council’s cabinet member for health and social care, is also worried.
“Primary care is in crisis and government is not paying attention,” he says. “It means the system will collapse.”
He is one of a growing number of people in the sector who believe that despite the data being muddier than those for hospitals, the alarm among GPs and other primary care staff can and must now be sounded louder.
Our story last week of the GP who downed tools was a symptom of the ‘combustible frustrations’ shared by colleagues, he says.
“But for me, personally, there is a bigger picture here and precedent to prove that together we can succeed, where the individual alone cannot,” he says, adding: “When the voters are on your side, the politicians must listen.
“The entire system of primary care could be about to collapse. But that should be our call to arms.”
For Dr Mehra, meanwhile, there are both short-term and longer term decisions that need to be made quickly by ministers.
“I think government should certainly collect the data,” he says.
“I think it should be investing in the bits that can be changed on a quicker basis. So there was a small amount of locum GP capacity within the workforce that could be brought in. Also recently retired GPs have been drafted back in to help with vaccination.
“There is a wider workforce that may be tied up in other parts of the NHS or even the private sector that can be brought into action relatively quickly. These things will need investment.”
That’s before he gets to the longer term concerns: GP numbers that are lower in some places than they were when former health secretary Jeremy Hunt promised to provide 5,000 more in 2014; a generation of skilled nursing practitioners nearing retirement, with little trained workforce to replace them; and a chronic under-investment in estate.
In the meantime, the first thing GPs, public health directors and their colleagues want government to do is listen. Debbie Abrahams, Labour MP for Oldham East and Saddleworth, a former public health consultant and a fellow of the Faculty of Public Health, is now taking up the issue in the political arena.
“I am concerned about the pressures that both primary care and social care are under and the lack of consideration given to this in the government’s analysis of the responsiveness of the NHS to increased Covid-19 under the roadmap,” she says.
“When the Department for Health and Social Care and SAGE examine ‘NHS data’, they are only looking at hospital data, missing the main part of the NHS patients use - primary care and social care.
“For example, it’s our primary care staff, including community staff, who have been delivering large swathes of the vaccination programme on top of their existing work.
“The government should be examining the pressures on primary care in their ‘NHS data’ as we know that issues in accessing primary care services have a knock on effect on hospitals.”
A spokesman for the DHSC pointed to the extra surge testing and other support provided to areas such as Greater Manchester since the emergence of the Delta variant in recent weeks.
The DHSC and NHS England ‘always maintain an open dialogue with GP representatives to understand issues facing their members and work together to ensure high quality services for patients’, the department said.
It also said the number of face-to-face GP appointments in March, nationally, was one per cent below that pre-pandemic.
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Practices ‘should offer face to face appointments to patients unless there is a good clinical reason not to’, it said, ‘for example the patient has COVID-19 symptoms, and practice receptions must be open to walk-ins’.
“We are easing restrictions across the country in a way that is cautious and prioritises data over dates and we have delayed step 4 by up to four weeks as well as accelerating the vaccination programme to respond to the rapid spread of the Delta variant.
“Safe and continued access to key services is a priority and we are incredibly grateful for the tireless efforts of GPs and their teams, delivering 275 million appointments throughout the pandemic and continuing to provide care for all of us when we have health concerns.
“We have invested £270 million to help expand GP capacity so they can manage increased demands and recovery pressures as a result of COVID-19, on top of the £1.5 billion for extra staff committed for general practices until 2023/24.”