GP Appointment Availability

Margaret Greenwood Excerpts

Tuesday 26th October 2021 Westminster Hall

[Joy Morrissey (Beaconsfield) (Con)]

I beg to move,

That this House has considered GP appointment availability.

It is a pleasure to serve under your chairmanship for the first time, Mr Robertson. The chances of misdiagnosis can increase dramatically if GPs rely on emails or telephone calls exclusively. I speak from experience: for days, my mother-in-law was misdiagnosed as having a urinary tract infection, when she had actually suffered a severe stroke. Precious time was lost, and terrible damage done, because she was not seen by a GP. For every 100 ailments that can be diagnosed safely without seeing a GP, there will be one that cannot—one that could prove to be fatal, which is not a price worth paying.

I thank NHS workers and GPs for working tirelessly throughout the pandemic. I was encouraged to apply for this debate by my constituents, who came to see me again and again about this issue. I wanted to make sure that their voice was heard. I will read out some of their actual cases, because it is important to hear from them about what they have been experiencing. I would say that they are divided into two categories. The first is those who are disabled and perhaps suffer from dementia or other cognitive impairments, who find talking on the phone very difficult, and who really need to see a GP in person. The second is those who are happy to speak over the phone when they need a GP appointment, but find that the IT systems in place in certain GP surgeries cause issues with access to GPs.

The first example is from Marlow. A lady wrote to me and asked for an appointment to see me. She said:

“When I got through to the surgery, we were told that we should have a telephone appointment first. The GPs have my daughter’s number, as she cares for her grandmother. I explained that we do not live with her and cannot sit at her house and wait for a call. Also, there was a phone for her to sit around all day, and no one answers. She isn’t good with IT and has trouble explaining and expressing herself and telling someone what is wrong over the phone. I understand we are in extremely unusual circumstances, but there has to be exceptions, and there must be a way for elderly, and in some cases disabled, people to be able to get an appointment. Many do not have the capability to use the internet, and even phones in some cases.”

That was particularly true in the case of my mother-in-law, who had had a stroke. Luckily, we had power of attorney, but many people do not. I appreciate that the Government have made great strides in this regard, but we need to look at how we can protect those who are disabled, who perhaps have cognitive impairments and who need to have a carer come with them to a GP surgery in order to express what is wrong and explain what condition they have. Greater attention should be paid to this in the future.

We also have the issue of general IT and phone challenges. A resident in Farnham Common wrote to me and said:

“We have difficulty making the initial contact with GP surgeries. Most GPs operate a system which requires the patient to telephone when the surgery opens at 7 am to seek a consultation for that day. In our collective experience, it is often extremely difficult to get through. It takes a very long period of repeated calling. One friend recorded 140 unsuccessful attempts to reach the GP surgery.”

Some of the GP surgeries in my constituency are excellent. They were excellent during the vaccine roll-out and through covid, but we have certain GP surgeries that have had challenges meeting residents, challenges with the vaccine roll-out, and challenges in general throughout the covid period. Quite a number of residents have written to me and spoken to me about Burnham Health Centre, so I want to share specifically the IT challenges that it seems to face consistently.

One resident, Colin, said that if you are lucky enough to be 29th in the queue that morning at 7 am, you may get a message that says no appointments are left for the day. You can hang on in silence, or you may get to speak to a person—you may get through to a human being. You are told that there are no appointments and that you need to use Patient Access. When you try to book an appointment via Patient Access, it gives you possible ways to book, but only for things like contraceptive appointments, and nothing else. When Colin tried to access Patient Access, he was given an electronic form which he completed several times. It kept coming back saying that it could not be processed. He tried dozens of times and finally gave up and decided that Patient Access was not working.

He was not the only resident in Burnham who complained about Burnham Health Centre and Patient Access; several more wrote to me about the same issue. One said:

“I do think it’s ridiculous that you cannot get an appointment when you call, I am happy to wait a day or two, if it is urgent, there is always 111. The practice of releasing a limited amount of appointments at a certain time is not fair and just causes a bun fight. I do think the staff would benefit from customer service training”—

for everyone’s benefit.

A set amount of appointments are on a first-come, first-served basis. This seems to be unique to this GP surgery, but it has become a very agitating issue for people in the area who already suffer from some health inequality. They perhaps do not have the financial ability to go privately. Many are older and vulnerable, and it is demoralising that they often cannot get hold of a GP for even a phone call and consultation. Just getting a phone call would be a positive step in certain cases in my patch.

[Margaret Greenwood (Wirral West) (Lab)]

The hon. Lady is making really good points on this massively important issue. She just remarked that it was unique to where she is. Not at all; I have similar issues and I am sure other Members will talk about their issues. It is so important. Does she agree that the difficulty people have in accessing GPs has a knock-on effect on the National Health Service in other areas? We see people going to A&E out of frustration, because they cannot see their GP. This is really a problem that needs to be tackled head on. I congratulate the hon. Lady on introducing the debate to put pressure on exactly that.

[Joy Morrissey]

I thank the hon. Lady for her contribution. I agree that the problem has a trickle-down effect throughout the NHS. We will see more people presenting at A&E and perhaps with more advanced stages of disease, because they have not been seen in person. Encouraging GPs or creating a covid incentive programme for them to see people in person will decrease the amount of hospital admissions and lead to earlier diagnosis for cancer and heart disease. These things can really only be done in person. If someone is healthy and just needs a phone appointment, that is fine, but certain things cannot be seen unless a person’s vitals—their heart pressure—can be physically checked. Only a GP can do that and really only in person. If we want to reduce the overall burden on the NHS this winter, finding a safe and secure way for more residents to see their GP will reduce the overall pressure long term on the NHS. I know we have an aging population, and that GPs are under huge amounts of pressure and strain, but I believe there is a way we can work together to find a solution.

[Joy Morrissey]

The hon. Lady is stealing my thunder, but I agree with that comment. With the multi-disciplinary approach, even nurse practitioners and others could be recruited into a GP surgery structure, to help with many of the ailments that people are presenting at A&E with or asking for an appointment about. There is a wide range of healthcare professionals who could help and support GPs, and I think this is an important issue that needs to be further discussed and debated.

When this matter came before the House in July, several relevant questions were raised. One of them was about NHS England and NHS Improvement, or NHSEI, which leads the programme of work support practices, using digital and online tools to widen access. I would just love to hear what progress has been made since this topic was debated in July. Also, what is the progress of NHSEI’s independent evaluation of GP appointments? Again, I would like to see whether we have had any progress on that independent evaluation. Finally, what is being done by the NHSEI access improvement programme to support practices where patients are experiencing the greatest access challenges, such as drops in appointment provision, long waiting times, poor patient experiences or difficulties in embedding new ways of working related to covid-19, such as remote consultations as part of triage? I would really welcome any updates on those questions.

We could perhaps discuss today how we can provide GPs and their surgeries with some kind of in-person patient incentive during covid. Perhaps that could come from existing regional funding streams. Perhaps each time a GP sees a patient in person, they could receive an extra payment, or they could receive an additional payment for visiting someone in their home. That would mitigate the additional cost of PPE and also the additional risk posed to the GP themselves by having to see people in person during covid or high levels of winter flu.

Some GP surgeries are already receiving additional funding for cervical cancer and diabetes screening, and we have seen uptake increased in those areas very successfully, so this type of programme has been modelled in the past. It would help to mitigate the risk and burden for GPs, while still getting as many of our constituents as possible into in-person appointments if they need them.

The NHS claims that it would like more patients treated at home rather than having to stay in hospital for extended periods of time. This model could be enhanced if GPs were given the financial incentive to carry out in-home treatments for patients who traditionally would have remained in hospital. Obviously, this allocation would have to be set by the integrated care system in each region and it would be decided on within regional NHS structures, but it is worth considering.

In my own personal experience with my mother-in-law, she has been at home all the time 24/7. She is now completely disabled and needs 24-hour care, but the most difficult challenge was the out-of-hospital care provision—getting the GP, the hospital and the council to co-ordinate the care effectively. It is a full-time job for someone to co-ordinate that care. If we can make those pathways of care and co-ordination easier for everyone, then, as was said earlier in the debate, it would reduce the overall pressure on the NHS.

[Margaret Greenwood]

Does the hon. Lady share my concerns about the provision in the Health and Care Bill for the assessment of patients to take place after they have been discharged from hospital instead of before, as happens at the moment? I have very serious concerns about that issue. I tabled a couple of parliamentary questions, which were answered by a different Minister to the one who is here in Westminster Hall today. One question was about the fact that this discharge-to-assess approach has been going on under the Coronavirus Act; I asked how many patients had been discharged that way. The reply came back that 4 million patients had been discharged from hospital without having their assessment. I asked how many of those had been readmitted within 30 days; the Minister replied that the Government did not know because the information was not held nationally.

This is a very serious concern, because we are talking about vulnerable people. I know the hon. Member for Beaconsfield is talking about a particular relative. The idea that somebody with dementia, or early-stage dementia that has not been fully diagnosed yet, should be discharged before their needs are fully understood is very alarming. An independent review of this is going on at the moment, and I would be grateful if the Minister could give us an idea when that is going to be published. It is meant to be this autumn. I would like to raise this with the Minister as a very serious issue and wondered if she would like to comment on it.

[Mr Laurence Robertson (in the Chair)]

Order. I remind hon. Members that interventions need to be brief.

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[Rachael Maskell]

My hon. Friend hits the nail on the head. We cannot look at part of the health service without looking at the entire health service, and the pressures that are brought to bear. As we have heard, many people do go to their A&E or urgent care centre, because that is the only way that they know they can confidently access the service, which puts more pressure on those parts of the service. We must look at the whole.

However, when it comes to trying to engage with our community practitioners—that is what primary care is all about: people who would traditionally have known the patient and the family—medicine has changed so much, yet we have not caught up with where it is. I saw both the call handlers and the GPs facing burnout. They are reducing the number of sessions that they are working because, we must remember, a session then extends right through into the night, as they are catching up with paperwork, ordering tests and following things through. Individuals are just saying “If I don’t step back, it will have a serious impact on my own wellbeing.” We have got to protect the wellbeing of GPs. They are a precious resource in delivering our healthcare services.

[Margaret Greenwood]

My hon. Friend is making an excellent speech. Does she share my concern about the shortage of GPs? The Government have committed to having an extra 6,000 GPs by 2024 or 2025, I think. The pressures GPs are under is a direct consequence of the failure to address the issue.

[Rachael Maskell]

My hon. Friend raises the next point in my speech. We are in this mess because for over a decade we have had failed workforce planning across the system. We have seen that most acutely in primary care. The pandemic continues to be mismanaged, which I want to stress. The Government may be looking at the numbers when it comes to intensive care and hospital admissions, but as people are less sick they instead go to see their primary care physician. That puts more pressure on them. We need to see more measurements and data on the pressure that has been put on primary care during the pandemic. In addition, we have long covid as well. In York there are around 3,000 cases. It is not coded, so can the Minister get that sorted urgently? We need to look at the support that people with long covid require.

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[Chris Green (Bolton West) (Con)]

It is a pleasure to serve under your chairmanship, Mr Robertson. It is a pleasure to follow the hon. Member for York Central (Rachael Maskell), who makes important points in her speech. I congratulate my hon. Friend the Member for Beaconsfield (Joy Morrissey) on securing the debate and making many compelling arguments. I congratulate my hon. Friend the Minister on taking her position on the Front Bench. She is one of a small number of individuals in Parliament who has recent frontline experience and I am sure she will bring that to bear in her role.

GP appointments are an important issue about which there have been concerns for many years. The principal concern at the moment relates to coronavirus and the lockdown. We cannot avoid that or simply touch on the subject, then concentrate on a wealth of other concerns. We have to focus on that issue as the prime driver of the current problems in the sector.

The Chancellor has put forward substantial resources, but more are always needed to make sure that resources are available for the national health service and for general practitioners. More needs to be done, and I am sure that, in the coming months and year or so, more resources will come forward.

I am here to raise the concerns of my constituents who are increasingly worried. At the beginning of the coronavirus lockdown, many people chose not to take up available GP or hospital appointments, but many of those conditions that have not been investigated or checked in the last 19 months are now far worse. The pressure and demand on hospitals and GPs are more severe. People are increasingly less frightened of coronavirus but more frightened about when they will get to see their family doctor, who is now difficult to see.

People are told by their GP receptionist to call at 8 o’clock, or earlier in some areas, but they have to make call after call after call for half an hour or 45 minutes. They cannot get through until it is too late and they are told to do the same tomorrow. That is happening day in, day out. Many people are now going to accident and emergency. For a long period at the beginning of the pandemic, A&Es were quiet because people were worried about going and getting coronavirus, but the situation has changed radically. People cannot access their GP surgeries and they are going to A&E, but it is far more difficult to get the service there too.

The system is coming under significant and increasing pressure, which is piling up as we head into winter. It is not just coronavirus. There is an expectation that the pressure from other respiratory viruses will mount up along with, as I mentioned, conditions that have not been checked or investigated for all those months such as cancer and other life-threatening conditions.

We have heard about elective care for issues such as cataracts and hip replacements. In the scheme of things, when we are thinking about life and death, they may seem relatively minor but they have a dramatic impact on people’s standard of living. The situation has negatively affected all those discretionary care items, but they have to be addressed too.

[Margaret Greenwood]

The hon. Gentleman is talking about rationing and what is happening in the wider system. With the Health and Care Bill, we are moving away from a national health service to 42 integrated care systems that will all have to balance their books every year under tight financial controls and will all have different strategies. Does he share my concern that that will embed the postcode lottery and increase the rationing of care? Have his constituents commented on that and do they share those concerns?

[Chris Green]

The hon. Lady makes some important points about the Bill, but the postcode lottery is already there. Most people view the national health service as a one-size-fits-all service that provides the same service wherever they are in the land, but that is not true and perhaps never has been. Access to medicines is very variable and IVF is a good example of something for which different areas have different agendas, policies and accessibilities. We all know that there is already a postcode lottery.

I do think that NHS England is too large an organisation. I was not intending to talk about this, but I was hopeful about health and social care devolution in Greater Manchester. The Mayor could have taken that up and championed it, but he has not made a single speech on the subject—he has not touched it. Having seen the failure of that devolution, the Government are now looking at other mechanisms to champion the cause of better accountability—

[Margaret Greenwood]

rose—

[Chris Green]

I am sorry, I have very little time—where local leaders may be able to champion the cause of better delivery, with organisations in a sufficiently large area in which they can make a difference, but which are close enough to people that local needs can be respected and identified. Different areas are often so very different.

About 5.5 million people are on hospital waiting lists. That is an extraordinary figure. However, there have been about 7 million fewer GP to hospital referrals during the pandemic. If we extrapolate from those figures, we have roughly 13 million people on the hospital waiting list. We need to get the GP service sorted out as soon as possible. It is appalling. I am disappointed in the British Medical Association for threatening strikes. The health system, the unions and the Government need to get together and deal with those problems as soon as possible.

I was concerned about the renewal of the Coronavirus Act 2020 because I know what that will symbolise to the civil service, the health system, the education system and wider society: that we have not and should not yet return to normal. As long as the Coronavirus Act is in place, I can see that the wider system of state, including GPs’ surgeries, will not return to normal. That has to be changed and normal service must resume as soon as possible.

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[Peter Aldous (Waveney) (Con)]

It is a pleasure to serve with you in the Chair, Mr Robertson. I congratulate my hon. Friend the Member for Beaconsfield (Joy Morrissey) on securing this debate and on her graphic and very personal assessment of the current position.

Over the past two to three months, I have received a great deal of correspondence on this issue, with constituents very upset that they have not been able to secure face-to-face appointments with their GPs. Late last month, I had a virtual meeting with GPs practising across the Waveney area, who themselves are very upset at the abuse that they have been receiving—something that they and their staff should not have to put up with.

There is clearly a major problem, and, at a time when the pressures on the NHS are growing at an exponential rate, there is a need to work together to find a solution. In the Norfolk and Waveney clinical commissioning group area, notwithstanding the enormous demand for GP services, the position with regard to appointments is positive, although it is recognised that more needs to be done. In August 2019, there were 478,160 GP appointments, and this August that figure increased to 482,993. The proportion of patients being seen face to face is increasing. This August it was 69%, compared to 67% in July and 66% in June. More patients are being seen face to face in Norfolk and Waveney than in other parts of the country: the August figure of 69% compares with a national average of 58%.

That said, it is recognised that a lot of people are very distressed, and in many cases very worried, that they have not been able to see their GP. The pandemic has meant that there is now an enormous increase in demand for GP services, with people on growing waiting lists needing support, and with those who were unable to see their GP during the pandemic wanting an appointment in order to highlight something that is causing them a lot of worry and distress.

The increase in demand for GP services has been happening for some time, but there are severe capacity constraints on the number of patients who can be seen face to face. The current infection, prevention and control measures that are needed to keep patients and staff safe mean that in-person appointments take much longer. Social distancing means that, at practices with smaller waiting rooms, people have to wait in their cars and staff have to go and get them when it is time for their appointment. Additional cleaning arrangements are also required between patients. There is a need to improve and standardise the way that remote appointments are operated and to adopt a whole-team approach, as there are many cases where a patient does not always need to see their GP and can often be cared for better by a physio or pharmacist.

[Margaret Greenwood]

The hon. Member is making some very interesting points. Does he agree that it is important that the Government review the outcomes of patients who have been consulted remotely? I have heard harrowing stories from my constituents. One woman thought she had a very minor ailment—she did not get seen by a GP, and she ended up with life-changing surgery. She will never be the same again. It is important that there is a national review of what has happened to such patients, rather than assuming that everything is all right because a patient does not come back.

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[Maria Caulfield]

My hon. Friend is certainly persistent in his questioning on that issue. It is a decision for the Secretary of State, who is looking at such factors. The vast majority of NHS staff have been vaccinated, for their own protection as much as anything else. I want to highlight that we are increasing the number of primary healthcare professionals across the board, aiming to replicate the model used in hospitals, where a consultant leads a team of multi-disciplinary professionals who will help see a patient and are, sometimes, more expert in dealing with certain clinical situation than GPs themselves.

[Margaret Greenwood]

I have had GPs talk to me, somewhat frustratedly, about not having sufficient GPs in their surgery and having physician associates who do not have the same level of training. There is a concern that this is a backing-away from the Government’s commitment of 6,000 extra GPs. Could the Minister confirm whether the Government are still committed to 6,000 extra fully qualified, trained GPs?

[Maria Caulfield]

We are committed to increasing GP numbers, as in our manifesto commitment. However, that does not stop us increasing the numbers of other healthcare professionals. We need to get the message out to patients that seeing a nurse, physio or paramedic at the GP surgery is not second best. These are highly qualified, experienced and educated professionals who often are better placed—though I do not want to upset the shadow Minister—to see a patient than a doctor. They can make a considerable difference, but very often patients feel they are being fobbed off or seeing the second best. We need to do a lot of work to reassure patients on that.

We have already recruited 10,000 of the additional 26,000 staff we stated in our manifesto would be working in general practice by the end of 2023-24. We are strengthening our plans to increase the number of doctors in general practice. To reassure Members, so far we have filled a record number of GP speciality training places this year, with the latest data showing that there are already 1,200 more full-time equivalent doctors in general practice than two years ago. It is a challenge; I am not going to say it is not, but we are making progress.

I feel particularly passionate about the use of community pharmacists. In many other countries, the pharmacist is the first port of call for minor ailments. They are highly qualified professionals with over five years of clinical training who are able to assist patients. Over 800 practices have already signed up to participate in the community pharmacist consultation service, which enables patients to see a pharmacist, on the same day in many cases, to deal with minor conditions. That will not only help patients, but it will free GPs up to see the patients that really need to see them for clinical conditions.