“I have a sneaking suspicion it will all come back to GPs who are already inundated anyway,” sighs one doctor. Pressure is mounting on a primary care system already splitting at the seams in Greater Manchester, GPs, community nurses and hospital medics alike have warned.
The official narrative is that the country is now ‘living safely with Covid’, and that the focus for the NHS should be getting delayed surgeries back on course - correcting a colossal backlog of operations built up through two years of stop-start procedures. But hospital staff have spoken out to the Manchester Evening News , fearing ‘another Omicron’ will hit their wards , after New Year marked among the most challenging moments of the pandemic for NHS workers. Staffing was stretched so thin that many felt the situation unsafe.
Now, GPs and community care staff in the region share their side of the story, as they ‘feel Covid pressure start to rise again’, while also trying to cope under the weight of millions of sick patients whose treatment could be years away.
‘We thought it was settling down, we were wrong’
During the wind down of Covid-19 safety measures, from February to April, the M.E.N has spoken to NHS staff from across the primary care, secondary care and public health systems.
Primary care services typically provide the 'first point of contact' with the NHS - GP services, community nursing, local pharmacies, dental and eye health care. Secondary care involves care beyond that generalised level - specialist doctors based at hospitals treating both inpatients and outpatients, for example. Meanwhile, public health involves organised measures to promote health, prolong life and prevent infection, such as council-led policies to increase residents' activity levels.
Some anonymous, others named, these sources from across the NHS tell of an exhausted organisation, sometimes in disbelief at how, two years into the pandemic, the pressure on GPs, A&Es and waiting lists isn't easing. In fact, they say, it will be years before the situation improves. In the meantime, patients will wait in pain, and vital medics will burn out and leave the profession.
Short-term, they dread seeing the latest rise in coronavirus cases. It typically marks an increase in 'acute' illnesses needing 'acute activity' - referring to serious illnesses needing treatment in hospital.
"We did feel like things were starting to ease up,” Bolton GP and the borough’s lead Covid-19 vaccinator, Dr Helen Wall tells the M.E.N. “Palpably, on the ground in practice, things had started to settle a little bit with acute illnesses.
“But over the last week or two, we've started to see an uptick in the number of Covid infections. There seems to be an increase in the number of over 75s who are getting infected, unfortunately.”
At least the borough has around 95 per cent of its over 75s in Bolton fully vaccinated, continued Dr Wall, so the majority of them are not ill enough for doctors to be concerned.
Still, the spike in cases is likely to spell pressure on primary care regardless, she adds. "It feels like it's probably going to start going up again. We can tell when the rates are starting to rise before the data comes, just by the level of acute activity that we see or hear of."
The impact of the elective backlog on GPs - and why another pause in surgeries ‘can’t be ruled out’
As the Omicron wave hit, Greater Manchester again cancelled its non-urgent surgery in January, a sure sign of desperate bed shortages as the number of patients shot up, and staffing shortages amid a workforce hit by positive tests. Almost all procedures were cancelled, in the words of one junior doctor at the time, ‘if it’s not going to kill you, we’re probably not going to do it’.
The kinds of procedures that have been cancelled throughout the pandemic are dubbed 'elective surgeries'. Electives are operations planned in advance, like joint replacements, as opposed to emergency surgeries needed in life-threatening situations, for example, after someone is rushed to A&E.
The elective work resumed only a few weeks later, but the halt was enough time to add hundreds to already-lengthy waiting lists. All of those patients, whose conditions are worsening, are piling into GP surgeries.
“In primary care, we've got a backlog based on the 6.1 million people who are on a waiting list, waiting to be seen across the country,” explains Dr Wall. “Those people aren't sitting there well, a lot of people will be in pain - say if they're waiting for a knee, hip, whatever operation - they're at home, having crises with pain.
“We are having a lot of contact with people, we're trying to manage the best we can because they are waiting. And that's not secondary care's fault, that's just where we are because of the number of times we've had to put a hold on elective activity due to rises in cases.
“I don't think we're going to see a level of demand go back to what it was pre-pandemic, a good few years really, because all of those people who are still waiting to be sorted out, but we are going to see peaks and troughs in the acute activity of really sick people."
Yet, another pause in elective surgeries could be on the horizon as coronavirus cases rise. ‘I don’t think we can rule out [another pause in planned surgeries], it’s a means to an end’ if the NHS system is overwhelmed by a future Covid wave, says Dr Wall.
But if another break in operations does happen, the ‘chronic’ pressure on primary care will continue to spiral. More and more patients will be added to waiting lists, their pain leaving them in need of continuous help from their GPs and community nurses - and the number of staff able to take on the caseload not increasing at the same speed.
"We are concerned with possible delays to elective surgery," explains Dr Faisal Bhutta, a GP based in Hyde. "It is leading patients to keep taking painkillers while their condition getting worse.
"In turn, it is increasing our work load as patient contact GPs for further assessment, prescriptions, letter to hospitals to expedite appointments."
“You almost end up worse off because those patients on waiting lists get worse and end up coming to A&E," adds Dr Wall. When they do get an appointment, their condition will be much more difficult to manage. It’ll take us a few years to get out of this.”
The concerns come as one Greater Manchester hospital admitted its staff have been pulled away from elective procedures to deal with repeated crises in a small A&E department, unable to cope with the sheer volume of patients coming through the door. It’s a decision not taken lightly, as the Department of Health and Social Care set huge targets earlier this year - slammed by some medics as being unrealistic - to end two-year waits by 2022, 18-month waits by 2023, 65-week waits by 2024, and one-year waits by 2025.
Beyond the wards, staffing struggles have plagued the year so far
At the same time, mental health nurses have seen members of their workforce in the community being pulled onto short-staffed hospital wards in recent months.
During the peak of the Omicron wave, one community mental health nurse told of how both patient and staff member’s ‘lives were being put at risk’ by major workforce shortages, saying: “It impacts patients on the wards because we, as community nurses, members of the home treatment, crisis teams, and more, are being asked to go onto wards to cover staffing absences - people that haven’t had any previous ward experience or haven’t worked on wards for years. They don’t know the layout of the ward, they don’t know the patients.
“Sometimes there’s only one qualified member of staff on a ward during a shift. It’s dangerous - from a patient safety perspective and from a staff perspective.”
In March, Greater Manchester Health and Social Care Partnership - a body which brings together organisations which have a say in health and social care in the region, such as councils, hospital trusts, and charities - said mental health staffing strains had 'stabilised and [were] improving.'
"Some community staff who held professional registration were required to be redeployed to inpatient wards however," said a spokesperson. "Roles were not outside of a person’s skill set and staff were not asked to undertake clinical duties they’re not qualified or trained to do."
‘Nobody wants to be a GP anymore’
Work-related stress plagues primary care, according to the staff the M.E.N. spoke to. For younger staff, in particular, the last two years of dogged pandemic work has impacted their career choices - which could prove a ‘crisis’ long after the throes of Covid-19 are over.
"Nobody wants to be a GP anymore,” comments a junior doctor, speaking on the condition of anonymity. He spent a number of months working in a GP practice as part of his training, and says general practice is not the favoured specialism among his peers.
“A lot of it is the media's impact on it," he says. "GPs have been shockingly treated by some of the tabloids which write sensationalist things about GPs.
"When I was on my GP rotation, a patient gave me a clipping about how GPs never work anymore. I was literally seeing them right then, what more did they want me to do? They found it hilarious, saying they could never get an appointment, while they were in an appointment.
“We're losing GPs at the moment. We were promised 8,000 new GPs in the last elections. In that time, we've actually lost 400 GPs from the total population. It's not getting better. They can throw as much money as they want at it, but it's a problem that requires a bit more than some superficial funding from the Secretary of State for Health.
"The GP crisis is something that is going to be even more evident after Covid. I think we're going to be left with a significant lack of GPs by the end of it all.”
The Department for Health and Social Care insists that the ‘GP crisis’ is not so bleak. “We are growing the GP workforce – there were over 1,600 more doctors working in general practice in December 2021 compared to 2019, a record-breaking number started training as GPs last year, and we’ve invested £1.5 billion until 2025 to create an extra 50 million appointments per year,” said a government spokesperson.
“We have set out our plan to tackle the Covid backlog which will deliver new surgical hubs and up to 160 community diagnostic centres – 73 of which are already open and which have already delivered over 700,000 additional tests.”
‘There’s living with Covid and there’s ignoring it’
Greater Manchester health leaders admit that Covid rates, elective backlogs, and staff sickness are putting unprecedented pressure on the system, but say support for a struggling workforce is in place.
Sarah Price, interim chief officer Greater Manchester Health and Social Care Partnership told the M.E.N: “NHS services continue to come under increased pressure for a range of reasons, including Covid-19 infection rates, a backlog in elective care and support for people with long-term conditions, and levels of staff sickness. Although Covid restrictions have been removed, the virus continues to present significant challenges for the NHS.
“We recognise that GP practices have faced an increase in demand and in recent months a raft of measures have been put in place to increase capacity and reduce the strain on hard working practice teams. Following feedback from primary care colleagues, existing mental health and wellbeing provision has been expanded to ensure that all general practice staff feel supported at work.”
But the Bolton GP suggests that coronavirus pressure could only escalate as the impact of the government’s decision to revoke free mass testing is fully felt.
Without Covid positive people reporting their results, or unable to tell their doctors whether they are sure they have the virus, GPs fear they are being ‘left in the dark’ about a ‘massive cohort of patients’. In the absence of hard data, doctors will have no idea who to call and check on, or who to offer extra help if they are immunosuppressed and catch the illness.
"I get that things have to go back to normal at some point,” says Dr Wall. “But I've said all along that there's living with Covid and there's ignoring it. I'm not sure the latter is a good idea - and it does feel a little bit like we might start doing that.
“Getting people vaccinated is the only thing we’re going to have left to keep the system stable. Without the data, we're going to be on the backfoot and we're going to be chasing these Covid waves and we're not going to be as prepared as we have been previously. And it's been really hard work when we have been prepared.”
This piece comes as part two in a series on the impact on the current coronavirus rise on the health system in Greater Manchester. To read part one, about hospitals, head here.
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