It's 8am on a damp, blustery Tuesday morning and the phones at Ferndale Medical Centre are ringing off the hook.
Receptionists at the GP practice, deep in the heart of the Rhondda Valleys, are manning 10 different lines as the morning scramble for an appointment intensifies.
One member of office staff has already been sent home with the telltale signs of coronavirus leaving their already depleted team a further person down.
Read more: Woman, 22, put in coma after contracting Covid-19 learns to walk and talk again
This story rings true for GP surgeries across Wales as they try to tackle both their routine work and the fallout from the Omicron variant which threatens to cause the NHS another massive headache.
Dr Andrew Dearden, who has been the clinical lead at the practice since July 2020, said his practice has been operating 10%-15% below normal staffing levels for the last 18 months caused either by Covid-19 or long-term stress.
The experienced GP had previously retired after a 22-year spell at a practice in Cardiff but was brought back into the fold as a locum before the pandemic led to him taking on a full-time role once again.
He said on a typical clinical day, which would start at around 7.30am and finish at 5pm – if he was lucky – he would triage, see, or speak to between 45 and 50.
In areas like the Rhondda, he explained, there are higher levels of chronic illness – such as chest and heart problems – along with industrial diseases which means a GP plays an integral role in the community.
"I'd say around 10 to 15% of patients I see have a socio-medical problem rather than a purely medical problem. That means issues with housing and benefits on top of everything else," he said.
"We've gone away from having the headmaster, or the bank manager, or the vicar or reverend to talk to. GPs are one of the very few professionals who are still around to offer that advice.
"I've helped kids fill out their Ucas forms, for example, as there's no-one else in the family who has any experience with it."
Dr Dearden, who initially worked with the British Medical Association and and World Medical Association upon his retirement, said when Covid-19 first arrived in the health board-managed practice it caused "havoc".
"Fifty years of practice suddenly stopped within two weeks. Every system we had was designed for face-to-face consultation. Phone triage was almost frowned upon and seen as substandard care – and video conferences were very few and far between," he admitted.
For the first three months Dr Dearden was responsible for seeing all Covid-19 patients at the practice's Maerdy branch so routine work could still be carried out in Ferndale.
"Our thinking was if we had one member of staff ill then it remained at one person rather than wiping out our entire team. It also allowed patients to be seen on the day and away from non-Covid cases," he added.
"There was an eight to 10-week period where I was admitting at least two or three people a week into hospital of which at least one or two died within two weeks.
"Normally, pre-Covid, around one in every 40 or 50 admissions would die but during that period it was almost one in two. At least half our staff live in the valley so they know the people who have died and their families."
Despite having to admit people to the Royal Glamorgan Hospital on a frequent basis with Covid he knew the site wasn't equipped to deal with a pandemic.
"I think [the Welsh NHS] did reasonably well considering how fast some things were put in place but only at the expense of putting all routine stuff off to one side," he added.
For the first six months of the pandemic the practice used every piece of technology going – including FaceTime and WhatsApp – to answer people's health queries.
"Later on we started having access to better systems that we could record things on. But within that first few months of the pandemic whatever we could get which worked we'd use," he added.
"Face-to-face consultations are always difficult for some people as they have to take time off work. They were always looking for an alternative. Phone triage is also very good for some conditions however there is a reassurance to people being seen in person."
For the first year of pandemic Dr Dearden said the community was "very understanding" about the situation at the practice and the pressures they were under.
"However people were so understanding that they didn't contact us when perhaps they should have," he said.
"In the second year a group of people became somewhat less understanding and receptionists have taken the brunt of their frustrations."
Due to delays in HR Dr Dearden said he has been waiting in excess of two months for two receptionists to start working in their team in a bid to bolster numbers.
He also admitted the practice has on occasion been run on two GPs – covering 7,500 patients – when it should be four. These staff shortages have caused deep frustration not only for him but for patients who have taken to social media to voice their disapproval at being unable to get a timely appointment.
"I often use this analogy: if you're at a bus stop waiting for a bus to come but it's choc-a-block full you don't think the bus driver is lazy. You would recognise that the bus was full and get the next one," he said.
"Although that concept is right here we don't have enough buses, seats, or drivers. People still get very upset when the next bus is full.
"In truth some of my colleagues have been frightened or concerned with the numbers of patients we're trying to cover with the number of doctors we have."
Dr Dearden, who thinks he may have caught Covid himself at the start of the pandemic after losing his taste for chocolate, said the practice also played a huge part in the vaccine rollout at the very beginning. They once again utilised their Maerdy base to deliver vaccination clinics on Thursdays, Fridays, and at weekends. However once again this had a major impact on resources.
Nevertheless, despite all the pitfalls, he said there still appeared to be an appetite for medical students to become GPs, with training places fuller than many other specialties. But recruitment, he warned, was still an ongoing issue as more opt to work part-time.
"For every GP that retires from the old working pattern you'd need one-and-a-half to replace them because people are now working two or three days a week. The intensity is impossible to maintain full-time," he admitted.
On December 1, 2021, a new General Medical Services (GMS) contract deal was agreed for 2021-22, backed by £12m of extra investment, which vowed to end the "morning scramble" to book an appointment.
Instead the new GP access commitment aims to ensure that practices implement more efficient online booking systems to better manage patient need. To read more about this go here.
"It will broaden avenues for patient access which is great if you have IT-savvy patients. However some of our more elderly patients don't even have phones," Dr Dearden added.
When asked about the community he serves he concluded: "We have a really kind group of patients. I'd probably count on the fingers of both hands those who I know will complain about anything and everything. Our complaint numbers have dropped in the last year. Considering everything that's gone on I think that's a reflection of the understanding that people have."
Office manager Nancy Read, who is on the frontline of the appointment booking system, said the morning call volumes at 8am have increased by as much as 35% in the past year – sometimes hitting up to 300 per day.
"It's the routine stuff that's really ramping up – and it's been extremely challenging," she said.
"Patients have been putting off contacting us for their long-term diagnoses, like diabetes, or if they find a lump or a bump. Now we're starting to catch up with that. They're wanting to see the consistency they experienced before the pandemic.
"They feel like this has gone on for long enough and the doctor should now be seeing patients face-to-face. That's definitely hard to manage."
She admitted that the abuse directed at office staff has got "a lot worse" in recent times and added: "They want us, as the reception team, to give them the world. Their expectations far outweigh the guidelines and resources we're given.
"But as an office manager my job isn't nearly as tough as the receptionists'. They have it the hardest. We've also seen a big increase in people on social media battering us."
Nancy said three of her team had to go off on long-term leave as they were shielding while there have been other absences due to stress.
She added: "I have never worked with a team that are so patient-focused. Most of them are from the community so they know their patients. I'd say two-thirds of the staff have been here over 10 years so they know the patients clinically and they want to do the best. It's just been very hard for them to disappoint people."
But she said the advancements in the way general practice is now run has been the one saving grace from this brutal pandemic.
"The pandemic has made us jump from where we were to where we hoped we'd be in five years' time. But patients haven't had the chance to catch up to the changes yet."
Nancy said office staff now play a vital role as "care navigators" who redirect people to pharmacists, physiotherapists, dentists, or opticians instead of them going to their GP unnecessarily.
Another additional tool in their growing armoury is eConsult, an online service where people can message their GP surgery about their health symptoms rather than having to call. Patient then normally receive a message back the next day.
"That works really well but only about 100 patients are signed up to it. If what they've said in the email cannot be redirected to anyone they will be put on the GP's list."
She concluded: "It's a common misconception that anyone can be a receptionist. They can but not everyone can be a GP receptionist. It takes six to nine months for someone with no experience to start working on their own."
Like most surgeries across Wales the Ferndale Maerdy Medical Group Practice team is made up of not just GPs and office staff but practice nurses, healthcare support workers, and pharmacists.
Fiona Hyde is a clinical pharmacist at the practice whose job has drastically changed since the start of the pandemic.
Previously she dealt with everything from medication reviews to letters from the hospitals and blood tests and generally made sure patients' prescriptions were up-to-date and clinically correct.
However some of this work had to stop in March 2020 with her focus turning to the huge backlog of prescriptions they have to re-authorise.
"We are now so far behind and have so much catching up to do," she said.
"We found that the things we used to do before, to make sure everything was as it should be, we just didn't have the time to do the background work anymore. We were just making sure the medication was safe for the patients.
"We all put in 110%. Nobody goes home at the time they're supposed to get home. We don't rush things. We do things very carefully. It's better to check twice and get it right than check once and get it wrong."
She said there is a lack of awareness around the fact pharmacists are based at the practice and said some people continue to go to their local pharmacy thinking their medication review was meant to be held there.
"We have a big and growing role in general practice and there's so much we can do to relive the burden on GPs so they can focus on their clinical work."
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