I was speaking to an elderly patient last week, well into their 90s, who was frail, unwell and needed some attention. Throughout the conversation, they could not stop apologising for, in their words ‘wasting my time’ as they knew how busy we all were. The conversation left me quite emotional if I’m honest, not least because that very same day I lost count of the number of appointment requests we received from, for example, people who had woken up with a bit of a raspy throat, or who had been congested and coughing from a cold or chest infection for the last week. The contrast in perspective of what the role of the health service should be could not have been sharper.
The average number of times an adult saw their GP in 2015 was seven times a year. Twenty years prior to that it was Three times a year. Much of the increase is related to an increase in chronic disease with which GPs must contend. But it also seems that the threshold with which patients seek help from their doctors, even in the face of headlines about how overwhelmed the NHS is, has lowered. The average adult will get two or three colds a year (the number is higher for children at eight or even more) and at no time is that something a GP needs to see. Yet GP surgeries are inundated with people suffering from sinus infections, colds and chest infections, the vast majority of which are caused by viruses and which will get better eventually on their own. Crucially there is nothing a GP can do to treat these infections. Antibiotics do not work against viruses. The natural course of these infections tends to be an initial sore throat and/or fever followed by congestion, coughing and fatigue. Often people will say the cough has gone to their chest. It seems to be a common misconception that this is the time to go and see a GP whereas it simply means the virus is either a bronchitis, effecting an area a bit lower down in the respiratory tract or even that the congestion is beginning to loosen and the virus us on the road to recovery. Granted the viruses are bad at the moment. Having endured a bit of down time during the social distancing prompted by covid, our bodies are a little less resilient to them and so they are more severe and last a bit longer. Three weeks is not uncommon. That still makes no difference ultimately in how we manage them.
Flu is also causing problems for much the same reason. Flu is also a virus and the vast majority of cases require rest, fluids and will get better on their own. Severe flu can be more serious and so if you are breathless at rest, really drowsy or unable to get enough fluid on board to stay hydrated, then contact your GP. Otherwise, no it’s not nice, no you probably won’t get out of bed for a few days, yes you’ll have a high fever, yes you’ll feel achy and tired but you don’t need to automatically contact your GP and you certainly don’t need antibiotics.
If you are at all worried, your first step should be to look at the NHS website. If you are not sure having looked at that, your next port of call is the pharmacy. Only after that should you consider contacting the GP surgery.
Part of the demand issue at the moment has been the Strep A outbreak which has understandably caused some concern, particularly for parents of school age children. Of course if you are concerned that this may be effecting your child, of course contact your GP but please do apply some common sense. There are lots of viruses that cause similar symptoms but if they develop the characteristic rash and red tongue should you call the GP.
GPs are commonly faced with demands for antibiotics from patients and surveys have shown that a majority have felt pressured into prescribing them even when they know they will do no good. Clearly it is inappropriate for patients to come in with such demands, but we as clinicians must take some of the blame. The truth is, in a busy hectic day (and they really are non-stop), sometimes the easy thing for a GP to do is to give someone an antibiotic. All that does is increase the number of people that come in for antibiotics the following year whilst adding to the already huge problem of antibiotic resistance – a calamity hiding in plain sight.
There are many things that need addressing in the NHS at the moment. Nurse to patient ratios on hospital wards have been unsafe for a long time. In the UK there are 2.8 doctors to every 1,000 patients compared with 3.7 per 1,000 in comparable EU nations. The population is ageing and the increase in prevalence of chronic issues such as diabetes, obesity, alcohol and substance abuse, heart disease and mental health mean that as people age, they do so with a high level of morbidity. In other words, people are less healthy. This necessitates a lot more GP and nursing time as they care for ever more complex patients as they spill over from hospitals and secondary care. One study showed that around 40% of all GP appointments are accounted for by just 10% of patients. This has doubled in the last 20 years.
Most of these people really do require that care but there is a proportion of patients that access health services entirely inappropriately and put extra strain on the system as a result.
As healthcare professionals we want to help people. But when it isn’t possible and moreover, when it starts to impact upon other people who are far more in need or our help – the person who is unwell with cancer, the person who’s been having symptoms preluding a heart attack, the person who is suicidal, the elderly in need of support and care – that is when it becomes more than a little frustrating from our side of things. When people start taking liberties with a health system that is on its knees, the system falls apart. Those who shout loudest are not always the ones who need help.
With that I wanted to end with a couple of suggestions. I won’t get involved in the political aspects. But there are two things that I think would make a huge difference to the pressures the service faces.
At the moment, much of the focus is on more funding, more staff, more hospitals and greater infrastructure. While that is all important, it is only necessary because demand has gone up. If the demand was impossible to reduce any further then absolutely, focus everything on increasing supply. But of course demand is no way near that lower threshold.
In the short term, reducing unnecessary utilization of the health service is something that could have a fairly immediate effect. Looking forwards, it is a case of empowering people to keep themselves healthier so that, even though the population is older, it is healthier and so requires less intensive input. It may seem simple and maybe even a little vague, but I have heard no better suggestion in the face of the ageing population.
As such, the following suggestions are the two key things I think we need to fight for in the face of the NHS crisis which deepens every year.
1 – Health and medicine as part of the school curriculum – while people need to know when it is not appropriate to access health care, it is at least as important for people to know when they should. There are lots of people out there who ignore health issues and do not get help when they need it. Education around health will also have invaluable longer-term benefits for a healthier and happier population.
2 – More aggressive action on the availability of food containing high levels of sugar and salt. Diabetes and heart disease along with obesity are chronic issues which are only getting worse. Shops lined with junk food are a feature only of the last few decades. Another example of the luxuries that we now take for granted but which have long been creating repercussions which affect us all, whether it be directly or indirectly.
As we see yet another ‘winter crisis’, rather than wait for the next shake-up or the next cash injection from the powers that be, the best way to heal the NHS – perhaps the only way – is if we take some ownership of the problem ourselves rather than relying on someone else to heal it for us.
