Letters

Evolving general practice consultation in Britain

BMJ 2002; 325 doi: http://dx.doi.org/10.1136/bmj.325.7355.104 (Published 13 July 2002) Cite this as: BMJ 2002;325:104

Increasing consultation time may not be straightforward

  1. Phil Wilson (p.wilson{at}clinmed.gla.ac.uk), general practitioner,
  2. Alex McConnachie, statistician,
  3. Mark Stirling, general practitioner
  1. Department of General Practice, University of Glasgow, Glasgow G12 0RR
  2. Ferguson Medical Practice, Broxburn Health Centre, Broxburn EH52 1JZ
  3. Pharmacy Practice and Medicines Management Group
  4. School of Healthcare Studies, University of Leeds, Leeds LS2 9UT
  5. Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TN

    EDITOR—Freeman et al plead for longer consultations in British general practice.1 A pilot study performed with six general practitioners in Glasgow shows that breaking the habit of short consultations may be difficult and longer consultations may lead to higher health service costs.

    Our study piloted a randomised controlled trial of the effect of an increased booking interval on identification of the patient's psychological distress.2 Each doctor's surgery was randomised to either 10 minutes per patient (the normal booking interval) or 15 minutes. One of us (MS) offered locum sessions to make up the shortfall in available consultations. We recorded 65 consultations at each booking interval for each practitioner. After the consultation, patients completed the general health questionnaire-12; doctors estimated psychological distress using a six point scale and recorded important outcomes of the consultations. Consultations were timed by a research assistant.

    Data were collected from 781 consultations. When booking interval was increased by 50% consultation length increased by 12%, from 8.7 minutes to 9.7 minutes. Longer booking intervals significantly increased the number of consultations in which the doctor arranged investigations (19.4% v 27.9%; P=0.0069) and follow up appointments (43.8% v 53.7%; P=0.0072). There was no significant effect on the proportion of consultations in which prescriptions were issued (51.0% v 54.7%; P=0.34), physical examination carried out (66.8% v 66.8%; P=0.96), or referral made (14.0% v 10.7%; P=0.20).

    There were no significant differences in identification of psychological distress between long or normal booking intervals (odds ratio 1.00 (95% confidence interval 0.63 to 1.59)).

    Although booking interval increased by 50%, consultation length increased by only 12%. This raises the question of what the doctors did with the extra time. It has been argued that increasing the length of consultations will save time and resources. Our results suggest that the opposite is true; doctors ask more patients to make follow up appointments after longer consultations and perform more investigations. Perhaps doctors given more time with patients simply uncover more problems. The lack of impact of an increased booking interval on the recognition of psychological distress in patients suggests that structural constraints are insufficient to explain low rates of recognition of distress by general practitioners.

    Our results must be interpreted with caution. A more sustained intervention might have led to more major changes in consulting behaviour. Our data suggest, however, that longer consultation intervals may cost more than remuneration for extra general practitioners' time.

    References

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    Longer consultations might necessitate redeployment of pharmacists

    1. Arnold G Zermansky, general practitioner (A.G.Zermansky{at}leeds.ac.uk),
    2. David K Raynor, head,
    3. Duncan Petty, research pharmacist,
    4. Nick Freemantle, professor of clinical epidemiology and biostatistics
    1. Department of General Practice, University of Glasgow, Glasgow G12 0RR
    2. Ferguson Medical Practice, Broxburn Health Centre, Broxburn EH52 1JZ
    3. Pharmacy Practice and Medicines Management Group
    4. School of Healthcare Studies, University of Leeds, Leeds LS2 9UT
    5. Department of Primary Care and General Practice, University of Birmingham, Birmingham B15 2TN

      EDITOR—Freeman et al open an overdue debate about the length of consultation times.1 They address the question of why consultations should be longer but do not consider how this might be achieved.

      The workload in primary care is increasing faster than the workforce is. This is fuelled partly by demography, partly by increased health expectations, and partly by developments in treatment. The unremitting commercial gamesplaying of the pharmaceutical industry, highlighted in an article in the same issue of the BMJ as Freeman et al's article, adds another turn to this screw.2

      General practitioners are fully occupied. There is no prospect of a huge increase in the general practitioner workforce in the next decade. The only way for doctors to have more time is therefore for them to stop doing things.

      There are a few activities that general practitioners might simply stop doing. Some may need legislative change, such as a move from repeat prescribing to repeat dispensing.3 This would probably save the average general practitioner about an hour a day. Other changes might need us to question some of our routine behaviours perpetuated by the convoluted fee structure of general medical services. Why do we need to see patients taking contraceptives twice a year? Why do we still dabble in antenatal care when midwives do it so much better? What is a “full postnatal examination” for?

      The most effective way of freeing up time is to delegate. Get someone else to do it—preferably someone who is better at it than you are. The extended roles of practice nurses and nurse practitioners are a move in this direction, but there are so many calls on nurses that we are probably close to the limit of available staff. The largest untapped source of underused skill, however, is community pharmacists: the fact that so many are trapped behind their counters selling baby food and offering cold remedies of questionable efficacy is a waste of their clinical skills.

      The future of the traditional high street pharmacy is threatened by the pincer movement of industrialised warehouse dispensing and the supermarket pharmacy. At present supermarket pharmacies are contributing to a manpower shortage, but warehouse dispensing could reverse this trend. The potential exists to redeploy pharmacists into general practices to review patients and supervise drugs, making best use of their knowledge and developing skills. 4 5 This would free up general practitioners and enable them to extend consultations and improve the depth and breadth of care.

      References

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      View Abstract