One problem
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3584 (Published 02 June 2014) Cite this as: BMJ 2014;348:g3584All rapid responses
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As is customary when time per patient is discussed, Margaret McCartney ignores the logistics. I remember one of our leading medical politicians (hospital based) saying that he could only provide care for a certain number of patients – his choice - and once this was reached he would not even provide telephone advice about someone new. Add an ability to say “not my problem” whilst insisting that all patients with a whole range of disorders (some relatively common and allowing clinics to be filled with easy problems) had to be under the care of hospitals and massive consultant expansion has followed.
A previous generation of GPs insisted that everything fell to their remit, combined with encouraging Society to “medicalise ” all sorts of life-events and problems and set various targets, failed to obtain similar expansion – and prided themselves on being able to cope. GPs are now in an impossible position. Yet the essential problem is one of opportunity costs. A 10 min appointment system for 1 problem (not just 1 symptom) as run by my own surgery seems a reasonable compromise. I can think of few problems where I would require more than 10 mins for an initial appointment – perhaps we need to educate our patients to learn how to use the system optimally. This applies particularly if I can see a GP who knows me. Obviously there will be some requiring a longer time, others shorter.
As a gut doctor, I found 15 minutes seemed about the time allowed to take a relevant history, endoscope and complete a summary with a plan of management. We should know the average consultation rate per head of population and the number of appointments likely to be needed (clearly there will be inter-practice variations). We can then calculate roughly how much time can be allocated to appointments and presumably this is working out at about 10mins. What we do not know is the number of people on the GP lists who are discouraged from seeking help when they should do so. They will be further discouraged if clinics see fewer people with longer appointments – it is already hard to book an appointment ahead without claiming “urgency”. The problem is not helped by our move towards trying to deal with certain groups of patients in preference to others so that some us feel decidedly edged out despite what could be quite significant symptoms.
It is always possible to spend more time with a patient – but how strong is the hard evidence that this really affects major outcome measures (not just a feel good factor ) weighing opportunity costs in the balance as well? Much of the non-medical discussion, lifestyle advice, etc, can be done equally well by other staff. What I find most objectionable is the failure of politicians (“doctor of your choice at the time of your choice”!) and certain patient groups who fail to grasp the problems but seem to find satisfaction in shooting the messenger – in this case the GP.
Competing interests: No competing interests
This is an important and relevant topic that is of concern to GPs and Practices every day. Irrespective of the duration of a consultation, the crux of the matter is the number of problems that can safely and effectively be dealt with in a single encounter. There is an inherent conflict between the need for access to primary care and the need to provide safe practice.
It is ludicrous to expect that all problems can be safely managed in a single consultation of even 30 minutes, unless they are all small and largely self limiting. What happens is that some issues are dealt with superficially or politely deferred for another day. It is better and safer to prioritise and deal safely with those that are clinically important (may not be those which are important for the patient) and request another appointment for remaining issues. To muddle though under pressure, becoming even later with subsequent appointments, some of whom again may have multiple issues is a recipe for disaster. In a population that is increasingly associated with multi-morbidity there has to be a prioritisation of services. I also find it absurd that I provide the same time for a patient with sore throat as for someone who has been just discharged form hospital having had coronary stents inserted and with the need to discuss his condition, medication, employment etc!
Primary care needs an investment in doctors, nurses, nurse practitioners etc if we are to begin to have the time to cover the multiplicity of problems that a patient may bring to a consultation.
For many years I have been providing care on the ‘one consultation one problem’ basis. So long as the policy is known to patients and is applied flexibly, problems seldom arise. I have not encountered any and I have often dealt with more than one problem when time permits. In those instances when time is at a premium I advise the patient to make another appointment or make one myself, if considered important.
Additionally, this topic is relevant to the need for a face-to-face encounter. The ‘smart’ use of consultations for those that need it may help reduce pressure on appointment systems. The provision of telephone access for matters as diverse as discussing test results, outcome of hospital visits, some modifications to medicine routines etc helps with availability of appointments to those who need them most.
Competing interests: No competing interests
Margaret MacCartney covers all the bases. But she has made the wrong diagnosis - it is much more about funding than it is about politicians. Politicians must always press their agenda, but British general practitioners remain wholly-independent sub-contractors.
I refer her to the entertaining and insightful Bird and Fortune GP consultation, which Bird ended by stating "our practice has a policy of ten minute consultations".
Exactly so. GPs are entirely free to consult for as long as they please, with the overriding consideration of 'can they afford it'. How many other more pressing problems are in the waiting room, the visit list, the phone messages list, or the mail?
James Dickinson asks
(1) why do we allow our governments to remunerate General Practice in such a way
answer - in the UK we don't.
(2) why do our organisations examine our graduates on their ability to conduct consultations in such impossibly short times.
answer - because that is an essential survival skill at current funding levels.
(3) Are we complicit in the organisational arrangements that ensure most General Practice provides bad medical care?
answer - yes, but only insofar as we accept the NHS contract terms, and demand adequate reward and a life outside work.
More funding means more people which means less stress per professional. But the workload/stress does not diminish arithmetically. The larger the practice the greater the 'communications' overhead, to offset any economies of scale.
We need small, experienced, and locally accessible GPs. Now can someone persuade me to stay on??
Competing interests: I am an NHS GP retiring in 63 days
Walk-in clinics around the world run on an overtly commercial model. In most fee-for service settings, they are explicit that they only make money for their owners by limiting duration of consultations, so turnover can be rapid. Only young people who talk fast can possibly describe their problem in a few minutes, be examined and have a (simple) problem solved in that time. If it is more complex, even one problem cannot even be explored in ten minutes. The elderly, and those who cannot focus their concerns have no chance. Thus this model is a recipe for bad medicine. Yet in many countries this is the model that even standard practices operate on: they often run late, because to actually talk to patients and try to solve their real problems takes longer, as you say.
So why do we allow our governments to remunerate General Practice in such a way, and why do our organisations examine our graduates on their ability to conduct consultations in such impossibly short times. Are we complicit in the organisational arrangements that ensure most General Practice provides bad medical care?
Competing interests: No competing interests
Re: One problem
This is a dream or maybe nearer to myth for all GPs and NPs, one problem and one consultation.
With most patients saving up their problems for an appointment, if the patient has something they have deemed minor it's even worse, as they will inevitably need a care plan review or have suddenly remembered they need a prescription issuing. I am so used to it, I barely give it a second thought. It's quite likely why I over run even with a 15 minute slots; I always seem make time somewhere.
I love my extra 5 minutes and all GPs should also push for this. It's not only the patients who have extra to say. It is 50/50 that I also manage to spot something else during my history or examination which needs time and attention.
I almost get irritated if someone comes as too easy, by this I mean a patient who woke with simple pain or simple viral sore throat and doesnt have the first clue in how to cope with their ailment despite the country wide campaigning and advice thats available on line and on television and radio. I will however use the time saved for all the other patients!
Competing interests: working in GP surgery as a nurse practitioner