Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: Opportunity costs and the time needed to treat

BMJ 2023; 380 doi: (Published 24 January 2023) Cite this as: BMJ 2023;380:p168
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

When you work as a GP a great many people seem to have bright ideas about things you should be doing to improve your patients’ health. The problem is that you have only a limited number of hours in a week.

Hashim Ahmed, chair in urology at Imperial College London, speaking on BBC Radio 4’s Today programme, recently advised all men over 50 to ask their GP for a prostate specific antigen (PSA) test to look for cancer.1 Such consultations would ideally involve discussions about personal risk factors, why regular PSA testing isn’t recommended by the UK National Screening Committee, recent advances in diagnostic techniques, and the tricky concept of overdiagnosis—explaining that some cancers wouldn’t cause harm in the course of the patient’s lifetime, but we don’t know which ones, and that the treatment itself may have negative health effects. This is not a brief add-on task but a whole separate GP appointment.

It’s also been suggested this month that all people with more than a 5% risk of heart attack or stroke in the next 10 years should consider taking statins, which reduce cholesterol.2 Quizzing QRISK3, the latest algorithm available for working out who falls into this category, I conclude that all women over 60 and all men over 55 are at risk by virtue of their age alone, even if they are non-smokers, are not diabetic, and have normal blood pressure.

Statins are relatively benign drugs, but patients still need a blood test to check liver and kidney function before starting, with further blood tests at three and 12 months.3 More importantly, patients need a proper consultation about the possible benefits and harms, as well as the other options they have to improve their cardiovascular health, such as increasing exercise, improving diet, and stopping smoking. Perhaps in an ideal world we’d do all of that, but my current question is: “What do you want me to stop doing in order to find the time?”

In this context, I was pleased to see Johansson and colleagues’ paper on the concept of clinicians’ time needed to treat.4 It suggests that all people writing guidelines should think about the practicalities of implementing their advice, calculate the hours of GP or nurse time involved, and grade the strength of their recommendations accordingly. It might be an appealing idea to assess every patient’s exercise status and give tailored brief advice but, looking at the numbers, this would take 15% of a GP’s or a nurse’s entire working week and would result in just one in 14 of the targeted patients increasing their exercise level.

Currently, GPs have too much to do and are juggling the need to preserve their practice income (by ticking boxes on metrics such as the Quality and Outcomes Framework) with the demand from patients in need of appointments. We really would welcome a bit of realism in guidelines, especially those that cover large numbers of our registered patients. Adopting the “time needed to treat” metric for every new proposal would be an excellent start.

Perhaps we could also have “time needed to read” on the emails that flood our inboxes daily: senders could then decide whether what they have to say actually requires that much of the recipient’s day or whether it could be conveyed more succinctly.