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Evolving general practice consultation in Britain: issues of length and context

BMJ 2002; 324 doi: (Published 13 April 2002) Cite this as: BMJ 2002;324:880

Rapid Response:

Increasing consultation time may not be straightforward and outcomes must be evaluated

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

Our pilot study was designed to inform the design of a randomised
controlled trial of the effect of increased booking interval on
identification of patient psychological distress (2). Each doctor's
surgery was randomised to either a normal booking interval (10 minutes per
patient) or 1.5 times the normal time. To enable practices to cope with
the resulting reduced number of consultations, one of us (MS) offered
locum sessions to make up the shortfall. The process was continued until
there were 65 consultations at each booking interval for each
practitioner. The General Health Questionnaire 12 was given to each
patient after the consultation as a measure of psychological distress, and
the doctor completed a six-point scale to estimate the patient’s degree of
psychological distress and a brief inventory of consultation events. Each
consultation was timed by a research assistant.

Data were collected from 781 consultations. When booking interval was
increased from 10 to 15 minutes consultation length only increased by 12%
from 8.7 minutes to 9.7 minutes. Long booking interval significantly
increased the number of consultations in which the doctor carried out
investigations (19.38% v 27.85%; p = 0.0069). It also significantly
increased the number of consultations in which the doctor asked the
patient to arrange a repeat appointment (43.81% v 53.67%; p = 0.0072).
There was no significant effect on proportion of consultations in which
prescriptions were issued (51.03% v 54.68%; p = 0.341), physical
examination carried out (66.75% v 66.84%; p = 0.959), or referral made
(13.95% v 10.69%; p = 0.201).

There were no significant differences between identification of
psychological distress at long or normal booking intervals. For
consultations in which the GHQ is positive, the odds ratio for
identification between long and short booking interval is 1.00 (95% CI
0.63 to 1.59).

Our results show that although booking interval increased by 50%,
consultation length increased by only 12%. This raises the obvious
question of what the doctors did with the extra time. It has been argued
that increasing the length of consultations may save time and resources in
the long run. These results suggest that the opposite is true; doctors ask
more patients to make further appointments after the longer consultations
and perform more investigations. Perhaps doctors given more time with
patients simply uncover more problems which require further consultations.
Increased booking intervals also made no difference to the recognition of
psychological distress.

Our results must be interpreted with caution. It is possible that a
longer intervention might lead to a more significant change in habits and
consequently cause more major changes in the doctors' consulting
behaviour. The lack of impact of increased booking interval on the
recognition of psychological distress may also suggest that structural
constraints are insufficient to explain low rates of recognition of
distress by general practitioners. The costs and benefits of increasing
consultation intervals require careful evaluation: health service costs
may be significantly higher than those simply resulting from paying for
more general practitioners’ time for the consultations.

(1) Freeman GK, Horder JP, Howie JGR, Hungin AP, Hill AP, Shah NC,
Wilson A. Evolving general practice consultations in Britain: issues of
length and context. BMJ 2002; 880-2

(2) Stirling M, Wilson P, McConnachie A. Consultation length, deprivation
and identification of psychological distress in general practice. BJGP
2001; 51: 456-460

Competing interests: No competing interests

19 April 2002
Phil MJ Wilson
Senior Research Fellow and GP
Mark Stirling, and Alex McConnachie
Department of General Practice, University of Glasgow, G12 ORR