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Ten-minute consultations 'must go', says NHS England director

The age of 10-minute GP appointments ‘has got to go’, as the limit is ‘unsafe’, a senior director of NHS England has said.

Speaking at the main debate rounding up the Pulse Live conference in London today, Dr Mike Bewick, NHS England’s deputy medical director, said this must ‘undoubtedly’ happen.

However GPC chair Dr Chaand Nagpaul said GPs could not lengthen consulations without reducing patient access to appointments.

Responding to a question from the floor, Dr Bewick said: ‘I think the age of the ten-minute appointment has got to go, undoubtedly. As a commissioner, I think it is unsafe as well.’

‘I think you have got to manage what comes in through the door as well, at least make an attempt to put something in that stops people getting through in cases where self care would have been more appropriate.’

‘I think that requires training, as an issue for practices, not necessarily for individual GPs, and probably a training issue for larger providers of general practice.’

The BMA voted in favour of abolishing the 10-minute appointment at its annual representative meeting in Edinburgh last year, declaring it a thing of the past, and GPC chair Dr Nagpaul, who was also on the Pulse Live panel, said: ‘Ten minutes is a total insult to so many of our patients… I would like to offer 15-20 minute appointments but if I do that I would have to tell them that they have to wait two weeks to see me.’

Questions from the floor also focused on reducing expectations and demand on GPs from patients, to which Dr Nagpaul responded that he would like to see schools educating children what to expect from GPs, as well as how to manage a cold.

He said:‘Demand management and self-care is very important – educating patients and the public about how to use a limited resource effectively and responsibly. I think children in school should be educated about the role of GPs, the role of the pharmacists, and actually how they can manage colds and sore throats themselves.’

Readers' comments (58)

  • Una Coales

    I spoke to a GP who is still alive and was present during the infamous 1966 GP strike. He said their bargaining tool then was to refuse to sign any sick notes.

    Scroll forward and in New Zealand doctors went on strike and refused to sign cremation forms. You can imagine that the strike only lasted 48 hours as the mortuaries filled up.

    If the government has bound the BMA in legalities preventing a strike, then we need trade union barristers like John Hendy QC to take on government as every trade union should have the right to strike or take action to ensure fair pay and fair working conditions,

    If you think it is greener on the other side, I just chatted with a young female who has completed a summer bank internship and said bankers are in the office from 4:30 am when the markets open and are there until 9 pm and then go drinking with clients until 1 am so many live on 3 hours sleep! And the money is not as good as it was 10 years ago (when our economy was in the black).

    I guess the bottom line is that the only way out is being your own boss and go private so you are not stressing over intolerable work demands, bureaucracy, reducing pay, etc. When there is a housing shortage, house prices go up. When there is a GP shortage, govt cuts GPs pay! Until then, we can demand a ballot for en masse resignation as we are no longer doormats!

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  • I retired much earlier than I had planned( to live a less materialistic but greatly more satisfying life) mainly because of the rise of telephone triage. The only way we could manage demand for appointments was to triage all appointment requests. My all time record was 130 calls( plus scripts,results,the odd home visit and walk-in). I used to lie awake at night worrying about all the wrong decisions I might have made. It seems inevitable that as demand grows more practices will be forced into this way of working. Prescribing over the phone without face to face assessment is asking for trouble. I sleep much better now, going to bed knowing I'm not going to be gambling with someone's life.

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  • I'm not sure why GPs are against being independent private contractors with a contract with the patient directly and payment directly or indirectly (insurance schemes etc). Why are we so adamant that we must stay with the NHS contract when it is causing more harm than good?

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  • Because many of us still believe at heart all should receive half decent health care?

    It may be hard to believe this as partners are always going on about the money. But the truth is, most of us are not trying to be mega rich on back of being a GP - we ask for appropriate income as a professional and at the moment we often look to balance our income with service levels so that both the patients and provider (us) are satisfied. In order to do so, we always have to look at money.

    Many of my regulars will not be able to afford any form of health care if each of them was liable for it, even at subsidized amount.

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  • One of my anxieties when I see my GP is the fact that I need the appointment in the first place.

    I have a variety of health problems and MY GP is the very best indeed, but I feel guilty asking for his help because he works flat out.
    At times my GP looks exhausted but always is every kind and caring offering me the very best of care ... but i do sometimes feel he is so overworked that going to A&E is a better option taking the pressure off my GP!

    How sad it is to have to do this, but who is actually looking after the health of our GP's? Some GP's may be single parents, are they expected to abandon their children to visit someone with a snotty nose, or an old lady in care home, that could quite easily be brought to the surgery?
    If GP's treated their patients like the NHS teat GP's they would be facing disciplinary action!
    The government have promised patients so much but have hope in hell of delivering ion that promise so are happy to blame GP's for not being able to work 24/7.

    Time the GP's had a seat in parliament and shook that lot up!

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  • Una Coales

    For surgeries on the brink of bankruptcy and closure, GP partners be aware of TUPE, as employers you may be liable for the redundancy of your long-serving staff even when left with no option but to close and liable for the ongoing tax liabilities for the next year or 2. So instead of gratitude after decades of service to ensure access for all, you will have to pay out of pocket in the end for the privilege of having served the NHS.

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  • gps have always been very flexible,practices have always been doing large amounts triage and have been trying to educate patients.
    as ever the problem is nhse..living on another planet,not resourcing and in fact reducing primary care resources,encouraging consumerism and access to minor issues that should be self managed ,facilitating by multiple short sighted means reduction in numbers.. by encouraging early retirement emigration lack of recruitment etc etc.
    the first requirement of enlightened good management is to spend time at the coal face to see reality before even opening one's mouth.i understand dr bewick does one or two gp sessions a week..if so he must work in an extremely untypical practice.

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  • Una Coales

    http://online.wsj.com/news/articles/SB10001424052702304279904579518273176775310?mg=reno64-wsj&url=http%3A%2F%2Fonline.wsj.com%2Farticle%2FSB10001424052702304279904579518273176775310.html

    Here is an article in the Wall St Journal mirroring what is happening to NHS GPs. In the US, govt health insurance called Medicaid/Medicare is mandating a while series of electronic health record tbox ticking that is driving physicians mental and cutting reimbursements. The context is the same as in the UK. Both nations have HUGE national deficits and are looking at ways to control government public expenditure on health. Here the govt health insurance is called the NHS and over the pond it is called medicaid for the poor and medicare for the elderly/disabled.

    Poignantly this physician writes of retiring early and suggests physicians not accept any medicare/medicaid patients. This is similar to us asking for an en masse walk out from the NHS GP contract.

    At the end of the day self paying patients means you are in control of your own business and keep your ICS. The longer you remain working for the public healthcare sectorr, the more you are likely to feel stress as the government continues cutting expenditure.

    Plan for more pressure and mandates to be dumped on remaining GP partnerships, to force them to amalgamate and move into new builds as feds to then be able to decommission them and commission APMS or US/UK healthcare giants to take over the government burden.

    A ballot for en masse resignation is to ask government to give GPs a lifeline, semi private, state+private sellf pay, else the public will only have 100% private care and who will look after the elderly and the poor?

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  • Una Coales

    Apologies for the typos. Can't find my reading specs and typing on an ipad. That's 'whole' series, 'box' ticking, 'sector' and 'self'.

    Fascinating rebuttals by another physician in Once more unto the breach http://theincidentaleconomist.com/wordpress/once-more-unto-the-breach/

    This physician compares the burden put on public sector physicians to that put on public sector teachers in the US.

    The bottom line is either we need a stronger trade union led by the likes of a Bob Crow pushing for en masse resignation or strike or we vote with our feet.

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  • Una Coales

    http://youtu.be/5cvHgGM-cRI Dr Pamela Wible US family physician explains on Tedx how 400 US doctors are now committing suicide every year due to the stresses of bureaucratic govt medicaid/medicare mandates and box ticking to receive reimbursements rather than face to face human patient encounters.

    This is happening with the NHS. Her solution was to call a town hall meeting and ask the public what their ideal GP surgery would look like and within a month created it! Before the overhead was 74% paying for the large building, the practice staff, admin, etc. and now her overhead is 10% as a sole practitioner and she offers 30-60 minute appointments via online booking! No queues of patients inside and outside the building! She even says she does not turn away anyone who cannot afford to pay! So like lawyers she mixes pro bono with PMI and self pay income. She can even work part time!

    I surmised that if she charged $70/30 min appt and offered 8 appts x 30 mins or 4 hours a day, she could earn £100/h or £400/day or £100k per year for what amounts to part time work!

    All NHS GPs have access to approx 2000 patients each on their list and they could write to them and say they are now going private and easily make double the living seeing 200 patients. The dr/pt ratio would be a lot safer and GPs would be happier.

    Her ideal clinics have spread like wildfire across 50 states of America and is saving doctors' lives from burnout.

    It would certainly increase GP recruitment if budding GPs saw a future for general practice in the UK and the public would be safer.

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  • As a prescribing nurse practitioner I have 20 mins; it's safer and productive; the patients deserve it. Maximise our potential either on the phone or face to face.

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  • Una Coales for GPC chair. Much sense spoken. I've left general practice now and could not face the prospect of going back just to be used and abused as everyone's doormat (patients, DOH, Daily Wail etc). It's a shame for a lot of the patients I used to enjoy seeing and helping. I've turned to the dark side of the force now and work 7 sessions as a permanent ED doctor. It's actually very rewarding and the way GP land is at the moment, I can't see me going back anytime soon.

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  • Dear Anthony, can anyone do 7 sessions of Erectile Dysfunction and stay sane?

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  • Una Coales

    @Anthony I am so glad to hear you made your exit in time. Yesterday I learned that a GP partner dear to me committed suicide in his early 50s. His family and mother are heartbroken. IMO the NHS contract killed him.

    Please GP partners out there, it is time for en masse resignation from this untenable and unworkable NHS contract that will either force you out through bankruptcy, burnout, ill health or God forbid suicide.

    We have our very own never event among us. It is time to demand a ballot to walk out of this nightmarish NHS contract and demand better working conditions, better pay and literally, demand a life-line!

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  • I am saddened to read about GP's committing suicide. surely a clear sign that the stresses of the job are more than is sustainable. GP's working all day to see 45 patients made me smile... just a little.

    A typical fracture clinic workload for me in some hospitals is 200 patients to be seen in the morning session, followed by 150 in the afternoon session. The NHS has always run on unpaid overtime. If the multiple layers of micromanagement were removed, the costs could be diverted to staffing the service with clinically useful staff.

    I had occasion to be hospitalised in the Netherlands. The GP charged for her services and the hospital she provided emergency care from within, billed me for her time and service. The hospital billed me for its services and I paid for them and recovered a proportion from my travel insurance.

    What struck me most about the hospital was that it was clean and well staffed and I assume that was because it was not competing with any other healthcare services providing institution for a very small slice of a total pot, subject to the whim of our political masters.

    My arrival post cardiac event in the Netherlands was to be told that my GP could see me for an URGENT appointment just three weeks after my arrival back in the UK. Clearly there is a workload/priority issue at my assigned multiple partner GP practice.

    I guess GP's need more help from HM Government. I really would not like to see the efforts of GP's squandered on propping up a system which no longer caters to the sick. Our treat the well culture, based upon nonsense research, has turned everyone into a patient. Please, GP's stop treating the worried well and go back to working with the clinically unwell.

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  • 07 May 2014 0:03am has pretty much summed up why the NHS is in a mess - 'turned everyone into a patient'

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  • Dear Jeff (0.03am), thanks for the comments, much appreciated.
    As you state, GPs often see upwards of 45 patients a day (and necessarily including home visits). Whilst it no way matches your staggering patient count of 350 patients a day, I would like to point out few facts.

    GP appointments are currently 10 minutes. Most of us agree this is no longer sufficient to deal with increasingly complex and multiple co-morbid patients we deal with, but that's by the by. According to your patient count you would by working 58.33hours a day to see all those fracture clinic patient of yours working on the principle of 10 minute appointments. Now clearly that would leave very little time for err.. life, but my point is without pointing out exactly what you do with the patients you see your figures don't really mean much. Do you answer the phone and book 350 patients every day, at a rate of one patient every 90 seconds? That would work out as 8.75hours working- a conventional working day. Do you plaster fractures every 2minutes? that would workout as 11.67hrs working day. Definitely full on, almost chicken farm factory level efficiency- but I wonder how much time that leaves you to provide holistic care and know the patients you see. Maybe that's not what your jobs about so is of no concern to your situation.

    As a GP I can see a parent brought in by a son or daughter worried about dementia in appointment, a woman in an abusive relationship but afraid to leave with the kids the next, followed by a patient with angina, hypertension, COPD and diabetes - all uncontrolled and the patient not seeing why he needs to take the medications even though he continues to make appointments because he feels so unwell. Or mum with baby who cries all night and is inconsolable, another with a toddler with a rash/temp/unwell/limp/fussy eater/too short - take your pick. Or a pregnant woman with abdominal pain and/or vaginal bleeding in her first trimester. All supposedly to be done in 10 minutes.

    Yes there are a few sick (sorry....fit) notes patients for the recurring depression/low back pain/work stress and morning after pills, routine BP checks and medication reviews to lighten the load, but on the whole 10 minutes does not even come close to the time that needs to be spent on the majority of patients to make a positive difference to their health.

    So I am glad that the 45 patients a day GPs up and down the country see on a daily basis made you smile - if even just a little.

    Now imagine a time when we aren't there for you to smile at. What will you do then?


    Disillusioned GP Partner (1yr)

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  • 2 points
    the ten minute appointment in my world does not exist, I end up dealing with what I am given in the time it takes to an extent. I get it wrong, I am the one to go to court) It does impinge then in the time one has at lunch time that is supossed to be admin, but suddenly there is also home visits. For a salaried doctor it just means working for free the admin time(not suistainable, no wonder so many are locums). Longer appointments at least will recognise part of this time.
    It is curious how in other professions there is real concern about the safety of long hours and overtime but when it comes to the people that everyday are making decisions that can mean late, wrong diagnosis , death it is conviniently forgotten.
    2- I think the system is bonkers. I am not a partner as I view it as becoming a slave of the nhs. There is no business in the private sector that would sign up to delivering things that are not paid for or not having clear indications as what exactly they are going to have to deliver. I think the time of a fix fee per patient whatever the work they generate should be scrapped. Pay by work delivered. This could even be for salaried GP's (giving them an incentive for seeing extra patients)maybe adopt a system where they are also self employed.

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