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GPs criticised for treating one condition at a time

A patient watchdog has criticised GPs for displaying signs telling patients that they will only deal with one condition at a time at routine consultations.

Aneurin Bevan Community Health Council (ABCHC), which monitors health services in South Wales, said some practices are continuing either to put up signs or to tell patients verbally that they will not deal with more than one condition at a routine appointment, despite previously being warned it was ‘clinically inappropriate and indefensible’.

However, the RCGP has argued that some practices are forced to make such rules to cope with heavy workloads.

The issue was raised at an Aneurin Bevan University Health Board meeting, where the ABCHC’s new annual report was highlighted.

The report states: ’Last year we drew the Health Board’s attention to the bluntly worded signs which we had observed in some GP surgeries indicating that only one medical issue could be dealt with in a routine GP consultation. We considered that such notices could inhibit patients from raising a number of symptoms which may be linked, and could discourage a fuller discussion which might assist an accurate diagnosis.

’The Health Board agreed with this view and the assistant medical director (general practice) communicated with all GP practices in the Gwent area to advise that a blanket policy was clinically inappropriate and indefensible.’

The board said that there has been a ‘reduction in this approach’, but that ’we are still seeing it continue in some areas’

It adds: ’While appreciating the time pressures in GP consulting rooms, we are concerned about the risk to patients if this issue is not fully resolved.’

But RCGP Wales vice-chair Dr Jane Fenton-May said: ’I can see where the CHC is coming from but this is one of the things that GPs have to do to regulate their workload. Some practices have been doing this for a long time.

’If a patient comes in with a shopping list of four or five things then sometimes you just have to tell them that you’ll look at the one that’s most important. Sometimes their problems are linked but sometimes they are not. We are limited to ten minutes per consultation, but the RCGP would like that to be longer.’

Dr David Bailey, Deputy Chair of the WGPC said: ‘GPs should treat holistically, although we understand that sometimes when providing urgent rapid access it may be important to clarify that the time slot is limited.

‘We would not support a blanket rule however, as sometimes a patients different problems are inextricably linked.’

NICE is currently working on guidelines for GPs dealing with multimorbidity, which are due next year.

Readers' comments (26)

  • so is it "clinically appropriate and defensible" to mismanage or misdiagnose serious pathology because the GPs was rushing to get through 4 or more potentially complex problems in one 10 minute slot. Let's be honest... the same patients who demand to shoehorn multiple problems into 10 min appointment are the very same one who would be the first to complain if something important was missed in the rush.

    This job gets more and more stupid by the day...

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  • usual LHBs doing nothing to curb innappropriate demands or support General Practice, No wonder theres a massive recruitment problem.... Gp's arent exactly queuing to work in the Gwent valleys. Well done Aneurin Bevan

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  • Russell Thorpe

    I agree with this one it goes against everything I consider inherent in being a GP to limit what the patient brings to the consultation. So its a longer consultation the next one with that person will be shorter. Not every consultation should be shoe horned into 10 minutes you just need to ave 10 minutes over a individual surgery.
    I know this opinion will fall onto stony ground.

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  • I don't give a flying fig what this health board think I should do. When are we going to stop being micro-managed and how dare people tell me how to consult? One of the key skills of general practice is time management. Most doctors can assess and manage a problem in an hour. It's only a GP who can do this at 10 minute intervals. If you want the free for all buffet to extend to unlimited time, then give me unlimited resources. No? Thought not.

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  • Years ago one would get an even mixture of "long" and "short" consultations that would balance things out. In today's society most consultations tend to be "long" due to the increasing complexity with the ageing population as well as the higher demands of the population in general. The 10 minute appointment is therefore outdated.

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  • Ildiko Spelt

    even for1 condition 10 min is the minimum in most of the cases ...we are not "supermen/superwomen" ...who wants more can go to the ski-fi films...

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  • I agree with Russell.

    Negotiating the priorities to be addressed during the consultation is a core GP skill - in fact, it's hard to think of any more fundamental task we face.

    I have worked at surgeries with such signs and am always embarrassed by them.

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  • Every man and his dog who has never done the job thinks they can tell GPs how to do their job. Funny how this doesn't seem to be the case with other jobs or professions. Think it has a lot to do with political interference and the agenda of keeping GPs down. Major lack of respect for ten plus years of training. But that's the entitled attitude in the UK.

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  • Blanket signs are wrong. however where I am a patient they have signs saying 'the GP will deal with one problem in one appointment, however if you have multiple problems make a list and the GP will discuss whichever is most important' - this is the best way, and it's how I consult.

    when a patient says 'well there's 4 things Doc', I quickly respond with 'well tell me what they are and we'll see if we can address them', usually swiftly followed with 'well they clearly concern you, but which are you most concerned about, let's talk about that one, make another appointment for the rest but make it a double'.

    patients don't understand or appreciate that for them it takes 10 seconds to say what's wrong, but sometimes it takes 10 minutes for us to work out what's wrong (if not more), and we just can't deal with 5 or 6 complaints in one go. I had this exact example a few days ago. somebody came in with a shopping list of problems (but didn't even give me the courtesy of being up front about it, you know, the kind of ...'oh and just one more thing doc' patient), and gave 2 word histories. literally 2 words. would not elaborate at all. 'elbow pain'. 'cough'. 'tummy hurts'. it was like dealing with a 2 year old. (FYI I quickly triaged them and they were all non-urgent).

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  • I recently went to a meeting about MSK problems. The Orthopaedic Consultant stated they should have 30 minutes per new patient in the local MSK clinic for one issue but only get 8 minutes.
    It is interesting the patient groups don't mention about GPs over running and making other patients wait who have other things planned in their day. If GPs dealt with every problem in one sitting it will be quite routine to be 1 hour behind and I feel sorry for those patients who have come on time and are having to wait.
    The answer is 15 minutes per patient and see less patients and use other ways of getting access. Either hire "cheaper" ANP/PA or cut list size.

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  • It is impossible to sort out 5 significant and varied things in a 10 min slot and a variety of "proitisation" and "co-ownership/education" tactics are already suggested in the thread.
    As some contributers have said this group of patients are recognisable.
    Take it a stage further and you can time audit their consultation length.
    We massively improved our global patient satisfaction by identifying this few patients , placing a major alert their standard consultation was to be double or triple appointment slots whenever they requested"an appointment" reducing delays of subsequent patients- actually "bottoming out" and modifying some of the consultation behaviours.
    yes we have not sorted out the service pressures of too few doctors too little time however we did identify the game playing "consultation terrorist" subgroup of inadequate personality types whose motivation is to " screw up some authority figure so I feel better about myself" and derived satisfaction from "getting a better deal than others" and "making GP take notice and suffer".
    Where they decline to adress their negative personality traits in a theraputic model we find the Dr patient relationship has deteriorated and move them on.
    Yes they then see someone else , but may eventiually "get it" after sufficient Doctors and change their ways- or the Nice Guidance on "management of Patients with Physical symptoms without Organic basis " may be resurected- its 0 years in development.

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  • I sometimes wonder if GP's want to bother with patients at all?
    GP's are really losing the support of patients, double appointments should be bookable and in the long run, it will save time. Sometimes problems are linked, you cannot deal with one without taking the other into consideration. Care should mean care, and patients will often return when they are anxious that something is being missed, which appears to be quite often theses days!
    Some appointments take a minute or two, others longer but they should balance out at the end of the day.
    GP's need to decide which is more important, care of the patient or clock watching!

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  • Other Health Professional 11:17 you need to read Zoe Norris' letter to her daughter on Huffington Post. Care of the patient v having a life is tipped so far against having a life my ability to care is fast waining.

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  • I don't like these signs either. Not because they're stopping us from making diagnoses (if we're even half-decent clinicians we'll elicit the relevant information) but because they actually encourage the behaviour that they're intended to discourage. What patients see is, "These signs mean that LOTS OF OTHER PEOPLE have been going into the doctor with a list of problems, therefore this is NORMAL BEHAVIOUR, so I can do it too."

    And I've had a patient come in and tell me that they've seen the sign but realise it's not meant for "people like them". I'm still scratching my head about that one.

    Unfortunately, we sometimes don't know which patients are genuinely consulting about their dandruff and which are going to say, after spending eleven minutes of a ten-minute slot perseverating about their dandruff, "Oh, by the way, doctor, is it normal to have blood in your poo?" or burst into tears and disclose domestic abuse.

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  • The principle of discussing one condition at a time is reasonable given the current workload. The history taken of the symptom discussed would of course bring out any other symptoms of relevance. This is indeed the principle of the D of H 111 system - they triage one symptoms and thee triage process brings out other relevant co-existing symptoms- why can GPs not do the same??

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  • Difficult topic.

    Clearly there may be linked symptoms, and I think we would all agree that if a patient comes in with a list, we can manage that.

    The difficulty is when you use your ten minutes wisely, only for the patient to say "whilst I am here..." and for some reason it is almost always benign sounding chest pain. I am certain some people leave more serious sounding problems till later on purpose.

    I agree "one appointment one problem" sounds too restrictive but would be nice if patients had a better grasp of how our timings work and could present a list of bullet points to allow us to prioritise.

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  • @11:17

    Giving patients the ability to book double appointments will clearly reduce the number of patients who can be seen in a day.

    So it will be benefiting those patients who manage to book the double appt at the expense of those who fail to get any appointment.

    My sense of justice suggests it's more fair to give a larger number of patients a small amount of time than a smaller number of patients a larger amount of time (and the rest no time at all).

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  • Anonymous | Other healthcare professional07 Oct 2015 11:17am

    I agree with you that double appointments are sometimes needed. However, you clearly have never worked in a GP practice, as in my experience 90% of people who want more than one problem dealing with don't tell the receptionist and don't even ask for double appointments, even when they are bookable.

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  • I am sick and tired of being criticized by those who have no clue about what we do. They will realise what damage they are causing when its to late. Human nature I'm afraid.

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  • Anonymous | Other healthcare professional07 Oct 2015 11:17am

    GP's need to decide which is more important, care of the patient or clock watching!


    What absolute tosh! I care about ALL my patients, means balancing my time as best I can and the way I see fit. You want the honest answer? We will bother with patients more when we start to feel more appreciated, by patients and the government. If patients aren't happy? Wait til we're private and you have to pay market rate for our expertise, or if you're happy to see a noctor, nurse, PA, pharmacist, go right ahead. Here's the honest truth, the majority of GPs are overworked, and we are ALL clock watching to stay sane.

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  • I've seena few practices with prominent notices saying 'If you want to discuss more than one condition with the GP please make a double appointment' which seems a politer way of making the same point, especially if reiterated in person.

    That said, I don't think I've ever been asked by a receptionist if I need a longer appointment or not - I think they tend to be desperate to get through the hell that is 8.30am when the phones open.

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  • I think it is frankly ridiculous to expect a safe assessment of more than one problem in a measly 10 minute appointment - appointments should be longer or they should book a double appointment atleast .The sanctimonious attitudes in some of the previous comments that we should just suck it up and do it is galling - I bet these are the 'portfolio' types who spend very limited time in face to face consultations or partners with salaried mules doing all the work.Especially when you consider how different the current climate is , say compared to even 10 years ago . Patients have much higher expectations now , usually unrealistic , and they are much more likely to complain and litigate . Hence we have to keep more detailed and copious notes -this also takes time . The necessity to get chaperones for an increasing number of examinations takes time . We have to deal with more multimorbidity and there is an increased need to organise investigations .The customer culture in healthcare means people get more irate if they are kept waiting as well . This all adds upto a vicious cycle and increases stress and risk of burnout .

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  • And will the GMC or Police or Coroner support the GP if they misdiagnosed a serious illness just because the GP was in a rush to deal with with all the multiple problems in one appointment and hence was sloppy ?I thought not .

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  • As a patient, I enjoy booked appointments at doctors and dentists more if there are up to date magazines to pass the time. Happy to wait. Never has it crossed my mind to complain.

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  • Just another example of the way in which medical care is service-centred rather than patient-centred. Patients are expected to fit in with the needs of doctors rather than doctors providing a service to meet the needs of patients.

    Diseases present with more than one symptom - how is the patient supposed to know which one symptom is the most important?

    Also surgeries don't exactly advertise the fact that they have double appointments available - so why blame the patient?

    A modern approach to medicine would involve considering how patients present and what can be done to meet their needs - it would not expect patients to fit into an idealised, unrealistic, standardised model of the "perfect patient".

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  • I've tried both, dealing with everything they ask about and restricting them to 1 problem so that everyone gets seen on time. I get shouted at either way. I really hate the way I feel at the end of a days work. I work hard, I'm nice and still I get shouted at. I then see the comment 00:57 and realise it'll never get better. The reason I'm shouted at is because they think we behave to serve our own needs.
    I feel like a dog confused about why my owner keeps beating me. No matter what I do it won't please them.

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