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Gold, incentives and meh

GPs have ‘chosen’ 10-minute consultations, claims NHS England lead

Practices are continuing to work in 10-minute appointment slots when they should be varying appointment length, NHS England’s head of general practice development has said.

Dr Robert Varnam also told delegates at the RCGP’s Annual Conference last week that the policy of practices restricting patients to one condition per consultation is 'unethical'. 

He was speaking after RCGP chair Professor Helen Stokes-Lampard appealed for GPs to have time to give the holistic care that patients increasingly need in her opening speech of the conference in Liverpool

Dr Varnam said: ‘I think we have chosen to work in 10-minute appointment slots when some people could be dealt with in five, and others couldn’t be dealt with in under 20.'

He likened these restrictions to the policy of practices asking patients not to bring multiple conditions to discuss at their appointment - which has been criticised by commissioners and in the national media. 

Dr Varnam added: 'I just think it’s bad medicine to force someone to say “no you can only talk about one”. I think it’s unethical, I think it’s uncaring, and I think it’s counter-productive.

‘Because while it’s understandable to do that under pressure – “because I’m protecting myself” - that person goes back to reception, books another appointment and you start from scratch again.’

But GP leaders have said Dr Varnam’s comments were ‘unhelpful’ as practices are best placed to know how to meet their patients’ needs, as well as being contractually entitled to do so.

Doncaster LMC medical secretary Dr Dean Eggitt accepted there were pros and cons to the 10-minute model, but fundamentally GPs were only able to give the service they were funded for.

He told Pulse: ‘What’s more unethical is if we turn a load of sick people away with nowhere else to go.

‘We’re stuck in this situation where we either give a substandard consultation in 10 minutes, or a brilliant consultation - taking however long the patient needs - and losing the opportunity cost of helping more people.’

The RCGP has campaigned for half-hour appointments to be the norm, while Professor Stokes-Lampard has repeatedly said NHS England’s pledged investment and workforce commitments must be delivered so that appointments can be longer and access improved.

GP leaders negotiating a new Scottish GP contract have said they expect it to be the end of restrictive 10-minute consultations.

Readers' comments (46)

  • Let's take him at his word and switch to 15 minute appointments en masse.

    He will not like the result.

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  • Prefer to take (on this occasion) Prof HSL's advice and go for half-hour appointments.

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  • What’s unethical is climbing up the greasy pole of being in a leadership role like head of NHSE General Practice development or RCGP chair and making repeated unsupporting and morale sapping remarks to grassroots GPs who are busting a gut in keeping this under funded out of date system going for their patients.

    Use your time to improve the awful system we work in for the improvement of patients and our health and stop being a government mouthpiece and puppet.

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  • Cobblers

    Most practices I have worked in, including my own when it was open, run a 10min basic appointment with an extended 20 min appointment if requested by patient or thought needed. If patient takes 5 mins then bonus.

    Just love it when Ivory Towers merchants tell us the way to do it when they would wet their britches if put in the pressure cooker environment that it NHS General Practice nowadays.

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  • National Hopeless Service

    Dear Dr Varman,

    This is what your new best friend Jeremy Hunt had to say at the RCGP conference;

    We have to recognise that too many GPs are knackered, feel often at the end of their tether. They feel they are on a hamster wheel of 10-minute appointments, 30 to 40 every day, don’t feel able to care like to give to patients.

    And so many GPs are talking to me about the problems of burnout. In the end, there’s a mismatch between the work we are asking GPs to do and the number of GPs we have to do that work and that is the root cause of that burnout, and we absolutely need to address that.

    The truth is, because we have underinvested in general practice over decades, we have made it much harder for you to deliver continuity of care.

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  • Dear All,
    I think i can claim to be the source of the "one appointment, one patient, one problem" concept from when i wrote our first local charter and self help guide, way back in the 1980s. It was adopted by the LMCs of South London and has spread. The flaw in Dr Varnnams hypothesis, and its a big and difficult to avoid one, is that no one knows how long the problem is going to take before its discussed, not me, not him, not the patient, not the receptionist. If we simply spent as long as was needed for each patient as they came in then we'd run fast ahead of schedule, then run late, then fast again because of the very unpredictability of general practice. One patient's chest pain might take 5 mins whereas another's might take 20. You cannot do what he advises if you also want to have any semblance of an appointments system. The only way you can spend as long as it needs as they come through is to have a walk in, first come first served, and "you'll have to wait as long as it takes for me to get to you before your turn" system. Hmm I can see the Head of General Practice Development and other GP gurus liking that.
    The ten minute one appointment one problem one patient is not ideal but its the best compromise in the circumstances.
    We tried allowing patients to select 5, 10 or 15 mins for their appointments to see if that would work but hey guess what, patients perceptions of how long their problem would take was a world away from clinical reality.
    Regards
    Paul C

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  • CENSORSHIP?

    Don't remember being asked...never mind choosing....
    NHS England is just exploitative....unfortunately goodwill is fast running out...
    So lists are ok.... add to this Qoff nags... add to this poor historians and late arrivals.... add to this appraisal reflection and logging.... add to this repeat med requests in consult........wake up.... something has to give
    Is it unethical to decline to see a relative brought in who did not have an appointment??? Signpost to available care.... Time manage to protect your sanity...

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  • Vinci Ho

    Ha ha ha
    As soon as I said NHSE could not afford to be so arrogant as like before the last general election, somebody wanted to prove me wrong. I slapped my face for this .
    There is a Chinese saying,' it is easy to change the mountain and river but the fundamental personalities of people can never be changed.'
    江山易改,本性難移

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  • CENSORSHIP?

    Look at the programme GP's behind closed doors... they look like they've got 30 minute appts.... How about showing real general practice...how about following a locum around.... will be eye opening...

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  • It’s fine saying increase the length your appointments, but NHSE know full well we are unable to do this as we simply would not get through the day. The reason is, we can’t stop them coming. Just because I give Mrs Jones 30 minutes to talk about her IBS doesn’t stop the scores of patients who also demand its ‘their right’ to be seen that day and contractually we have to. Until these magical hubs are developed to soak up the extra work.

    Comments like Dr Varnam’s are unhelpful and counter productive to the problems we face. It’s further denigration of GPs.

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  • Vinci Ho

    Dr Varnam said: ‘I think we have chosen to work in ten-minute appointment slots when some people could be dealt with in five, and others couldn’t be dealt with in under 20.'

    Mmmmmm
    Is he one of 'we' ? How many of you folks would agree to this categorisation.
    I tell you what is we ? We are the ones being oppressed by NHSE , those cynical commissioners and national media(you all know which one anyway).
    So , logically , is it 'unethical' for the oppressor(s) calling themselves 'we' , the ones being oppressed ?

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  • Vinci Ho

    And I have not said this for a long while:
    Please go home to look into the mirror and check if one's reflection is still there ..........

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  • AlanAlmond

    If you’ve got 22 people booked in to see you in a morning as I did today you get on with it, if they can be dealt with in 3 minutes you give them 3 minutes..if they insist on unloading 3 desperate unavoidable issues all over you, sometimes you’ve got no choice, you just have to deal with them all, and they eat up 20 easy. If you know what you are doing over the course of the morning you can just about balance the times but more often that not as time slips by you run later and later. This is just how it is. If you don’t have some kind of ‘standard’ for appointment time length then you are going to get pretty lost. That standard is currently 10 minutes. Perhaps it should be 15...but if you increase the standard time you are going to see fewer patients and ultimately be accused of being less productive, and be financially worse off.
    At the end of the day you get the service you pay for. If people expect longer appointments then that has funding implications. If people don’t want to pay for the health care they demand then I’m sorry they can’t have it. What I cannot abide is the constant pressure for GPs to provide care they aren’t being paid for because someone suggests they are morally obliged to. It’s basic blackmail and is a form of parasitism that sucks care out of GPs leaving them empty, burned out and pissed off.
    Folk can give speeches saying whatever they like...it’s all bull crap in the end. If you don’t fund a service adequately and rely on emotional blackmail to fill the holes , you end up with staff who want to leave and the mess we are currently in. You get clinical staff who choose to give speeches and preach to their clinical collegues instead of seeing patients ...that says it all doesn’t it.

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  • David Banner

    Wow.......just, ...wow
    GPs "choose" to keep 10 minute appts?!?!
    Well, thanks for nothing
    Let's go back to junior arithmetic.
    -10 minute appts mean 6 apps an hour.
    -15 minute appts mean 4 appts per hour
    -20 minute appts mean 3 appts per hour
    -ALL patients moan they can "never see my GP"
    -So 10 minute appts are the bare minimum we can offer to stop the system grinding to a halt. It is stressful, rushed and probably inadequate, but it's a compromise to keep the punters reasonably happy. We would all LOVE the Luxury of 15-20 minute appts, but we realise that the already dreadful waiting times would double.
    But this is blindingly obvious, isn't it? ISN'T IT?!?!

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  • ffs- general practice is falling apart - how dare he accuse GPs holding the whole sinking ship together of unethical behaviour-

    (acceptable) words fail me

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  • So you don't want me to time manage my consultation?

    No problem.When I am burnt out from allowing patients to didcuss 3-4 random problems in each appointment, I will expect my psychotherapist to listen to my woes for as long as it takes.

    Oh so the therapeutic hour is not 6 hours but 55 mins?

    Get a grip and please spare us your sermons

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  • To quote Dirty Harry 'Opinions are like a**holes...everyones got one'. he is only one voice amongst 40,000. His opinion carries no more weight than anyone elses. I think he's wrong. Within a practice different doctors might operate differently....When patients try to cram multiple issues into a single appointment mistakes are likely to happen as things get missed in the rush. I explain to patients this principle.. and that to keep things simple we focus on one or two things per appointment depending on how complex they are, and that for safety we don't try to cram, the way they don't try to cram extra people onto airlines, and that we would prefer multiple appointments instead, unless geographically they live far away..... its a concept patients understand... and to date patients seem happy with this. I also explain that we try to run to time to avoid people waiting for hours as a courtesy to other users, hence our one appointment one, or maybe two, problems.... and that multiple appointments can be booked ahead. When you run on time patients really don't seem to mind this.... Of course we get the odd bombshell that slows you down....longer appointments are often agreed in advance for those complicated patients....this is what works for me. Dr Varnums comments dont add anything to what we know and he doesnt offer any solutions... all he's saying is that different patients take different lengths of time, and that patients like to spend as long as they want talking about their bunions.... really Dr Varnum? Wow, you are so insightful... I am so glad you are in a position of responsibility, you are clearly such a visionary.... news flash.... we will never keep all the patients happy all the time... patients don't want to wait for hours..... they don't give a toss about other patients.....what they care about most is been seen on time (Most families are on a tight schedule) and that mistakes aren't made. You can't achieve this with a 'lets take as long as it takes' crpa or by squeeing multiple issues into every consultation, plus you don't mention the toll this takes on the doctor. You clearly have NO solutions and NO ideas.... I can see why you went into management.... and like HSL I can clearly see what you'll achieve.... zilch.

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  • Actually can anyone out there inform me of how any of the senior members of HSE/ RCGP /CQC have actually made any of our working days better and more productive, and improved the satisfaction with the job?
    (Actually I must accept the fact that their incompetence and my complete lack of faith in their 'Emperors new clothes' level of skill led to my decision to emigrate - so I should thank them for driving me away to somewhere more sensible...and better paid. Actually what way Does Dr Varnum run his clinics and does he run to time? Does he actually see any patients or did he work out like most of our other 'senior' mis-management teams that they were better off away from the coal face? Career politicians and noctors...

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  • Just Your Average Joe

    my clinic this morning only had 1 patient from 20 who had 1 problems - ironically booked after locum day before only dealt with the minor problem she attended for, as 1 problem per consultation for them!

    The rest ranged from 3 to 8 problems on lists!

    When kept waiting as over-running - several complained only to pull out their own lists or ask to also discuss their sons behavioural issues in depth as well etc.

    Patients expectations, and constant encouragement to complain is driving me up the wall, as I for some unknown reason still like to try and help patients.

    If only I was left alone to do that, without CQC or some other idiots telling patients to complain when they don't get what they want, or write to complain about how I rushed them when they tried to fit 4 problems in 1 consultation, then they felt insulted when I suggested that I couldn't do an insurance report as well as other patients were waiting when I had left her waiting 35 mins for her appointment.

    I love being a partner - but a small part of me is coming round to the DOH privatisation agenda - where we are all employed, but we will work to rule doing 1 patient 1 problem and 15 minute appointments, and see 12 in a session and then go home on time as we am not paid beyond the session time. Love to see how trusts won't have to follow the BMA salaried contract GMS practices have to follow (where PMS and APMS private companies don't have to! Level playing field my A£££)

    The 12 week wait for non-urgent appointments will be some politician or hospital trust managers problem, and CQC can beat them around the head instead.

    When they try and impose the 'You must see multiple problems because its unethical not to' - watch colleagues go off sick, and write in their own complaints and whistle blowing the bullying management.

    Watch the politicians meddle while Rome burns.

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  • I tend to agree with most of my irate colleagues.
    I think this is an excellent example of the extent which, those nominally running the health service, no longer even pretend to have any semblance of contact with reality.
    This is not an important article ,it is the important article of the year
    We should be grateful for a clear, and mercifully succinct,statement of intent from God
    This article needs to be shown to every medical student,then they should be given the rest of the week off, to think about it.
    There can be no more effective means of ending the health service,nor a more rapid one

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  • Agree with all of the above comments.
    I don’t think it is any coincidence that this comes off the back of JH’s speech at conference suggesting that GP’s can and should sort out their own problems - now the NHSE stooges are being wheeled out to reinforce the rhetoric that we aren’t helping ourselves.
    Meanwhile, back in the real world, patient expectations (and need?) are unmanageable.

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  • Vinci Ho

    For the record, it is essential to have the correct writings on the wall. I advise more colleagues speak out on this.

    Today's news is tomorrow's history. Repeatedly,we have seen history being twisted and betrayed by those trumiumphants in games of power . And their subordinates are never tired in uploading more lies and ideologies.
    What is the truth and reality? At least , it is not like what they described as the cause(s) of a failing system , diverting responsibilities to those working very hard in the frontline to ,at least ,keep the system sustaining.
    Those who talked about controversy are the persons of controversy. And they are the ones who have been hypnotising our conscience and as a result, we cannot look at the conscience of the world.
    Just looked the calendar this morning and realised that history has almost passed 100 years from the Red October Revolution of Russia in October 1917(November by western calendar). That was one of the hallmarks (alongside with the First World War) which set the beginning of an eventful 20th century with vigorous and ideological upheavals where so many innocent lives were disadvantaged and perished meaninglessly. Of course , there is a spilling over to this day in 21st century............

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  • Vinci Ho

    Correction
    .....triumphants....

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  • I have decided to limit my working day to 12 hours. Take off 2 hours for paperwork bloods etc leave 10 hours or 600 minutes . Peak work is 112 patient contacts or 5 minutes 21 seconds each. My feelings about the article are pre moderated so please just imagine

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  • Many GPs have contracts stating min appts/week. Given payment for this is minimal there are little opportunities to offer longer slots. Trying to make this a moral issue is particularly offensive.

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  • “NHS England’s head of general practice development”........great.
    I find these comments (as reported) insulting to those of us trying to do the best we can for increasing numbers of patients with increasingly complex medical problems. There has to be a compromise between availabilty and length of appointment. I do not consider it to be “bad medicine” to concentrate on the most important/urgent problem and continue the consultation (not “start from scratch”) at a later date and in a single/double/triple appointment when necessary. Routine 1/2 hour appoinmtents would waste so much time, much of it probably taken by patients complaining how long they had been waiting to be seen.

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  • Vinci Ho

    You see
    Never look back after labelling NHSE as Ministry of Plenty ( and the rest).
    Recently on this platform, we seem to have some sympathisers(including one of our respectable, young , female columnists) commenting that people actually working very hard in NSHE to improve NHS and general practice which I could understand.
    Problem is always coming from the leaders instead. Well ,this public statement from NHSE is phenomenal and perhaps should remind sympathisers the need of eyes wide open.
    An enemy is an enemy, remains an enemy.....

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  • It must be quite hypoxic from the rarefied atmosphere at the top of the greasy pole so far removed from the reality of daily working to appear to be as obtuse as this.

    Chapeau.

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  • I know where you are, Dr Varnam. You're down in the Ministry of Truth, altering the headlines. For I'm old enough to remember 10-minute appointments being IMPOSED on us, and it sticks firmly in my mind because at the time I worked in a practice which had a long and successful tradition of walk-in surgeries. It was only a choice in the sense of, "Do you want to be paid and be allowed to remain open, or don't you?"

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  • This is such an emotive issue simply because this is all about control... over our lives. Will workload be dictated by the "specialists" from ivory towers, or will we be able to have any say.
    Thanks RCGP, another stab in the back.
    Shamefully had to join in order to play the game and get training practice approval. Cancelling membership on Monday.
    No winners here. Will they ever learn to listen to the grassroots? Doubt it. Massively inflated sense of self-importance will always stand in the way.

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  • He's not the RCGP.

    You can choose an appointment system that gives more flexibility but to do this you need proper funding and a full complement of staff.

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  • He is not. But he follows HSL laments about loneliness and holistic care... do you not get a sense that you're just never going to be good enough? That customer might just need more of your time?
    And plenty of other reasons to cancel RCGP membership any day.

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  • Rubbish, GPs dont choose to have 10 minute appointments, they are forced to because of the way we are paid, and the unlimited demand.
    Our useless union needs to immediately change our contract. If we spend as long as required to see all our patients properly, do all the possibly required tests and then refer or treat as needed, but CHARGE NHSE for all the time involved, then the problem will become theirs.
    It is our contract which is wrong.

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  • As a single handed GP I have never seen the point of restricting patients to a single problem. Why should I? they will only book in to see me tomorrow.
    Single problem consultations are a game playing strategy that GPs use where there is a high probability that another GP will see the patient when they rebook. Although it goes against the grain I have to agree with Dr Varnam, it is a disrespectful practice.

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  • Has 'Dr' Varnham ever worked as a real Doctor?

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  • as usual NHSE and DOH blame GPs for the problems, and expect us to fix it ourselves. Offer huge long appointments, deal with every problem in everybody's life (boiler checks anyone?) and make sure we give unprecedented access to everybody under the sun all at the same time.

    how about for once the powers that be take responsibility and ownership and actually HELP rather than disparage us and we might get along a little better.

    can't wait to emigrate and finally take control of my working life.

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  • Sorry Gary
    I have to respectfully disagree, but appreciate your contrary point of view. I respect my patients time and hence aim to run on time.... I see the same patients back myself, I do not palm them onto other doctors....... we work step wise through the problems in small bites which keeps the confusion down, especially if there is a lot of information to impart, and means that I get too see the patient on a number of conditions, and interestingly how the symptoms vary episode to episode. It also often raises symptoms or other issues that the patient forgot at the first appointment. You say not listening to all the problems at one go is disrespectful.... funny, I was always told that keeping others waiting is disrespectful. I havent had a single complaint from the patients about multiple single appointments, and actually because I am seeing them more frequently, like any other skill, small amounts regularly and often is a better way to learn about a patient than intermittent long drawn out consultations where you are under pressure as the clock ticks by. Different doctors will use different styles that work for them, but it would be interesting to see the data from different consultation styles on patient outcomes and adverse incidents/ significant events. All the research from other industries shows that interruption or trying to do too much in to little time results in error.

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  • UNETICAL to make such comments. patient can spend one hour discussing their problems.
    patient who is seriously ill and you are arranging ambulance and they ask about a rash and repeat script and ask you to discuss the list they brought.
    I am happy to tell them get your priority right. when you come out of hospital we can sort others problems out.

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  • I am totally shocked, appalled and concerned by the comments of Dr Varnam. They simply make NO sense in front line jobbing general practice.
    If this is how the Chief of General Practice in NHSE views things, how else are others in his position looking down on NHS general practice?

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  • Hi Macdonalds
    There is a nice paper on what patients consult on https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4750725/
    Which has some interesting findings - namely a mean number of problems of 2.6 with a quarter of consultations being for 4 or more problems. This finding was not related to this specific study, as it quotes many other studies from across the globe where it has been found that GPs universally see multiple problems.
    It seems that the consultations where only one problem was raised were mostly for acute problems.
    Interesting.

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  • Wow, Varnam some achievement, even more hated than the utterly odious 'prof' Field, major respect my man, I am sure a wonderful career awaits (just avoid dark alleys)

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  • I think Dr Varnam may have misunderstood the problem.

    GPs are not complaining that they are obliged to offer exactly 10 minutes - no more, no less - to each patient.

    The are complaining because the AVERAGE consultation time needs to be more than 10 minutes.

    Flexible appointment lengths does nothing to address this (without unacceptable knock-on effects on access)

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  • I have recently worked in 3 practices where patients are offered consultations of any length IN MULTIPLES OF 10 MINUTES (except flu-jab day, when no other services are available, and they get about 3.3minutes each).
    Patients CHOOSE how long, based on how many conditions THEY want to discuss. If patient CHOOSES only ONE condition, that is NOT my fault, and does NOT make me 'unethical'.
    It makes the patient who tries to rush us into dealing with 4 conditions in insufficient time a bully, a risk to themselves, and a liability unfairly to us.
    This 'senior doctor' might do better to improve patient education than to make disreputable criticisms of hard-working, caring, ethical, professionals.
    Has anyone reported him to the GMC yet?

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  • Having worked in NHS management roles it is safe to say a telephone call is never less than 30 mins in the diary, most meetings are over an hour and will be followed by further meetings to follow up on the issues raised in the previous one. This does allow adequate time to deal with things and resolve them, we need to be realistic about how long things take. Clinical consultation length cant be the hours in the day divided by the open ended number of people wanting to speak to you if we expect the consultations to be effective. Lengthening the consultations may reduce the consultation rate and improve quality! We are not working in a factory on a production line with predictable work, trying to pretend we are is unhelpful.

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