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CAMHS won't see you now

Should GPs refuse to squeeze in ‘extras’ at the end of surgery?

Dr David Coleman and Dr Matthew Piccaver debate the issue

Dr Matthew Piccaver


Being any kind of healthcare professional is hard work and dealing with the misery and suffering of others soon takes its toll. Other specialties solve this problem by throwing up walls – we’ve probably all received the sort of letter that implies our patient is the wrong kind of ill.

General practice isn’t able to do this. While we relish the ‘jack of all trades’ role, our boundaries now seem limitless. We are expected to know everything about everything, do everything for everyone, and all day, all night, all week, all year, if the Government gets its way. We’re expected to plough through the list with a smile, and view each patient as if he or she was the first of the day.

I’m sure I’m not alone when I admit I regularly work 12 to 16 hours a day. We’re somehow exempt from the Working Time Directive, but not from the consequences of fatigue. Reception will add ‘just one more’, and our desire to be a ‘good doctor’ will frequently lead to that patient being seen. Like Mr Creosote in Monty Python’s Meaning of Life, at some point we are going to explode. A review of working time regulations by Durham University in 2012 found that long hours increased the risk of error, and of accidents on the drive home.1 It is not uncommon for me to not recall my journey home, especially after an out-of- hours shift, and working when tired the risk of clinical error is likely to increase.

Consultation rates are climbing. It is estimated that there are 340 million GP consultations per year in England alone.2 Examples in Pulse of two doctors caring for 10,000 patients, and calls for practice shutdowns at times of extreme stress only serve to emphasise the problem.3

Ever met a doctor that isn’t tired? No, me neither. We might think we’re doing our patients a service, but we aren’t. Just one more ‘wafer-thin’ patient to squeeze in. One more chance to make a mistake. I went into this career to help people, not to hurt them. Perhaps it’s time we stopped offering ‘extras’.

Dr Matthew Piccaver is a GP in Cambridge.


Dr David Coleman


When NHS England contacted CCGs last May about priorities from the Urgent and Emergency Care Review, it was no surprise to see access to general practice top the list: ‘No patient should have to attend A&E because they could not get a GP appointment.’ We all want to offer the best care. But an increasing number of obstacles are making it difficult.
Popular consensus suggests patient demand is the major issue. The same was true when Dr David Mechanic surveyed almost 1,000 GPs in 1966.4

Nearly 50 years on, discussions about demand still feature criticism of society’s inability to self-care. In 1976, Dr Julian Tudor Hart urged us to ‘accept that input is a variable … we can influence only slowly, and with great care to avoid damage to our work’.5 So if we can’t reduce demand for urgent appointments, should we set a limit and divert additional requests to another struggling service? I don’t believe this is the answer.

The Friday rush of late requests frustrates me as much as the next GP, but should we not find the time to assess them on the phone rather than turn them away? I typically invite up to one-third of these requests for an urgent appointment. I don’t see these patients ‘abusing the system’; I see frightened parents, concerned spouses, isolated elderly patients who can only come when their neighbour returns from work.

Of course, the ‘new deal’ looks likely to render this debate redundant. The health secretary’s speech in June certainly didn’t hint towards a Rooseveltian intervention to save primary care. For GPs, continuing to do more with less is a recipe for disillusionment and disaster and with insufficient workforce planning to support it, seven-day working will be the death knell for general practice as we know it.

And who will see the extras then?

Dr David Coleman is a GP in Conisbrough, South Yorkshire.


1 Morrow G, Burford B, Carter M et al. The Impact of the Working Time Regulations on Medical Education and Training: Literature Review. Durham University, 2012.

2 Pulse. Funding crisis to lead to 34 million fewer appointments per year

3 Pulse. Practice treating 10,000 patients with two GPs.

4 Mechanic D. General Practice in England and Wales: Results from a Survey of a National Sample of General Practitioners. Medical Care 1968; Vol. 6, No. 3:245-260

5 Hart JT. General-practice workload, needs, and resources in the National Health Service. J R Coll Gen Pract. 1976 Dec; 26(173):885-892

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Readers' comments (18)

  • Both GPs appear to be saying that they are overworked. This leads to stress, mistakes and ultimately disillusionment.

    The main problem is that most GPs and RCGP / GPC still think that by moaning the Government will eventually put more financial resources into primary care. This is not going to happen. Don't forget that secondary care is now poorly resourced as well.

    Collectively all Doctors should be coming together to design a new NHS with private health insurance packages. The Government can part fund this if they wish, but we must make sure that our service meets high standards so that patients receive an excellent level of care without the burn out of Doctors and Nurses. Work load must be manageable and financial remuneration reasonable.

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  • Yes. Simple

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  • Would it be possible to work out the amount of service that is funded and supply that ? All else is then paid for or we agree to do it for free.

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  • surely fee for service would solve this debate?

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  • We could use our income tax to fund the extras.

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  • It's a difficult issue. I have never turned away "extra" patients but I think we have to acknowledge that there is a limit for every GP beyond which mental and emotional exhaustion and depersonalisation starts to kick in. We can't keep doing more with less. However I don't want to aim my ire at individual patients but at the system which is over-burdening and failing to support GPs. For example I would advocate closing lists, if only temporarily if tha practice cannot cope with its current workload. This will send a clear message to NHSE and local CCG that all is not well and needs addressing.

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  • I think adding extras to a normal surgery is always going to be stressful - I still remember 5 minute appointments and 'extras'. We now run an acute service with a neighbouring practice where all the on the day demand is sent and this has reduced the stress levels for both the doctors doing normal surgeries and the two running the acute service.

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  • @10:22 FEE FOR SERVICE WILL NEVER WORK IN UK!! keep dreaming buddy.

    you have a fixed contract for endless contacts and that's what the government (your employer) wants; why would they pay you 20 quid when they can pay you 5quid, or 4 quid or 3 quid per consultation????

    there is no debate her UK doctors. your turkeys and you don't get to vote for xmas..... either be prepared to walk away or put up with the nonsense you keep coming on here to moan about........ and no the public doesn't have any sympathy either because they've been brainwashed.... for goodness sakes its 2015 and when the topic of General practice comes up all the papers are still twittering on about the "2004 GMS contract and how GP's got a 50 per cent pay increase for opting out of evenings and weekends"??

    you've got no support from the public because average joe makes 18k a year and even a GP on 50k looks like a big shot;

    get it into your heads.....demand is only set to increase and you will be given fewer and fewer resources.........sad but true

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  • Harry Longman

    Demand is predictable by practice, by day and almost by hour. By day, +/- 10% or less. But also predictable that more deprived populations consult much more. Range is 5% to 10% of list per week, with most around 6%. So with the right capacity, there would rarely be a problem. All sorted then. Next please.

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  • @6.51
    You are so right!

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