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What's stopping GPs looking their patients in the eye?

GPs admit box-ticking makes them unable to give patients eye contact or proper attention, a Pulse survey reveals

By Nigel Praities

GPs admit box-ticking makes them unable to give patients eye contact or proper attention, a Pulse survey reveals

The camera rolls as a GP videos a real-life consultation by one of his practice's registrar as part of her training.

These are his words: ‘I watched as she touch-typed her way through the whole thing. In the entire 10 minutes, she didn't look at the patient once.

‘That's an extreme example, but it does illustrate how bad things can get.'

Sadly, the trainer could have been talking about a growing number of GPs who also find themselves unable look their patients in the eye - because they are too buried in computer work or red tape.

It wasn't trainees but experienced GPs who told Pulse this week that Government targets and primary care organisations were ‘actively obstructive' to their practice's ability to provide high-quality patient care.

Paperwork and data entry now takes up around a third of each consultation with a patient, our survey of 600 GPs reveals.

And in almost 40% of cases, GPs say they are not able to make enough eye contact with patients during the consultation as a result.

GPs complain they are being squeezed from both sides, barely able to engage with patients because of increasingly complex consultations and administrative demands. Three-quarters say the type of consultations they conduct has greatly increased in complexity and intensity in the past five years.

Many GPs have increased the length of their consultations in an effort to cope, but most feel appointment times are far short of what is required for the complex work they are now doing, as more complex cases are shifted from secondary care.

GPs are incentivised through the QOF to hold appointments for over 10 minutes, and our survey finds just over half have increased their appointment times in recent years, with the average consultation now lasting 11 minutes.

But it's nowhere near enough. When asked how long appointments need to be, GPs said 14 minutes on average, with 35% in line with RCGP chair Professor Steve Field's belief that GPs should now be offering appointments of at least 15 minutes.

There are significant barriers to reaching that hallowed land, with the burden of bureaucracy eating away at the time available for patients.

As expected, that burden is heaviest on partners – who estimate they spend 40% for of their working week on paperwork. But salaried GPs too are caught up in red tape, estimating they spend 35% of their week on paperwork.

Inevitably, this is having a direct effect on amount of time GPs are able to spend on addressing individual patient needs, with GPs estimating that only just over half of the consultation is spent directly addressing the patient's agenda.

GPs complain a major factor is the stream of unnecessary communications from PCTs, requesting information and paperwork for the QOF and enhanced services.

Dr Neel Basudev, a GP in Stockwell, south London, says: ‘I would estimate less than half my time is spent on face-to-face consultation with patients. Most new PCT ideas seem ill-conceived and unnecessary – and the deadlines given are often unworkable.'

Half of GPs in our survey say their local primary care organisation does not actively support their practice in offering high-quality patient care, and 27% say the PCI is ‘actively obstructive' in this aim.

One GP respondent to our survey – who did not wish to be named – remarked he would have to work 70 hours a week to fulfil what his PCT expected of him.

‘Most of the paperwork is box-ticking to persuade the PCT that we are not criminals delinquents, liars or cheats,' he says.

GPs face increasing scrutiny from PCTs on their prescribing costs and the referrals they make, with our survey revealing 37% of GPs receive at least one or two emails from their PCT a day, and 42% even more than this.

Clinical guidance is also increasing, with the number of NICE guidelines released per year more than doubling from 2006 to 2008, and further bulletins and advice issued by a range of bodies, including SIGN, the National Prescribing Centre, UK Medicines Information and professional bodies.

The conflicting advice issued by Government agencies, NHS managers and politicians in the first flush of the swine flu pandemic earlier this year is often cited as a case in point.

Dr Mary Sloper, a locum GP who works at a practice in Pinner, Middlesex, says the ‘multitude of agencies' communicating with GPs is a major problem.

‘During the height of the first wave of swine flu in the UK we received swathes of electronic conflicting advice.

‘At one time we were told by a professional body not to comply with the swine flu bosses' insistence regarding vouchers for Tamiflu prescriptions. What chaos!'

Medico-legal concerns are also a problem, with GPs increasingly recording large amounts of information to defend themselves from any future legal action.

With freezes in income, revalidation, registration with the Care Quality Commission and future changes to the QOF to come, GP time is going to come under further strain.

In this climate, should GPs simply roll over and become slaves to their PCOs? Dr Grant Ingrams, chair of GPC West Midlands, says GPs may feel under siege but the only solution for practices is to start saying ‘no'.

‘PCTs believe they are running our practice and should be micromanaging everything we do. But they should butt out.

‘Just because the PCT has asked you to do something does not mean you have to do it. When you get a letter saying "You must do this", the first thing you should say is "Can you just point to the place in my contract where it says I have to?"' he says.

Dr Ingrams also advises practices to ‘constantly review' their procedures to see how the workload of GPs could be shared among the practice team.

‘Sit down with your colleagues and decide the best way to do it. Discuss this with the other staff, even the receptionists - do they need to be doing all the things they are doing, and could they be doing other things instead?'

Professor Mike Pringle, professor of primary care at the University of Nottingham, says paperwork is an integral part of general practice and the key is to manage it effectively.

‘Part of what people are feeling is the pain of being expected to keep good clinical records, but I have always thought that was the duty of GPs.'

Professor Pringle recommends GPs turn their computer screens towards patients to involve them in the recording of data, and to spread their work among other members of the practice team.

‘The big issue is the clinical demands being made upon us. It is arguable that this makes the job more satisfying and more rewarding, but it does mean the ratio of GPs to patients may not be sustainable unless we get a lot of extra support from non-medical professionals – highly skilled nurses and others.'

This is a view others share. Professor Field says the only way for practices to achieve longer appointment times is to work in larger teams or in federated practices, in order to be able to shift some of their workload elsewhere.

‘GPs will have to have longer consultations. We will be looking at 15 to 20 minute consultations and a lot of the volume of minor illnesses will be done by physician's assistants working in a rules-based way and nurses.

‘GPs will need to be brave and work in larger, federated healthcare teams to take on this challenge.'

Professor Field reckons nurses and GPs need better training and says Pulse's survey results would ‘help enormously' in concentrating the Department of Health's mind on workforce planning in primary care.

‘I am worried that the DH is not engaging effectively with workforce planning in primary care. A radical rethink of the primary care workforce is needed,' he says.

Almost 40% of GPs say paperwork and data entry mean they cannot make enough eye contact with patients Almost 40% of GPs say paperwork and data entry mean they cannot make enough eye contact with patients Guest editor

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