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How GPs went on strike to enforce a safe limit on patient contacts

Every GP in the UK knows the workload pressure they face. There have been suggestions that there should be a cap on patient contacts in an attempt to prevent GP burnout and protect patient safety. But these have never materialised.

At last year’s BMA Annual Representative Meeting, GP leaders voted in favour of a motion calling for the introduction of a maximum workload cap for GPs.

However, some GPs argued that it would be difficult practically-speaking. At the time, Tower Hamlets LMC chair Dr Jackie Applebee said: ‘General practice is in meltdown, we can’t go on as we are, but what would a sensible cap be and how would we enforce it?’

In October last year, a petition was started calling for a cap on working hours following the suicide of a GP the month prior. Yet little has happened since.

Pulse’s workload survey will report early next month on the average day of a GP, and the hours worked.

But in Catalonia, they have been through the process of calculating workload – and have taken drastic action, by taking to the streets to put a limit on the number of patient consultations.

In November last year, 5,700 Catalan doctors working in the public health sector went on a week-long strike, including gynaecologists, paediatricians and general practitioners.

63% of primary care teams have not not yet hired any family doctors

Catalan doctors’ union

They began by demanding the Catalan Government implement a cap to the number of daily patient consultations, and to improve working conditions.

According to the doctors’ union of Catalonia, Metges De Catalunya (MC), it has been a decade-long dispute with the authorities – starting when the Government’s fired more than 900 doctors across the board and cut doctors’ wages by 30% following the 2008 financial crisis.

During last year’s strike, protestors blocked Gran Via de les Corts Catalanes, one of Barcelona’s main roads, and occupied the Catalonia Health Institute (ICS) headquarters. GPs are located in CAPs (Centre d’Atenció Primària) and are managed by ICS

Both the doctors’ union and the ICS guaranteed that emergency services will be fully available during the strike, as well as other departments providing minimum services.

After four days of striking, the two bodies came to an agreement, including on the biggest demand from the union – the cap on the number of patient appointments.

The agreement was to hire 300 more primary care professionals, reduce workload to a cap of 25-28 patient consultations per day – depending on the demographic, socioeconomic and geographical characteristics of each province – and secure a minimum time of 12 minutes per appointment.

Yet enforcing such a cap has proved difficult to implement. MC told Pulse that according to an internal survey conducted by the union in February, in which over 1,000 Catalan doctors participated, the majority of practices (65%) weren’t assigning 12 mins per appointment, and ‘80% of those doctors are still conducting more than 30 daily appointments, of which 28% surpasses 35 consultations per day.’

gp spanish protest suo alamy r4 yeb1 580x387px

gp spanish protest suo alamy r4 yeb1 580x387px

A spokesperson for MC said that in some areas, ‘doctors still have an average of more than 40 appointments per day’. MC also said: ‘Three months after signing the agreement, the survey also shows that 63% of primary care teams (EAP) have not included any of the 309 family medical practitioners – an updated figure according to the latest workload study – that the ICS should have hired to reduce the pressure and, in the case of the centres that have done so, 60% have hired only one more professional.’

El País reported earlier last month that the ICS needed more time to reverse the cuts.

Due to the difficulty of finding more professionals, the Government remunerated existing GPs to take on more work. They said: ‘So far, more than 600 doctors have accepted this method that entailed between 10 -30% more work. This signifies between 2-5 hours more to the weekly schedule to see patients.’

An ICS spokesperson also said the 12 minutes per appointment was a target and ‘in the last month, the average in ICS health centres was 26 daily appointments per doctor.’

As a result, the union has demanded the Government take immediate action or they will arrange another protest.

The union has said they hope the agreement will be implemented over the long-term, and hopes will ‘modify the work conditions for doctors and strengthen these measures to reduce work pressure.’

Sustainable GP workload seems to be a long shot around Europe, but according to Dr Mary McCarthy, Vice President of the European Union of General Practitioners (UEMO), a sustainable workload comes from enforcing an appropriate number of GPs for the patient list size.

In Italy for example, if you go over 1000 patients, you have to employ another GP

Dr Mary McCarthy

Based on a survey UEMO did some years ago, she says: ‘One of the questions was “do you think general practice is reasonable, the workload is reasonable and sustainable?”. Of those, 60% said that it wasn’t, 12/14% thought it might be if some adjustments were made, but about 24% thought the workload in their country was sustainable and reasonable. I looked a bit closer at those countries and they had certain things in common.

‘They tended to have lists of around 1,000 patients [per GP]. As you know, our list size is about 2,000 patients. In a lot of European countries, GPs are limited to 1,000 patient listing. In Italy for example, if you go over 1000 patients, you have to employ another GP.’

Compared with other professions, Dr McCarthy said that the level of workload for GPs is unprecedented.

She says: ‘I’ve got data on solicitors who think 5-6 clients a day is enough; on people dealing with international contracts, where they think a heavy contract is something that’s complicated that would take about 20 phone calls a day and that would be the highest number they could visualise. I’ve looked at outpatient clinics at hospitals which are limited to 8-10 patients per session, which would make 20 patients in a working day.

‘When I tried to look at other ways to quantify this, the nearest I could get was some American journals where they had done surveys that had shown if you had more than 20 clients in a day, the quality of care went down. The only trouble with this is the data was published in journals of veterinary medicine. It still applies to humans though.’

It seems that unless commissioners outline clear policies to reduce workload, patient safety and the pressure on GPs’ wellbeing, it won’t be a surprise if the movement to limit patient contacts will increase in the UK too.