Dr Beth McCarron-Nash says moving towards 15 minute appointments – or more flexible times – is a logical way to improve patient care. But Dr John Chapman insists the suggestion is bot5h impractical and unecessary
GPs are facing many pressures and challenges within an extremely difficult financial climate. UK general practice is recognised throughout the world as one of the most cost-effective, high-quality deliverers of care and it is highly valued by patients. But studies report that patients want more information and involvement in their care and evidence shows this takes more time. Research from the Picker Institute shows that, overall, UK general practice still has relatively low levels of patient centeredness. It is also notable that the length of consultations in the UK remains among the shortest in Western Europe.
Expectations of patients, society, politicians, the wider health community and GPs themselves are changing. Since the introduction of QOF we have seen the standard of care improve, but there is ever increasing pressure for GPs to deliver more and more within the same consultation times. With demand and patient expectation both rising, many GPs report feeling stressed and under pressure trying to juggle their many roles and also provide excellent care. Patients describe feeling frustrated when surgeries run late and one of the main complaints received by the Patients Association is that patients feel their doctor now spends more time entering data into the computer rather than looking at and listening to them.
Prior to the new contract 10 minute appointments were often considered a luxury whilst today they are a marker of quality practice. Moving to 15 minutes, or a mix of flexible appointment times to suit the patient's clinical need, would be a logical step to improve quality of care for the patient and quality of working- life for GPs. Longer appointments are associated with better health outcomes and ten minutes is often not enough to address more than one problem. Co-morbidity is increasingly the rule rather than the exception as people live longer. Studies show that assessment focusing on single diseases may distort the provision of good health care by not addressing the potential interactions of different conditions, and therefore not optimally managing chronic illness. It also leads to offering more appointments in the long-term as co-existing morbidities are not sorted out at the initial consultation so costing the NHS more in the long-run.
An aging population and changing lifestyles, with associated problems such as obesity, alcohol dependency and cancer, are having a major impact on demand. As triage and new ways of working, as well as new roles such as physician assistants and nurse practitioners, develop to cope with this increase in demand, the caseload of GPs will become increasingly complex. Skill mixing will be essential as this will allow GPs to spend longer with patients who have more complicated health needs and this will be one way to increase consultation length where needed. Real change however will not happen without a substantial increase in the number of GPs to deliver this care. The BMA will continue to lobby Government for the resources to provide the funding and extra GPs this will require; otherwise we will end up with an increasingly harassed workforce that is performing sub-optimally because they don't have enough time to spend with their patients and an NHS which is not making the most of its highly trained GPs. The pressure felt by the profession is summed up by a poster I saw in one practice: "one appointment, one problem. Remember others are waiting". It is only through funding for more GPs, appropriate skill mix, organisation and an increased workforce that we can increase consultation times and put an end to notices like this and give our patients the care they rightly deserve.
Dr Beth McCarron-Nash GPC Negotiator, and GP in St Columb Major, Cornwall
I have no doubt at all that some- many - GP appointments need 15minutes (my personal record is an hour and a half for one spectacularly challenging problem). But to suggest that all appointments should be scheduled to last 15 minutes or longer is unreasonable and impracticable.
It's unreasonable because it is unnecessary and it's impractical because there aren't enough hours in the day to do it; I'd need 50% more consulting time and I don't have a time machine.
As a student and then a hospital doctor I clerked many hundred acute medical admissions and on a busy take had to deal with three or four patients an hour but I got quicker as I learnt more. If an acute medical admission can be done in 20 minutes a primary care assessment of a patient whose notes are available and for whom there is continuity of care should need considerably less time. So it should be unnecessary.
On entering family practice and becoming a trainee 10 minutes appointments were standard but as a partner with open access surgeries I settled to a comfortable consulting rate of 8 to the hour- 7.5 minutes per patient.
We have gone to appointments of 10 minutes as pressured to by the Government and that leaves plenty of time to see the patient, and for the QOF. Our consultation rate per patient per year is normal- so I'm not bringing people back with unfinished problems.
One of the standard departure comments patients make is ‘thanks for your time doc' and I'm pretty sure that isn't sarcasm- they keep coming back to see me for new problems. In that average of 10 minutes some consultations take three minutes and some 20 but I usually finish on time.
I see up to 40 patients a day and that takes 6 hrs and 40 minutes- usually less which I'm happy about because more than six hours consultation in a day is exhausting and non-GPs forget about the correspondence, the results, the phone calls, the repeat prescriptions and practice admin – not to mention And the meetings with (and hassles from) the PCT.
To go to 15-minute appointments I'd need to spend 10 hours consulting to see those 40 patients; that's impractical.
I've heard it suggested that my current practice represents an inefficient use of time. Yes- a nurse practitioner could see the simple, quick patients and leave my precious time for more in-depth management of patients with more complex problems. But this misses the point and the beauty of primary care - which is that most of the patients I see are known to me and if I've seen them with a "trivial" problem it is much easier to spot a serious one. I have seen small children often enough to have gained their trust and people who have decided I'm a reasonable sort open up and tell me what their real agendas are. Usually. Eventually.
Of course this aspect of practice has been overlooked by the protagonists of the consumerist approach to primary care.
If general practice starts to become more like hospital outpatient care, with less continuity and increased numbers of staff reinventing the doctor patient relationship at each encounter; with ancillary staff taking on what may have been triaged as trivial consultations and GPs seeing 24 patients in 6 hours of consultation a day then care may suffer and patient satisfaction will decrease. There will need to be a lot more primary care workers and the average cost will increase. I don't think care will improve.
But I'm a dinosaur. Let the GP and the patient decide how long each consultation needs and let's have no more interference with consultation durations.
Dr John Chapman is a GP in Sutton Coldfield, West Midlands.Should GP appointments be at least fifteen minutes? Yes No