Time is a precious resource, but at the moment GPs are not being paid for their time. They are being paid notionally for the work of caring for a list of patients. When I was in my mid-fifties, getting tired after years of 12-hour days as a partner, I reduced my commitment. Friends and neighbours were astonished that the residual 36 hours of work were considered ‘part-time’.
The BMA salaried GP contract defines a session as four hours and 10 minutes, with the expectation that within this, the ratio of clinical to admin work is in the region of three to one, excluding meetings.
This is not the reality for most partners, or indeed many salaried GPs. A session may be working as duty doctor, starting at 8am, dealing with an uncapped list of self-defined urgent problems, and going on to do visits, and coming back to do routine prescribing and correspondence and other admin. Or a session could be a pre-booked list of 15 people, all with complex issues including mental illness, that would require five hours – 20 minutes each – to be dealt with properly including admin. Or it could be a telephone triage session. Or a session just for visits. In other words, the work in a session is not defined.
Of course the work of a consultation is not defined either. Most GPs will recognise some tensions in teams between doctors with different consultation styles. A good team, however, will combine the strengths of all its practitioners, and we do now have consensus that GPs are being asked to squeeze too much work into not enough time.
If consultants in hospitals can have their workplan defined in terms of hours, why can’t GPs?
UK GPs consistently see more patients in a day, and for shorter times, than their counterparts in any European country. Our paymasters may see this as good, but high consultation rates for a GP are not necessarily linked to efficiency and good outcomes. The challenges now often relate to diagnostic uncertainty, engaging the unengaged and discovering barriers to care so that the influence of the inverse care law can be diminished and earlier diagnoses delivered, including for cancer. This inevitably takes clinicians’ time.
Many doctors are finding that the only way they can exert control over their working time is to accept roles with clearly defined hours, such as working as locums, or in out-of-hours, urgent care or telemedicine shifts. Creating practice-based GP work that is compatible with the hours most GPs can work sustainably would open the doors again to those doctors who want the delights of long-term care delivery.
The recent GMC Annual State of Medical Education and Practice Report found that roughly one in three GPs said insufficient time with a patient affected accuracy of a diagnosis at least weekly. We cannot do more in an hour than we can do in an hour.
Let’s be straightforward and measure our work in hours. If consultants in hospitals can have their workplan defined in terms of hours, why can’t GPs?
I am told that thinking of GP work in terms of hours not sessions would inevitably lead to a slide away from self-employment. But surely if we don’t have a feeling for the time taken to do a job we can’t price our labour? Self-employed lawyers aren’t hesitant to bill by the hour.
One line of thinking recently debated at the LMC England conference was to cap list sizes at 1,500 without a reduction in resources. The proposal was defeated by doctors afraid that they would lose the potential to earn more by doing more work, or by working with less expensive staff. Some also thought it was ‘pie in the sky’.
However, if the NHS 10-year plan funds general practice realistically this would include provision for a skill mix to enable GPs to see the complex people that they are trained to manage. This could allow the provision of the precious commodity of time so most GPs could settle for a workload giving job satisfaction and good pay, but seeing fewer patients for longer.
In an independent contractor system, those few doctors who choose to work differently and see more patients or have longer clinics could still do so if they wish, but we need enough capitation funding so that a GP could have a satisfactory income for a 40-hour week. A 40-hour week is surely a reasonable aspiration for a doctor who wishes to earn a competitive professional income after undertaking speciality training in general practice.
Our negotiators should be giving this clear message, and GPs need to be prepared to take action to save UK NHS general practice if our needs are not met.
Dr Pam Martin is a GP in south-east London