Authors: Kathy Oxtoby
Publication date: 26 5月 2010
From stress and pay to patient care, consultation times are controversial ground. Kathy Oxtoby looks at the arguments
“Open the windows and remove all the chairs.” That was the advice some 20 years ago to one trainee general practitioner from his trainer to speed up Saturday patient consultations.
Although such draconian measures were not the norm, some GPs say consultations used to be shorter and sharper. “In the old style of consultation, people queued up and you rattled through them, giving patients about five minutes at a time,” recalls Michael Fitzpatrick, a GP in London.
Now, most GPs offer 10 minutes for routine appointments, which is recognised in the GP contract as an indicator of quality. But 10 minutes may not be enough, given that GPs are increasingly dealing with chronic and complex conditions, a growing elderly population, health promotion targets, and the need to bring care closer to home.
Calls for longer appointments
In response to the increased workload faced by GPs, the Royal College of General Practitioners (RCGP) has called for longer appointment times with patients in its UK-wide pre-election manifesto, Leading the way: high quality care for all through general practice.
Steve Field, chairman of the RCGP, says: “It has become blindingly obvious that the old type of consultation doesn’t give GPs enough time. Not only the diagnosis but also the treatment of patients has become more complex, and GPs need longer to share their views with them.”
Although he stresses that the length of a consultation should be down to individual GPs, Professor Field believes “15 minutes, or even longer in some cases, may be appropriate.”
The BMA has made a similar pledge for longer consultation times in its pre-election manifesto. Beth McCarron-Nash, General Practitioners Committee lead on training and workforce, says workload pressures are forcing many GPs to over-run their surgeries. “Anecdotally, GP colleagues tell me that they have never felt so stressed and have never been so overworked,” she says.
Dr McCarron-Nash believes that lengthening appointments to 15 minutes where necessary would ease doctors’ stress and be better for patient care, allowing GPs to spend more time on health promotion, which would be “extremely cost effective for the NHS in the long run.”
To deliver longer consultations would require more GPs, and funding for this could come from “rewarding those practices that offer longer appointments,” Dr McCarron-Nash suggests.
Other ways to ensure that patients have the consultation that fits their clinical need would be to offer them a variety of ways to access their doctor, including telephone and email consultations. Allowing nurse colleagues to help manage patient demand would also make longer consultations possible, says Dr McCarron-Nash.
A longer training period for GPs would help them manage more challenging cases in the community as part of the government’s drive to bring care closer to home. The RCGP wants to extend training to five years, and this initiative is supported by the BMA.
Most GPs agree that it would be helpful to be able to spend more time with patients if necessary. “Patients are more likely to be satisfied with their consultation and less likely to need a prescription or to present the following month,” says Mike Dixon, chair of the NHS Alliance. “Longer consultations also reduce the stress of GPs having to ‘clock watch’ and the feeling that patients haven’t had the chance to get their point across.”
But although he welcomes longer consultations, Dr Dixon questions whether it is realistic to ask for more GPs at a time when David Nicholson, the NHS chief executive, is reported to want trusts to deliver up to £20bn in efficiency savings by 2013/14. To justify longer appointments, GPs would need to prove this extra time can cut costs, he believes.
“If we spend more time with patients we will need to show a reduction in, say, referrals or prescribing,” he says.
Longer consultations would require a “dramatic rise” in the number of GPs, says Martin Turner, a GP in west London. But using other health professionals, such as nurses, is not a cure all to fill the skills gap, he believes. “Nurse practitioners don’t have the depth of medical knowledge necessary to arrive at a reasoned judgment,” he says.
Even if it was possible to boost GP numbers, Keith Hopcroft, a GP in Essex, questions where these doctors would come from and where they would go. “Where do you find more GPs and where do you put them? There’s only so much space and our health centre is full to capacity,” he says.
A real need?
Dr Hopcroft asks whether longer consultations would necessarily be of value to patients. “Research shows that people only remember on average three things from any one consultation—‘hello, it’s a virus, goodbye.’ So that’s an argument for not making any one consultation too long, for having follow-up consultations, and for providing patients with written information,” he says.
And no matter how long the consultation time, it is likely GPs will always fill that space—and more, Dr Hopcroft says. “When you get accustomed to a longer consultation you never go back. The work expands to fill the space available.”
That space is being filled with the need to satisfy government demands, says Dr Turner. “Government health policies are creating a whole raft of expectations from patients. Ten minutes would be sufficient if we didn’t have to deal with the whole political agenda that has hijacked the consultation, forcing us to collect data, fill in unnecessary forms, and deal with layers of bureaucracy, just to feed the requirements of politicians.”
Dr Fitzpatrick believes this “nanny state” has resulted in GPs being “swamped by fears from ‘worried well’ patients.” “The biggest heart sink is when a healthy young person says they need a complete check-up. These consultations are stopping us from seeing patients who are really ill.”
The medicalising of public health issues is also taking up too much consultation time, some GPs feel. Phil Peverley, a GP in Sunderland, says: “People are being made to think they can’t give up smoking or lose weight without seeing their doctor. I don’t think we’re effective at dealing with these issues and it’s a waste of our time.”
While welcoming the fact that GPs can now do more to diagnose more complex diseases, Dr Fitzpatrick believes that GPs should go “back to basics” so that they can spend more time “focusing on those who are really ill.”
Dr Peverley would like to see a return to a more direct approach to consultations. “Being a lifestyle guru is not why I became a GP. There’s too much hand-holding. People in my area tend to want GPs to be more paternalistic and to tell them what the best treatment is.”
However, a return to a tougher approach to consultations might not be best for patient care, believes Jonathan Silverman, associate clinical dean and director of communication studies at the University of Cambridge School of Clinical Medicine.
“There’s not a lot of evidence that telling people what to do makes them do it. The negotiated style of consultation is more likely to pay dividends.”
This style of consultation can actually speed up the process he believes. “Using good listening skills early on in the consultation can often short circuit its length.”
Flexible appointment times
When it comes to the style and length of consultation, GPs agree that there is no “one size that fits all.” But giving patients the option to choose what suits them best might be one solution to helping them get the most from their doctor’s time.
Patients naturally gravitate to the GPs that are the best fit with their preferred style of consultation, Dr Hopcroft suggests. “One of the joys of working in a group practice is patients can often choose the consultation style that suits them, from ‘hand holding’ to being more direct. And often the same doctor can adapt their style according to what the patient wants.”
Whether its 10 or 15 minutes, Dr Peverley believes “there’s never going to be enough consultation time.” But he is considering letting patients choose the length of consultation most suited to their needs, by offering five, 10, and 15 minute appointments and letting patients decide how long their appointment should be.
“This would balance out the time taken to see those who turn up for a sick note and those who need a longer consultation. After all, most people are sensible, they know what they want and how long they need to spend with their doctor.”
Consultants on consultation times
Lengthening GP consultations to 15 minutes could ease pressures on secondary care, says Paul Flynn, deputy chairman of the BMA Central Consultants and Specialists Committee.
“If GPs had more time to spend with their patients, then they might be able to sort out their problems without having to refer them on to hospital,” says Dr Flynn.
Longer consultant appointments also benefit patients and the NHS as a whole, he believes. “If you have time to carry out a consultation, patients feel they are making progress from the start, rather than that their concerns are being ignored.
“Longer consultations also mean it’s less likely you’ll need to ask people to come back for follow-up visits. So spending more time with patients wouldn’t actually lead to a greater burden on the NHS.”
However, the BMA Central Consultants and Specialists Committee has no plans to call for longer consultations “across the board,” he says. Appointments vary widely in length depending on the specialty and the clinician’s style of consultation, so any concerns are best dealt with on an individual basis through the job planning process, says Dr Flynn.
Consultants are spending more time with their patients than 20 years ago, he observes, partly because in the past doctors had a more “paternalistic attitude towards patients. We recognise patients need to be ‘active partners’ in the consultation process, which takes up more time,” he says.
But Sarah Burnett, a consultant radiologist working in private practice in London, says in her experience of NHS hospital consultations, pressure to see more patients means that appointments are becoming shorter and consequently less detailed.
“Often in radiology we’re trying to cram more patients through to cut waiting lists. Sometimes patients referred to me haven’t even been asked the basic questions you’d expect in an initial consultation.
“In the old days we were probably more thorough in terms of history taking and examinations, but now consultants don’t have the time.”
Dr Burnett would like to see appointments increase from seven to 20 minutes but stresses, “to have longer consultations we’d need an awful lot more doctors.”
Peter McDonald, a consultant gastrointestinal surgeon in London, would also welcome longer consultations and agrees that 20 minutes is the “ideal time.” However, currently, Mr McDonald says, “clinics are often rushed, too full, and patients have to wait.”
When it comes to giving the best care for patients, Dr Burnett believes it’s about the quality of communication that counts, not the quantity of time spent in a consultation. “If you’re a good communicator, you can give patients a two minute consultation of fantastic quality and achieve the same outcome as a 20 minute consultation that’s rubbish.”
Competing interests: None declared.
Kathy Oxtoby freelance editor