Fifteen minutes with the patient, please
Authors: Graham Easton
Publication date: 06 Oct 2007
Do 10 minute appointments leave you feeling stressed and your patients feeling short-changed? Graham Easton wonders whether today's GPs can justify asking for 15 minute slots
How do you do it? How do you manage to squeeze everything into a 10 minute consultation? Sore throats, otitis media—sure, they're in and out faster than you can say “inappropriate prescribing,” but those express encounters seem few and far between these days. General practitioners (GPs) are dealing with more complex chronic illnesses; patients expect to be included more; there are endless health promotion boxes to tick for the new contract; and that's before you've even thought about “choose and book.”
At the moment, as a GP returner, I'm relishing the luxury of 15 minute appointments. I'm less stressed than I used to be as a 10 minute doc, and patients seem happier. I'd love it to stay this way. But what are the pros and cons of longer appointment times, and could I really justify that way of working to a future employer?
Perhaps the most authoritative and up to date information on GP consultation times comes from the Audit Commission report of 2004. It found that although planned consultation times of 10 minutes were common in England, the actual time doctors spent with patients was consistently longer. The median consultation length for GPs was 13.3 minutes, although there was wide variation between practices and primary care trusts, with a small number of practices stretching consultations to 20 minutes or more (see boxes). The report says that “the findings suggest that 10 minute slots do not give patients sufficient time with the doctor. In turn this may introduce delays for other patients and increase pressure in surgeries.”
Box 1: A 10 minute GP
Naureen Bhatti, general practitioner, east London
I do 10 minute slots. As an inner city practice we have very high consultation rates, which means that people have to book well in advance and consequently we have very high DNA [did not attend] rates. So I find that these empty slots, and the odd quick consultation like a pill check or sore throat, allow me to keep fairly near to time. If I did 15 minute slots these DNAs would waste a lot of time, and could increase the time patients have to wait to get an appointment. Also, the doctors in our practice who do longer consultations do longer surgeries; I think I would find it hard to do longer surgeries than the three hour ones I already do.
In the past 30 years, consultation times have roughly doubled. From six to seven minutes in the 1970s and 1980s, the average consultation expanded to 8.33 minutes in 1990, and was 9.36 minutes by 1997. So why do we seem to need so much longer nowadays? Freeman and colleagues have suggested some possible reasons. They feel that shorter consultations were more appropriate when the population was younger, when even a brief absence from work required a doctor's sick note, and when many simple remedies were only available on prescription. Recently, they say, several changes have meant GPs now have to squeeze more into each consultation.
Why do we need longer consultations?
Since the 1980s GPs have been taught consulting skills, and nowadays we're all supposed to pay close attention to the patient's agenda, beliefs, understanding, and agreement. Patients now expect this too. The General Medical Council, aware that communication problems underlie many complaints about doctors, has hammered home the importance of involving patients in consultations in its guidance to medical schools. All this should improve patient outcomes, but it often takes more time.
In 21st century medicine, with more elderly patients and a shift towards community care for chronic diseases such as coronary heart disease or diabetes, there's often more to do in the average consultation. Given that it can take several minutes for an elderly person to undress and dress again, that doesn't leave much time for examination, discussion, and actually managing the problems. Add to that the current “points mean prizes” system of the new General Medical Services contract, with the need to measure blood pressure and manage cardiovascular risk at every cough and spit, perhaps it's not surprising that some GPs are struggling to cram everything into 10 minutes or less.
Freeman and colleagues also point to the loss of continuity of care as a potential cause of late running surgeries and professional frustration. In the days when patients usually saw the same doctor at each visit, there was less duplication of stories, less risk of “naive” diagnoses, and less risk of conflicting advice. Knowing the doctor well, they suggest, allowed patients to get the care they needed in a shorter time.
Box 2: A 15 minute GP
Neil Crowley, general practitioner, west London
I have recently opted for a mixture of 15 minute and 10 minute slots. I like this arrangement because I can do more in each consultation and I don't have the stress of running late. I no longer finish surgeries feeling like a wet rag. I can put any gaps to good use by catching up on mail, dealing with results, or answering queries from staff. The downsides are that my surgeries are about 50% longer (I start earlier), and patients do tend to bring more problems with them.
Do longer consultations mean better care?
So is there any hard evidence to convince your practice that if you had 15 minute appointments you would provide better quality care and improve clinical outcomes? I'm afraid not. But there is plenty of evidence from observational studies that suggests that longer consultations are probably a good thing. A useful paper to quote would be the systematic review by Wilson and Childs, which looked at 10 studies assessing the relationship between consultation length, process, and outcomes in general practice.
The key findings were that doctors who consult more slowly tend to prescribe less and do more health promotion. They also recognise and handle psychological problems better, and achieve higher levels of enablement (which means, for example, that patients understand their problems better, and feel more able to cope) and some elements of satisfaction. One study found that faster doctors (average consultation less than seven minutes) recognised and dealt with fewer long term problems than slower doctors (average nine minutes or more).
There's no clear relationship between average consultation length and referral or investigation rates, but there is some evidence that longer consultations lead to fewer follow-up consultations and re-consultations. The authors of this review conclude that “consultation length may reflect other attributes of the doctor, but the evidence suggests that doctors with longer consultation times are more likely to incorporate important elements of care.”
Box 3: A 20 minute GP
David Kirby, general practitioner, east London
I now book 20 minute slots, so as not to keep people waiting. There are very few DNAs [did not attends]. If you need to make a referral, typing the letter, printing it for the patient to take, then doing the choose and book procedure takes about 10 minutes, so you need the 20. If there are gaps there is always plenty to do; phoning people to arrange their appointments, checking results, reading mail, and so on. This is experimental, but feels better than having a system where waiting is built in. Telephoning everyone who requests an appointment provides excellent access as people can be redirected, their investigations started, etc—and reduces demand so that there is not a long wait to see those who need to be seen. The main challenge is reception retraining while we pilot the new system.
For many years GPs and patients have complained about short consultation times, although a national survey in 1998 reported that 87% of patients were satisfied with the length of their most recent consultation. And in a questionnaire study of 243 patients, Jenkins and colleagues looked to see if there was a simple relation between the duration of the consultation and the number of things that patients wanted or received. Their research suggested that consultations in their study were of similar length whether patients wanted (or got) almost all of the things they asked about, or they wanted (or got) very few. They concluded that, from the patient's perspective, it seems that satisfactory consultations do not have to be long ones.
Fifteen minutes in practice
Of course, if you want to have 15 minutes instead of 10, you'll have to persuade your colleagues that they won't end up carrying most of the patient load. It'll probably mean starting earlier or finishing later, or both, to make sure you see as many patients as they do. In consultations that last only 5 minutes, you'll have to make the most of the extra time doing paperwork or dictating letters rather than twiddling your thumbs. Another option is to mix up some 10 minute slots with 15s, or even to stick with 10 minute slots but block out one every hour or so for catch-up time.
You may have to deal with a natural resistance to change, and be sensitive to the possible ramifications for patients and practice staff if you want to start or finish at a different time. You could be faced with an underlying feeling that somehow you aren't quite up to the job. Some doctors may see a “pack ‘em in and sell ‘em cheap” approach to general practice as a sort of badge of honour. Know what you want, be sure of your arguments, and prepare for any concerns and objections. It may not be possible in your practice, but if you don't ask, you'll never know.
The long and the short of it
No one seems to be suggesting that all long consultations are good ones, or that all short ones are ineffective. But as Heaney and colleagues argue, although an individual consultation doesn't have to be long, doctors who on the whole provide shorter consultations are likely to be providing less good care.
I'm sure that for many doctors, 10 minutes (or less) works just fine. But as I search for a salaried post, I will certainly be putting my case for the full 15. I suspect it won't go down too well with some practices. But who knows? With an evidence based argument and a flexible plan to ensure I'm still pulling my weight, they might even let me.
- Audit Commission. Transforming primary care: the role of PCTs in shaping and supporting general practice . London: Audit Commission, 2004.
- Royal College of General Practitioners. General practice in the UK: a basic overview . London: RCGP, 2005.
- Freeman GK, Horder J, Howie JGR, Hungin P, Hill AP, Shah NC Evolving general practice consultation in Britain: issues of length and context. BMJ 2002;324:880-2.
- Wilson A, Childs S. The relationship between consultation length, process and outcomes in general practice: a systematic review. Br J Gen Pract 2002;52:1012-20.
- Airey C, Erens B. The national survey of NHS patients: general practice: 1998 . London: DoH, 1999.
- Jenkins L, Britten N, Barber N, Bradley C, Stevenson F. Consultations do not have to be longer. BMJ 2002;325:388.
- Heaney D, Maxwell M, Howie J. Consultations should be longer. BMJ 2002;325:1241 [letter].
Graham Easton general practitioner and journalist Gp.email@example.com Ealing, London