27 February

The BMA’s 2016 report “Safe Working in General Practice”, said that determining the appropriate workload limit was complex and largely depended on the ‘unique circumstances of each practice’ taking account of patient mix and complexity, list size and workforce, among other factors.

However, the report did outline that the introduction of 15-minute appointments ‘would allow improved decision making and case management and should reduce the administrative burden outside clinic times’. The BMA proposed that 115 15-minute appointments should be considered the ‘quantified commissioned activity of an NHS GP’ bringing the number of face-to-face consultations to below 25 a day.

What happens in other countries?
A 2016 a questionnaire looked at the issue of sustainable general practice in 25 EU member states.

Practice list sizes varied from 600 per GP in Belgium to 3,500 per GP in Turkey, and consultation rates per GP varied from 10–50 a day. However, the researchers did note that some of the responses included telephone consultations whilst others only quantified face-to-face consultations. The majority of those surveyed advocated 15-minute GP consultations, however Scandinavian countries tended towards 20-25 minutes.

Doctors in nations with 25 consultations or less a day reported general practice manageable. In countries where GPs had more than 25 patient contacts a day (including phone or face-to-face consultations) doctors found general practice unsustainable. The researchers said that these countries also had problems with GP recruitment and retention.

How much are UK GPs currently working?
Clearly, most GPs in the UK are seeing considerably more than 25 patients each day. 20% of GPs in a recent poll responded that on an average day they delivered more than 40 patient consultations per day.

A study published in The Lancet in 2016 suggested that between 2007 and 2014 practices’ clinical workloads had increased by 16% and that GPs were effectively working the equivalent of an extra day a week by the end of that period.

The increase in workload was due to a rise in population, an increase in the number of times people consulted their GP and an increase in consultation lengths. Average consultation rates rose from 4.67 consultations per person per year in 2007/8 to 5.15 in 2013/14. There was also a 6.7% rise in the overall duration of GP consultations during the period and telephone consultation rates almost doubled from 0.27 to 0.45 per person per year.

A BMA survey in 2016, which covered almost a third of practices in England, found that only 2% of practices believed their workload was manageable, with 55% of respondents reporting the quality of service in their practice had deteriorated due to workload pressures.

Are there plans to introduce a working limit for GPs?
GPs responding to the survey were overwhelmingly in favour of a workload limit, with the majority thinking that this should be set at around 30 consultations a day.

Currently any decision about working limits would be up to practices or other employers to introduce. The GPC plans to release guidance to help practices set safe workload limits for GPs but there is currently no news on when this will be available and what it may contain.

Any change that is recommended seems unlikely to revolve around hours worked as this is seen as too restrictive by most GPs, with potential knock-on effects for out-of-hours services. It is more likely that the BMA guidance will focus more on the number of patient contacts in a day. But whether it will be prescriptive about recommending limits, or just offer advice on how practices can move towards longer appointments, with a view to limiting GP patient contacts, remains to be seen.

Is it just the number of appointments that is the problem?
It is not just patient contacts that are of concern to GPs with ever-increasing administrative tasks also highlighted as major stresses during the day. Whilst reducing the number of patients GPs see within a day might help with some of this admin, other aspects, such as repeat prescriptions, correspondence from secondary care and various other tasks would remain.

One GP said: ‘A cap would not be functional for GPs who work well at a fast pace, but a realistic balance needs to be sought to allow the time spent with patients to be valuable. GP workload is a significant concern, with paperwork seeming to be the main problem.’

‘Seeing patients is the relatively easy bit – It’s the additional clinical and non-clinical tasks which takes the time,’ said another. ‘Lab links, referral letters, associated tasks from secondary care, other results, prescriptions/EPS, reports, reception queries, faxes and home visits. As well as HR issues and finance.’

Would 15-minute consultations help?
The general consensus was that the 10-minute consultation is now too short for GPs to effectively deal with the increased complexity they see in patients. A huge number of GPs have voiced an opinion about extending appointments to 15-minutes to help them deal with patients more effectively.

‘Longer appointments would allow us to do more with each patient. In the long term I feel this would result in fewer attendances,’ one GP said.

‘Ten-minute consultations are unsustainable and not safe for patients in modern day clinical practice,’ another added. ‘Patients present with increasingly complex medical complaints and higher expectations for their care than ever before. The system needs to adapt to recognise this.’


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