Debrief: Consultation length matters

The second BJGP Research Conference went out in style with a stirring keynote from Clare Gerada. She suggested, provocatively, that GPs need to stop being martyrs and decide what they are going to give up. We can’t do it all and we have to let go of something to sustain ourselves.

She offered one idea: we should abandon care of the very frail, very old patients. Let’s give it back to geriatricians and teams with the specialist skills. I’ll leave her to argue that one. She also mentioned, en passant, the problem of 10-minute consultations and I’ll take up the argument.

The 10-minute consultation is a glaring lose–lose that now represents a singular failure in the structure of UK general practice. They are a disservice to our patients and, importantly, to ourselves.

A systematic review of average GP consultation times in 2017 placed the UK firmly in global mid-table mediocrity with an average of less than 10 minutes.¹ Most European colleagues enjoy upwards of 15 minutes, with Sweden, Bulgaria, and the US revelling in 20 minutes for their average consultation time. The routine 10-minute consultation is indefensible and getting more unjustifiable with every passing month as complexity and multimorbidity bite. We could, in every practice in the country, simply choose longer consults. It’s in our own hands.

This is the martyrdom to which Clare Gerada referred. I’d suggest it is even a form of groupthink: the desire to avoid conflict among well-meaning GPs has resulted in the perpetuation of an irrational situation. Anxieties about patients waiting for appointments might be raised in opposition to change. So naysayers are shushed and GPs who can’t cope with 10-minute consultations feel instead the cheek-burning shame of personal failure. Undoubtedly some practices have moved to longer consultations. I fear, though this is anecdotal and based on my local experience, that it is the relatively affluent areas where longer consultations are the norm. Tudor Hart is never far away from any discussion in UK general practice.

Why have we allowed this to continue unchallenged? We should be rising up with righteous indignation, pitchforks in hand. One clue may be in our fundamental motivations. The entomologist EO Wilson studied the sociobiology of ants and, like them, we are also eusocial creatures. Humans can be selfish but we regularly commit ourselves to the needs of the larger community. He’d recognise us in his models. Michael Harris would label GPs and the practice model as a classic example of super-cooperators.² We work together, self-sacrificing, for families, for patients and communities, and for the NHS. Disruption, even one that results in long-term gains, is not welcome.

I’ve sat in several meetings recently where concern about portfolio careers has been raised by senior leaders. It goes like this: young GPs need to buckle down and learn the trade before they diversify. The word ‘lofty’ hangs unsaid but implied when it comes to those career ambitions. These leaders are beacons of excellence and inspiration. They almost all experienced a period of time after qualification where they consolidated their clinical skills. It has face validity but it feels like a manifestation of survivor bias — perhaps we should call it a ‘thriver’ bias. Suggesting that inexperienced colleagues, on a training programme that everyone recognises is too short, with inadequate consultation time, should swallow modern workload pressures is a one-eyed policy of convenience. Blaming them, even indirectly or unintentionally, is beyond the pale when something as basic as consultation length has been left unaddressed.

In those closing moments of the BJGP Research Conference, Norway was held up as one of the few countries where GPs are content. Yet they have a continuing recruitment crisis and the evocatively named Trønder rebellion in 2017 was sparked off as work flowed from secondary care into primary care without the funding and resources.³ Sound familiar?

Workload pressures in general practice are complex, and rebellion may be more than we can stomach, but if we give up anything in primary care it should be 10-minute consultations.

• © British Journal of General Practice 2019