Highlights
This month our research includes a study presenting a valid measure of complexity in consultations; a qualitative study on the experience of group consultations; and a systematic review that considers the underlying reasons why people miss their appointments. Editorials explore the meaning and challenges of general practice, the critical role for primary care in eliminating hepatitis C, plus we have reflections on racism and on how we can help manage patients after bariatric surgery.
In March 2021 we had a call for articles for BJGP Life on your hopes for general practice after COVID. Life & Times this month features some of the best, with an introduction from the Deputy Editor, Professor David Misselbrook. You will find plenty here to get you thinking about the future.
And don’t miss two informative Analysis articles closely linked to the consultation that both get to the essence of general practice, and a Clinical Practice article on post-vaccination lymphadenopathy.
Letting the consultation breathe
Almost everyone agrees about the importance of the consultation in general practice but it is being slowly strangled by workloads. We can wax lyrical about the romance of the consultation and the joy of patient-centred care but it all rings hollow after the 50th contact of the day. A recent BJGP study of 300 000 consultations pegged the average length at a lowly 10.9 minutes with less time being spent with people in deprived areas.1 There are fewer doctors in deprived communities and these areas are now fighting to pull out of this unsustainable doomloop of demand and resources. The same study showed patients with multimorbidity got more time — an average of a whole 54 seconds.
One could argue consultation length is a design choice in our system and we can’t blame a market-driven profit motive — ironically, paying for consultations may in fact be a driver for longer consultations to ensure perceived value for the patient-consumer. Consultation length is not mandated in the contract and that flexibility is welcome at practice level allowing elasticity to manage demand with consultation length tending to be a secondary function of the number of contacts the average GP faces in a day. It has been suggested, looking at other European systems, that 25 contacts per day is a reasonable threshold for a sustainable system.2
This is the gauntlet that thuds at our feet. Could we bring ourselves to make such a demand? It would disappoint patients and the expectations of the selfless doctor are inextricably linked with our identity. It makes it almost impossible for us to embrace the notion of saying: ‘Enough!’. It is another threat to the ‘medical self’.3 Perhaps this can be helped if we can establish the consequences and the academic community should step forward to consider: What are the true costs of longer appointments and limiting contacts and consultations? What are the potential benefits of capping GP workloads on recruitment and retention? How do we construct systems that limit workload yet prioritise the most vulnerable rather than the sharpest elbowed?
The new GP contract offers familiar promises of more troops to come. It is, as Lewis Carroll’s White Queen would say: ‘jam tomorrow’. We need to be more explicit — how about a campaign for 25 contacts per day by 2025?
Without a basic conceptualisation of what a sensible working day should entail then more GPs are just being poured into a leaky bucket. Increases in consultation length and, perhaps more importantly, limitations on daily contacts must be baked in. The consultation is precious but we need to let it breathe. And we need to know our limits.
- © British Journal of General Practice 2021
