What is a GP for? – The End of the Fixed Consultation Period?

General Practitioners throughout the UK provide ten-minute consultation slots by default. An increasing portion of patients are seen for chronic disease and increasingly routine consultation are carried out by practice nurses. Telephone consultations are routine in many practices. The idea is that the GP should see the more complex cases. In theory this skill substitution should liberate time allowing GPs to provide larger default slots to patients. However, this has not happened, likely because demand has increased. Given that a further expansion in the GP cadre is not going to happen any time soon, should this state of affairs be accepted? It seems to me that the status quo cannot be endured – at least not without concerted effort to change it.

Consider first the patient. Can the needs of the patient really be met in such a short consultation unless they are very straightforward? And if they are straightforward, then is a highly trained and expensive professional needed? Dealing with depression, managing refractory blood pressure in a diabetic patient who is also complaining of a sore foot, counselling a patient who is considering whether or not to have a third round of chemotherapy – these are not ten minute tasks, but they are the stuff of primary care.

If you cannot provide compassionate care in five minutes, then how can you make a diagnosis? You need to record the symptoms, ask the patient to undress, elicit signs, and think about what it all means. Twenty-two percent of cancers present as emergencies,[1] and many of these patients have been seen by GPs before presentation.[2]

And what about the provider? I am consumer-orientated by philosophy, but at some point the provider interest becomes the consumer interest. Imagine consulting all day long, five days a week, for 45 years, at six patients per hour! Contrast that with an “old-fashioned” doctor; deliver a baby, consult in rooms, set a fracture, few more consultations, home visits.

Back in the 1950s the great Michael Balint spotted the problem. He advocated fewer consultations in greater detail for non-psychotic mental illness.[3] [4] So the idea is not new, and the challenge now is to find a way to make best use of advanced medical skills. Lots of things that seemed inviolate have been changed by human agency – the closing of the great mental asylums to be replaced by community care, for example. So let’s model how the service could look based on real patient lists. Then let’s simulate different methods to change the pattern of care, invoking plentiful skill substitution and perhaps greater reliance on technology and self-help. Then we could pilot it and finally roll it out, seeking buy-in from professional bodies. In fact, reverse that – let the professional bodies make the running while researchers in organisations such as CLAHRCs provide scientific ballast.

— Richard Lilford, CLAHRC WM Director

Reference:

  1. National Cancer Intelligence Network. Routes to Diagnosis 2006-13. 2015.
  2. Kidney E, Berkman L, Macherianakis A, et al. Preliminary results of a feasibility study of the use of information technology for identification of suspected colorectal cancer in primary care: the CREDIBLE study. Br J Cancer. 2015; 112(s1): s70-6.
  3. Balint M. The Doctor, his Patient, and the Illness. Lancet. 1955; 265(6866): 683-8.
  4. Balint M. The Doctor, his Patient, and the Illness. 2nd Edinburgh: Churchill Livingstone, 2000.
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