By Martin Marshall, on 6 May 2015
Professor Martin Marshall
Lead, Improvement Science London
‘Perfunctory work by perfunctory men’. That’s how an eminent physician once described general practice. ‘A ridiculous claim’ cried GPs, rising to the defence of their discipline, ‘specialists just don’t understand the nature of general practice. They don’t value our ability to make quick decisions based on a deep understanding of our patients and their context, our exceptional skill at managing risk and uncertainty, of using serial consultations to optimise the effectiveness of our diagnostic and therapeutic interventions’.
GPs went even further. Not only could they deal with the presenting problem in 10 minutes, but they could also deliver the other components of the consultation models that they learnt about in their training. Like managing on-going conditions, offering advice about prevention and health education, modifying help seeing behaviours. Was there no end to their efficiency?
But it’s time GPs stopped fooling themselves. In 2015 the 10 minute consultation is an anachronism. It is damaging to patients, damaging to clinicians and damaging to the reputation of general practice as a speciality that provides holistic and patient-centred care.
If we are honest with ourselves, perhaps the short consultation that characterises general practice in the UK and in some other European countries was never really viable; it is certainly becoming less and less so. The pressure is mounting as the complexity and intensity of the consultation increases. More patients to see, more problems presented, more information sources to search, more solutions to consider and balance, more templates and forms to complete, more ideas to discuss and negotiate. Something has to give and it shouldn’t be the quality or safety of clinical care that patients receive, or the humanity that underpins that care, or the mental health of clinicians struggling to maintain a sense of achievement that they have understood and sorted out a problem. It is the travesty of the too brief encounter that must give.
Even within the constraints of the established system and the strangely modest expectations of too many patients, clinicians, managers and policy makers, there is good research evidence that time matters. For most patient groups longer consultations are associated with greater patient satisfaction, a stronger focus on health promotion and disease prevention, increased willingness to address psychological problems and fewer prescriptions. Time is a key component of the effectiveness of the clinical encounter, rushed consultations are the enemy of high quality care.
Some years ago a GP professional leader complained to the then Secretary of State about the time constraints in general practice. ‘Show me the legislation that restricts the consultation length’ the politician retorted. Some of the solutions do lie in professional hands. Some practices already offer 15 minute appointments, actively support patients to self-care, utilise triage and make more effective use of nurses, pharmacists and healthcare assistants. All of these approaches help and should be used more intensively and in a more coordinated fashion. But the solution is also a political one; we need more GPs and an aligned set of values and incentives that encourage longer consultations.
Perfunctory work done by perfunctory people? It can’t go on.