Great expectations

Carol Sinnott is a GP and THIS Institute’s Senior Clinical Research Associate. Her work involves looking at the provision of complex care in general practice, and the development of interventions to improve the quality of care.

Carol contributed to a paper authored by Stephen H Bradley and others called “Great expectations? GPs’ estimations of time required to deliver BMJ’s ‘ten-minute consultations’” which looks at the high expectations placed on GPs with their ‘ten-minute consultation’ series. The series aims to give busy GPs an outline of what they need to cover in ten minutes with a patient who consults them about a specific condition.

The study revealed that in many of articles in the ten-minute consultation series, the allocated ten-minute appointment time wasn’t long enough to properly cover everything that the writers suggested was essential.

We asked Carol to tell us more.

A standard GP appointment in the UK lasts up to 10 minutes. Why do you think there’s a difference between the BMJ series’ suggestions of what a GP can fit into a ten-minute appointment, and what the study found could actually be covered?

The series addresses what GPs can reasonably cover in a time-limited consultation and aims to offer pragmatic advice. But even with that focus, the suggested tasks exceed the time that is routinely available for consultations, perhaps because some of the basic activities of the consultation have not been acknowledged. For example, we have found in our research at THIS that even the three GP tasks of reading a patient’s notes, calling them into the consultation room and then making notes in their chart after they leave take around two and a half minutes – or about 25% of the time available for the consultation!

The individual authors of the 10-minute consultation articles would have been mindful not to leave important information or recommendations out and may have been exhaustive in this regard. Because of this, while the articles offer recommendations for very high-quality care, in practice, clinicians working under time constraints might have to make shortcuts using their prior knowledge of the patient or their ability to see the patient again if things do not go to plan. Of course, these compensatory mechanisms of continuity and ready access to follow-up appointments are also under threat.

The study suggests that GPs normally address several problems in a consultation – not just one. Is this your experience, and what are the impacts on getting the information across to patients that they need?

Yes, evidence shows that most patients attend their GPs with multiple issues – approximately 2.5 issues per consultation. We also know that patients with long-term conditions are more likely to have multiple conditions rather than just one.

The pressures on appointment systems have led to patients “stacking” issues to discuss with their GP because they experience difficulty getting an appointment for each issue as it arises – we’re currently doing qualitative interviews with patients which have vividly demonstrated this. For GPs, this presents a challenge. We are committed to delivering comprehensive, holistic care for our patients – and this means addressing all of their needs and not just one. However, squashing the assessment of multiple issues into one short consultation leaves the patients and us vulnerable to risks and safety issues. One of the solutions to this dilemma is ensuring that our most complicated patients can have longer consultations, ideally with a GP they are familiar with.

GPs frequently contend with time and attention-consuming system failures and interruptions during consultations. What are these likely to be on a daily basis, and how do they impact on a day-to-day appointment list?

GPs are responsible for coordinating patients’ care across providers and services. However, the systems to facilitate coordination of care have not yet caught up with the complexity of patients needs. Consequently, GPs spend a lot of time chasing information on patients’ care elsewhere in the healthcare system, or trying to figure out what the management plan for a patient might be without adequate communication from other providers – all work that must be done in constrained windows, which adds pressure, stress and uncertainty to their work.

Although the paper suggests that lengthening the standard appointment time to 15 minutes might exacerbate difficulties in access to primary care – is there any evidence that might suggest that it would improve the situation?

There has been huge pressure on GP appointments over recent years – this has been caused by increasing patient needs as well as fewer GPs. Despite this, more appointments than ever are being provided in NHS general practice. Increasing the duration of GPs’ appointments might initially add to the pressure on appointment systems, but over time, we might see that demand would fall because we know most people want to discuss multiple things in each GP consultation. Giving patients and GPs more time to adequately address these issues in one go might be more time-efficient than asking patients to reattend for second and third appointments.

The paper mentions ‘expectation-inflation’ – could you explain what that means, and how it fits in with your own research?

In terms of this paper, we used the term expectation-inflation to describe a situation where more and more was being expected of GPs in terms of clinical care, investigations and management over time.

We didn’t find that the recommendations presented in the ten-minute consultation series were associated with expectation-inflation. However, consultations are experiencing additional pressures for other reasons, including the fact that the majority of patients have multiple issues that require GP attention in each consultation, and that the systems that GPs work in – for example the pathways that GPs use to refer patients for other services, sometimes add additional complexity to GPs’ work. Further GPs are also charged with tasks relating to preventative care and oversight of long-term conditions during consultations, so overall there is less time available within consultations to implement the recommendations in the series.

If, as the paper suggests, the title “ten-minute consultations” is a misnomer that places unrealistic expectations onto GPs, do you have any suggestions for a better title?

Patients’ needs vary hugely as does the level of familiarity they have with the GP treating them (that is continuity of care), and these factors influence how long a consultation will take. I would like an alternative title to be less time specific and more orientated to the attributes of high-quality care in a primary care environment.”