Martin Marshall: The travesty of the 10 minute consultation

martin_marshall“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 manage on-going conditions, offer advice about prevention and health education, and modify 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.

Martin Marshall is a GP in East London and professor of healthcare improvement at UCL. 

Competing interests: None declared.

  • Celeste Collins-Bothma

    I totally agree. Our appointments at our FHT are 15 minutes long, with our more urgent appointments 10 minutes long to provide access to more urgent patient needs. However, there are more complex issues to consider. Thank God I am in a FHT. We have nurse practitioners, social workers, a diabetic nurse, nurses etc etc. Without these ladies my life would have been much more miserable. In fact, I love and enjoy what I do for the first time in 30 years and only because I have been part of this team for the last 6 years. But what about my colleagues who do not have this privilege? How do they survive on 15-30 minute appointments!? We all know of that one patient in a crisis that can suck up an hour of your day in a second. I can redistribute my load and deal with the crisis. Neither self nor patients like that, as I have become quite attached to my largely geriatric patient population and I dare say they have become attached to me. What do my colleagues, working FFS, do? Their overhead stays the same, their staff need to be paid regardless of the fact that they have to deal with a crisis that will displace 5 patients from that day’s schedule. No, this does not happen infrequently. This happens every week and sometimes days in a row in family practice. What do they get paid for that hour they spend forming a paitient, calling around to find a specialist and on and on? We all know that we get a miserably small fee for services like that, despite the fact that we are in a specialty of our own.
    The point is, everytime there is a fee cut, the GP’s are in the front of the queue. Why? It is very frustrating when everyone out there constantly yells at us, and our staff, that we need to do more, be more, provide more. Many specialists see us as their secretaries. They pick up the hefty fee, but the GP has to order this, follow up on that and please prescribe such and so. Their consult notes read like novels, but the patient reports spending only 5-10 minutes with them. Not all, but most do that. I find that whole issue the most exhausting of all – the expectation of GP’s having to do it all for everyone out there. Being dumped on, really. Until we are seen by everyone as Specialists in Family Medicine and treated accordingly, this ridiculous situation will continue. Do you ever read a note from a cardiologist to a respiratory specialist ( somewhere near the end of a consult letter) telling him to do another pulmonary function test? Of course not. How often do you read something like: ” The family doctor can or should do…”? Too often. My colleagues and I spend up to three hours a day on administrative work and we still average 25 patients a day. Until recently we also spent 2 hours a day, minimum, at the hospital. We still do hospital work, but in one week blocks.
    When we get paid what we are worth, we can spend more time with our patients. I think we would all love to do it. The point is, we would put many out of jobs if that were the case. Our referrals would drop, our test-ordering would drop. Healthcare will be what it should be.
    Burocracy is slowly killing Healthcare. When the statistics and the dollars count more than the person or the value of the service, you are in serious trouble. We are in serious trouble.