Tuesday, May 30, 2023

Helen Salisbury: Fictive schedules and the unbearable load of general practice

On paper, a GP’s working schedule can look quite inviting: consulting for three and a half hours in the morning, with a coffee break in the middle, then a gap for lunch and home visits before a similar length afternoon surgery, finishing at 6 pm. I remember a Ladybird book about The Doctor, which had an illustration of the GP going home to hang nappies on the line before heading back to see her afternoon patients. Nowadays we consider ourselves lucky if we can nip to the shop next door for a sandwich. Ideally, we eat it with coffee among colleagues, but too often we just spread crumbs over our keyboards as we check results and sign prescriptions.

Carol Sinnott and colleagues did a time and motion study of GPs’ working days last year and concluded that “the formal schedule of clinical sessions did not accommodate the realities of how GPs spent their time.”1 Interestingly, the researchers were present only during formal sessions and saw only a fraction of the untimetabled work—missing everything done early in the morning, in that fantasy lunch break, late in the evening, and on days off.

The 10 or 15 minutes allotted to an appointment don’t include the time needed to make any associated referral, which can often take me as long as the original consultation by the time I’ve found the appropriate proforma and filled in all required fields. There’s no allotted time in my day to read the many letters from hospital, let alone follow up all the requests (or, more truthfully, instructions) for “GP to kindly prescribe X and monitor Y and Z.”

Looking after patients who are elderly, those with multiple health problems, or people at the end of their lives is one of the most satisfying parts of general practice. It involves lots of conversations—with the patient, family members, specialist colleagues, district and palliative care nurses—that shouldn’t be rushed. For this reason they often happen on my nominal afternoon off.

How have we reached a situation where GP timetables frequently bear so little relation to what we actually do? Mostly it’s because we can’t reduce the number of appointments offered each week, as practices already struggle to see their patients in an acceptable time frame. We’ve failed to push back on the steady transfer of work from hospitals to general practice, which has happened without a matching flow of resources.2 While hospital consultant numbers have steadily increased (up by 89% since 2004), GP numbers have been static or falling.34 The growing workload is shouldered by an ever shrinking group of very tired and stressed doctors.

It’s no wonder that we face a workforce crisis. If politicians are serious about bringing back the family doctor they’ll have to think hard about what will entice those doctors home from overseas or out of retirement—and stop those of us still here from throwing in the towel.5

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