Longer appointments for all!
Authors: A. Esmail
Journal: Journal of the Royal Society of Medicine (2006)

It seem bizarre that if we look at the way that a general practitioners' surgery is planned and organized in 2006, it is not very different from that which existed in 1948 at the creation of the NHS. It is true that the advent of information technology has had a profound impact on the exchange and recording of information but it has had little impact on the process of consultation between patient and doctor. There is a greater team of people working in primary care and patients are able to see and receive care from a greater range of professionals, but in terms of the doctor-patient interaction, much remains the same. In 1948, the average consultation time was five minutes. Until recently it was seven and a half minutes and it may be that it is now nearer ten minutes. Yet the complexity of problems that we deal with are far greater than they were in 1948. Access to investigation and treatments, the information that is presented for each individual consultation, the interventions that are available and the co-ordination of the care that is required are all much greater.

How can we possibly deal with it in the space of a seven and a half minute consultation?

The reality is that we do and we do it imperfectly. An eminent GP1 once boasted that in actual fact the GP consultation is nearer 47 minutes a year. This was based on the assumption that the average person consults their GP about five times a year for about nine minutes and the consultation is therefore part of an on-going conversation. This takes no account of the fact that the average person will see several GPs a year, albeit as part of the same practice. It seems an incredibly inefficient way to organize care, bringing the patient back five times so that we can complete our history taking, examination, investigation and management plan. From the patients' perspective it takes no account of the amount of time a patient may spend trying to get an appointment and waiting to be seen. The net result of our 1948 view of the consultation is that we have to keep seeing patients more regularly, creating a self-perpetuating demand for appointments that are never quite long enough. We seem to be fulfilling the negative comments about general practice made by a social commentator in 1912 as ‘perfunctory work... of perfunctory men!’2 And all the time the mandarins tell us that we need to be seeing patients more quickly. You can't reconcile continuity with easy access—or, ultimately, patient satisfaction with short, sharp, ineffective appointments.

So here's an inconvenient truth. Why not introduce a right for patients to have a minimum 15 minute appointment with their GP? It should be a standard for the NHS just as much as clean wards, reduced waiting times for operations and free care at the point of delivery. Reinforce it by stating that GPs should see a maximum of 28 patients a day and see what happens. It will reduce the demand for appointments, improve satisfaction for both patient and doctor, and allow doctors to deliver the more advanced care that current knowledge requires—and so reduce the demands on the secondary care services.

Try it and see. All we have to fear is another sixty years of the same!