Can we set workload limits in general practice?

According to a poll by GPonline, 81% of GPs believe the number of patient consultations they undertake in a day should be capped. But could a workload limit in general practice work?

What is a ‘safe workload’ for GPs?

In its 2016 report Safe Working in General Practice, the BMA said that determining appropriate workload limits was complex and would depend on the ‘unique circumstances of each practice’ taking account of list size, patient mix and complexity, and workforce, among other factors.

However, the report said that introducing 15-minute appointments ‘would allow improved decision making and case management, and should reduce the administrative burden outside clinic times’. The BMA proposed that 115 15-minute appointments should be considered the ‘quantified commissioned activity of an NHS GP’. This would bring the number of face-to-face consultations to below 25 a day.

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What happens in other countries?

A 2016 article in the BJGP looked at the issue of sustainable general practice in 25 EU member states using a questionnaire.

Practice list sizes varied from 600 per GP in Belgium to 3,500 per GP in Turkey, and consultation rates per GP varied from 10–50 a day. However, the researchers cautioned that some of these responses included telephone consultations and others just face-to-face consultations. Most nations had 15-minute GP consultations, with Scandinavian countries tending towards 20-25 minutes.

Doctors in nations with 25 consultations or less a day find general practice manageable. In countries where GPs had more than 25 patient contacts a day (including phone or face-to-face consultations) doctors found general practice unsustainable. The researchers said that these countries also had problems with GP recruitment and retention.

How much are UK GPs currently working?

Clearly most GPs in the UK are seeing considerably more than 25 patients each day. GPonline's poll found that some 20% of GPs said that on an average day they delivered more than 20 patient consultations per session, meaning they are seeing more than 40 patients a day.

A study published in The Lancet in 2016 suggested that between 2007 and 2014 practices’ clinical workloads had increased by 16% and that GPs were effectively working the equivalent of an extra day a week by the end of that period.

The increase in workload was due to a rise in population, an increase in the number of times people consulted their GP and an increase in consultation lengths. Average consultation rates rose from 4.67 consultations per person per year in 2007/8 to 5.15 in 2013/14. There was also a 6.7% rise in the overall duration of GP consultations during the period and telephone consultation rates almost doubled from 0.27 to 0.45 per person per year.

A BMA survey in 2016, which covered almost a third of practices in England, found that only 2% of practices believed their workload was manageable. Some 55% of respondents reported that the quality of service in their practice had deteriorated in the previous 12 months due to workload pressures.

Meanwhile in a BMA survey of 900 GPs in Scotland in December 2016 90% said that workload levels had damaged the quality of care they were able to give to patients. More than half said there should be longer appointments for specific groups of patients, while 40% said there should be more time allocated for every consultation.

Are there plans to introduce a working limit for GPs?

GPs responding to our survey were overwhelmingly in favour of a workload limit, with the majority thinking that this should be set at around 30 consultations a day.

At present any decision about working limits would be up to practices or other employers to introduce. At the England LMCs conference in November last year, the GPC revealed that it was planning to release guidance to help practices set safe workload limits for GPs early in 2018. The GPC has a working group, which has been looking at the issue, but there is currently no news on when this will be available and what it may contain.

At the same conference, LMC leaders backed a motion that called on NHS England and the government to help make patients aware of the importance of reducing GP workloads to safe levels. However it rejected part of the motion that wanted to limit the number of hours GPs work to 12 a day.

It seems unlikely that any guidance on workload limits would revolve around hours worked as this is generally viewed as too restrictive by most GPs and could have implications for out-of-hours services. So it could be that the BMA guidance will focus more on the number of patient contacts in a day. But whether it will be prescriptive about recommending limits, or just offer advice on how practices can move towards longer appointments with a view to limiting GP patient contacts, remains to be seen. The BMA's Safe Working in General Practice report advocates the use of hubs to see patients when practices' capacity is reached, so any recommendations may well push CCGs to adopt this model.

Is it just the number of appointments that is the problem?

However, it is not just patient contacts that are of concern to GPs. Among those responding to the GPonline poll, ever-increasing paperwork, administrative tasks and the amount of work involved with checking test results were also highlighted as major stresses during the day. And while reducing the number of patients GPs see within a day might help with some of this admin, other aspects, such as repeat prescriptions, correspondence from secondary care and various other tasks would remain.

One GP said: ‘A cap would not be functional for GPs who work well at a fast pace, but a realistic balance needs to be sought to allow the time spent with patients to be valuable. GP workload is a significant concern, with paperwork seeming to be the main problem.’

‘Seeing patients is the relatively easy bit - It's the additional clinical and non-clinical tasks which takes the time,’ said another. ‘Lab links, referral letters, associated tasks from secondary care, other results, prescriptions/EPS, reports, reception queries, faxes and home visits. As well as HR issues and finance.’

Would 15-minute consultations help?

The general consensus from the GPonline poll was that the 10-minute consultation is now too short for GPs to effectively deal with the increased complexity they see in patients. A huge number of respondents said that they would like to see appointments extended to 15-minutes to help them deal with patients more effectively.

‘Longer appointments would allow us to do more with each patient. In the long term I feel this would result in fewer attendances,’ one GP said.

'Ten-minute consultations are unsustainable and not safe for patients in modern day clinical practice,' another added. 'Patients present with increasingly complex medical complaints and higher expectations for their care than ever before. The system needs to adapt to recognise this.'

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