November 25. Just under a week to go before the official start of winter, but already the NHS news reports are sounding pretty wintry. Down south, the BMA has got into a spat with the government over the viability of GP home visits. Here, there is a horror story about a patient’s miserable experience seeking out-of-hours care, and an interminable wait in an out-of-hours GP clinic. For the next three months we can expect that the NHS will be under intolerable strain. There may be more horror stories to come. Yet paradoxically, the more the NHS appears to fail, the more it will be upheld as a sacred cow which must under no circumstances be sold to Mr Trump. Since we are in the midst of an election campaign, we can expect some extravagant financial gestures of goodwill in the NHS’ direction. We may also be sure to hear that there are technological solutions to the NHS’ woes, particularly in the fields of Information Technology and Artificial Intelligence. You know the sort of thing. Robots caring for the elderly.
As somebody who has been there, done that, and got the T-shirt (if I may say so) in the fields of emergency medicine and general practice, I’m always struck by the absence in these arguments of consideration of what might constitute a tolerable burden for a GP (or indeed an emergency physician) in their day-to-day practice. Yet this seems to me to be a valid starting point: think of what an individual can reasonably do and then integrate that computation into the whole picture.
I offer no evidence base here, but rather an assessment based on personal experience. A contented GP who in the long term is not running the risk of burnout will see no more than 100 patients per week. Fifteen minute appointments. What would that look like in reality?
Something like this:
Monday: morning surgery 0900 – 1130: 10 patients
11.30 – 11.45: Coffee.
11.45 – 1400: admin, home visits (say 3), liaison with colleagues, and lunch, scheduled according to need.
1400 – 1630: afternoon surgery: 10 patients.
1630 – 1800 admin and any further home visits (say 1).
Total: 24 patients. Enough already. Ask any GP. After you’ve seen 30 patients in a day you begin to get tetchy. But some busy urban GPs are seeing in excess of 40 patients a day. It’s unsustainable.
I should say a word about what constitutes “admin”. The most important elements are the surveillance of correspondence and laboratory investigation results, and further contact and correspondence with colleagues, particularly within the secondary and tertiary sectors (ie hospital specialists).
Tuesday might look a bit like Monday.
Wednesday morning also looks the same, but Wednesday afternoon is free, because it so happens that Wednesday is the GP’s night on call (yes, I’m advocating bringing the responsibility of out-of-hours care back to the GP surgery). So after 1800, the GP remains in the surgery or health centre, and provides out-of-hours cover for the practice, and probably a group of neighbouring practices who will return the favour on another night. (Because this burden is being shared with other practices, this may not be a weekly commitment.) Ideally, he or she will be accompanied by a practice nurse. (Working alongside a colleague is so much more rewarding than working alone.) The evening and night’s activity will involve consultations on site, and home visits. A driver will be provided.
Thursday: the day post night on-call is a non-clinical day. If the night has been busy, the GP will need to sleep. Otherwise the day is devoted to the GP’s special interest – research, administration, further education and professional development etc.
Friday – normal day.
Saturday and Sunday: must be covered as with any weekday evening. Depending on the local arrangements, the GP might have to fulfil a single weekend shift approximately once a month. If that shift happens to be Sunday night, then for the following week the GP’s protected day will become the Monday.
That works out as a working week of about 60 hours, which sounds a lot, but around 18 of them will constitute time on call, including the average weekend commitment, and 9 of them will be protected for non-clinical activities. That is sustainable.
In order for doctors to achieve this lifestyle, their patient list (per full-time equivalent GP) needs to be a flock of around 1,000 souls. GPs are paid partly on a per capita basis. If you look after 1,000 people, you won’t get rich, but you have a chance of being happy. We need to train and retain more GPs.
In the endless debate about how the health service is run, you seldom hear opinions about modus operandi at this level of detail. Instead, the BMA tells the Health Secretary the GPs are too busy to do house calls, and the Health Secretary tells the BMA that house calls are mandatory. Shouldn’t the health secretary be asking the GPs what they need, and shouldn’t the GPs be replying with – well, something along the lines of what I’ve just written?