Contract needs to enable doctors to offer first class care

EDITOR—Jenkins et al found that patients vary both in what they want from a consultation with their general practitioner and in what they get.1 They found a poor correlation between these and the length of the consultation. The catchy front cover headline “Consultations don't have to be longer to be better” seriously overgeneralises these results. Some short consultations may be highly effective, but a systematic review earlier this year summarised a range of patient outcomes that are improved when doctors have more time.2

In one large English survey 12% of patients complained about having insufficient time with their general practitioner, but this figure rose to 30% when patients were seen for five minutes or less.3 It may be that the doctors need additional time in consultations—perhaps more than their patients. Medical practice has become more complex, and more needs to be done during the course of consultations. This may explain why clinical care is inferior in practices with short consultations.4 Patients may sometimes get what they want in short consultations—but they may not always realise that it isn't good medical care.

It is 16 years since David Morrell and I and colleagues published the first experimental study showing the limitations of short consultations.5 It is well past time to consign surgeries booked at intervals as short as five minutes to history. The current payment system for general practitioners encourages a “pack 'em in and sell 'em cheap” approach to general practice. This needs to be addressed in the contract currently being negotiated so that all general practitioners have time to offer their patients first class care.

Consultations should be longer

EDITOR—Consultations are infinitely variable and difficult to research quantitatively. After the better part of 20 years attempting to do this, we think the following conclusions can be safely drawn. In longer consultations, long term comorbidity and psychosocial problems as well as the presenting complaint are more likely to be recognised, and, having been recognised, they will be addressed. More health education is also likely to be offered. Patients and doctors are more likely to be satisfied.1

We have identified a subset of satisfaction-like questions (which include important outcomes such as patients understanding their problems better and feeling more able to cope) as enablement. We have consistently found that doctors who enable more people, and who enable people more, are those whose average consultation time is longer. Their patients also know them better (a proxy for continuity). An association therefore exists between longer consultations and better processes and outcomes; we cannot say to what extent the relation is causal, although it is reasonable to say that it will be at least in part. Almost certainly, further important variables—for example, empathy—are also important correlates, but these too are difficult to research.2

No one has ever suggested that all long consultations are good ones, or that short ones cannot be effective, and Jenkins et al did not imply that.3 We argue that, although an individual consultation does not have to be long, doctors who on the whole provide shorter consultations are likely to be providing less good care. Similarly, patients who have never had the opportunity for longer consultations are unlikely to have their wants met.

At a time when sensitive negotiations on the contract for general practitioners are in progress, scientifically simplistic headlines such as those the BMJ has used serve neither doctors nor patients well. The message should be that consultations do have to be longer. We still believe that there should also be a contractual reward or incentive for providing such a service.2

Longer consultations can improve patient satisfaction

EDITOR—Jenkins et al indicate from a general practice perspective that consultations do not have to be longer to achieve benefit.1 What they do not address is the nature of the consultation. Clearly, if it is about a wart, an attack of acute bronchitis or urinary tract infection, a rash, or whether to smoke, the consultation can be succinct and short. But what about when a patient comes with a problem that has been beset with publicity arising from politicians and sensational and one sided media coverage? In such circumstances, when the problem is multifactorial, time is of the essence.

In this department we see patients referred both by military and civilian doctors. The common complaint has always been that there has never been enough time to talk about the issues involved. Here, because we need the time, and indeed have the time, average consultations are one and a half hours per patient. As a result of this approach, we have a 95% patient satisfaction rate in questionnaires completed by patients when they leave. Such data have been collected on an anonymised, aggregated basis.

We do not believe that generalisations can be made. Our experience has been that longer consultations have resulted in higher patient satisfaction rates. Our perspective is that patients would agree that longer consultations result in more satisfactory outcomes.

Time and stress are limiting holistic care in Scotland

EDITOR—Freeman et al, in their paper on consultation length in relation to quality of care in general practice in the United Kingdom, have provoked responses that highlight the complexity and question the benefit of providing longer consultations.1^–3 The need for a shift in focus to the content of the consultation, rather than time itself, has also been raised.4 We report the findings of a national survey of the views of Scotland's general practitioners on holism in primary care.

We sent a postal survey to all 3713 principals in general practice in Scotland in February 2001. The overall response rate was 62.2% (2311) after two postal reminders. Respondents were similar to the total workforce of principals in general practice in terms of age and sex, although more part time general practitioners were represented in the sample compared with the total workforce (part time 552; 23.9% sample v 620; 16.7% total general practitioners' workforce). Locality of practice was recorded as urban (1076, 46.6%), rural (749, 19.9%), or mixed (461, 32.4%) and socioeconomic area of the practice as high deprivation (380, 16.4%), medium/mixed (1015, 43.9%), marginal deprivation (537, 23.2%), or no deprivation (339, 14.7%).

Nearly nine out of 10 general practitioners (1925/2205, 87.3%) believed that a holistic approach was essential to providing good health care, but only one in 15 (158/2311, 6.8%) thought the current organisation of primary care services made it possible. The main constraint on holism in the consultation was seen as the time available, followed by the general practitioner's own stress level. Mean values (95% confidence intervals) for constraints, rated on a scale of 0 (not limiting) to 10 (extremely limiting), were: time 7.6 (7.49 to 7.67), stress 4.9 (4.84 to 5.04), training 4.7 (4.66 to 4.84), skills 4.2 (4.13 to 4.30), motivation 3.4 (3.33 to 3.50), attitudes of partners 2.9 (2.82 to 3.02), and own personality 2.6 (2.51 to 2.66). General practitioners working in urban, high deprivation areas felt more constrained by time and stress than general practitioners in the other areas (Kruskal-Wallis H test, P<0.005, results not shown). Additionally, general practitioners working in full time employment reported higher levels of stress than those working part time (P<0.005, results not shown).

Scotland's general practitioners believe that holistic care is being critically constrained by organisational factors. Time and stress are the top two issues in the consultation. These results give voice to deep concerns among a nation's general practitioners who remain committed to a holism they are struggling to deliver.

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