Our vision: to transform access to medical care.

So how long should a GP consultation take?

I’m not going to answer the question, because “should” implies a right answer. Consider only so far as the patient, the doctor, and the problem, and already the product of the variables is infinite.  Even though GPs successfully consult with patients millions of times every week, there is no way to specify a correct amount of time.

But given the pressure on GP capacity it is an important question.  It seems to me more useful to examine the evidence on how much time GPs actually take.  We have clinical system data from dozens of practices recording the duration of consultations, and patterns emerge.

Telephone consultations last about half as long as face to face

The data for this study is from The Elms in Liverpool, featured as a case study and using the GP Access method since April 2012.  Firstly, note the the context

  • the service is for a registered list of patients, with full medical records
  • the GP phones all patients to begin the episode
  • the GP may decide to bring the patient in, and has space today
  • the patient may insist on coming in (though rarely does so)

    Elms consult duration phone

    Telephone consultation duration, frequency chart over 4 weeks May 2014 (click charts to enlarge)

Times are measured from the opening and closing of the patient record, so no extra work was required to produce the data. The mode of 3 minutes may seem short, but as one third of consultations result in the patient coming in, many of these calls will be ended quickly when a face to face is arranged.  But the mean is just below six minutes as a few calls are much longer.  Note that no norm is applied:  the consultation is as long as it needs to be.

Face to face consultations are longer and more variable

Central to this system of operation is that the time allowed for a consultation is determined by the clinician who therefore has greater control over the day and can allocate an appropriate time, based on the earlier brief telephone call.

This means that the time is not constrained to 10 minutes, patients hurried through because of a queue in the waiting room.  There is more time to deal with all problems in one go (Norman Lamb is not the first patient to be told, one problem at at time only, you need to rebook.  This takes longer overall, for patient and doctor).

Elms consult duration f2f

Face to face consultations vary significantly in duration.

The shape of the curve highlights the extent of variation, though the mean is just under 12 minutes and little changed from a traditional face to face system.  While the mode is 10 minutes, many are much longer. In the GP contract 2014 the requirement for a 10 minute consultation has sensibly been dropped.  Some clamour for 15 minutes – and they are right, but for only a small minority of patients.  Many more need under 10 minutes, also right.  What is inefficient is allocating the wrong time – too short, and rework results.  Too long, throughput falls and waits rise.

How to improve efficiency

Elms consult duration runchart

Runchart of consultation durations, face to face and telephone

True efficiency is hard to measure, because it depends on the quality of the consultation which is hard to measure.  There is no point being very fast, but causing rework as problems are left unsolved and frustrated patients come round again.  But again the problem is important for capacity, and an inefficient system would result in patients being turned away.  This crude measure of efficiency is a product of telephone and face to face consultation times, and the resolve rate – those that needed only a phone call taking much less time overall.  In this practice, interestingly despite lengthy experience, consultation times are very stable.  We have seen a few others come near to 4 minutes over time.

It is important not to impose targets or expectations:  the Doctor First site claims 3 calls can be made in 10 minutes (although analysis of their own evidence shows an average duration over 4.5 minutes).  Very few individuals can safely achieve a 3 minute average, and our evidence says it is an unrealistic expectation for most GPs, resulting in disappointment.

Elms resolve rate runchart

Resolve rate has increased here to 70%

Resolve rate, the ratio of telephone to all consultations at the Elms has increased.  This is often the case with more experience.  We find the range is between 50% and 70%.  Below 50% saves no time; above 70% overall may result in rework if patient problems are not solved.

Conclusions

Released from the straitjacket of one size fits all, GPs are able to help patients most efficiently when they can tailor duration to need. Efficiency is however not simply down to individual consulting skills, but a system which allows that flexibility alongside rapid access and continuity.

Our current view is that the simplest most efficient design is for all (barring a few exceptions) requests for a GP to begin with a phone call from the GP.  I look forward to see whether this changes over time: meanwhile, there is much to be gained in every practice from what we already know.

Harry Longman

 

8 responses to “So how long should a GP consultation take?”

  1. Dr Helen Miller says:

    A couple of years ago we had a system where all appointment requests were triaged by a GP .It worked brilliantly for 12 to 18 months ; patients ,staff and GPs were happy but then the telephone call creep started .patients would ring and ask which GP was on duty and we then started to get more and more calls for minor problems. We are a small surgery 4,500 . When one morning I had 60 calls on my telephone list and I still had to see 20 I called an end to this system and we have gone back to pre-booked face to face or telephone appointments . I still do do telephone follow ups and ring with results but I will never go back to GP telephone triage . So, beware the initial statistics which look good , you are all in the honeymoon period !!!!!

    • Harry Longman says:

      I take your points Helen – we didn’t work with you, but we have with dozens of others over the last 3 years. Some of the pioneers have now been going 14 years, so it’s no honeymoon. Repeatably practices tell us, they are never going back, even though they sometimes have difficulties. It can take perseverance, but then they look back they see the difference. I don’t know exactly how you managed your system, but we have very good data now and methods for improvement. Doctors, patients and the NHS need change.

  2. Clive says:

    We had the same experience as Helen…. using Doctor First admittedly but the principles are the same. We are slightly over doctored and were already offering most appts same day The honeymoon period was ok but most of the GPs soon started to hate telephone consultations as the default. A consultation is a consultation after all and over the telephone, inevitably lower in quality. Patient complaints were numerous, although from a probable minority but vociferous perspective.

    So unhappy GPs, unhappy patients, larger numbers of patient contact and decision density. Too stressful and we had to stop. The only plus side was some control of your otherwise over full day and improved convenience for a few patients.

    The problem we have to solve is changing the threshold and way people seek help by developing supported self care and effective pre consultation signposting….. whilst maintaining trust, quality and the best outcome with the resources we have…. as well as not burning out our GPs and helping them with their work life balance.

  3. Hazel says:

    I so hope we never switch to telephone triage. I think it ends up that those who can shout the loudest will get the attention and those who can’t will get left behind as they are not able to communicate their needs so easily over the telephone. It worries me that this system will marginalise the most vulnerable.

    • Harry Longman says:

      Dear Hazel,
      If it did marginalise the most vulnerable I would not be doing it. The reverse is true: it’s more efficient, therefore the GPs have more capacity. That means that they have more time for patients, and that is particularly good news for the vulnerable or those who don’t shout very loud (often they are in fact the most needy). We know that around 1 in 8 patients calling their GP is turned away by reception, no appointments left. With this system, there is time for everyone.

  4. Waheed says:

    We have recently introduced telephone appointment as we felt we wanted to improve patient access. Our practice ha routine appointments available within 72 hours and had a on call doctor too. We had appprox 320-350 appms per week for a list size of 4500.Introducing telephone appointment has increased access to over 550 appointments per week but are routine appms has moved from 72 hours to 3 weeks. Patients that would normally self manage now call in expecting a call back, Reception staff are more stressed as the demand has shot up through the roof. I am not sure what the solution is but pretty convinced that telephone consultations should be for a minority not majority of consultations, Self care should form an important component and patients expectation/responsibility needs to be managed better.

    • Harry Longman says:

      Waheed, thank you for your comments. We had no part in helping you change so I have no knowledge of the situation beyond what you have written. Already I can see features of your system which, although they seem logical, actually ensure failure. It is sad that while we have all the evidence of what works, proven time after time, people are falling into these same traps. I would love to talk in more detail if you wouldn’t mind?

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