S5 E6: "Signing Scripts For Xmas" song; "Great Expectations - time required to deliver BMJ’s 10 minute consultations": interview with Dr Stephen Bradley & Dr Alice Harper

Welcome to the Christmas Hot Topics Podcast from NB Medical with Dr Neal Tucker. It’s time for a bit of light-hearted festive fun so if you’ve finished signing all your scripts for Christmas then join us for a discussion with Dr Stephen Bradley and Dr Alice Harper about “Great Expectations: GPs estimations of time required to deliver BMJ’s 10minute consultations”.

This new paper explores how long it REALLY takes to do everything that’s recommended in clinical guidance. If you’ve ever felt like there just isn’t enough time in your general practice day, this might explain it, and you are not the only one.

Merry Christmas everyone, see you in the New Year. Neal

References

Great Expectations: GPs estimations of time required to deliver BMJ’s 10minute consultations

The Health Foundation: Identifying Operational Failures in General Practice

BMJ Guidelines should consider clinicians time needed to treat

www.nbmedical.com/podcast

Transcript

Speaker 2: 0:18

Music. Signing scripts for Christmas. Oh, I wish I could see some faces. But I'm signing scripts for Christmas. I'm working through my line and it seems so clear to me Everyone's putting early for their holiday Cause they're gone away. So I'm sitting in my room Signing scripts for Christmas. Signing scripts for Christmas. Gonna take some time but I'll get there. Highest thing for your Godache Might need coding on top of that. You're waiting for your goldbladder up so you can eat more Christmas fat. And here's one asking for A Marxist ceiling to help their virus go. It's time for Christmas. Well, it doesn't work like that. I'm not signing that script for Christmas. Signing scripts for Christmas. Or the one asking me to send it to Paris. Paris, what's a Marxist ceiling? In French anyway, a Marxist ceiling. Music Ben's lost to take the edge off.

Speaker 1: 2:28

That's a patient request.

Speaker 2: 2:29

That's not for me, but I don't think it's in your best interest, can't deal with the phone call so I'm gonna send a text instead. But deep down, I know in ten You'll be here shouting at reception, but I won't hear you cause I'm sitting in my room Signing those scripts for Christmas, signing your scripts for Christmas, and I'm almost there, almost there To keep you happy to keep you healthy.

Speaker 1: 3:23

It's like a little Christmas present, just with more side effects than Toblerone Music. It's Friday, the 22nd of December 2023, and this is the Hot Topics Podcast Music. Ho Ho Ho, merry Christmas everyone. Welcome to the Hot Topics Podcast.

Speaker 1: 4:08

For the last time this year, I am Neil Tucker and in this episode we're not gonna spend a lot of time talking about the news. We're not gonna spend a lot of time talking about research, because it's Christmas. You're probably driving home from work right now. You've got better things to do. I wanna keep it lighthearted and fun. So the focus of today is about a fun piece of research With some important findings.

Speaker 1: 4:33

Let me set the scene. Do you ever feel like there just isn't enough time, that the expectations of all the different aspects that we have to cover in a consultation Seem impossible in the time we are given? Well, if so, you are probably not alone. Today I'm joined by Dr Steve Bradley and Dr Alice Harper, who are the authors of a new paper. The title is Great Expectations GPs Estimations of Time Required to Deliver the BMJ's 10-Minute Consultations. So we've covered these BMJ articles a lot on the Hot Topics course over the years. They're primary care focused articles on a clinical topic. They discuss presentation, management, complications, red flags and lots, lots more To provide a framework for clinicians who are faced with a particular condition. But the big question here is can you actually do all of that in a 10-minute consultation? Let's bring in our experts here so I'll get you to both introduce yourself. I'm going to start with the top of my page, so let's bring in you, steve, so tell everyone a little bit about who you are and what you do.

Speaker 3: 5:46

Hello Neil. So I'm Steve Bradley. I'm an academic GP and I work at the University of Leeds and York Street Practice in Leeds City Centre.

Speaker 1: 5:55

And Alice, tell me a little bit about yourself.

Speaker 4: 5:58

Hi Neil, so my name is Alice. I'm a GPS T2, so that means I'm in the second year of my GP training and I work at a practice in the south of Bristol and I'm also got an academic post. So from next year I'll have some time dedicated to doing primary care related research associated with the University of Bristol.

Speaker 1: 6:20

So let's start with the question. Then, steve, over to you first, what made you think about doing this research?

Speaker 3: 6:26

I don't know about you, neil, but I've always read these articles, these time-in-a-consultations, and I really enjoy them and find them helpful. But I have wondered sometimes is this plausible? You would actually do this in 10 minutes and some of them seem a wee bit exhaustive actually, and rather long. I've also wondered whether these articles are getting longer, whether there's an inflation of expectation that's been lumped on us. Are we expected to do more and more in the consultation? I always thought that would be something interesting to look at.

Speaker 1: 6:55

I would definitely agree. As someone who reads a lot of guidelines, it feels like they have extended a lot over the years. Alice, maybe fill us in with how did you then conduct the study?

Speaker 4: 7:06

So we chose to get 44 of the published articles.

Speaker 4: 7:10

So we looked at the first article ever published and then we took two from each calendar year since then up until the first article of 2022.

Speaker 4: 7:19

I read all the articles and extracted the tasks that were recommended in each article and we then categorized them according to the type of task, so thinking about history taking or prescribing, and also whether or not the tasks were required for all patients or only in specific circumstances, such as prostate examination in male patients only, for example.

Speaker 4: 7:42

We then asked for GPs, who were a range of different career stages but all practicing within the NHS, and we asked them to estimate the time that they think they would take to complete the relevant tasks. From that we then took a sort of median time of their four estimates and we calculated the minimum estimated consultation length. So that was the estimated time required to complete tasks for all patients and also a maximum estimated consultation length. So tasks for all patients and also those specific tasks that I mentioned. That might not be done in all circumstances. We also wanted to look at how demands may have increased over time. So we charted the estimates by year and also in five year periods to look at if there'd been a change over the 22 years since the articles were first published.

Speaker 1: 8:38

I'm very impressed that you've read all 44 of these articles. You must be a true expert in these areas by now. So what were the findings then? Maybe let's start off with those minimum and maximum consultation lengths.

Speaker 4: 8:52

Looking first towards the median for the minimum estimated consultation length, so thinking about the time that GPs estimated to complete the tasks that were recommended for all patients, that time estimate was 15.7 minutes, so a little bit over the 10 minutes that is usually permitted, and then thinking about the maximum estimated consultation length, that was a lot higher. That was 28.4 minutes.

Speaker 1: 9:20

This might explain why both my surgeries yesterday ran over by at least an hour. I was kind of taking it personally, but no, maybe there's something more to it than that. Okay, so the timescales don't necessarily fit into what we might consider a classic general practice consultation. Steve, what's your take on the clinical implications of these findings?

Speaker 3: 9:41

Firstly, to start with the positive. I think this article is a real celebration of the variety of general practice and all the things that we've done, all the things that general practice can do and is meant to be doing, which is an incredible range of articles, and you can see in the supplementary results there's a table where we actually list these 44s, so there's things like COPD, a tingling hand, snoring, gout, mineralia. They're just such a huge variety of stuff. We've got to celebrate what we do. It's incredible, actually, in terms of policy and clinical implications from this, though, I think as a community we've got to get real really about the expectations of what we can actually deliver in the time that we have permitted.

Speaker 3: 10:21

I would say these are quite conservative estimates. They don't take into account the sort of system feelings that we see every day, the problems around things not working, products not being in pharmacy, stuff like that and we mentioned in the discussion that actually, patients don't come with one problem. They come with an average 2.5 problems, and if you were to map this out over what's said to be an average of 38 consultations a day, now a GP would spend the whole 24 hours of their day just having consultations. So clearly that's an absurd proposition. I think we need to recognise and be explicit that actually what's happening is GPs are very pragmatically allocating their time which is the main resource that we deal with in our day-to-day work to where they see the clinical needs.

Speaker 1: 11:05

Were there any limitations to this research?

Speaker 3: 11:09

Yeah, neil, it's an important question, and we'd just like to say up front that this is quite limited. In a lot of ways. This is a highly theoretical exercise in which GPs estimated how long they thought things would take. It's a very speculative endeavour, I would say. A real strength of this paper, I think, is that we pre-registered the protocol, so we really stuck to the analysis plan. All the data is available. Everybody can see for themselves what the timings are and explore that data for themselves. I think a real problem with a lot of research of this type is that it's vulnerable to constructing the narrative after the event and working, tinkering with the analysis to get the most eye-catching results, and we were very pleased to declare all our methods beforehand, so that would absolutely not be the case.

Speaker 1: 11:58

And I'll put a link to the paper in the podcast description so you can go and have a look at it yourself. Maybe, if you fancy it, got a bit of spare time during the day. I know that's unlikely, but you could have a look at your real-world experience on some of these topics and compare it against this data. Alice, what's the GP trainee perspective on this?

Speaker 4: 12:18

Well, I think as a trainee, we're quite fortunate because we do start on longer consultations, but I think they're very much needed. When I first started, I was on 30-minute consultations and sometimes I was still overrunning and then I was filled with dread with the idea that I'd have to reduce it down to 20 minutes. But yeah, if someone told me again tomorrow that I need to half my appointment times again, that would fill me with dread, definitely. This study highlights the importance of trainees having enough time to consult patients, and then also we spend a lot of the time referring back to the guidelines as well, so we need to have enough time to be able to complete all the relevant tasks.

Speaker 1: 12:59

I think maybe we are seeing a shift in how practices organise their day, with longer consultations. The practice I was working in yesterday typically has 15-minute consultation times. I'm sure going back 10 years ago, that would have been 10 minutes. I think back to when my wife was a GP registrar and they were still doing five-minute appointments for acute illness slots. I couldn't get my head around that at all. I can barely say hello to a patient in five minutes. What staggered me about yesterday was the complexity of so many of the patients that I was seeing. And, of course, if you're going to manage those patients well and safely, then it does take more time. The BMJ still has the title of 10-minute consultations. Most GPs, I think, would now be thinking more about 15-minute consultations. This data questions whether even that is sufficient. Steve, what do you think?

Speaker 3: 13:56

Yeah, we discussed this in the paper. Actually there is the findings would seem to support a move to 15-minute consultations. That doesn't necessarily address the problem of access, but it does seem to me logical that we ought to move to 15-minute appointments because it really feels slightly disapproachable actually, too patients and they're concerned to try to pretend that we can actually address their problems in 10 minutes. I've never actually really managed to do that satisfactorily where I work as 15 minutes appointments I mean. Another thing we say in the paper, which maybe feels like a slightly trivial point but actually I think is rather important, is that we are suggesting BMJ renames this article series because it just seems to set up expectations that aren't possible and colludes in this kind of this expectation that we do everything in a very, very short period of time, which just, which just really can't be met and I think contributes to the sort of moral distress that a lot of us feel about the mismatch between what we would like to do if there was the time available and what we actually can do.

Speaker 1: 14:57

What next, then? Is there more work that you think is required in this area?

Speaker 3: 15:02

Well, as you know, every, every conclusion of every study is more research is required. So I wouldn't I wouldn't want to break with that noble tradition. I mean, one of our colleagues, carl Sinet, who is a co-author on this paper, has done a lot of work around this area, particularly looking at systems failures and how that affects timing of consultations. A few things that I thought should be looked at is how we build some consensus around this stuff that we ought to not do or de-prioritise, because there's a whole lot of workload and I think we need to try to understand what is the stuff that is least important or has least direct effects for patients that we can stop doing.

Speaker 3: 15:40

Another thought I've had on this is around process automation and artificial intelligence. I mean, one thing that's disappointed me a little bit around the narrative with AI is that everybody seems fixated on replacing doctors with AI cyborgs, which seems to me to miss the point. What we would actually like, and I think what patients would like, is for us to have more time to spend with them. I think we should be looking at that technology to replace the stuff that we do that's tedious and could be automated, stuff like if reports could be written automatically filing of routine results, things like that. There's so many fiddly little tasks that take up a lot of time and attention and actually are very, very draining, and I think if we could focus the technology in that direction, then maybe that could free us a bit more to actually do the stuff we want to do just talking to patients about what matters to them.

Speaker 1: 16:28

I think the other thing that your research highlights is the necessity of having GPs and other primary health care clinicians intrinsically involved in the guideline writing process. It's still true that primary and secondary care don't necessarily understand very well what each other does, so we need a strong voice that can push back a little bit. Sometimes they can say that sounds fantastic, but this is the reality and, by doing so, making these guidelines more relevant and practical for us and our patients.

Speaker 3: 17:01

Yeah, there was a fantastic article in BMJ last year, I think, that called for time to be taken into account with guidelines and this emerging body of evidence around this. Most of it is around guidelines rather than what we looked, which was peer recommendations. But I think time does need to be explicitly considered and if we do need to push back a bit and challenge and say, ok, we might be able to do that, what is it that you would like us to not do?

Speaker 1: 17:26

And Alice, what's next for you?

Speaker 4: 17:28

Well, the AKT is the end of January, so that's the big next step for me, and then currently thinking about what I'm going to do with when I have some dedicated academic time. I'm interested in patients and carers with multiple long term conditions, thinking about how we can support them in primary care. Personalised care planning project to be confirmed.

Speaker 1: 17:52

One final question, then, in homage to your title Great Expectations. If you had to be one character from the Charles Dickens novel, what would you be? To be honest, stephen, I've already got you pegged as Pip.

Speaker 3: 18:06

I thought maybe, joe, you know honest, dependable.

Speaker 1: 18:10

OK, so Alice can be Pip and I'll be Miss Haversham.

Speaker 3: 18:14

I was thinking the conflict with you.

Speaker 1: 18:18

No comment. Thank you both for joining us on the podcast today. It's been brilliant to have you along and have the opportunity to chat a little bit about how we do general practice. I know that, steven, you're heavily involved in cancer research relating to primary care. I'm sure we're going to hear more from you in the near future, so I look forward to having you back on the podcast then.

Speaker 3: 18:38

Yeah, thanks so much, neil, and it's really been lovely to talk to you and a big fan of it the podcast and I'd just like to say thank you, if that's okay, to the four GPs who really did the work for us. These are not academic GPs. They took extra time out to think about how long things would take, which is actually quite a big ask to make of them. So thank you very much to Nigel Taylor, harriet DeLapp, helen Pike and James Gurkin. We're so grateful that you did this work with us.

Speaker 1: 19:05

And a big thank you as well to Dr Alice Harper, who I'm sure will be seeing lots more of in the future. Thanks, alice.

Speaker 4: 19:10

Thanks very much, neil.

Speaker 1: 19:12

That's a wrap for the Hot Topics podcast for 2023. Thanks for joining us throughout the year. Remember, you can always get in touch on hot topics at mbmedicalcom. In January, mb Medical has live webinars for our Hot Topics in Dermatology and our latest main Hot Topics course as well. Join us for those and I'll be back with a podcast sometime in a few weeks. Merry Christmas, everyone. Happy New Year. Look after yourselves, bye, bye.