Dr Vasumathy Sivarajasingam Offers Five Top Tips on Optimising Patient Care Within the Constraints of the 10-minute Appointment
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Primary care is the bedrock of the NHS, and the public’s first point of contact with the health service. However, general practice—which has been on the front line of the NHS’s response to COVID-19, and is now facing growing waiting lists and workforce shortages—is currently under the most severe pressure in the history of the health service. In addition, a shift in the provision of services from secondary to primary care, in combination with an ageing population with multiple comorbidities, rising demand for chronic disease management, growing practice list sizes, and higher patient expectations, have placed increasing strain on general practice.
As well as coping with these pressures, clinicians must accommodate referrals to specialists, medication reviews, and advice on behaviour modification in their appointments with patients. Clinicians are also expected to tackle elements from the Quality and Outcomes Framework and other targets and incentive schemes during patient consultations. Furthermore, for medicolegal reasons, clinicians must spend sufficient time on accurate, precise documentation of their discussions with patients.
Despite this, some patients expect all of their issues to be resolved in a single appointment. Most GPs allow 10 minutes for routine appointments, and the average number of problems discussed in each GP consultation is 2.5. GPs often overrun if a patient requires extra assistance with a problem or additional reassurance for any worries they may have. Provision of a fit note or attending to a minor illness may be managed in under 10 minutes with ease; but if the situation is more complex—for example, involving an elderly patient with numerous comorbidities—10 minutes may not be enough. However, giving these patients the time they deserve will have a knock-on effect—and a waiting room full of patients who are frustrated or anxious when their appointments are delayed will challenge even the most experienced clinical and administrative staff.
The principal aim of the primary care team is to deliver high-quality, person-centred care to patients in the community. However, very few GPs feel that they can comfortably provide satisfactory, holistic care in a 10-minute appointment slot. Although some factors that affect the length of a consultation are outside of a GP’s control, others—such as time management and communication with patients—are within our purview and can be enhanced to optimise 10-minute consultations. This article provides five top tips on the effective management of 10-minute appointments to help GPs cope with their workload while providing excellent patient care.
1. Allocate Appointments to the Most Appropriate Healthcare Professional
Continuity of care is becoming the exception within the NHS; this may be as a result of changes in working patterns such as part-time working, employment of locums, or expansion of the multidisciplinary primary care team, and political mandates such as extended access. Currently, patients are often encouraged to accept an appointment with a clinician they have not met rather than wait for a delayed appointment with their preferred clinician. Since the start of the COVID-19 pandemic, it has become more difficult for patients to see a clinician, with many people experiencing prolonged waits for an appointment.
The reception team should be trained to allocate appointments to the healthcare professional with the most relevant knowledge and skills for each patient, and all practice staff should be made aware of the clinical and specialist expertise in the practice in order to direct patients appropriately. Patients should be directed to the clinicians (doctors, nurses, or clinical pharmacists) who have a special interest in—or experience of managing—their specific condition. This will support the entire team to manage patients’ concerns more effectively, simultaneously easing GP workloads and improving patient satisfaction.
2. Structure Consultations to Meet Patients’ Needs Effectively
Build a Rapport
Effective consultations rely on a good relationship between clinicians and their patients, which takes time to develop. Building a rapport during consultations involves good communication skills: listening to the patient while extracting useful biopsychosocial information, and collaborating with them to draw up a comprehensive and personalised management plan.
With growing patient lists, it is impossible for clinicians to meet every single patient registered at a practice. The flow of the consultation will therefore depend upon whether the clinician has met the patient previously. When encountering a patient for the first time, it is crucial to work on building a rapport—a warm introduction and open questions such as ‘How can I help?’ or ‘What can I do for you today?’ may help to get the consultation off to a good start.
Taking the extra time to build a relationship in this way will generate trust with patients—this may save time during future consultations, and prevent patients from booking additional appointments with other clinicians because they feel dissatisfied with the outcome.
Stay Focused, Summarise, and Set an Agenda
It is essential to remain focused, selecting key aspects of the patient’s history and executing the examinations that are most appropriate. Most of the relevant information emerges from the patient within the first moments of the consultation, and can be ascertained by avoiding interruption and letting the patient talk.
Once the patient has expressed their concerns, summarise their points and set an agenda, listing all of the issues raised by the patient. If the patient wishes to discuss multiple problems, then negotiate how to progress the consultation to best address their worries. For instance, with the patient’s consent, the clinician may wish to select the most concerning item to manage during the current consultation, and address any other issues by inviting the patient to attend another pre-booked appointment. This will help clinicians to manage the consultation more efficiently.
Incorporate Shared Decision Making, a Management Plan, and Safety Netting
It is essential to explain to the patient how the consultation will progress, whether by asking more specific questions relating to the complaint, performing a physical examination, or ordering further investigations. Use of closed questions and inquiries about red flags will help to rule out any serious pathology, in addition to differentiating between the need for emergency treatment, an urgent or routine referral, or a watch-and-wait approach.
Clinicians should use the information gathered during the consultation to explain the findings to the patient, and agree on a management plan with them in a clear, concise manner that avoids the use of medical jargon. Allow time for patients to digest the information provided, and give them the opportunity to ask questions—this ensures that the patient understands their condition and the plan of action, which may help to avoid future confusion related to any ambiguities. Shared decision making increases patients’ satisfaction with the decisions made, understanding of the risks and benefits of the available options, and concordance with the agreed treatment plan, which may save time in future.
Finally, patients should be provided with a ‘safety net’, explaining what they should do if their symptoms worsen or what red-flag symptoms to look out for, and a review appointment should be booked if deemed necessary.
General practice has the advantage of being able to follow patients up, providing continuity of care. Various problems can be managed by reviewing patients frequently within a short space of time. For instance, when patients come in with multiple problems, including unresolved issues from previous consultations, we can review their prior consultations and aim to solve their remaining concerns within the 10 minutes—particularly as we or our team would have seen the patients before and documented their plan of action.
In addition, any issues that are not addressed during the scheduled appointment can be brought back to another appointment. This ensures that consultations do not overrun, and that patients do not feel rushed or that they have not been heard.
3. Make Full Use of the Multidisciplinary Primary Care Team
Learn to use the experience and expertise of practice staff and Additional Roles Reimbursement Scheme members (such as social prescribing link workers, clinical pharmacists, paramedics, mental health practitioners, and occupational therapists) to share workloads, thereby making the best use of consultation time. Constantly review the skill mix of the team and identify areas of deficiency. By offering the necessary training, a team can be established that ensures that optimal care and support is given to the patient population.
For example, a patient who is a frequent attender with social, emotional, and practical needs may benefit from referral to a social prescriber, who will give them time, focus on what matters to them, engage in shared decision making, and undertake personalised care and support planning. Another example is appropriate direction of administrative tasks to the nonclinical team. Both of these initiatives will aid clinicians to manage their consultation time more effectively.
4. Cultivate Clear Policies at the Practice
Policies need to be implemented to ensure that patients keep to their appointment times. Have a system in place at the surgery to remind patients to cancel their appointments well in advance if they are no longer able to attend. To maximise attendance, patients can be sent text message reminders about their scheduled appointments.
Furthermore, it may also help to notify patients about any unusual situations, such as building works or a lack of parking, that could prevent them from arriving on time. By being proactive, we can ensure that patients are seen on time and that clinicians’ consultation time is used to best effect.
5. Adapt GP Consultations to Incorporate New Ways of Working
At Hillview Surgery, we introduced a ‘total triage’ model during the pandemic, with remote consultations available via video, telephone, and online. Consequently, at our practice, patients can choose the mode of consultation, with advice from clinicians on which would be the most appropriate and efficient to suit them and their concern. This initiative improved patient access while reducing workload pressures in general practice.
Remote consultations reduce consultation length, and patients generally appreciate the additional option. Digital consultations benefit both patients and clinicians, providing more channels of communication with clinicians, ensuring that consultations are conducted safely, and increasing patient and clinician satisfaction.[13,14] However, the choice should be a joint decision, and practices should be open to—and prepared to switch between—different modes of consultation depending on an individual’s circumstances.[13,14] Care must be taken to ensure that patients who are elderly, vulnerable, or lack access to the required technology are not marginalised, and face-to-face consultations should be made available to patients who request them.
Video consultations replicate face-to-face interaction as closely as possible, and are a ‘visual upgrade’ of telephone consultations.13 Many long-term conditions are suited to management via video consultations, including diabetes, hypertension, asthma, stroke, psychiatric illnesses, cancer, and chronic pain. In addition, video consultations are more suitable for certain patient types—such as people who are housebound, residents of nursing or care homes, or those requiring palliative care—and have the added benefit of reducing the need for home visits.
Online consultations provide patients with a choice in how they interact with clinicians, and offer a fast, convenient, and secure alternative to visiting a practice. They play a crucial role in preventative healthcare, health education, and managing nonurgent medical issues, and expanding access to care, especially for patients with physical disabilities or those who live in remote areas. In addition, they can help healthcare professionals to manage their workload in a more efficient and controlled fashion. For example, in the management of skin conditions, patients treated via online consultations can submit photographs of rashes, pigmentation, or moles, increasing the efficacy of the appointment.
Adopting a blended approach to communication with patients (for example, using a mixture of text message, online, telephone, video, and face-to-face consultations) prioritises their needs and may give them better control over the type of consultation.[13,14] Being able to offer different kinds of consultation depending on technical, patient, or clinical factors will ensure patient safety and maximise patient and clinician satisfaction.[13,14] An added benefit of this approach for clinicians is that working remotely is more flexible and convenient. By selecting the most suitable mode of consultations for patients, clinicians can manage their workloads and consultations more efficiently.
The duty of care that primary healthcare professionals have to their patients is of paramount importance. Although the patient’s agenda should be foremost, prevention, chronic disease management, and behaviour modification cannot be neglected. Therefore, accommodating everything in a typical 10-minute GP appointment can be challenging.
Organisation of the appointment system in collaboration with the multidisciplinary team and optimisation of the structure of the allocated consultation can enable clinicians to manage their workloads more effectively and use their consultation time more efficiently, delivering a better quality of healthcare to patients.
Dr Vasumathy Sivarajasingam
GP Partner, Hillview Surgery, West London