7.30am – 8.15am
My day starts with 45 minutes of paperwork: looking through correspondence, discharge summaries, out-of-hours reports and test results.
8.15am – 9.00am
I spend 45 minutes taking telephone triage calls for people requesting same-day appointments, requesting home visits or chasing test results.
9.00am – 1.00pm
Morning surgery: a total of 18 patients are booked in; the first patient arrives at 9.00am. Between seeing my own patients I am called in to review others with my GP registrar. The most unwell patient of the morning is a pregnant woman with poorly controlled diabetes who has what appears to be pneumonia. She struggles in with her 18-month-old child, who is breathless and wheezy. He does not have an appointment but needs urgent treatment. Once his breathing has stabilised we arrange for his father to come and collect him. I then contact the hospital to arrange an emergency admission for his mother. By the time the patient is safely in an ambulance my morning surgery is running 40 minutes late. The patients who have been kept waiting are understandably unhappy.
1.00pm – 1.45pm
I finish my delayed morning surgery at 1.00pm. We had planned a short practice meeting to discuss some staffing issues but three of the seven GP partners have emailed to say they can’t attend due to over-running clinics or home visits. The meeting is rearranged for an evening the following week. I move on to home visits. One visit is to an older patient who has been feeling dizzy when she stands up. Her blood pressure drops significantly when she stands. I review her long list of medications, and we agree to try cutting down the dose of one of her three anti-hypertensives and arrange a follow-up home visit in a week.
1.45pm – 2.15pm
I sit down with my registrar for a brief supervision.
2.15pm – 3.00pm
Before my afternoon surgery starts I have four referrals to write, 18 clinic letters to process, 28 prescriptions to sign and 36 lab results to check and action. I do this while eating lunch at my desk. One stool sample comes back with Shigella, a serious infectious disease that must be reported. The patient – a man in his 70s – has since been admitted to hospital. I get through to him on his mobile and find out the ward details in order to ensure the result reaches his clinicians.
3.00pm – 3.30pm
I phone patients who had called earlier, a hospital doctor wanting to know a patient’s detailed medical history, and the Coroner querying a death certificate I had completed. I also speak to a patient who is travelling to Oman and needs a letter for the airline as she is six months pregnant – her flight leaves that evening.
3.30pm – 5.30pm
Afternoon surgery: there are 12 patients booked in, many with mental health problems. One patient has had an 11-week admission to a private psychiatric hospital and is re-adjusting to life ‘back on the outside’. He is doing well. Another patient is a nanny who has an eating disorder; she forgot to feed the children she looks after as she is so preoccupied with her problems. We discuss her fitness to work. These patients definitely need longer than the 10 minutes they are booked in for.
5.30pm – 6.30pm
After the clinic I make 12 more phone calls. I return a call from social services and another from a district nurse who is worried that a patient’s wound has become infected. The rest of the calls are with patients. I speak to a concerned man who had been admitted to hospital that morning for elective surgery to repair an enlarging aortic aneurysm, but his operation was cancelled.
6.30pm – 7.00pm
I sit down with my registrar to discuss the patients from her afternoon surgery. We squeeze in some brief teaching on the treatment options for migraine.
7.00pm – 7.45pm
After completing two more referrals and dealing with some medication queries, I finally get round to dealing with my 43 emails. Most are related to management of the practice or my work for the clinical commissioning group (CCG).
On my way home I reflect on the list of things I have left un-done.
I think this looks good and the intention is great. However, this is missing a very important rate limiting step : the primary / secondary care interface. " I speak with the consultant psychiatrist...". I nearly dropped my phone. Unless you work in Shangri-la, this is harder to do than to meet the Queen.
My most difficult job is not seeing patients, it is doing the dirty work of secondary care.... Inappropriate disvharges, chasing up results initiated by them, etc ,etc.
Problem is secondary care is answerable to CCG and not GPs and CCG is powerless to effect change. I do not forma moment doubt the difficulties faced by my secondary care colleagues. They have their own battles. Unless some one improves this vital interface, GP morale will be low and patients will suffer.
Answer is not more funding but dedicating appropriate resources to this interface. But then that needs thinking out of the box. Politicians and NHS England are not even aware what GPs do and pay lip service to fancy words like " working at scale ', etc and these mean nothing!
I find the concepts fascinating and the NUKA model has obviously worked elsewhere. I don't understand the funding model behind this working?
nurse case manager
health care assistant
Unless you are accessing funding from elsewhere there is a GP (£85k), Nurse Manager (£45k), Pharmacist (£50k), Paramedic (£40k) plus the HCA and admin support. That is ALOT of resource.
Surely most of the improvement here comes from having employed several more people. Our generation's challenge is to do more work with the same amount of staff. Massively increasing our workforce as in this story is not an option.
Shame there’s no mention of repeat prescriptions . Our study shows up to two hours a day spent on repeats by GPs and there’s an alternative ( electronic repeat dispensing) that saves 45mins of gp time per practice per day.
Forward view also discusses Mental Health Professional in GP practices.
I start as an ANP in a GP practice in a few weeks.
A fantastic article however as others of mentioned in the current model a single GP is completing 30 consultations, one home visit, 28 prescriptions, 36 lab results and 12 phone calls for an approximate cost of 100K/yr. In the alternative model involving the GP, practice nurse and paramedic cost will be>>100K/yr is there the funding within Primary Care for this?
Other considerations: to achieve the seamless integrated care the alternative model requires a huge learning curve whereby the allied medical professionals feel confident to make independent decisions without having to 'run it by' the GP- again cost implications in training.
There is also a learning curve for patients to feel comfortable with seeing other members of the practice team rather than the GP. Issues around patients getting used to alternative consultation modalities eg email or virtual. Data from the uptake of the electronic prescribing service shows huge variations between practices ranging from 5% uptake to 50% update.
In this model when things go wrong where does the liability ultimately rest: is it with the GP? or is it with the entire organisation?
The most difficult metric to measure is the benefit to GP wellbeing the current model has vs the alternative model, we all know the answer but obtaining hard data is more difficult.
Thank you Kings Fund for highlighting this important issue!!
Sorry to detract, but the comparison model does not equate to the workload as itemised.
However it's divided up, the workload exists as finite demand, unachievable by the current workforce. Stratification does not address capacity. All the 'innovative' models require additional staff.
My 'innovative' 11-13hr days involve FIVE hours of 'doctor-first' triage, which may reduce the conversion rate for appointments, but raises the risks of missing important pathology and raises the rate of repeat consultations for those not seen or seen by ANPs etc.
e-prescribing actually takes longer due to clunky IT and even clunkier and intrusive embedded 'optimisation' software.
Easy e-advice interface with secondary care is let down by clunky e-RS, not integrated with medical records.
Unlike the small practice used in this example, our large practice (which should additionally benefit from economies of scale) ticks most boxes for 'innovative' models but we have not seen any significant reduction in workload.
Your proposed alternative day is simply unrealistic. We need to stop pretending that shifting workload around the system will do anything other than just that.
We would all welcome more ancillary staff in general practice, but need the honesty to recognise that they are additional, not replacements for more skilled staff.
Coherent integrated software, increase from 8% to 11% of budget and realistic proposals for GP retention and recruitment are the basic basics we all need now. Please stop reorganising my working life with nothing but wishful thinking.