The rising workload of modern-day general practice

As I write, all is quiet in the land of general practice. Everyone is still busy, but it is not the frenzied wintertime busyness, or the anxiety-laden summer busyness with the uncertainty of getting a locum to cover a holiday. At a recent continuing medical education (CME) meeting, the last one until autumn, the atmosphere among attendees was relaxed and calm. People were glad to see each other, happy to have nothing major to report, grateful for the longer evenings, and the chance to catch our breath.

The CME evening consisted of multiple small-group case discussions, followed by a large-group plenary with an expert advisor. The cases revolved around the hazards of writing prescriptions, transcribing prescriptions issued by others, particularly hospital consultants and junior staff, and following up on care initiated elsewhere. How do we ensure everything is done to the highest possible standard, and every patient is followed up correctly?

For instance, what if we receive a letter and buried deep within the body of the text is a recommendation that we re- peat a PSA in six months? What if we don’t see that recommendation, and the patient doesn’t get the blood test, and he develops prostate cancer? This is a significant adverse event for this patient. Or what if we do see it and notify the patient, but he doesn’t attend for the test and goes on to develop the disease? Or what if he does attend, but doesn’t come back for the result, or comes back to another doctor for a completely different problem, at which time the result is buried in the file, and nobody notices it?

These scenarios can happen easily. In the context of a 10-minute consultation, with a patient who may be in pain, depressed, anxious, or acutely unwell, it is not possible to trawl through the ever-increasing list of reports and blood results received by email, and post, and sometimes both, and note every detail. And if a patient suffers harm as a consequence of a missed result, and it is deemed that such harm could have been minimised or avoided, the GP will almost certainly be accountable.

On that particular evening, we learnt that ‘GP informed’ means the GP is responsible, unless you write back to the specialist and tell them you are not taking responsibility for performing this test. But who has time for that? And such letter-writing is not a great use of a GP’s time. Most of the time, these recommendations for follow-up are not missed, and even though we might believe that the specialist who accepts the patient is responsible for monitoring and further investigation, we will do the test.

Which leads to the point: What happens then? Medical Council guidelines basically state ‘whoever does the test does the rest’. So now we have clearly accepted responsibility. It appears there is no risk-free option. Whichever way we turn, we find ourselves ensnared in a clinical risk web. Every report, blood result, and helpful suggestion by other healthcare providers entered in the file pulls that web a little tighter: Refer for MRI; reduce anticholinergic load; wean off PPI. All helpful and clinically relevant, but taken togeth- er, they amount to an impossible workload for a GP.

Meanwhile, patients may not realise how much effort this requires. Advice given to come back is forgotten, even when it is written down, because patients are people too, with lives and responsibilities, and everyone is so short of time. So, we stay after hours and ring, send messages, write letters, and update the records so that the plan is clear to those who might see this patient next and there will be no omissions or mishaps.

But it was spring, the birds were singing, there was still light in the evening, and despite the content of the meeting, no one seemed excessively concerned. GPs are a resilient and resourceful lot. “Life’s too short for all this letter-writing and record-keeping, texting, and messaging,” the GP sitting next to me said. “When are we supposed to see patients?” He was right. We can spend so much time managing people’s records, following other people’s agendas, that we can fail to see that the patient is desperately trying to catch our eye.

General practice is not a finely tuned machine and no patient file can adequately reflect the complexity of what happens there or the effort required to keep patients safe, no matter how many hours we spend on record maintenance.

I am not a Luddite. I own a smartphone and can book flights, taxis, and tickets, but sometimes I yearn for the bad old days, when a patient’s history could be contained between the covers of a cardboard folder, and ‘searching’ consisted of flicking to the back cover to see when they last had a full blood count.