I have spent a lot of time trying to manage my time over 28 years as a GP and have probably wasted quite a lot of it in the process. The lessons are straightforward around priorities, lists, doing today’s work today, delegation and saying no to tasks which are not my responsibility or that I do not see as important. That would all be easy if I had more time and someone to whom I could delegate work. Our admin staff would probably leave and patients would wonder why I have become so grumpy or obstructive.
I am often asked by patients if I am busy, sometimes in a slightly sarcastic tone having just spent 30 minutes in a heaving waiting room. My answer depends on that tone. It may be ‘not really’ which makes them think I have been having a snooze or was determined to finish the sudoku puzzle or more often I reply that I start the day with a full timetable then see how many other tasks/patients I can squeeze in.
To prioritise work you can use a matrix of urgent and important boxes.
|1. Chest pain
UTI, Patient worried
|4. Queens score
Box 1 will be directed to 999 or NHS24.
Box 2 up to 2 weeks
Box 3 a letter to say the request is being considered
Box 4 sometime in the corridor
If I worked in an office with a door that shut firmly, fixed appointments daily and access electronically then I could fit all tasks into each box and respond with a timescale mainly determined by me. Medicine is not like that.
Most GP work starts in Box 3 driven by patient perception of urgency but should really be in Box 2. I would like more to move to Box 4 as that may be more important to me on different days such as when Rangers visit Palmerston. Most consultations will really end in Box 4 as there is no diagnosis to be made or it will be self-limiting. Box 1 has been moved to the ambulance service but those symptoms can easily be moved to any other box depending on the underlying cause. A 1 week old rash from a new perfume may be urgent due to patient concern but will heal whatever I do, so over to Box 4. A reported rash which turns out to be a nasty cellulitis with rigors should be Box 1.
The problem is that to make these decisions I have already spoken or seen the person so the time has already gone. Our appointment systems cope with same-day demand to manage Box 3 when Box 2 could really be the starting point. The e-mail attachment has already been opened or the letter read before I can decide on the box. So I wondered how I could metaphorically shut the door without becoming totally unavailable and I realised that everyone else except me had worked it out years ago
– A PERSONAL REFERRAL TEMPLATE!
This would have the usual pre-amble about national guidelines, urgency, exclusions, links to other (more appropriate) services and a telephone ‘hot-line’ with 8 different pre-recorded messages, all spoken quite quickly so you would have to press 9 to repeat them.
As an aside, when I was a GP trainee the other GPs wondered why one partner had quieter nights than them. Then they listened to the message he left on the telephone and knew why.
The referral page would include examples of urgency and several mandatory boxes to complete, including, of course, some of which you would never have thought of asking such as weight, exercise tolerance and smoking status which are irrelevant to most requests but help me update QOF figures.
Exclusions would include tasks which should have been done by another clinician, prescription requests by in-patients or for the deceased (not kidding), urgent requests for medication needed for a holiday booked 2 months ago or anyone asking for a house visit having just flown back from Florida that day or specifying which time they will be in.. Similarly any replacement of sedatives or opiates even when the police have been informed. These will all need a covering letter.
Important but non-urgent requests such as ongoing symptoms, medical reports, HGV exams, meeting requests and replacement certificates will be put on a waiting list. This will be within 4 weeks for sore knees and shoulders and 8 weeks for all other problems.
Ideally, of course, a period of consultation, staff communication and public awareness of this new system will be vital to its success. I will write a strategic document with an implementation timescale and financial projections which will be circulated but unfortunately I have been unable to assess any impact on other parts of the service…
……I don’t have the time.
John Locke is a General Practitioner