The document discusses constraints to delivering expert generalist care in the UK. It notes that lack of time during consultations is a key constraint reported by GPs. While evidence is limited, increased consultation length has been associated with benefits like improved patient satisfaction and quality of life for those with multimorbidity. A small increase in time may help GPs better manage complex patients.

1. Medical generalism in the UK:
Caring against the clock:
Greg Irving
Clinical Lecturer in General Practice

2. “Many respondents talked about
having adequate time to do really
good diagnostic practice,
especially in the context of more
complex patients, more
investigative and management
options to explore”
複雑な背景を持ち、
多くの検査が必要だったり、
マネジメントを色々考える必要があったり。
回答者は、しっかりとした診療の実施のた
めの、十分な時間の確保について触れて
いた。

3. “…ten minutes is now very short to
combine a patient-centred
approach to information
gathering, do a proper
examination….”
情報を集め、適切な検査をし、患者中
心の医療を提供するには、10分という
診療時間では、とても足りなくなってい
る。

5. Constraints to generalism
• Qualitative study identifying constraints to
delivering expert generalist care
• Participants from 14 WONCA Europe countries
• Generalist capacity assessment framework
(questionnaire & topic guide)
– Sense making
– Engagement
– Action
– Monitoring
ジェネラリズムを制約するもの

6. Generalist capacity assessment framework
https://www.surveymonkey.com/s/QCL6R3K

7. Constraints to generalism
• Lack of time in consultation was a key
constraint to delivery expert generalist care.
GP trainee: “Time spent looking after complex
patients is well spent but there is often no time
for this on a busy day.’

8. Hasegawa H et al. PHCRD 2005; 6: 320–328

15. “7 minutes had become the summary
statistic of the day”
Sir Denis Pereira Gray PRCGP
1998
Pereira Gray D. BJGP. 1998;48:1816–1817

16. Year 1997 2006 2008 2014
Mean consultation
length (mins)
9.37
Mean no.
consultations (any
health
professional) /
year
4.01
Mean number of
GP consultations /
year
2.92
Total time /year
(mins)
27.8
Irving G et al. BJGP 2012;62:404

17. Year 1997 2006 2008 2014
Mean consultation
length (mins)
9.37 11.7
Mean no.
consultations (any
health
professional) /
year
4.01 5.22
Mean number of
GP consultations /
year
2.92 3.23
Total time /year
(mins)
27.8 37.8
Irving G et al. BJGP 2012;62:404

18. Year 1997 2006 2008 2014
Mean consultation
length (mins)
9.37 11.7 -
Mean no.
consultations (any
health
professional) /
year
4.01 5.22 5.5
Mean number of
GP consultations /
year
2.92 3.23 3.4
Total time /year
(mins)
27.8 37.8 -
Irving G et al. BJGP 2012;62:404

19. Year 1997 2006 2008 2014
Mean consultation
length (mins)
9.37 11.7 - -
Mean no.
consultations (any
health
professional) /
year
4.01 5.22 5.5 8.3
Mean number of
GP consultations /
year
2.92 3.23 3.4 3.49
Total time /year
(mins)
27.8 37.8 - ~40.8
Irving G et al. BJGP 2012;62:404

20. SAGE consultation model
• SAGE = School for Advancing Generalist Expertise
• Assumes a competence in the basics of consultation
• Not a replacement for, but an extension of the work
described by Pendelton, Neighbour, and etc

22. Cochrane review (Wilson et al 2009)
• 4 trials : Short term, not of high quality, 1978-1992
• Insufficient evidence to say whether increasing consultation
length provides patient benefit (or not)
• With longer consultations
• More health promotion
• GP did not run more tests
• Patients were not any more satisfied with care
• Patients did not alter follow-up behavior
Wilson A et al. Cochrane Database of Systematic Reviews 2006;1:CD003540

23. Systematic review (Hutton et al 2007)
• Focus on psychological problems
• 29 studies included
• Consultations with a recorded diagnosis of a psychological problem
were longer.
• GPs reported that time pressure is a major barrier to treating
depression.
• Evidence that increased consultation length is associated with more
accurate diagnosis of psychological problems.
Hutton C et al. BMC HSR 2007; 7: 71

24. Care plus trial (Mercer)
• Pilot cluster randomised trial
• Intervention - longer consultations for patients with
multimorbidity
• Longer consultation led to increased :
– Patient satisfaction
– Patient enablement
– Quality of Life

25. Summary
• Lack of time is a key system constraint to delivering expert generalist
care
• Large number of GPs is associated with increased consultation length
• Evidence limited to say whether increasing consultation length
provides patient benefit (or not) – more needed
• Small increase in time may help enable patients with complex needs
• Increased consultation length is associated with more accurate
diagnosis of psychological problems.
診療時間が足りないことが、優れたジェラリストケアを提供する上での主な制約
多くのGPが診療時間の延長に関連している
診療時間の延長が患者にとって有益かどうかについて、まだエビデンスは弱いーもっと研究
多少の診療時間の延長は複雑な背景を持つ患者にはよいかもしれない
診療時間の延長と、心理的問題の正確な診断は関連している