Averages in general practice*

• GP list size is 2,087 patients.
• Practice list size is 8,757.
• Number of repeat prescription items issued per patient per annum is 13.
• Number of GP referrals made per month is 9 per GP.
• Number of consultations per patient per annum is about 3.

As a practice manager and AMSPAR tutor, I was always fascinated by the statistics of general practice and I still am. As a manager, looking at a full waiting room and listening to the constantly ringing phones, I took this as an indication of a high workload. But as a patient, I might phone for a non-existent appointment, speak to a doctor instead, only to find myself in an almost empty waiting room still waiting to see a doctor. How do you ‘account’ for that in workload terms? Has it saved any time?

It’s a judgement call

How do you judge whether a practice is efficient and effective? How do you measure the demand for GP services, and how do you match demand with the accurate supply of service providers? My answer has always been guided by statistics. Probably as a result of my background in the administration of family practitioner services, I’ve always looked at the average list size in a practice. Certainly, prior to 2004, the average list size in a well-doctored practice might hover around 1,800 patients. Such a practice was judged to have sufficient doctors. However, as the average increased to, say, 2,100 plus, the warning signs were there to indicate that another doctor might be required. The danger level was reached when the average list size exceeded 2,500 patients. Practices in this situation were encouraged to take another partner but the political view at the time was that there were few areas left in the country that were regarded as ‘designated’ to need more GPs and the system of managing GP manpower was abolished.

Left to their own devices

Since 2004, it’s been left to practices to manage their own affairs, but there are many factors that have come into play that affect both the demand for services and the supply of clinicians to provide those services. I’ve used the word ‘clinician’ deliberately as the health professionals providing general medical services are no longer just doctors. The list now includes healthcare assistants, nurse practitioners who can prescribe, and practice-based pharmacists. This is in addition to trainee GPs and practice nurses. The question arises, how do you calculate the average list size if you take into account the other clinicians? The value of a clinician might be measured by looking at the sessional time spent seeing patients and the average amount of time spent with each patient. For instance, the average time a GP spends in a consultation is said to be around 9 minutes. But what if a telephone consultation has also taken place? Of course, the patient population has changed and we must consider an ageing population, the level of immigration, more students at university and changes to the restriction of boundaries to practice areas.

Methods for calculating appointments

• 72 appointments per week per 1,000 patients, or
• 1 session for every 200 patients per week

Historically, GPs have always made a sessional commitment to work in a practice. The BMA’s definition of a session was a period of 3 to 3.5 hours. The GP model contract definition states that full-time is 9 sessions per week or 37.5 hours per week. However, the core hours are 8:00 to 18:30. The BMA now regards the length of a session as 4 hours 10 minutes. So, you could legitimately ask how is the total weekly core of 52.5 hours manned and by whom? Now we move into the realms of imagination. A typical session might include 15 ten-minute booked appointments, updating the patient computer records, approving repeat prescriptions, reading and actioning clinical letters, writing referral letters and other administrative and clinical duties such as managing QOF and liaising with colleagues. But do all these duties need to be performed by a GP?

Changing faces

The face of general practice has changed for many patients who can no longer make an appointment to be seen today but instead may speak to a doctor. In some practices, patients are seen by a nurse practitioner, which is deemed to be a solid solution to the workload problem. You note that in the previous paragraph, I referred to booked appointments. The average number of patients seen per GP session is said to be around 21 patients. So, each GP session will arguably overrun by at least an hour. Other complicating factors include annual leave and outside commitments. A GP will normally work only 46 weeks per annum and of course the surgery is closed on bank holidays. The habit of working 9 sessions allowed for the fact that GPs historically took a half-day off each week. Was this to compensate for working on Saturday mornings or did GPs take another half-day off to balance out their commitment? The reality is that fewer and fewer GPs now work full-time, and a four-day week has become the norm rather than 9 sessions. Add to that half-days or days lost attending meetings then the real reduction in commitment is much greater. And the fact that there’s more pressure to allow for family-friendly working practices means that doctors working less than 8 sessions and less than four days per week is even more common. Another worrying factor is the trend for doctors to take early retirement and for doctors to take the view that they can earn more working as a GP locum.

Other mitigating factors

Looking at GP workload in more detail calls for an idea of the number of repeat prescriptions issued in a practice, which has an impact on the workload of one or more individual practitioners. On average, around 13 repeat prescriptions are issued per patient per annum – i.e. one item every four weeks. What’s the level of repeat prescribing in your practice? How many referrals are made by your doctors each week? Is it around 9 referrals per doctor each month or is it much higher? How many clinical letters arrive for processing each day? One doctor in an NHS England report stated that he read over 70 letters per day, but a close examination of the letters, to judge whether he needed to read and act on them or not, reduced the number to 4 per day!

So, whilst it might be simple to measure workload by averaging the number of patients against the number of sessions worked, there are many more factors that a practice might wish to look at, for example:

• What weight would you give to a GP trainee or nurse practitioner session?
• What weight would you give to a GP working 8 clinical sessions but blocking out appointment sessions to carry out other duties, such as managing QOF and the finances of a practice?
• How would you regard a doctor whose sickness and absence levels are excessive and the burden of looking after patients falls to others?

It’s no easy task working out what services you need to provide to meet an ever-changing demand. You may have to look at the number of appointments used, the number of telephone consultations, the number of prescription requests, etc. You may well have local factors which create far more workload. I suggest you keep a regular eye on the statistics you collect and compare them with national averages.

*Sources include Pulse, GP Online, the BMA and NHS England.

Author – Robert Campbell