Apr 1, 1990 - A BONESETTER SEVERELY CENSURED. On February 22nd an inquest was held at the Blaina Police. Station, before Mr. W. B. Walford, ...
GENERAL PRACTICE
Workload of general practitioners before and after the new contract David Hannay, Tim Usherwood, Maria Platts Abstract Objective-To assess changes in general practitioners' workload associated with the new contract introduced in April 1990. Design-Weekly workload diary completed during four weeks in February-March 1990 and during the same period in 1991. Setting-Sheffield, United Kingdom. Subjects-All 300 general practitioners on Sheffield Family Health Services Authority list as principals in 1990 and 1991. Main outcome measures-Mean number of hours worked per week, number of patients seen each week, and mean time spent per patient. Results- 181 (60%) general practitioners responded in 1990 and 163 (54%) in 1991. Of these, 18 (10%) were not working in 1990 and 14 (7%) in 1991. General medical service work increased during a "normal working week" from a mean of 38-6 hours a week in 1990 to 40-6 hours in 1991, and non-general medical service work decreased from 5-4 hours a week to 4-5 hours. Hours spent on call were similar before and after the contract. For the 99 general practitioners who responded in both years, time spent on general medical service duties increased significantly (40.4 h in 1990 v 42-6 h in 1991; p=0033), mainly due to more time being spent in clinics. Significantly more patients were being seen in clinics (9 v 14; p=0-001); the average time spent per patient remained at about 8/2 minutes during surgeries and 16 minutes for a home visit, and rose from 13 to 14 minutes for patients seen in clinics. The time spent on practice administration fell but not significantly.
Conclusion-Since the new contract there has been a significant increase in general medical services work, mainly due to more patients being seen in clinics, with no reduction in the time spent per patient.
Department of General Practice, University of Sheffield, Sheffield S10 2RX David Hannay, FRCGP, professor Tim Usherwood, MRCGP, senior lecturer Maria Platts, SEN, research assistant
Correspondence to: Professor Hannay. BMJ 1992;304:615-8 BMJ
VOLUME 304
Introduction The new contract for general practice was published in the wake of the government's white paper Working for Patients' and came into force on 1 April 1990. The reforms were intended to change the way in which general practitioners worked with an emphasis on accountability, competition, prevention, and value for money.2 Several studies of general practitioner workload were made before the new contract was published,3 notably the report prepared for the doctors and dentists review body by the Department of Health and Social Security and the General Medical Services Committee in 1985-6.4 This survey was repeated in 1989-90, the year preceding the introduction of the contract in April 1990.5 Later that year the GMSC commissioned management consultants to research the workload of general practitioners after the contract, but this was abandoned due to lack of response. 7 MARCH 1992
We assessed the effect of the new contract on workload by surveying the same group of general practitioners for one month before the new contract came into effect and again one year later.
Subjects and methods All 300 general practitioner principals on Sheffield Family Health Services Authority list were sent a weekly workload diary during the four weeks 18 February to 18 March 1990 and again a year later during the equivalent four weeks 17 February to 17 March 1991. The diary covered seven days and was sent to 75 different doctors in each of the four weeks. The diary was designed to cover categories of general medical services duties and non-general medical services duties which were comparable with those used in the 1985-6 workload study.4 It also included details of hours on call and the numbers of patients seen each day. Time was recorded to the nearest half hour on a daily basis from 7 pm one day until 7 pm the next. After a pilot study responders were encouraged to complete the diary retrospectively for each 24 hour period as soon after 7 pm as possible, rather than continuously recording every half hour as for the government GMSC surveys.45 The daily results for each respondent were aggregated to weekly totals before analysis. These data were analysed by the statistical package SPSS-PC. Most frequency distributions were highly skewed, so comparisons between those doctors who responded in both 1990 and 1991 were made with the Wilcoxon signed rank test. The null hypothesis was rejected if the test statistic exceeded 0-05. No details of individual doctors were collected apart from their workload. Responses were identified by only a code number and no names appeared on the forms to ensure confidentiality. The survey was supported by the local medical committee, and in both years was preceded by a letter to all Sheffield general practitioners to encourage a high response rate and accurate recording. The weekly diaries with a covering letter and instructions were distributed a week in advance of the recording week, and all general practitioners were sent a follow up letter at the end of the four weeks. Results Three hundred general practitioners were on Sheffield Family Health Services Authority list for the four weeks in both 1990 and 1991, although they were not all the same doctors. Workload diaries were returned by 181 general practitioners (60%) in 1990 and 163 (54%) in 1991. Eighteen doctors were not working during the study period in 1990 and 14 were not working in 1991, mainly because of holidays or illness (table I). Between one quarter and a third of general practitioners were working seven days a week, and those working in both
615
TABLE I-Days spent working during four weeks in 1990 and 1991 No (%) of general practitioners No of days working per week 7 6 5 4 3 2
1990
1991
(n=181) (n=163) 55 (30) 35 (19) 56 (31) 12 (7) 4 (2) 1 (1)
39 (24) 36 (22) 61 (37) 10 (6) 2 (1) 1 (1)
18 (10)
14 (9)
0
0
years had an average of 1 3 days off in seven. Ninety nine doctors who completed diaries were working in both 1990 and 1991. Table II compares the average normal working week for the 163 respondents in 1990 who were working during the study period with that for the 149 respondents who were working in 1991. There was an increase in total general medical services work mainly due to more time being spent in clinics, but more time was also being spent in patients' homes and on teaching. Although time spent discussing cases and on paperwork increased, time spent on practice administration fell. The increase in other general medical service activities was mainly due to minor surgery. Less time was spent on non-general medical service work after the new contract, largely because of a decrease in time spent doing hospital clinical assistantships. Overall there was an increase of just over one hour a week in the average total number of hours worked. Both the amount and the range of activities undertaken by doctors varied considerably in both years. The proportion who taught rose from 32% to 42% over the two years, and the percentage undertaking other general medical service activities such as minor surgery increased from 12% to 22%. The proportion of doctors attending courses fell from 47% to 31%, and the proportion engaged in clinical non-general medical service work such as clinical assistantships fell from 50% to 41%. Although there was little overall change in the total number of hours on call, there was an increasing tendency for out of hours on call to be shared with other practices (table III). The proportion of doctors on call for another practice as well as their own increased from 9% to 15% during working hours and from 12% to 18% out of hours and during weekends. The proportion of doctors on call for only their own practice out of hours fell from 69% to 53%. Both before
and after the new contract only 4% of doctors were working for the deputising services, and the proportion of general practitioners who were on call for their own practices at sometime during working hours remained the same at 91%. Table IV compares the average number of patients seen per week and the time spent per patient in 1990 and 1991. Activity varied considerably, with a maximum of 324 and 347 patients being seen overall in 1990 and 1991 respectively. The maximum number of home visits by a doctor was 100 (recorded in 1990), and the maximum number of clinic patients seen was also 100 (recorded in 1991). The average time spent with patients was calculated from the total time spent with patients and the numbers of patients seen. The minimum mean time spent per patient in surgery was 3-1 minutes (one doctor in 1991) and the maximum 24-5 minutes (one doctor in 1990). The maximum average time spent per patient was one hour in clinics and 48 minutes for house calls. Because of the large variations in work patterns among doctors, as indicated by the size of the standard deviations, it is difficult to know how much of the differences was caused by there being different groups of respondents in the two years. To minimise these differences we also compared workload for the same doctors who responded and were working in both 1990 and 1991 (tables 11-IV). Total general medical service work increased significantly, mainly because of more time being spent in clinics. Significantly more patients were being seen in clinics after the new contract than before, and slightly more time was being spent per patient (table IV). Significantly more time was spent on other general medical service activities, much of which was accounted for by minor surgery. The amount of non-general medical service work fell, mainly due to less time being spent on clinical work in assistant grades in hospital. The average number of hours on call before and after the contract did not change
TABLE II-Mean (SD) weekly working hours in 1990 and 1991 for doctors who were working during study Doctors working in both years (n=99)
All doctors working during study Wilcoxon test 1990 (n= 163)
Generalmedicalservices Surgery: Travel toand from Seeingpatients House calls: Travellingtime In patients' homes Clinicattendance Teaching Discussion of cases and paperwork Practice administration Other Non-general medical services Attendanceatcourses Non-clinical Clinical
1991 (n= 149)
385(11 1)
1990
406(119)
3-6(1-9) 16 5 (5 2)
3-3 (1-7) 16-9(4-7)
17 4(5 0)
3-3(2 0) 5-2 (2-8) 1-6(1-5) 0-7(1-3)
3-3(1 8) 5 6 (3-2) 2-4(2 1) 0-9(1 6)
38 (2-5)
4-2 (3-0) 3-6 (3-3) 0-4 (1 3)
40 (2 6) 4-3 (3 3) 0-1 (0 4)
Totalwork
3 8 (3-1) 0 1 (0 4) 5-4 (6-7)
3-4(1-6)
1-8(2 7) 1-1 (4-4) 2-5 (3-7) 43-9(12-1)
42-5(116)
45-1(12 3)
p Value
0.033*
2138
3-4(1-7) 17 6(4-5)
0-120 0-423
0 904 0-672
3 5(2-1)
3-5(1 8)
5 4 (2-7) 1-5 (1-4) 0-8(1-3)
5-9 (3-1) 2 5 (2 3)
0-728 0-227
1-0(1-7)
0-348 1-207 4-428 1408
4-2 (3-2) 4 1 (3 7) 0-4 (1-0)
0 779 0 974 2 306
0-436 0-330
4-5 (6-1) 1-3 (2 6) 1-2 (4 6) 2-0 (3-5)
Z
1991
405(106)
5-7 (7 5)
1-7(2 7) 1 3 (5-4) 2-6 (4-1) 46-2(11-9)
0.000* 0-159
0.021*
4-8 (6 6) 1 4(2 8) 1-4 (5 1) 2-0 (3-3)
0-082
1-742
0-165 0 816 0-098
1-390 0-233 1-653
47-3(11-4)
1-141
0-254
*Significant result (p
