General practice cannot be piecework

Lara Shemtob is an academic clinical fellow in general practice and occupational health physician.

Kabir Varghese is a GP and occupational health physician.

Shriti Pattani is a consultant occupational physician and president of the Society of Occupational Medicine.

Piecework is a type of employment where a worker is paid a fixed rate for each task completed, regardless of the time taken. Piecework is advantageous for production where output volume is a reliable proxy for productivity, and monitoring and incentivising output volume does not compromise quality.

When piecework systems are imposed in contexts where the unit of production is variable, there is a risk that workers are not fairly remunerated. The quality and sustainability of the work can become compromised as workers struggle to keep up with the pace of production.¹

Though this is not a perfect analogy, appointments have become perceived as a key unit of productivity in general practice. General practice activity data collected and published by NHS Digital consists mainly of appointments. Practices must offer 75 appointments per week per 1000 patients registered.

In November 2022, practices in England delivered almost double this quota.² Yet, mainstream media reporting focuses on an inadequate number of appointments being offered rather than appointment time or appointment quality. Demand far outweighs resource and data on number of appointments is not a meaningful reflection of care in isolation.

Treating GP appointments as piecework is problematic as the resource required to complete an appointment can vary significantly. Appointments in general practice data for November 2022 demonstrates 10 million appointments were completed in 10 minutes, while 11 million appointments took between 11 and 60 minutes. The remaining 7 million appointments that month were of unknown duration.²

The way practice workload is broken down into bookable increments with little redundancy creates pressure to complete any appointment in the same fixed arbitrary timeframe, in time for the next queued appointment. This may come at the cost of safety and quality. Data on appointment duration is likely to be an underestimate as it records the time between initial entry and initial exit into the patient record, which may not capture the full extent of time spent per appointment.

The hidden administrative workload generated by appointments is not recorded or recognised in activity reporting and may not be given adequate ringfenced time in the working day. Administrative work extraneous to appointments is a further workstream that often goes completely unacknowledged in the general practice workload. Number of appointments offered is not a meaningful reflection of access let alone quality of care without context.

GP appointments cannot be a standard unit of production. In addition, there is a significant administrative workload in general practice that falls outside of delivering appointments, which is pushed to outside of working hours due to the model that focuses on number of appointments. The workforce cannot keep up with the demand generated in each appointment in combination with the number of appointments they have to deliver per day.

Demand that outweighs resource is contributing to work-related stress, moral injury, and burnout. The most recent General Medical Council national training survey reveals around 60% of GP trainees and 50% GP trainers are at least at moderate risk of burnout.³ The workforce is not adequately financially remunerated for the time they spend working. Some data suggests that more than 75% of GPs undertake additional work each week equivalent to an additional unpaid session.^4,5 There are personal and financial opportunity costs of unpaid labour. Wherever they are in their career, GPs cannot afford to undertake patient-facing work full-time anymore.^6,7

What is the solution? General practice cannot be piecework. Appointments with arbitrary time allocations without room for flexibility cannot adequately reflect workload.^8,9 This is contributing to the workforce overworking and being underpaid as a consequence, with the sustainability of general practice under threat.⁴

One route to fixing this is to attempt to capture genuine workload rather than number of appointments offered, which is the tip of the iceberg and does not reflect demand. Another route to fixing this would be to move away from the piecework model and give the GP workforce more autonomy and flexibility in how they work, trusting the workforce to give more time to their patients where necessary, without penalising them with unpaid labour undertaken outside of their paid working hours, an outcome of the current model.⁵ This may come at the cost of a number of GP appointments but would be more reflective of actual capacity and workforce resource. This should feedback into a healthier and safer workforce able to undertake more sessions delivering care.

The British Medical Association (BMA) has recommended 25 patient contacts per day as the limit to deliver safe care.¹⁰ On average, GPs undertake almost 50% more patient contacts than this limit per day.¹¹ Current BMA standards set out that no more than 3 hours in a 4-hour and 10 minute session should be spent in consultation with patients.¹⁰ Emotional labour (regulating emotions when undertaking patient-facing care) and decision fatigue, both of which contribute to burnout, build with each patient contact. Uncapped demand, where clinicians are expected to undertake any number of patient contacts per day is also dangerous and must be avoided.¹⁰

A culture shift away from number of appointments as a standard unit of production is essential for stakeholders, including the NHS, the media, and patients. In order to survive, general practice teams need adequate flexibility to meet their patients’ needs. The full remit of the general practice workload must be acknowledged and remunerated. Demand must be capped according to resource.

References

1. Black J, Hashimzade N, Myles G. Piecework. In: Black J, Hashimzade N, Myles G, eds. A Dictionary of Economics. 4th edn. Oxford: Oxford University Press, 2013.
2. NHS Digital. Appointments in general practice. 2022. https://app.powerbi.com/view?r=eyJrIjoiMTQ4NjZjYjMtM2VlZS00NWFlLTlmOWEtYzE1MDQ0NDZiZjQ4IiwidCI6IjUwZjYwNzFmLWJiZmUtNDAxYS04ODAzLTY3Mzc0OGU2MjllMiIsImMiOjh9 (accessed 12 Jan 2023).
3. General Medical Council. Burnout for all trainees and trainers. 2022. https://reports.gmc-uk.org/analytics/saw.dll?Dashboard&PortalPath=%2Fshared%2FEducation%20Reports%2FEvidence%20Reports%2FBurnout%20Reports%2FBurnout-Dashboard-Public&Page=All%20doctors%20UK-wide&P1=dashboard&Action=Navigate&ViewState=veo76pusm0vs5ea1mpjt7lcbi2&P16=NavRuleDefault&NavFromViewID=d%3Adashboard~p%3Aevkf7qvbniab2isj (accessed 12 Jan 2023).
4. Pulse Today. More than a quarter of GPs work beyond safe hours every week. Pulse Today 2017; 17 Jan: https://www.pulsetoday.co.uk/news/workload/more-than-a-quarter-of-gps-work-beyond-safe-hours-every-week (accessed 12 Jan 2023)
5. Haynes L. Three in four GPs working extra unpaid session each week, poll finds. GPonline 2022; 21 Feb: https://www.gponline.com/article/1738895 (accessed 12 Jan 2023).
6. Bergman K. Workload issues affecting GP trainees’ plans for their future careers. 2022. https://www.kingsfund.org.uk/blog/2022/09/workload-issues-affecting-gp-trainees-plans-their-future-careers (accessed 12 Jan 2023).
7. Salisbury H. Helen Salisbury: where have our GPs gone? BMJ 2022; 377: o1158.
8. Flaxman P. The 10-minute appointment. Br J Gen Pract 2015; DOI: https://doi.org/10.3399/bjgp15X687313.
9. Salisbury H. Helen Salisbury: the 10 minute appointment. BMJ 2019; 365: l2389.
10. British Medical Association. Safe working in general practice. 2023. https://www.bma.org.uk/advice-and-support/gp-practices/managing-workload/safe-working-in-general-practice (accessed 12 Jan 2023).
11. Phillips S, Ede R, Landau D. At your service. A proposal to reform general practice and enable digital healthcare at scale. 2022. https://policyexchange.org.uk/publication/at-your-service (accessed 12 Jan 2023).

Featured photo by Remy Gieling on Unsplash.