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It’s about time: A conundrum in General Practice

Jens Foell (pictured) s a GP and GP Trainer in North Wales

Nina Cakiroglu is GP and GP Trainer in Bangor

Amit Singh is an eight-session GP in Conwy

 

“What is this life if, full of care,
We have no time to stand and stare?” (WH Davies)1

In a recent BMJ analysis, Johansson and Montori plead for the introduction of TNT (time needed to treat).2 We argue that Fordist-like approaches in manufacturing rely on accurately measuring the time it takes to perform tasks in a digitalised workplace.3 We juxtapose this with the concept of time as the time it takes in the mystery of General practice.

The pact with the devil, hidden reserves and burn-out

This is about doctor-exceptionalism. Doctors make a metaphorical ‘pact with the devil’ at the start of their career. The devil promises fulfilment and privileges but says he will claim his dues at some point in the future. They get used to digging into their reserves. They go the extra mile, deliver the extra smile. The way the industry works means that they must dig into these reserves on a regular basis. The industry norm is that one must deliver work on this basis, and often the service relies on ignoring self-preservation and regeneration. Sometimes it can turn into workaholism. Burn-out may occur, if networks of support are broken or the underlying set of values, commitment and solidarity are eroded.

…this assumption… assumes there is always a hidden extra tank of love, of listening, of time, that can be mobilised when it can be tapped into or unleashed.

In accolades of appraisals or obituaries doctors are praised to go the extra mile, but what if they don’t? If they work to rule, if their work is good enough, but not more? It assumes that there are always two modes of working – parcel-mode and poppet-mode.4

There is a catch in this assumption, and it blends in with doctors’ hubris. It assumes there is always a hidden extra tank of love, of listening, of time, that can be mobilised when it can be tapped into or unleashed. There may be infinite generosity, but time is finite. On a personal and on an organisational level time resources are finite.

GP Training: “getting trainees up to speed”

Getting trainees “up to speed” is an ongoing theme in GP education. GPs are (in-)famous for the speed of their interactions. GP magazines feature topics ending with “in a 10 min consultation”. Generalists should do in 10minutes what “partialists” are doing in 30- 45 minutes. “Perfunctory work done my perfunctory men”? (Lord Moran) Or a legitimate way to cut corners to either serve the needs of the population or to maximise income when payment is by numbers. What is this elusive and important speed?

Training schedules see trainees starting with seeing patients in 20-30-min-tact. The frequency goes up in line with their capability to examine, listen, ask the right questions, being organised, knowing the system. Consultation times vary widely between individuals and between practices.
There are several tricks of the speed trade in GP folklore. “Only one complaint at a time” was displayed as laminated quote in a colleague’s consultation room. Time-management features prominently in GP appraisals. The jury is out whether listening is associated with more time, or whether it is a special skill that can be applied even in speed-dating-style consultations. However, being rushed is rarely something both patients and clinicians value. It is risky. The clue lies in being present, which introduces a different concept of time.

Pre- or post-Fordism in digitalised General Practice?

Breaking complex or difficult production processes into smaller pieces and delegating them to groups of workers is the basic premise of industrial production. Ford’s T model assembly line is the emblem for this way of working. It relies on measuring and monitoring the time it takes for a skilled worker to undertake the manoeuvre he or she is asked to do.

However, exactly this has not been done in digitalised General Practice and it is very likely that the time needed to carry out a task or a succession of tasks varies widely between practitioners who are familiar with the case or not, between routined and experienced practitioners or novices, between perfectionists and perfunctionists etc. This applies particularly to clinical administration processes, eg interpretation of blood results or acting on clinic letters.

Such a seemingly mundane administrative task can relatively quickly be done if the doctor knows the case. However, current ways of working in large practices with fragmented workforce and role substitution (medicine management by pharmacy technicians and pharmacists, correspondence management by administrators) break the process up into components acted upon by different professionals with various degrees of training and less entitlement and capability to act flexibly with more discretionary space around the interpretation of abnormalities.

“Complex common” is complex and common, which means that it takes time to unpack presentations. In dense administrative environments it also takes time to process consultations (referrals, information management, data management).

Comedian Spike Milligan comments on innovations “I’ve just invented a machine that does the work of two men. Unfortunately, it takes three men to work it”. It captures the role of technology in the NHS. General Practice operates paperless. Most secondary care operates with paper-notes, patients have large folders. The NHS still operates with fax machines, the very devices you can see in science-and-technology-museums as examples of information technologies that are superseded by better information technologies. BUT examples of the sociomaterial realities of service provision include people having to use their personal smartphones to communicate between services, whilst exactly this is banned by protocol. These “workarounds” are typical for NHS work.

The speed of implementation of technology into healthcare is limited by the healthcare system’s ability to pick up and use the technology. The focus is too much on new developments and not enough healthcare systems ability to pick up and use the technology. The new technology may not be in sync with the exact requirements of healthcare and is often thrust from above – ‘co-production’ is the way forward. Adoption and implementation take time – almost never budgeted for.5 The old adage “10% technology and 90% sociology” remains true. Justice and fairness must remain at the core of any technology adoption and implementation.

There are different degrees of expertise between fully fledged expert generalists like GPs and primary care workers from different professional backgrounds whose wings are clipped.
As much as authors compare the generalist craftsman/craftswoman “GP” with their historical counterpart “engineer” before the erosion of their craftsmanship in the time of industrial manufacture, the analogy is only partially working.6 The basic work of standardisation of work items has not been properly undertaken. The multifactorial multidimensional work of meeting undifferentiated primary care does not lend itself to the way industrial processes are analysed and reassembled. So, in a paradox way, General Practice is at the same time pre-Fordist and post-Fordist.

All sorts of managers have been casted in by higher powers in top-down NHS management and failed. Retail managers did not get it, Management consultants got paid high amounts without understanding the industry they are paid to observe.

We are arguing to calculate the time it takes to do the tasks that need to be done in General Practice. This has been done in environments like NHS 111, but they operate on a different basis. They do not include all the hidden tasks that form part of the work of GPs – supervising staff and learners, all the little favours, “whilst I am here, doctor”. A huge amount of the work in General Practice is invisible.
Our take on Fordism or Toyotism is that they have limited value in describing the predicaments of healthcare as an industry, which includes emotional labour, cognitive labour, administrative tasks in multidimensional wicked environments.

Going back to Charlie Chaplin at the Fordist assembly line it means that the items that need to be assembled under time pressure are not uniform and standardised. They are dysfunctional Rubik-cubes, 1000-piece-puzzle sets with 80 pieces missing, memory sets in the wrong package or other impossible tasks. And they keep transforming: what is for one worker a Rubik Cube becomes a game of snakes and ladders for the next.

All sorts of managers have been casted in by higher powers in top-down NHS management and failed. Retail managers did not get it, Management consultants got paid high amounts without understanding the industry they are paid to observe.

Chronos and Kairos meet finite time: the mastery of General Practice

Dentists, Psychotherapists, data handlers and other professionals do not have a problem with accurately predicting the time it takes to carry out a task. Their task is defined, the time commitment more suitable to be commodified. In contrast GPs are dealing with undifferentiated primary care. What they see on the triage blurb is not what they get. It makes time calculations difficult. GP consultation rooms are TARDIS-capsules and the clocks on the wall bend like the ones in Dali-pictures. This elasticity of time and attention makes some people think that there is a secret stash of time that they can release for special circumstances or as afterburner-booster for the special poppets in contrast to ordinary parcels.

It only means that GPs are drawing time from an invisible account. Time, however, is a finite entity.
A personality-disorder-activist emphasises how important it is for “them” to have planning security. This means that the sophisticated psychotropic cocktails must be available at the chemist on time. Surgeries must run on time for doctors to be dependable for people with insecure attachments.

Time wasting: the past, the present and the future met in a bar. It was tense….

Time is a precious resource that should not be wasted. The trope of wasting time pervades the NHS as service and its users. It is built on the notion of scarce resources, deservedness, and entitlement. Older people may say at the end of the consultation where their fears have been alleviated that they are sorry for having wasted clinician’s time. Management is obsessed with “efficiency savings”. The discipline of cost-effectiveness-calculations takes all measurable factors into account and calculates the impact of service regulations on money and time. There is a bizarre common ground between the drive of capitalist economies to maximise profit and the socialist aspiration to ensure that the scarce resources of universal healthcare are used wisely, and waste is avoided. The NHS is in the middle of this Venn-diagram. Some clinicians enjoy getting lost in the moment, “wasting time” as much as Guy Debord sees drifting as an anticapitalist act of resistance.7 In his book “Momo” Children’s book author Michael Ende deliberates about the concept of time saving in the allegory of the grey men as time thieves, who steal the ability of being in the moment (like a playing child is completely immersed in the moment):
“The odd thing was, no matter how much time he saved, he never had any to spare; in some mysterious way, it simply vanished. Imperceptibly at first, but then quite unmistakably, his days grew shorter and shorter.”8
Consultations can be like child play. Unforeseen events may change a therapeutic situation. The unforeseen silence in a consultation may lead to patients disclosing important information. Paradigm changes do happen by serendipity. There are two discourses of time: Chronos and Kairos.9 There are chronometers, but there is no kairometer, because time as good opportunity or as golden moment is intangible and unmeasurable.

Infinite time: the mystery of General Practice

The counterargument against conceptualising General Practice as supply industry or gatekeeping function for specialist care is that General Practice has a different character, different epistemology, different value system and in our opinion even a different concept of time.10 Most patient contacts in the NHS happen in General Practice. This includes holding work as pastoral care. It also includes helping the ones you cannot help, dealing with medically unexplained disability and all other shapes of situations that do not fit into the precise stencils of specialist services.11,12
This time often resembles spiral time, not the linear time of production processes with a finite outcome. Even death is not a finite end product in General Practice. The evaluation whether the death of a loved one has been a good death or not, dignified or not, changes over time. And the grief of the loved ones is the next task in the pastoral care over generations. GP time is circular….

References

1. Davies W. Nature Poems And Others. Plymouth: Brendon and Son; 1908.
2. Johansson M, Guyatt G, Montori V. Guidelines should consider clinicians’ time needed to treat. BMJ. 2023;380:e072953.
3. Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the Time Needed to Provide Adult Primary Care. Journal of General Internal Medicine. 2023;38(1):147-55.
4. Maben J, Adams M, Peccei R, Murrells T, Robert G. ‘Poppets and parcels’: the links between staff experience of work and acutely ill older peoples’ experience of hospital care. International journal of older people nursing. 2012;7(2):83-94.
5. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovations in service organisations: systematic literature review and recommendations for future research. Milbank Q. 2004;82:581 – 629.
6. Iliffe S. From General Practice to Primary Care: The Industrialisation of Family Medicine in Britain. Journal of public health policy. 2002;23(1):33-43.
7. McDonough T. Guy Debord and the Situationist International: texts and documents: MIT press; 2004.
8. Ende M. Momo. London: Puffin; 1984. 240 p.
9. Smith JE. Time, Times, and the ‘Right Time’; Chronos and Kairos. The Monist. 2014;53(1):1-13.
10. Heath I. The mystery of general practice: Nuffield Provincial Hospitals Trust London; 1995.
11. Cocksedge S, Greenfield R, Nugent GK, Chew-Graham C. Holding relationships in primary care: a qualitative exploration of doctors’ and patients’ perceptions. British Journal of General Practice. 2011;61(589):e484-e91.
12. Vickers N. Winnicott’s Notion of ‘Holding’ as Applied to Serious Physical Illness. British Journal of Psychotherapy. 2020;36(4):610-20.

Featured photo taken by Andrew Papanikitas, 2023

Ethics of the Ordinary is a regular column on BJGP Life that explores ethical and moral concerns relevant to general practice and primary care.

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