The complex consultation – are we seeing more complex patients and why?

Nada Khan is an Exeter-based GP and clinical academic, and an Associate Editor at the BJGP.

You might be left scratching your head after a long clinic with consecutive, complex consultations, an occurrence that feels increasingly common to me.  I wrote recently about the domino effect of unintentional consequences from the Additional Roles Reimbursement Scheme (ARRS), a complex intervention within a complex system.  In their report, ‘The Future of General Practice’, the House of Commons Health and Social Care Committee suggested that the introduction of these new professionals into practice have left GPs dealing with multiple challenging cases ‘one after another’, which they cite as a contribution to clinician burnout, decision fatigue and increasingly detrimental effects on patient safety.¹  But do the ARRS roles lead to GP clinics filled with increasing complexity, and what are the other contributory factors?

What makes a consultation complex?

Multimorbidity is common and is increasing, especially amongst an aging demographic here in the UK. Recent projections suggest that amongst people aged over 65, more than 68% of the population will have more than two chronic medical conditions by 2035.²  GPs know that this aging and increasingly multimorbid population is leading to increasingly complex work, usually without additional resources.³  But it’s not just multimorbidity and an aging population at play here.  The catalogue of factors contributing to increasing consultation complexity also include increased management of chronic conditions in primary rather than secondary care, earlier discharge from hospital, increasing management of patients on long secondary care waiting lists, and increasing social care needs.

What really makes a consultation complex, and is it possible to measure consultation complexity?  To answer this question, a research team used a Delphi consensus approach, then a cross-sectional study to develop and validate a measure of consultation complexity, which in its final iteration included factors such as multimorbidity, polypharmacy, mental health presentations, and doing more than two preventative or routine tasks in the consultation.⁴  However, the authors acknowledge that the concept of complexity is ‘nebulous’, and while clinicians know what it means to them, it’s hard to define, and indeed, may not be defined or measured in the same way by those thinking about it or experiencing it in a different way.  It would, however, be interesting to use tools such as this to examine trends in complexity by professional group to examine the Health and Social Care Committee assertion that GPs are increasingly left dealing with the complex cases.

Losing the ‘easy wins’

With patient, system and social factors contributing, how might the increasing workforce mix in general practice impact on consultation complexity?  Some GPs feel that ARRS team members peel off the ‘easy wins’, leaving them with the complex, multimorbid patients who come to clinic with a list of issues to tackle within a 15, or even more challenging 10 minute consultation. A Kings Fund report looking at the integration of ARRS roles into general practice mirrored this view, with one GP commenting that ‘every time somebody takes an aspect of my work, they often take the work that is either simplest or fun and that leaves me with ever-more complex and exhausting things…’⁵  Bethan Jones and colleagues very recently published a paper in the BJGP looking at the views of ARRS professionals on the implementation of the scheme in practice. While some practitioners, such as pharmacy technicians, felt that they were reducing the administrative load from GPs, many others on the ARRS scheme acknowledged that they were not reducing the clinical burden.⁶

Are ARRS team members ready to take on complexity?  Some of those in ARRS roles, for instance, paramedics and some nurse practitioners, have more experience in acute care sectors.  A recent workforce impact assessment of ARRS roles led by the Queen’s Nursing Institute suggested that these members of the ARRS team may have limited experience in managing long-term conditions, which leaves other clinicians left to undertake more complex reviews.  The report described this as ‘taskification’ where people with less experience in primary care delivered more fragmented, task-based care rather than a holistic patient based care model.⁷

Fragmentation of care

GPs can experience several challenges when working with patients with more complex needs, including dealing with this fragmented care in a time of decreasing relational continuity.  Most clinical guidelines are written for single conditions that don’t always take multimorbidity and complexity into account, so GPs need to rely more heavily on their clinical judgement.⁸  Consecutive complex consultations can contribute to cognitive fatigue.

Here is where meaningful continuity really counts.  GPs who don’t know their patients feel they have to go back to ‘square one’ with complex patients, and that takes more time to try to get right.³  And probably that’s where the complexity peels away, because over time, as a doctor and patient begin to understand their relationship and what they bring to the table, many problems won’t seem quite so complex after all.  This rings true to the core of relational continuity as person-focused care over time, rather than a focus on just managing disease.⁹  With relational continuity, one practitioner with knowledge about the patient can help to develop a holistic view of the patient, their priorities, and how to manage complexity as a whole, and dare I say, sometimes ends up leading to a rewarding encounter for the clinician and the patient.  This is a far cry from the increasing ‘taskification’ of primary care, so thought needs to be given as to how to offer better relational continuity and management of complexity within the multidisciplinary team.

Final thoughts

We have just heard that the funding for the ARRS scheme is being continued, which provides us with an opportunity to think carefully and reflect on our experiences so far.  Fragmentation of care is one area that is impacting on patient and practitioner experiences, and with increasing diversity in the multidisciplinary team, the evolution of the primary care micro-team needs further testing and evaluation.  Could there be a role for adopting a practice policy of extended, person-centred consultations for particularly complex patients as suggested in a recent paper published here in the BJGP?¹⁰  And as more evaluations of the scheme roll in and we learn from how workforce diversification impacts the multitude of complexities in general practice, we have an opportunity to think carefully how to rejig services accordingly.

References

1. 1. 1. 1. The future of general practice: Fourth report of session 2022-23. House of Commons, Health and Social Care Committee; 2022.Contract No.: HC 113.
         2. Soley-Bori M, Ashworth M, Bisquera A, Dodhia H, Lynch R, Wang Y, et al. Impact of multimorbidity on healthcare costs and utilisation: a systematic review of the UK literature. Br J Gen Pract. 2021;71(702):e39-e46.DOI: https://doi.org/10.3399/bjgp20X713897
         3. Cheshire A, Ridge D, Hughes J, Peters D, Panagioti M, Simon C, et al. Influences on GP coping and resilience: a qualitative study in primary care. Br J Gen Pract. 2017;67(659):e428-e36. DOI: https://doi.org/10.3399/bjgp17X690893
         4. Salisbury C, Lay-Flurrie S, Bankhead CR, Fuller A, Murphy M, Caddick B, et al. Measuring the complexity of general practice consultations: a Delphi and cross-sectional study in English primary care. Br J Gen Pract. 2021;71(707):e423-e31. DOI: https://doi.org/10.3399/BJGP.2020.0486
         5. Baird BL, L.; Bhatt, R.; Beech, J.; Dale, V. Integrating additinal roles into primary care networks. The King’s Fund; 2022.
         6. Jones B, Anchors Z, Voss S, Walsh N. A qualitative investigation of the Additional Roles Reimbursement Scheme in primary care. Br J Gen Pract. 2024. https://doi.org/10.3399/BJGP.2023.0433
         7. Leary AP, G. ARRS Workforce Impact Survey. London The Queen’s Nursing Institute; 2024.
         8. Wallace E, Salisbury C, Guthrie B, et al. Managing patients with multimorbidity in primary care. BMJ. 2015; 350: h176. DOI: https://doi.org/10.1136/bmj.h176
         9. Starfield B. Primary Care: Balancing Health Needs, Services and Technology: Oxford University Press; 1998.
         10. Bogerd MJL, Exmann CJC, Slottje P, et al. Predicting ‘anticipated benefit’ from an extended consultation to personalise care in multimorbidity: A development and internal validation study of a prioritisation algorithm in general practice. Br J Gen Pract 2023. DOI: https://doi.org/10.3399/BJGP.2023.0114

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