Helen Salisbury: Playing to our strengths

Way back in the last century when I was a newly qualified doctor, I spent a lot of my time doing what we called scut work. This was the boring, repetitive, relatively unskilled work required to keep the ward running, tasks such as filling in forms and tracking down x rays. It made some sort of sense as we were definitely the lowest paid staff in the hospital, especially at weekends. It also contributed to the very long hours and sleep deprivation suffered by my generation of junior doctors.

Now at the other end of my career, I still find myself in the surgery late into the evening, glued to my computer screen long after the last patient has left and the cleaners have been and gone. I’ve recently, belatedly, been analysing the tasks I do and thinking about what’s best done by me and what I can delegate.

In an effort to reduce the burden on GPs, the Additional Roles Reimbursement Scheme funds non-medical staff to work alongside doctors in their surgeries, and this is specifically meant to be patient facing work. But is this what we really need and want? The arrival of clinical pharmacists in our practice has been very welcome—but much more for the behind-the-scenes help they give us in rationalising medications after hospital admissions or handling queries about out-of-stock medicines, rather than for face-to-face work with patients.

In many practices most of the simpler patient presentations are seen by paramedics, nurse practitioners, or physician associates. This has consequences. If all the clinically straightforward consultations are done by others, GPs are left with wall-to-wall, dawn-to-dusk complex patients, which is a sure recipe for burnout. Sometimes we long for a simple sore throat or infected ingrown toenail to interrupt the flow of patients with multiple symptoms and too many medications, severe depression, or cancer. Diverting simpler cases to other staff also disrupts continuity and our attempts to establish relationships. If I don’t see the teenagers when they come about their acne, will they later trust me with their eating disorders, unplanned pregnancies, or substance misuse?

What would really help is not an allied health professional doing some of my consultations but relief from the tedious paperwork. A recent role added to the reimbursement scheme is that of general practice assistant.1 Some of the tasks in the role specification would normally be done by a healthcare assistant (phlebotomy, ECGs), but much of it is administrative. This, at last, seems to be a step in the right direction: funding and training for staff to ease the burden of paperwork that keeps many doctors so busy late into the night.

Many other surgeries are probably ahead of us in this field, but I have a new zeal for ensuring that our doctors’ time is valued and is spent doing what they do best, which is consulting with patients. We’ll never avoid the clinical admin work entirely, as writing referrals, issuing prescriptions, and deciding how to respond to abnormal pathology results require clinical judgment and can’t always be delegated. However, with well designed processes we can safely pass some of this work to others in our team—just as soon as I can find the time to write the protocols.