Multimorbidity, deprivation and consultation length The inverse care law persists in general practice

Dr Becks Fisher, a GP in Oxford and Senior Policy Fellow at the Health Foundation, reflects on the length of GP consultations and the persistence of the inverse care law.

Barely a week goes by without a consultation with C.

On paper, C’s age suggests mid-life. But a tough life, underscored by poverty, has aged her beyond her years. C has a variety of physical health problems, but it’s her mental health challenges that require frequent GP time. She knows my regular working days and saves up her thoughts accordingly, tumbling them out in lengthy conversations covering her many difficulties, feelings of anger, despair and desperation.

Giving C the time she needs isn’t always easy as it’s a commodity in short supply in general practice. The Health Foundation’s analysis of the 2019 Commonwealth Fund Survey – a comparison of the experience of GPs across 11 high-income countries – showed that just 5% of UK GPs feel satisfied with the amount of time they can spend with their patients. That’s significantly lower satisfaction than in any of the other countries surveyed, but perhaps isn’t surprising – UK GPs also report the shortest consultation times.

So, given that time is something we’re short of in general practice, are we at least dividing it up fairly?

Time in proportion with need?

People who live in poverty are more likely to develop multiple health conditions, and at a younger age – 10 to 15 years earlier in the most deprived populations than in the most affluent. It seems reasonable to assume that people with multiple health conditions might need more GP time: more appointments, and longer consultations.

Focus on frequency alone, and this does seem to happen. People with multiple health conditions do get more GP consultations. It’s less clear what happens with consultation length. Studies show that increasing consultation length does appear to improve outcomes, and the Royal College of General Practitioners (RCGP) recommend that GPs should offer longer consultations for people with multimorbidity. But in Scotland, patients who are multimorbid and living in deprived areas don’t get longer appointments, though their counterparts in the most affluent areas do. Does that hold true south of the border?

Resoundingly ‘yes’. We analysed data from 1.25 million GP consultations over 2 years in England, representing contact with over 190,000 patients. Unlike in Scotland, we find that consultation length does increase for all patients with multiple health conditions (and by slightly more if one of those conditions relates to mental health). But at all levels of multimorbidity, consultations are shorter in more deprived areas. In summary, if you live in a deprived area, having multiple health conditions will on average get you a slightly longer GP consultation, but it’ll still be shorter than if you lived in a more affluent area.

So what?

It’s hard to equate our findings directly with quality of care. It’s possible that GPs practising in areas of high deprivation are more efficient, achieving the same outcomes in shorter times. But other indicators suggest this isn’t the case – GP practices in areas of high deprivation on average do worse on all major indicators of quality – Quality and Outcomes Framework (QOF) scores, CQC ratings and patient satisfaction surveys.

And although we can’t say why consultations are shorter in more deprived areas, we can hazard some guesses. Patient-related factors will play a part, but recent Health Foundation analysis shows that general practices in areas of high deprivation are under-funded and under-doctored relative to need. Practices serving the most deprived populations receive around 7% less funding per need-adjusted patient. A GP working in a practice serving the most deprived patients will on average be responsible for the care of almost 10% more patients than a GP serving patients in more affluent areas. Factor in the more complex health needs that those extra patients are likely to have, and it’s unsurprising that GPs in more deprived areas have to spread their time more thinly.  

So back to C. I fully expect to speak with her next week. When I do, I’ll be grappling with my usual concerns – one of them being how to equitably divide up the precious resource of my own time. C needs more time than a 10-minute consultation allows, and she’s not the only patient I’ll be speaking with that day with extremely complex, often acute, needs. With 12-hour days the norm, staying later and later isn’t a viable solution.

The fact that GPs working in areas of high deprivation are not able to give longer consultations to patients with multimorbidity can’t be remedied at individual GP level. This isn’t about individuals working longer or harder. It is about a system needing to change to put equity first – dividing up resource in proportion with need. Tudor Hart described the inverse care law in 1971, but almost 50 years later – and in the midst of a pandemic which highlights and exacerbates health and socioeconomic inequalities – neither funding nor workforce are equitably distributed in English general practice. Until this is remedied, expect more study findings like ours: the inverse care law persists in 2020.

Rebecca Fisher (@BecksFisher) is a GP in Oxford and Senior Policy Fellow at the Health Foundation.