NIHR Signal Using a ‘telephone first’ approach may increase the total time GPs spend consulting

Published on 14 November 2017

A system where all patients have a telephone call with their GP before an appointment decreased the number of face-to-face consultations but increased telephone consultations. There was an overall 8% increase in the time GPs spent consulting, though there was large variation across practices.

This NIHR-funded study compared 147 practices in England before and after the implementation of the telephone management system and also with a sample of surgeries using a standard appointment system.

Telephone first systems improved patient’s perception of the time to be seen or spoken to. Most patients surveyed were called back within the hour. Patients, though, had mixed views about the approach.

It was linked to a small subsequent increase in hospital admissions, which overall slightly increased secondary care costs.

The variable findings indicate that a telephone first approach may work for some but not all practices. Practice size, population mix (such as age, ethnicity, urban/rural) and staff familiarity with telephone management systems may all have influenced the likelihood of success.

Using a ‘telephone first’ approach may increase the total time GPs spend consulting

Share your views on the research.

Why was this study needed?

GPs are facing an increased demand for consultations. A recent study found that the overall workload of GPs in England rose by 16% between 2007 and 2014. Patients in England are also waiting longer to see a doctor. According to the latest survey, the average waiting time to see a GP is now two weeks.

This study evaluated a telephone first system that was developed by two commercial companies (Doctor First and GP Access). The system is GP-led, providing appointment scheduling and other help for workload planning. Patients who wish to see a doctor are phoned back on the same day by a GP, who will assess their condition and decide whether or not a face-to-face appointment is needed.

A previous NIHR funded study (ESTEEM) compared nurse-led and GP-led telephone management systems to usual care. Primary care contacts increased, but there were no apparent cost savings.

What did this study do?

This observational study compared trends in consultation rates and times before and after the introduction of the system for 147 GP surgeries. It also used survey data and hospital admission data from the telephone first practices to compare them with a random sample of 10% of surgeries in England using an appointment-based system.

Nearly 30,000 patients from telephone first practices completed the GP Patient Survey in 2011-16, assessing patient satisfaction. Hospital Episodes Statistics data (2008-16) was used to compare emergency and elective admissions and referrals in the 12 months before and after introducing the telephone first system. An economic analysis looked at changes in secondary care costs.

The study design is appropriate to the questions being asked. However, the data need to be seen in context. Practices with more efficient systems may be more likely to participate in the research. Patient safety and health outcomes weren’t examined. There was minimal data on consultation length or the effects on other staff like receptionists or practice nurses.

What did it find?

  • These changes resulted in an overall 8% increase in the mean time that GPs spent consulting. However, there was considerable variation in workload between practices meaning this just fell short of statistical significance (95% confidence interval [CI] -1% to 17%).
  • The telephone first system led to a 28% increase in total GP consultations. The number of face-to-face consultations decreased from a mean (average) of 13.0 to 9.3 consultations per 1000 patients per day.
  • Patient views were mixed, with some patients very happy with the convenience of the system while others found it uncomfortable discussing their issue over the phone. Nearly two-thirds of patients reported being called back within an hour (based on 837 patient responses). Advice was given in 17.3% of telephone calls; a prescription was given for 21.9% and 43.8% of calls resulted in a subsequent GP appointment.
  • The introduction of the telephone system was followed by a small increase (2%) in hospital admissions (95% CI 1% to 3%) and a similar decrease in what had previously been an increasing rate of emergency department attendance (2% per year, 95% CI 1% to 3%) compared with national trends.
  • There was an estimated overall increase in secondary care cost of £11,766 per 10,000 patients in the first year after the telephone system.

What does current guidance say on this issue?

There are no guidelines on the use of telephone management systems.

An evidence review by NHS England advocates telephone consultations as a useful tool for both patients and GPs, requiring fewer resources. They report that practices using the telephone first approach had a 20% lower use of emergency departments and provided cost savings of about £100,000 per practice through preventing avoidable attendance and admission to secondary care.

NHS England caution that some patients may be less confident in following telephone advice, so may seek a second opinion, which could lead to a duplication of service provision.

What are the implications?

This research challenges previous evidence by showing wide variability in the success of telephone first practices with no overall benefit to GP workload or secondary care use.

It would be valuable to explore factors that may deter or disadvantage patients from a telephone first approach, such as language barriers, inability to find a confidential space to speak, and the need to “show” rather than describe their condition. Further, GPs may vary in their aptitude for telephone consultations.

It may be worth investigating other models of care, such as email services or allocating set time to walk-in patients, and looking at how they work together, rather than as mutually exclusive options.

Citation and Funding

Newbould J, Abel G, Ball S, et al. Evaluation of a telephone first approach to demand management in English general practice: an observational study. BMJ. 2017;358:j4197.

This project was funded by the National Institute of Health Research (HS&DR Project 13/59/40).

Bibliography

Campbell J, Fletcher E, Britten N, et al. The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial). Health Technol Assess. 2015;19(13).

Kaffash J. Average GP waiting times remain at two weeks despite rescue measures. PULSE. 2017.

McKinstry B. Telephone first consultations in primary care. BMJ. 2017;358:j4345.

NHS England. High-quality care now and for future generations: Transforming urgent and emergency care services in England. 2013; London: NHS England: 35-6.

Thompson M, Walter F. Increases in general practice workload in England. Lancet. 2016;387:2270-72.

Why was this study needed?

GPs are facing an increased demand for consultations. A recent study found that the overall workload of GPs in England rose by 16% between 2007 and 2014. Patients in England are also waiting longer to see a doctor. According to the latest survey, the average waiting time to see a GP is now two weeks.

This study evaluated a telephone first system that was developed by two commercial companies (Doctor First and GP Access). The system is GP-led, providing appointment scheduling and other help for workload planning. Patients who wish to see a doctor are phoned back on the same day by a GP, who will assess their condition and decide whether or not a face-to-face appointment is needed.

A previous NIHR funded study (ESTEEM) compared nurse-led and GP-led telephone management systems to usual care. Primary care contacts increased, but there were no apparent cost savings.

What did this study do?

This observational study compared trends in consultation rates and times before and after the introduction of the system for 147 GP surgeries. It also used survey data and hospital admission data from the telephone first practices to compare them with a random sample of 10% of surgeries in England using an appointment-based system.

Nearly 30,000 patients from telephone first practices completed the GP Patient Survey in 2011-16, assessing patient satisfaction. Hospital Episodes Statistics data (2008-16) was used to compare emergency and elective admissions and referrals in the 12 months before and after introducing the telephone first system. An economic analysis looked at changes in secondary care costs.

The study design is appropriate to the questions being asked. However, the data need to be seen in context. Practices with more efficient systems may be more likely to participate in the research. Patient safety and health outcomes weren’t examined. There was minimal data on consultation length or the effects on other staff like receptionists or practice nurses.

What did it find?

  • These changes resulted in an overall 8% increase in the mean time that GPs spent consulting. However, there was considerable variation in workload between practices meaning this just fell short of statistical significance (95% confidence interval [CI] -1% to 17%).
  • The telephone first system led to a 28% increase in total GP consultations. The number of face-to-face consultations decreased from a mean (average) of 13.0 to 9.3 consultations per 1000 patients per day.
  • Patient views were mixed, with some patients very happy with the convenience of the system while others found it uncomfortable discussing their issue over the phone. Nearly two-thirds of patients reported being called back within an hour (based on 837 patient responses). Advice was given in 17.3% of telephone calls; a prescription was given for 21.9% and 43.8% of calls resulted in a subsequent GP appointment.
  • The introduction of the telephone system was followed by a small increase (2%) in hospital admissions (95% CI 1% to 3%) and a similar decrease in what had previously been an increasing rate of emergency department attendance (2% per year, 95% CI 1% to 3%) compared with national trends.
  • There was an estimated overall increase in secondary care cost of £11,766 per 10,000 patients in the first year after the telephone system.

What does current guidance say on this issue?

There are no guidelines on the use of telephone management systems.

An evidence review by NHS England advocates telephone consultations as a useful tool for both patients and GPs, requiring fewer resources. They report that practices using the telephone first approach had a 20% lower use of emergency departments and provided cost savings of about £100,000 per practice through preventing avoidable attendance and admission to secondary care.

NHS England caution that some patients may be less confident in following telephone advice, so may seek a second opinion, which could lead to a duplication of service provision.

What are the implications?

This research challenges previous evidence by showing wide variability in the success of telephone first practices with no overall benefit to GP workload or secondary care use.

It would be valuable to explore factors that may deter or disadvantage patients from a telephone first approach, such as language barriers, inability to find a confidential space to speak, and the need to “show” rather than describe their condition. Further, GPs may vary in their aptitude for telephone consultations.

It may be worth investigating other models of care, such as email services or allocating set time to walk-in patients, and looking at how they work together, rather than as mutually exclusive options.

Citation and Funding

Newbould J, Abel G, Ball S, et al. Evaluation of a telephone first approach to demand management in English general practice: an observational study. BMJ. 2017;358:j4197.

This project was funded by the National Institute of Health Research (HS&DR Project 13/59/40).

Bibliography

Campbell J, Fletcher E, Britten N, et al. The clinical effectiveness and cost-effectiveness of telephone triage for managing same-day consultation requests in general practice: a cluster randomised controlled trial comparing general practitioner-led and nurse-led management systems with usual care (the ESTEEM trial). Health Technol Assess. 2015;19(13).

Kaffash J. Average GP waiting times remain at two weeks despite rescue measures. PULSE. 2017.

McKinstry B. Telephone first consultations in primary care. BMJ. 2017;358:j4345.

NHS England. High-quality care now and for future generations: Transforming urgent and emergency care services in England. 2013; London: NHS England: 35-6.

Thompson M, Walter F. Increases in general practice workload in England. Lancet. 2016;387:2270-72.

Evaluation of telephone first approach to demand management in English general practice: observational study

Published on 1 September 2017

J Newbould, G Abel, S Ball, J Corbett, M Elliott, J Exley, A Martin, C Saunders, E Wilson, E Winpenny, M Yang, M Roland

BMJ Open , 2017

Objective To evaluate a “telephone first” approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation. Design Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data. Participants 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England. Intervention Management support for workload planning and introduction of the telephone first approach provided by two commercial companies. Main outcome measures Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies’ protocols. Results After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices −38%, 95% confidence interval −45% to −29%; P<0.001). An average practice experienced a 12-fold increase in telephone consultations (1204%, 633% to 2290%; P<0.001). The average duration of both telephone and face to face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95% confidence interval −1% to 17%; P=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Compared with other English practices in the national GP Patient Survey, in practices using the telephone first approach there was a large (20.0 percentage points, 95% confidence interval 18.2 to 21.9; P<0.001) improvement in length of time to be seen. In contrast, other scores on the GP Patient Survey were slightly more negative. Introduction of the telephone first approach was followed by a small (2.0%) increase in hospital admissions (95% confidence interval 1% to 3%; P=0.006), no initial change in emergency department attendance, but a small (2% per year) decrease in the subsequent rate of rise of emergency department attendance (1% to 3%; P=0.005). There was a small net increase in secondary care costs. Conclusions The telephone first approach shows that many problems in general practice can be dealt with over the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care.

Expert commentary

Despite the fact that it increases GP workload, without reducing the cost to the health service, some form of telephone triage has been introduced into most UK practices as a preferred way of managing demand. Perhaps this has happened because, as confirmed in this study, many problems can indeed be managed safely by relatively short telephone calls.

Interestingly, there is wide variation in practices' experience of introducing triage. Practices are unique in available resource, skill mix and patient population. 

Individual teams must identify which is the best demand management model for their environment, their staff and for the people they serve.

Dr Tim A. Holt, Senior Clinical Research Fellow, University of Oxford