Telephone first consultations in primary careBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4345 (Published 27 September 2017) Cite this as: BMJ 2017;358:j4345
All rapid responses
GP Access Ltd supplied nearly half the practice identities to the study, all those we worked with on an "Intention To Treat" basis. We also supplied all the consultation data to the study, extracted from GP clinical systems (it did not come from both companies as the article suggests). We stated that the telephone consultation duration could only be supplied for a minority of these, and the rest was imputed.
The article states, "Commercial companies marketing these systems report large reductions in GP workload and impressive reductions in attendance at emergency departments and emergency admissions." We don’t. Although I wrote a paper showing 20% lower A&E in a small scale study, we could not reproduce that result on a larger scale and stopped making any such claim in 2013. Still today you can see that claim made on the Doctor First website http://productiveprimarycare.co.uk/ along with one for £30k saving per GP per year. We have never made such a claim and it is unfair for the authors to imply equivalence to two unconnected companies.
The heading “Policy makers should reconsider their unequivocal support for these systems” is, I submit, misleading. No funds have been allocated to support these systems, in contrast to £45m allocated to online consultations (qv reported lack of benefit, BJGP http://bjgp.org/content/early/2017/11/06/bjgp17X693509).
Failure to measure any change in efficiency, even to investigate the reasons for differences in outcomes, denies general practice significant potential benefit at a time when it is most in need.
Competing interests: Founder & Chief Executive, GP Access Ltd
The astonishing patient service benefits shown in this study have been overlooked by the editorial authors, who have turned to one element which the study authors called highly variable and largely based on imputed data, namely the alleged 8% rise in "workload". It is critical to understand where this came from and what it means.
8% rise in "consulting time". This is only one element of workload, It could only be measured for SystmOne practices, a minority of the subject practices supplied by ourselves GP Access Ltd. This made up around 20% of all subjects, so the rest of the data was imputed, as well as highly variable.
Workload? No, this did not include a measure of visits, which is hard to do, although many GPs tell us their visits have fallen.
DNAs have fallen by typically 80%, so increased "consulting time" results as less time is wasted.
Most significant of all, no account is taken here of unmet need. We offered the study our measures (n>200,000 audits) of demand before and after change, which show 14% of patients turned awary before change, very few after change as the rise in efficiency means close to all can be helped every day.
This means that even without other effects, a 14% rise in patients helped would be expected within the same workload.
Had the study measured EFFICIENCY instead of an error prone subset of "workload" the headline would have been quite different.
Many GPs practising the model have been mystified by this particular outcome, and the editorial. They would never go back, because they know the model is more efficient. Many other GPs have tried DIY implementations with varying degrees of success, and we see a general increase in telephone consults. This is because GPs want to save time, and are saving time through the method. Not necessarily - poor understanding and poor implementation can indeed be less efficient, and it is the whole system approach, with consistent measurement, which has been sustainable.
It is interesting to note that new entrants to the GP provider market are operating a similar model: they know where efficiency lies. The effect of this editorial will be to dissuade those who could make great gains in efficiency, and their patients meanwhile will continue the frustrating weeks of waiting to get help.
Competing interests: Founder & Chief Executive, GP Access Ltd
Newbould et al's (1) study results are consistent with results provided by the Esteem trial(2) in 2014 and by Bunn Cochrane Review(3) ten years before: “telephone first” approach to the same day consultation request when compared to usual primary care access decreases the need for face to face consultation, increases the number of phone contacts - particularly return consultations – in the end increasing the GP overall workload (an outcome that hopefully should be reduced).
The authors' conclusions are: "The telephone first approach […]is not a panacea for meeting demand".
McKinstry et al's (4) comment in the Editorial was: "Telephone first systems alone will not solve the perennial problem of ensuring timely, safe, effective, and equitable access to primary care when demand is increasing and resources are not". They claim: “Policy makers should reconsider their unequivocal support for these systems”.
These conclusions could be conceptually biased by the lack of training for telephone call handlers and this should address future research.
As Newbould et al do not provide details about training, we wrote last 16 October to the commercial companies involved in the study to know how they train their call handlers: one has not yet answered and one answered they offer an e-learning program of about 2 hours, scenarios and examples presented by GPs.
The problem of the training of telephone call handlers has been known for at least 10 years(5) and was the topic of our Cochrane review(6) showing no evidence on how to train clinicians in order to improve their telephone consultation skills and the effect on patient outcomes.
At the same time the studies by Derkx et al(7,8) and Pasini et al(9) showed how poor the quality of telephone consultation could be both from clinical and relational point of view. Evidence coming from the Esteem trial shows also that professional characteristics are related to call dispositions because nurses who reported feeling 'more prepared' for the role were more likely to manage the call definitively.
So, how sure are we that the increase in telephone consultations detected in Newbould et al's study and in the Esteem trial(10) is not due to a lack of training and inability to manage the call definitively?
Considering the telephone first approach leads to a decrease of face to face consultations, the increase of overall workload could be attributable to the increase of return consultations due to the lack of training.
The research of Newbould et al lacks information about the quality of the communication, investigated the outcomes but we need to know more about the quality of the road call handlers followed.
Could this factor eventually provide an explanation to the "wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase", effect detected by Newbould et al and , therefore, are practices that experience a substantial reduction in workload served by more better prepared doctors?
Researchers in the future should consider more carefully the importance and weigh of training in telephone consultation outcomes: if call handlers have no training in telephone consultation they will be not be confident enough in closing the clinical cases, giving safety net advice to patients, or they will not be able to gain enough of the trust of patients on the phone in addressing their resource consuming behaviors.
How can we be reasonably sure that a telephone first approach led by untrained call handlers might realistically modify hard outcomes like emergency department attendance or referral?
Would we trusted a mountain guide for a climb without knowing anything about his/her skills and experience?
We think the results by Newbould et al should be taken with caution especially in the UK because it could enable commissioners to change schemes that are already working.
1 Newbould J, Abel G, Ball S et al. Evaluation of telephone first approach to demand management in English general practice: observational study. BMJ. 2017 Sep 27;358:j4197. doi: 10.1136/bmj.j4197.
2 Campbell JL, Fletcher E, Britten N et al. Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis. Lancet. 2014 Nov 22;384(9957):1859-1868
3 Bunn F1, Byrne G, Kendall S. Telephone consultation and triage: effects on health care use and patient satisfaction.
Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004180
4 McKinstry B, Campbell J, Salisbury C. Telephone first consultations in primary care. BMJ 2017;358:j4345
5 Car J, Freeman GK, Partridge MR et al. Improving quality and safety of telephone based delivery of care: teaching telephone consultation skills. Qual Saf Health Care 2004;13:2–3.
6 Vaona A, Pappas Y, Grewal RS et al. Training interventions for improving telephone consultation skills in clinicians.Cochrane Database Syst Rev. 2017 Jan 5;1:CD010034
7 Derkx HP, Rethans JJ, Maiburg BH et al. Quality of communication during telephone triage at Dutch out-of-hours centres.
Patient Educ Couns. 2009 Feb;74(2):174-8.
8 Derkx HP, Rethans JJ, Muijtjens AM et al. Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study. BMJ. 2008 Sep 12;337:a1264
9 Pasini A, Rigon G, Vaona A. A cross-sectional study of the quality of telephone triage in a primary care out-of-hours service. J Telemed Telecare. 2015 Mar;21(2):68-72
10 Varley A1, Warren FC2, Richards SH et al. The effect of nurses' preparedness and nurse practitioner status on triage call management in primary care: A secondary analysis of cross-sectional data from the ESTEEM trial. Int J Nurs Stud. 2016 Jun;58:12-20
Competing interests: No competing interests
I appreciate that the health service is very short of money. Professor Caan's cry from the heart finds an echo here with me.
If the deaf cannot hear, they cannot respond. Might I request the public health specialists to take Professor Caan's comments to their planning meetings?
(I assume the people I am addressing my appeal are not hard of hearing, nor lacking in sight.)
Competing interests: At the moment a little hard of hearing, a little DEAF.
Exploring why GPs switch to telephone first consulting would have enhanced this important paper. The GP workforce is struggling to meet demand. This style of working enhances the streaming of demand to other providers of care as we increasingly rely on skill mix to deliver care. I would echo that telephone first working increases total consultation, however proactively managing daily work helps to reduce work related stress. I would like to have known how many of those practices who switched to this style of working would now revert to a traditional appointment system, after three of working in this way our practice has no plans to change
Competing interests: No competing interests
Offering patients and their carers a variety of means to contact a GP is a wise move, provided the patient chooses the most appropriate communication channel for them. However, using the telephone to screen out time-consuming patients could contravene the Public Sector Duty of Equality. The editorial by McKinstry et al does consider the problems of telephone consultations for non-English speakers, but I wish to focus on Equality of access for people with disabilities. In every local patient list there will be people with hearing or speech problems or both. Face-to-face lip reading, note taking or signing is hard enough in a hurried GP surgery, but adding an initial 'phone barrier could discriminate against thousands of patients.
Our research found that in the past adults with learning disabilities had a specially high risk of institutional exclusion by NHS services. Problems of illness and disability were amplified by difficulties in self-advocacy and a lack of professional training. In the last Labour government several teams developed promising models of health facilitation for primary care. This sort of initiative stalled when the Conservatives came to power in 2010, and the Health and Social Care Act 2012 has led to disastrous fragmentation (and often neglect) of services for children or adults with disabilities. This Winter both Health and Social Care are coming under extreme pressure, so the vital expertise of the general medical practitioner may be spread very thinly across their patient list. Practitioners under pressure may not find it easy to weigh up their Duty of Equality, so in relation to patients with disabilities, I just ask them to keep in mind a Duty of Humanity ?
 Caan W, Hampton-Matthews S. One from the heart, for people with a learning disability. British Journal of Nursing 1999; 8: 97-100.
 Thomson K, Gripton J, Lutchmiah J, Caan W. Health facilitation in primary care seen from practice and education. British Journal of Nursing 2007; 16: 1156-1160.
Competing interests: Past involvement in disability rights, e.g. Every Disabled Child Matters, and a former Learning Disability Champion
Some of the conclusions in the report and editorial are not justified by the evidence presented. The problem is inherent to any evaluation of a complex intervention and raises big questions about how to report evidence about such interventions.
The editorial summarises the results like this: "There was distinct variation among practices in how well the system functioned. Some noted large reductions in workload while others experienced big increases." But then goes on to say; "Although the delay to see or speak to a doctor is greatly reduced by the introduction of telephone first systems, overall workload for doctors increases. The marked reduction in time spent consulting in surgery is more than compensated for by an increase in time spent on telephone consultations."
The problem is that the second part uses the average result across all trials to make a statement about whether the intervention works or not but this isn't consistent with the degree of variation which shows, at the very least, that the benefits are sometimes large. Unless we understand the reason for the variation we can't draw a clear conclusion that the average result is really measuring whether the intervention works.
The problem is caused because there are two major sources of variation here: one is the population variation among GP practices (this is analogous to the metabolic and physiological variation among patients in an RCT of a drug). But unlike a drug trial where the actual intervention can be carefully controlled (we test whether the pills are all the same etc.) you can't control the variation in the way telephone triage was managed by the practices. If this was a drug trial we would be testing pills with unknown amounts of variation in their content and strength). What this means in practice is that the outcomes cannot be attributed to the simple use of telephone triage but may have large factors dependent on how the practices managed their use of telephone triage.
An analogy might help (this one was used by the respected economist John Kay to illustrate a common error in business strategy). Imagine you have the ambition to be a great concert violinist. You observe that the great performers have certain characteristics in common: they all wear evening dress, they all have expensive violins, for example. You reason that to become a great violinist you must copy those visible characteristics so you buy yourself expensive clothes and an Amati violin. You are still a useless violinist.
The lesson is that copying the visible characteristics is not the important thing that makes you a great violinist: that would require you copy the things the great violinist did that you cannot see (practising for 10 hours a day for a decade and having a good teacher, for example).
The same is true for complex healthcare interventions in general and telephone triage in particular. The easy-to-see part is that some form of telephone triage is done. What is more difficult to tell is what else a practice has to get right to get any benefit from this. How well do they manage the process? How do they learn what can be resolved over the phone and doesn't require a face-to-face appointment? How do they redesign the practice workflow to exploit the benefits of the intervention? It is worth noting that a similar problem arises in healthcare (and every other industry for that matter) when trying to get benefits from the use of IT. Unless the work is reorganised to exploit the benefits of the technology, there won't be any. So many studies report that computers are a waste of time despite the fact that they could yield benefits if the complicated additional task of redesigning the work was also undertaken.
In telephone triage we can tell whether the system will work using a handful of characteristics of the system: what proportion of calls can be resolved over the phone? how long does the average call take? how long are face-to-face appointments? It is easy to construct a simple model showing, from these numbers, whether there is an overall time saving. But all those numbers depend on skill and experience and can be improved with good management. Those factors are far from being visible when testing telephone triage. If the practice doesn't have the skill and doesn't monitor the numbers to drive improved skill then there won't be significant benefits (and this isn't made easier by the fact that one major vendor of GP clinical systems appears to be unable to record how long telephone calls last). It isn't just adding telephone triage to the system that yields the benefits: it is getting those other factors right.
So to argue from the average benefits across a large number of practices that telephone triage doesn't work is a logical mistake. It is obvious from the report that some practices saw big benefits and time savings. It is also obvious that most practices saw much faster access for patients. But a general claim that triage systems don't work is a bit of a logical leap when the data shows that sometimes do.
We should not be claiming that this study shows phone triage doesn't yield benefits to GPs; we should be asking what factors mattered to give benefits in some places and not others.
The report and editorial are right, though, that policy-makers have an endearing but dangerous belief in "magic-bullets". Pushing telephone triage won't help unless the complicated set of supporting management practices that make it work are understood. And they are rarely understood by the people who make policy. Unfortunately this is a common error that greatly inhibits many efforts to improve quality and efficiency across the whole NHS.
It would also be good if the vendors of the systems were clearer about the need for fine-tuning the way the systems are operated to maximise the benefits (full disclosure, I currently support one of them and one of my goals is to develop better ways of providing analysis to practices to support them to improve the way they operate).
In summary, the right conclusion from the study should not be "phone triage doesn't work" but "phone triage sometimes yields big benefits and we really need to start asking which factors make it work in some places and not in others".
Competing interests: GP Access is a client of mine, though I'm commenting in a personal capacity.
Telephone triage may seem an attractive way to ensure that valuable clinic time is prioritised for those that need face-face discussions and examinations, and enable more patient contacts in the limited time available. However, expanding numbers of patient contacts raises the risks of 'decision fatigue' (1) and impaired self-regulation and decision quality (2).
General Practice is already stretched to its limits, with bulging patient:GP ratios, increasing complexity, guidelines, inspections, revalidation and scope of work. Ultimately, this all adds to the burden of decisions placed on individual doctors, both clinical and non-clinical. So the conclusions of this study do not surprise me. It is logical that increased patient contacts, decisions and complexity lead to fatigue, thus resulting in attempts to simplify, delay or refer decisions, and increased referrals or recalled patients.
To some extent this was recognised by the RCGP(3). Increasing demands and decreasing resources, on a historical background of unsustainable ideals of professionalism, is leading General Practice faster down the tracks of self-destruction.
In the interests of protecting professional quality and patient safety, the RCGP has a responsibility to speak up and openly question politically-driven incentives that could further stress people and systems on the verge of collapse.
1) Danziger S, Levav J, Avnaim-Pesso L. Extraneous factors in judicial decisions. Proceedings of the National Academy of Sciences. 2011 Apr 26;108(17):6889-92.
2) Vohs KD, Baumeister RF, Schmeichel BJ, Twenge JM, Nelson NM, Tice DM. Making choices impairs subsequent self-control: a limited-resource account of decision making, self-regulation, and active initiative.
3) Royal College of General Practioners. Patient safety implications of general practice workload. July 2015 http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z...
Competing interests: No competing interests