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

BMJ 2017; 358 doi: (Published 27 September 2017) Cite this as: BMJ 2017;358:j4197
  1. Jennifer Newbould, research leader1,
  2. Gary Abel, senior lecturer in medical statistics2,
  3. Sarah Ball, analyst1,
  4. Jennie Corbett, analyst1,
  5. Marc Elliott, senior principal researcher and, distinguished chair in statistics3,
  6. Josephine Exley, senior analyst1,
  7. Adam Martin, analyst1,
  8. Catherine Saunders, senior research associate4,
  9. Edward Wilson, senior research associate4,
  10. Eleanor Winpenny, analyst1,
  11. Miaoqing Yang, analyst1,
  12. Martin Roland, emeritus professor of health services research4
  1. 1Cambridge Centre for Health Services Research, RAND Europe, Westbrook Centre, Cambridge CB4 1YG, UK
  2. 2University of Exeter Medical School, Smeall Building, St Luke’s Campus, Exeter EX1 2LU, UK
  3. 3RAND Corporation, 1776 Main Street, Santa Monica, CA 90401-3208, USA
  4. 4Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Cambridge CB2 0SR, UK
  1. Correspondence to: M Roland mr108{at}
  • Accepted 1 September 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.


  • We thank members of our study steering group, including the patient members, who provided advice during the course of the study; the patients, GPs, and the practice manager who were part of our steering group, those who came and contributed to our learning events, and patients who completed questionnaires as part of our patient survey; and the commercial companies (Productive Primary Care and GP Access) that provided contact details of practices using their approaches and the staff and patients from the practices taking part in the study.

  • Contributors: All authors contributed to the conception or design of the work, the acquisition, analysis, or interpretation of the data. GA, JE, CS, and ME led on the statistical analysis. EW, AM, and MY led on the economic analysis. All authors were involved in drafting and commenting on the paper and have approved the final version. MR is guarantor.

  • Funding: The study was funded by the National Institute for Health Research (HS&DR Project 13/59/40). Part of the funding was used to pay for data to be extracted from practice records by one of the commercial companies providing management support for the telephone first approach (GP Access). GP Access had no input into the analysis or interpretation of the data. The study was sponsored by Cambridgeshire and Peterborough Clinical Commissioning Group (CCG), who gave initial approval for the project. The CCG’s main role thereafter was in administration of financial and contractual aspects of the grant.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study was approved by the West of Scotland NHS Research Ethics Service (7th May 2015, REC reference 16/WS/0088).

  • Data sharing: No additional data are available.

  • Transparency The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted. There are no significant discrepancies from the study as planned.

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