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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

Rapid Response:

Patient perspectives on telephone first system

The report by Newbould et al [1] is important as the telephone first system has been introduced into many general practices without a proper evidence base.

Writing as representatives of a major patient charity, we think the authors have not paid enough attention to the adverse effects patients experienced and the extra costs incurred by hospitals.

A 4% immediate increase in ambulatory care admissions (“conditions for which admission could, in principle, be avoided by good primary care”) and increasing thereafter is bad news for patients (Table 5[1]). This fits well with the finding the ESTEEM study [2] that after doctor triage there was an increase of 22% in patients having to seek medical help out of hours [3]. Telephone first essentially converts many GP consultations from face to face to telephone consultations and it is now clear that GPs are not as effective in these much shorter consultations where they cannot observe or examine patients [4].

Whilst good and bad comments from patients are reported, the overall ratings from all the patients in the intervention group are what matter. For these, despite a 20% gain in immediate access, “the GP communication composite” is significantly negative (P<0.001). “Would you recommend your GP surgery?” Significantly negative (P<0.01), and “Seeing preferred GP” is also significantly negative (P<0.035). And all this incurs extra costs for secondary care at the rate of £1.12 per patient registered with the GP. The last thing NHS hospitals want now is thousands of extra admissions and additional costs of about £50 million pa if applied nationally.

In general practice, as patients, we do regret the significant shortening of GP consultations as longer duration is associated with greater quality [5] and being more patient-centred [6]

Telephone first is a doctor dominant system that reduces patient autonomy, which is why patients see the GP of their choice significantly less often. It can force patients to discuss embarrassing symptoms on the telephone with a doctor they have never met.

Newbould et al. conclude that there is “clear evidence that a considerable part of the GP workload can be dealt with through phone consultations.” This statement could only be justified if increasing the proportion of telephone consultations led to outcomes as good as usual care, delivered at the same or lower costs and their own findings show that they are not.

N.A.P.P therefore opposes this system.

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

2. Campbell JL Fletcher E Britten N Green C Holt TA Lattimer V 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; doi:10.1016/s0140-6736(14)61058-8.

3. Campbell JL Warren F et al. Patient perspectives on telephone triage in general practice. Lancet 2015; 385 :688. [letter]

4. Pereira Gray D and Wilkie P Patient perspectives on telephone triage in general practice. Lancet 2015; 385 :687 [letter]

5. Wilson, A. and Childs, S. The relationship between consultation length, process and outcomes in general practice: a systematic review. Br J Gen Pract 2002; 52 (485) :1012-1020.

6. Orton PK and Pereira Gray D (2016) Factors influencing consultation length in general/family practice. Fam Pract 2016; 33 (5) :529-534.

Competing interests: No competing interests

05 October 2017
Denis Pereira Gray
Patron, N.A.P.P.
Patricia Wilkie, President, N.A.P.P.
National Association for Patient Participation (N.A.P.P.)
National Association for Patient Participation (N.A.P.P.), Dennington, Ridgeway Horsell, WOKING, Surrey, GU21 4QR