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

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4197 (Published 27 September 2017) Cite this as: BMJ 2017;358:j4197

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

Mr Longman rightly points out that headline writers focused on some negative outcomes of our evaluation (increased time consulting) rather than the positive ones (patients seen or spoken to much more rapidly). The latter was clearly set out in our findings, hence there is no need for the restatement that Mr Longman calls for. We were appropriately cautious in our conclusions about increased workload, but they are fully compatible with the substantial net increase in total consultations (telephone and face to face) conducted by practices adopting the new approach. We are clear in the paper that the analysis included all data made available over the period one year before and up to one year after the intervention; also we only imputed data in Mr Longman’s ‘GP Access’ group of practices where data were missing – not to the wider group of practices in the study. Moreover, only the duration of a consultation was imputed and only in cases where we were aware that a consultation had taken place but data on duration was missing.

Mr Longman says that we omitted to measure visits and asserts that these were reduced ‘sometimes by half’. We did in fact analyse data on visits from his practices and found that, on average, visits increased after the adoption of the telephone first approach. However, we had some concerns about the reliability of coding of home visits by GPs and hence we decided not to report these analyses in the paper. Our study was not able to determine which practices would ‘succeed’ and which would ‘fail’ in the new approach or why, though we comment on some possible reasons in our discussion. However, even within those practices which find the new approach works well, our study suggests there will be some individual staff members and patients for whom the approach ‘succeeds’ and others for whom it ‘fails’. Mr Longman is right in suggesting that GPs are unlikely to continue to use an approach that was working badly. However, we note that of the 58 practices initially identified as using the ‘GP Access’ approach, only 29 (50%) were still using the system as designed when we asked Mr Longman to identify those practices which were still operating the telephone-first approach according to his protocols (in order to do a ‘per protocol’ sensitivity analysis): the remainder had stopped or substantially modified the approach.

Dr Vaona and colleagues raise the question of training for telephone consultations. Both companies involved in our study offered training but we don’t know how often this was taken up. However, telephone consulting now forms some part of most GPs’ work and several doctors commented to us during the study that training for telephone consulting now forms part of vocational training for general practice.

Competing interests: No competing interests

23 November 2017
Martin Roland
Emeritus Professor of General Practice
Gary Abel, University of Exeter, Jenny Newbould RAND Europe.
University of Cambridge