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Telephone first consultations in primary care

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4345 (Published 27 September 2017) Cite this as: BMJ 2017;358:j4345

Rapid Response:

Re: Telephone first consultations in primary care

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

08 November 2017
Alberto Vaona
MD, PhD, Cochrane reviewer
O’Malley J. MD, retired Medical Director, Mastercall Healthcare – UK Meer A. Andreas Meer, MD, MHIM, In4medicine AG - Switzerland Derkx H, MD, PhD – The Netherlands Demurtas J, MD - Italy
Azienda ULSS9 Verona – Italy
aisamaisa@gmail.com