A ‘telephone first’ approach is not a panacea for reducing workload in UK general practice and there is no evidence that it saves money, finds a study in The BMJ today.

General practice in the UK, as in many other countries, is under considerable strain and policy makers are looking for ways to improve patient access and ease staff workload.

One approach is ‘telephone first’ in which a GP speaks to all patients on the telephone to decide whether the problem can be resolved over the phone, if a face to face appointment is needed, or if seeing another professional such as a nurse or pharmacist might be more appropriate.

Commercial companies claim this system reduces GP workload and cuts costs – and these claims also appear in NHS England literature.

To test their validity, the National Institute for Health Research commissioned an independent evaluation led by Jennifer Newbould and Professor Martin Roland at the Cambridge Centre for Health Services Research.

Telephone (PD)

Dr Newbould and her team analysed routine health data from 147 English general practices adopting the telephone first approach compared with a 10% random sample of other practices in England. They also reviewed responses to patient satisfaction surveys.

Adoption of a telephone first approach led to fewer face to face consultations (from a mean of 13 to 9 per day/1000 patients) and more telephone calls (from a mean of 3 to 12 per day/1000 patients), suggesting that much of the work of general practice can be managed on the telephone.

However, almost half of patients in the study needed to be seen in person.

There was wide variation among practices in how well the system functioned, with some noting large reductions in workload while others experienced big increases. The reasons for this were unclear and warrant further investigation. But, overall, a telephone first system was associated with increased GP workload.

Patients too expressed varied views. For example, many patients reported being seen much more quickly in telephone first practices, but other aspects of patient experience were slightly more negative, such as difficulty communicating on the phone.

The telephone first approach was not associated with a reduction in attendances at hospital emergency departments and led to an increase in emergency admissions, suggesting that such systems might increase overall costs.

This is an observational study, so no firm conclusions can be drawn about cause and effect, and the authors outline some limitations. Nevertheless, they say a telephone first approach “shows that many problems in general practice can be dealt with over the phone.”

They acknowledge that the approach “does not suit all patients or practices and is not a panacea for meeting demand.” And they point out that there was “no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care.”

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,” argue Professor Brian McKinstry at the University of Edinburgh and colleagues, in a linked editorial.

They urge practices “to think carefully about the wider, possibly unanticipated, consequences of a switch to telephone first system and call on policy makers to reconsider their unequivocal support for such systems. It is also yet another reminder of the importance of independent evaluation of initiatives before investment in widespread implementation,” they conclude.

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