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‘Telephone first’ approach does not reduce primary care workload, costs

Findings published in BMJ demonstrated that the “telephone first” approach significantly decreased face-to-face consultations.

However, the approach did not suit all patients and practices, and was not associated with reductions in secondary care costs.

According to study background, the telephone first technique involves general practitioners engaging with patients in a phone conversation to ascertain the necessity of a face-to-face consultation. Researchers noted that two commercial companies have claimed this method abates the need for face-to-face consultations, reduces workload-related stress for general practitioners and practice staff, lowers ED attendance and emergency hospital admissions, and increases patient satisfaction and continuity of care.

In part because of these claims, the National Institute for Health Research commissioned this independent service evaluation, according to researchers.

Outcomes were number of consultations, total time consulting, patient experience, and secondary care costs and use. The primary analysis was intention to treat. Researchers limited sensitivity analyses to practices believed to be adhering closely to the commercial companies’ protocols.

Overall, 147 general practices using the telephone first approach were compared with 10% of randomly chosen practices in England that did not.

According to results, not all of the touted benefits of the telephone first approach were achieved.

Specifically, researchers found that face-to-face consultations decreased significantly (adjusted change within practices, –38%; 95% CI, –45 to –29) in practices that used the telephone first approach, with the average practice seeing a 12-fold increase in telephone consultations (1,204%; 95% CI, 633-2,290). The average time of telephone and face-to-face consultations decreased, but there was an 8% increase in the mean time general practitioners spent consulting, although there was “large uncertainty” in these figures.

“These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase,” the researchers wrote.

Results also found that when compared with other practices, those using the telephone first approach observed a 20-percentage point improvement in the time a patient waited for an appointment and a 2% per year decrease in the subsequent rate of rise of ED attendance. However, telephone first practices had no initial change in ED attendance, a small net increase in secondary care costs, and a 2% increase in hospital admissions.

“Supported by informal observations in practices not reported here, our impression is that the [telephone first] approach worked better in highly organized data driven practices that already had a handle on demand and was less likely to prove successful in practices where the ability to cope with demand was already out of control,” the researchers wrote.

In a related editorial, Brian McKinstry, MD, of the University of Edinburgh, John Campbell, MD, of the University of Exeter, U.K., and Chris Salisbury, MB, ChB, MSc, of the University of Bristol, U.K., wrote that the findings underscore the need for a thorough review of potential solutions to physicians’ workloads.

“The study by Newbould and colleagues should cause practices to think carefully about the

wider, possibly unanticipated, consequences of a switch to a ‘telephone first’ system and should lead policy makers to reconsider their unequivocal support for such systems,” they wrote, adding that telephone first is yet another reminder of the importance of independent initiative evaluation before investment in widespread implementation. – by Janel Miller

Disclosures: The authors report no relevant financial disclosures.