How does a ‘Telephone first’ approach in primary care, speaking to a doctor on the telephone first before making a face to face appointment impact patient experience, practice workload and secondary care utilisation?

Problem

Due to increasing demands being placed on primary care around 150 practices in England have implemented, with support from one of two commercial providers, a ‘telephone first’ approach. This involves a system wide change where any patient who wants to speak to a GP is initially given a call back by a GP on the day of booking. The GP will then either deal with the issue on the phone or invite the patient for a face-to-face consultation, usually on the same day. The impact of this system on patient experience, practice workload and secondary care utilisation is currently unknown.

Approach

We used seven measures of patient experience from the GP Patient Survey (2012-2016), hospital episode statistics data on accident and emergency attendances and admitted patient care (2009-2016) and data on appointments taken from computer systems of 59 practices. Mixed-effects models are used to assess the change in experience scores, attendances or admissions coinciding with the start of the ‘telephone first’ approach. A random selection of 10% of English practices not using the approach act as a control, meaning the estimated effect of the intervention is compared to that expected given national changes over time, seasonal effects and individual practice trends. For data from practice systems no controls are available and so changes are restricted to comparisons to that expected given individual practice trends.

Findings

For six of the seven patient experience items either non-significant or small reductions in patient experience scores were seen coinciding with the launch of the ‘telephone first’ approach. In the case of the rating of the time until seen or spoken to, a dramatic improvement was seen (20 points on 0-100 scale 95%CI 18-22, p<0.001). There was a 28% increase in the number of appointments (rate ratio 1.28, 95%CI 1.17-1.39 p<0.001), comprised of a 38% decrease in face-to-face appointments and a 12-fold increase in telephone appointments. On average appointment lengths got shorter by about one minute, largely reflecting the shift from face-to-face to telephone appointments. There was weak evidence (p=0.054) that the total time spent consulting with patients increased by 9% (duration ratio 1.09, 95%CI 1.00 to 1.18). Across all outcomes there was wide variation in the effect of the intervention in individual practices, such that what might be expected in any one practice could differ substantially from these average effects. Findings related to secondary care utilisation will also be presented.

Consequences

With little negative impact on patient experience and dramatically increased timeliness of access, a ‘telephone first’ approach may benefit patients. The limited evidence on increasing workload combined with the heterogeneity of effect suggests that this system is not a solution for all practices facing workload difficulties.