The NHS must be careful to ensure that it bases its information and recommendation on robust evidence.
As UK general practices struggle with rising demand from patients, more work being transferred from secondary to primary care, and increasing difficulty in recruiting general practitioners, one proposed potential solution is a ’telephone first’ approach, in which every patient asking to see a GP is initially phoned back by their doctor on the same day. At the end of this phone call the GP and the patient decide whether the problem needs a face-to-face consultation, or whether it has been satisfactorily resolved on the phone.
Two commercial companies provide similar types of management support for practices adopting the new approach, with claims that the approach dramatically reduces the need for face-to-face consultations, reduces workload stress for GPs and practice staff, increases continuity of care, reduces A&E attendance and emergency hospital admissions, and increases patient satisfaction.
Some of these claims are repeated in NHS England literature, including the assertion based on claims from one of the companies that practices using the approach have a 20% lower A&E usage and that "the model has demonstrated a cost saving of approximately £100k per practice through prevention of avoidable attendance and admissions to hospital". Several Clinical Commissioning Groups have subsequently paid for the management support required for the approach to be adopted by practices in their area.
The National Institute for Health Research (NIHR) acknowledged the need for robust and independent evaluation of current services and therefore commissioned the team led by Martin Roland, Emeritus Professor of Health Services Research at the University of Cambridge. The results of the evaluation, which looked at data sources including GP and hospital records, patient surveys and economic analyses, are published today in The BMJ.
The study found that adoption of the ’telephone first’ approach had a major effect on patterns of consultation: the number of telephone consultations increased 12-fold, and the number of face-to-face consultations fell by 38%.
However, the study found that the ’telephone first’ approach was on average associated with increased overall GP workload; there was an overall increase of 8% in the mean time spent consulting by GPs, but this figure masks a wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase.
Dr Jennifer Newbould from RAND Europe, part of the Cambridge Centre for Health Services Research, the study’s first author, says: "There are some positives to a ’telephone first approach’; for example, we found clear evidence that a significant part of patient workload can be addressed through phone consultations. But we need to be careful about seeing this as a panacea: while this may increase a GP practice’s control over day-to-day workload, it does not necessarily decrease the amount of time GPs spend consulting and may, in some cases, increase it."
The researchers found no evidence that the approach substantially reduced overall attendance at A&E departments or emergency hospital admissions: introduction of the ’telephone first’ approach was followed by a small (2%) increase in hospital admissions, no initial change in A&E attendance, but a small (2% per year) decrease in the subsequent rate of rise of A&E attendance. However, far from reducing secondary care costs, they found overall secondary care costs increased slightly by £11,776 per 10,000 patients.
Professor Roland adds: "Importantly, we found no evidence to support claims made by one of the companies that support such services - claims that have been repeated by NHS England - that the approach would be substantially cost-saving or reduce hospital referrals. This has resulted in some Clinical Commissioning Groups across England buying their consultancy services based on unsubstantiated claims. The NHS must be careful to ensure that it bases its information and recommendation on robust evidence."
Newbould, J et al. Tele-First. Evaluation of a ’telephone first’ approach to demand management in English general practice: observational study. BMJ (2017). DOI: 10.1136/bmj.j4197