Are telephone consultations replacing face to face consultations?
As GP Practices battle to provide adequate numbers of face to face appointments I was wondering if other forms of providing consultations are on the increase. I spotted recently a notice in my local surgery which declared that almost one third of consultations in July had been on the telephone. This amounted to a remarkable 40+ per day, and it struck me that that would have taken some dealing with. What it didn’t say was how many telephone conversations resulted in a need for the patient to be seen face to face. What if the patient actually needed to be examined, not just subjected to a telephone inquisition.
Telephone Consultations not effective?
A major survey carried out in 2014 the results of which are on the NHS Choices web site,( https://www.nhs.uk/news/medical-practice/phone-consultations-do-not-reduce-gp-workload/) suggested that whilst telephone consultations provided an alternative method of consultation they were not necessarily as effective. The survey also claimed that telephone consultations did not reduce a GPs workload. It found that almost 12% of consultations had been carried out on the telephone, representing a four fold increase over the previous 20 years. I do recall that the process of telephoning patients who had requested an urgent appointment or a home visit starting in my Practice around 15 years ago very reluctantly and only a handful of calls were made in the early days. One GP in particular much preferred a face to face contact and had five minute appointments.
Triaging Calls becomes run of the mill!
Nowadays, a system of triaging appointment requests is not unusual, although the personnel that filter the calls may range from a receptionist to a nurse practitioner or a doctor first. In my mind there are always inherent risks involved where a non-clinician becomes involved. To be on the safe side it requires a well trained and experienced clinician to sift and sort the problems presenting on the telephone. I recently came across an example of a telephone consultation being offered by a receptionist in three days time but when the patient needed a referral. So Practices do need to adopt a safe system of filtering calls and allocating appointments. Practices tend to get a GP to phone the patient back, if no offer of an appointment is accepted or simply to be on the safe side!
Seeing today’s patients today
Around the time the Quality Outcomes Framework was introduced the idea of seeing today’s patients today was also marketed, which at the time was a fine aim, but the pressures of demand from patients and the inadequacies of supply from doctors have since created a situation where Practices desperately look for alternatives ways of providing a service to patients. The concept of 10 Minute appointment may no longer be valid or achievable. When we first used a senior Practice Nurse to see patients with minor illnesses I have to say that it broadly failed. The nurse saw less patients than the doctors and there was of course the problem of raising prescriptions. The nurse was not a prescriber. Now the likelihood is that a Practice will have a nurse prescriber, even a pharmacist and better training and qualifications mean that the prescriber will probably see just as many patients as their GP colleagues. I can certainly comment that a good nurse practitioner can become a valuable and effective member of the Practice.
Demand outstrips Supply
However, what happens if the level of demand still outstrips the availability of prescribing clinicians. Here are some thoughts:
• Over the Counter Medicines
Encouraged by CCGs and NHS England practices are introducing widely schemes to not prescribe OTC (Over The Counter) preparations that can be purchased from a pharmacy. So once patients realise that their medical practice will no longer prescribe simple remedies will the demand for appointments reduce. Practices or CCGs might employ a pharmacist to help manage more effective prescribing. According to NHS England 40% of Practices have access to a Clinical Pharmacist. (https://www.england.nhs.uk/gp/gpfv/workforce/building-the-general-practice-workforce/cp-gp/)
• Signposting to Pharmacy
Signposting patients to pharmacies is another alternative. But it depends how well staffed and how well stocked a pharmacy is for such a service to be successful. A recent suggestion that Gasviscon Advance be replaced by Peptac resulted in a 24 mile round trip to a local town to find a pharmacy that stocked. It cost over £3 whilst Gaviscon Advance was around £8. The bus journey would have cost me £11. Practices, both GPs and Practice Pharmacists need to work with local pharmacies when changing either their prescribing habits or offering OTC advice to patients.
• Using 111
Suggesting patients, make a first port of call to the NHS (111) telephone line is another option. In June 2015, 111 received an average of 23 calls per minute. That month approaching 1 million calls were received. Now that takes some managing.
But nothing in my view replaces seeing a patient. Those answering the telephone to filter requests for appointments need to be aware that patients might not describe their problem adequately. Likewise they may want to tell an unknown voice what they would tell a doctor or nurse. The idea of an experienced and trained clinician phoning a patient back is probably much safer. But there will be occasions when actually seeing the patient and examining them cannot be achieved in a telephone conversation. The question is what is the appropriate balance between seeing patients face to face or talking to them on the telephone.
More recent findings
The BMJ published an article last September (2017) (https://www.bmj.com/content/358/bmj.j4345) which looked at the growing Practice of patients speaking to a doctor first. Even the new Health Secretary is promoting the development of online GP services. But the question remains as to whether it is a better way to provide services or just an alternative. The BMA article states that much of the work of general Practice can be managed on the telephone. The reduction in consultations is compensated by the time spent on the telephone, but around half of the patients still need to be seen face to face. The article goes onto explain that the success of a telephone system depends on how well it is organised. There is an issue of prompt call back and Practices need to make allowances for patients who have problems dealing with telephone calls. Perhaps too Practices need to make clear that the telephone consultation is a new feature of the service being provided and not an alternative caused by lack of doctors and high demand!