Telephone first consultations in primary care

Newbould et al's (1) study results are consistent with results provided by the Esteem trial(2) in 2014 and by Bunn Cochrane Review(3) ten years before: “telephone first” approach to the same day consultation request when compared to usual primary care access decreases the need for face to face consultation, increases the number of phone contacts - particularly return consultations – in the end increasing the GP overall workload (an outcome that hopefully should be reduced).

The authors' conclusions are: "The telephone first approach […]is not a panacea for meeting demand".

McKinstry et al's (4) comment in the Editorial was: "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". They claim: “Policy makers should reconsider their unequivocal support for these systems”.

These conclusions could be conceptually biased by the lack of training for telephone call handlers and this should address future research.

As Newbould et al do not provide details about training, we wrote last 16 October to the commercial companies involved in the study to know how they train their call handlers: one has not yet answered and one answered they offer an e-learning program of about 2 hours, scenarios and examples presented by GPs.

The problem of the training of telephone call handlers has been known for at least 10 years(5) and was the topic of our Cochrane review(6) showing no evidence on how to train clinicians in order to improve their telephone consultation skills and the effect on patient outcomes.

At the same time the studies by Derkx et al(7,8) and Pasini et al(9) showed how poor the quality of telephone consultation could be both from clinical and relational point of view. Evidence coming from the Esteem trial shows also that professional characteristics are related to call dispositions because nurses who reported feeling 'more prepared' for the role were more likely to manage the call definitively.

So, how sure are we that the increase in telephone consultations detected in Newbould et al's study and in the Esteem trial(10) is not due to a lack of training and inability to manage the call definitively?
Considering the telephone first approach leads to a decrease of face to face consultations, the increase of overall workload could be attributable to the increase of return consultations due to the lack of training.
The research of Newbould et al lacks information about the quality of the communication, investigated the outcomes but we need to know more about the quality of the road call handlers followed.

Could this factor eventually provide an explanation to the "wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase", effect detected by Newbould et al and , therefore, are practices that experience a substantial reduction in workload served by more better prepared doctors?

Researchers in the future should consider more carefully the importance and weigh of training in telephone consultation outcomes: if call handlers have no training in telephone consultation they will be not be confident enough in closing the clinical cases, giving safety net advice to patients, or they will not be able to gain enough of the trust of patients on the phone in addressing their resource consuming behaviors.

How can we be reasonably sure that a telephone first approach led by untrained call handlers might realistically modify hard outcomes like emergency department attendance or referral?

Would we trusted a mountain guide for a climb without knowing anything about his/her skills and experience?

We think the results by Newbould et al should be taken with caution especially in the UK because it could enable commissioners to change schemes that are already working.

1 Newbould J, Abel G, Ball S et al. Evaluation of telephone first approach to demand management in English general practice: observational study. BMJ. 2017 Sep 27;358:j4197. doi: 10.1136/bmj.j4197.
2 Campbell JL, Fletcher E, Britten N et al. Telephone triage for management of same-day consultation requests in general practice (the ESTEEM trial): a cluster-randomised controlled trial and cost-consequence analysis. Lancet. 2014 Nov 22;384(9957):1859-1868
3 Bunn F1, Byrne G, Kendall S. Telephone consultation and triage: effects on health care use and patient satisfaction.
Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004180
4 McKinstry B, Campbell J, Salisbury C. Telephone first consultations in primary care. BMJ 2017;358:j4345
5 Car J, Freeman GK, Partridge MR et al. Improving quality and safety of telephone based delivery of care: teaching telephone consultation skills. Qual Saf Health Care 2004;13:2–3.
6 Vaona A, Pappas Y, Grewal RS et al. Training interventions for improving telephone consultation skills in clinicians.Cochrane Database Syst Rev. 2017 Jan 5;1:CD010034
7 Derkx HP, Rethans JJ, Maiburg BH et al. Quality of communication during telephone triage at Dutch out-of-hours centres.
Patient Educ Couns. 2009 Feb;74(2):174-8.
8 Derkx HP, Rethans JJ, Muijtjens AM et al. Quality of clinical aspects of call handling at Dutch out of hours centres: cross sectional national study. BMJ. 2008 Sep 12;337:a1264
9 Pasini A, Rigon G, Vaona A. A cross-sectional study of the quality of telephone triage in a primary care out-of-hours service. J Telemed Telecare. 2015 Mar;21(2):68-72
10 Varley A1, Warren FC2, Richards SH et al. The effect of nurses' preparedness and nurse practitioner status on triage call management in primary care: A secondary analysis of cross-sectional data from the ESTEEM trial. Int J Nurs Stud. 2016 Jun;58:12-20

Exploring why GPs switch to telephone first consulting would have enhanced this important paper. The GP workforce is struggling to meet demand. This style of working enhances the streaming of demand to other providers of care as we increasingly rely on skill mix to deliver care. I would echo that telephone first working increases total consultation, however proactively managing daily work helps to reduce work related stress. I would like to have known how many of those practices who switched to this style of working would now revert to a traditional appointment system, after three of working in this way our practice has no plans to change

Some of the conclusions in the report and editorial are not justified by the evidence presented. The problem is inherent to any evaluation of a complex intervention and raises big questions about how to report evidence about such interventions.

The editorial summarises the results like this: "There was distinct variation among practices in how well the system functioned. Some noted large reductions in workload while others experienced big increases." But then goes on to say; "Although the delay to see or speak to a doctor is greatly reduced by the introduction of telephone first systems, overall workload for doctors increases. The marked reduction in time spent consulting in surgery is more than compensated for by an increase in time spent on telephone consultations."

The problem is that the second part uses the average result across all trials to make a statement about whether the intervention works or not but this isn't consistent with the degree of variation which shows, at the very least, that the benefits are sometimes large. Unless we understand the reason for the variation we can't draw a clear conclusion that the average result is really measuring whether the intervention works.

The problem is caused because there are two major sources of variation here: one is the population variation among GP practices (this is analogous to the metabolic and physiological variation among patients in an RCT of a drug). But unlike a drug trial where the actual intervention can be carefully controlled (we test whether the pills are all the same etc.) you can't control the variation in the way telephone triage was managed by the practices. If this was a drug trial we would be testing pills with unknown amounts of variation in their content and strength). What this means in practice is that the outcomes cannot be attributed to the simple use of telephone triage but may have large factors dependent on how the practices managed their use of telephone triage.

An analogy might help (this one was used by the respected economist John Kay to illustrate a common error in business strategy). Imagine you have the ambition to be a great concert violinist. You observe that the great performers have certain characteristics in common: they all wear evening dress, they all have expensive violins, for example. You reason that to become a great violinist you must copy those visible characteristics so you buy yourself expensive clothes and an Amati violin. You are still a useless violinist.

The lesson is that copying the visible characteristics is not the important thing that makes you a great violinist: that would require you copy the things the great violinist did that you cannot see (practising for 10 hours a day for a decade and having a good teacher, for example).

The same is true for complex healthcare interventions in general and telephone triage in particular. The easy-to-see part is that some form of telephone triage is done. What is more difficult to tell is what else a practice has to get right to get any benefit from this. How well do they manage the process? How do they learn what can be resolved over the phone and doesn't require a face-to-face appointment? How do they redesign the practice workflow to exploit the benefits of the intervention? It is worth noting that a similar problem arises in healthcare (and every other industry for that matter) when trying to get benefits from the use of IT. Unless the work is reorganised to exploit the benefits of the technology, there won't be any. So many studies report that computers are a waste of time despite the fact that they could yield benefits if the complicated additional task of redesigning the work was also undertaken.

In telephone triage we can tell whether the system will work using a handful of characteristics of the system: what proportion of calls can be resolved over the phone? how long does the average call take? how long are face-to-face appointments? It is easy to construct a simple model showing, from these numbers, whether there is an overall time saving. But all those numbers depend on skill and experience and can be improved with good management. Those factors are far from being visible when testing telephone triage. If the practice doesn't have the skill and doesn't monitor the numbers to drive improved skill then there won't be significant benefits (and this isn't made easier by the fact that one major vendor of GP clinical systems appears to be unable to record how long telephone calls last). It isn't just adding telephone triage to the system that yields the benefits: it is getting those other factors right.

So to argue from the average benefits across a large number of practices that telephone triage doesn't work is a logical mistake. It is obvious from the report that some practices saw big benefits and time savings. It is also obvious that most practices saw much faster access for patients. But a general claim that triage systems don't work is a bit of a logical leap when the data shows that sometimes do.

We should not be claiming that this study shows phone triage doesn't yield benefits to GPs; we should be asking what factors mattered to give benefits in some places and not others.

The report and editorial are right, though, that policy-makers have an endearing but dangerous belief in "magic-bullets". Pushing telephone triage won't help unless the complicated set of supporting management practices that make it work are understood. And they are rarely understood by the people who make policy. Unfortunately this is a common error that greatly inhibits many efforts to improve quality and efficiency across the whole NHS.

It would also be good if the vendors of the systems were clearer about the need for fine-tuning the way the systems are operated to maximise the benefits (full disclosure, I currently support one of them and one of my goals is to develop better ways of providing analysis to practices to support them to improve the way they operate).

In summary, the right conclusion from the study should not be "phone triage doesn't work" but "phone triage sometimes yields big benefits and we really need to start asking which factors make it work in some places and not in others".