Intended for healthcare professionals

Editorials

Using telephones in primary care

BMJ 2002; 324 doi: https://doi.org/10.1136/bmj.324.7348.1230 (Published 25 May 2002) Cite this as: BMJ 2002;324:1230

A significant proportion of consultations might take place by phone

  1. Peter D Toon (Petertoon{at}aol.com), senior lecturer
  1. Department of Primary Care and Population Sciences, University College London, London N19 3UA

    NHS Direct, the United Kingdom's open access telephone advice system, which is staffed by nurses supported by computer decision software, has been the subject of a long and often bitter debate. Is it value for money; is this system the most effective; how should it relate to other services; and what is its effect on them? But this concentration on one particular initiative ignores wider questions about telephone consultation in primary care. What is its role? Who should do it? What background and training do its providers need?

    The telephone has been around for more than a century, but the literature on these questions is scanty. A recent Medline search on telephone consultation found only 77 references on its use in primary care over 35 years. Most of these references were reviews, commentaries, or case studies, with only a handful of controlled trials.

    Just as the recent debate has centred on NHS Direct, so the literature focuses on use of the telephone out of hours (33 of the 77 papers dealt with calls made out of hours, which account for 1-2% of primary care contacts) and to triage urgent problems, although there are many other types of encounter in primary care. In the United States and elsewhere, up to a quarter of primary care contacts are by telephone. 1 2 I recently reviewed consultation patterns in an east London practice that had encouraged the use of the telephone by setting up a daily telephone surgery. The surgery's rate of phone contacts was also around a quarter, although the norm in the United Kingdom is far lower. Only half the encounters were for new problems; others were requests for information on treatment options, side effects of drugs, queries on the organisation of care, and follow up of acute and of chronic problems. We need to know far more about the telephone's potential as a mode of delivering routine primary care.

    Reading the literature, it often feels as if the main purpose of the telephone is to keep patients at arm's length, its use assessed by its impact on medical workload rather than by improved access and convenience for them.3 For more than a decade enthusiasts have encouraged consulting over the telephone and documented their experience, yet their findings have had little impact on general practice as a whole.4 5 6 Despite its support for NHS Direct, the government shows little interest in other aspects of telephone access, and the General Medical Council's guidance on the subject makes telephone consulting feel like a slightly shady activity, best avoided by respectable and prudent practitioners.7

    These negative attitudes are curious. If, as is often stated, 80% of diagnoses are made from the history, and since not all encounters entail diagnosis, one might expect that an appreciable proportion of consultations could take place by telephone. This could help patients, who save travel time and costs and do not need to arrange childcare or work cover, even if it does not save time for health professionals. We need to measure both the benefits and the limits of telephone medicine compared with face to face consultation, and how best to organise it, so that both doctors and patients can use it as effectively as possible.

    The telephone is clearly a communications tool with several restrictions, including an absence of visual clues and non-verbal communication (although this may change in the future).

    Despite this there has been little study of telephone consulting skills and little critical thinking about how best to work on its limitations and what background and training (which is scant) users need. 1 2 The relative merits of intuitive clinical expertise versus systematic enquiry guided by computer algorithms; of nursing and medical backgrounds and education, with their different emphases on systematic management and diagnostic judgment; and of telephone and face to face encounter are separate issues, yet they are often confounded. Interprofessional rivalries between nurses and doctors and the financial implications of their different pay scales may influence policy and add to the confusion.

    Other questions remain unanswered. What impact does prior acquaintance with a patient, access to personal medical records, and continuity of care have on making telephone consultation more effective, safer, and increasing its potential? How good is telephone contact for patient education and monitoring of chronic diseases? The literature suggests hypotheses, but we need systematic and controlled data. Commercial organisations like banks have put considerable effort into telephone advice systems (with varying success) and telephone helplines such as that run by the Samaritans are an important feature of the voluntary sector. What lessons can we learn from these?

    Most of all we need to understand why the telephone, after being part of our lives for so long, has met with so much suspicion and so many irrational assumptions, and why there is so little evidence on how best to use this simple piece of communication technology.

    References

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