As GP practices battle to provide an adequate number of face-to-face appointments, I was wondering if other forms of consultation 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 carried out on the telephone. This amounted to a remarkable 40+ per day. What it didn’t say was how many telephone conversations resulted in a need for the patient to be seen face-to-face.

Are telephone consultations ‘effective’?

A major survey carried out in 2014, the results of which are on the NHS Choices website , suggested that whilst telephone consultations provided an alternative method of consultation, they weren’t necessarily as effective. The survey also claimed that telephone consultations didn’t reduce a GP’s workload. It found that almost 12% of consultations had been undertaken on the phone, representing a fourfold increase over the previous 20 years. I recall that the process of telephoning patients who’d requested an urgent appointment or a home visit started 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 face-to-face contact and had five-minute appointments.

Triaging calls becomes ‘run of the mill’!

Nowadays, a system of triaging appointment requests isn’t unusual, although the personnel who filter the calls may range from a receptionist to a nurse practitioner or a ‘doctor first’. To my mind, there are always inherent risks involved when 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 presented on the phone. What if the patient needs to be examined and possibly needs an urgent referral? Practices do need to adopt a safe system of filtering calls and allocating appointments. Practices do 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 whereby practices desperately look for alternative ways of providing a service to patients. The concept of 10-minute, even 15-minute, appointments may no longer be 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 fewer patients than the doctors and there was, of course, the problem of raising prescriptions as the nurse wasn’t a prescriber. Now the likelihood is that a practice will have a nurse prescriber, even a pharmacist, who’s better trained and qualified. This means 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.

When demand outstrips supply

But 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 schemes to not prescribe OTC (over the counter) preparations which 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 now have access to a clinical pharmacist

• Signposting to pharmacies

Signposting patients to pharmacies is another alternative, but it depends on how well staffed and how well stocked a pharmacy is for such a service to be successful. A recent suggestion that Gaviscon Advance be replaced by Peptac resulted in a 24-mile round trip to a local town to find a pharmacy that stocked it. It cost just over £3 whilst Gaviscon Advance was around £8, but 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 to ensure that supplies are readily available.

• Using ‘111’

Bearing in mind the above suggestion to go to your local pharmacy, my local pharmacy has a poster suggesting that patients make a first port of call to the NHS (111) telephone line for ‘urgent medical attention’. In June 2015, the ‘111’ service received an average of 23 calls per minute. In that month, almost 1 million calls were received.

• Online messages and repeat prescriptions

Many practices now use a messaging service built into the online EMIS patient access ‘app’. (Other versions are available.) Again, this may help avoid appointments and telephone consultations. However, the response time to replying to messages and emails, if such a service is offered, needs to be reasonably prompt, as does the issue of prescriptions.

Possible pitfalls

Nothing, in my view, replaces seeing a patient. Those who are responsible for answering the telephone to filter requests for appointments need to be aware that patients might not describe their problem adequately. Likewise they may not 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, of course, 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) 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’s a better way of providing services or just an alternative. The BMJ 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 on to explain that the success of a telephone system depends on how well it’s organised. There can be issues surrounding prompt call-backs, and practices need to make allowances for patients who have problems dealing with telephone calls. Perhaps, also, practices need to make clear that the telephone consultation is a new feature of the service being provided and not just an alternative to face-to-face consultations caused by a lack of doctors and high demand!