Unresolved questions in telephone consulting

Improving access to healthcare is a major priority for both patients and the UK National Health Service (NHS).¹ Increasingly and internationally, many traditional services once transacted face to face (e.g. banking and shopping) are transacted by telephone and electronically. Starting in the USA this trend has been mirrored in healthcare where in many countries the telephone has now often become the first point of contact.

While initially utilized in the UK mainly for advice out-of-hours both from general practitioners (GPs) and nurse-led services such as NHS 24 and NHS Direct, increasingly it has been used as a means of optimizing available resources for the management of in-hours work—particularly requests for same-day appointments, but with increasing enthusiasm and evidence for its use in other types of consultation such as chronic disease management.^2,3 Despite the apparent opportunities in terms of access to care and potential cost and time savings,⁴ a recent randomized controlled trial of telephone triage⁵ reignited practitioner reservations about telephone consulting, including:

• whether GP workload is altered

• whether patients and practitioners perceive the telephone as an appropriate vehicle to conduct different types of consultation^5,6

• whether or not some groups who have difficulty using the telephone may be disadvantaged

• the impact on quality of care and opportunistic health interventions.⁵

Little is known about the content of telephone consultations used for different purposes (e.g. acute triage, follow-up consultations, chronic disease management) or the quality of the advice given by telephone in comparison with face-to-face consulting.⁷ Recent systematic reviews^8,9 have shown that most studies comparing face-to-face consulting to telephone consultation have used purely observational methods. However, observational methods suffer from difficulty in eliminating systematic bias. While several of these studies have demonstrated that telephone consultations are briefer than face-to-face consulting,^3,5,10 and may be cost effective⁴ the only controlled trial⁵ of day-time telephone triage by GPs demonstrated that patients managed in this way were 50% more likely to re-consult within 2 weeks than those who had been seen face-to-face.

It is not clear why telephone consultations are briefer, i.e. if it is due to loss of physical examination time, discussion of fewer problems, less health promotion, less social speech or if it is achieved at the expense of patient-centredness or holistic care. There is a dearth of studies exploring the content of telephone consultations in relation to face-to-face consulting and measures of quality have largely been restricted to patient satisfaction outcomes either by questionnaire or qualitative interviews that are insensitive to clinical quality issues. In a recent pilot study of out-of-hours telephone consultations (Heaney D, personal communication 2005) clinical quality, while difficult to measure reliably, appeared worryingly poor.

With both telephone consulting and any future utilization of newer technologies there is the potential problem of inequity. While most patients have access to telephones, the most disadvantaged may only have access to expensive mobile devices. In addition, some minority groups such as those who are hard of hearing (43% of those over 70 years¹¹) and those who do not use English as a first language may be disadvantaged by systems that insist on the telephone being the first point of contact. However, the advantages to others, e.g. to the housebound, the geographically isolated and those whose jobs take them away during normal working hours, need also to be considered.

Currently, telephone consulting appears to be rather indiscriminately used for many very different problems, presentations and patient groups despite scant information on quality of care, patient acceptability and impact on workload. Particularly as this form of consultation appears to be increasingly used and in new ways it is important to establish for which types of consultation and problems and for which patients it is most appropriate. There is a need therefore for rigorous qualitative and trial research in this area.