Trouble getting an appointment at your GP surgery? Findings from an evaluation of a ‘telephone first’ approach to demand management in general practice

Martin Roland and Jenny Newbould, Cambridge Centre for Health Services Research

It’s certainly an increasingly common problem.  You spend ages trying to get through to your GP surgery, only to be told there is not an appointment for a week or two; maybe even six weeks if you want to see Dr Popular.  So, why can’t patients get an appointment at their GP surgery?

Well, there are two answers to this. One is a simple lack of capacity. In theory, this is being addressed by the extra £2.4bn promised in the General Practice Forward View1 (including 5000 extra GPs by 2020).  The second, related, answer, is that practices need to work more efficiently to deal with rising demand. Two commercial companies (GP Access and Doctor First) offer a way of approaching this. After conducting a detailed analysis of patterns of practice workload, they offer support for an approach where patients have to speak to a GP on the phone before being offered a face to face appointment. In these systems, there is therefore almost no advance booking of face to face consultations. Dramatic claims have been made that this approach greatly improves the availability of appointments, reduces GP workload, increases continuity of care and reduces secondary care costs (especially A&E attendance). Some of the claims by Doctor First are reproduced in NHS England literature 2, leading to CCGs commissioning services from the two companies.

So does the ‘telephone first’ approach work? Our paper published today in the BMJ explores this.  The answer?  In part, but not all the claims are justified. Certainly, patients get appointments much more readily, and up to half of patients’ problems can be dealt with on the phone. However, we found that, on average, GP workload was increased rather than reduced (combining time for phone and face to face consultations). Additionally, there was no impact on continuity of care and no reduction in A&E attendance.  So if nothing else, these schemes demonstrate the potential for GPs to make more use of the phone.

However, these ‘average’ results mask wide variation between practices in almost every aspect that we looked at.  Some practices responded speedily to patients’ requests with a rapid phone call back and an offer (if needed) of a face to face consultation. In others, GPs were overwhelmed with phone consultations, sometimes still phoning patients back at 7pm. It’s clear that the ‘telephone first’ approach is going to run into problems if there’s a basic mismatch between demand and capacity (and demand can be revealed by offering unlimited phone consultations). There were also wide variations in what people thought. Some patients loved it and others hated it, though a small majority said they preferred it to what their practice offered before. Similarly, some staff valued the order that it brought to the day, whereas others reported that the approach had brought practices to breaking point, with unhappy GPs leaving. It’s interesting to note that our evaluation was complicated by most practices modifying the scheme in one way or another, such as by allowing limited booking ahead of time, even if the system is premised on the belief that this could undermine the whole basis of the approach.

The ‘telephone first’ approach does not, therefore, offer an easy answer to meeting patients’ needs in general practice. It can work well for some patients retired patients rather liked being able to be called back at home) and not for others (such as working people who couldn’t receive calls easily at work, especially if the practice couldn’t say when they’d get a call back). We also got the impression that it worked better in highly organised data-driven practices, but could increase the chaos in practices whose workload was already out of control.

The bad news is this approach is not a ‘magic wand’ to solve the problems of general practice – but for some practices it did make the workload feel more manageable and for patients provided improved access to get an appointment with their GP.

References

1 NHS England (2016) General Practice ‘Forward view’. NHS England.

2  NHS England (2013) High quality care for all, now and for future generations: Transforming urgent and emergency care services in England. NHS England

Funding

This project was funded by the National Institute for Health Research, Health Services and Delivery Research Programme (project 13/59/40). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Health Services and Delivery Research Programme, NIHR, NHS or the Department of Health.

To view the full article:

Newbould, J et al. Tele-First. Evaluation of a ‘telephone first’ approach to demand management in English general practice: observational study. BMJ 2017;358:j4197

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