Family Practice Vol. 18, No. 2, 156-160
© Oxford University Press 2001
Patients' experiences of receiving telephone advice from a GP co-operative
a Departments of General Practice and Primary Care, and
b Palliative Care and Policy, Guy's, King's and St Thomas' School of Medicine, London and
c Centre for Primary Health Care Studies, University of Warwick, Warwick, UK.
Fiona Payne, Department of General Practice and Primary Care, Guy's, King's and St Thomas' School of Medicine, The Weston Education Centre, Cutcombe Road, London SE5 9PJ, UK.
Payne F, Shipman C and Dale J. Patients' experiences of receiving telephone advice from a GP co-operative. Family Practice 2001; 18: 156–160.
Received 19 April 2000; Revised 17 August 2000; Accepted 30 October 2000.
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Abstract |
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Background. The use of the telephone to deliver health care advice has increased considerably in recent years. Little research has been carried out to explore the experience of patients who receive such advice and its acceptability.
Objectives. The aim of this study is to describe the expectations of patients, or third party callers, who had contacted a GP out-of-hours co-operative and their satisfaction with telephone advice received.
Methods. Semi-structured interviews were conducted by telephone 7–10 days after contact with one inner city GP co-operative.
Results. A total of 47 telephone consultations were followed up with an interview. Of these, 23 (48.9%) callers had expected to be offered a home visit when they called. Reasons for wanting a home visit were either to do with the nature of the condition and its perceived severity, problems in being able to attend the primary care centre and the risks of travel, or because of problems in communicating over the telephone. Satisfaction with telephone consultations centred mostly on the doctor being able to provide reassurance and give adequate time to allay concerns. The most common reasons given for dissatisfaction were the caller feeling that the doctor could not make a correct diagnosis without having seen the patient, or the caller being made to feel that they were wasting the doctor's time. Many patients were anxious about their ability to describe symptoms over the telephone, or understand and follow the advice that they received.
Conclusions. There appears to be a need for patients to be better informed about the service they can expect to receive from GP co-operatives. Recent developments such as NHS Direct may have an influence on the telephone consultation rate to GP co-operatives.
Keywords. General practice, GP co-operatives, NHS Direct, out-of-hours, patient satisfaction.
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Introduction |
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Providing telephone advice is not new in health care, there are reports as early as 1897.1 However, the volume of telephone consultations and the context in which they are provided have changed greatly in recent years. There is, though, relatively little research about patients' experience of receiving telephone advice. A national survey suggested that, on average, 40% of callers to out-of-hours co-operatives receive telephone advice (range 9–65.6%).2 There is evidence that many GPs find providing telephone advice stressful, often because of a mismatch between the caller's expectations and the GP's perceptions of their needs.3
This paper reports on a qualitative study of patients' experiences of receiving telephone advice from a GP co-operative in London. It is one of two papers focusing on patients' experience of different service responses provided by the co-operative.4 The patients interviewed were a subsample of those participating in a postal survey of patient satisfaction which found that patients were less satisfied with telephone consultations than other forms of service delivery, for example primary care centre consultations and home visits. Those receiving telephone consultations who had called with the expectation of a home visit were less satisfied, and higher levels of dissatisfaction were expressed for the explanation/ advice received and the doctor's manner (P < 0.001) than by patients who attended the primary care centre or who had a home visit.5 The current study was undertaken to elucidate the dimensions of issues that influenced satisfaction with telephone advice. The results are of particular interest now given recent developments in primary care, for example the introduction of NHS Direct.
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Methods |
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As part of a larger patient satisfaction study, a sample of 94 patients who received telephone advice (or the person making contact with the co-operative, if not the patient) was selected to participate in a telephone interview. Details of the original study, the sampling procedure and analysis are given in the accompanying paper by Shipman et al.4 on those who attended the primary care centre.
The semi-structured interview schedule included questions about how well the caller was able to explain the problem to the doctor over the telephone, how easy it was to understand the advice they were given on the telephone, what their expectations of the service were and their overall satisfaction with the consultation.
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Results |
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Of the 94 callers selected for interview, none sent back a letter declining participation. In all, 48 (51.1%) of callers were contacted successfully for interview within 7–10 days of their contact with the co-operative. Of the 48 contacted, 47 (97.9%) were interviewed, and one refused. The remaining 46 that were selected for interview were unable to be contacted after three attempts, by which time the 7–10 days after initial contact time frame had elapsed.
Table 1
gives details of the characteristics of patients for whom interviews were conducted. There was no significant difference between the age distribution of patients in the subgroups of the potential interviewees who were and were not contacted successfully.
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Wanting a home visit
We asked the 23 callers (48.9%) who said that they had expected a home visit why they had felt this to be necessary. The themes that emerged related to the severity of symptoms, the perceived need to see a doctor and views about the inappropriateness and risks of travel. The symptoms most often associated with wanting a home visit were severe pain, high temperature (particularly in children), vomiting, asthma and difficulty breathing, swelling and rashes. In addition, those with multiple health problems were more likely than others to expect a home visit.
A number of patients reported having been offered the opportunity of attending a primary care centre, but felt unable to do so. The reasons they gave were related to either physical factors (e.g. mobility problems or difficulty in breathing) or social factors (e.g. lack of money, lack of access to transport, or other dependants). Some patients felt that it was not appropriate to be asked to travel, for example women afraid to travel alone late at night. Some felt that it was risky to take a sick child out of the house.
One of the themes that emerged related to concerns that the doctor had not seemed to comprehend and appreciate the nature and severity of their problem. This was particularly true for patients with chronic symptoms who felt they had greater knowledge of their condition than an unfamiliar doctor and so were better able to judge whether a home visit was needed.
Illustrations of interviewee comments are shown in Box 1.
| BOX 1 Interviewee comments on reasons for specifically wanting a home visit
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Feeling understood
Overall, 39 (41%) felt that they had been able to explain their concerns sufficiently over the telephone, but others were concerned about the adequacy of telephone consultations because they felt unable to describe their symptoms effectively or because they doubted the doctor's ability to diagnose without seeing the patient. They perceived a need for a face-to-face consultation, as the comments in Box 2 illustrate.
| BOX 2 Interviewee comments on problems with telephone consultations
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Satisfaction with telephone advice
The accessibility and convenience of telephone consultations generally were felt to be positive aspects of the service. Satisfaction with the consultation was often associated with the perceived quality of the GP's communication skills: for example, sounding unrushed; being empathetic; providing advice and information in ways that allayed concerns.
- "The doctor I spoke to didn't give me the impression I was wasting his time, he was quite happy to speak to me for quite a long time as well." (773: mother of a 9-month-old boy who was agitated and had been crying all day)
- "To think that he's sitting in an office somewhere and I can reach him. I suppose it's the telephone, it's so handy." (1500: 68-year-old woman living alone)
- "He was very reassuring and said don't hesitate to contact if she doesn't settle." (2354: mother of a 2-year-old girl with a high temperature and cough)
Most negative comments were related to the doctor not agreeing to visit the patient. This was often interpreted by the patient as reflecting a lack of sympathy for, or understanding of, the problem. Some felt the GP taking the call sounded too rushed or disinterested. In some cases, although the patient was satisfied with what the doctor had told them over the telephone, they still did not rate the consultation overall as being satisfactory as they felt that a doctor should have visited.
- "I would have liked it more if he'd have talked about actually visiting me, that didn't even sound like it was on the cards from his point of view. He sounded like he wanted to get me off the line." (3758: 23-year-old male with cold and flu symptoms)
The delay between making contact with the co-operative and the GP calling back was a further source of dissatisfaction. Another commonly cited reason for dissatisfaction was having to explain the problem to the receptionist and then again to the doctor when they called back. Many patients felt that this unnecessarily wasted time.
- "Being told that you're going to have a phone call and waiting around for it and it's not happening. And having to wait in a queue and phone back and wait in another queue. When you have a child that's unwell you want advice really." (1501: mother of a 1-year-old boy in pain and crying)
- "The fact that you have to give details to the receptionist and then you're anxiously waiting for the doctor to ring you back." (3217: mother of an 11-year-old boy with asthma)
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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This study describes patients' experiences of receiving telephone advice. The data were collected from patients at one GP co-operative and not all the findings may be generalizable outside this setting. Compared with other co-operatives, the one in this study was large (288 GPs compared with a national average of 77), and had an above average rate of telephone advice (62.1% compared with a national average of 40%).2 The setting was a socially deprived area of inner London.
A further limitation to the research is that there were a number of exclusions. Full details are reported elsewhere.5 Therefore, the views expressed in this study may not include, for example, the very elderly or the very ill. In addition, those without access to a home telephone were not able to take part in this study, and those who were unable to communicate by telephone because of language difficulties or disability would not have been able to take part.
However, the interviews identified key themes that related to receiving medical advice via the telephone, and the qualitative approach used in this study allowed us to examine aspects of satisfaction with service delivery in greater depth than was possible with the questionnaire survey alone.
Our analysis suggests several factors that influence satisfaction both positively and negatively. Patients welcomed the ease of using the telephone and the relative speed of response. They welcomed the advice and reassurance they received, especially where they were not made to feel that they had been wasting the doctor's time.
Dissatisfaction fell into two main categories. First, when there were unmet expectations for a home visit and the perception that GPs could not make a ‘proper’ diagnosis without physically examining the patient. Secondly, dissatisfaction was related to communication issues. Many patients, particularly those whose first language is not English, felt that they were unable to describe symptoms accurately over the telephone and that they may not be able to follow instructions or advice. Older people too may be less familiar and less trusting of advice by telephone.6
Given that a third of all contacts to the co-operative during the study period were for children under the age of 5, the expectations and attitudes of parents are of particular relevance. Previous research has found that parents of young children are concerned to know how doctors evaluate a young child and particularly how they can determine the severity of illness in babies.7 With the added difficulty of doing this over the telephone, and often at night when children may be seen by parents as being more vulnerable,8 it is not surprising that this led to lower levels of satisfaction.
It has been argued that home visits should only be conducted for terminal illness or if there is a clear risk of deterioration if the patient were moved.9 However, we found that a perception that a doctor had refused to visit commonly caused dissatisfaction. There was also an apparent paradox that some patients reported being satisfied with the advice they received by telephone from the doctor but stated, overall, that they were not satisfied as they would have preferred to see a doctor. This might reflect the time lag between changes in out-of-hours arrangements and changes in patients' expectations. It may be that as patients become more used to the new organizational arrangements, satisfaction with telephone advice will increase.
Good communication skills are vital to telephone consultations.10 Acknowledging the patients' expectations, concerns and knowledge of their condition, plus using techniques of active listening, summarizing and checking, are likely to have an impact on satisfaction levels. Guidelines for receptionists on giving clear information about how long it will be before the doctor calls back, and keeping the patient informed of unexpected delays, might also be valuable and relatively easy to introduce. Guidelines for GPs on when to undertake home visits that take into account factors other than purely the medical condition may also be useful. However, previous research has highlighted the difficulties in doing this.11
Providing clear information to all patients, prior to contact, on the organization of out-of-hours services and how out-of-hours calls are dealt with may contribute to changing the culture of expectation. Other national developments, such as the introduction of NHS Direct, may also help to change the culture of expecting a home visit. Many of the findings are encouraging for the development of this service. Some of the problems associated with the use of the telephone for contacting a GP were about GPs being rushed and not being able to provide a proper diagnosis over the telephone. Nurses working for NHS Direct may be able to provide less rushed consultations, or call patients back when they have quieter periods. The aim of this service is not to diagnose, but to direct callers to the most appropriate service or offer self-care advice. This may be beneficial to callers advised to contact a GP urgently in the out-of-hours period as they will be less likely to feel they are wasting the doctor's time.
In conclusion, this study has identified a range of factors that affect satisfaction with GP telephone consultations. Many of those that lead to dissatisfaction may be amenable to simple organizational modifications or may be improved by new service developments, for example NHS Direct.
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Acknowledgments |
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We thank the GP co-operative that provided data for the study and the patients who participated in the interviews. We also thank Natalie Boston for assisting in carrying out the telephone interviews, and members of the Lambeth, Southwark and Lewisham Out-of-hours Project for their support and advice in carrying out this work, in particular Lynda Jessopp. Lambeth, Southwark and Lewisham Health Authority funded this study.
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References |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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1 Hallam L. You've got a lot to answer for Mr Bell. A review of the use of the telephone in primary care. Fam Pract 1989; 6: 47–57.
2 Payne F, Jessopp L, Dale J. Second National Survey of GP Co-operatives: A Report. London: Department of General Practice and Primary Care, King's College School of Medicine and Dentistry, 1997.
3 Foster J, Jessopp L. Telephone Consultation Course: An Evaluation Report. London: Department of General Practice and Primary Care, King's College School of Medicine and Dentistry, 1997.
4
Shipman C, Payne F, Dale J, Jessopp L. Patient-perceived benefits of and barriers to using out-of-hours primary care centres. Fam Pract 2001; 18: 149–155.
5
Shipman C, Payne F, Hooper R, Dale J. Patient satisfaction with out-of-hours services; how do GP co-operatives compare with deputizing and practice-based arrangements? J Public Health Med 2000; 22: 149–154.
6 Foster J. Public Perspectives on Out of Hours Services. London: Department of General Practice and Primary Care, Guy's, King's and St Thomas' School of Medicine, 1998.
7
Kai J. Parents' difficulties and information needs in coping with acute illness in preschool children: a qualitative study. Br Med J 1996; 313: 987–990.
8 Morrison JM, Gilmour H, Sullivan F. Children seen frequently out of hours in one general practice. Br Med J 1991; 303: 1111–1114.
9 Shamash J. Call for rule change on GP home visits. Pulse 1999; 20 March.
10 Foster J, Jessopp L, Dale J. Concerns and confidence of general practitioners in providing telephone consultations. Br J Gen Pract 1999; 49: 111–113.[Web of Science][Medline]
11
Court BV, Bradley CP, Cheng KK, Lancashire RJ. Responding to out of hours requests for visits: a survey of general practitioner opinion. Br Med J 1996; 312: 1401–1402.
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