Telephone consultationns form a large proportion of consultations. This is due to the way patients now wish to access their GP but also because practices need to appropriately direct the flow of work to improve efficiencies within the service.
They are also part of the workplace-based assessments in the form of audio COTs and may appear as a station in the CSA. There is more advice on the audio COT here.
Telephones consultations can be:
- In-hours triage (for acute problems)
- Routine planned telephone consultations
- Telephone reviews arranged by a clinician
- Out-of-hours triage
The term triage is derived from the french verb trier meaning to sort.
Telephone consultations should be approached in a similar way to face-to-face consultations. They carry more risk in comparison to face-to-face consultations due to the inability to see the patient, but a methodical approach using verbal and non-verbal cues should allow for a safe acceptable disposition at the end of the consultation.
Prior to the call, ensure you are in a quiet environment free from distractions.
A planned call means the patient will likely be expecting a call at a certain time so try and avoid running late where able.
Review the patients records. There maybe some information as to why the telephone consultation has been booked. Are there any recent letters? Are there any recent blood results or imaging?
Familiarise yourself with the patients medical history and medication list. Are there any relevant documents, for example advanced care plan, emergency health care plan? Are there any safeguarding issues?
If the telephone consultation is not planned, i.e for an acute problem (which make up the majority of telephone consultations in the out-of-hours setting), then the same pre-consultation preparation applies. If you are in out-of-hours you may not have the full medical record, but ensure you use any 111 information and any information you have via the summary care record. Remember you require the patient's consent to access this.
Ensure you introduce yourself clearly and check at least one piece of patient identifiable data, for example date of birth. Signpost how the consultation will progress.
Structure your consultation as you would in a face-to-face consultation. Try and speak to the patient where able. This is still possible with young children and those in a nursing home setting.
Start with an open question and allow the patient to tell their story. Avoid any early interruptions. Be alert to verbal cues, although this is more difficult over the telephone. Take a focussed history and used closed questions where appropriate. Identify any emergencies early on in the consultation.
Explore the patient's social situation. If the patient is elderly, how are they coping at home with activities of daily living? Is there any family support or external support?
If applicable, explore the patient's ideas, concerns and expectations around the telephone assessment.
Although most examination is not possible over the telephone, some information can be gathered, for example is there any sign of respiratory distress or wheeze? Could you ask the patient to count their own pulse, or a parent to count the child's breathing rate?
After your assessment, share your thoughts with the patient. Let them know what you feel the problem is and draw on their ideas, concerns and expectations to help you tailor your explanation. Find out what the patient already knows about the problem.
Ensure your explanations are jargon free. It is much more difficult to gauge whether a patient is following your trail of thought and explanation over the phone. Use your skills of chunking and checking to ensure patients are clear on what you feel the problem is.
Shared decision making
If applicable, provide the patient with options for their problem. Knowing what the reason for the call is, will be useful at this point.
Possible dispositions following a telephone consultation include:
- Telephone advice and intervention.
- Need for a face-to-face consultation in surgery.
- Need for a face-to-face consultation at home.
- Need for a face-to-face consultation with another health care professional e.g district nurse, physiotherapist.
- Need for a social assessment via a social worker
- Need for an emergency response i.e 999 or direct admission via non-urgent ambulance.
Safety netting, red flags and follow up
Regardless of outcome, ensure you provide the patient with an adequate safety net for what to do if things do not progress as expected. Be very clear to the patient on who to call and what to look out for. Be very specific with red flag symptoms and time frames.
Phrases to consider:
- 'I would expect X to last X weeks.'
- 'If your symptoms are no better in X weeks then please seek medical advice as we may need to investigate your symptoms further, or if before this you develop y or, z then contact us before X weeks.'
- 'If you develop x then please call 999.'
Consider what follow-up you feel the patient needs. If out of hours, do they need to see their own GP or the practice nurse? If in-hours and an intervention is made over the telephone, do they need a telephone review or a face-to-face appointment within 48 hours? A number off factors will determine how you action this.
Signpost patients to NHS Choices or patient.co.uk for relevant patient leaflets.
Ensure you keep good records and document them in a timely manner. Make it clear in the record (if in hours) that this is was a telephone consultation.
Useful communication skills
Micro-commuication skills applying to telephone consultations include:
- Empathic statements
- Echoing patients words.
- Chunking and checking pieces of information
- Avoiding jargon.
Unsuccessful telephone consultations are most likely when GPs:
- Don't check demographic data
- Don't speak to patient directly
- Ask leading questions
- Use too many closed questions
- Display a lack of empathy
- Fail to discover the reason for the call and the patient's concerns.
- Fail to review the patients record if able.
Dr Pipin Singh is a GP trainer in Northumberland